Advanced trauma life support, 8th edition, the evidence for change

Emergency medicine techniques and the forensic autopsy

Emergency medicine measures often have to be carried out under suboptimal conditions in emergency situations and require invasive patient treatment. In the case of a fatal outcome these measures have to be evaluated at autopsy, regarding indications, correct implementation and possible complications. As well, alongside the more familiar procedures--such as endotracheal intubation, insertion of chest drains, external cardiac massage and cannulation of central and peripheral veins--there are alternative techniques being increasingly applied, that include new tools for the management of hemorrhagic shock, drug delivery and alternative airway management devices. On the one hand, all of these measures are essential for the survival and appropriate treatment of the injured and/or sick patient, but on the other hand they can damage the patient and thus contain a significant risk of both medical and forensic relevance for the patient and the physician. In the following review we provide an overview of established, new and alternative techniques for emergency airway management, administration of drugs and management of hemorrhagic shock. The aim is to facilitate the understanding and autopsy evaluation of current emergency medicine techniques.

What are predictors of mortality in patients with pelvic fractures?

BACKGROUND

Our knowledge of factors influencing mortality of patients with pelvic ring injuries and the impact of associated injuries is currently based on limited information.

QUESTIONS/PURPOSES

We identified the (1) causes and time of death, (2) demography, and (3) pattern and severity of injuries in patients with pelvic ring fractures who did not survive.

METHODS

We prospectively collected data on 5340 patients listed in the German Pelvic Trauma Registry between April 30, 2004 and July 29, 2011; 3034 of 5340 (57%) patients were female. Demographic data and parameters indicating the type and severity of injury were recorded for patients who died in hospital (nonsurvivors) and compared with data of patients who survived (survivors). The median followup was 13 days (range, 0-1117 days).

RESULTS

A total of 238 (4%) patients died a median of 2 days after trauma. The main cause of death was massive bleeding (34%), predominantly from the pelvic region (62% of all patients who died because of massive bleeding). Fifty-six percent of nonsurvivors and 43% of survivors were male. Nonsurvivors were characterized by a higher incidence of complex pelvic injuries (32% versus 8%), less isolated pelvic ring fractures (13% versus 49%), lower initial blood hemoglobin concentration (6.7 ± 2.9 versus 9.8 ± 3.0 g/dL) and systolic arterial blood pressure (77 ± 27 versus 106 ± 24 mmHg), and higher injury severity score (ISS) (35 ± 16 versus 15 ± 12).

CONCLUSION

Patients with pelvic fractures who did not survive were characterized by male gender, severe multiple trauma, and major hemorrhage.

LEVEL OF EVIDENCE

Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality?

AIM

The aim of this study was to validate the classification of hypovolaemic shock given by the Advanced Trauma Life Support (ATLS).

METHODS

Patients derived from the TraumaRegister DGU(®) database between 2002 and 2010 were analyzed. First, patients were allocated into the four classes of hypovolaemic shock by matching the combination of heart rate (HR), systolic blood pressure (SBP) and Glasgow Coma Scale (GCS) according to ATLS. Second, patients were classified by only one parameter (HR, SBP or GCS) according to the ATLS classification and the corresponding changes of the remaining two parameters were assessed within these four groups. Analyses of demographic, injury and therapy characteristics were performed as well.

RESULTS

36,504 patients were identified for further analysis. Only 3411 patients (9.3%) could be adequately classified according to ATLS, whereas 33,093 did not match the combination of all three criteria given by ATLS. When patients were grouped by HR, there was only a slight reduction of SBP associated with tachycardia. The median GCS declined from 12 to 3. When grouped by SBP, GCS dropped from 13 to 3 while there was no relevant tachycardia observed in any group. Patients with a GCS=15 presented normotensive and with a HR of 88/min, whereas patients with a GCS<12 showed a slight reduced SBP of 117mmHg and HR was unaltered.

CONCLUSION

This study indicates that the ATLS classification of hypovolaemic shock does not seem to reflect clinical reality accurately.

Evolution and development of the Advanced Trauma Life Support (ATLS) protocol: a historical perspective

The Advanced Trauma Life Support (ATLS) protocol is a successful course offered by the American College of Surgeons. Once based on didactic lectures and seminars taught by experts in the field, trauma training has evolved to become a set of standardized assessment and treatment protocols based on evidence rather than expert opinion. As the ATLS expands, indices to predict outcome, morbidity, and mortality have evolved to guide management and treatment based on retrospective data. This historical, perspective article attempts to tell the story of ATLS from its inception to its evolution as an international standard for the initial assessment and management of trauma patients.

[Resuscitation damage control in the patient with severe trauma]

Severe trauma is the principle cause of death among young people in developed countries, with the main causes being due to road traffic accidents and accidents at work. The principle cause of death in severe trauma is the massive uncontrolled loss of blood. Most of the severe traumas with a massive haemorrhage develop coagulopathy, with some controversy over what is the best treatment for this. Patients with severe trauma are complex patients; they have a high mortality, they consume a significant amount of sources and can require rapid, intensive and multidisciplinary treatment encompassed within the concept of resuscitation damage control. In this article we attempt to present a current view of the pathophysiology of severe trauma and resuscitation damage control that may be applied to these types of patients.

