Yearly Archives: 2012

All Updates, Guidelines, ICU, Resus

Extubation guidelines

Leave a comment

Tracheal extubation is a high risk procedure in anaesthesia and critical care. Until now most guidelines have focused on intubation, with little to guide the process of extubation. Complications may relate to the following issues:

  • Exaggerated reflexes – laryngospasm (which can lead to both hypoxia and negative pressure pulmonary oedema) and bronchospasm
  • Reduced airway reflexes
  • Dysfunctional laryngeal reflexes
  • Depletion of oxygen stores at extubation
  • Airway injury
  • Physiological compromise in other systems
  • Human factors

The goal is to ensure uninterrupted oxygen delivery to the patient’s lungs, avoid airway stimulation, and have a back-up plan, that would permit ventilation and re-intubation with minimum difficulty and delay should extubation fail.
The Difficult Airway Society has now published guidelines for the management of tracheal extubation, describing four steps:

Step 1: plan extubation.

Step 2: prepare for extubation.

Step 3: perform extubation.

Step 4: post-extubation care: recovery and follow-up.

During step 3, emphasis is on pre-oxygenation, positioning, and suction. This is followed by simultaneous deflation of the tracheal tube cuff and removal of the tube at the peak of a sustained inflation. This generates a passive exhalation, which may assist in the expulsion of secretions and possibly reduce the incidence of laryngospasm and breathholding.
The guideline refers to low-risk and at-risk extubations. ‘Low-risk’ (routine) extubation is characterised by the expectation that reintubation could be managed without difficulty, if required. ‘At-risk’ means the presence of general and/or airway risk factors that suggest that a patient may not be able to maintain his/her own airway after removal of the tracheal tube. ‘At-risk’ extubation is characterised by the concern that airway management may not be straightforward should reintubation be required.
These guidelines are written for the peri-operative patient but the text contains some interesting points that are pertinent to the ED or ICU patient. Some simple algorithms are presented:






Difficult Airway Society Guidelines for the management of tracheal extubation
Anaesthesia. 2012 Mar;67(3):318-40 Free full text

More guidelines from the Difficult Airway Society

All Updates, Resus

Australasian ED Airway Registry

Leave a comment

Managing the emergency airway is one of the most important and risky things we do. We have a responsibility to record, monitor, report and improve our performance.
In the US, the National Emergency Airway Registry has been running for over a decade and has significantly contributed to our airway knowledge base.
In the UK, the NAP4 audit provided fascinating and scary insight into complications of emergency airway management.
Pre-hospital registries have been developed, like Minh Le Cong’s Flying Doctor Emergency Airway Registry; and many of us are now contributing to the Airway Management Study in Physician Manned Helicopter Emergency Medical Services (AIRPORT) study.
Now there is an opportunity for Australasian emergency departments to contribute to a national audit.
Dr Toby Fogg FACEM, emergency physician at Royal North Shore Hospital in Sydney, who began the registry, explained in a recent Life in The Fast Lane response:


I have been running an airway registry in the ED at The Royal North Shore Hospital in Sydney for the last 2 years.

I presented the first 18 months of data at the ASM in Sydney last year and I must admit, they showed room for improvement!.

One of the many things we have subsequently done is introduced a Pre Intubation Checklist which I have published, along with our preliminary findings, at www.airwayregistry.org.au.

I am happy for people to download the file and use it as is, or with appropriate modifications.

Furthermore I would love to hear from anyone keen to undertake an Airway Registry in their own ED — a PDF of the data collection form we use is also on the website.

As the authors of the NAP4 study conclude, it is essential we all audit our practice of this potentially high risk procedure.

Dr Toby Fogg uses his C-MAC video laryngoscope to demonstrate the audit form


Background: Successful airway management is one of the cornerstones of care for critically ill or injured patients in the Emergency Department (ED). The risks of intubation are known to be higher in this environment than in the operating theatre (OT) yet there are no published data on airway management in an Australian ED.

