An Iranian study showed 10% of afebrile well appearing infants had petechiae and they remained well on follow up. This is in keeping with previous studies on both afebrile and well-appearing febrile infants.
Prevalence and location of petechial spots in well infants
Arch Dis Child. 2010 Jul;95(7):518-20
Ultrasound of intracranial haematoma
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
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.
Sucking chest wound
The old idea of three-sided taping of an occlusive dressing to treat open / sucking chest wounds has been replaced with just closing the hole with an occlusive dressing and treating any tension pneumothorax. If you don’t have an alternative then you can use an adhesive defibrillator pad to achieve this.
Tactical Combat Casualty Care
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
NICE Alcohol Guidelines
The UK’s National Institute for Health and Clinical Excellence (NICE) has produced guidelines on alcohol-related physical complications, including alcohol withdrawal syndrome, Wernicke’s encephalopathy, acute and chronic pancreatitis, and acute alcoholic hepatitis.
The acute alcohol withdrawal section includes the following recommendations:
Offer drug treatment for the symptoms of acute alcohol withdrawal, as follows:
- Consider offering a benzodiazepine or carbamazepine.
- Clomethiazole may be offered as an alternative to a benzodiazepine or carbamazepine. However, it should be used with caution, in inpatient settings only and according to the summary of product characteristics.
- Follow a symptom-triggered regimen for the drug treatment of acute alcohol withdrawal in people who are:
- in hospital or
- in other settings where 24-hour assessment and monitoring are available.
Treatment for delirium tremens or seizures
- Offer oral lorazepam as first-line treatment for delirium tremens. If symptoms persist or oral medication is declined, give parenteral lorazepam, haloperidol or olanzapine.
- For people with alcohol withdrawal seizures, consider offering a quick-acting benzodiazepine (such as lorazepam) to reduce the likelihood of further seizures.
- If delirium tremens or seizures develop in a person during treatment for alcohol withdrawal, review their withdrawal drug treatment.
- Do not offer phenytoin to treat alcohol withdrawal seizures.
Alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications
Quick reference summary
MRA for PE not very good
Wouldn’t it be great to have a reliable, radiation-free way to diagnose pulmonary embolism? Unfortunately, Magnetic Resonance Angiography is not it. In a study of 371 patients across 7 hospitals from the PIOPED III (Prospective Investigation of Pulmonary Embolism Diagnosis III) investigators, the test was technically inadequate because of poor-quality images in 25% of cases. In those tests that were readable, the sensitivity was only 78%.
Gadolinium-Enhanced Magnetic Resonance Angiography for Pulmonary Embolism: A Multicenter Prospective Study (PIOPED III)
Ann Intern Med. 2010 Apr 6;152(7):434-43
High-Dose N-Acetylcysteine Therapy for H1N1
A case report describes the improvement of a critically ill patient with H1N1 ‘flu after the administration of N-acetylcysteine in a dose similar to that used to treat paracetamol (acetaminophen) overdose.
Influenza virus induces reactive oxygen species that activate nuclear factor kappa B to produce cytokines. High-dose N-acetylcysteine, an antioxidant, is thought to reduce the production of this cytokine storm which contributes to the lethality of influenza. More studies are clearly needed.
High-Dose N-Acetylcysteine Therapy for Novel H1N1 Influenza Pneumonia
Ann Intern Med. 2010 May 18;152(10):687-8