Keywords: level I, Level II, Level III, Trauma Center, Accessibility (PubMed Search)
This study found that 22% of Americans do not have access to a trauma center within 60 minutes. Eight percent of the population relied on Level III centers. Not unexpectantly, Black and Native Americans were overly represented in the group receiveing care at Level III centers. White and Native Americans were over represented in the group without access to trauma care within 60 minutes. Most disappointing of all, none of this has changed since 2010. Some states have a robust trauma network, while others need to evaluate their needs and potentially add Level III centers to cut down the time to trauma care. What is your area's trauma coverage and what level?
Jarman, Molly P. PhD, MPH; Dalton, Michael K. MD, MPH; Askari, Reza MD; Sonderman, Kristin MD, MPH; Salim, Ali MD; Inaba, Kenji MD
Accessibility of Level III trauma centers for underserved populations: A cross-sectional study
Journal of Trauma and Acute Care Surgery: November 2022 - Volume 93 - Issue 5 - p 664-671
Keywords: Pet ownership, cardiovascular health, risk reduction (PubMed Search)
Dog ownership has become more common especially during the pandemic.
Almost 70% of US households own a pet and almost half own ≥1 dogs.
There are many health benefits associated with dog ownership including: reduced risk of asthma and allergic rhinitis in children exposed to pets during early ages, improvement in symptoms of PTSD, overall wellbeing & alleviation of social isolation in elderly individuals and increased physical activity.
The main positive impact of dog ownership seems to be in relation to cardiovascular risk including an association with lower blood pressure levels, improved lipid profile, and diminished sympathetic responses to stress.
Study: A systematic review and meta-analysis (10 studies, over 3 million participants) to evaluate the association of dog ownership with all-cause mortality, with and without prior cardiovascular disease, and cardiovascular mortality. Mean follow up 10 years.
Results: Dog ownership was associated with a 24% risk reduction for all-cause mortality as compared to non-ownership (relative risk, 0.76; 95% CI, 0.67–0.86) with 6 studies demonstrating significant reduction in the risk of death.
In individuals with prior coronary events, dog ownership was associated with an even more pronounced risk reduction for all-cause mortality (relative risk, 0.35; 95% CI, 0.17–0.69). When authors restricted the analyses to studies evaluating cardiovascular mortality, dog ownership conferred a 31% risk reduction for cardiovascular death (relative risk, 0.69; 95% CI, 0.67–0.71).
The cause of this benefit is unclear. Though some activities such as the act of petting a dog has been observed to lower blood pressure levels, the mechanism for the longer survival is likely through enhanced physical activity provided by dog walking.
Conclusion: Dog ownership is associated with reduced all-cause mortality likely driven by a reduction in cardiovascular mortality. Dog ownership as a lifestyle intervention may offer significant health benefits, particularly in populations at high-risk for cardiovascular death.
Finally, meet Winston, a French bulldog who, last night, won the National Dog Show!
This small study looked at patients with penetrating neck injuries and tried to determine in those with "hard signs" of injury (hemorrhage, expanding hematoma, or ischemia) if they required immediate operative managment. The authors concluded:
"Although hard signs in PCVIs are associated with the need for operative intervention, initial CT imaging can facilitate endovascular options or nonoperative management in a significant subgroup. Hard signs should not be considered an absolute indication for immediate surgical exploration."
This is a small study and it is unclear why some patients went to CT vs directly to the operating room. This may not be a practice changing study, but it may validate provider gestalt of CT vs direct to operating room. We can add this to the growing body of evidence that CT scanning in penetrating trauma can be used to diffrentiate who needs emergent operative intervention vs. endovascular therapy vs close observation. This study certainly opens the door for further reaserch in the area of management of penetratign neck injuries.
Reading the signs in penetrating cervical vascular injuries: Analysis of hard/soft signs and initial management from a nationwide vascular trauma database
Marrotte, Alexander MD; Calvo, Richard Y. PhD; Badiee, Jayraan MPH; Rooney, Alexandra S. MPH; Krzyzaniak, Andrea MA; Sise, Michael MD; Bansal, Vishal MD; DuBose, Joseph MD; Martin, Matthew J. MD; the AAST PROOVIT Study Group; Morrison, Jonny MD, PhD
Journal of Trauma and Acute Care Surgery: November 2022 - Volume 93 - Issue 5 - p 632-638
Keywords: Pediatric trauma, blood transfusion, ratios (PubMed Search)
Akl M, Anand T, Reina R et al. Balanced hemostatic resuscitation for bleeding pediatric trauma patients: A nationwide quantitative analysis of outcomes. Journal of Pediatric Surgery 2022. epub ahead of print.
