[Permissive hypotension in severe trauma]

4A after access: a new mnemonic to aid timely administration of IV/IO treatment in trauma patients

Administration of medication is a well-established part of prehospital trauma care. Guidance varies on the types of recommended medications and when they should be administered. Mnemonics have become commonplace in prehospital medicine to facilitate recall and retention. However, there is no comprehensive aid for the administration of medication in trauma patients. We propose a new mnemonic for the delivery of relevant intravenous or intraosseous medications in trauma patients. A '4A after Access' approach should enhance memory recall for the efficient provision of patient care. These 4As are: antifibrinolysis, analgesia, antiemesis and antibiotics. This mnemonic is designed to be used as an optional aide memoire in conjunction with existing treatment algorithms in the military prehospital setting.

[Traumatic vascular injuries]

Since the beginning of the twentieth century and the implementation of anesthesia and antisepsis, the knowledge and possibilities in treatment of vascular injury has continuously improved. We are currently experiencing improvements in the preclinical management due to various damage control procedures. Depending on the type of vascular injury (blunt, sharp, with or without defect) the treatment can be conservative in individual cases but in most cases endovascular or open vascular surgery is necessary. In the twenty-first century the surgical treatment by direct suture or replacement of the vessel by a graft is increasingly being supplemented by various endovascular procedures.

[Extended medical quality management exemplified by the tracer diagnosis multiple trauma. Pilot study in the air rescue service]

BACKGROUND

Adequate prehospital and inhospital primary care is a decisive factor in the successful treatment of multiple trauma patients. For optimization of treatment algorithms the implementation of a medical quality management is of utmost importance. The aim of this study was to extend quality management by including data on process quality.

METHODS

A retrospective study of primary rescue missions of the Helicopter Emergency Medical Service (HEMS) Christoph 22 in Ulm over a period of 2.5 years was performed. In a detailed analysis of filter criteria, in which relevant deviations from the recommendations (not fulfilled in  > 10% of the cases) occurred, process data was included (vital data, measurements and events).

RESULTS

In the study population (n = 298, males 71.8%, mean age 39.8 ± 21.8 years) 2 filter criteria were identified in which relevant deviations where observed: time management where prehospital treatment time  ≤ 60 min in 36% of the cases was not fulfilled and circulatory management where the systolic blood pressure, detected with Riva-Rocci method (RR(sys))  ≥ 120 mmHg on hospital admission in patients with severe head trauma was not fulfilled in 45% of the cases. In patients with deviations in time management, prehospital treatment time was prolonged (75.6 ± 18.3 min versus 50.5 ± 6.7 min; p < 0.01) caused by a prolonged on scene attendance time (34.1 ± 22.1 min versus 20.6 ± 9.2 min; p < 0.01) and transport time (17.3 ± 9.4 min versus 13.3 ± 4.8 min; p < 0.01). In entrapment trauma prehospital treatment time was expanded (44% versus 10%; p < 0.01). Patients in whom circulatory management deviations were observed were more often in shock on arrival at the scene (RR(sys)  ≤ 90 mmHg: 60% versus 30%; p < 0.01), more often hypoxemic [pulse oximeter oxygen saturation (S(p)O(2)) ≤ 90%: 36% versus 19%; p < 0.05] and more often sustained a trauma to the chest as well as to chest and abdomen/pelvis (69% versus 52% and 42% versus 28%, respectively; p < 0.05). Furthermore, the infusion volume of colloids was higher (1241 ± 810 ml versus 753 ± 359 ml; p < 0.05) and the combined usage of small volume resuscitation and catecholamines was more often necessary (42% versus 25%; p < 0.05).

CONCLUSIONS

Including process data of prehospital mission data recording facilitates an extended medical quality management.

[The "time" factor. Its impact in pathophysiology and therapy of multiple trauma]

Pathophysiology of multiple trauma is characterized by different trauma-associated repercussions like organ destruction, haemorrhage, immune cell activation by foreign antigen, for example. The length of time while such impairments take hold of the organism substantially impacts the extent of the post trauma secondary injury. Short interruptions in microcirculation can mostly be compensated, whereas elongated ischemic periods definitely cause structural cell damage up to death. The current review highlights the importance of the time duration of posttrauma second hits on the pathophysiology of systemic inflammation and multiple organ failure. The quick termination of such secondary impairments by immediate therapeutic intervention mainly impacts the patients' prognosis.

