The Eastern Association for the Surgery of Trauma has published guidelines on the nonoperative management of penetrating abdominal trauma.
RECOMMENDATIONS
Patients who are hemodynamically unstable or who have diffuse abdominal tenderness should be taken emergently for laparotomy (level 1).
Patients who are hemodynamically stable with an unreliable clinical examination (i.e., brain injury, spinal cord injury, intoxication, or need for sedation or anesthesia) should have further diagnostic investigation performed for intraperitoneal injury or undergo exploratory laparotomy (level 1).
A routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds (SWs) without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centers with surgical expertise (level 2).
A routine laparotomy is not indicated in hemodynamically stable patients with abdominal gunshot wounds (GSWs) if the wounds are tangential and there are no peritoneal signs (level 2).
Serial physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen, if performed by experienced clinicians and preferably by the same team (level 2).
In patients selected for initial nonoperative management, abdominopelvic CT should be strongly considered as a diagnostic tool to facilitate initial management decisions (level 2).
Patients with penetrating injury isolated to the right upper quadrant of the abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination, and minimal to no abdominal tenderness (level 3).
The majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness (level 3).
Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration (level 2).
Practice Management Guidelines for Selective Nonoperative Management of Penetrating Abdominal Trauma J Trauma. 2010 Mar;68(3):721-733
The World Health Organisation has published updated guidelines on drug treatment of Influenza A(H1N1)2009 and other influenza viruses. Their recommendations are summarised in this table: Full text of the guidelines is available here WHO Guidelines for Pharmacological Management of Pandemic Influenza A(H1N1) 2009 and other Influenza Viruses WHO website
A multinational European working group produced the following evidence-based recommendations for preventing acute kidney injury (AKI). Read the full guideline before criticising – some are just suggestions, some recommendations; I have not included the strength of recommendation or grade of evidence in my summary below. Volume expansion
Controlled fluid resuscitation in true or suspected volume depletion
There is little evidence-based support for the preferential use of crystalloids or colloids
Avoid 10% HES 250/0.5 as well as higher-molecular-weight preparations of HES and dextrans in sepsis
Prophylactic volume expansion by isotonic crystalloids in patients at risk of contrast nephropathy. Use isotonic sodium bicarbonate solution, especially for emergency procedures
Prophylactic volume expansion with crystalloids to prevent AKI by certain drugs (amphotericin B, antivirals including foscarnet, cidofovir, and adefovir, as well as drugs causing crystal nephropathy such as indinavir, acyclovir, and sulfadiazine)
Diuretics
Do not use loop diuretics to prevent or ameliorate AKI
Vasopressors and inotropes
Maintain mean arterial pressure (MAP) at least 60–65 mmHg, however, target pressure should be individualized where possible, especially if knowledge of the premorbid blood pressure is available.
In case of vasoplegic hypotension as a result of sepsis or SIRS use either norepinephrine or dopamine (along with fluid resuscitation) as the first-choice vasopressor agent to correct hypotension.
Do not use low-dose dopamine for protection against AKI.
Vasodilators
Use vasodilators for renal protection when volume status is corrected and the patient is closely hemodynamically monitored with particular regard to the development of hypotension.
Prophylactic use of fenoldopam, if available, in cardiovascular surgery patients at risk of AKI. Do not use fenoldopam for prophylaxis of contrast nephropathy.
Use theophylline to minimize risk of contrast nephropathy, especially in acute interventions when hydration is not feasible.
Do not use natriuretic peptides as protective agents against AKI in critically ill patients, while its use may be considered during cardiovascular surgery.
Hormonal manipulation and activated protein C
Avoid routine use of tight glycemic control in the general ICU population. Use “Normal for age’’ glycemic control with intravenous (IV) insulin therapy to prevent AKI in surgical ICU patients, on condition that it can be done adequately and safely applying a local protocol which has proven efficacy in minimizing rate of hypoglycemia.
Do not use thyroxine, erythropoietin, activated protein C or steroids routinely to prevent AKI.
Metabolic interventions
All patients at risk of AKI should have adequate nutritional support, preferably through the enteral route
Do not use N-acetylcysteine as prophylaxis against contrast induced nephropathy or other forms AKI in critically ill patients because of conflicting results, possible adverse reactions, and better alternatives.
Do not routinely use selenium to protect against renal injury.