Initial assessment of chest X-ray in thoracic trauma patients: Awareness of specific injuries

AIM: To compare the reported injuries on initial assessment of the chest X-ray (CXR) in thoracic trauma patients to a second read performed by a dedicated trauma radiologist.

METHODS: By retrospective analysis of a prospective database, 712 patients with an injury to the chest admitted to the University Medical Center Utrecht were studied. All patients with a CXR were included in the study. Every CXR was re-evaluated by a trauma radiologist, who was blinded for the initial results. The findings of the trauma radiologist regarding rib fractures, pneumothoraces, hemothoraces and lung contusions were compared with the initial reports from the trauma team, derived from the original patient files.

RESULTS: A total of 516 patients with both thorax trauma and an initial CXR were included in the study. After re-evaluation of the initial CXR significantly more lung contusions (53.3% vs 34.1%, P < 0.001), hemothoraces (17.8% vs 11.0%, P < 0.001) and pneumothoraces (34.4% vs 26.4%, P < 0.001) were detected. During initial assessment significantly more rib fractures were reported (69.8% vs 62.3%, P < 0.001).

CONCLUSION: During the initial assessment of a CXR from trauma patients in the emergency department, a significant number of treatment-dictating injuries are missed. More awareness for these specific injuries is needed.

Accurate placement of a pelvic binder improves reduction of unstable fractures of the pelvic ring

The aim of this study was to assess the accuracy of placement of pelvic binders and to determine whether circumferential compression at the level of the greater trochanters is the best method of reducing a symphyseal diastasis. Patients were identified by a retrospective review of all pelvic radiographs performed at a military hospital over a period of 30 months. We analysed any pelvic radiograph on which the buckle of the pelvic binder was clearly visible. The patients were divided into groups according to the position of the buckle in relation to the greater trochanters: high, trochanteric or low. Reduction of the symphyseal diastasis was measured in a subgroup of patients with an open-book fracture, which consisted of an injury to the symphysis and disruption of the posterior pelvic arch (AO/OTA 61-B/C). We identified 172 radiographs with a visible pelvic binder. Five cases were excluded due to inadequate radiographs. In 83 (50%) the binder was positioned at the level of the greater trochanters. A high position was the most common site of inaccurate placement, occurring in 65 (39%). Seventeen patients were identified as a subgroup to assess the effect of the position of the binder on reduction of the diastasis. The mean gap was 2.8 times greater (mean difference 22 mm) in the high group compared with the trochanteric group (p < 0.01). Application of a pelvic binder above the level of the greater trochanters is common and is an inadequate method of reducing pelvic fractures and is likely to delay cardiovascular recovery in these seriously injured patients.

Utilization profile of the trauma intensive care unit at the Role 3 Multinational Medical Unit at Kandahar Airfield between May 1 and Oct. 15, 2009

BACKGROUND

In the war against the Taliban, Canada was the lead North Atlantic Treaty Organization (NATO) nation to provide medical and surgical care to NATO soldiers, Afghanistan National Army soldiers, Afghanistan Nation Police, civilians working in and outside Kandahar Airfield and Afghanistan civilians at the Role 3 Multinational Medical Unit (R3MMU) from February 2006 to October 2009.

METHODS

We obtained data from the Joint Theatre Trauma Registry between May 1 and Oct. 15, 2009; 188 patients were admitted to the R3MMU intensive care unit (ICU). We analyzed the ICU data according to types and causes of trauma, mechanical ventilation prevalence, ICU medical and surgical complications, blood products utilization, length of stay in the ICU and mortality.

RESULTS

The admitting services were general surgery (35%), neurosurgery (29%), orthopedic surgery (18%) and internal medicine (3%). Improvised explosive devices (46%) and gunshot wounds (26%) were the main causes of ICU admissions. The mean injury severity score for all patients admitted to the ICU was 37, and 81% of ICU patients required mechanical ventilation for a mean duration of 3 days. The main ICU complications were coagulopathy (6.4%), aspiration pneumonia (4.3%), pneumothorax (3.7%) and wound infection (2.7%). The following blood products were most used: packed red blood cells (55%), fresh frozen plasma (54%), platelets (29%) and cryoprecipitate (23%). The average length of stay in the ICU was 4.3 days, and the survival rate was 93%.

CONCLUSION

The high survival rate suggests that ICU care is a necessary and vital resource for a trauma hospital in a war zone.

Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13

BACKGROUND

The Glasgow Coma Scale (GCS) classifies traumatic brain injuries (TBIs) as mild (14-15), moderate (9-13), or severe (3-8). The Advanced Trauma Life Support modified this classification so that a GCS score of 13 is categorized as mild TBI. We investigated the effect of this modification on mortality prediction, comparing patients with a GCS score of 13 classified as moderate TBI (classic model) to patients with GCS score of 13 classified as mild TBI (modified model).

METHODS

We selected adult TBI patients from the Pennsylvania Outcome Study database. Logistic regressions adjusting for age, sex, cause, severity, trauma center level, comorbidities, and isolated TBI were performed. A second evaluation included the time trend of mortality. A third evaluation also included hypothermia, hypotension, mechanical ventilation, screening for drugs, and severity of TBI. Discrimination of the models was evaluated using the area under receiver operating characteristic curve (AUC). Calibration was evaluated using the Hosmer-Lemershow goodness of fit test.

