Should prophylactic antibiotics be given to burns patients? A systematic review of 17 trials concludes they may reduce all-cause mortality when given for 4-14 days after admission; there was a reduction in pneumonia with systemic prophylaxis and a reduction in wound infections with perioperative prophylaxis. However the overall methodological quality of the trials was poor and in three trials, resistance to the antibiotic used for prophylaxis significantly increased. The authors consequently do not recommend prophylaxis for patients with severe burns other than perioperatively.
Take home message: not needed as part of critical care resuscitation
Prophylactic antibiotics for burns patients: systematic review and meta-analysis
BMJ. 2010 Feb 15;340:c241
Category Archives: All Updates
Battlefield resuscitation
An excellent review of the current British military practice to prevent and treat the acute coagulopathy of trauma shock (ACoTS) describes pathophysiology and treatment options and offers an algorithm for management. Key components of the system (when indicated according to their algorithm) outlined include:
- Pre-hospital damage control shock resuscitation by a forward medical team, consisting of RSI with reduced dose thio or ketamine with suxamethonium or rocuronium, large bore sublclavian access, and early use of warmed blood products
- 1:1:1 packed red cells, fresh frozen plasma, and platelets,
- Cryoprecipitate
- Tranexamic acid
- Recombinant activated factor VII
- Permissive hypotension aiming for a systolic BP of 90 mmHg, using blood products and avoiding vasopressors according to a ‘flow rather than pressure’ philosophy
- Avoiding hypothermia by giving warmed blood products and employing active patient warming methods
- Buffering acidosis using Tris-hydroxymethyl aminomethane (THAM), which may be superior to bicarbonate by not affecting minute ventilation or coagulation, and maintaining its efficacy in hypothermic conditions
- Minimising hypoperfusion with an anaesthetic strategy that provides effective analgesia and vasodilation, using high dose fentanyl and a low concentration volatile agent
- Using fresh whole blood for resistant coagulopathy
Battlefield resuscitation
Curr Opin Crit Care. 2009 Dec;15(6):527-35
Sorting ABCD issues pre-hospital
Prospectively collected data on 727 major trauma patients from a Portugese trauma centre registry enabled the comparison of mortality between three groups of patients with a priori defined life threatening ‘ABCD’ problems: those whose ABCD issues were treated in the field by a pre-hospital emergency physician, those that were treated at another hospital prior to trauma centre transfer, and those whose ABCD issues were first treated on arrival at the trauma centre. The study population included mixed urban and rural trauma.
Patients from the pre-hospital and first hospital groups had 20% and 27% mortality respectively, compared to 38% among those whose life-threatening events were corrected only at the trauma centre.
Patients whose life- threatening events were treated in the pre-hospital environment had lower mortality but at the same time were younger and less severely injured, so a multivariate logistic regression was performed to adjust the odds of death to patient characteristics and trauma severity as well as time from accident to trauma centre. Logistic regression showed that increases in mortality were associated with female gender and older age, penetrating type of trauma, higher anatomic severity (ISS), higher physiological severity (RTS) and having the life-threatening events corrected only at the trauma centre. Logistic regression showed that patients whose life-threatening events were corrected only at the trauma centre had an odds of death 3.3 times greater than those from the pre-hospital group, adjusted for patient and trauma characteristics and time to trauma centre.
Correcting life-threatening events pre- trauma centre (pre-hospital and first hospital) increased the total time from the accident to trauma centre, but long pre-hospital times were not associated with worse outcome.
The importance of pre-trauma centre treatment of life-threatening events on the
mortality of patients transferred with severe trauma
Resuscitation. 2010 Apr;81(4):440-5
Normal ECG still doesn't rule out PE
ECGs from a prospective study of patients in the ED with suspected pulmonary embolism were studied to identify the relative frequency of ECG features of pulmonary hypertension. For a patient to be eligible for enrollment, a physician was required to have sufficient suspicion for pulmonary embolism to order objective diagnostic testing in the ED. Such testing included D-dimer measurement, computed tomography pulmonary angiography, ventilation/perfusion scanning, or venous ultrasonography.
ECGs were done in 6049 patients, 354 (5.9%) of whom were diagnosed with pulmonary embolism. The frequency, positive likelihood ratio (LR+) and 95% confidence interval (CI) of each predictor were as follows:
- S1Q3T3 8.5% with pulmonary embolism versus 3.3% without pulmonary embolism (LR+ 3.7; 95% CI 2.5 to 5.4)
- nonsinus rhythm, 23.5% versus 16.6% (LR+ 1.4; 95% CI 1.2 to 1.7)
- inverted T waves in V1 to V2, 14.4% versus 8.1% (LR+ 1.8; 95% CI 1.3 to 2.3)
- inversion in V1 to V3, 10.5% versus 4.0% (LR+ 2.6; 95% CI 1.9 to 3.6)
- inversion in V1 to V4, 7.3% versus 2.0% (LR+ 3.7; 95% CI 2.4 to 5.5)
- incomplete right bundle branch block, 4.8% versus 2.8% (LR+ 1.7; 95% CI 1.0 to 2.7)
- tachycardia (pulse rate>100 beats/min), 28.8% versus 15.7% (LR+ 1.8; 95% CI 1.5 to 2.2).
The authors point out that the study may be subject to reporting bias or incorporation bias because those patients with ECG abnormalities may have then been more likely to undergo further evaluation for PE.
Overall, they summarise that the main findings were that the S1Q3T3 pattern and precordial T-wave inversions had the highest LR(+) values with lower-limit 95% CIs above unity, whether or not the patient had preexisting cardiopulmonary disease, but emphasise that the sensitivities of each of these findings were low, and clinicians should not decrease their suspicion for pulmonary embolism according to their absence.
