Emergency physicians in Cambridge and Ipswich in the UK prospectively documented their echo use in cardiac arrest. Images were easily acquired, were quickly obtained, and influenced management. In keeping with previous studies, absence of ventricular wall motion predicted lack of return of spontaneous circulation, with a negative predictive value of 97%.
An evaluation of echo in life support (ELS): is it feasible? What does it add?
Emerg Med J. 2010 Oct 4. [Epub ahead of print]
Category Archives: Trauma
Care of severely injured patient
RCT of 7.5% saline in head injury
Over a thousand patients in North America with blunt traumatic head injury and coma who did not have hypovolaemic shock were randomised to different fluids pre-hospital. 250 ml Hypertonic (7.5%) saline was compared with normal (0.9%) saline and hypertonic saline dextran (7.5% saline/6% dextran 70). There was no difference in 6-month neurologic outcome or survival.
Out-of-Hospital Hypertonic Resuscitation Following Severe Traumatic Brain Injury
JAMA. 2010;304(13):1455-1464.
Two smaller lines may be quicker
Using Poiseuille’s law and standardized gauge sizes, an 18-gauge (g) intravenous catheter (IV) should be 2.5 times faster than a 20-g IV, but this is not borne out by observation, in vitro testing, and manufacturer’s data. A nice simple study on normal volunteers compared simultaneous flow rates between a single 18G iv in one arm with two 20G ivs in the other arm. The two smaller ones provided significantly faster flow than the single larger one, although flow rates were slower than manufacturer’s estimates. This is in keeping with this other study on cannula flow rates.
Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter?
Am J Emerg Med. 2010 Jul;28(6):724-7
Scoop minimises cervical movement
A cadaveric study using a 3-dimensional electromagnetic tracking device to asses cervical motion compared the application of a scoop stretcher with two other manual transfer techniques, including log rolling onto an extrication (spine) board. The scoop method restricted cervical spine movement more than log rolling, although this was not statistically significant.
The authors conclude: the effectiveness of the scoop stretcher to limit spinal motion in the destabilized spine is comparable or better than manual techniques currently being used by primary responders.
Are scoop stretchers suitable for use on spine-injured patients?
Am J Emerg Med. 2010 Sep;28(7):751-6
Give all sick patients oestrogen?
A thought provoking article in Critical Care Medicine outlines basic science, animal, and human studies that suggest oestrogen may have a protective effect in a wide range of critical illnesses from cardiac arrest to trauma to stroke. It urges clinical trials of sex hormones, some of which are underway. Regarding traumatic brain injury, the authors state: “To date, studied interventions to treat the effects of secondary injury, such as induced hypothermia or sedative-hypnotic coma, have had disappointing results… Clearly, EMS (or emergency department) infusion of a single IV bolus of estrogen, a therapy shown in the laboratory to be a strong, direct, easy-to-deliver antioxidant, antiapoptotic, and anti-inflammatory intervention, has a much better chance of decreasing the severity of injury.”
Bold? Let’s see if studies such as this one show this intervention to be so beneficial.
Rationale for routine and immediate administration of intravenous estrogen for all critically ill and injured patients
Critical Care Medicine. 38(10):S620-S629, October 2010
No benefit from pre-hospital trauma doctor in Holland
Being human, I suffer from confirmation bias: I’ve become aware that I’m always on the look out for studies that show benefit from physician-provided pre-hospital care and therefore it’s possible I miss the ones that show no benefit. Of course, no ‘level 1’ evidence is out there yet. This study isn’t hugely impressive, but worth adding to the list. After adjusting for injury severity, trauma patients treated on scene by Dutch physicians had no difference in mortality compared with those that received standard care. In the subgroup analysis for patients with severe traumatic brain injury, the mortality rate with physician involvement was lower than that without, but was not statistically significant. On scene times averaged 2.7 minutes longer in the physician group although factors that might have contributed to this, such as entrapment or on scene interventions, were not recorded.
A major limitation in study design is that patients who died while under care at the scene or during transport were excluded from the analysis. The on scene time in these patients could have been prolonged by medical interventions in the field possibly contributing to the adverse outcome.