RESULTS

In the first evaluation, the AUCs were 0.922 (95% CI, 0.917-0.926) and 0.908 (95% CI, 0.903-0.912) for classic and modified models, respectively. Both models showed poor calibration (p < 0.001). In the third evaluation, the AUCs were 0.946 (95% CI, 0.943-0.949) and 0.938 (95% CI, 0.934-0.940) for the classic and modified models, respectively, with improvements in calibration (p = 0.30 and p = 0.02 for the classic and modified models, respectively).

CONCLUSION

The lack of overlap between receiver operating characteristic curves of both models reveals a statistically significant difference in their ability to predict mortality. The classic model demonstrated better goodness of fit than the modified model. A GCS score of 13 classified as moderate TBI in a multivariate logistic regression model performed better than a GCS score of 13 classified as mild.

Association between a single-pass whole-body computed tomography policy and survival after blunt major trauma: a retrospective cohort study

INTRODUCTION

Single-pass, whole-body computed tomography (pan-scan) remains a controversial intervention in the early assessment of patients with major trauma. We hypothesized that a liberal pan-scan policy is mainly an indicator of enhanced process quality of emergency care that may lead to improved survival regardless of the actual use of the method.

METHODS

This retrospective cohort study included consecutive patients with blunt trauma referred to a trauma center prior to (2000 to 2002) and after (2002 to 2007) the introduction of a liberal single-pass pan-scan policy. The overall mortality between the two periods was compared and stratified according to the availability and actual use of the pan-scan. Logistic regression analysis was employed to adjust mortality estimates for demographic and injury-related independent variables.

RESULTS

The study comprised 313 patients during the pre-pan-scan period, 223 patients after the introduction of the pan-scan policy but not undergoing a pan-scan and 608 patients undergoing a pan-scan. The overall mortality was 23.3, 14.8 and 7.9% (P < 0.001), respectively. By univariable logistic regression analysis, both the availability (odds ratio (OR) 0.57, 95% confidence interval (CI): 0.36 to 0.90) and the actual use of the pan-scan (OR 0.28, 95% CI: 0.19 to 0.42) were associated with a lower mortality. The final model contained the Injury Severity Score, the Glasgow Coma Scale, age, emergency department time and the use of the pan-scan. 2.7% of the explained variance in mortality was attributable to the use of the pan-scan. This contribution increased to 7.1% in the highest injury severity quartile.

CONCLUSIONS

In this study, a liberal pan-scan policy was associated with lower trauma mortality. The causal role of the pan-scan itself must be interpreted in the context of improved structural and process quality, is apparently moderate and needs further investigation with regard to the diagnostic yield and changes in management decisions. (The Pan-Scan for Trauma Resuscitation [PATRES] Study Group, ISRCTN35424832 and ISRCTN41462125).

A large left atrial myxoma detected in emergency department using bedside transthoracic echocardiography

We present a case of a 55-year-old woman with episodes of recurrent pulmonary edema that was diagnosed to have a large left atrial myxoma using bedside transthoracic echocardiography. This case illustrates the importance of a screening focused ultrasound examination of involved systems by emergency physicians in detecting causes for emergency clinical presentations.

Effects of terlipressin in a rat model of severe uncontrolled hemorrhage via liver injury

BACKGROUND

Animal experiments and clinical studies have shown that vasopressin infusion in cases of uncontrolled hemorrhagic shock is a promising treatment. However, there are only a few studies regarding the application of terlipressin in hemorrhagic cases. This study was designed to evaluate the effects of terlipressin vs controlled fluid resuscitation on hemodynamic variables and abdominal bleeding in a rat model of uncontrolled hemorrhage via liver injury.

METHODS

A total of 21 average weight 250 ± 30 g Wistar rats were used. A midline celiotomy was performed, and approximately 65% of the median and left lateral lobes were removed with sharp dissection. After creation of the liver injury, rats were randomized into 1 of 3 resuscitation groups, the control group, Lactated Ringer's (LR) group, and terlipressin group, with 7 rats in each group. Blood samples were taken from rats for arterial blood gas analysis. At the end of the experiments, free intraperitoneal blood was collected on preweighed pieces of cotton, and the amount of free blood was determined by the difference in wet and dry weights.

RESULTS

In response to resuscitation, the terlipressin group demonstrated a significant elevation in mean arterial pressure (MAP). Blood loss was greater in the LR group compared with the control group (12.8 ± 1.9 mL vs 8.2 ± 0.7 mL, P < .05). At the end of the experiments, 5 rats in the control group, 5 in the LR group, and 2 in the terlipressin group died. The average survival rates were 28.6%, 28.6%, and 71.4%, respectively.

CONCLUSIONS

Compared with the control group, intravenous terlipressin bolus after liver injury contributed to an increase in MAP and survival rates without increasing abdominal bleeding.

Near hanging: Early intervention can save lives

Hanging is a common method of suicide/homicide in the Indian scenario. We report three successive cases of attempted suicidal hangings seen over a period of 4 months in our intensive care wards. All of them presented gasping with poor clinical status and required immediate intubation, resuscitation, assisted ventilation and intensive care treatment. None had cervical spine injury, but one patient developed aspiration pneumonia. All the three patients received standard supportive intensive care and made full clinical recovery without any neurological deficit. We conclude that the cases of near hanging should be aggressively resuscitated and treated irrespective of dismal initial presentation. This is well supported by the excellent outcomes in our cases despite their poor initial condition.

