The College of Emergency Medicine (UK) has updated its guideline on ketamine sedation in children.
The summary is copied below Full text is available here Guideline for ketamine sedation of children in Emergency Departments
Before ketamine is used all other options should be fully considered, including analgesia, reassurance, distraction, entonox, intranasal diamorphine, etc.
The doses advised for analgesic sedation are designed to leave the patient capable of protecting their airway. There is a significant risk of a failure of sedation if the procedure is prolonged, and the clinician must recognise that the option of general anaesthesia may be preferred in these circumstances.
There is no evidence that complications are reduced if the child is fasted, however traditional anaesthetic practice favours a period of fasting prior to any sedative procedure. The fasting state of the child should be considered in relation to the urgency of the procedure, but recent food intake should not be considered as an absolute contraindication to ketamine use.
Ketamine should be only used by clinicians experienced in its use and capable of managing any complications, particularly airway obstruction, apnoea and laryngospasm. The doctor managing the ketamine sedation and airway should be suitably trained and experienced in ketamine use, with a full range of advanced airway skills.
At least three staff are required: a doctor to manage the sedation and airway, a clinician to perform the procedure and an experienced nurse to monitor and support the patient, family and clinical staff. Observations should be regularly taken and recorded.
The child should be managed in a high dependency or resuscitation area with immediate access to full resuscitation facilities. Monitoring should include ECG, blood pressure, respiration and pulse oximetry. Supplemental oxygen should be given and suction must be available.
After the procedure the child should recover in a quiet, observed and monitored area under the continuous observation of a trained member of staff. Recovery should be complete between 60 and 120 minutes, depending on the dose and route used.
There should be a documentation and audit system in place within a system of clinical governance.
The brave men and women of the military not only risk their lives for us – they also provide a wealth of trauma experience and publish interesting stuff.
This month’s Journal of Trauma contains a military trauma supplement. One of the articles describes the latest guidelines on Tactical Combat Casualty Care. These include:
tourniquet use
Quikclot Combat Gauze as the haemostatic agent which has replaced Quikclot powder and HemCon. This preference is based on field experience that powder and granular agents do not work well in wounds in which the bleeding vessel is at the bottom of a narrow wound tract or in windy environments. WoundStat was a backup agent but this has been removed because of concerns over possible embolic and thrombotic complications.
longer catheters for decompression of tension pneumothorax (Harcke et al. found a mean chest wall thickness of 5.36 cm in 100 autopsy computed tomography studies of military fatalities. Several of the cases in their autopsy series were noted to have had unsuccessful attempts at needle thoracostomy because the needle/catheter units used for the procedure were too short to reach the pleural space*.)
close open chest wounds immediately with an occlusive material, such as Vaseline gauze, plastic wrap, foil, or defibrillator pads
a rigid eye shield and antibiotics for penetrating eye injury
Tactical Combat Casualty Care: Update 2009
The Journal of TRAUMA 2010;69(1):S10-13 (no abstract available) Full text of guidelines in PDF at itstactical.com
*Harcke HT, Pearse LA, Levy AD, Getz JM, Robinson SR. Chest wall thickness in military personnel: implications for needle thoracentesis in tension pneumothorax. Mil Med. 2007;172:1260 –1263
The UK’s National Institute for Health and Clinical Excellence (NICE) has produced guidelines on alcohol-related physical complications, including alcohol withdrawal syndrome, Wernicke’s encephalopathy, acute and chronic pancreatitis, and acute alcoholic hepatitis.
The acute alcohol withdrawal section includes the following recommendations:
Offer drug treatment for the symptoms of acute alcohol withdrawal, as follows:
Consider offering a benzodiazepine or carbamazepine.
Clomethiazole may be offered as an alternative to a benzodiazepine or carbamazepine. However, it should be used with caution, in inpatient settings only and according to the summary of product characteristics.
