Category Archives: Resus

Life-saving medicine

Acute Med, All Updates, ICU, Kids, PHARM, Resus

Don't ignore the diastolic

Leave a comment

Most of us are pretty good at spotting hypotension and activating help or initiating therapy.
But ‘hypotension’ in many practitioners’ minds refers to a low systolic blood pressure. Who pays serious attention to the diastolic blood pressure? A low diastolic in a sick patient to me is a warning sign that their mean arterial pressure (MAP) is – or will be – low. After all, we spend about twice as long in diastole as in systole, so the diastolic pressure contributes more to the MAP than does the systolic.
A recent study showed that a low diastolic BP was one of several factors predictive of cardiac arrest on hospital wards: the most accurate predictors were maximum respiratory rate, heart rate, pulse pressure index, and minimum diastolic BP. These factors were more predictive than some of the variables included in the commonly used Early Warning Scores that trigger an emergency review.
The ‘pulse pressure index’ examined in the study is the pulse pressure divided by the systolic blood pressure (ie. [SBP-DBP]/SBP) which of course will be higher with lower diastolic blood pressures.
Importantly, the authors point out:


“In addition, our findings suggest that for many patients there is ample time prior to cardiac arrest to provide potentially life-saving interventions.”

…suggesting that there is still room for improvement in the identification and management of patients at risk for cardiac arrest, as the NCEPOD report ‘Cardiac Arrest Procedures: Time to Intervene?’ also showed.
They also recommend:


“…although systolic BP is commonly used in rapid response team activation criteria, incorporation of pulse pressure, pulse pressure index, or diastolic BP in place of systolic BP into the predictive model may be superior.”

Perhaps this may remind all of us to keep an eye on the diastolic as well as systolic BP when patients first present to us, and to include the importance of recognising diastolic hypotension in the teaching we provide our medical, paramedical and nursing students.

Predicting Cardiac Arrest on the Wards: A Nested Case-Control Study
Chest. 2012 May;141(5):1170-6 Free Full Text here
[EXPAND Click to read abstract]


Background: Current rapid response team activation criteria were not statistically derived using ward vital signs, and the best vital sign predictors of cardiac arrest (CA) have not been determined. In addition, it is unknown when vital signs begin to accurately detect this event prior to CA.

Methods: We conducted a nested case-control study of 88 patients experiencing CA on the wards of a university hospital between November 2008 and January 2011, matched 1:4 to 352 control subjects residing on the same ward at the same time as the case CA. Vital signs and Modified Early Warning Scores (MEWS) were compared on admission and during the 48 h preceding CA.

Results: Case patients were older (64 ± 16 years vs 58 ± 18 years; P = .002) and more likely to have had a prior ICU admission than control subjects (41% vs 24%; P = .001), but had similar admission MEWS (2.2 ± 1.3 vs 2.0 ± 1.3; P = .28). In the 48 h preceding CA, maximum MEWS was the best predictor (area under the receiver operating characteristic curve [AUC] 0.77; 95% CI, 0.71-0.82), followed by maximum respiratory rate (AUC 0.72; 95% CI, 0.65-0.78), maximum heart rate (AUC 0.68; 95% CI, 0.61-0.74), maximum pulse pressure index (AUC 0.61; 95% CI, 0.54-0.68), and minimum diastolic BP (AUC 0.60; 95% CI, 0.53-0.67). By 48 h prior to CA, the MEWS was higher in cases (P = .005), with increasing disparity leading up to the event.

Conclusions: The MEWS was significantly different between patients experiencing CA and control patients by 48 h prior to the event, but includes poor predictors of CA such as temperature and omits significant predictors such as diastolic BP and pulse pressure index.

[/EXPAND]

Acute Med, All Updates, ICU, PHARM, Resus

COPD and heart disease interactions

Leave a comment

Ischaemic heart disease (IHD) and chronic obstructive pulmonary disease (COPD) often affect the same patient; in fact, more than one-third of patients with angiography-proven IHD also have COPD on spirometry(1).
A recent study suggests COPD exacerbations in patients with IHD were associated with longer (5 more days) recovery times and suffered more severe breathlessness between exacerbations(2).
An accompanying editorial highlights some important points:

  • Patients admitted with COPD exacerbations are more susceptible to myocardial infarction during the admission.
  • Infective COPD exacerbations may contribute to heart failure through systemic inflammation, autonomic activation, and increased fluid in the lung. Lung infection can increase ventilation/perfusion mismatch and increased work of breathing, further straining the heart.
  • Heart failure can be very difficult to diagnose during a COPD exacerbation because cough, dyspnoea and wheeze are common to both disorders. Physical examination may not be discriminatory, and chest radiography is insensitive to milder degrees of heart failure.