Randomised clinical trial comparing pressure characteristics of pelvic circumferential compression devices in healthy volunteers

INTRODUCTION

The role of pelvic circumferential compression devices (PCCDs) is to temporarily stabilise a pelvic fracture, reduce the volume and tamponade the bleeding. Tissue damage may occur when PCCDs are left in place longer than a few hours. The aim of this randomised clinical trial was to quantify the pressure at the region of the greater trochanters (GTs) and the sacrum, induced by PCCDs in healthy volunteers.

MATERIALS AND METHODS

In a crossover study, the Pelvic Binder(®), SAM-Sling(®) and T-POD(®) were applied successively onto 80 healthy participants in random order. The pressure was measured using a pressure mapping system, with the volunteers in supine position on a spine board and on a hospital bed. Data were analysed using Mixed Linear Modelling.

RESULTS

On a spine board, the pressure exceeded the tissue damaging threshold at the GTs and the sacrum. Pressure at the GTs was highest with the Pelvic Binder(®), and lowest with the SAM-Sling(®). Pressure at the sacrum was highest with the Pelvic Binder(®). The pressure at the GTs and sacrum was reduced significantly for all three PCCDs upon transfer to a hospital bed.

CONCLUSION

The results of this randomised clinical trial in healthy volunteers showed that patients with pelvic fractures, temporarily stabilised with a PCCD, are at risk for developing pressure sores. The pressure on the skin exceeded the tissue damaging threshold and is, besides PCCD type, influenced by BMI, waist size and age. Regardless with which PCCD trauma patients are stabilised, early transfer from the spine board is of key importance to reduce the pressure to a level below the tissue damaging threshold. Clinicians should be aware of the potential deleterious effects associated with the application of a PCCD, and every effort must be made to remove the PCCD once haemodynamic resuscitation has been established.

[Volume replacement in intensive care medicine]

Volume substitution represents an essential component of intensive care medicine. The amount of fluid administered, the composition and the timing of volume replacement seem to affect the morbidity and mortality of critically ill patients. Although restrictive volume strategies bear the risk of tissue hypoperfusion and tissue hypoxia in hemodynamically unstable patients liberal strategies favour the development of avoidable hypervolemia with edema and resultant organ dysfunction. However, neither strategy has shown a consistent benefit. In order to account for the heavily varying oxygen demand of critically ill patients, a goal-directed, demand-adapted volume strategy is proposed. Using this strategy, volume replacement should be aligned to the need to restore tissue perfusion and the evidence of volume responsiveness. As the efficiency of volume resuscitation for correction of tissue hypoxia is time-dependent, preload optimization should be completed in the very first hours. Whether colloids or crystalloids are more suitable for this purpose is still controversially discussed. Nevertheless, a temporally limited use of colloids during the initial stage of tissue hypoperfusion appears to represent a strategy which uses the greater volume effect during hypovolemia while minimizing the risks for adverse reactions.

Impact of trauma societies on the clinical care of polytrauma patients

INTRODUCTION

Trauma societies have an influence on the management and outcome of polytrauma. Its contributions include setting up standard definitions, trauma registries, evidence-based medicine guidelines, and the creation of educational tools such as specific courses of trauma care and decision-making.

METHODS

Literature and web-based search of definitions and available information.

RESULTS

The history of and accomplishments of trauma societies in the above-mentioned domains are reviewed, including the major trauma registries (Major Trauma Outcome Study, National Trauma Data Bank, The American Pediatric Surgical Association, the American Burn Association trauma, and the German Trauma Society trauma registries). Several learned societies in the field of trauma have created recommendations and/or guidelines concerning polytrauma (the Eastern Association for the Surgery of Trauma, The Society of Critical Care Medicine, and the German Trauma Society, Brain Trauma Foundation, and the Essential Trauma Care (EsTC) Guidelines). Several practical, hands-on courses and scoring systems for improving the quality of management of polytrauma patients have been founded and implemented in the past 35 years, including the Advanced Trauma Life Support (ATLS(®)) Course of the American College of Surgeons, the Definitive Surgical Trauma Care (DSTC(TM)) Course, the National Trauma Management Course (NTMC(TM) Course,) the Advanced Trauma Operative Management (ATOM) Course, and the European Trauma Course (ETC).

CONCLUSIONS

Trauma and emergency care societies have made an elaborate, substantial contribution by developing trauma registries and creating specific guidelines courses on trauma care and decision-making.

Validation of the Thorax Trauma Severity Score for mortality and its value for the development of acute respiratory distress syndrome

BACKGROUND

The aim of the present study was to evaluate and to validate the Thorax Trauma Severity Score (TTSS) for mortality.

METHODS

By database analysis 712 patients with an injury to the chest admitted to the Universal Medical Center Utrecht between 2000 and 2004 were studied. All patients with a score of ≥1 on the AISthorax were included in the study. The patients' file was evaluated for: TTSS, intensive care unit stay, days on ventilation, thorax trauma-related complications (eg, acute respiratory distress syndrome [ARDS]), total hospital stay, and mortality.

RESULTS

Of the 516 patients included in the study, 140 (27%) developed thorax-related complications. The overall in-hospital mortality rate was 10%. The receiver operating characteristic curve for predicting mortality demonstrated an adequate discrimination by a value of 0.844. The TTSS was statistically significant higher in patients who died of thorax-related complications than in patients who died because of nonthorax-related complications and survivors (P < 0.001, confidence interval [CI] 95%). In patients who developed ARDS the TTSS was significant higher (P = 0.005, CI 95%).