Extracorporeal therapies
Use periprocedural continuous veno-venous hemofiltration (CVVH) in an ICU environment to limit contrast nephropathy after coronary interventions in high-risk patients with advanced chronic renal insufficiency
Prevention of acute kidney injury and protection of renal function in the intensive care unit
Expert opinion of the working group for nephrology, ESICM Intensive Care Med. 2010 Mar;36(3):392-411
International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding have been published. Here is a summary of the recommendations; a link to the full text document is at the bottom of this page.
Prognostic scales are recommended for early stratification of patients into low- and high-risk categories for rebleeding and mortality.
Blood transfusions should be administered to a patient with a hemoglobin level of 70 g/L or less.
In patients receiving anticoagulants, correction of coagulopathy is recommended but should not delay endoscopy.
Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield.
Selected patients with acute ulcer bleeding who are at low risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy.
Preendoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay endoscopy (the observed lesion downstaging attributable to PPI therapy before endoscopy may be even more beneficial in situations in which early endoscopy may be delayed or when available endoscopic expertise may be suboptimal).
Early endoscopy (within 24 hours of presentation) is recommended for most patients with acute upper gastrointestinal bleeding.
A finding of a clot in an ulcer bed warrants targeted irrigation in an attempt at dislodgement, with appropriate treatment of the underlying lesion.
The role of endoscopic therapy for ulcers with adherent clots is controversial. Endoscopic therapy may be considered, although intensive PPI therapy alone may be sufficient.
Epinephrine injection alone provides suboptimal efficacy and should be used in combination with another method.
Clips, thermocoagulation, or sclerosant injection should be used in patients with high-risk lesions, alone or in combination with epinephrine injection
Routine second-look endoscopy is not recommended.
An intravenous bolus followed by continuous-infusion PPI therapy should be used to decrease rebleeding and mortality in patients with high-risk stigmata who have undergone successful endoscopic therapy.
Patients should be discharged with a prescription for a single daily-dose oral PPI for a duration as dictated by the underlying etiology.
Most patients who have undergone endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours thereafter.
Where available, percutaneous embolization can be considered as an alternative to surgery for patients for whom endoscopic therapy has failed.
Patients with bleeding peptic ulcers should be tested for H. pylori and receive eradication therapy if it is present, with confirmation of eradication.
Negative H. pylori diagnostic tests obtained in the acute setting should be repeated
In patients with previous ulcer bleeding who require an NSAID, it should be recognized that treatment with a traditional NSAID plus PPI or a cyclooxygenase-2 (COX-2) inhibitor alone is still associated with a clinically important risk for recurrent ulcer bleeding.
In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk for recurrent bleeding from that of COX-2 inhibitors alone.
In patients who receive low-dose ASA and develop acute ulcer bleeding, ASA therapy should be restarted as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding.
In patients with previous ulcer bleeding who require cardiovascular prophylaxis, it should be recognized that clopidogrel alone has a higher risk for rebleeding than ASA combined with a PPI.
International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding Ann Intern Med. 2010 Jan 19;152(2):101-13 (Full Text)
The UK National Health Service’s National Patient Safety Agency published a report entitled Minimising risks of suprapubic catheter insertion ‘, reporting three incidents of death and seven causing severe harm from suprapubic catheter placement between September 2005 and June 2009, nine of which involved bowel perforation. There were also 249 other incidents reported relating to suprapubic catheters causing lesser degrees of harm. They issue the following recommendations under the title ‘For IMMEDIATE ACTION by medical directors in acute and community hospitals (NHS and Independent Sector). Deadline for ACTION COMPLETE is 29 April 2010’:
Information about the risk of this procedure is immediately distributed to all staff who may insert or request the insertion of a suprapubic catheter.
A named lead for training is identified and a training plan developed.
Local guidelines/policies are reviewed or developed in the light of this report and forthcoming British Association of Urological Surgeons (BAUS) standards.
Ultrasound is used wherever possible to visualise the bladder and guide the insertion of the catheter. There should be ultrasound machines available in the relevant areas and staff trained in their use.
Local incident data relating to suprapubic catheterisation is reviewed, appropriate action is taken and staff are encouraged to report further incidents and to take part in the BAUS national clinical audit.