Category: Critical Care
Keywords: Wellness, ICU, physicians, coping, COVID-19, pandemic (PubMed Search)
This was a cross-sectional survey for the Diversity-Related Research Committee of the Women in Critical Care (WICC) Interest Group of the American Thoracic Society.
Settings: 62 sites in Canada and the US
Participants: Attending physicians who worked in ICUs
· Measure of Moral Distress for healthcare professionals (27 items),
· Maslach burnout inventory (2 items),
· Stanford Professional Fulfilment Index (14-items), Brief Cope scale (14-items)
· 431 participants (approximately 43.3% response rate).
· 334 (65%) participants worked at University-affiliated hospitals
· 387 (89.0%) worked in Adult ICUs.
· Pre-pandemic, clinical days/months was 10.1 (± 14) days, and increased to 13.1 (± 16) days during the pandemic.
2. Measure of moral distress: Average score 95.6 ± 66.9 (maximum 417).
· The highest score (mean 8.5 ± 4.8), for distress, came from the item: “Follow the family insistence to continue aggressive treatment even though it is not in the best interest of the patient.” ((Family wanted to do everything).
3. Stanford Fulfillment Index:
· 387 (91.9%) intensivists found their work meaningful and 365 (86.5%) felt worthwhile at work, although most felt physically (297, 71.6%), emotionally (266 [63.8%]) exhausted.
4. Coping strategies:
· Participants resorted to a wide variety of scoping strategies ranging from Acceptance (90%), Self-distraction (85%) to Substance abuse (32%) and Denial (18%).
· Most physicians (231 [55.9%]) reported that their coping remained the same before and during the pandemic.
· Physicians are quite resilient. The authors found that physicians who worked more days experienced significantly more moral distress but with similar Stanford Professional Fulfillment score.
· This finding was similar to an exploratory analysis from a meta-analysis that showed physicians, among other healthcare workers, were less likely to have severe symptoms of PTSD (2).
· Women and physicians who were persons of color experienced significantly higher moral distress and burn-out.
There was moderate moral distress and burn-out, although physicians who worked in ICUs still achieved moderate professional fulfillment. Up to 20% of ICU physicians used a maladaptive coping strategy
1. Burns KEA, Moss M, Lorens E, Jose EKA, Martin CM, Viglianti EM, Fox-Robichaud A, Mathews KS, Akgun K, Jain S, Gershengorn H, Mehta S, Han JE, Martin GS, Liebler JM, Stapleton RD, Trachuk P, Vranas KC, Chua A, Herridge MS, Tsang JLY, Biehl M, Burnham EL, Chen JT, Attia EF, Mohamed A, Harkins MS, Soriano SM, Maddux A, West JC, Badke AR, Bagshaw SM, Binnie A, Carlos WG, Çoruh B, Crothers K, D'Aragon F, Denson JL, Drover JW, Eschun G, Geagea A, Griesdale D, Hadler R, Hancock J, Hasmatali J, Kaul B, Kerlin MP, Kohn R, Kutsogiannis DJ, Matson SM, Morris PE, Paunovic B, Peltan ID, Piquette D, Pirzadeh M, Pulchan K, Schnapp LM, Sessler CN, Smith H, Sy E, Thirugnanam S, McDonald RK, McPherson KA, Kraft M, Spiegel M, Dodek PM; Diversity-Related Research Committee of the Women in Critical Care (WICC) Interest Group of the American Thoracic Society. Wellness and Coping of Physicians Who Worked in ICUs During the Pandemic: A Multicenter Cross-Sectional North American Survey. Crit Care Med. 2022 Oct 27. doi: 10.1097/CCM.0000000000005674. Epub ahead of print. PMID: 36300945.