The authors recommed a high index of suspicion combined with consideration of biomarkers (BNP or pro-BNP) and imaging such as echocardiography or even nuclear medicine scans, cardiac MRI, and cardiac catheterisation.
So, next time you’re managing a COPD exacerbation, ask yourself:

  • Could there be concomitant heart failure contributing to symptoms?
  • If not, is the patient at risk of cardiac events during this admission, for which we need to be vigilant?
  • Do I need to consider additional laboratory (BNP) or imaging (echo) investigations? Remember BNP may be elevated in pneumonia and other non-cardiac critical illness, although a normal BNP rules out heart failure.
  • Should I add empiric anti-failure therapy to the acute treatment regimen?
  • If there is combined COPD exacerbation and heart failure, are there any conflicting priorities in therapy (eg. the pros and cons of beta-agonists, anticholinergics, and steroids)?

1. The complex relationship between ischemic heart disease and COPD exacerbations
Chest. 2012 Apr;141(4):837-8
2. The impact of ischemic heart disease on symptoms, health status, and exacerbations in patients with COPD
Chest. 2012 Apr;141(4):851-7
[EXPAND Click to read abstract]


BACKGROUND: Comorbid ischemic heart disease (IHD) is a common and important cause of morbidity and mortality in patients with COPD. The impact of IHD on COPD in terms of a patient’s health status, exercise capacity, and symptoms is not well understood.

METHODS: We analyzed stable-state data of 386 patients from the London COPD cohort between 1995 and 2009 and prospectively collected exacerbation data in those who had completed symptom diaries for ≥ 1 year.

RESULTS: Sixty-four patients (16.6%) with IHD had significantly worse health status as measured by the St. George Respiratory Questionnaire (56.9 ± 18.5 vs 49.1 ± 19.0, P = .003), and a larger proportion of this group reported more severe breathlessness in the stable state, with a Medical Research Council dyspnea score of ≥ 4 (50.9% vs 35.1%, P = .029). In subsets of the sample, stable patients with COPD with IHD had a higher median (interquartile range [IQR]) serum N-terminal pro-brain natriuretic peptide concentration than those without IHD (38 [15, 107] pg/mL vs 12 [6, 21] pg/mL, P = .004) and a lower exercise capacity (6-min walk distance, 225 ± 89 m vs 317 ± 85 m; P = .002). COPD exacerbations were not more frequent in patients with IHD (median, 1.95 [IQR, 1.20, 3.12] vs 1.86 (IQR, 0.75, 3.96) per year; P = .294), but the median symptom recovery time was 5 days longer (17.0 [IQR, 9.8, 24.2] vs 12.0 [IQR, 8.0, 18.0]; P = .009), resulting in significantly more days per year reporting exacerbation symptoms (median, 35.4 [IQR, 13.4, 60.7] vs 22.2 [IQR, 5.7, 42.6]; P = .028). These findings were replicated in multivariate analyses allowing for age, sex, FEV(1), and exacerbation frequency where applicable.

CONCLUSIONS: Comorbid IHD is associated with worse health status, lower exercise capacity, and more dyspnea in stable patients with COPD as well as with longer exacerbations but not with an increased exacerbation frequency.

[/EXPAND]

All Updates, Resus, Trauma, Ultrasound

Is it time to abandon plain radiography in the trauma room?

Leave a comment

For patients who will be having a chest CT, perhaps sonography could replace chest radiography in the resus room as the initial imaging step; this recent prospective study shows its superiority over the ‘traditional’ ATLS approach.

In haemodynamically stable patients with prophylactic pelvic splints in place, one could easily argue against plain pelvis films too (the caveat being rapid access to CT is necessary). The arguments against resus-room lateral cervical spine x-rays were made ages ago and these are now rarely done in the UK & Australia.

Is it time to abandon plain radiography altogether for stable major trauma patients?


Background: The accuracy of combined clinical examination (CE) and chest radiography (CXR) (CE + CXR) vs thoracic ultrasonography in the acute assessment of pneumothorax, hemothorax, and lung contusion in chest trauma patients is unknown.

Methods: We conducted a prospective, observational cohort study involving 119 adult patients admitted to the ED with thoracic trauma. Each patient, secured onto a vacuum mattress, underwent a subsequent thoracic CT scan after first receiving CE, CXR, and thoracic ultrasonography. The diagnostic performance of each method was also evaluated in a subgroup of 35 patients with hemodynamic and/or respiratory instability.