Emergency medical preparedness during the 2006 World Cup in Frankfurt, Germany

This paper describes emergency medical preparedness during FIFA (Fédération Internationale de Football Association) World Cup matches in Frankfurt, Germany, in 2006. The methods employed were document analysis and personal observation of games over five days in June-July 2006. The medical authorities in Frankfurt drew on a wide range of scientific literature and experiences to elaborate a National Concept. They paid attention to different models of handling mass catastrophes in shaping the final version of the document. The participation of designated authorities, associations, and volunteer organisations was coordinated sufficiently and the games in Frankfurt proceeded without great incident, even though more than 300,000 people in total attended. The adopted emergency medical procedure was appropriate for a mass gathering event. Official and volunteer organisations collaborated precisely in emergency preparedness. While one uniform concept for all mass gatherings events cannot be developed, case reports and experiences are useful tools.

Fluid management in traumatic shock: a practical approach for mountain rescue. Official recommendations of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM)

Sumann, Günther, Peter Paal, Peter Mair, John Ellerton, Tore Dahlberg, Gregoire Zen-Ruffinen, Ken Zafren, and Hermann Brugger. Fluid management in traumatic shock: a practical approach for mountain rescue. High Alt. Med. Biol. 10:71-75, 2009.-The management of severe injuries leading to traumatic shock in mountains and remote areas is a great challenge for emergency physicians and rescuers. Traumatic brain injury may further aggravate outcome. A mountain rescue mission may face severe limitations from the terrain and required rescue technique. The mission may be characterized by a prolonged prehospital care time, where urban traumatic shock protocols may not apply. Yet optimal treatment is of utmost importance. The aim of this study is to establish scientifically supported recommendations for fluid management that are feasible for the physician or paramedic attending such an emergency. A nonsystematic literature search was performed; the results and recommendations were discussed among the authors and accepted by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Diagnostic and therapeutic strategies are discussed, as well as limitations on therapy in mountain rescue. An algorithm for fluid resuscitation, derived from the recommendations, is presented in Fig. 1. Focused on the key criterion of traumatic brain injury, different levels of blood pressure are presented as a goal of therapy, and the practical means for achieving these are given.

Developing alternative strategies for the treatment of traumatic haemorrhagic shock

PURPOSE OF REVIEW

The optimal strategy of stabilizing haemodynamic function in uncontrolled traumatic haemorrhagic shock states is unclear. Although fluid replacement is established in controlled haemorrhagic shock, its use in uncontrolled haemorrhagic shock is controversial, because it may worsen bleeding.

RECENT FINDINGS

In the refractory phase of severe haemorrhagic shock, arginine vasopressin has been shown to be beneficial in selected cases due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site towards the heart and brain, and decrease in fluid resuscitation requirements. Especially in patients with severe traumatic brain injury, rapid stabilization of cardiocirculatory function is essential to ensure adequate brain perfusion and thus to prevent neurological damage and to improve outcome. In addition, despite wide distribution of highly developed and professional emergency medical systems in western industrialized countries, survival chances of patients with uncontrolled traumatic haemorrhagic shock in the prehospital setting are still poor.

SUMMARY

A multicenter, randomized, controlled, international clinical trial is being initiated to assess the effects of arginine vasopressin (10 IU) vs. saline placebo in prehospital traumatic haemorrhagic shock patients, not responding to standard shock treatment, being managed by helicopter emergency medical services [vasopressin in traumatic haemorrhagic shock (VITRIS.at) study].

