Using a 2Mhz transducer insonating through the temporal acoustic bone window, Italian physicians detected the expansion of an extradural haematoma. In their discussion they highlight that transcranial sonography of brain parenchyma in adults has been proposed by several authors for the evaluation of the ventricular system, monitoring of midline shift, diagnosis and follow-up of intracranial mass lesions. In one study, of 151 patients, 133 (88%) had a sufficient acoustic bone window. Note that the skull contralateral to the acoustic bone window is visualised.
Bedside detection of acute epidural hematoma by transcranial sonography in a head-injured patient
Intensive Care Med. 2010 Jun;36(6):1091-2
Category Archives: Resus
Life-saving medicine
Guidelines on trauma in pregnancy
Guidelines on trauma in pregnancy have been published by the The Eastern Association for the Surgery of Trauma (EAST):
RECOMMENDATIONS
Level I
There are no level I standards.
Level II
- All pregnant women >20-week gestation who suffer trauma should have cardiotocographic monitoring for a minimum of 6 hours. Monitoring should be continued and further evaluation should be carried out if uterine contractions, a nonreassuring fetal heart rate pattern, vaginal bleeding, significant uterine tenderness or irritability, serious maternal injury, or rupture of the amniotic membranes is present.
- Kleihauer-Betke analysis should be performed in all pregnant patient > 12 week-gestation.
Level III
- The best initial treatment for the fetus is the provision of optimum resuscitation of the mother and the early assessment of the fetus.
- All female patients of childbearing age with significant trauma should have a human chorionic gonadotropin (HCG) performed and be shielded for X-rays whenever possible.
- Concern about possible effects of high-dose ionizing ra- diation exposure should not prevent medically indicated maternal diagnostic X-ray procedures from being per- formed. During pregnancy, other imaging procedures not associated with ionizing radiation should be considered instead of X-rays when possible.
- Exposure <5 rad has not been associated with an increase in fetal anomalies or pregnancy loss and is herein deemed to be safe at any point during the entirety of gestation.
- Ultrasonography and magnetic resonance imaging are not associated with known adverse fetal effects. However, until more information is available, magnetic resonance imaging is not recommended for use in the first trimester.
- Consultation with a radiologist should be considered for purposes of calculating estimated fetal dose when multiple diagnostic X-rays are performed.
- Perimortem cesarean section should be considered in any moribund pregnant woman of ≥24 week gestation.
- Delivery in perimortem cesarean sections must occur within 20 minutes of maternal death but should ideally start within 4 minutes of the maternal arrest. Fetal neuro- logic outcome is related to delivery time after maternal death.
- Consider keeping the pregnant patient tilted left side down 15 degrees to keep the pregnant uterus off the vena cava and prevent supine hypotension syndrome.
- Obstetric consult should be considered in all cases of injury in pregnant patients.
Practice Management Guidelines for the Diagnosis and Management of Injury in the Pregnant Patient: The EAST Practice Management Guidelines Work Group
Journal of Trauma 2010;69(1):211-4
Full text guidelines are available here. They are dated 2005 the recommendations appear to be indistinguishable from those published in the July 2010 issue of Journal of Trauma
New College Ketamine Guideline
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.
Tactical Combat Casualty Care
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
Less RSI desaturation with Roc
Some of my pre-hospital critical care colleagues in the UK exclusively use rocuronium in preference to suxamethonium for rapid sequence induction (RSI) of anaesthesia in critically ill patients. I couldn’t see a good reason to switch although now there’s some evidence that adds to the argument.
The muscle fasciculations caused by the depolarising effect of suxamethonium may increase oxygen consumption, which may shorten the apnoea time before desaturation. Non-depolarising neuromuscular blockers such as rocuronium should allow a longer apnoea time after RSI. In addition, drugs which reduce fasciculations (such as lidocaine and fentanyl) should delay the the onset of desaturation when given prior to suxamethonium.
These hypotheses were tested in a blinded, randomised controlled trial in 60 ASA-1 or -2 patients, who were scheduled for elective surgery under general anaesthesia. All patients received 2mg/kg propofol. One group was randomised to receive suxamethonium 1.5 mg/kg, a second group received rocuronium 1mg/kg plus lidocaine 1.5mg/kg and fentanyl 2mcg/kg, and a third group was given suxamethonium 1.5 mg/kg plus lidocaine 1.5mg/kg and fentanyl 2mcg/kg. The facemask was removed 50 seconds after the neuromuscular blocker was given and patients were intubated; the tube was then left open to air until desaturation to 95% occurred, which was timed.