2. Andhavarapu S, Yardi I, Bzhilyanskaya V, Lurie T, Bhinder M, Patel P, Pourmand A, Tran QK. Post-traumatic stress in healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Psychiatry Res. 2022 Oct 8;317:114890. doi: 10.1016/j.psychres.2022.114890. Epub ahead of print. PMID: 36260970; PMCID: PMC9573911.
Keywords: musculoskeletal pain, analgesia, opioids (PubMed Search)
Opioids & NSAIDs for MSK pain in the ED: Effectiveness and Harms
Study selection: A recent systematic review in Annals of Internal Medicine attempted to evaluate the effectiveness and harms of opioids for musculoskeletal pain in the emergency department.
Included were RCTs of any opioid analgesic as compared with placebo or a nonopioid analgesic.
Conditions studied: bone injuries, soft tissue injuries, spinal pain, and mixed presentations.
Out of 2464 articles, they included 42 trials (n=6128).
Effectiveness data: Opioids were statistically but not clinically more effective in reducing pain in the short term (approximately 2 hours) versus placebo and Tylenol but were not clinically or statistically more effective than NSAIDs.
Take home: Opioids and NSAIDs may have about the same pain outcomes.
Harm data: The results on harms were very mixed. Overall, there were fewer harms with NSAIDs than opioids. However, many studies showed less of a difference. The benefit with NSAIDs due to fewer harms may be less in patients with mixed musculoskeletal conditions.
Opioids may carry higher risk for harms than placebo, Tylenol, or NSAIDs. Authors also found that an increased opioid dose may increase harms from opioids.
Limitations: Limited data on long-term outcomes and longer-term pain management
Jones CMP, Lin CC, et al. Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain: A Systematic Review and Meta-analysis. Ann Intern Med. 2022 Oct 18.
Category: Critical Care
DOSE VF (DOuble SEquential External Defibrillation for Refractory VF) Trial
Background - High quality data regarding the use of double sequential external defibrillation (DSED) and vector-change (VC) defibrillation in refractory vfib is limited
-Three-group, cluster-randomized, controlled trial in six Canadian paramedic services
-OHCA with refractory vfib (initial presenting rhythm of vfib or pulseless VT that was still present after three consecutive rhythm analyses and standard defibrillations separated by 2 minute intervals of CPR) of presumed cardiac etiology (405 patients)
-Some notable exclusion criteria:
-suspected drug overdose, hypothermia, traumatic cardiac arrest
-First 3 defib attempts in the standard (anterior-lateral) position
-If remained in vfib after three consecutive shocks randomized to one of:
1. Standard defib for all subsequent attempts (136 pts)
2. VC defib (all subsequent attempts in anterior-posterior position) (144 pts)
3. DSED (applied second set of pads in AP position) with near simultaneously (<1 sec) defib shocks (125 pts)
-Primary outcome: survival to hospital discharge
-38 patients (30.4%) in the DSED group vs. 18 (13.3%) in the standard group (RR 2.21; 95% CI, 1.33 to 3.67) (Fragility index of 9)
-31 patients (21.7%) in the VC group (RR [vs. standard], 1.71; 95% CI, 1.01 to 2.88) (Fragility index of 1)
-Notable secondary outcome: survival with a good neurologic outcome
-34 patients (27.4%) who received DSED vs. 15 patients (11.2%) with standard defibrillation (RR, 2.21; 95% CI, 1.26 to 3.88)
-68% of arrests witnessed, 58% received bystander CPR, median response time of 7.4-7.8 min
-Did not reach planned sample size 2/2 COVID pandemic
-No reporting of post-arrest care (e.g. TTM, PCI)
-Overall rates of survival and good neuro outcome on the higher side even with standard of care
-More/larger studies needed, but can consider DSED for refractory vfib, particularly if you are in a setting without more advanced circulatory support/resources
Cheskes S, Verbeek PR, Drennan IR, et al. Defibrillation strategies for refractory ventricular fibrillation. N Engl J Med. Published online November 6, 2022:NEJMoa2207304.
Keywords: DEI, Intimate Partner Violence (PubMed Search)
IPV can occur once or over years by a current or former romantic partner. Types of IPV include: Physical and/or Sexual violence, Stalking, and Psychological/Financial aggression (the use of verbal and non-verbal communication to harm mentally or emotionally and to exert control over another partner).