Results: Of the 237 lung fields included in the study, we observed 53 pneumothoraces, 35 hemothoraces, and 147 lung contusions, according to either thoracic CT scan or thoracic decompression if placed before the CT scan. The diagnostic performance of ultrasonography was higher than that of CE + CXR, as shown by their respective areas under the receiver operating characteristic curves (AUC-ROC): mean 0.75 (95% CI, 0.67-0.83) vs 0.62 (0.54-0.70) in pneumothorax cases and 0.73 (0.67-0.80) vs 0.66 (0.61-0.72) for lung contusions, respectively (all P < .05). In addition, the diagnostic performance of ultrasonography to detect pneumothorax was enhanced in the most severely injured patients: 0.86 (0.73-0.98) vs 0.70 (0.61-0.80) with CE + CXR. No difference between modalities was found for hemothorax.
Conclusions: Thoracic ultrasonography as a bedside diagnostic modality is a better diagnostic test than CE and CXR in comparison with CT scanning when evaluating supine chest trauma patients in the emergency setting, particularly for diagnosing pneumothoraces and lung contusions.

Diagnostic accuracy of ultrasonography in the acute assessment of common thoracic lesions after trauma
Chest. 2012 May;141(5):1177-83

All Updates, ICU, PHARM, Resus

Size matters when you're sick

Leave a comment

A nice example of a difference between elective anaesthesia and critical care practice when it comes to airway management is the selection of appropriate tracheal tube size when intubating, which is highlighted in a recent Anaesthesia article.
In recent years progressively smaller tubes have been used in anaesthesia in pursuit of decreased tracheal injury, sore throat, and hoarseness and increased ease of placement.
Patients likely to remain intubated for some time due to critical illness, however, may benefit from larger diameter tubes for the following reasons:

  • Accumulation of biofilm debris, which increases with duration of intubation – this can significantly decrease the luminal internal diameter, but is less likely to be significant with larger tubes.
  • Work of breathing during weaning: spontaneous breathing trials prior to extubation require patients to breathe through tracheal tubes. Volunteer studies have demonstrated that work of breathing increases as tube diameter decreases.
  • Bronchoscopes and suction catheters: the standard adult ICU fibreoptic bronchoscope has a diameter of 5.7 mm with a 2-mm suction channel to enable adequate suction, which limits the tracheal tube to those larger than 7.5–8.0 mm, and even with an 8.0-mm tube, the bronchoscope occupies more than 50% of the tube diameter, which can lead to ventilation issues during bronchoscopy.

The authors conclude by recommending:


‘If admission to ICU is contemplated then the time-honoured ‘8.0 for females, 9.0 for males’ is a reasonable rule of thumb, unless circumstances dictate otherwise, e.g. in difficult airways or particularly small patients.’

Size matters: choosing the right tracheal tube
Anaesthesia. 2012 Aug;67(8):815-9

All Updates, ICU, PHARM, Resus, Trauma

The Bleeding Trauma Patient

Leave a comment

The Bleeding Trauma Patient
by Dr Pete Sherren
By popular request, Here are the slides from a presentation given by HEMS critical care physician Dr Pete Sherren.

These notes accompany the slides:
Hypothermia, acidaemia and coagulopathy or the ‘lethal triad’, is a well described entity in the trauma population and is associated with significant mortality [1]. Traditionally the aetiology of a trauma induced coagulopathy was thought to be multifactorial and involve hypothermia, acidaemia, dilutional coagulopathy, pre-existing bleeding diathesis and disseminated intravascular coagulation (Figure 1).

Figure 1. A diagram showing some of the mechanisms leading to coagulopathy in the injured.

In 2003 Brohi et al showed that around 25% of severely injured trauma patients present to hospital with a significant coagulopathy which was unrelated to fluid administration [2]. This early coagulopathy has become known as the Acute Traumatic coagulopathy (ATC) or Acute Coagulopathy of Trauma Shock (ACoTS). It is associated with an increase in transfusion requirements, injury severity scores, organ dysfunction and mortality rates [2-5].
ATC is an impairment of haemostasis involving a dynamic interaction between endogenous anticoagulants and fibrinolysis that is initiated immediately after an injury [5]. ATC is driven by an endothelial injury and hypoperfusion, which results in in increased thrombomodulin expression and activation of protein C (Figure 3). The inhibitory effect of activated protein C on clotting factors V/VIII and plasminogen activator inhibitor-1 (PAI-1), would appear key in the development of ATC [5,6].

Figure 2. Expression of thrombomodulin following a traumatic injury results in increased activation of protein C with resulting impairment of clotting factors V/VIII and reduction in thrombin generation. Activated Protein C also has an inhibitory effect on PAI-1 which results in unregulated tPA activity and fibrinolysis.

Damage control resuscitation (DCR) describes a package of care for the haemorrhaging trauma patient. It involves early damage control surgery, haemostatic resuscitation and permissive hypotension. DCR aims to control haemorrhage early while aggressively targeting the ATC and lethal triad. DCR has emerged as the accepted standard of care and some observational studies have suggested a survival benefit [6].

