Author- Steve Schenkel, MD MPP Professor of Emergency Mediciner at UMEM:
A recent Annals of Emergency Medicine Publication (here https://www.annemergmed.com/article/S0196-0644(22)01276-8/fulltext) tested a predictive rule for Likelihood to Occupy an Inpatient Bed associated with a common Electronic Health Record.
At the individual patient level, the score performed ok. Depending on the chosen threshold, it traded off sensitivity and specificity and generally became more accurate the longer the patient was in the ED.
The authors and the associated editorial (here https://www.annemergmed.com/article/S0196-0644(22)01401-9/fulltext) suggest a different, potentially more beneficial use: to allow aggregate prediction of admissions across an entire department and therefore prompt earlier planning to prevent crowding on account of boarding.
The takeaway: Administrative prediction rules oriented toward individual patients may be more meaningfully used to predict resource needs, including in-patient beds, across the ED population.
Use of intravenous lidocaine has been proposed as an adjunct/replacement for opioids in trauma patients with rib fractures. These small studies show a signal that the use of lidocaine decreased the need for opiate pain medication in this cohort of patients. Larger studies are needed, however, trauma surgeons maybe reaching for intravenous lidocaine in patients they are admitting with rib fractures. Also, transdermal lidocaine patches have been shown to have a similar effect in this patient cohort. “In admitted trauma patients with acute rib fractures not requiring continuous intravenous opiates, lidocaine patch use was associated with a significant decrease in opiate utilization during the patients’ hospital course.” 3
Recognizing that the studies discussing emergency department thoracotomy (ERT) in traumatic injuries are performed at large institutions where surgical back-up is available, emergency physicians should be familiar with the indications of emergency department thoracotomy in the setting of trauma. An informed decision should be made based on resources available along with the limited literature available to make the best decision for the patient and staff present.
Adding to last week’s pearl of no cardiac activity and no pericardial fluid on FAST exam, what else prognosticates intact survival? A 2020 paper concluded “ERT had the highest survival rates in patients younger than 60 years who present with signs of life after penetrating trauma. None of the patients with blunt trauma who presented with no signs of life survived.” 1A review in Trauma last month recommended: “Based on our scoping review of existing literature, we can conclude three major findings in the context of RT: (1) Resuscitative Thoracotomies (RT) performed in the setting of blunt trauma have a worse prognosis compared to patients undergoing RT for penetrating injuries, (2) procedures that have the potential to delay patient transport to hospital, such as intubation, may significantly increase the risk of mortality and (3) the presence of signs of life or hemodynamic stability in the prehospital or in-hospital setting are positive survival predictors in the setting of RT” 2 The best outcome is in patients brought immediately to an ED (preferably a trauma center) with limited on scene time. Police transport had a major association with survival in these patients. Stab wounds have the highest rate of intact survival.
For those at non-trauma centers, have a conversation within your ED group as well as with general surgeons (if available) to decide ahead of time if this procedure will be utilized in the setting of traumatic cardiac arrest and in which patient population.
Take away: Be prepared (with blood products and/or vasopressors) for hypotension in trauma patients post-intubation particularly the elderly and severely injured. Pre-intubation tachycardia predicts post-intubation hypotension. Resuscitation with saline in traumatically injured patients is inferior to blood products or permissive hypotension.
A UK study retrospectively looked at trauma patients undergoing helicopter based emergency medicine intubation using induction agents of fentanyl, ketamine, and rocuronium for hypotensive episodes. “This study demonstrates that more than one in five patients who undergo PHEA have a new episode of significant hypotension within the first ten minutes of induction. Increasing patient age, multi-system injuries, a higher baseline heart rate, and intravenous crystalloid administration by the ambulance service before HEMS arrival were all significantly associated with PIH, whereas the addition of fentanyl to the induction drug regime was not.”
Bottom Line: Lack of pericardial fluid or cardiac motion on FAST exam leads to no intact survivors for ED RT for trauma.
Zone 1 REBOA may be as good or better than ED RT for those requiring aortic occlusion after trauma.
Intact neurologic survival after emergency department resuscitative thoracotomy (ED RT) for trauma is low. Best outcomes have been shown for stab wounds to the chest with loss of vital signs in the ED or just prior to ED arrival. Worst outcomes are for blunt trauma with loss of vital signs in the field.
Two studies help us further evaluate the use of emergency department resuscitative thoracotomy. Inaba et al. illustrate in patients undergoing a FAST exam prior to or concomitant with ED RT “The likelihood of survival if pericardial fluid and cardiac motion were both absent was zero.” Cralley et al. compared survival after ED RT to Resuscitative Endovascular Balloon Occlusion of the Artery (REBOA) zone 1 (above celiac axis) and found REBOA was as good or better when used in centers with experience with both procedures. They advocate for a randomized trial to compare the two procedures further.
A study looking at 177 trauma patients (predominately skiing injuries) treated with oral trans mucosal fentanyl (600 and 800 mcg dosing) found a statistically and clinically significant reduction in pain. This therapy could be an adjunct to patients who require pain relief but IV access is delayed for various reasons.
