This review article reminds us that abdominal hypertension and compartment syndrome need to remain on our differential diagnosis for critically ill and injured patients. Pressure is measured with an intra-bladder catheter. Normal pressure is 5-7 mm HG. Sustained over 12 mm Hg is hypertension and sustained over 20 mm Hg is compartment syndrome.
This study looking at pre and post-phenobarbital order set use to treat inpatient alcohol withdrawal syndrome found:
“AWS symptoms resolved more rapidly after implementation, with a 4.2- to 5.0-point reduction in daily maximum CIWA-Ar scores at 24 to 96 hours from hospital presentation, 30.1-hour reduction in AWS treatment duration (95% CI, 16.7-43.5 hours), and 2.2-day reduction in time to hospital discharge (95% CI, 0.7-3.7 days). Safety outcomes did not significantly differ before and after implementation.”
Remember phenobarbital can be used for alcohol withdrawal for our ED patients as well.
Here is the protocol:
Nursing
Vital signs 10 minutes after phenobarbital loading dose
Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-Ar) every 1-4 hours based on score
Loading Dose
Phenobarbital 15 mg/kg intravenous piggyback (recommended for most patients)
Phenobarbital 10 mg/kg intravenous piggyback (low risk or heavily pretreated with benzodiazepines)
As-Needed Doses
Phenobarbital 130 mg intravenous twice as needed for uncontrolled agitation or CIWA-Ar ?15
Phenobarbital 260 mg intravenous once as needed for uncontrolled agitation or CIWA-Ar ?15
This systematic review of the literature found four findings associated with intercranial hemorrhage in older patients after a fall. They were: focal neurologic findings, external signs of trauma on the head, loss of consciousness, and male sex.
We still need better studies as this is completely based on the quantity and quality of literature available to review. This information is not enough to change liberal CT imagining in older patients after a fall. It is the beginning of the study process.
The National Association of EMS Physicians, the American College of Surgeons Committee on Trauma, and the American College of Emergency Physicians recommends:
• Prehospital TXA administration may reduce mortality in adult trauma patients with hemorrhagic shock when administered after lifesaving interventions.
• Prehospital TXA administration appears safe, with low risk of thromboembolic events or seizure.
• The ideal dose, rate, and route of prehospital administration of TXA for adult trauma patients with hemorrhagic shock has not been determined. Current evidence suggests EMS agencies may administer either a 1-g intravenous/intraosseous dose (followed by a hospital-based 1-g infusion over 8 hours) or a 2-g intravenous/intraosseous dose as an infusion or slow push.
• Prehospital TXA administration, if used for adult trauma patients, should be given to those with clinical signs of hemorrhagic shock and no later than 3 hours post-injury. There is no evidence to date to suggest improved clinical outcomes from TXA initiation beyond this time or in those without clinically significant bleeding.
• The role of prehospital TXA in pediatric trauma patients with clinical signs of hemorrhagic shock has not been studied, and standardized dosing has not been established. If used, it should be given within 3 hours of injury.
• Prehospital TXA administration, if used, should be clearly communicated to receiving health care professionals to promote appropriate monitoring and to avoid duplicate administration(s).
• A multidisciplinary team, led by EMS physicians, that includes EMS clinicians, emergency physicians, and trauma surgeons should be responsible for developing a quality improvement program to assess prehospital TXA administration for protocol compliance and identification of clinical complications.
These authors reiterate principles that have been discussed previously regarding intubation in head/brain injured patients.
-Avoid hypoxia with preoxygenation
-Avoid hypotension by fluid resuscitation/vasopressors/blood in the correct clinical setting
-Use hemodynamically neutral induction agents such as Etomidate or Ketamine (it is ok use this in head injured patients!)
-Video laryngoscope gives best first pass success which minimizes hypoxia/raised ICP
-Post-Intubation aim for eucapnia (avoid hyperventilation)
-Use adequate post-intubation sedation to avoid raised ICP
From this position statement on management of HTN key points are beta blockers are a second line medication choice, dual therapy in a combination pill is often warranted and primary medications should be thiazides, long acting calcium channel blockers, ACE or Arbs.
While this study is imperfect and may not be measuring patient important outcomes, it does fit with other literature on the topic of intensive blood pressure control in patients with acute ischemic stroke. These patients were randomized to aggressive blood pressure control (SBP 130-140 within 1 hour of TPA administration continued for 72 hours) or the standard SBP <180. Repeat imaging was performed to assess the degree of cerebral swelling that each group developed. There was no difference in swelling between the two groups.
Take away is aggressive blood pressure management in this group of ischemic stroke patients does not seem to be beneficial.
This editorial reminds us about the use of frailty measures in the geriatric population.
The authors write that frailty “describes a state of vulnerability causing an impaired ability to maintain homeostasis due to reduced physiologic reserve. Frailty is associated with disability, multimorbidity, cognitive impairment, institutionalization, and mortality. **Analogous to troponin testing, frailty assessment has been used to risk stratify older adults.**”
They also remind us that frailty is a syndrome not a disease in and of itself. It impacts how disease affects the patient and should inform our care, but not generate ageism or therapeutic nihilism.
Once frailty is identified, it allows for further assessment looking at the “Geriatric 5M's framework: Mind, Mobility, Medications, Multicomplexity, and Matters Most.”
In this retrospective study at 103 hospitals of patients over age 65 who received a head CT:
5948 total patients
3177 (53%) were on at least one anti-thrombotic (warfarin, direct oral anticoag, or anti-platelet agent)
781 (13%) had inter cranial hemorrhage. (ICH)
No form of AC showed an increased risk of ICH.