  • Damage Control Surgery – The priority for any haemorrhaging trauma patient is good haemostasis. Unstable patients with major trauma do not tolerate prolonged definitive surgery and hence the emergence of damage control surgery. The aim of damage control surgery is to normalise physiology at the expense of anatomy.
  • Haemostatic resuscitation – Describes the aggressive early use of packed red blood cells, clotting products and coagulation adjuncts in an attempt to mitigate the effects of the ATC and lethal triad in major trauma patients. The exact PRBC:FFP ratio remains unclear, but should ideally be less than 2:1 [7]. In massive transfusions along with appropriate FFP, platelet and fibrinogen supplementation, consideration should be given to early adjunctive therapies such as tranexamic acid [8] while maintaining ionised calcium levels greater than 1.0 mmol/L [9].
  • Permissive hypotension – Involves titrated volume resuscitation, which targets a subnormal end point that maintains organ viability until haemorrhage is controlled. By avoiding overzealous fluid resuscitation which targets normotension, the hope is to preserve the first and often best clot. Although permissive hypotension is frequently employed in traumatic haemorrhage, there is really only robust evidence that it is advantageous in penetrating trauma [10]. In blunt trauma there is a relative paucity of good evidence to guide practice, while strong evidence exists for maintaining cerebral perfusion pressures when there are associated head injuries. The end points for resuscitation will depend on age, premorbid autoregulatory state and acute pathology.

DCR is an ever evolving concept and potential emerging management strategies include –

  • Thromboelastometry (TEG/ROTEM) to guide haemostatic resuscitation instead of ratio based transfusions.
  • Prothrombin complex concentrate (FII, VII, IX and X) in non-warfarin patients
  • Fibrinogen complex concentrate (fibrinogen and FXIII) over cryoprecipitate.
  • Alkalising agents such as Tris-hydroxymethyl aminomethane (THAM) in massive transfusion with severe acidaemia
  • Novel hybrid resuscitation strategies.
  • High flow/low pressure resuscitation – endothelial resuscitation and microvascular washout.
  • Suspended Animation
  • Platelet function analysis in trauma with platelet mapping and aggregometry vs traditional PF-100

Learning points

  • Early coagulation dysfunction is common in trauma patients with haemorrhagic shock.
  • Tailored management of the ‘lethal triad’ and ATC is essential.
  • DCR is an emerging standard of care; however, some of its components are pushing the boundaries of what is good evidence based medicine.

References
1. Moore EE. Staged laparotomy for the hypothermia, acidosis, and coagulopathy. Am J Surg 1996;172:405-410.
2. Brohi K, Singh J, Heron M, Coats T. Acute Traumatic coagulopathy. J Trauma. 2003;54:1127-1130.
3. Davenport R, Manson J, De’Arth H, Platton S, Coates A, Allard S, Hart D, Pearse RM, Pasi J, MacCullum P, Stanworth S, Brohi K. Functional definition and characterization of acute traumatic coagulopathy. Crit Care Med. 2011;39(12):2652-2658.
4. Maegele M, Lefering R, Yucei N, Tjardes T, Rixen D,Paffrath T, Simanski C, Neugebauer E, Bouillon B; AG Polytrauma of the German Trauma Society (DGU). Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury. 2007 Mar;38(3):298-304.
5. Firth D, Davenport R, Brohi K. Acute traumatic coagulopathy. Curr Opin Anaesthesiol. 2012 Apr;25(2):229-34.
6. Cotton BA, Reddy N, Hatch QM, LeFebvre E, Wade CE, Kozar RA, Gill BS, Albarado R, McNutt MK, Holcomb JB. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg. 2011 Oct;254(4):598-605.
7. Davenport R, Curry N, Manson J, De’Ath H, Coates A, Rourke C, Pearse R, Stanworth S, Brohi K. Hemostatic effects of fresh frozen plasma may be maximal at red cell ratios of 1:2. J Trauma. 2011 Jan;70(1):90-5; discussion 95-6.
8. CRASH-2 collaborators, Roberts I, Shakur H, Afolabi A, Brohi K, Coats T, Dewan Y, Gando S, Guyatt G, Hunt BJ, Morales C, Perel P, Prieto-Merino D, Woolley T. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011 Mar 26;377(9771):1096-101, 1101.e1-2.
9. Dawes R, Thomas GO. Battlefield resuscitation. Curr Opin Crit Care. 2009 Dec;15(6):527-35
10. Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994 Oct 27;331(17):1105-9.
11. Schöchl H, Maegele M, Solomon C, Görlinger K, Voelckel W. Early and individualized goal-directed therapy for trauma-induced coagulopathy. Scand J Trauma Resusc Emerg Med. 2012 Feb 24;20:15.