Objectives: To describe the practice of intubation in the ED of a tertiary hospital in Australia, with particular emphasis on the number of attempts, adjuncts used, the seniority of staff involved and the rate of complications.

Methods: A prospective, observational study.

Results: Over the 18-month study period, 295 episodes of intubation occurred with a total of 345 attempts. Consultant supervision occurred in 69.8% of cases, registrars made the first attempt at intubation in 57.5% and SRMOs in 31.0% of the patients. 83.7% of the patients were intubated at the first pass with a further 13.0% intubated one the second attempt. This leaves 10 patients (3.4%) that required ≥3 attempts, 4 (1.4%) ≥4 attempts and 1 (0.4%) required a 5th attempt. Difficult laryngoscopy, as defined by Cormack and Lehane grade III or IV, occurred in 24% of the first attempts. Bougies were used in 36% of attempts, whilst a stylet in 35%. Video laryngoscopy was used in 47.5% of attempts. Complications occurred in 28%.

Discussion: The success rate within two attempts is comparable to the anaesthetic literature, and although high, the rate of complications is comparable to data from EDs overseas. The rate of difficult laryngoscopy, however, is surprisingly high. The study has prompted a significant review of airway training and management within the ED at Royal North Shore Hospital and the results of the interventions will be monitored.

The Royal North Shore Hospital Emergency Department Airway Registry. A Prospective Observational Study of Airway Management in a Tertiary Hospital Emergency Department in Sydney, Australia
Annesley N,Vassiliadis J, Kerry Hitos K, Fogg T
Emerg. Med. Australas. 24 (Suppl. 1):27-28

Study authors Toby Fogg and Nick Annesley demonstrate the 'Happiness Triad'

Acute Med, All Updates, ICU, Resus, Trauma

Red cell transfusion guidelines

Leave a comment

The AABB (formerly the American Association of Blood Banks has issued guidelines on red blood cell transfusion1, providing some number-based targets which may be helpful for some practitioners or organisations. Editorialist and heavyweight intensivist Jean-Louis Vincent argues for a more individual patient-based assessment2, and highlights some of the weaknesses of existing studies, in particular the often quoted but now fairly old TRICC study3 which suffered from poor recruitment and the possible lack of applicability to modern practice now that leucodepleted products are used.
Prof Vincent states:
“Transfusion decisions need to consider individual patient characteristics, including age and the presence of CAD, to estimate a specific patient’s likelihood of benefit from transfusion. The decision to transfuse is too complex and important to be guided by a single number.”


Description: Although approximately 85 million units of red blood cells (RBCs) are transfused annually worldwide, transfusion practices vary widely. The AABB (formerly, the American Association of Blood Banks) developed this guideline to provide clinical recommendations about hemoglobin concentration thresholds and other clinical variables that trigger RBC transfusions in hemodynamically stable adults and children.

Methods: These guidelines are based on a systematic review of the literature on randomized clinical trials evaluating transfusion thresholds. We performed a literature search from 1950 to February 2011 with no language restrictions. We examined the proportion of patients who received any RBC transfusion and the number of RBC units transfused to describe the effect of restrictive transfusion strategies on RBC use. To determine the clinical consequences of restrictive transfusion strategies, we examined overall mortality, nonfatal myocardial infarction, cardiac events, pulmonary edema, stroke, thromboembolism, renal failure, infection, hemorrhage, mental confusion, functional recovery, and length of hospital stay.

Recommendation 1: The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence).

Recommendation 2: The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence).

Recommendation 3: The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence).

Recommendation 4: The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence).

1. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB
Ann Intern Med. 2012 Mar 26. [Epub ahead of print] Full Text
2. Indications for Blood Transfusions: Too Complex to Base on a Single Number?
Ann Intern Med. 2012 Mar 26. [Epub ahead of print] Full Text
3. A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care
N Engl J Med 1999; 340:409-417 Full Text

All Updates, ICU

Ventilated patients better able to communicate pain with dexmedetomidine

Leave a comment

A multicentre European trial on intensive care units showed dexmedetomidine was non-inferior to midazolam or propofol in achieving target sedation levels, but patients were better able to communicate pain compared with midazolam and propofol. Dexmedetomidine reduced duration of mechanical ventilation compared with midazolam, but not compared with propofol.


