An algorithm for the management of patients with stab wounds to the neck has been proposed by authors of a review of the topic.
‘Hard’ signs of vascular injury include severe active bleeding, unresponsive shock, evolving stroke, and large/expanding haematoma. ‘Soft’ signs include a non-expanding moderate haematoma, a bruit/thrill, or a radial pulse deficit (although some consider the latter two to be hard signs). Mentioned in the text, but omitted from the algorithm, is the option of placing a Foley catheter into the wound and inflating the balloon to blindly control bleeding in a crashing haemodynamically unstable patient in order to buy time to get to the operating room.
Review article: Emergency department assessment and management of stab wounds to the neck.
Emerg Med Australas. 2010 Jun;22(3):201-10
Tag Archives: Trauma
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
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
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
Exsanguinating pelvis – occlude the aorta
Some patients with life-threatening arterial haemorrhage from a pelvic fracture may be peri-arrest prior to transfer to the angiography suite. French authors describe their use of a balloon catheter to occlude the infrarenal aorta to allow resuscitation to achieve sufficient stability for the transfer. As well as exsanguinating pelvic haemorrhage, intra-aortic balloon occlusion has already been described for the treatment of hemorrhagic shock in the case of ruptured abdominal aortic aneurysm, in abdominal trauma, in gastrointestinal bleeding, and in postpartum hemorrhage.
Features of note regarding the technique include:
- it can be done blind (without radiological guidance)
- it can be done prior to transfer to a centre with interventional radiology
- it can be done in cardiac arrest (and has resulted in ROSC and subsequent survival)
The authors are at pains to point out that the intra-aortic balloon occlusion method described in the study ‘should be reserved to patients in critically uncontrollable hemorrhagic shock (CUHS) and is not a first-line treatment of pelvic fractures in hemorrhagic shock.’
Intra-Aortic Balloon Occlusion to Salvage Patients With Life-Threatening Hemorrhagic Shocks From Pelvic Fractures
J Trauma. 2010 Apr;68(4):942-8.
Tranexamic acid saves lives in trauma
A convincing, practice-changing trial is a rare thing in major trauma, but here comes a biggie:
The CRASH-2 trial recruited over 20 000 patients from 40 countries (sadly excluding the US because the trial investigators couldn’t afford the insurance – a sign that no large drug company was funding this trial of an inexpensive therapy).
The antifibrinolytic drug tranexamic acid was compared with placebo in adult trauma patients with, or thought to be at risk of, significant haemorrhage. Clinicians were blinded to the intervention and the primary outcome was death in hospital within 4 weeks of injury. Secondary outcomes were vascular occlusive events (myocardial infarction, stroke, pulmonary embolism, and deep vein thrombosis), surgical intervention (neurosurgery, thoracic, abdominal, and pelvic surgery), receipt of blood transfusion, and units of blood products transfused. Treatment groups were balanced with respect to all baseline patient characteristics.
All-cause mortality was significantly reduced with tranexamic acid and the risk of death due to bleeding was significantly reduced. Vascular occlusive events (fatal or non-fatal) did not differ significantly between the groups (and were fewer in the tranexamic acid group compared with the placebo group).
All cause mortality in the tranexamic acid group was (1463/10 060) = 14·5% and in the placebo group was (1613/10 067) = 16·0%. So absolute risk reduction is 1.5% and Number Needed to Treat = 67.
The same trials group is investigating the effect of tranexamic acid in post-partum haemorrhage, in a study known as the WOMAN Trial
Take Home Message: the early administration of tranexamic acid to trauma patients with, or at risk of, significant bleeding reduces the risk of death from haemorrhage with no apparent increase in fatal or non- fatal vascular occlusive events. All-cause mortality was significantly reduced with tranexamic acid.
Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial
The Lancet, Early Online Publication, 15 June 2010
Traumatic Aortic Injury
Two recent papers expand our knowledge of blunt traumatic aortic injury.
UK crash data identified risk factors for low impact blunt traumatic aortic rupture, or ‘LIBTAR’ (crashes at relatively low speed): age >60, lateral impacts and being seated on the side that is struck are predictive of LIBTAR. This study should raise our index of suspicion of aortic injury in low-impact scenarios since low-impact collisions account for two thirds of fatal aortic injuries.
Low-impact scenarios may account for two-thirds of blunt traumatic aortic rupture
Emerg Med J. 2010 May;27(5):341-4
Data from the Victorian State Trauma Registry showed pre-hospital mortality from traumatic thoracic aortic transection was approximately 88.0%, whereas patients who survive to reach hospital have a much lower hospital mortality (33.3%, and once patients who arrived in extremis were removed hospital mortality was reduced to 5.9%). Repair was performed in 46 patients, with 22 receiving initial endovascular repair and 24 receiving initial open repair. Mortality rates following surgery were 9.1% and 16.7%, respectively.
The majority of patients arriving at hospital (57.1%) had an ISS of over 40 highlighting that these patients are unlikely to have only one serious injury and are likely to be more seriously injured than the normal trauma population. An ISS greater than 40 was a main predictor of mortality before repair.
Aortic transection: demographics, treatment and outcomes in Victoria, Australia
Emerg Med J. 2010 May;27(5):368-71
The myth of ketamine and head injury
A literature review addresses the myth that ketamine is contraindicated in head injured patients. They summarise articles from the 1970’s which identified an association between ketamine and increased ICP in patients with abnormal cerebrospinal fluid pathways (such as those caused by aqueductal stenosis, obstructive hydrocephalus and other mass effects). In more recent studies no statistically significant increase in ICP was observed following the administration of ketamine in patients with head injury; some of the studies showed a net increase in CPP following ketamine administration. They list ketamine’s stable haemodynamic profile and potential neuroprotective effects as further rationale for its use.
The authors boldly summarise:
‘Based on its pharmacological properties, ketamine appears to be the perfect agent for the induction of head-injured patients for intubation.’
Myth: ketamine should not be used as an induction agent for intubation in patients with head injury
CJEM. 2010 Mar;12(2):154-7