Desaturation occurred significantly sooner in the suxamethonium-only group, followed by the sux/lido/fentanyl group, followed by the roc/lido/fentanyl group.
Of course these results are not necessarily directly applicable to the critically ill patient, and in this study there was no direct comparison between induction agent + rocuronium only and induction agent + suxamethonium only. Nevertheless the argument that suxamethonium-induced muscle fasciculations contribute to an avoidable increase in oxygen consumption is persuasive.
Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction
Anaesthesia. 2010 Apr;65(4):358-61
Steroids for pneumonia?
Steroids are useful in asthma and COPD exacerbations, which are lung problems. Pneumonia is a lung infection, so steroids might help there too right? Erm… no.
A double blind randomised controlled trial demonstrated no benefit from steroids (prednisolone) versus placebo in patients with community acquired pneumonia, and late therapaeutic failure (>72 h after admission) was more common in the prednisolone group.
Efficacy of Corticosteroids in Community-acquired Pneumonia: A Randomized Double-Blinded Clinical Trial
Am J Respir Crit Care Med. 2010 May 1;181(9):975-82
Two tier trauma team
Rather than activating a full trauma team based on traditional criteria, this team devised a two tier approach; if there were no positive anatomical or physiological criteria, a trauma team ‘consult’ approach was adopted, in which the patient was evaluated by emergency department and general surgery doctors only.
Of 1144 trauma activations, 468 (41%) were full trauma and 676 (59%) were consult trauma activations.. Sensitivity of the triage tool for the major trauma outcome (ISS>15, death, or needing critical care or urgent surgery) was 83%, specificity was 68%, undertriage was 3% and overtriage was 27%. There were no deaths in undertriaged patients.
This is an important study that has the potential to improve resource utilisation and even patient experience.
Prospective evaluation of a two-tiered trauma activation protocol in an Australian major trauma referral hospital
Injury. 2010 May;41(5):470-4
Military pre-hospital thoracotomy
Military doctors in Afghanistan reviewed their experience of thoracotomy done within 24 hours of admission to their hospital. The ballistic nature of thoracic penetrating trauma (mainly Afghan civilians without body armour) differs from the typical knife-wound related injury seen in survivors of thoracotomy reported in the pre-hospital literature.
Six of the patients presented in cardiac arrest – four PEA and two asystole. One of the PEA patients survived; this patient had sustained a thoracoabdominal GSW and had arrested 8 minutes from hospital. Following emergency thoracotomy, aortic control, and concomitant massive transfusion, return of spontaneous circulation (ROSC) was achieved and damage control surgery undertaken in both chest and abdomen.
The two patients in asystole had sustained substantial pulmonary and hilar injuries, and ROSC was never achieved. The patients in PEA all had arrested as a consequence of hypovolaemia from solid intra-abdominal visceral haemorrhage. All patients in PEA had ROSC achieved, albeit temporarily.
Following thoracotomy, patients required surgical manoeuvres such as pulmonary hilar clamping, packing and temporary aortic occlusion; hypovolaemia was the leading underlying cause of the cardiac arrest. These factors lead the authors to conclude that although isolated cardiac wounds do feature in war, they are unusual and the injury pattern of casualties in conflict zones are often complex and multifactorial.
Is pre-hospital thoracotomy necessary in the military environment?
Injury. 2010 Jul;41(7):1008-12
New meningococcal guideline
The UK’s National Institute for Health and Clinical Excellence has produced a guideline on the management of bacterial meningitis and meningococcal septicaemia in children.
The guidelines cover when to treat a petechial rash, when to give steroids, when to do an LP (and what to test), how much fluid to give, and a number of other areas that otherwise can cause confusion.
The management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care
NICE guidance
Infant CPR: two thumbs even when alone
Infant CPR guidelines recommend two-finger chest compressions with a lone rescuer and two-thumb with two rescuers. Two-thumb provides better chest compression but is perceived to be associated with increased ventilation hands-off time. A manikin study revealed more effective compressions with the two-thumb technique with only four fewer compressions per minute compared with two-fingers.
Two-thumb technique is superior to two-finger technique during lone rescuer infant manikin CPR
Resuscitation. 2010 Jun;81(6):712-7