Context Long-term sedation with midazolam or propofol in intensive care units (ICUs) has serious adverse effects. Dexmedetomidine, an α2-agonist available for ICU sedation, may reduce the duration of mechanical ventilation and enhance patient comfort.

Objective To determine the efficacy of dexmedetomidine vs midazolam or propofol (preferred usual care) in maintaining sedation; reducing duration of mechanical ventilation; and improving patients’ interaction with nursing care.

Design, Setting, and Patients Two phase 3 multicenter, randomized, double-blind trials carried out from 2007 to 2010. The MIDEX trial compared midazolam with dexmedetomidine in ICUs of 44 centers in 9 European countries; the PRODEX trial compared propofol with dexmedetomidine in 31 centers in 6 European countries and 2 centers in Russia. Included were adult ICU patients receiving mechanical ventilation who needed light to moderate sedation for more than 24 hours (midazolam, n = 251, vs dexmedetomidine, n = 249; propofol, n = 247, vs dexmedetomidine, n = 251).

Interventions Sedation with dexmedetomidine, midazolam, or propofol; daily sedation stops; and spontaneous breathing trials.

Main Outcome Measures For each trial, we tested whether dexmedetomidine was noninferior to control with respect to proportion of time at target sedation level (measured by Richmond Agitation-Sedation Scale) and superior to control with respect to duration of mechanical ventilation. Secondary end points were patients’ ability to communicate pain (measured using a visual analogue scale [VAS]) and length of ICU stay. Time at target sedation was analyzed in per-protocol population (midazolam, n = 233, vs dexmedetomidine, n = 227; propofol, n = 214, vs dexmedetomidine, n = 223).

Results Dexmedetomidine/midazolam ratio in time at target sedation was 1.07 (95% CI, 0.97-1.18) and dexmedetomidine/propofol, 1.00 (95% CI, 0.92-1.08). Median duration of mechanical ventilation appeared shorter with dexmedetomidine (123 hours [IQR, 67-337]) vs midazolam (164 hours [IQR, 92-380]; P = .03) but not with dexmedetomidine (97 hours [IQR, 45-257]) vs propofol (118 hours [IQR, 48-327]; P = .24). Patients’ interaction (measured using VAS) was improved with dexmedetomidine (estimated score difference vs midazolam, 19.7 [95% CI, 15.2-24.2]; P < .001; and vs propofol, 11.2 [95% CI, 6.4-15.9]; P < .001). Length of ICU and hospital stay and mortality were similar. Dexmedetomidine vs midazolam patients had more hypotension (51/247 [20.6%] vs 29/250 [11.6%]; P = .007) and bradycardia (35/247 [14.2%] vs 13/250 [5.2%]; P < .001).
Conclusions Among ICU patients receiving prolonged mechanical ventilation, dexmedetomidine was not inferior to midazolam and propofol in maintaining light to moderate sedation. Dexmedetomidine reduced duration of mechanical ventilation compared with midazolam and improved patients’ ability to communicate pain compared with midazolam and propofol. More adverse effects were associated with dexmedetomidine.

Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials
JAMA. 2012 Mar 21;307(11):1151-60

All Updates, Trauma, Ultrasound

Only when I laugh

Leave a comment

A middle-aged martial arts enthusiast was training in Krav Maga, and participated in a high-contact punching and grappling sparring exercise in which his (younger, heavier) partner threw him to the ground and landed on him. During the throw the patient felt a ‘pop’ in his right side, and wondered whether he’d fractured a rib. During the subsequent five rounds against two additional sparring partners he noticed a clicking in the same area every time he was grappling, and pain in the right side when pushing up off the floor with his right arm. As a trained emergency physician, he assessed his own level of breathing comfort throughout the training to reassure himself he didn’t have a significant pneumothorax, and therefore elected to continue to fight in the interests of assessing his ability to defend himself while injured.
Pain on deep inspiration, coughing, and squeezing the chest suggested a fractured rib, so out of curiosity at work the next day he ultrasounded the area of maximum tenderness:

Discontinuity in cortex signifies rib fracture

Examination of the lung confirmed pleural sliding, B-lines, and ‘pearls on a string’, which excluded pneumothorax.
Sonography is more sensitive than radiography for the detection of rib fractures and may also detect costochondral junction injuries and disruption of costal cartilage1. This video from Hennepin County Medical Centre takes you through the simple procedure:

Although the management of rib fractures is no different from that of chest wall contusion, knowledge of the presence of fracture in this case is helpful to this patient in deciding when to return to the questionably sane ‘hobby’ of fighting bigger guys half his age.
The patient’s consent was obtained prior to the publication of the ultrasound image.

1. Sonography Compared with Radiography in Revealing Acute Rib Fracture
AJR Am J Roentgenol. 1999 Dec;173(6):1603-9.
Full text article
[EXPAND Click to read abstract]


OBJECTIVE: This study was undertaken to compare the sensitivities of sonography and radiography for revealing acute rib fracture.

SUBJECTS AND METHODS: Chest radiography and rib sonography were performed on 50 patients with suspected rib fractures. Sonography was performed with a 9- or 12-MHz linear transducer. Fractures were identified by a disruption of the anterior margin of the rib, costochondral junction, or costal cartilage. The incidence, location, and degree of displacement of fractures revealed by radiography and sonography were compared. Sonography was performed again after 3 weeks in 37 subjects.

RESULTS: At presentation, radiographs revealed eight rib fractures in six (12%) of 50 patients and sonography revealed 83 rib fractures in 39 (78%) of 50 patients. Seventy-four (89%) of the 83 sonographically detected fractures were located in the rib, four (5%) were located at the costochondral junction, and five (6%) in the costal cartilage. Repeated sonography after 3 weeks showed evidence of healing in all reexamined fractures. Combining sonography at presentation and after 3 weeks, 88% of subjects had sustained a fracture.

CONCLUSION: Sonography reveals more fractures than does radiography and will reveal fractures in most patients presenting with suspected rib fracture. Further scientific studies are needed to clarify the appropriate role for sonography in rib fracture detection.

[/EXPAND]

Acute Med, All Updates, Guidelines, ICU, PHARM, Resus, Trauma, Ultrasound

International recommendations for lung ultrasound

Leave a comment

A multidisciplinary panel of 28 experts from eight countries reviewed the literature and came up with consensus guidelines in point-of-care lung ultrasound. There were some big names involved – all the big players in emergency/critical care ultrasound from around the World. Conspicuously absent were Matt and Mike from the Emergency Ultrasound Podcast, but maybe there was a maximum awesomeness limit or something.

Here are some snippets, taken out of context and without the grade of recommendation attached. Try to get hold of the original if you can, which might not be easy. I never understand it when ‘international recommendations’ are published as subscription-only articles. Either they want people to follow them or not. Oh well – here are some of their recommendations:
Pneumothorax

  • The sonographic signs of pneumothorax include the following: Presence of lung point(s); Absence of lung sliding; Absence of B-lines; Absence of lung pulse
  • The lung pulse refers to the subtle rhythmic movement of the visceral upon the parietal pleura with cardiac oscillations and is a rule-out sign for pneumothorax
  • In the supine patient, the sonographic technique consists of exploration of the least gravitationally dependent areas progressing more laterally.
  • Bedside lung ultrasound is a useful tool to differentiate between small and large pneumothorax, using detection of the lung point.

Interstitial syndrome

  • B-lines are defined as discrete laser-like vertical hyperechoic reverberation artifacts that arise from the pleural line (previously described as ‘‘comet tails’’), extend to the bottom of the screen without fading, and move synchronously with lung sliding.
  • The presence of multiple diffuse bilateral B-lines indicates interstitial syndrome. Causes of interstitial syndrome include the following conditions: Pulmonary edema of various causes; Interstitial pneumonia or pneumonitis; Diffuse parenchymal lung disease (pulmonary fibrosis)

Lung consolidation

  • The sonographic sign of lung consolidation is a subpleural echo-poor region or one with tissue-like echotexture.
  • Lung ultrasound is a clinically useful tool to rule in pneumonia; however, lung ultrasound does not rule out consolidations that do not reach the pleura.
  • In mechanically ventilated patients lung ultrasound should be considered as it is more accurate than portable chest radiography in the detection of consolidation.