Follow a symptom-triggered regimen for the drug treatment of acute alcohol withdrawal in people who are:
in hospital or
in other settings where 24-hour assessment and monitoring are available.
Treatment for delirium tremens or seizures
Offer oral lorazepam as first-line treatment for delirium tremens. If symptoms persist or oral medication is declined, give parenteral lorazepam, haloperidol or olanzapine.
For people with alcohol withdrawal seizures, consider offering a quick-acting benzodiazepine (such as lorazepam) to reduce the likelihood of further seizures.
If delirium tremens or seizures develop in a person during treatment for alcohol withdrawal, review their withdrawal drug treatment.
Do not offer phenytoin to treat alcohol withdrawal seizures.
Alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications Quick reference summary
A patient is resuscitated from an out-of-hospital cardiac arrest and is in your emergency department, comatose, with a pulse.
You know that therapeutic hypothermia is indicated and are happy with the protocol for that. You clinically assess for the underlying cause with history, examination, ECG, and other investigations as indicated.
Someone asks you if you want to give some magnesium “as per the guidelines”. As you are wondering what that’s for someone else asks you how long myocardial stunning lasts for and whether that’s the likely cause of hypotension now.
Luckily you avoid getting annoyed with all these reasonable questions by suddenly remembering that there are international recommendations for the management of ‘Post–Cardiac Arrest Syndrome’. You excuse yourself from the room on the pretext of going to the lavatory and quickly find a quiet area where you scan the following article for help: Post–Cardiac Arrest Syndrome Epidemiology, Pathophysiology, Treatment, and Prognostication
A Consensus Statement From the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council Circulation 2008;118;2452-2483 Full Text Article
Guidelines for preventing, detecting, and treating Clostridium Difficile infection from the Infectious Diseases Society of America have been published. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Infect Control Hosp Epidemiol 2010;31:431–455 Full Text
Lots of interesting and up to date information in this thick document from December 2009 Full text is available here 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update)
Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease have been published by a collaboration between a number of professional bodies including the American Heart Association. Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease Circulation. 2010 Apr 6;121(13):e266-369 – free Full Text as PDF HTML full text
Update 2013: since this post was written in 2010, new guidelines have been written entitled: “Management of bleeding and coagulopathy following major trauma: an updated European guideline” which are available here
The 2007 guidelines on management of bleeding in trauma have been updated in the light of new evidence and modern practice. The guideline group summarises their recommendations as:
We recommend that the time elapsed between injury and operation be minimised for patients in need of urgent surgical bleeding control. (Grade 1A).
We recommend adjunct tourniquet use to stop life-threatening bleeding from open extremity injuries in the pre-surgical setting. (Grade 1C).
We recommend that the physician clinically assess the extent of traumatic haemorrhage using a combination of mechanism of injury, patient physiology, anatomical injury pattern and the patient’s response to initial resuscitation. (Grade 1C).
We recommend initial normoventilation of trauma patients if there are no signs of imminent cerebral herniation. (Grade 1C).
We recommend that patients presenting with haemorrhagic shock and an identified source of bleeding undergo an immediate bleeding control procedure unless initial resuscitation measures are successful. (Grade 1B).
We recommend that patients presenting with haemorrhagic shock and an unidentified source of bleeding undergo immediate further investigation. (Grade 1B).
We recommend early imaging (FAST or CT) for the detection of free fluid in patients with suspected torso trauma. (Grade 1B).
We recommend that patients with significant free intraabdominal fluid and haemodynamic instability undergo urgent intervention. (Grade 1A).
We recommend further assessment using computed tomography for haemodynamically stable patients who are either suspected of having torso bleeding or have a high risk mechanism of injury. (Grade 1B).
We do not recommend the use of single haematocrit measurements as an isolated laboratory marker for bleeding. (Grade 1B).
We recommend both serum lactate and base deficit measurements as sensitive tests to estimate and monitor the extent of bleeding and shock. (Grade 1B).