All Updates, PHARM, Resus, Trauma

Head injury was not predictive for cervical spine injury

Leave a comment

Two papers examining the same massive European trauma dataset identify risk factors for spinal injury. The first examined all spinal injury(1), and the most recent focuses on cervical injury(2). Male gender, decreased GCS, falls > 2m, sports injuries, and road traffic collisions were predictors of any fracture/dislocation or cord injury. Head injury was not an independent risk factor, contrary to much popular teaching. I’ve summarised the two papers’ findings in this table. The odds ratios are reported in the abstracts.

Download Keynote presentation slide (for Mac)

1. Epidemiology and predictors of spinal injury in adult major trauma patients: European cohort study
Eur Spine J. 2011 Dec;20(12):2174-80. Free full text
[EXPAND Click to read abstract]


This is a European cohort study on predictors of spinal injury in adult (≥16 years) major trauma patients, using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Predictors for spinal fractures/dislocations or spinal cord injury were determined using univariate and multivariate logistic regression analysis. 250,584 patients were analysed. 24,000 patients (9.6%) sustained spinal fractures/dislocations alone and 4,489 (1.8%) sustained spinal cord injury with or without fractures/dislocations. Spinal injury patients had a median age of 44.5 years (IQR = 28.8–64.0) and Injury Severity Score of 9 (IQR = 4–17). 64.9% were male. 45% of patients suffered associated injuries to other body regions. Age <45 years (≥45 years OR 0.83–0.94), Glasgow Coma Score (GCS) 3–8 (OR 1.10, 95% CI 1.02–1.19), falls >2 m (OR 4.17, 95% CI 3.98–4.37), sports injuries (OR 2.79, 95% CI 2.41–3.23) and road traffic collisions (RTCs) (OR 1.91, 95% CI 1.83–2.00) were predictors for spinal fractures/dislocations. Age <45 years (≥45 years OR 0.78–0.90), male gender (female OR 0.78, 95% CI 0.72–0.85), GCS <15 (OR 1.36–1.93), associated chest injury (OR 1.10, 95% CI 1.01–1.20), sports injuries (OR 3.98, 95% CI 3.04–5.21), falls >2 m (OR 3.60, 95% CI 3.21–4.04), RTCs (OR 2.20, 95% CI 1.96–2.46) and shooting (OR 1.91, 95% CI 1.21–3.00) were predictors for spinal cord injury. Multilevel injury was found in 10.4% of fractures/dislocations and in 1.3% of cord injury patients. As spinal trauma occurred in >10% of major trauma patients, aggressive evaluation of the spine is warranted, especially, in males, patients <45 years, with a GCS <15, concomitant chest injury and/or dangerous injury mechanisms (falls >2 m, sports injuries, RTCs and shooting). Diagnostic imaging of the whole spine and a diligent search for associated injuries are substantial.

[/EXPAND]
2. Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study
J Trauma Acute Care Surg. 2012 Apr;72(4):975-81
[EXPAND Click to read abstract]


Patients with cervical spine injuries are a high-risk group, with the highest reported early mortality rate in spinal trauma.

METHODS: This cohort study investigated predictors for cervical spine injury in adult (≥ 16 years) major trauma patients using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Univariate and multivariate logistic regression analyses were used to determine predictors for cervical fractures/dislocations or cord injury.

RESULTS: A total of 250,584 patients were analyzed. Median age was 47.2 years (interquartile range, 29.8-66.0) and Injury Severity Score 9 (interquartile range, 4-11); 60.2% were male. Six thousand eight hundred two patients (2.3%) sustained cervical fractures/dislocations alone. Two thousand sixty-nine (0.8%) sustained cervical cord injury with/without fractures/dislocations; 39.9% of fracture/dislocation and 25.8% of cord injury patients suffered injuries to other body regions. Age ≥ 65 years (odds ratio [OR], 1.45-1.92), males (females OR, 0.91; 95% CI, 0.86-0.96), Glasgow Coma Scale (GCS) score <15 (OR, 1.26-1.30), LeFort facial fractures (OR, 1.29; 95% confidence interval [CI], 1.05-1.59), sports injuries (OR, 3.51; 95% CI, 2.87-4.31), road traffic collisions (OR, 3.24; 95% CI, 3.01-3.49), and falls >2 m (OR, 2.74; 95% CI, 2.53-2.97) were predictive for fractures/dislocations. Age <35 years (OR, 1.25-1.72), males (females OR, 0.59; 95% CI, 0.53-0.65), GCS score <15 (OR, 1.35-1.85), systolic blood pressure <110 mm Hg (OR, 1.16; 95% CI, 1.02-1.31), sports injuries (OR, 4.42; 95% CI, 3.28-5.95), road traffic collisions (OR, 2.58; 95% CI, 2.26-2.94), and falls >2 m (OR, 2.24; 95% CI, 1.94-2.58) were predictors for cord injury.