Pleural effusion

  • Both of the following signs are present in almost all free effusions: A space (usually anechoic) between the parietal and visceral pleura; Respiratory movement of the lung within the effusion (‘‘sinusoid sign’’)
  • In opacities identified by chest radiography, lung ultrasound should be used because it is more accurate than chest radiography in distinguishing between effusion and consolidation.
  • Visualization of internal echoes, either of mobile particles or septa, is highly suggestive of exudate or hemothorax


BACKGROUND: The purpose of this study is to provide evidence-based and expert consensus recommendations for lung ultrasound with focus on emergency and critical care settings.

METHODS: A multidisciplinary panel of 28 experts from eight countries was involved. Literature was reviewed from January 1966 to June 2011. Consensus members searched multiple databases including Pubmed, Medline, OVID, Embase, and others. The process used to develop these evidence-based recommendations involved two phases: determining the level of quality of evidence and developing the recommendation. The quality of evidence is assessed by the grading of recommendation, assessment, development, and evaluation (GRADE) method. However, the GRADE system does not enforce a specific method on how the panel should reach decisions during the consensus process. Our methodology committee decided to utilize the RAND appropriateness method for panel judgment and decisions/consensus.

RESULTS: Seventy-three proposed statements were examined and discussed in three conferences held in Bologna, Pisa, and Rome. Each conference included two rounds of face-to-face modified Delphi technique. Anonymous panel voting followed each round. The panel did not reach an agreement and therefore did not adopt any recommendations for six statements. Weak/conditional recommendations were made for 2 statements, and strong recommendations were made for the remaining 65 statements. The statements were then recategorized and grouped to their current format. Internal and external peer-review processes took place before submission of the recommendations. Updates will occur at least every 4 years or whenever significant major changes in evidence appear.

CONCLUSIONS: This document reflects the overall results of the first consensus conference on “point-of-care” lung ultrasound. Statements were discussed and elaborated by experts who published the vast majority of papers on clinical use of lung ultrasound in the last 20 years. Recommendations were produced to guide implementation, development, and standardization of lung ultrasound in all relevant settings.

International evidence-based recommendations for point-of-care lung ultrasound
Intensive Care Med. 2012 Apr;38(4):577-91

All Updates, Guidelines, ICU, Resus, Trauma

Spinal imaging for the adult obtunded blunt trauma patient

1 Comment

‘You can’t clear the cervical spine until the patient wakes up!’ How often have you heard this said about a patient with severe traumatic brain injury who may not ‘wake up’ for weeks, if at all?
A controversial area, but many institutions now allow collar removal if a neck CT scan is normal. Does this rule out injury with 100% sensitivity? No – but it probably pushes the balance of risk towards removing the collar – an intervention with no evidence for benefit and plenty of reasons why it may be harmful to ventilated ICU patients. For example, clearing the cervical spine based on MDCT was associated with less delirium and less ventilator associated pneumonia, both of which have been associated with increased mortality in critically ill patients (this is referenced in the paper below).
The UK’s Intensive Care Society has had pragmatic guidelines along these lines since 2005, which can be found here. This month’s Intensive Care Medicine publishes an updated literature review providing some further support to this approach.


PURPOSE: Controversy exists over how to ‘clear’ (we mean enable the clinician to safely remove spinal precautions based on imaging and/or clinical examination) the spine of significant unstable injury among clinically unevaluable obtunded blunt trauma patients (OBTPs). This review provides a clinically relevant update of the available evidence since our last review and practice recommendations in 2004.

