All posts by TheTraumaPro

EAST 2016: Scene Time And Mortality

The old “scoop and run” vs “stay and play” debate has gone on for years. It would seem to be intuitive that trauma patients, who should be assumed to be bleeding to death, would do better with shorter prehospital times and quicker transport to definitive care. 

However, several studies have not shown worse outcomes in the “stay and play” patients. Once again, mortality is a very crude indicator of “worse” outcomes, and may not be a good enough measure. Nonetheless, the debate continues to rage. A group at the University of Pittsburgh used the Pennsylvania Trauma Registry to review a huge number of EMS transports, looking at mortality as the measure of interest.

Recognizing that total prehospital time can be influenced by delays in specific phases (response, scene, or transport), they analyzed the impact of problems in each. If one particular phase represented more that 50% of the total prehospital time, it was considered a delay. Logistical regression was used to match patients to try to control for any confounding issues.

Here are the factoids:

  • Over 164,000 records with prehospital times were reviewed over a 14 year period.
  • There was a statistically significant increase in mortality if the scene time phase was prolonged.
  • No differences in mortality were noted with longer response or transport times.
  • Prolonged extrication and intubation had a tendency to prolong scene time, and were independently associated with higher mortality.
  • Lengthy scene time without extrication or intubation was not associated with higher mortality.

Bottom line: This registry-based study has helped us to slice and dice the prehospital time issue a little bit better. As with other studies, the times themselves may not necessarily be the problem. It’s what is causing the delay that matters. Extrication and intubation tend to indicate sicker trauma patients, but they are also somewhat unavoidable. Prehospital trauma professionals will need to focus on tools and exercises that save time during these critical interventions.

Reference: Not all prehospital time is equal: influence of scene time on mortality. EAST 2016 Oral abstract #9, resident research competition.

EAST 2016: (F)utility of CPR In Hemorrhagic Shock

Ahh, another (f)utility study. Does it work, or doesn’t it? And yes, I know. It’s another animal study. But it may give us a glimpse of where we are really going with this. 

A team at the University of Tennessee – Knoxville devised a dog experiment to study how well performing CPR works in critically hypovolemic animals. They used three groups of dogs that received a severe shock insult: hemorrhage until loss of pulse, then waiting for 30 minutes in that pulseless state. At that point, one of three interventions was performed for 20 minutes.

One group received CPR only, another group underwent CPR plus fluid administration, and the last group got fluids only

Here are the factoids:

  • The insult to all three groups was similar.
  • Vital signs and lab studies were similar in the CPR+fluid and fluid only groups.
  • The CPR only group had significantly lower mean arterial pressures and higher pulse rates than the other CPR+fluid and fluid only groups.
  • Ejection fraction was lower in the CPR only group, and it also had a higher incidence of end organ damage. 
  • Two of the six dogs in the CPR only group died before the end of the study.

Bottom line: Tread with caution here. It makes sense that pounding on an empty tank won’t do much. But this study doesn’t exactly prove this. Only the vital signs measurements were significantly different. All other results are just trends in this very small study. And finally, dogs are (obviously) different than people, in their physiology and their chest wall shape. This can certainly make a difference, and does not mean that we should abandon CPR in humans in hemorrhagic shock.

Reference: Utility of CPR in hemorrhagic shock, a dog model. EAST 2016 Oral abstract #8, resident research competition.

January Trauma MedEd Newsletter Released!

Welcome to the current newsletter. This is the second of two issues that will give quick analyses of some of the better oral and poster abstracts that will be presented at the 2016 Annual Scientific Assembly this month. Here’s the scoop on what’s inside:

  • How Long Does VTE Risk Last In TBI?
  • Measuring Volume Status Using Jugular Ultrasound
  • (F)utility Of Antibiotic Use In Facial Fractures
  • Use Of Scribes To Increase Charge Capture
  • Nursing Interruptions In The SICU
  • Pain And Tourniquet Efficacy

Subscribers received the newsletter last Sunday night. If you want to subscribe to get early delivery in the future (and download back issues), click here.

Click here to download newsletter.

EAST 2016: (F)utility Of Transfusion In Flight

Air transport of trauma patients has resulted in the creating a mobile intensive care unit in the passenger compartment of the aircraft. Since trauma patients frequently need blood, it was logical to begin stocking blood products on board. Once again, though, it sounds like a good idea. But does it make a difference?

Vanderbilt University carried out a retrospective review of aeromedical transports to its Level I trauma center. The authors chose overall mortality and 24-hour mortality as their endpoints.

Here are the factoids:

  • 5581 patients were entered into the study. This represented all trauma scene transports to this trauma center over 7 years.
  • Only 4% of these patients (231) received blood in the aircraft.
  • Multivariate regression analyses were performed with and without propensity score matching. (Sorry, just had to throw that in there to make your head spin!)
  • There was no significant improvement in 24-hour or overall mortality when blood was given. This was true using all of their statistical methods.

Bottom line: This abstract seems to corroborate a few other studies that show no benefit to prehospital blood administration. So why do we still do it? Because we don’t know the full answer yet. Using mortality alone is a very crude outcome measure. What about early complications, ventilator times, time in the ICU, and other soft measures? More work is needed to slice and dice this appropriately enough to answer the question.

Reference: Blood transfusion: in the air tonight? EAST 2016 Oral abstract #5, resident research competition.