Risk factors for ICH were: “a high-level fall, a Glasgow coma scale of 14, a cutaneous head impact , vomiting, amnesia, a suspected skull vault fracture or of facial bones fracture”
To me this really begs the question are we ordering head CTs on the right patients? Was there any indication of head injury in these patients or did the mere presence of a patient on AC prompt the imaging order? More work should be done to prevent needless imaging cost, patient time in the emergency department and radiologist work load/turn around time.
Over 300 ml of blood on a chest CT in a traumatically injured patient requires a tube thoracostomy. How do you calculate 300 ml of blood on a chest CT?
This review article answers the basic question: when does a traumatic pneumothorax require tube thoracostomy?
“A pneumothorax greater than 20% of the thoracic volume on chest x-ray or greater than 35 mm on CT, measured radially from the chest wall to the lung parenchyma, should be treated with tube thoracostomy. Pneumothoraces smaller than this may be observed; approximately 10% of these will fail observation and require tube thoracostomy treatment.”
This paper outlines the long term effects of surviving a gunshot wound. The authors conclude:
“Firearm injury survivors frequently experience chronic pain, nerve injury, retained bullet fragments that may cause lead toxicity, physical limitations, and PTSD and are at risk for reinjury. In addition to supportive medical and psychiatric care, survivors of firearm injury may benefit from health care–based violence intervention programs.”
Looking at a trauma database of over 3 million patients, 1% presented with prehospital hypothermia (<35 degrees C). These patients had longer hospital stays, higher resource utilization and higher mortality. Even isolated head injury patients with hypothermia had worse outcomes. Rewarming did increase survival slightly for all patients.
Take away: rewarm hypothermic trauma patients as soon as possible to improve mortality.
A scoping review of the literature regarding anxiety in older patients found the follow areas had the biggest impact on anxiety level:
“The variables most strongly associated with anxiety—either as risk or protective factors—are age, female gender, physical activity, physical health conditions, depression, perceived and family support, and social participation. New variables linked to anxiety include body mass index (BMI) and dietary habits.”
Asking questions related to these areas can give you a better picture of your patient’s risk for anxiety.
Looking at 140 patients retrospectively who had abdominal gunshot wounds with associated fractures, prophylactic antibiotics longer than three days did not offer any benefit in preventing fracture infection. Only two patients experienced fracture related infections and 65 total experienced any infection related complications.
From and ED standpoint, it appears reasonable to give a dose of antibiotics in this very rare subset of gunshot wound patients.
This prospective cohort study from Germany found an under triage rate of 58% of trauma patients over 70 years presenting to 12 trauma centers. One area that consistently lead to undertriage was not using a systolic blood pressure under 110 as a criteria for trauma team activation.
The older cohort had 3 times the mortality than younger, were more likely not to arrive by helicopter and mechanism was more commonly ground level fall. This study echos many others in USA and Australia. Better trauma triage criteria are needed for older patients.
A retrospective, single Australian center review of 300 patients who had blunt cerebral vascular injuries found:
-9.8% had an inpatient CVA
-Most occurred in first 72 hours
-Those receiving no anti coagulation or antiplatelets had 28% CVA incidence.
-Those treated had a 3.6% CVA incidence (anti platelets were better than anti coagulation)
-Carotid artery injury was less common than vertebral artery but had higher frequency of CVA
-associated factors: low GCS, rib fractures, severe trauma
Take away: non-treatment of blunt cerebral vascular injuries had higher inpatient stroke risk. Antiplatelet agents such as aspirin and Clopidogrel performed better than anticoagulants
This paper looked at the literature regarding missed injuries in trauma patients. Missed injuries was defined as an injury discovered after the patient was discharged. Most of the missed injuries and causes are not novel but are worthy of remembering.
They suggest a Trauma Tertiary Survey helps prevent missed injury. “Tertiary Survey (TTS), which includes a thorough in-hospital re-examination and a review of diagnostic investigations within the first 24 h, has been shown to significantly reduce the occurrence of missed injuries (1–9 %) in severe trauma patients found after a primary and secondary survey.” This concept is similar to a discharge time out in emergency medicine where all data is reviewed, viral signals are confirmed normal and a team discharge is performed.
The paper offers these suggestions to avoid missed injuries:
1.
Standardize Tertiary Trauma Surveys (TTS).
2.
Be Cognizant of Cognitive Biases (e.g., Anchoring Bias).
3.
Repeat Imaging When Clinically Indicated.
4.
Use Protocolized Imaging Techniques (CT/MRI).
5.
Ensure Radiology-Trauma Communication.
6.
Prioritize High-Risk Populations.
7.
Implement Peer Review or Double-Check Systems.
8.
Encourage a Culture of Collaboration and Humility.
9.
Limit Provider Fatigue and Overload.
10.
Create Tailored Checklists for Subtle Injuries.
Outcomes in traumatic brain injury are improved when physiologic homeostasis is achieved as soon as possible after injury. Here are the American College of Surgeons’ recommendations. Note SBP over 110 and a hemoglobin over 7. A study looking at a more liberal transfusion target showed worse ARDS and no mortality benefit.
An open label pragmatic study in 29 Japanese hospitals randomized septic shock patients over age 65 to either a high (MAP 80-85) or control (65-70) group. They then looked at all cause 90 day mortality. The study was stopped early due to a significantly higher percentage of mortality in the higher MAP group.
The study isn’t blinded and is only done in one country, however it does raise the question of what is the ideal MAP for older septic shock patients.