METHODS: Medline, Embase. Google Scholar, BestBETs, the trip database, BMJ clinical evidence and the Cochrane library were searched. Bibliographies of relevant studies were reviewed.

RESULTS: Plain radiography has low sensitivity for detecting unstable spinal injuries in OBTPs whereas multidetector-row computerised tomography (MDCT) approaches 100%. Magnetic resonance imaging (MRI) is inferior to MDCT for detecting bony injury but superior for detecting soft tissue injury with a sensitivity approaching 100%, although 40% of such injuries may be stable and ‘false positive’. For studies comparing MDCT with MRI for OBTPs; MRI following ‘normal’ CT may detect up to 7.5% missed injuries with an operative fixation in 0.29% and prolonged collar application in 4.3%. Increasing data is available on the complications associated with prolonged spinal immobilisation among a population where a minority have an actual injury.

CONCLUSIONS: Given the variability of screening performance it remains acceptable for clinicians to clear the spine of OBTPs using MDCT alone or MDCT followed by MRI, with implications to either approach. Ongoing research is needed and suggestions are made regarding this. It is essential clinicians and institutions audit their data to determine their likely screening performances in practice.

Clinical review: spinal imaging for the adult obtunded blunt trauma patient: update from 2004
Intensive Care Med. 2012 Mar 10. [Epub ahead of print]

All Updates, ICU, Resus

Awake video laryngoscopy

Leave a comment

A nice study reminds of us the option of awake video laryngoscopy as an alternative to fibreoptic instrumentation of the airway. The study was done on healthy volunteers so we have no idea of the applicability to the patient group we would be interested in using this on – those with an anticipated difficult airway sufficiently stable to allow tolerance and preparation for this procedure. The videolaryngoscopy was performed with patients upright in a face-to-face position, with the laryngoscope inserted in the inverted handle-down (“tomahawk”) position (this is the way I remove fishbones using a direct laryngoscope and Magill’s forceps).
Visualization was faster with video laryngoscopy, and grade of view was similar in both groups. Cormack Lehane grading was used to assess view, whereas the POGO score (percentage of glottic opening) might have provided a better means of assessing which view is superior. The study did not evaluate endotracheal tube insertion.
Local anaesthesia was provided with 5 ml nebulised 4% lidocaine and weight-based doses of 4% lidocaine were then sprayed into the nose and oropharynx through a mucosal atomisation device to a maximum of 9 mg/kg. Oxymetazoline was applied nasally for the flexible fibreoptic laryngoscopy.


Study objectives: We compare laryngoscopic quality and time to highest-grade view between a face-to-face approach with the GlideScope and traditional flexible fiber-optic laryngoscopy in awake, upright volunteers.

Methods: This was a prospective, randomized, crossover study in which we performed awake laryngoscopy under local anesthesia on 23 healthy volunteers, using both a GlideScope video laryngoscopy face-to-face technique with the blade held upside down and flexible fiber-optic laryngoscopy. Operator reports of Cormack-Lehane laryngoscopic views and video-reviewed time to highest-grade view, as well as number of attempts, were recorded.

Results: Ten women and 13 men participated. A grade II or better view was obtained with GlideScope video laryngoscopy in 22 of 23 (95.6%) participants and in 23 of 23 (100%) participants with flexible fiber-optic laryngoscopy (relative risk GlideScope video laryngoscopy versus flexible fiber-optic laryngoscopy 0.96; 95% confidence interval 0.88 to 1.04). Median time to highest-grade view for GlideScope video laryngoscopy was 16 seconds (interquartile range 9 to 34) versus 51 seconds (interquartile range 35 to 96) for flexible fiber-optic laryngoscopy. A distribution of interindividual differences demonstrated that GlideScope video laryngoscopy was, on average, 39 seconds faster than flexible fiber-optic laryngoscopy (95% confidence interval 0.2 to 76.9 seconds).

