Trauma

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

POCUS and Blunt Thoracoabdominal Injuries

A Cochrane review urges caution with negative findings from point of care ultrasound (POCUS). While positive findings are helpful, it was found that in blunt abdominal trauma “a negative POCS exam does not rule out injuries and must be verified by a reference test such as CT. This is of particular importance in paediatric trauma, where the sensitivity of POCS is poor”. The now ubiquitous ultrasound in the Emergency Dept. has its limitations!

link

Thromboelastometry: new ROTEMsigma

The new generation of ROTEM automates this point of care device for assessing coagulation, relative contributions of clotting factors, fibrinogen, platelets and fibrinolyis. The two technologies of ROTEM and TEG have been studied and early evidence suggests utility in trauma, obstetrics and perhaps in major blood-loss surgeries such as liver or cardiac.

This study found ROTEMsigma exhibited high precision and correlation with previous generation ROTEMdelta devices.

link

A review of this point of care coagulation assessment is found here link

Concussion and Anesthesia

The APSF provides an article on the definition, pathophysiology and management of concussive head injuries.  Numerous alterations in brain metabolism, cerebral blood flow, and neuronal dysfunction occur, and possible deposition of beta-amyloid and neurofibrillary tangles in chronic concussions.

The authors suggest the concussed brain is vulnerable to anesthesia and it may be prudent to delay elective procedures.

link

 

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.

cmaj link

 

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.

link

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.

link

 

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.

link