UMEM Educational Pearls - By Robert Flint

Category: Trauma

Title: Troponin in geriatric fall patients?

Keywords: troponin fall geriatric trauma (PubMed Search)

Posted: 6/20/2024 by Robert Flint, MD (Updated: 6/22/2024)
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A prospective European study of patients over age 65 presenting with a ground level fall obtained troponin levels to ascertain if myocardial infarction was a cause of the ground level fall. Troponin levels were elevated in a majority of patients however only 0.5% were defined as having a myocardial infarction. Of the 3% who died within 1 year, troponin was found to be higher than those that survived the one-year study period.  The authors concluded “Our data do not support the opinion that falls may be a common presenting feature of MI. We discourage routine troponin testing in this population. However, hs-cTnT and hs-cTnI were both found to have prognostic properties for mortality prediction up to 1?year.”

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Category: Trauma

Title: Creating the next generation of tourniquets?

Keywords: hemorrhage, tourniquet, innovation, Delphi (PubMed Search)

Posted: 6/9/2024 by Robert Flint, MD (Emailed: 6/16/2024) (Updated: 6/16/2024)
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Appropriately, a  great deal of time and energy is being expended to educate on the use of tourniquets to prevent mass hemorrhage. Are the current generation of tourniquets the best that we can have? These authors performed a Delphi study to assess needs with tourniquet design.

They concluded the next generation of tourniquets should have the following: “Capable of being used longer than 2 hours, applied and monitored by anyone, data displays, semiautomated capabilities with inherent overrides, automated monitoring with notifications and alerts, and provide recommended actions.”

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Category: Trauma

Title: Modified Brian Injury Guidelines and Transfers

Keywords: BIG, transfer, head trauma, brain injury (PubMed Search)

Posted: 6/9/2024 by Robert Flint, MD (Updated: 6/22/2024)
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This study used the modified Brain injury Guidelines retrospectively to assess whether the guidelines would have saved transfers to their level one facility safely.  They concluded the guidelines would have effectively prevented unnecessary  mBIG 1 and mBIG2 transfers with no patient harm.

TABLE 1 - Modified Brain Injury Guidelines Radiologic Stratification, as per Kahn et al.

  mBIG 1 mBIG 2 mBIG 3
Skull fracture No Non-displaced Displaced
SDH ?4 mm 4–7.9 mm ?8 mm
EDH No No Yes
SAH ?3 sulci and <1 mm Single hemisphere or 1–3 mm Bihemisphere or >3 mm
IVH No No Yes
IPH ?4 mm 4–7.9 mm ?8 mm or multiple

EDH, epidural hematoma; IPH, intraparenchymal hemorrhage; IVH, intraventricular hemorrhage; SAH, subarachnoid hemorrhage.

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Category: Trauma

Title: Oral anticoagulants and head injury

Posted: 5/29/2024 by Robert Flint, MD (Emailed: 6/1/2024) (Updated: 6/1/2024)
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In this Scandinavian study looking at 2,362 head injury patients on oral anticoagulants, the authors found only 5 cases of delayed hemorrhage and none of the five  underwent neurosurgery.  The authors concluded:

“In patients with head trauma, on oral anticoagulation, the incidence of clinically relevant delayed intracranial hemorrhage was found to be less than one in a thousand, with detection occurring four days or later after initial presentation.”

It would appear based on this study and others that it is safe to discharge these patients with a normal head CT and giving strict return precautions for headache, nausea, vomiting or other changes.

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Category: Geriatrics

Title: Importance of Frailty Screening in ED patients

Keywords: Geriatrics, frailty, screening (PubMed Search)

Posted: 5/27/2024 by Robert Flint, MD
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This Delphi study and companion editorial highlight current thought on frailty screen in emergency department patients. Key takeaways are:

  1. Those with a high degree of frailty may have different care goals and needs than those with lower frailty. 
    2. Screening should include functional status in the past 2-4 weeks. 
    3. Screening should include functional ability, cognition, mobility, medication use and social situation. 
    4. Screening is practical and can be completed quickly. 
    5. Screening should occur in the first 4 hours of an ED visit. 
    6. ED protocols designed for streamlined, single problem focused visits won’t work well for those with a high degree of frailty.

Emergency departments should be instituting procedures that incorporate screening older patients for frailty. These references are a good starting point.