Likelihood ratios and specificities were similar when patients with previous cardiopulmonary disease were excluded from analysis.
12-Lead ECG Findings of Pulmonary Hypertension Occur More Frequently in Emergency Department Patients With Pulmonary Embolism Than in Patients Without Pulmonary Embolism
Ann Emerg Med. 2010 Apr;55(4):331-5
Atypical chest pain renders AMI more likely
A prospective study of 796 ED patients with suspected cardiac chest pain assessed the value of individual historical and examination findings for diagnosing acute myocardial infarction (AMI) and the occurrence of adverse events (death, AMI or urgent revascularization) within 6 months. AMI was diagnosed in 148 (18.6%) of the 796 patients recruited.
The results may surprise some physicians:
Sweating observed by the ED physician was the strongest predictor of AMI (adjusted OR 5.18, 95% CI 3.02–8.86).
Reported vomiting was also a fairly strong predictor of AMI (adjusted OR 3.50, 1.81–6.77).
Pain located in the left anterior chest was found to be the strongest negative predictor of AMI (adjusted OR 0.25, 0.14–0.46).
Patients who described the pain as being the same as previous myocardial ischaemia were significantly less likely to be having AMI!
Following adjustment for age, sex and ECG changes, the following characteristics made AMI more likely (adjusted odds ratio, 95% confidence intervals):
- pain radiating to the right arm (2.23, 1.24-4.00)
- pain radiating to both arms (2.69, 1.36-5.36)
- vomiting reported (3.50, 1.81-6.77), central chest pain (3.29, 1.94-5.61)
- sweating observed by physician (5.18, 3.02-8.86)
Pain in the left anterior chest made AMI significantly less likely (0.25, 0.14-0.46)
The presence of rest pain (0.67, 0.41-1.10) or pain radiating to the left arm (1.36, 0.89-2.09) did not significantly alter the probability of AMI.
Compare these results with the American Heart Association guidelines which state that “chest or left arm pain or discomfort as the chief symptom reproducing prior documented angina” is associated with a high likelihood of ACS, or the European Society of Cardiology guidelines which state that “the typical clinical presentation of NSTE-ACS is retrosternal pressure or heaviness radiating to the left arm, neck or jaw”, which the authors of this study point out are statements made based on expert opinion for which references are not given.
The authors summarise with a powerful message: ‘Several ‘atypical’ symptoms actually render AMI more likely, whereas many ‘typical’ symptoms that are often considered to identify high-risk populations have no diagnostic value.’
The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes
Resuscitation. 2010 Mar;81(3):281-6
Spine immobilisation in penetrating trauma
In a retrospective study of 45,284 penetrating trauma patients, unadjusted mortality was twice as high in the 4.3% of patients who underwent spine immobilisation, compared with those who were not immobilised.
An accompanying editorial comments: ‘The number needed to treat with spine immobilization to potentially benefit one penetrating trauma patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.‘
Spine immobilization in penetrating trauma: more harm than good?
J Trauma. 2010 Jan;68(1):115-20
A human suction unit for choking
A case is described of a 12 month old who completely obstructed her airway from an inhaled plastic ketchup container. As she did not improve with backslaps or chest thrusts her father, a physician, suctioned her airway using his own mouth (intermittently spitting out secretions) until the obstruction was relieved and the object removed. Something to think about if you’re at the end of your own child’s choking algorithm and you have no airway equipment with you.
Maneuver for the recovery of a foreign body causing a complete airway obstruction: illustrative case.
Pediatr Emerg Care. 2010 Jan;26(1):39-40
Win with the chin
Medical students and junior doctors were successfully taught correct airway management positioning for intubation on a manikin when told to position the manikin in the best position to win a running race, where the chin wins the race. (The so-called ‘win with the chin’ position). This was superior to the traditional ‘sniff the morning air’ position.
Teaching airway management to novices: a simulator manikin study comparing the ‘sniffing position’ and ‘win with the chin’ analogies
Br J Anaesth. 2010 Apr;104(4):496-500
Extreme white cell counts
Febrile children aged three months to three years with a white cell count over 25000/mm3 and fever were compared with controls whose leucoytosis was less extreme (15000-24999). The ‘extreme’ group had serious bacterial infection (SBI) in 39% compared with 15.4% controls. Pneumonia was the commonest SBI.
The authors conclude that in febrile children aged 3–36 months, the presence of extreme leucocytosis is associated with a 39% risk of having SBIs. The increased risk for SBI is mainly due to a higher risk for pneumonia. I conclude that leucocytosis is like fever: the cause may be benign, but the higher the number the less likely that is, even though the majority still won’t have SBI.
Extreme leucocytosis and the risk of serious bacterial infections in febrile children
Arch Dis Child. 2010 Mar;95(3):209-12
NIV in chest trauma
ICU patients with thoracic trauma who had no other indication for intubation than marked hypoxaemia (pO2/FiO2 < 200 mmHg) were randomised to intubation vs non-invasive ventilation (NIV). Analgesia was via epidural bupivacaine / fentanyl or iv remifentanil. Numbers are small (total 50 patients) - partly because the trial was stopped early due to large difference in the outcome of tracheal intubation between the two groups favouring NIV. Length of hospital stay was significantly shorter in the NIV group but there was no survival difference.
Noninvasive ventilation reduces intubation in chest trauma-related hypoxemia: a randomized clinical trial
Chest. 2010 Jan;137(1):74-80