[Vasopressin for therapy of persistent traumatic hemorrhagic shock: The VITRIS.at study]

While fluid management is established in controlled hemorrhagic shock, its use in uncontrolled hemorrhagic shock is being controversially discussed, because it may worsen bleeding. In the irreversible phase of hemorrhagic shock that was unresponsive to volume replacement, airway management and catecholamines, vasopressin was beneficial due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site towards the heart and brain and decrease of fluid resuscitation requirements. The purpose of this multicenter, randomized, controlled, international trial is to assess the effects of vasopressin (10 IU IV) vs. saline placebo IV (up to 3 injections at least 5 min apart) in patients with prehospital traumatic hemorrhagic shock that persists despite standard shock treatment. The study will be carried out by helicopter emergency medical service teams in Austria, Germany, Czech Republic, Portugal, the Netherlands and Switzerland. Inclusion criteria are adult trauma patients with presumed traumatic hemorrhagic shock (systolic arterial blood pressure <90 mmHg) that does not respond to the first 10 min of standard shock treatment (endotracheal intubation, fluid resuscitation and use of vasopressors) after arrival of the first emergency physician at the scene. The time window for randomization will close after 30 min of shock treatment. Exclusion criteria are terminal illness, no intravenous access, age <18 years, injury >60 min before randomization, cardiac arrest before randomization, presence of a do-not-resuscitate order, untreated tension pneumothorax, untreated cardiac tamponade, or known pregnancy. Primary study end-point is the hospital admission rate, secondary end-points are hemodynamic variables, fluid resuscitation requirements and hospital discharge rate.

Effects of low-volume hemoglobin glutamer-200 versus normal saline and arginine vasopressin resuscitation on systemic and skeletal muscle blood flow and oxygenation in a canine hemorrhagic shock model

OBJECTIVE

To test the hypothesis that low-volume resuscitation with hemoglobin glutamer-200 improves hemodynamic function and tissue oxygenation, whereas arginine vasopressin resuscitation improves blood pressures more than low-volume saline or hemoglobin glutamer infusion but compromises systemic and muscle blood flow and oxygenation.

DESIGN

Randomized laboratory investigation.

SETTING

University research facility.

SUBJECTS

Nineteen dogs.

INTERVENTIONS

Dogs were instrumented to determine heart rate; arterial, central venous, pulmonary arterial, and pulmonary arterial occlusion pressures; cardiac output; and quadriceps muscle blood flow and oxygen tension (PMo2). Total and plasma hemoglobin, oxygen content, lactate, pH, standard base excess, and arginine vasopressin levels were determined, and systemic oxygen delivery (Do2I) and extraction ratio were calculated. Measurements were made before and 30 mins following hemorrhage. Dogs were resuscitated over 60 mins with saline (8.5 mL/kg), arginine vasopressin (0.4 IU/kg bolus plus 0.08 IU x kg x min), or 1:1 diluted hemoglobin glutamer-200. Recordings were then repeated. Subsequently, animals received 30 mL/kg shed blood (60 mL x kg x hr), and recordings were repeated immediately and 1 hr later.

MEASUREMENTS AND MAIN RESULTS

Hemorrhage ( approximately 52 mL/kg) caused characteristic changes in hemodynamic, hematologic, systemic PMo2, and acid-base variables. Saline resuscitation increased both Do2I and muscle perfusion by 42% and 51%, while arginine vasopressin treatment reduced heart rate by 31% and increased mean arterial pressure by 22% but not cardiac output, Do2I, or muscle blood flow, resulting in a further decrease of PMo2 by 68% and worse metabolic acidosis. Hemoglobin glutamer-200 infusion caused systemic and pulmonary vasoconstriction, however, without deterioration of cardiac output, Do2I, muscle blood flow, or PMo2 despite lack of oxygen content increase. Blood transfusion restored most variables.

CONCLUSIONS

Low-volume crystalloid or hemoglobin glutamer-200 resuscitation posthemorrhage may improve (but not restore) macro- and microvascular functions and tissue oxygenation, while arginine vasopressin infusion may only improve blood pressures and result in lower overall systemic perfusion compared with low-volume saline or hemoglobin glutamer-200 treatment and worsening of anaerobic conditions in skeletal muscle.