CONCLUSION

This study supports the use of the TTSS for predicting mortality in thoracic injury patients. Furthermore, the TTSS appears capable of predicting ARDS.

Fluid resuscitation in multiple trauma patients

PURPOSE OF REVIEW

Fluid resuscitation in trauma patients with hemorrhagic shock is controversially discussed in the literature. The coincidence of brain injury complicates management of these patients. This article summarizes the current knowledge on nonblood component fluid resuscitation and choice of fluids in patients with multiple trauma.

RECENT FINDINGS

Whereas current evidence suggests the efficacy of fluid therapy in hemorrhagic shock without active bleeding, experimental and clinical data demonstrate that aggressive volume challenge may be futile or even deleterious in the setting of uncontrolled hemorrhage. Large amounts of isotonic crystalloids may be associated with hypothermia, acidosis and inflammation. In patients with traumatic brain injury hypertonic solutions may positively influence inflammation and intracranial pressure without affecting neurologic outcome or mortality.

SUMMARY

To date no large-scale clinical studies exist to either support or refute the use of nonblood component fluid resuscitation of hemorrhagic shock in trauma patients. The optimal choice of fluid remains to be determined, but existing evidence suggests avoiding crystalloids in favor of hypertonic solutions. The role of modern, iso-oncotic colloids in the treatment of hemorrhagic shock has not yet been sufficiently defined. In patients with concomitant brain injury, arterial hypotension must be avoided and infusion of hypotonic solutions is obsolete, whereas administration of hypertonic solutions may exert beneficial effects beyond hemodynamic stabilization.

Utility and relevance of diagnostic peritoneal lavage in trauma education

OBJECTIVES

During the last 2 decades, the advent of new technologies in trauma patient care may have resulted in a decreased number of diagnostic peritoneal lavage (DPL) evaluations. In this study, it is hypothesized that fewer DPL are being performed at a midwestern trauma center. Such negative trends may make the inclusion of DPL in current trauma education potentially outdated and no longer universally appropriate in trauma evaluation algorithms.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective observational study of a level I trauma center includes patients from January 1998 through September 2010. The total number of trauma-related DPL procedures performed annually during the study period was determined along with accompanying facility and trauma patient level data.

RESULTS

A total of 24 DPLs were performed at the target trauma center during the study period. There was a significant decrease (p = 0.0018) in the use of DPL despite a significant increase (p < 0.0001) in the proportion of trauma patients with an injury severity score > 15.

CONCLUSIONS

Study data demonstrated a decrease in the use of DPL as a diagnostic modality in the evaluation of blunt abdominal trauma patients at a medium-sized midwestern center. These data provide historic facility-level evidence of a practice change. Such information may support a recommendation that the American College of Surgeons revisit its current curriculum for Advanced Trauma Life Support (ATLS). Specifically, we propose the American College of Surgeons consider changing DPL instruction to an optional component of ATLS. COMPETENCIES: Patient Care, Medical Knowledge, Practice Based Learning and Improvement.

Uncrossmatched blood transfusions for trauma patients in the emergency department: incidence, outcomes and recommendations

BACKGROUND

Early transfusion of blood products for severely injured patients can improve volume depletion, acidosis, dilution and coagulopathy. There is concern that some patients are unnecessarily exposed to the risks of emergent transfusion with uncrossmatched red blood cell products (URBC) in the emergency department (ED). The goal of this study was to evaluate the transfusion practices in our ED among all patients who received URBC.

METHODS

We analyzed all injured patients transfused at least 1 URBC in the ED at a level-1 trauma centre between Jan. 15, 2007, and Jan. 14, 2008. Demographics, injuries and outcomes were reported. We used standard statistical methodology.

RESULTS

At least 1 URBC product was transfused into 153 patients (5% of all patients, mean 2.6 products) in the ED (median Injury Severity Score [ISS] 28; hemodynamic instability 94%). Sixty-four percent of patients proceeded to an emergent operation and 17% required massive transfusion. The overall mortality rate was 45%, which increased to 52% and 100% in patients who received 4 and 5 or more URBC products, respectively. Nonsurvivors had a higher median ISS (p=0.017), received more URBC in the ED (p=0.006) and possessed more major vascular injuries (p<0.001). Among nonsurvivors, 67% died of uncontrollable hemorrhage. Unnecessary URBC transfusions in the ED occurred in 7% of patients.

CONCLUSION

Overtransfusion was minimal based on clinical acumen triggers. Early transfer of patients receiving URBC products in the ED to the operating room, intensive care unit or angiography suite for ongoing resuscitation and definitive hemorrhage control must be strongly considered.

Introduction to interventional radiology in trauma

Interventional radiology (IR) has much to offer in the treatment of the trauma patient and should be integral in multidisciplinary trauma management. Many minimally invasive endovascular techniques are available with a vast amount of evidence to support their successful application. These techniques are both safe and effective and can in many circumstances negate further trauma caused by surgery in this high risk group. IR should not necessarily be considered a direct replacement for surgery as the two can often be synergistic in providing optimal care to many trauma patients. Despite the body of evidence and wealth of experience, IR is often overlooked or thought of late in trauma management when therapies are less effective. This article explores the role of IR and reviews the techniques and evidence behind their use.