This study looked at 20 years of death by firearm and stratified the location of death from urban to rural. The authors concluded:
“Descriptively, in all county types and both decades of the study, per capita gun suicides were more common than per capita gun homicides, and the most rural counties had higher rates of firearm death compared with the most urban counties. Firearm death rates were meaningfully higher in 2011-2020 compared with 2001-2010, primarily because of an increase in gun suicides.”
It is time to abandon the ABC's that ATLS teaches and move to hemorhage control (circulation) as well as resucitation before we deal with airway in the majority of trauma patients. Tounriquets save lives. Pelvic binders save lives. Blood transfusion (whole blood) saves lives. Poisitive presssure ventilation, sedativies, and decreasing sympathetic drive in hypoternsive patients makes their hypotension worse.
Please consider changing to a CAB approach to the hyhpotensive trauma patient.
Does IV contrast help to make the diagnosis in ED abdominal pain patients undergoing CT scan? The authors of this study tried to answer that question. This study was a retrospective diagnostic accuracy study looking at contrast enhanced vs. non-enhanced images in 201 consecutive ED patients. The study demographics were:
“There were 201 included patients (female, 108; male, 93) with a mean age of 50.1 (SD, 20.9) years and mean BMI of 25.5 (SD, 5.4).”
The study found: “Unenhanced CT was approximately 30% less accurate than contrast-enhanced CT for evaluating abdominal pain in the ED.”
This study is limited by the small size, the overwhelming female to male inclusion, the reliance on radiology reading as the gold standard of pathology, and the retrospective nature. It does, however, show that there is a need for further study and at this time giving IV contrast has limited down side and potentially improves diagnostic accuracy of abdominal CT scans.
Delayed sequence intubation can be valuable in the agitated, combative trauma patients who will not tolerate pre-intubation pre-oxygenation. We know peri-intubation hypoxia leads to significant morbidity and mortality. DSI offers us an option to avoid peri-inubation hypoxia.
This study randomized 200 trauma patients into a rapid induction group (Ketamine followed immediately by succinylcholine with immediate intubation) vs. delayed induction group (Ketamine followed by a 3-minute oxygenation period followed by succinylcholine, followed by intubation). The authors found: “Peri-intubation hypoxia was significantly lower in group DSI (8 [8%]) compared to group RSI (35 [35%]; P = .001). First-attempt success rate was higher in group DSI (83% vs 69%; P = .02).”
This extensive review looks at the literature surrounding vasopressors in trauma. Take away points are:
1. Most of the studies were done when the use of crystalloid was still being used as initial resuscitation fluid instead of blood.
2. Use of whole blood and mass hemorrhage protocols are not reflected in the literature regarding vasopressor use.
3. There are physiologic reasons vasopressors could be useful, particularly in head injured patients where we want increased mean arterial pressures.
4. European guidelines include vasopressor use whereas American ones do not.
5. Vasopressin and norepinephrine appear to be the vasopressors of choice if using a vasopressor in a trauma patient.
6. We need better studies looking at this topic
7. We need better studies looking at permissive hypotension in trauma now that our resuscitative strategy emphasizes mass hemorrhage protocol of blood, blood products, TXA and hemorrhage control.
8. As with all things in medicine, never say never.
This is a review of the literature surrounding using mechanical compression devices for in-hospital cardiac arrest. The bottom line is there isn’t much evidence to support the use of these devices and there is scant literature in general on this topic. This is an area in need of further research
In a systematic review looking at patients over age 65 who sustained a cervical spine injury from a low-level fall, there was a 3.8% prevalence of injury identified. The paper could not correlate injury with GCS level or altered level of consciousness due to the quality of the data available.
Bottom line again is patients over age 65 with low-level falls should be considered to have significant injury until proven otherwise.
This paper looks at the possibility of intramuscular tranexamic acid (TXA) administration. Pharmacologic studies support this route as giving correct drug bioavailability to control hemorrhage. Several London, England pre-hospital services have begun using intramuscular TXA for trauma patients when intravenous access cannot be quickly obtained. This paper suggests 500 mg intramuscular injection dosing.
A retrospective review of patients over age 13 presenting to one urban level one trauma center and one urban community hospital looked at traumatic injuries in patients presenting for sexual assault. They looked at 157 patients and found 61% of assailants were acquaintances, 22% strangers, and 15% intimate partners. One third of all patients had some traumatic injury however only 12 patients has serious injuries such as non-fatal strangulation or a fracture. Assault by an intimate partner was more likely to lead to injury/trauma including non-fatal strangulation. Drug and alcohol use was not associated with presence of injury.
This study is a secondary analysis of another studying looking at hypertonic saline in traumatic brain injury (TBI) making it not the most robust study however it found that TBI patients who’s PaO2 dropped below 100 had a worse outcome than those whose PaO2 did not fall below 100.
Bottom line: This is a reminder that traumatic brain injury patients do not do well with hypoxia or hypotension even if transient (during intubation, etc.). Pre-oxygenate and resuscitate prior to intubation and maintain oxygen saturations in the mid-90s for your traumatic brain injured patients. This applies to prehospital, emergency department, and ICU settings