[Targeted cardiovascular therapy: shock treatment in ambulance, emergency room and intensive care unit]

Since the prognosis for all forms of shock essentially depends on immediate and effective therapy, early diagnosis and determination of the underlying cause are of central importance to the disease course. Except for cardiogenic shock, all forms of shock require early and adequate fluid substitution. It has previously been shown that septic shock treatment guided by central venous oxygen saturation may lead to a reduction in mortality in patients with septic shock. Similar therapeutic strategies are currently being developed for the more invasive monitoring procedures used in intensive care, but their effectiveness has to yet to be proven. Novel therapeutic approaches for the treatment of septic shock include improved adjunctive sepsis therapy and the use of vasopressin. However, the effectiveness of the latter treatment option cannot yet be conclusively assessed.

Pre-hospital fluid therapy in the critically injured patient--a clinical update

Venous access and fluid therapy should still be considered to be essential elements of pre-hospital advanced life support (ALS) in the critically injured patient. Initiation of fluid therapy should be based on a clinical assessment, most importantly the presence, or otherwise, of a radial pulse. The goal in penetrating injury is to avoid hypovolaemic cardiac arrest during transport, but at the same time not to delay transport, or increase systolic blood pressure. The goal in blunt injury is to secure safe perfusion of the injured brain through an adequate cerebral perfusion pressure, which generally requires a systolic blood pressure well above 100 mmHg. Patients without severe brain injury tolerate lower blood pressures (hypotensive resuscitation). Importantly, using systolic blood pressure targets to titrate therapy is not as easy as it seems. Automated (oscillometric) blood pressure measurement devices frequently give erroneously high values. The concept of hypotensive resuscitation has not been validated in the few studies done in humans. Hence, the suggested targeted systolic blood pressures should only provide a mental framework for the decision-making. The ideal pre-hospital fluid regimen may be a combination of an initial hypertonic solution given as a 10-20 minutes infusion, followed by crystalloids and, in some cases, artificial colloids. This review is intended to help the clinician to balance the pros and cons of fluid therapy in the individual patient.

[Priority-oriented shock trauma room management with the integration of multiple-view spiral computed tomography]

In major trauma it is essential to immediately recognize and treat life-threatening problems and conditions. Most trauma protocols reserve the use of computed tomography for the secondary survey, as patients cannot be attended to during the examination and must be transferred from the emergency room to the CT suite. The relevant reduction in the scanning time of multidetector computed tomography (MDCT) or multislice computed tomography (MSCT) justifies its use as the major diagnostic adjunct for primary trauma survey and initial resuscitation. According to our ATLS((R))-based trauma algorithm, the multidetector scanner situated in the emergency department is utilized immediately after the correction of respiratory problems to detect causes of bleeding or intracranial hematomas. In a prospective series a total of 125 consecutive major trauma patients were evaluated. After focused sonography in trauma (FAST) and plain chest films in intubated patients, whole body MDCT was performed. By retrieving data from our trauma registry and a picture archiving and communication system (PACS), time from trauma room admission to the end of head CT scan for the entire MDCT study and calculation of multiplanar reconstruction (MPR) was analyzed. Additionally, relevant complications such as untreated tension pneumothorax or circulatory arrest during MDCT examination were recorded. The time from admission to the trauma room until completion of head CT scan without contrast was 21:12 min (median, IQR 18:13-27:52). The entire contrast-enhanced MDCT study, including pilot scan and contrast application, required 6:08 min (median, IQR 4:33-8:14) with a total scanning time of 0:59 min (median, IQR 0:55-1:03). MPR calculation of the spine and bony pelvis was performed in 11:37 min (median, IQR 8:03-16:41). A relevant life-threatening complication due to CT scanning during primary trauma survey was not observed in the 125 cases (0/125 CI 95% 0%-3%). Complete diagnostic imaging can be performed within 30 min after trauma room admission by using MDCT. During the primary survey, treatment of the patient is interrupted just for the few minutes of the CT scan and contrast application. An adequate survey of injuries can be achieved earlier and a targeted therapy can be initiated ahead of time. Integration of MDCT scanners in the primary trauma survey provides a high standard of imaging in a very short time without endangering the patient. When dealing with multiple casualties, MDCT could be used also as an accurate and time-efficient means of hospital triage to diagnose and prioritize patients and to plan further surgical interventions and intensive care.

