Trauma

Frailty and Geriatric Trauma

Frailty in the elderly is now well established as a marker for adverse outcome. This retrospective study implemented an interdisciplinary care pathway for older, frail trauma patients, which included early ambulation, bowel/pain regimens, non-pharmacological delirium prevention, nutrition/physical therapy consults, and geriatrics assessments.

A significant decrease in their delirium and 30-day readmission risk was found.

The study highlights again the importance of non-pharmacological and proactive approaches to delirium and other potential outcome improvements in this vulnerable population.

link

Mortality Reduction in Military Trauma

Much of the early evidence in trauma management has been gleaned from military combat experience in recent years.

While many confounding variables exist in such a retrospective study, the conclusions appear in step with current trauma management (recent link )

The analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction.

full text

Prehospital Analgesia With Intranasal Ketamine

This randomized study compared the efficacy of intranasal Ketamine when added to Nitrous Oxide in acute pain in out-of-hospital settings.

The dose chosen was pragmatic in attempting to balance side effects and efficacy, 0.75mg/kg. Bioavailability is about 45%, blood levels are detectable in 2 mins, peak levels achieved at 30 mins, and analgesia reported for some 3 hours.

The results: Added to nitrous oxide, intranasal ketamine provides clinically significant pain reduction and improved comfort compared with intranasal placebo, with more minor adverse events.

More patients receiving ketamine reported adverse effects, primarily dizziness, feeling of unreality, and nausea. All adverse effects were considered minor, with no patients requiring any intervention.

Intranasal Ketamine has also been used successfully in pediatric sedation in the hospital setting, usually at higher doses. The intranasal route is now commonly employed for sedation and/or analgesia with agents as diverse as Midazolam, Dexmedetomidine, and Fentanyl.

full text

Major bleeding and coagulopathy following trauma

The full text European guidelines on assessing and managing coagulopathy after trauma provides a comprehensive evidence base to reflect current approaches in this area.

The issues include initial stabilization and hemorrhage control, damage control surgery, point of care coagulation assessment, use of fluids, blood and factor products, vasopressors, antifibrinolytics and many more concepts.

link

Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma has seen renewed interest recently but data is scarce on outcomes. This retrospective study casts doubt and underlines the need for more studies before employing the procedure widely.

Placement of REBOA in severely injured trauma patients was associated with a higher mortality rate compared with no REBOA. Patients in the REBOA group also had higher rates of acute kidney injury and lower leg amputations.

“There is a need for a concerted effort to clearly define when and in which patient population REBOA has benefit”.

link

Pediatric Severe Traumatic Brain Injury Guidelines

These updated guidelines on brain trauma in infants, children and adolescents help in determining our approach to brain trauma. The article does note that while progress has been made, overall the level of evidence informing these guidelines remains low. There is a need for quality randomized trials. With that in mind, the guidelines and evidence level include:

Use of ICP monitoring suggested (III)

If brain tissue oxygenation (PbrO2) used, keep > 10 mm Hg (III)

Excluding elevated ICP from a normal initial (0–6 hr after injury) CT examination of the brain is not suggested in comatose pediatric patients (III)

Routine repeat CT scan after 24 hours is not suggested for decisions about neurosurgical intervention, unless there is either evidence of neurologic deterioration or increasing ICP (III)

ICP target < 20 mm Hg suggested (III)

CPP minimum target 40 mm Hg (40-50 suggested) (III)

Bolus Hypertonic Saline (HTS) (3%) is recommended for intracranial hypertension. Recommended 2 to 5 mL/kg over 10–20 minutes (II)

Continuous infusion HTS is suggested in patients with intracranial hypertension. Suggested 3% saline between 0.1 and 1.0 mL/kg of body weight per hour, administered on a sliding scale. The minimum dose needed to maintain ICP less than 20 mm Hg is suggested (III)

Bolus of 23.4% HTS is suggested for refractory ICP. The suggested dose is 0.5 mL/kg with a maximum of 30 mL (III)

Avoid bolus administration of midazolam and/or fentanyl during ICP crises due to risks of cerebral hypoperfusion (III)

