A comprehensive review of the literature, the findings of which showed ‘compelling’ consistency: digital rectal examination (DRE) as a screening test had sensitivities ranging from 0% to 50%, had consistently high false-positive and false-negative rates, and did not improve the predictive value of the other components of a typical trauma examination.
Based on case reports of five patients, the authors suggest DRE may be of value during trauma evaluation in the following settings: (1) patients with evidence of penetrating trauma in the vicinity of the rectum, (2) cases in which the presence of neurologic injury is neither completely supported nor refuted by the clinical ﬁndings, and (3) before pharmacologic paralysis. A selective approach is therefore recommended. Some good news for your patients if this will persuade you to discard another piece of longstanding dogma perpetuated in basic trauma teaching.
Should the digital rectal examination be a part of the trauma secondary survey?
Ann Emerg Med. 2009 Feb;53(2):208-12
This CT study of 110 trauma patients showed: ‘the standard 4.4-cm angiocatheter is likely to be unsuccessful in 50% (95% conﬁdence interval = 40.7–59.3%) of trauma patients on the basis of body habitus. In light of its low predicted success, the standard method for treatment of tension pneumothorax by prehospital personnel deserves further consideration’. Consistent with several other Ultrasound and CT-based studies published on the same subject then.
Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography
Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7
Blood transfusion in trauma is a risk factor for acute respiratory distress syndrome (ARDS). An analysis of 14070 patients in a trauma database showed that 521 (4.6%) developed ARDS. Logisitc regression analysis demonstrated that, independent of injury type, injury severity, or pneumonia, (1) early PRBCs transfusion of more than 5 units during the ﬁrst 24 h of hospital admission predicted ARDS and (2) each unit of PRBCs transfused early after admission increased the risk of ARDS by 6%.
Early packed red blood cell transfusion and acute respiratory distress syndrome after trauma.
Anesthesiology. 2009 Feb;110(2):351-60
Further evidence from the UK shows that patients with acute traumatic brain injury suffer delays in the neurosurgical evacuation of intracranial haematomas which are increased from an average of 3.7 hours to 5.4 hours if they have to undergo interhospital transfer. Coordinated regional trauma systems please!
A prospective study of the time to evacuate acute subdural and extradural haematomas.
Anaesthesia. 2009 Mar;64(3):277-81
Two English HEMS services covering the same geographical area, one physican / paramedic crewed and one double paramedic crewed, were compared. There were no differences in scene times. As well as predictably providing more rapid sequence induction, nerve blocks, and ketamine use, the physician-paramedic team discharged more people at scene and were more likely to cease resuscitation attempts in GCS 3 patients.
Influence of air ambulance doctors on on-scene times, clinical interventions, decision-making and independent paramedic practice.
Emerg Med J. 2009 Feb;26(2):128-34
Careflight Queensland report a 9 month series of intubations by their doctor-paramedic HEMS teams who performed 39 intubations (and assisted hospital doctors in an additonal 4), of which less than half were pre-hospital. There was one failed intubation, successfully ventilated with a laryngeal mask airway.
Emergency intubation: a prospective multicentre descriptive audit in an Australian helicopter emergency medical service.
Emerg Med J. 2009 Jan;26(1):65-9
171 rural Australian HEMS missions were retrospectively analysed. Some of the data contrast starkly with the more limelight-occupying urban services: average time from dispatch to scene was 48 minutes, average scene time was 50 mins, and average total distance flown was 160 nautical miles (297 km!) – the longest reported in the literature. There was no difference in injury severity between physician-staffed and paramedic-staffed missions, and no difference in mortality. When transport times for distances less than 50km from the hospital were compared, road responses were significantly faster than helicopter dispatch, whereas helicopter use created significant time savings at distances over 100km. The authors suggest that in the absence of special circumstances, a helicopter response within 100 km from base does not improve time to definitive care. They also recommend caution in mandating physician staffing of HEMS, particularly in environments with a limited pool of critical care doctors.
Helicopter use in rural trauma
Emerg Med Australas. 2008 Dec;20(6):494-9
London HEMS doctors describe their use of ketamine for pre-hospital analgesia and sedation in 1030 retrospectively reviewed cases, concluding its prehospital use is safe.
Pre-hospital use of ketamine for analgesia and procedural sedation
Emerg Med J. 2009 Jan;26(1):62-4