The role of the emergency pharmacist in trauma resuscitation

The clinical pharmacist in the emergency department is now commonly incorporated as a member of the emergency department trauma team. As such, the emergency pharmacist needs to have detailed knowledge of the pharmacotherapy of resuscitation and be able to apply the skills needed to function as a valuable member of this team. In addition to the traditional skills of the discipline of clinical pharmacy, the emergency pharmacist must be familiar with the intricacies of treating life-threatening injuries in an emergent setting and be able to anticipate the direction of the patient's care. The ability to provide valuable pharmacological interventions throughout the resuscitation and stabilization process requires familiarity with the process of resuscitation, including rapid sequence induction, analgesia and sedation, seizure prophylaxis, appropriate antibiotic and tetanus prophylaxis, intracranial pressure control, hemodynamic stabilization, and any other specific drug therapy that the clinical situation demands. This article discusses the aforementioned pharmacotherapeutic topics and describes the role of the Emergency Pharmacist on the ED trauma team.

[Interruption of the diagnostic algorithm and immediate surgical intervention after major trauma--incidence and clinical relevance. Analysis of the Trauma Register of the German Society for Trauma Surgery]

BACKGROUND

Life-threatening situations after multiple trauma which require interruption of the diagnostic algorithm and immediate surgical treatment after admission are a challenge for the multidisciplinary trauma team. The purpose of this study was to evaluate the incidence, causes, implications and relevance of life-threatening situations for major trauma patients after admission to trauma centers.

PATIENT AND METHODS

Data of 12,971 patients listed in the German Trauma Register of the German Society for Trauma Surgery (DGU, 2002-2007) were analyzed. Patients with an injury severity score (ISS) > 16, no isolated head injury and primary admission to a trauma center were included. Data were allocated according to patients where the diagnostic algorithm in the resuscitation room was interrupted to perform emergency surgery (group Notop, n = 713, 5.5%) and patients who received early surgical care after completed diagnostics (group Frühop, n = 5,515, 42.5%). Comparative parameters were the pattern and severity of injury, physiological state and clinical outcome.

RESULTS

Patients receiving emergency surgery showed an average ISS score of 39 ± 15 points, whereas patients receiving early surgery showed an average ISS of 31 ± 12 points. On admission patients in the emergency surgery group (44%) suffered from hemodynamic shock considerably more often than patients in the early surgery care group (15%, p < 0.001). This was indicated by the significant differences in systolic blood pressure on admission, amount of preclinical substituted volume, base excess on admission and substituted erythrocyte concentrates in early clinical course. Mortality was 46% in the emergency surgery group and 13% in the early surgical care group (p < 0.001). Severe injuries (AIS ≥ 4) of the thorax, abdomen and extremities (including the pelvis) were encountered considerably more often in the emergency surgery group. There was no statistical difference in occurrence of severe head injuries between the groups. Emergency surgery consisted of 50.5% laparatomy, 19.8% craniotomy, 10.0% thoracotomy and 9.3% pelvic surgery.

CONCLUSION

Life-threatening situations after major trauma which require immediate surgical intervention in the resuscitation room rarely occur in Germany. Nevertheless, they are associated with a high mortality and prolonged and complex clinical course if primarily survived. Indications and decision-making processes of these challenging situations have to be practiced with standardized algorithms and should be considered for the future education of orthopedic surgeons in Germany.

Use of hypertonic saline injection in trauma

PURPOSE

The use of hypertonic saline injection in trauma patients is discussed.

SUMMARY

Patients with hemorrhage, burns, and traumatic brain injury (TBI) may develop hypovolemic shock and require resuscitation. Compared with conventional isotonic crystalloids, hypertonic saline has several advantages, including hemodynamic, immune-modulating, and antiinflammatory effects, for use in trauma patients for resuscitation. In addition, hypertonic saline is also used in patients with TBI to reduce intracranial pressure (ICP). Overall, studies have not shown a difference in mortality or other clinically important outcomes with the use of hypertonic saline for resuscitation in trauma patients; however, most of these studies were not adequately powered to show significant differences. A recent Cochrane review concluded that there is no evidence that hypertonic crystalloids are better than isotonic or near-isotonic crystalloids for fluid resuscitation in trauma patients. Two recent trials that were adequately powered to investigate a mortality endpoint were halted for futility. A few small randomized controlled studies found that hypertonic saline was more effective than mannitol as a hyperosmolar agent for ICP reduction. Recent guidelines from the American Burn Association have suggested that hypertonic saline may be used for burn shock resuscitation by experienced providers with close monitoring to avoid excessive hypernatremia. One of the main concerns with the use of hypertonic saline is its potential to cause central pontine myelinolysis due to a rapid increase in serum sodium levels.

CONCLUSION

There is no evidence that hypertonic saline provides any additional benefit over isotonic crystalloid solutions for trauma resuscitation. Hypertonic saline may be more effective than mannitol at reducing ICP in patients with TBI.