CONCLUSIONS: 3.5% of patients suffered cervical spine injury. Patients with a lowered GCS or systolic blood pressure, severe facial fractures, dangerous injury mechanism, male gender, and/or age ≥ 35 years are at increased risk. Contrary to common belief, head injury was not predictive for cervical spine involvement.

[/EXPAND]

All Updates, PHARM, Resus

A better way to tilt pregnant patients?

Leave a comment

To alleviate aortocaval compression, it is recommended to tilt pregnant patients into the left lateral tilt position during resuscitation. Aortocaval compression may however occur despite a lateral tilt of up to 34°, thought to be due to the relative immobility of the gravid uterus, although tilting beyond 30° is likely to lead them to slide off the bed or stretcher.

It may be more effective to tilt the patient into the full left lateral position first before returning them to the left lateral tilt position.


Positioning the parturient from supine to the left lateral tilt position (supine-to-tilt) may not effectively displace the gravid uterus, but turning from the left lateral position to the left lateral tilt position (left lateral-to-tilt) may keep the gravid uterus displaced and prevent aortocaval compression.

Fifty-one full-term parturients were randomly placed in the left lateral position, supine-to-tilt and left lateral-to-tilt positions using a Crawford wedge. Femoral vein area, femoral vein velocity, femoral artery area, pulsatility index, resistance index and right arm mean arterial blood pressure and heart rate were recorded.

Our results showed a lower mean (SD) femoral vein area (82.2 (14.9) vs 96.2 (16.4) mm(2) ), a lower pulsatility index (3.83 (1.3) vs 5.8 (2.2)), a lower resistance index (0.93 (0.06) vs 0.98 (0.57)), a higher femoral artery area (33.3 (3.8) vs 30.9 (4.4) mm(2) ) and a higher femoral vein velocity (7.9 (1.2) vs 6.1 (1.6) cm.s(-1) ) with left lateral-to-tilt when compared with supine-to-tilt (all p < 0.001).
Our results suggest that moving a full-term parturient from the full left lateral to the lateral tilt position may prevent aortocaval compression in full-term parturients more efficiently than when positioning the parturient from a supine to left lateral tilt position.

Effect of positioning from supine and left lateral positions to left lateral tilt on maternal blood flow velocities and waveforms in full-term parturients
Anaesthesia. 2012 Aug;67(8):889-93

Acute Med, All Updates, Kids, Resus, Trauma

Life, limb and sight-saving procedures

Leave a comment
The challenge of competence in the face of rarity

by Dr Cliff Reid FCEM, and Dr Mike Clancy FCEM
This article is to be published in Emergency Medicine Journal (EMJ), and is reproduced here with permission of the BMJ Group.
Emergency physicians require competence in procedures which are required to preserve life, limb viability, or sight, and whose urgency cannot await referral to another specialist.
Some procedures that fit this description, such as tracheal intubation after neuromuscular blockade in a hypoxaemic patient with trismus, or placement of an intercostal catheter in a patient with a tension pneumothorax, are required sufficiently frequently in elective clinical practice that competence can be acquired simply by training in emergency department, intensive care, or operating room environments.
Other procedures, such as resuscitative thoracotomy, may be required so infrequently that the first time a clinician encounters a patient requiring such an intervention may be after the completion of specialist training, or in the absence of colleagues with prior experience in the technique.
Some techniques that might be considered limb or life saving may be too technically complex to acquire outside specialist surgical training programs. Examples are damage control laparotomy and limb fasciotomy. One could however argue that these are rarely too urgent to await arrival of the appropriate specialist.
The procedures which might fit the description of a time­‐critical life, limb, or sight saving procedure in which it is technically feasible to acquire competence within or alongside an emergency medicine residency, and that cannot await another specialist, include:

  • limb amputation for the entrapped casualty with life-­threatening injuries;
  • escharotomy for a burns patient with compromised ventilation or limb perfusion;

 
Defining competence for emergency physicians
A major challenge is the acquisition of competence in the face of such clinical rarity. One medical definition of competence is ‘the knowledge, skill, attitude or combination of these, that enables one to effectively perform the activities of a particular occupation or role to the standards expected’[1]; in essence the ability to perform to a standard, but where are these standards defined?
If we look to the curricula which are used to assess specialist emergency physicians in several English-­speaking nations, all the procedures in the short list above are included, although no one single nation’s curriculum includes the entire list (Table 1).