We recommend that routine practice to detect post-traumatic coagulopathy include the measurement of international normalised ratio (INR), activated partial thromboplastin time (APTT), fibrinogen and platelets. INR and APTT alone should not be used to guide haemostatic therapy. (Grade 1C) We suggest that thrombelastometry also be performed to assist in characterising the coagulopathy and in guiding haemostatic therapy. (Grade 2C).
We recommend that patients with pelvic ring disruption in haemorrhagic shock undergo immediate pelvic ring closure and stabilisation. (Grade 1B).
We recommend that patients with ongoing haemodynamic instability despite adequate pelvic ring stabilisation receive early preperitoneal packing, angiographic embolisation and/or surgical bleeding control. (Grade 1B).
We recommend that early bleeding control of the abdomen be achieved using packing, direct surgical bleeding control and the use of local haemostatic procedures. In the exsanguinating patient, aortic cross-clamping may be employed as an adjunct. (Grade 1C).
We recommend that damage control surgery be employed in the severely injured patient presenting with deep hemorrhagic shock, signs of ongoing bleeding and coagulopathy. Additional factors that should trigger a damage control approach are hypothermia, acidosis, inaccessible major anatomic injury, a need for time-consuming procedures or concomitant major injury outside the abdomen. (Grade 1C).
We recommend the use of topical haemostatic agents in combination with other surgical measures or with packing for venous or moderate arterial bleeding associated with parenchymal injuries. (Grade 1B).
We recommend a target systolic blood pressure of 80-100 mmHg until major bleeding has been stopped in the initial phase following trauma without brain injury. (Grade 1C).
We recommend that crystalloids be applied initially to treat the bleeding trauma patient. (Grade 1B) We suggest that hypertonic solutions also be considered during initial treatment. (Grade 2B) We suggest that the addition of colloids be considered within the prescribed limits for each solution in haemodynamically unstable patients. (Grade 2C).
We recommend early application of measures to reduce heat loss and warm the hypothermic patient in order to achieve and maintain normothermia. (Grade 1C).
We recommend a target haemoglobin (Hb) of 7-9 g/dl. (Grade 1C).
We recommend that monitoring and measures to support coagulation be initiated as early as possible. (Grade 1C).
We recommend that ionised calcium levels be monitored during massive transfusion. (Grade 1C) We suggest that calcium chloride be administered during massive transfusion if ionised calcium levels are low or electrocardiographic changes suggest hypocalcaemia. (Grade 2C).
We recommend early treatment with thawed fresh frozen plasma in patients with massive bleeding. (Grade 1B) The initial recommended dose is 10-15 ml/kg. Further doses will depend on coagulation monitoring and the amount of other blood products administered. (Grade 1C).
We recommend that platelets be administered to maintain a platelet count above 50 × 109/l. (Grade 1C) We suggest maintenance of a platelet count above 100 × 109/l in patients with multiple trauma who are severely bleeding or have traumatic brain injury. (Grade 2C) We suggest an initial dose of 4-8 platelet concentrates or one aphaeresis pack. (Grade 2C).
We recommend treatment with fibrinogen concentrate or cryoprecipitate if significant bleeding is accompanied by thrombelastometric signs of a functional fibrinogen deficit or a plasma fibrinogen level of less than 1.5-2.0 g/l. (Grade 1C) We suggest an initial fibrinogen concentrate dose of 3- 4 g or 50 mg/kg of cryoprecipitate, which is approximately equivalent to 15-20 units in a 70 kg adult. Repeat doses may be guided by thrombelastometric monitoring and laboratory assessment of fibrinogen levels. (Grade 2C).