[Preclinical management of multiple trauma]

Approximately 8000 patients with multiple trauma are admitted annually to an emergency room in Germany. The prognosis of these severely injured patients is influenced in particular by concomitant craniocerebral injury, an abdominal wound, or thoracic trauma. Hypoxia and hypotension subsequent to shock induced by hemorrhagic-traumatic effects are of prime importance. Preclinical management thus includes examining the injured patient, immobilizing the spine, ensuring airway patency, stabilizing cardiovascular status suitting the approach to the injury pattern, commensurate care of partial injuries, pain therapy, as well as rapid and careful transportation to the nearest qualified trauma center. Management of patients with multiple trauma poses a particular challenge to the responding team. This article in the continuing education series deals with current algorithms for preclinical management of patients with multiple injuries with particular focus on the significant factor of time.

Die Behandlung des hämorrhagischen Schocks

The future of shock treatment depends on the importance of scientific results, and the willingness of physicians to optimize, and to reconsider established treatment protocols. There are four major potentially promising approaches to advanced trauma life support. First, control of hemorrhage by administration of local hemostatic agents, and a better, target-controlled management of the coagulation system. Second, improving intravascular volume by recruiting blood from the venous vasculature by preventing mistakes during mechanical ventilation, and by employing alternative spontaneous (i.e. use of the inspiratory threshold valve) or artificial ventilation strategies. In addition, artificial oxygen carriers may improve intravascular volume and oxygen delivery. Third, pharmacologic support of physiologic, endogenous mechanisms involved in the compensation phase of shock, and blockade of pathomechanisms that are known to cause irreversible vasoplegia (arginine vasopressin and K(ATP) channel blockers for hemodynamic stabilization). Fourth, employing potentially protective strategies such as mild or moderate hypothermia. Finally, the ultimate vision of trauma resuscitation is the concept of "suspended animation" as a form of delayed resuscitation after protection of vital organ systems.

[Pre-clinical management of shock patients]

The preclinical diagnosis of shock is still based on the patient's history, the physical examination, the injury pattern and a few hemodynamic parameters available in the emergency set-up. The clinical picture is characterised by hypotension and tachycardia, tachypnoe and dyspnoea as well as cerebral impairment. Results from recent clinical trials indicate, that a adapted and specific therapeutic approach for the various shock forms is necessary. In case of traumatic hypovolemic-hemorrhagic shock it is of particular relevance if penetrating trauma and/or uncontrolled bleeding exists. Under these conditions an immediate definite surgical treatment is required ("scoop and run") and a moderate hypotension should be tolerated. ("treat and run"). Fluid substitution and therapy with catecholamines should be used conservatively. In all other forms of shock the treatment approach can and should be more aggressive in order to improve microvascular perfusion as early as possible. Besides adequate fluid resuscitation in a combination of crystalloid and colloid solutions catecholamines and-under specific circumstances-also vasopressin should be used. Of utmost importance in the pre-clinical management of patients in shock is the optimal selection of the centre that the patient is referred to in order to establish the fastest and best possible definite treatment for the patient.

[The future of preclinical emergency medicine in Germany]

Against the background of an ever-increasing shortage of financial support, closure of smaller hospitals and shortage of personnel in the medical branch, the necessity of the Federal emergency system is being increasingly called into question. In reality the number of missions which are relatively indicated are clearly increasing nationwide: an emergency doctor is not absolutely necessary in many situations. However, for complex emergency situations in Germany, an emergency medical system must remain an integral component of the preclinical care system in addition to the well-trained rescue service personnel. Hereby it is less important to have more emergency medical doctors, but more important to have a higher emergency medical qualification, possibly by a reduction in the density of emergency service stations. By the introduction of a ranked assistance system and the inclusion of "first responders", the time period before the arrival of the highly qualified emergency medical doctor can be bridged by qualified paramedics and general practitioners. The impulse of the legislators, assimilation of the rescue service acts, restructuring of rescue service catchment areas and the introduction of integrated demand-oriented control stations with a consequent quality management system as well as the implementation of a medical leader rescue system can reduce costs and further improve the quality of the emergency medical rescue system.