Full-body radiography (LODOX Statscan) in trauma and emergency medicine: a report from the first European installation site

Lodox Statscan is a whole-body, skeletal and soft-tissue, low-dose X-ray scanner with digital enhancement and enlargement capabilities. Ten years ago it was introduced as a screening device for the examination of trauma patients. Its incorporation into the Emergency Room enabled anterior-posterior and lateral thoraco-abdominal studies to be performed in 3—5 min with only about one-third of the radiation required for conventional radiography. Since its approval by the Food and Drug Administration in the USA, several trauma centres have incorporated this technology into their Advanced Trauma Life Support protocols. This review provides an overview of the system, and reports on the authors’ own experience with the system and that of others over the past 10 years, based on a literature search for all review articles, original articles, conference proceedings, case reports and short reports related to the Lodox Statscan device.

Targeted modulation of the neuroinflammatory response after spinal cord injury: the ongoing quest for the "holy grail"

This Commentary discusses the role of inflammation after spinal cord injury.

Surgisis® in the management of the complex abdominal wall in trauma: a case series and review of the literature

Managing complex abdominal wall injuries acutely or at the time of reconstruction is challenging. Contaminated surgical fields, devitalized tissue, intestinal fistula and tissues under tension contribute to clinical scenarios where closure is not possible or morbidity is unacceptable. The introduction of an absorbable extracellular matrix derived from porcine small intestinal submucosa (Surgisis) adds a potentially useful tool to the surgeon's armamentarium. A retrospective case series of the initial experience in 5 patients with complex abdominal wall injury following trauma managed with Surgisis is described. A review of the literature describing the use of Surgisis in contaminated fields is also performed.

Hydrocephalus communicans after traumatic upper cervical spine injury with a cerebrospinal fluid fistula: a rare complication

Secondary hydrocephalus communicans after traumatic upper cervical spine injuries with leakage of cerebrospinal fluid is a rare and hardly described complication. A case of a 75-year-old woman sustained a type II dens axis without other injuries, especially without evidence of a hydrocephalus in the primary CT scan. Dorsal atlanto-axial fusion was performed. Postoperative drainage was prolonged and positive for β2-transferrin. Wound revision with an attempt to seal the leakage was not successful. Secondary CT scans of the brain were performed due to neurological deterioration and showed a hydrocephalus with typical EEG findings. No anatomical reason for a circulative obstruction was found in the CT scan. After application of a ventriculo-peritoneal shunt the neurological status improved and the patient could be discharged to neurological rehabilitation.

Blunt traumatic carotid artery dissection still a pitfall? The rationale for aggressive screening

Introduction

The optimal diagnostic strategy for carotid dissection following blunt trauma is yet unclear. The rationale for aggressive screening will be discussed based on a consecutive case series of blunt traumatic carotid artery dissection (CAD).

Materials and methods

Five patients admitted to our level I trauma center developed severe complications as a consequence of blunt traumatic CAD. The diagnosis of CAD was delayed in all five patients until serious cerebral ischemia occurred. Despite the current awareness that CAD can result from blunt trauma, this type of injury is often overlooked. Clinical and radiological advances have considerably increased the knowledge of incidence and underlying mechanisms of traumatic CAD. This could have implications for case identification and the evaluation of treatment strategies in clinical trials in the future.

Conclusion

Screening may increase the rate of early CAD diagnosis, but it is unclear if screening will also result in early detection of a treatable lesion. Trials have to provide the answer to whether initiating therapy will lead to improvements in the outcome in traumatic CAD. We therefore believe that screening is a basic condition for initiation of future clinical trials.

Hemodynamic support of the trauma patient

PURPOSE OF REVIEW

The aim of this review is to address and summarize some key issues and recent insights into the hemodynamic support of the trauma patient related to fluid administration.

RECENT FINDINGS

Colloids are not superior to crystalloids in treating hypovolemia in the trauma patient and show no survival benefit. Furthermore, several adverse effects (renal failure, bleeding complications and anaphylaxis) have been reported with the use of artificial colloids. Hypertonic saline is effective and well tolerated in the treatment of hypovolemic shock and traumatic brain injury. Potential benefits are reduced fluid requirements and immune modulation. Resuscitation strategies should depend on the type of injury (penetrating vs. blunt; concomitant brain injury). Excessive fluid resuscitation, which can cause acute respiratory distress syndrome, abdominal compartment syndrome and brain edema, should be avoided. Dynamic parameters to guide volume therapy are probably more reliable than static parameters and minimally invasive techniques to monitor the microcirculation are becoming more important to determine the endpoints of resuscitation.

SUMMARY

Hemodynamic support is an early goal in the treatment of the trauma patient. The use of crystalloids is currently recommended in trauma resuscitation. The amount of fluid we give should be tailored to the individual trauma patient in which clear endpoints of resuscitation are of vital importance to maximize the chances of survival.

Resuscitation with fresh whole blood ameliorates the inflammatory response after hemorrhagic shock

BACKGROUND

Hemorrhagic shock is the leading cause of potentially preventable death after traumatic injury. Hemorrhage and subsequent resuscitation may result in a dysfunctional systemic inflammatory response and multisystem organ failure, leading to delayed mortality. Clinical evidence supports improved survival and reduced morbidity when fresh blood products are used as resuscitation strategies. We hypothesized that the transfusion of fresh whole blood (FWB) attenuates systemic inflammation and reduces organ injury when compared with conventional crystalloid resuscitation after hemorrhagic shock.

METHODS

Male mice underwent femoral artery cannulation and hemorrhage to a systolic blood pressure of 25 mm Hg +/- 5 mm Hg. After 60 minutes, the mice were resuscitated with either FWB or lactated Ringer's solution (LR). Mice were decannulated and killed at intervals for tissue histology, serum cytokine analysis, and vascular permeability studies. Separate groups of mice were followed for survival studies.

