Of 203 patients attending a US Level 1 trauma centre who had pre-hospital airway management, 25 (12%) had unrecognised oesophageal intubations.
Patients were treated in the field by fire rescue personnel of various municipalities and with different experience levels. Patients transported by air were significantly more likely to be successfully intubated than those transported by ground, perhaps due to both increased experience and the use by air crews of succinylcholine. The authors in their discussion contrast these results with those of European studies which report higher success rates with pre-hospital systems that employ emergency physicians and anaesthetists.
Prehospital intubations and mortality: a level 1 trauma center perspective
Anesth Analg. 2009 Aug;109(2):489-93
Category Archives: Trauma
Care of severely injured patient
Vehicle Rollover
Vehicle rollover as an indicator of mechanism of injury was investigated in a study examining accident databases and the medical literature. Only 2.4% of crashes involved rollovers but they accounted for one third of occupant deaths.
Some facts on vehicle rollover from the article:
- Rollover is defined as a vehicle overturned by at least one quarter turn (at least onto its side).
- Some rollovers involve many quarter turns and the final resting position may be on the vehicle’s side, roof, or back on its wheels.
- Factors that cause a vehicle to roll over include trajectory (i.e., turning vs. straight), vehicle type, and speed (precrash velocity may be the most predictive factor)
The importance of vehicle rollover as a field triage criterion
J Trauma. 2009 Aug;67(2):350-7
Deciding who doesn't need abdominal CT in trauma
A derivation then validation study on adults with blunt torso trauma found the absence of the following factors to be associated with a very low risk of significant (intervention-requiring) abdominal pathology and such patients were unlikely to benefit from abdominal CT scanning:
- GCS score less than 14
- costal margin tenderness
- abdominal tenderness
- femur fracture
- hematuria level greater than or equal to 25 red blood cells/high powered field
- hematocrit level less than 30%
- abnormal chest radiograph result (pneumothorax or rib fracture)
Clinical Prediction Rules for Identifying Adults at Very Low Risk for Intra-abdominal Injuries After Blunt Trauma
Ann Emerg Med. 2009 Oct;54(4):575-8
Paramedics apply cervical spine rule successfully
The Canadian C-Spine rule – a decision instrument designed to clinically rule out important cervical spine injuries in alert patients – was successfully and safely applied by Canadian paramedics in a study of 1949 patients. Any misinterpretation erred on the side of safety.
This important work could ultimately result in less stress, discomfort, and wasting of ambulance resources and time for this large subgroup of pre-hospital patients.
The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics
Ann Emerg Med. 2009 Nov;54(5):663-671
Tying the tracheal tube
After intubation it is critical to securely fasten the tracheal tube so it does not dislodge during transfer. Dedicated devices are available for this although mostly cloth tape is used.
Different knots have been compared although not found be significantly different in terms of security1. One favoured knot, which is easy to learn and to teach, is the lark’s head (also called cow’s hitch)2.
The tape is folded in half so there is a loop at one end and two free ends at the other. The loop is wrapped around the tube and the two free ends are fed through the loop, and then taped around the patient’s head. It has been suggested that this results in the tape gripping the tube over the widest possible area, thereby reducing the potential for slippage and displacement.
Easy!
1.The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes
BMC Emerg Med. 2006 May 24;6:7 Open Access
2. A knotty problem resolved
Anaesthesia. 2007 Jun;62(6):637
Burns formulas and fluid resuscitation
In most cases either the modified Brook formula or the Parkland formula was used for burned military casualties in Iraq and Afghanistan over the three years covered in this study.
The modified Brooke formula is 2mls x body surface areas burned (BSAB) x weight.
The Parkland formula is 4mls x body surface areas burned (BSAB) x weight.
Both formulas estimate the first 24 hour fluid requirements from the time of the burn, with half the amount given in the first 8 hours.
In this study which compared outcomes between the Brooks and Parkland groups, there were no differences in clinical outcomes. In both groups many patients were overresuscitated in terms of urine output goals. The authors’ main conclusion is that burns resuscitation can be successfully accomplished with lower initial fluid volumes. Take home message: individualise fluid resuscitation to patient’s clinical response, and avoid the ‘fluid creep’ of unphysiologic resuscitation management.
Resuscitation of severely burned military casualties: fluid begets more fluid
J Trauma. 2009 Aug;67(2):231-7
Successful trauma airway management
Of 6088 patients requiring intubation within the first hour of arrival at a Level 1 trauma centre, 21 (0.3%) required a surgical airway for unanticipated difficult upper airway anatomy. There were no deaths from failed airway management. The authors ascribe their effective airway management to a simple protocol based on rapid sequence induction of anesthesia, judicious use of selected adjunctive devices (bougie, LMA), and the supervision by a small group of experienced anesthesiologists.
The Success of Emergency Endotracheal Intubation in Trauma Patients: A 10-Year Experience at a Major Adult Trauma Referral Center
Anesth Analg. 2009 Sep;109(3):866-72
Rectal exam for urethral injury a waste of time?
Of 41 male patients with proven blunt urethral injury over a thirteen year period at a major trauma centre, only one had an abnormal prostate on digital rectal examination (DRE). Meatal blood and haematuria prior to catheterisation were more common findings (8 and 7 patients, respectively). All patients had haematuria after catheter insertion. In blunt urethral injuries, DRE has very low sensitivity.
Traumatic urethral injuries: Does the digital rectal examination really help us?
Injury. 2009 Sep;40(9):984-6
Ketamine lowered ICP in brain-injured kids
Ketamine lowered ICP in brain-injured kids
Ventilated children between the ages of 1 and 16 with traumatic brain injury and elevated intracranial pressure (ICP) were given ketamine and effect on cerebral perfusion pressure (CPP) and ICP was measured. Ketamine decreased ICP while maintaining blood pressure and CPP.
These results refute the notion that ketamine increases ICP. The authors conclude: “Ketamine is a safe and effective drug for patients with traumatic brain injury and intracranial hypertension, and it can possibly be used safely in trauma emergency situations”
Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension
J Neurosurg Pediatr. 2009 Jul;4(1):40-6 (Full text)
Prehospital management of severe traumatic brain injury
Prehospital management of severe traumatic brain injury
A review of current practice and evidence base of this important topic can be found at
BMJ. 2009 May 19;338:b1683
http://www.ncbi.nlm.nih.gov/pubmed/19454738
Full text http://www.bmj.com/cgi/content/full/338/may19_1/b1683