IPV is more prevalent that Aortic Dissection and Pulmonary Embolism combined. Think about how risky it is to NOT recognize IPV.
1:4 women and 1:10 men have been victims of IPV during their lifetime.
1:5 homicide victims are killed by an intimate partner.
Over 50% of female homicide victims are killed by a current or former intimate partner. Patients who have been strangled are 4 times more likely to be killed within a year.
Your Spidey Sense should go off when:
Once patient is identified as a victim:
Category: Pharmacology & Therapeutics
Keywords: sugammadex, TBI, neurologic exams (PubMed Search)
Sugammadex works by chelating non-depolarizing neuromuscular blocking agents (NMBA) such as rocuronium and vecuronium to reverse the effects of paralysis. Dosing per package insert varies based on time from administration of the NMBA, and side effects, although rare, include severe bradycardia, hypotension, and asystole. While sugammadex is routinely used by our anesthesia colleagues, it is rarely utilized in the emergency department (ED) or intensive care unit (ICU) setting.
A recent single-center study assessed 11 patients with either a traumatic brain injury (TBI) or intracranial hemorrhage (ICH) who received sugammadex for neurologic assessment in the ED or ICU. The median dose was 240mg and the median time since last NMBA administration was 101 minutes.
In 6/11 patients, the neurosurgical plan changed and it affirmed a poor prognosis in 3/11 patients. In the ICU patients, sugammadex was associated with reduction in unnecessary tests.
All patients had a GCS of 3T prior to administration and 67% responded to sugammadex with a median increase to 8T (P=0.0156). MAP reductions were common with a median of -8 mmHg.
Bottom Line: Sugammadex can assist in determining a neurosurgical or clinical prognosis plan in patients with TBI and ICH. Larger studies are needed in this patient population and caution should be used inpatients who are already hypotensive or bradycardic. A reasonable dose, especially when given >1h from intubation would be 200mg. The team should be available at administration to note changes in GCS.
Hyland S J, Pandya P A, Mei C J, et al. (October 19, 2022) Sugammadex to Facilitate Neurologic Assessment in Severely Brain-Injured Patients: Retrospective Analysis and Practical Guidance. Cureus 14(10): e30466. doi:10.7759/cureus.30466
Keywords: trauma, elderly, pelvic fracture, plain radiographs (PubMed Search)
This retrospective study compared plain radiographs to CT scan for the detection of pelvic fractures in patients over 65 years of age. The authors concluded “Pelvic radiographs have low sensitivity in detecting traumatic pelvic fractures. These radiographically occult fractures may be clinically significant as a cause of long-term pain and may require orthopedic consultation and possible surgical management.”
If you have a high clinical suspicion due to pain or inability to ambulate, CT may be warranted if the X-Ray is negative.
Ma, Y., Mandell, J.C., Rocha, T. et al. Diagnostic accuracy of pelvic radiographs for the detection of traumatic pelvic fractures in the elderly. Emerg Radiol (2022). https://doi.org/10.1007/s10140-022-02090-w
Keywords: rehydration, fluid management (PubMed Search)
Subcutaneous Fluid Administration for Rehydration
Caccialanza R, Constans T, et al. Subcutaneous Infusion of Fluids for Hydration or Nutrition: A Review. Journal of Parenteral and Enteral Nutrition. 2018; 42 (2): 296-307
Spandorfer PR. Subcutaneous Rehydration. Pediatric Emergency Care. 2011; 27 (3):230-236.
Category: Critical Care
Keywords: APRV, TCAV, Mechanical Ventilation (PubMed Search)
Airway Pressure Release Ventilation (APRV) is an "advanced" mode of mechanical ventilation that has long been considered a "rescue" mode of ventilation and has recently garnered much more attention during the COVID pandemic. Given the long boarding times of critical care patients in the ED with widespread improvement in sight, I wanted to send out some great resources that have come out recently delineating the difference in thought process between APRV as a "rescue" mode and as a "primary" mode.
Rory Spiegel of EMNerd and former UMMC CCM fellow has recently given a great talk on APRV and its use as a rescue mode of ventilation. See also Phil Rola's recent paper listed on that webpage.
