Tag Archives: Trauma

All Updates, Guidelines, ICU, Resus, Trauma

Massive haemorrhage guideline

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The Association of Anaesthetists of Great Britain and Ireland has published guidelines on the management of massive haemorrhage. Their summary:

  1. Hospitals must have a major haemorrhage protocol in place and this should include clinical, laboratory and logistic responses.
  2. Immediate control of obvious bleeding is of paramount importance (pressure, tourniquet, haemostatic dressings).
  3. The major haemorrhage protocol must be mobilised immediately when a massive haemorrhage situation is declared.
  4. A fibrinogen < 1 g.l)1 or a prothrombin time (PT) and activated partial thromboplastin time (aPTT) of > 1.5 times normal represents established haemostatic failure and is predictive of microvascular bleeding. Early infusion of fresh frozen plasma (FFP; 15 ml.kg)1) should be used to prevent this occurring if a senior clinician anticipates a massive haemorrhage.
  5. Established coagulopathy will require more than 15 ml.kg)1 of FFP to correct. The most effective way to achieve fibrinogen replacement rapidly is by giving fibrinogen concentrate or cryoprecipitate if fibrinogen is unavailable.
  6. 1:1:1 red cell:FFP:platelet regimens, as used by the military, are reserved for the most severely traumatised patients.
  7. A minimum target platelet count of 75 · 109.l)1 is appropriate in this clinical situation.
  8. Group-specific blood can be issued without performing an antibody screen because patients will have minimal circulating antibodies. O negative blood should only be used if blood is needed immediately.
  9. In hospitals where the need to treat massive haemorrhage is frequent, the use of locally developed shock packs may be helpful.
  10. Standard venous thromboprophylaxis should be commenced as soon as possible after haemostasis has been secured as patients develop a prothrombotic state following massive haemorrhage.

Blood transfusion and the anaesthetist: management of massive haemorrhage – full document

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Scene times & penetrating trauma

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An observational cohort study of penetrating trauma patients treated by the Mobile Emergency Care Unit in Copenhagen, Denmark over a seven-and-a-half year period sought to determine the effect of on-scene time on 30-day mortality.
In this setting, in cases of penetrating trauma to the chest, or abdomen, a Mobile Emergency Care Unit (MECU) and Basic Life Support unit are dispatched simultaneously, and rendezvous at the site of the incident. The MECU is staffed with consultants in anaesthesiology, intensive care and emergency medicine, as well as a specially trained ALS provider.

The physician manning the MECU administers medication and is able to perform procedures such as intubation, thoracocentesis, pleural drainage, intravenous and intraosseous access for fluid resuscitation. Although some patients were in cardiac arrest due to penetrating torso trauma (9 patients received chest compressions, and all were dead at 30 follow up), thoracotomy was not listed as a skill provided.
Of the 467 patients registered, 442 (94.6%) were identified at the 30-day follow-up, of whom 40 (9%) were dead. A higher mortality was found among patients treated on-scene for more than 20 min (p<0.0001), although on-scene time was not a significant predictor of 30-day mortality in the multivariate analysis; OR 3.71, 95% CI 0.66 to 20.70 (p<0.14). The number of procedures was significantly correlated to a higher mortality in the multivariate analysis.
The authors conclude that on-scene time might be important in penetrating trauma, and ALS procedures should not delay transport to definite care at the hospital. However their adjusted Odds Ratio for on scene time >20 minutes as a predictor of 30 day mortality was 3.71 with very wide 95% confidence intervals (0.66 to 20.70) and there were several weaknesses and confounding factors in the study which the authors acknowledge.
The only real information this study provides appears to be on the idiosyncrasies of the Copenhagen pre-hospital care system. Looking at their list of procedures and their practice of chest compressions in cardiac arrest due to penetrating trauma, it is very hard to ascertain what, if any, advantage their physicians offer over trained paramedics. As the authors point out: “Currently, strict guidelines are not practiced. Hence, the decision to treat by a ‘scoop and run’ or a ‘stay and play’ approach is at the discretion of the physician”
On-scene time and outcome after penetrating trauma: an observational study
Emerg Med J. 2010 Oct 9. [Epub ahead of print]

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Evidence refutes ATLS shock classification

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I have always had a problem with the ATLS classification of hypovolaemic shock, and omit it from teaching as any clinical applicability and reproducibility seem to be entirely lost on me. I was therefore reassured to read that real physiological data from the extensive national trauma registry in the UK (TARN) of 107,649 adult blunt trauma patients do not strongly support this classification. A key observation we regularly make in trauma patients is the frequent presence of normo- or bradycardia in hypovolaemic patients, which is well documented in the literature.

