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
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
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. "Intubate Meee!!" 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
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
A retrospective review of appropriate vs inappropriate antimicrobial therapy was undertaken in over four thousand septic shock patients from multiple centres. In terms of definitions, the authors state:
“Appropriate antimicrobial therapy was considered to have been initiated if an antimicrobial with in vitro activity appropriate for the isolated pathogen or pathogens (or in the case of culture-negative septic shock, an antimicrobial or antimicrobial agent concordant with accepted international norms for empiric therapy and modified to local flora) was either the first new antimicrobial agent with which therapy was started after the onset of recurrent or persistent hypotension or was initiated within 6 h of the administration of the first new antimicrobial agent. Otherwise, inappropriate therapy was considered to have been initiated.”
The results are striking: survival rates after appropriate and inappropriate initial therapy were 52.0% and 10.3%, respectively (odds ratio [OR], 9.45; 95% CI, 7.74 to 11.54; p < 0.0001).
A multivariable logistic regression analysis of possible factors that may affect outcome showed the appropriateness of the initial antimicrobial therapy remained most strongly associated with outcome (OR, 8.99; 95% CI, 6.60 to 12.23; p < 0.0001) among all the risk factors assessed. Initiation of Inappropriate Antimicrobial Therapy Results in a Fivefold Reduction of Survival in Human Septic Shock Chest. 2009 Nov;136(5):1237-48 N.B. This work was done by the same authors who brought us the study that showed the earlier antibiotics were given to hypotensive septic patients, the better the outcome:
Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34:1589-1596
Even though we might not know it’s called that, many of us are familiar with the Baux score, defined as the sum of age in years and percent body burn, to predict percent mortality after severe burns. This is however a little out of date due to advances in burn care, and does not take into account inhalational injury.
The Baux score was modified using data on 39,888 burned patients using a logistic regression model that showed that age and percent burn contribute almost equally to mortality and that the presence of inhalation injury added the equivalent of 17 years (or 17% burn). These observations suggested a revised Baux Score:
Per Cent Mortality = Age + Percent Burn + [17 x (Inhalation Injury, 1= yes, = no)] Simplified Estimates of the Probability of Death After Burn Injuries: Extending and Updating the Baux Score J Trauma. 2010 Mar;68(3):690-7
An observational study of near term infants (34 weeks gestation to 36 weeks and 6 days) born in an Italian centre over a 5 year period showed that nearly 10% of near-term infants needed positive pressure ventilation at birth, confirming that this group of patients is more vulnerable than term infants. Most were able to be managed with either bag-mask ventilation (BMV) or with a size 1 laryngeal mask airway (LMA). Of the 86 infants requiring PPV, 36 (41.8%) were managed by LMA, 34 (39.5%) by BMV and 16 (18.6%) by tracheal intubation. Why not slap a tiny LMA on your neonatal resuscitation cart – it could come in handy! Delivery room resuscitation of near-term infants: role of the laryngeal mask airway Resuscitation. 2010 Mar;81(3):327-30
In non-trauma patients, do you base your decision to intubate patients with decreased conscious level on the GCS? These guys in Scotland describe a series of poisoned patients with GCS range 3-14 managed on an ED observation unit without tracheal intubation, with no demonstrated cases of aspiration. They say: ‘This study suggests that it can be safe to observe poisoned patients with decreased consciousness, even if they have a GCS of 8 or less, in the ED‘. Small numbers, but gets you thinking. This subject would make a great randomised controlled trial. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department J Emerg Med. 2009 Nov;37(4):451-5
No rescuer or bystander has ever been seriously harmed by receiving an inadvertent shock while in direct or indirect contact with a patient during defibrillation. New evidence suggests that it might even be electrically safe for the rescuer to continue chest compressions during defibrillation if self-adhesive defibrillation electrodes are used and examination gloves are worn. This paper reviews the existing evidence, but warns more definite data are needed to make absolutely sure that there is no risk before defibrillation safety recommendations are changed. Is external defibrillation an electric threat for bystanders? Resuscitation. 2009 Apr;80(4):395-401
Previous studies have suggested the following are necessary for a successful Valsalva manoeuvre with maximum vagal effect:
Supine posturing
Duration of 15 seconds
Pressure of 40 mmHg (with an open glottis)
One popular method of generating a Valsalva Manoeuvre is to get the patient to blow into a syringe in an attempt to move the plunger. Different syringe sizes were tested. A 10ml (Terumo) syringe was best The 10 mL syringe is useful in generating the recommended standard of 40 mmHg intrathoracic pressure for the Valsalva manoeuvre Emerg Med Australas. 2009 Dec;21(6):449-54