APRV as a primary mode of ventilation has been used in the STC for years and is often referred to in the literature according to the basic ventilatory philsophy called Time Controlled Adaptive Ventilation. I realize this may be heresy to some and perhaps a curiousity to others. I recommend you take some time to peruse the following resources:
1. Dr. Habashi has done a great deal of work in the basic and translation literature on APRV and TCAV. His recent review dispels many myths and concerns surrounding APRV
Myths and Misconceptions of Airway Pressure Release Ventilation: Getting Past the Noise and on to the Signal - https://www.frontiersin.org/articles/10.3389/fphys.2022.928562/full
2. The TCAV Network has great resources for those who want to do a deeper dive into this topic.
(Can also find their recommended protocols at the Multi Trauma Critical Care education website: https://stcmtcc.com/handouts/)
Keywords: abdominal trauma, seat belt sign, Ct scan, discharge, hollow vicsus injury (PubMed Search)
Traditional trauma teaching is to admit trauma patients with abdominal wall ecchymosis caused by seat belts (seat belt sign) for fear of missing a hollow viscus injury leading to peritonitis and sepsis.
Over the past few years there have been studies pointing toward the safety of discharging blunt abdominal trauma patients with a negative CT even if they do have a seat belt sign.
In this most recent study, a negative CT was defined as
1. No free fluid (free fluid was the leading indicator of occult hollow viscus injury)
2. No solid organ injury
3. No bowel wall irregular contours, thickening, hematoma or air
4. No abdominal wall soft tissue contusion
5. No mesenteric stranding or hematoma
6. No bowel dilatation
If the patient’s CT did not include any of these findings, there was a 0.01% chance of finding a delayed hollow viscus injury. The authors conclude it is safe to discharge patients meeting these criteria.
If we include no rebound or guarding on physical exam along with a negative CT scan, it appears to be safe to discharge trauma patient’s with seat belt sign.
Category: Critical Care
Keywords: arterial line, square wave test, overdamped, underdamped (PubMed Search)
Arterial line waveform interpretation and troubleshooting are essential skills for any physician caring for critically ill patients. Overdamping and underdamping of the arterial line waveform leads to inaccurate systolic and diastolic blood pressure readings which can lead to unidentified hypertension or hypotension. In addition to scrutiny of the arterial waveform pattern, the square-wave test is a tool to identify overdamped or underdamped arterial lines.
Overdamped arterial waveforms will underestimate systolic blood pressure and overestimate diastolic blood pressure. Underdamping will have the opposite effect and overestimate systolic blood pressure and underestimate diastolic blood pressure. In both cases, the mean arterial pressure (MAP) often remains the same.
The square-wave test is a rapid flush that is applied to the arterial line for approximately 1 second. This rapid high-pressure surge results in vibration and oscillation of the arterial catheter. These oscillations are then read by the pressure transducer and the number and amplitude of these oscillations can be measured. 0 or 1 oscillations is suggestive of overdamping. 3 or more oscillations is suggestive of an underdamped system.
Major causes of an overdamped arterial line waveform include low infusion bag pressure, loose connectors, air bubbles in the tubing, blood clot in the circuit, or kinking of vascular catheter. An underdamped arterial line, however, is caused by overly stiff circuit tubing or a defective transducer.
Scrutiny of the arterial waveform and utilization of the square-wave test can be helpful to both identify erroneous arterial line blood pressure readings as well as suggest likely corrective measures.
Keywords: penetrating trauma, trauma, obesity, armour phenomenon (PubMed Search)
This meta-analyisis looked at whether obesity was a protective factor for penetrating trauma (the armour phenomenon). The authors concluded that insteaed of being protective, obesity added to morbidity and mortality.
"Obese patients that sustained stab injuries underwent more nontherapeutic operations. Obese patients that sustained gunshot injuries had longer intensive care and total hospital length of stay. Obese patients suffered more respiratory complications and were at an increased risk of death during their admission."
Further evidence that obesity is a major health concern in both medical and trauma pateints.