Unreferenced dogma that became viral

An excellent discussion section in this paper states: ‘it is clear that the ATLS classification of shock that associates increasing blood loss with an increasing heart rate, is too simplistic. In addition, blunt injury, which forms the majority of trauma in the UK, is usually a combination of haemorrhage and tissue injury and the classification fails to consider the effect of tissue injury‘
Testing the validity of the ATLS classification of hypovolaemic shock
Resuscitation. 2010 Sep;81(9):1142-7

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Burr holes by emergency physicians

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Emergency physicians at Hennepin County Medical Centre (HCMC) are trained in skull trephination (drilling a burr hole) for patients with coma, anisocoria and epidural (extradural) haematoma (EDH) who have not responded to osmotic agents and hyperventilation. This may be particularly applicable in centres remote from neurosurgical centres where delays caused by interfacility transfer are associated with increased morbidity and mortality.
Dr Smith and colleagues from HCMC describe a series of five talk-and-deteriorate patients with EDH who underwent skull trephination. 3 had complete recovery without disability, and 2 others had mild to moderate disability but with good to excellent cognitive function. None had complications from the procedure other than external bleeding from the already lacerated middle meningeal artery. In 4 of 5 cases, the times were recorded. Mean time from ED presentation to trephination was 55 min, and mean time from ED to craniotomy was 173 min. The mean time saved was 118 min, or approximately 2 h.
All trephinations were done by emergency physicians, who had received training in skull trephination as part of the HCMC Emergency Medicine Residency or as part of the Comprehensive Advanced Life Support (CALS) course. Training was very brief and involved discussion of the treatment of EDH, review of a CT scan of EDH, and hands-on practice on the skull of a dead sheep, using the Galt trephinator.

An excellent point made by the authors reminds us that patients with EDH who talk-and-deteriorate (those with the traditionally described “lucid interval”) have minimal primary brain injury and frequently have no brain parenchymal injury. Thus, if the EDH is rapidly decompressed, the outcome is significantly better than for deterioration due to other aetiologies. The authors recommend in EDH that the procedure should be done within 60–90 min of onset of anisocoria. A review of other studies on the procedure would suggest that case selection is critical in defining the appropriateness of the procedure: talk-and-deteriorate, coma, anisocoria, and a delay to neurosurgical decompression.
Emergency Department Skull Trephination for Epidural Hematoma in Patients Who Are Awake But Deteriorate Rapidly
J Emerg Med. 2010 Sep;39(3):377-83

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RCT of 7.5% saline in head injury

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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.

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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 Dutch Doctor

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

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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

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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

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Unexpected survivors after pre-hospital intubation

Data on patients with moderate to severe traumatic brain injury from the San Diego Trauma Registry were analysed using modified TRISS methodology to determine predicted survival, from which an observed-predicted survival differential (OPSD) was calculated. The mean OPSD was calculated as the primary outcome for the following comparisons: intubated versus nonintubated, air versus ground transport, eucapnia (PCO2 30–50 mm Hg) versus noneucapnia, and hypoxemia (PO<90 mm Hg) versus nonhypoxemia. Of note in this region is that ground EMS staff intubate without drugs, whereas air medical services use rapid sequence intubation with suxamethonium plus either etomidate or midazolam. The rationale behind this methodology was to eliminate the possible selection bias present in previous studies linking pre-hospital intubation with mortality (sicker patients are able to be intubated without drugs). A total of 9,018 TBI patients had complete data to allow calculation of probability of survival using TRISS. A total of 16.7% of patients were intubated in the field; 49.6% of these were transported by air medical providers. Patients undergoing prehospital intubation, transported by ground, with arrival eucapnia, and without arrival hypoxemia had higher mean OPSD values. Intubated patients were more likely to be “unexpected survivors” and live to hospital discharge despite low predicted survival values; patients transported by air medical personnel had higher OPSD values and had a higher proportion of unexpected survivors. No statistically significant differences were observed between air- and ground-transported patients with regard to arrival PCO2 values arrival PO2 values. Prehospital Airway and Ventilation Management: A Trauma Score and Injury Severity Score-Based Analysis
J Trauma. 2010 Aug;69(2):294-301

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Decompressive craniectomy

Neuro-folks at LAC+USC Medical Centre describe outcomes for patients with traumatic brain injury without space-occupying haemorrhage who underwent decompressive craniectomy for intracranial hypertension refractory to maximal medical therapy. Of 43 included patients, 25.6% died (11 of 43), and 32.5% (14 of 43) remained in vegetative state or were severely disabled. Favourable outcome (Glasgow Outcome Scale 4 and 5) was observed in 41.9% (18 of 43). More evidence will result from two ongoing randomised multicentre trials: the European RescueICP study and the Australian DECRA trial.

Decompressive craniectomy: Surgical control of traumatic intracranial hypertension may improve outcome
Injury. 2010 Jul;41(7):934-8