RESULTS

When compared with FWB, mice resuscitated with LR required increased resuscitation fluid volume to reach goal systolic blood pressure. When compared with sham or FWB-resuscitated mice, LR resuscitation resulted in increased serum cytokine levels of macrophage inflammatory protein-1alpha, interleukin-6, interleukin-10, macrophage-derived chemokine, KC, and granulocyte macrophage colony stimulating factor as well as increased lung injury and pulmonary capillary permeability. No survival differences were seen between animals resuscitated with LR or FWB.

CONCLUSIONS

Resuscitation with LR results in increased systemic inflammation, vascular permeability, and lung injury after hemorrhagic shock. Resuscitation with FWB attenuates the inflammation and lung injury seen with crystalloid resuscitation. These findings suggest that resuscitation strategies using fresh blood products potentially reduce systemic inflammation and organ injury after hemorrhagic shock.

Improving trauma care in India: a recommendation for the implementation of ATLS training for emergency department medical officers

BACKGROUND

Trauma is major cause of morbidity and mortality in India. The Advanced Trauma Life Support (ATLS) programme teaches a standardised method for the initial assessment and management of trauma patients, and has been adopted by more than 50 countries worldwide.

AIM

We sought to assess the theoretical knowledge of ATLS principles among emergency department (ED) medical officers (MOs) in Salem, Tamil Nadu, India, and from the Royal Adelaide Hospital, Adelaide, South Australia.

METHODS

All MOs answered a trauma management quiz based on ATLS-type questions. Quiz scores were compared between senior and junior MO groups for each country, and within each professional group between countries. Categorical data were analysed using chi(2). An alpha value less than 0.05 was deemed to be statistically significant.

RESULTS

We discovered significant differences in the theoretical knowledge of ED MOs from Salem compared with colleagues in Adelaide. Our results demonstrated the positive influence of completion of an ATLS programme upon obtaining a passing grade on the trauma quiz. We failed to determine a link between self-rated experience in trauma management and the ability to pass the quiz.

CONCLUSIONS

Our study demonstrated the positive influence of completion of an ATLS-type programme on the score obtained on the trauma management quiz. Although previous work has demonstrated mixed results concerning improvement in the care of trauma patients following completion of an ATLS programme, we recommend that such programmes be integrated into the training of Indian ED MOs and suggest that ATLS should be viewed as an integral part of medical training.

Airway management and initial resuscitation of the trauma patient

PURPOSE OF REVIEW

This review will analyze and comment on selected recent literature pertaining to airway management and initial fluid resuscitation in the trauma patient. It will also review airway devices currently being used in the trauma setting.

RECENT FINDINGS

Although a recent study has questioned the efficacy of manual inline immobilization, this technique continues to be endorsed by trauma guidelines and is safely used in most trauma centers. Clinicians have also incorporated the use of videolaryngoscopy and other adjuncts for difficult airway management in trauma patients. However, no single airway management tool has proven to be superior in this setting. Crystalloid solutions remain frontline therapy for the initial resuscitation of the hemorrhagic trauma patient, as studies with hypertonic saline and vasopressors have not shown superior results. Conversely, increased amounts of fresh frozen plasma and fibrinogen have been reported to increase survival in trauma patients.

SUMMARY

As trauma continues to be a major cause of morbidity and mortality worldwide, the use of newer airway adjuncts needs to be specifically investigated in trauma patients, as this population frequently has airway management difficulties. Further research is also required to elucidate the type and amount of fluid that will provide an adequate organ perfusion without increasing nonsurgical bleeding.

Detection and management of hypothermia at a large outdoor endurance event in the United kingdom

OBJECTIVE

Optimum detection of hypothermia in athletes during outdoor exposure events remains controversial. The aims of this study were firstly to assess whether temperature readings affected competitor discharge from the treatment station and secondly to assess agreement between oral and tympanic thermometer measurements.

METHODS

All competitors treated for symptomatic hypothermia at an outdoor endurance event in the United Kingdom during January 2009 were included. Temperature readings were taken using oral (Digitemp digital oral thermometer) and tympanic (Braun Thermoscan IRT 4520 ExacTemp) thermometers, with a temperature <35 degrees C classifying hypothermia.

RESULTS

From 4700 competitors, 64 (1.4%) were treated for symptomatic hypothermia. Of these, 92% were male, the mean age was 26 years, and the mean treatment time was 25 minutes. There was no severe/life-threatening hypothermia, and no competitors required transport to a hospital for hypothermia. At discharge, 19% of competitors were still classed as hypothermic in the oral group and 28% in the tympanic group, despite competitors only being discharged when no longer symptomatic. Oral readings at discharge were significantly lower than tympanic readings (33.8 degrees C [95% CI, 33.2 degrees C to 34.5 degrees C] vs 35.0 degrees C [95% CI, 34.6 degrees C to 35.3 degrees C], respectively, P = .003).

CONCLUSIONS

The use of thermometers had a limited role in discharging competitors at this event, who were apparently safely discharged when no longer symptomatic. Treating clinicians and the thermometers did not always agree on whether a patient was hypothermic or not. Oral and tympanic thermometers had poor agreement. Routine thermometer readings at future events may be unnecessary, although screening competitors of concern will remain useful.