Trauma

Mental Health after Major Trauma

A retrospective analysis in Ontario showed that survivors of major trauma are at a higher risk of developing mental health conditions or death by suicide in the years after their injury. Thise with pre-existing mental health disorders or who are recovering from a self-inflicted injury are at particularly high risk.

This study adds to the huge developing body of evidence of health issues after critical illness – mental, PTSD, neurocognitive, other health issues.

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Prothrombin Complex Concentrates For Vitamin K Antagonist Reversal

The following figures emerge from this Anesthesiology review: Annual rates of major hemorrhagic events ranged from 1.0 to 7.4% in a systematic review of patients with atrial fibrillation receiving vitamin K antagonist therapy, while rates of intracranial hemorrhage in the same population ranged from 0.1 to 2.5%. Major bleeding occurred in 3.3% of warfarin-treated patients undergoing elective surgery, but 21.6% in patients in emergency surgery

Fresh Frozen Plasma brings risks of fluid overload, lung injury, infection and is slow to act and less effective. Vitamin K alone is feasible only when surgery can be delayed 24-48 hours.

Current guidelines recommend prothrombin complex concentrates (PCC), specifically four-factor prothrombin complex concentrates, with concomitant intravenous vitamin K, as the preferred therapy for urgent vitamin K antagonist reversal, which are effective in 30 minutes or so. PCCs reduces bleeding and some studies suggest mortality also. Many studies show them to be more effective than FVIIa. Thromboembolism has not been found to be increased to date.

Whereas specific reversal agents are in use or being introduced for Factor Xa Inhibitors and Direct Thrombin Inhibitors, PCCs may be worth considering for hemorrhage in such patients in the interim although their efficacy is very variable for non-vitamin K antagonist reversal.

The full review surveys all the published studies and also examines evidence in various scenarios such as intracranial hemorrhage, cardiac surgery and trauma.

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ROTEM® EXTEM A5 to predict massive transfusion

Point of care viscoelastic assays like TEG and ROTEM are used to guide transfusion of blood products. They allow early recognition of clotting factor deficiency, platelet depletion or dysfunction, and fibrinolysis. The EXTEM assay maximum clot firmness (MCF) is a ROTEM measure that takes about 30mins. EXTEM A10, the clot firmness at 10 min, is an accepted early surrogate and this study focussed on A5, the clot firmness at 5 min.

They conclude: “ROTEM EXTEM A5 is as useful clinically as A10 and MCF in making early treatment decisions in bleeding following trauma”.

The study was observational and while viscoelastic tests may predict massive transfusion need and survival, further randomized trials are needed. In the interim they can be incorporated into the overall clinical scenario or aid judgement.

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Optic nerve sheath diameter and intracranial pressure

There have been a number of studies on the use of ocular ultrasound measurement of optic nerve sheath diameter to non-invasively diagnose raised intracranial pressure. This meta-analysis shows that while it seems to be reasonable, wide confidence intervals suggest caution in its use. It can be employed as an aid certainly, and to dictate further assessment.

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Pre-Hospital Plasma for Shock

A trial compared standard resuscitation to thawed plasma resuscitation in patients at risk of hemorrhagic shock during pre-hospital air transport. There was a significant reduction in PT and more importantly in 30 day mortality in the plasma group. “No significant differences between the two groups were noted with respect to multiorgan failure, acute lung injury–acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions“.

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A similar study in a different setting – “during rapid ground rescue to an urban level 1 trauma centre, use of prehospital plasma was not associated with survival benefit. Blood products might be beneficial in settings with longer transport times, but the financial burden would not be justified in an urban environment with short distances to mature trauma centres”.   link

Cervical Spine Injury Intubation

The type of airway management for unstable cervical spine injury is described in this review from a Level I trauma centre. A dramatic change has occurrred from the traditional recommendation of flexible fibreoptic bronchoscopic (FOB) intubation. Videolaryngoscopy (VL) was used in about 50%, asleep FOB was performed alone (30.6%) or in conjunction with VL (13.5%). Awake FOB was rarely performed (2.3%), as was direct laryngoscopy (2.8%). All techniques were associated with high first-attempt success rates, and no cases of neurological injury attributable to airway management technique were identified.

While experience with videolaryngoscopy is becoming widespread, there is also a need to maintain FOB skills, but VL (even awake) is now clearly an accepted go-to technique.

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Whole Blood Resuscitation

Increasing interest is being reported in returning to whole blood rather than component transfusion in trauma. Much of the earlier experience comes from military studies, many of which are subject to selection or survivial biases and retrospective in nature. The overall evidence and rationale, as well as risk, is summarized in this review, with the usual scenario being a combination of whole blood with combination products. Further study is required to define what place whole blood transfusion may have in resuscitation.

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Traumatic Brain Injury and Hypothermia

A systematic review on therapeutic hypothermia finds the same results as known: “High-quality studies show no significant difference in mortality, poor outcomes, or new pneumonia. In addition, this review shows a place for fever control in the management of traumatic brain injury“. 

As in the post cardiac arrest scenario, 36° is just as good without the potential harmful effects of hypothermia, but fever or hyperthermia should be aggressively managed.

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