 
So an emergency physician is expected to be able to conduct these procedures, and a competent emergency physician effectively performs them to the ‘standards’ expected. It appears then that the question is not whether emergency physicians should perform them, but to what standard should they be trained? Only then can the optimal approach to training be decided.
There are convincing arguments that even after minimal training the performance of these procedures by emergency physicians is justifiable:

  • All the abovementioned interventions could be considered to carry 100% morbidity or mortality if not performed, with some chance of benefit whose magnitude depends on the timeliness of intervention. In some cases that risk is quantifiable: cardiac arrest due to penetrating thoracic trauma has 100% mortality if untreated, but an 18% survival to discharge rate, with a high rate of neurologically intact survivors, if performed by prehospital emergency medicine doctors in the field according to defined indications[2] and using a simple operative procedure[3]. In this extreme clinical example, no further harm to the patient can result from the procedure but a chance of supreme benefit exists. Thus, the ethical requirements of beneficence and non-­maleficence are both met even in the circumstance of very limited training for the procedure. It is hard to conceive of many other circumstances in medicine where the benefit:harm ratio approaches infinity.
  • The procedures in question are technically straightforward and can be executed without specialist equipment in non-­operating room environments. These factors appear to be underappreciated by non-­emergency specialist opponents of emergency physician-­provided thoracotomy whose practice and experience is likely to be predominantly operating room-­based[4].
  • Some of the procedures are recommended or mandated by official guidelines[5], raising the possibility of medicolegal consequences of failure to perform them.
  • The procedures are time-­critical and cannot await the arrival of an alternative specialist not already present. Simple pragmatism dictates that emergency physicians be trained to provide the necessary interventions.

 
The challenge of training
So how does one best train for these procedures? High volume trauma experience provided by a registrar term with the London Helicopter Emergency Medical Service or at a South African trauma centre will be an option for a very limited subset of trainees. Alternative training can be provided using simulation, animal labs, and cadaver labs, without risk to patients or requiring dedicated surgical specialty attachments.
Simulation manikins are not yet available for all the procedures mentioned, and lack realistic operable tissue. Human cadaver labs and live animal training bring administrative, legal, ethical and financial challenges that may be prohibitive to time and cash‐limited training schemes, or be less available to the ‘already trained’ providers in existing consultant posts. Even excellent focused cadaver-­based courses such as the Royal College of Surgeons’ Definitive Surgical Trauma Skills course[6] may not be appropriate for the emergency medicine environment: on such a course one of the authors (CR) was publicly castigated by a cardiothoracic surgeon instructor for inexpert suture technique during the resuscitative thoracotomy workshop, despite the former having successfully performed the procedure on several occasions ‘in the field’ without need of elaborate needlework.
An additional training challenge is that of metacompetence: the decision and ability to apply the competence at the right time. In the light of the relative technical simplicity of the practical procedures under discussion, this may indeed be the greatest challenge. Both authors can recount sad tales of colleagues failing to provide indicated life-­saving interventions despite being technically capable of intervening. Reasons for reticence include ‘I haven’t been properly trained’, and ‘I wouldn’t feel supported if it went wrong’.
 
Where do we go from here?
We have presented clinical, ethical, practical, and medicolegal arguments in favour of emergency physicians providing these procedures. Collectively, the emergency medicine curricula of English-­speaking nations mandate competence in them. The relative technical simplicity and overwhelming benefit:harm equation obviate the need to match the competence of a surgical subspecialist; these factors suggest training can be limited in time and cost as long as the metacompetences of ‘decision to act and knowing when to act’ are taught, simulated, and tested.
While we should capitalise on the technical expertise of surgical colleagues in the training situation, it is imperative that emergency physicians appreciative of the emergency department environment and equipment are directly involved in translating this training to emergency medicine practice. The rarity of the situations requiring these procedures requires that training should be revisited on a regular basis, preferably in the context of local departmental simulation in order to optimise equipment and teamwork preparation.
Finally, the College of Emergency Medicine needs to make it clear to its members and fellows that these procedures lie unquestionably within the domain of emergency medicine, and that emergency physicians are supported in performing them to the best of their abilities with limited training when circumstances dictate that this in the best interests of preserving a patient’s life, limb, or sight.
 