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Category: Trauma

Title: Lefort Fracture Review

Keywords: Lefort, facial, trauma, fracture (PubMed Search)

Posted: 5/26/2024 by Robert Flint, MD (Updated: 6/22/2024)
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On exam, assess for facial instability and airway patency. CT scan is the imaging of choice. The higher the number, the more complex the fracture, the more unstable and the more difficult the airway managment will be. Look for open lacerations or blood in the sinuses and treat with antibiotics if these are found. Consult ENT or plastics urgently for further management. 
The reference is a nice review of these fractures    

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Category: Ultrasound

Title: Does IV contrast help identify injuries in blunt abdominal trauma patients?

Keywords: Abdomen, ultrasound, trauma, contrast (PubMed Search)

Posted: 5/23/2024 by Robert Flint, MD (Updated: 6/22/2024)
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This very small study looked at the utility of using IV contrast media to enhance abdominal sonography in identifying injuries in blunt abdominal trauma patients. The comparison was CT scanning of the abdomen to identify injuries. The study concluded:

“With the addition of contrast and careful inspection of solid organs, abdominal sonography with contrast performed by the emergency physician improves the ability to rule out traumatic findings on abdominal CT. CEUS performed by emergency physicians may miss injuries, especially in the absence of free fluid, in cases of low-grade injuries, simultaneous injuries, or poor-quality examinations.”

To me, this is a limited study and the technique is not ready for wide spread use but further study is warranted.

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Category: Trauma

Title: Vasopressors in hemorrhagic shock

Keywords: vasopressor, hemorrhage, shock, trauma (PubMed Search)

Posted: 5/19/2024 by Robert Flint, MD (Updated: 6/22/2024)
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In this podcast, the concept of vasopressor use in hemorrhagic shock is discussed.  Key take away points:

  1. US and UK literature is much less supportive of vasopressor use in hemorrhagic shock than continental European literature.
  2. Concept is while filling the tank with blood, getting some squeeze in the venous system to keep it circulating.
  3. If a young trauma patient has cool extremities, they are already vasogenic and unlikely to benefit from vasopressors. Warm extremities mean they may benefit from vasopressors.
  4. Norepinephrine is the drug of  choice. Aim for a maintenance dose of 3-5 mcg/min and no need to titrate because you are not looking for arterial constriction, just venous tone.
  5. Low dose Vasopressin drip may be beneficial as well, however more literature is needed. 
  6. Blood is still the answer in these patients! Vasopressors are an adjunct to creating a balanced resuscitation.

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This retrospective study looked at patients diagnosed with urinary tract infections receiving an IV dose of antibiotics  prior to discharge and compared ED length of stay and return visit rate. They found:

“Parenteral antibiotic administration in the ED was associated with a 60-minute increase in ED LOS compared with those who received an oral antibiotic (P < 0.001) and a 30-minute increase in ED LOS compared with no antibiotic (P < 0.001). No differences were observed in revisits to the ED at 72 hours”

Appears no benefit to the practice of IV antibiotics prior to discharge in UTI patients.

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Category: Trauma

Title: Brain Injury Associated Shock

Posted: 5/12/2024 by Robert Flint, MD (Updated: 6/22/2024)
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Hemodynamic instability in trauma patients is most often associated with hemorrhagic shock, however, there is an entity known as brain injury associated shock (BIAS). BIAS is thought to be associated with catecholamine surges secondary to brain injury.  BIAS is found in both isolated head injury pts as well as multi-trauma patients. Studies have identified BIAS in 13% of adult  trauma patients and up to 40% of pediatric major trauma patients.  
We know hypotension in brain injury worsens outcome.  We should assume hemorrhagic etiology until we prove otherwise. Once we suspect BIAS and have excluded hemorrhagic etiology our strategy should switch to  blood pressure support using non-blood product management.

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Category: Trauma

Title: Blunt Cardiac Injury

Keywords: trauma, blunt, cardiac injury, shock, thoracic (PubMed Search)

Posted: 5/5/2024 by Robert Flint, MD
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Blunt Cardiac Injury is a continuum from asymptomatic, not clinically relevant to catastrophic, life ending disease . Consider blunt cardiac injury in patients with significant force to the chest wall or sudden deceleration injuries (motor vehicle crashes, motorcycle crashes, falls from height etc.). This algorithm is helpful when working up patients suspected of having significant blunt cardiac injury. 

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In a cohort of  93,512 ED patients discharged with a diagnosis of hypertension there were 4400 who received a prescription for antihypertensives. The group receiving a prescription had fewer 30 day revisits and adverse events such as MI, CHF, etc. 

Previous study’s have found it is safe to prescribe antihypertensives from the ED. 