Prophylactic seizure treatment is suggested to reduce the occurrence of early (within 7 d) seizures (III)

Hyperventilation to a PaCO2 less than 30 mm Hg in the initial 48 hours not recommended. If used for refractory intracranial hypertension, advanced neuromonitoring for evaluation of cerebral ischemia is suggested (III)

Prophylactic moderate (32–33°C) hypothermia is not recommended over normothermia (II)

Moderate (32–33°C) hypothermia is suggested for ICP control, with slow rewarding 0.5-1° per 12 – 24 h (III)

High-dose barbiturate therapy is suggested in hemodynamically stable patients with refractory intracranial hypertension despite maximal medical and surgical management (III)

Decompressive craniectomy (DC) is suggested to treat refractory neurologic deterioration, herniation, or intracranial hypertension (III)

Decompressive craniectomy is suggested to treat refractory neurologic deterioration, herniation, or refractory intracranial hypertension (III)

Use of an immune-modulating diet is not recommended (II)

Initiation of early enteral nutritional support (within 72 hr from injury) is suggested (III)

The use of corticosteroids is not suggested to improve outcome or reduce ICP (III)

Full evidence link

Initial Care of the Severely Injured Patient

A subscriber article from NEJM updates current approaches to major trauma.

Tourniquets fell out of favour due to limb ischemia in the past but with modern rapid evacuation are back as a standard of care to prevent limb exsanguination, along with hemostatic dressings.

Antifibrinolytics are now recognized as reducing hemorrhage and mortality but critically time sensitive, only recommended in the first 3 hours after trauma. Treatment with tranexamic acid (1 g administered IV over 10 minutes, followed by a 1 g intravenous infusion over 8 hours is recommended.

The long held ATLS advice to administer 2 liters of crystalloid fluid as initial hypotension treatment is now considered obsolete. Permissive hypotension until surgical control is accepted, with judicious plasma or blood for hypotension < 80 systolic.

Damage control surgery – stopping bleeding and contamination for more severe injury is performed without initial abdominal closure while Critical Care stabilizes hypothermia, acidosis and coagulopathy prior to subsequent surgeries.

The “golden hour’ concept is discussed, involving early hemorrhage control, including initial care, triage, rapid evacuation, and resuscitation.

Initial 1:1 ratio of blood:plasma is now standard, with rapid infusion by warming device. It is still not a substitute for surgery to control hemorrhage.

FAST (focused abdominal sonography for trauma), often including the chest, is now ubiquitous in the ER, as unstable patients cannot be sent to CT scanning departments.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging technique to control noncompressible, intracavitary hemorrhage below the diaphragm. Limb or bowel ischemia limits the time of occlusion.

NEJM link

Erector Spinae Block for Rib Fractures

Another study uses an arguably simpler block than paravertebral for rib fractures. It quantified incentive spirometry pre and post block.

The majority had continuous catheters and the study found that erector spinae plane blocks were associated with improved inspiratory capacity and analgesic outcomes following rib fracture, without haemodynamic instability.

link

Rib Fractures and Paravertebral Catheters

This retrospective study over four years showed almost half of patients with rib fractures had ultrasound guided paravertebral catheters inserted by the fourth year. Only minor complications were reported. The conclusion was that “paravertebral catheters are a safe and effective technique for rib fracture analgesia; however, our data were insufficient to demonstrate any improvement in mortality.”

They seem clearly useful as part of an opioid free or sparing approach to rib fractures.

link

Traumatic Brain Injury and Goal Directed Therapy

“The Progesterone for the Treatment of Traumatic Brain Injury III clinical trial rigorously monitored compliance with goal-directed therapy after traumatic brain injury. Multiple significant associations between physiologic transgressions, morbidity, and mortality were observed. These data suggest that effective goal-directed therapy in traumatic brain injury may provide an opportunity to improve patient outcomes”

This was a planned secondary analysis and the physiologic transgressions referenced include deviations like anemia (Hb <8), hyperglycaemia, low mean (< 65) or systolic blood pressure, raised INR > 1.4, and raised ICP > 20

link