Keywords: hip, dislocation, DDH (PubMed Search)
Developmental dysplasia of the hip (DDH)
Keywords: intuccesption, air enema, reduction timing (PubMed Search)
Category: Critical Care
Keywords: posterior reversible encephalopathy syndrome, PRES, transplant, calcineurin inhibitors, tacrolimus, cyclosporine (PubMed Search)
Emergency physicians are familiar with posterior reversible [leuko]encephalopathy syndrome as an entity associated with untreated hypertension. It also happens to be a well-documented entity amongst solid organ transplant patients.
While the exact pathophysiology remains unclear, PRES is characterized by posterior subcortical vasogenic edema due to blood-brain barrier disruption, usually in the setting of elevated blood pressure with loss of cerebral autoregulation and/or endothelial dysfunction.
The immunosuppressants used in this population, namely calcineurin inhibitors (CNI) such as tacrolimus and cyclosporine, are thought to contribute most to this endothelial dysfunction and development of PRES in transplant patients, although high-dose corticosteroids, ischemia-reperfusion injury during surgery, and antibiotics have also been implicated.
Presentation of PRES post-transplant:
Patients with a history of solid organ transplant are at risk for PRES. While ED stabilization of these patients remains the same, recognition of PRES as a potential etiology for a transplant patient's presentation is crucial to proceed with important testing and necessary changes to their immunosuppressive regimen.
Keywords: trauma, transport, police, ALS, penetrating trauma, rapid transport, prehospital, EMS (PubMed Search)
In this prospective, observational study performed at 25 urban trauma centers, police transport (18%) was compared to Advanced Life Support (ALS) transport (81%) for mortality in penetrating trauma patients with an injury severity score over 16. There was no difference in outcome for those transported by ALS.
The authors conclude "Police transport of penetrating trauma patients in urban locations results in similar outcomes compared with ALS. Immediate transport to definitive trauma care should be emphasized in this patient population."
Category: Critical Care
Keywords: COVID, Steroids, Dexamethasone (PubMed Search)
Needless to say, therapeutics for COVID-19 pneumonia have been controversial. From hydroxychloroquine to ivermectin to remedesivir to steroids to bleach (sorry, but it had to be said...), it depends on who you ask whether medications make a difference in COVID, how much of a difference, when they should be given, and what the correct dose is.
Dexamethasone, however, ala the RECOVERY trial, is one of the relatively few therapies supported by the majority of the literature and guidelines, and generally is recommended when respiratory support is required for COVID-19 pneumonia. Further add to this that steroids for ARDS is a long-running point of critical care controversy (e.g. DEXA-ARDS, Meduri, etc), and all you need to say to an intensivist is "how much steroid should I give this patient?" and you can walk away and come back 10 minutes later to find them having not noticed you had ever left.
Wu et all did a fairly small (n=107) single-centered RCT looking at dexamethasone 6 mg daily vs dexamethasone 20 mg daily for COVID-19 requiring O2. There are several notable limitations to this study, but in short it did NOT add support to the notion that higher dose dexamethasone is a good thing for COVID-19 pneumonia. In fact, the 20 mg group trended towards worse outcomes. Small sample size, single-center, limited follow up, variable use of biologics between the groups, and failure to investigate intermediate doses between 6 and 20 are all significant limitations of this trial. Of note, DEXA-ARDS, which was conducted before COVID (2013-2018), looked at 20 mg x 5 days followed 10 mg x 5 days and DID find a significant benefit, as well as pretty darn good NNT and p values (and was a higher quality trial), so in my opinion it is also not unreasonable to use DEXA-ARDS dosing if the patient meets moderate-severe ARDS (P:F < 200) criteria, even though of course DEXA-ARDS was before COVID and Wu et al slightly contradicts it.
When faced with a very sick COVID-19 pneumonia patients many intensivists will do either RECOVERY or DEXA-ARDS dexamethasone (with relatively limited basis to choose one vs the other), and some will do Meduri protocol methylprednisolone (1-2 mg/kg/day). Relatively few nowadays will omit steroids unless there's a contraindication.
Bottom Line: It probably remains a good idea to give dexamethasone to your COVID-19 pneumonia patients with hypoxia, but you can probably stick to RECOVERY (see reference below; 6 mg daily x 10 days) dosing as opposed to higher doses. If they're REALLY sick (P:F < 200), consider DEXA-ARDS (20 mg x 5 days followed by 10 mg x 5 days) dosing.