 
References
1. British Medical Association. Competency-­based assessment discussion paper for consultants, May 2008. http://www.bma.org.uk/employmentandcontracts/doctors_performance/1_app raisal/CompetencyBasedAssessment.jsp Accessed 22nd March 2012
2. Davies GE, Lockey DJ. Thirteen Survivors of Prehospital Thoracotomy for Penetrating Trauma: A Prehospital Physician‐Performed Resuscitation Procedure That Can Yield Good Results. J Trauma. 2011;70(5):E75-­8
3. Wise D, Davies G, Coats T, et al. Emergency thoracotomy: “how to do it”. Emerg Med J. 2005; 22(1):22–24 Free full text
4. Civil I. Emergency room thoracotomy: has availability triumphed over advisability in the care of trauma patients in Australasia? Emerg Med Australas. 2010;22(4):257­‐9
5. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation. 2010;81(10):1400-­33 Full text
6. Definitive Surgical Trauma Skills course. http://www.rcseng.ac.uk/courses/course-search/dsts.html Accessed 22nd March 2012
7. http://www.collemergencymed.ac.uk/Training-Exams/Curriculum/Curriculum%20from%20August%202010/ Accessed 22nd March 2012
8. http://www.eusem.org/cms/assets/1/pdf/european_curriculum_for_em-aug09-djw.pdf accessed 17 May 2012
9. The Model of the Clinical Practice of Emergency Medicine http://www.abem.org/PUBLIC/portal/alias__Rainbow/lang__en-%C2%AD%20US/tabID__4223/DesktopDefault.aspx Accessed 22nd March 2012
10. http://rcpsc.medical.org/residency/certification/objectives/emergmed_e.pdf Accessed 22nd March 2012
11. http://www.acem.org.au/media/publications/15_Fellowship_Curriculum.pdf accessed 17 May 2012
12. http://www.collegemedsa.ac.za/Documents/doc_173.pdf accessed 17 May 2012
Life, limb and sight-saving procedures-the challenge of competence in the face of rarity
Emerg Med J. 2012 Jul 16. [Epub ahead of print]

All Updates, Resus, Trauma

Leadership & experience count in trauma resuscitation

Leave a comment

These findings shouldn’t be a surprise – and the authors acknowledge a number of methodological weaknesses in what is essentially a pilot study – but the conclusions are worth reminding people about.


INTRODUCTION: Leadership plays a key role in trauma team management and might affect the efficiency of patient care. Our hypothesis was that a positive relationship exists between the trauma team members’ perception of leadership and the efficiency of the injured patient’s initial evaluation.

METHODS: We conducted a prospective observational study evaluating trauma attending leadership (TAL) over 5 months at a level 1 trauma center. After the completion of patient care, trauma team members evaluated the TAL’s ability using a modified Campbell Leadership Descriptor Survey tool. Scores ranged from 18 (ineffective leader) to 72 (perfect score). Clinical efficiency was measured prospectively by recording the time needed to complete an advanced trauma life support (ATLS)-directed resuscitation. Assessment times across Leadership score groups were compared using Kruskal-Wallis and Mann-Whitney tests (p < 0.05, statistically significant).

RESULTS: Seven attending physicians were included with a postfellowship experience ranging from ≤1 to 11 years. The average leadership score was 59.8 (range, 27-72). Leadership scores were divided into 3 groups post facto: low (18-45), medium (46-67), and high (68-72). The teams directed by surgeons with low scores took significantly longer than teams directed by surgeons with high scores to complete the secondary survey (14 ± 4 minutes in contrast to 11 ± 2 minutes, p < 0.009) and to transport the patient for CT evaluation (19 ± 5 minutes in contrast to 14 ± 4 minutes; p < 0.001). Attending surgeon experience also affected clinical efficiency with teams directed by less experienced surgeons taking significantly longer to complete the primary survey (p < 0.05).

CONCLUSION: The trauma team’s perception of leadership is associated positively with clinical efficiency. As such, more formal leadership training could potentially improve patient care and should be included in surgical education.

Trauma leadership: does perception drive reality?
J Surg Educ. 2012 Mar-Apr;69(2):236-40

Acute Med, All Updates, Guidelines, ICU, Resus

Upper GI bleeding guideline update

Leave a comment

The UK’s National Institute for Health and Clinical Excellence has issued updated guidance on the management of acute upper gastrointestinal bleeding.
The initial resuscitation section recommends haemostatic blood product resuscitation for unstable patients in line with massive transfusion practice in trauma.
A risk assessment is recommended using the Blatchford score pre-endoscopy at first assessment, and the full Rockall score after endoscopy.
Consider early discharge for patients with a pre-endoscopy Blatchford score of 0.
In non-varicesal haemorrhage, acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) before endoscopy are not recommended.
Terlipressin should be given to patients with suspected variceal bleeding at presentation and continued until definitive haemostasis has been achieved, or after 5 days, unless there is another indication for its use.
Prophylactic antibiotic therapy should be offered at presentation to patients with suspected or confirmed variceal bleeding.

Click image to go to interactive pathway on NICE website

National Institute for Health and Clinical Excellence: CG141 Acute upper GI bleeding: NICE guideline
http://guidance.nice.org.uk/CG141/NICEGuidance/pdf/English