The UK National Health Service’s National Patient Safety Agency published a report entitled ‘Risks of chest drain insertion’, reporting 12 deaths and 15 cases of serious harm related to chest drain insertion over a three year period. They issue the following recommendations under the title ‘For IMMEDIATE ACTION by the NHS and independent sector – Deadline for ACTION COMPLETE is 17 November 2008’:
Clinical governance leads in local organisations should audit current practice and develop local policies to ensure:
Chest drains are only inserted by staff with relevant competencies and adequate supervision
Ultrasound guidance is strongly advised when inserting a drain for fluid
Clinical guidelines are followed and staff made aware of the risks
Identify a lead for training of all staff involved in chest drain insertion
Written evidence of consent is obtained from patients before the procedure, wherever possible
Local incident data relating to chest drains is reviewed and staff encouraged to report further incidents
I gave some hydroxycobalamin today for suspected cyanide poisoning. This reminded me to take another look at the College of Emergency Medicine’s Guideline on Antidote Availability
Two major British surgical associations, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the British Orthopaedic Association (BOA) have worked together to create updated multi-disciplinary standards for the treatment of open fractures of the lower limb
The recommendations are summarised as: Standards for Practice Audit: 1. Intravenous antibiotics are administered as soon as possible, ideally within 3 hours of injury: Co-amoxiclav (1.2g) or Cefuroxime (1.5g) 8 hourly and are continued until wound debridement. Clindamycin 600mg, 6 hourly if penicillin allergy 2. The vascular and neurological status of the limb is assessed systematically and repeated at intervals, particularly after reduction of fractures or the application of splints 3. Vascular impairment requires immediate surgery and restoration of the circulation using shunts, ideally within 3-4 hours, with a maximum acceptable delay of 6 hours of warm ischaemia 4. Compartment syndrome also requires immediate surgery, with 4 compartment decompression via 2 incisions 5. Urgent surgery is also needed in some multiply injured patients with open fractures or if the wound is heavily contaminated by marine, agricultural or sewage matter. 6. A combined plan for the management of both the soft tissues and bone is formulated by the plastic and orthopaedic surgical teams and clearly documented 7. The wound is handled only to remove gross contamination and to allow photography, then covered in saline-soaked gauze and an impermeable film to prevent desiccation 8. The limb, including the knee and ankle, is splinted 9. Centres that cannot provide combined plastic and orthopaedic surgical care for severe open tibial fractures have protocols in place for the early transfer of the patient to an appropriate specialist centre 10. The primary surgical treatment (wound excision and fracture stabilisation) of severe open tibial fractures only takes place in a non-specialist centre if the patient cannot be transferred safely 11. The wound, soft tissue and bone excision (debridement) is performed by senior plastic and orthopaedic surgeons working together on scheduled trauma operating lists within normal working hours and within 24 hours of the injury unless there is marine, agricultural or sewage contamination. The 6 hour rule does not apply for solitary open fractures. Co-amoxiclav (1.2g) and Gentamicin (1.5mg/kg) are administered at wound excision and continued for 72 hours or definitive wound closure, which ever is sooner 12. If definitive skeletal and soft tissue reconstruction is not to be undertaken in a single stage, then vacuum foam dressing or an antibiotic bead pouch is applied until definitive surgery. 13. Definitive skeletal stabilisation and wound cover are achieved within 72hours and should not exceed 7 days. 14. Vacuum foam dressings are not used for definitive wound management in open fractures. 15. The wound in open tibial fractures in children is treated in the same way as adults
The full guidelines are available here
A young patient presents with pulmonary embolism. Should you send blood to the lab for a thrombophilia screen? What if she is pregnant? How about a patient with an upper limb DVT, or a child with a stroke?
The answers, in order, are: not necessarily; possibly – trials are ongoing; it depends; and ‘not indicated’. At least according to the The British Committee for Standards in Haematology (BCSH) in their 2009 document ‘Clinical guidelines for testing for heritable thrombophilia’
The document highlights the lack of evidence that the results of thrombophilia screening influence type or duration of management, or predict likelihood of recurrence in unselected patients with symptomatic venous thrombosis. Furthermore, the results of thrombophilia tests are frequently misinterpreted. Many more situations and conditions are covered in the full document. ‘Clinical guidelines for testing for heritable thrombophilia’ Other The British Committee for Standards in Haematology guidelines
Radiographs of 49 spontaneous pneumothoraces were studied, showing that in the expiratory films, pneumothoraces were on average 9% larger. When applying British Thoracic Society or American College of Chest Physicians guidelines, this difference would have led to a different management strategy. What is the difference in size of spontaneous pneumothorax between inspiratory and expiratory x-rays? Emerg Med J. 2009 Dec;26(12):861-3