We suggest that antifibrinolytic agents be considered in the bleeding trauma patient. (Grade 2C) We recommend monitoring of fibrinolysis in all patients and administration of antifibrinolytic agents in patients with established hyperfibrinolysis. (Grade 1B) Suggested dosages are tranexamic acid 10-15 mg/kg followed by an infusion of 1-5 mg/kg per hour or ε-aminocaproic acid 100-150 mg/kg followed by 15 mg/kg/h. Antifibrinolytic therapy should be guided by thrombelastometric monitoring if possible and stopped once bleeding has been adequately controlled. (Grade 2C).
We suggest that the use of recombinant recombinant activated coagulation factor VII (rFVIIa) be considered if major bleeding in blunt trauma persists despite standard attempts to control bleeding and best-practice use of blood components. (Grade 2C).
We recommend the use of prothrombin complex concentrate for the emergency reversal of vitamin K-dependent oral anticoagulants. (Grade 1B).
We do not suggest that desmopressin (DDAVP) be used routinely in the bleeding trauma patient. (Grade 2C) We suggest that desmopressin be considered in refractory microvascular bleeding if the patient has been treated with platelet-inhibiting drugs such as aspirin. (Grade 2C).
We do not recommend the use of antithrombin concentrates in the treatment of the bleeding trauma patient. (Grade 1C).
As soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin therapy have been offered, formally assess individual risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]).
Consider intravenous eptifibatide or tirofiban as part of the early management for patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission.
Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first admission to hospital to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%) if they have no contraindications to angiography (such as active bleeding or comorbidity). Perform angiography as soon as possible for patients who are clinically unstable or at high ischaemic risk.
When the role of revascularisation or the revascularisation strategy is unclear, resolve this by discussion involving an interventional cardiologist, cardiac surgeon and other healthcare professionals relevant to the needs of the patient. Discuss the choice of the revascularisation strategy with the patient.
To detect and quantify inducible ischaemia, consider ischaemia testing before discharge for patients whose condition has been managed conservatively and who have not had coronary angiography.
Before discharge offer patients advice and information about:
– their diagnosis and arrangements for follow-up
– cardiac rehabilitation
– management of cardiovascular risk factors and drug therapy for secondary prevention
– lifestyle changes
One of the most potentially confusing areas is the choice of antithrombin therapy. Whereas the low molecular weight heparin enoxaparin is currently widely used, the guideline recommends the following:
The guideline summary is here and the full guideline is here
One of the key changes in international resuscitation guidelines between the 2000 and 2005 has been to minimise potentially deleterious hands-off time, so that CPR is interrupted less for pulse checks and DC shocks.
These two approaches have been compared in a randomised controlled trial of 845 patients in France requiring out of hospital defibrillation, in which the control group were shocked using AEDs with prompts based on the 2000 guidelines (3 stacked shocks before CPR resumed, and pulse checks done), and the intervention group were shocked using devices that prompted according to the 2005 guidelines, in which there were fewer and shorter intervals for which the AED required the rescuer to stay clear of the patient (single shocks, no pulse checks).
There was no difference in the primary endpoint of survival to hospital admission (43.2% versus 42.7%; p=0.87), or in survival to hospital discharge (13.3% versus 10.6%; p=0.19). The study was not powered to assess one year survival. In the authors’ words: “our randomized controlled trial now provides more definitive evidence that this combination of Guidelines 2005 CPR protocol changes does not measurably improve outcome. Although the protocol changes accomplish the desired effect of increasing chest compressions, they may also cause other effects, such as earlier refibrillation and more time spent in VF, with as yet unknown consequences.”
Interestingly the Cardio-pump was used in this study to provide chest compressions, which is an active compression-decompression device, potentially limiting the generalisability of the findings to manual compression-only CPR situations. Potential bias was also introduced by the exclusion of patients in whom consent from relatives was not obtained. Nevertheless it’s good to see such rigorous clinical research applied to this area. DEFI 2005. A Randomized Controlled Trial of the Effect of Automated External Defibrillator Cardiopulmonary Resuscitation Protocol on Outcome From Out-of-Hospital Cardiac Arrest Circulation. 2010;121:1614-1622