Conclusion: GlideScope video laryngoscopy can be used to obtain a Cormack-Lehane grade II or better view in the majority of awake, healthy volunteers when an upright face-to-face approach is used and was slightly faster than traditional flexible fiber-optic laryngoscopy. However, flexible fiber-optic laryngoscopy may be more reliable
at obtaining high-grade views of the larynx. Awake, face-to-face GlideScope use may offer an alternative approach to the difficulty airway, particularly among providers uncomfortable with flexible fiber-optic laryngoscopy.

GlideScope Versus Flexible Fiber Optic for Awake Upright Laryngoscopy
Ann Emerg Med. 2012 Mar;59(3):159-64

All Updates, PHARM, Resus, Trauma

Simple emergency haemorrhage control

Leave a comment

I had the honour of attending trauma rounds with leading South African trauma surgeons today at Groote Schuur Hospital in Cape Town. This was the first day of an intense week-long trauma education tour that I have organised for myself and three of my Sydney HEMS colleagues.
A technique for haemorrhage control in penetrating trauma is to place a Foley catheter (FC) in the wound and inflate the balloon to try to achieve compression of bleeding vascular structures. This has been life-saving in many cases and buys time to get the patient to a trauma or vascular surgeon or in some cases an interventional radiologist.

Catheter is knotted (black arrow) to occlude lumen. The wound is sutured around the catheter (white arrow).

First described by Gilroy and colleagues from Baragwanath Hospital in Johannesburg1, another, larger case series was subsequently reported by Cape Town’s Navsaria2, the Professor who conducted today’s trauma round I attended. In his paper he describes:


An 18- or 20-G FC was introduced into the bleeding neck wound. An attempt was made to follow the wound tract. The balloon was inflated with 5 ml of water or until resistance was felt. The FC was either clamped or knotted on itself to prevent bleeding through the lumen. The neck wound was sutured in two layers around the catheter. Continued bleeding around the catheter was an indication to proceed to surgery.

There were no deaths attributable to the use of FC balloon tamponade.
Prof. Navsaria describes the following algorithm for the subsequent investigation and management of these patients:

 I’ve been teaching this technique as an option in penetrating trauma for a few years but have never actually done it for real. Nice to finally see examples of its successful implementation by people who do this all the time. I’ve seen four patients with Foleys sticking out of their necks in the first 24 hours of being here.
1. Control of life-threatening haemorrhage from the neck: a new indication for balloon tamponade.
Injury. 1992;23(8):557-9
[EXPAND Click to read abstract]


We report the use of a Foley catheter, placed through the wound, to provide balloon tamponade of major bleeding from the neck and supraclavicular fossae. In 10 consecutive explorations for exsanguinating injury in these regions balloon tamponade was used eight times, and was judged to be fully effective in four patients, partly effective in one, and ineffective in three patients.

[/EXPAND]
2. Foley catheter balloon tamponade for life-threatening hemorrhage in penetrating neck trauma
World J Surg. 2006 Jul;30(7):1265-8
[EXPAND Click to read abstract]


BACKGROUND: Foley catheter (FC) balloon tamponade is a well-recognized technique employed to arrest hemorrhage from penetrating wounds. The aim of this study was to review our experience with this technique in penetrating neck wounds and to propose a management algorithm for patients with successful FC tamponade.

METHODS: A retrospective chart review (July 2004-June 2005 inclusive) was performed of patients identified from a prospectively collected penetrating neck injury computer database in whom FC balloon tamponade was used. The units’ policy for penetrating neck injuries is one of selective nonoperative management. All patients with successful FC tamponade underwent angiography. A venous injury was diagnosed if angiography was normal. Ancillary tests were performed as indicated. Removal of the FC was performed in the OR.

RESULTS: During the study period, 220 patients with penetrating neck injuries were admitted to our unit. Foley catheter balloon tamponade was used in 18 patients and was successful in 17 patients. Angiography was positive in 3 patients, all of whom underwent surgery. The FC was successfully removed in 13 patients at a mean of 72 (range 48-96) hours. One patient bled after removal of the catheter, mandating emergency surgery.

CONCLUSION: Foley catheter balloon tamponade remains a useful adjunct in the management of selective patients with penetrating, bleeding neck wounds.

[/EXPAND]