 This study is limited by the fact it is not a randomized control trial and there are many variables as to why the select patients received prescriptions  

The authors conclude: “Prescription antihypertensive therapy for discharged ED patients is associated with a 30-day decrease in severe adverse events and ED revisit rate.”

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A small study retrospectively looking at recorded calls to a level 1 trauma center transfer line specifically looking at patients who died or were discharged to hospice without surgical intervention found only 10% had goals of care discussed prior to transfer. Most were brain hemorrhage patients. 
As a transferring facility, clearly outlining goals of care and addressing futility of care can have a major impact on trauma transfers and the cost and family burden associated with transfers.

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PECARN  has a decision tool to identify blunt trauma patients under age 18 who are low probability for important intra-abdominal injuries. The questions to ask are:

  1.  Evidence of abdominal wall trauma/seatbelt sign
  2. GCS <14 with abdominal trauma
  3. Abdominal tenderness
  4. >1 of thoracic wall trauma, vomiting, complaint of abdominal pain, decreased breath sounds

Answering no to all yields  <0.1% chance of intra-abdominal trauma requiring intervention.  (See MedCalc link for other calculations)

A prospective validation study in the Lancet yielded 100% sensitivity and negative predictive value in 7542 patients under age 18  

This tool can likely be used to guide imaging choices in pediatric blunt abdominal trauma patients

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This study looked at survival pre and post implementation of an airway guideline for prehospital traumatic brain injury (TBI) patients who received positive pressure airway interventions.  The guideline “focused on the avoidance and aggressive treatment of hypotension and 3 airway-related goals: (1) prevention or treatment of hypoxia through early, high-flow oxygen administration; (2) airway interventions to optimize oxygenation or ventilation when high-flow oxygen was insufficient; and (3) prevention of hyperventilation or hypocapnia by using ventilation adjuncts (ie, rate timers, flow-controlled ventilation bags, end-tidal carbon dioxide monitoring).”

Post implementation, survival to admission increased in all severity levels of TBI and in the most severely injured, survival to discharge improved. 

Useful for those involved in prehospital education and as a reminder for in hospital airway management  in TBI patients.

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Category: Trauma

Title: Is a systolic blood pressure of 90 the best measure of illness in trauma patients?

Keywords: Trauma, blood pressure, shock index, predictor, mortality (PubMed Search)

Posted: 4/8/2024 by Robert Flint, MD
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Traditionally, a systolic blood  pressure (SBP) of 90 has been used as a marker of severe illness in trauma patients. This study looked at a large database and found shock index (SI) and systolic blood pressure were the best predictors of early mortality in trauma patients. 
They found: 

prehospital SI 0.9 and SBP 110,

ED SI 0.9 and SBP 112,

and

in elderly 

prehospital SI 0.8 SBP 116 

ED SI 0.8 SBP 121 

were the cutoffs to predict early mortality.  
We should rethink our protocols and approach to trauma patients using a higher systolic blood pressure than 90. Also note elderly had a different number than younger trauma patients.

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Category: Trauma

Title: No evidence to support use of markers for penetrating trauma radiographs

Keywords: Marker, penetrating trauma, radiopaque (PubMed Search)

Posted: 4/7/2024 by Robert Flint, MD (Updated: 6/22/2024)
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Using radiopaque markers such as paperclips to mark penetrating wounds prior to radiographs has been taught in trauma bays for decades. This article points out there is no evidence to support this practice and is purely based on expert opinion. With the heavy use of CT imaging to assess wound tracks, the use of markers on plain films appears to be of limited utility.

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This retrospective population cohort study looked at  first time ED visits for adolescents and young adults comparing those with visits related to alcohol to those not related to alcohol. Patients in the alcohol related visit group had  a threefold increased one year mortality rate.  Cause of death was trauma, poisoning by drug and alcohol. Risk factors include being male, age 20-29, history of mental health and having a visit for withdrawal.  

Adolescents and young adults presenting to an emergency department for an alcohol related complaint are high risk for one year mortality and deserve intervention and appropriate referral.

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Category: Trauma

Title: A benzodiazepine sparing protocol for alcohol withdrawal in trauma patients

Keywords: Alcohol, withdrawal, trauma, protocol, sparing (PubMed Search)

Posted: 3/24/2024 by Robert Flint, MD (Updated: 6/22/2024)
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This study compared  admitted trauma patients with alcohol withdrawal or those at risk of withdrawal before and after a  benzodiazepine sparing protocol (using clonidine and gabapentin) was initiated. They found a lower daily CIWA score and significantly less lorazepam use in the benzodiazepines sparing group. This sparing protocol appears to be safe and effective.

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