Take home message? More evidence needed.
The Association of Mobile Medical Team Involvement on On-Scene Times and Mortality in Trauma Patients
J Trauma. 2010 Sep;69(3):589-94
EZ-IO outperformed B.I.G
A small randomised trial of adult emergency department patients showed faster insertion and higher success rates with the EZ-IO compared with the Bone Injection Gun (B.I.G). This is in keeping with my own experience and that of several services I have worked for.
Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study
Resuscitation. 2010 Aug;81(8):994-9
Scene time not linked to outcome in large cohort
Okay – I admit to loving this paper, partly because it blows away the dogma of short scene times and ‘scoop & run’, and the oft-quoted but obnoxious assertion that the only pre-hospital fluid of benefit is gasoline.
A massive database of 3656 sick trauma patients (SBP < 90, 10>resp rate>29, GCS≤12, or advanced airway intervention), transported by 146 EMS agencies to 51 hospitals, was analysed to identify any association between mortality and emergency medical services (EMS) timings (activation, response, on-scene, transport, and total time). Overall mortality in this group was 22%.
There was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01).
The authors state: “In this study, we were unable to support the contention that shorter out-of-hospital times… improve survival among injured adults with field-based physiologic abnormality… Our findings are consistent with those of previous studies that similarly have failed to demonstrate a relationship between out-of-hospital time and outcome using different patient populations, trauma and EMS systems, regions, data sources, and confounders”
Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort
Ann Emerg Med. 2010 Mar;55(3):235-246
Increased mortality with non-trauma centre care
A trauma database was analysed to see if patients who were transported from the field to a non-trauma centre (NTC) and subsequently sent on to a trauma centre (TC) for definitive care fared worse than similar patients who were transferred directly to the TC.
There were 1,112 patients of whom 318 (29%) were initially triaged to a NTC. After adjusting for confounders, this was associated with an increase in prehospital crystalloids (4.2 L vs. 1.4 L, p < 0.05) and a 12-fold increase in blood transfusions (60% vs. 5%, p < 0.001). Age, injury severity score, Acute Physiology and Chronic Health Evaluation II score, and time from injury to TC arrival were independent predictors of mortality. The odds of death were 3.8 times greater (95% CI, 1.6–9.0) when patients were initially triaged to a nontrauma facility.
The authors conclude: triaging severely injured patients to hospitals that are incapable of providing definitive care is associated with increased mortality. Attempts at initial stabilization at an NTC may be harmful. These findings are consistent with a need for continued expansion of regional trauma systems.
Scoop and Run to the Trauma Center or Stay and Play at the Local Hospital: Hospital Transfer’s Effect on Mortality
Journal of Trauma-Injury Infection & Critical Care September 2010;69(3):595-601
rFVIIa did not reduce trauma mortality
An industry sponsored placebo-controlled multicentre randomised controlled trial has shown no mortality reduction from recombinant activated Factor VII (rFVIIa) in patients with trauma.
rFVIIa acts physiologically by enhancing clot formation in the presence of tissue factor expressed on injured or ischemic vascular subendothelium. It also acts pharmacologically, binding directly to activated platelets, increasing thrombin burst, and promoting the formation of a stable hemostatic plug.
Blunt and/or penetrating trauma patients aged 18 years to 70 years were eligible if they had continuing torso and/or proximal lower extremity bleeding after receiving 4 units of RBCs despite standard hemostatic interventions. There was no 30 day mortality reduction, although fewer blood products were transfused from dosing to 24 hours in the rFVIIa group.
No significant difference was seen in the safety profile of rFVIIa compared with placebo.
The CONTROL trial was terminated early (573 of 1502 patients) after an interim analysis suggested a high likelihood of futility in demonstrating the primary endpoint in the blunt trauma population.
Results of the CONTROL Trial: Efficacy and Safety of Recombinant Activated Factor VII in the Management of Refractory Traumatic Hemorrhage
Journal of Trauma-Injury Infection & Critical Care September 2010 69(3):489-500