The March newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is Imaging.
In this issue you’ll find articles on:
- CT contrast via IO catheter
- FAST exams in children
- CT scanning before transfer to pediatric trauma centers
- Radiation exposure in pediatric trauma
- IV contrast in trauma
- And more!
Subscribers received the newsletter first over the weekend. If you want to subscribe (and download back issues), click here.
Download the newsletter here!
You know the routine. Trauma patients get the usual ATLS primary survey secondary survey double play. An important part of the secondary survey is examining the back. Without it, you’ve failed to inspect nearly 50% of the body.
Usually this part is easy, especially if you’ve got a reasonably sized trauma team. Two or three people carefully logroll the patient, one stabilizes the cervical spine, while another inspects and palpates the back. At our center, we routinely logroll to the patient’s left side, because the examiner is normally stationed at their right.
But what if they have fractured extremities? Which way to go?
Once again, this is philosophy unsupported by literature. No one does studies on mundane stuff like this. The real questions are, rolling to which side will create the least additional injury and cause the least pain?
First, let’s address the injury question. The usual rule is that all patients with fractures must have them splinted before they leave the resus room. This decreases pain, bleeding, and the opportunity for additional tissue injury. Ideally, splinting should occur before the logroll, since this maneuver can involve more movement than rolling around the hospital or moving back and forth to x-ray tables.
Next, there’s pain. Make sure that your patient has been given adequate analgesia early in the resuscitation, and sedation if indicated.
Finally, the roll. My rule is that the fractures should be rotated upwards, with helpers stabilizing each splinted extremity to keep them aligned. Avoid rolling the patient onto their own fractures (fractures down). The combination of weight and movement can and will shift the broken bones, causing exactly what you’ve sought to avoid!
Hemostatic resuscitation (HR) is the new buzzword (buzz phrase?) these days. The new ATLS course touts it as a big change, and quite a few publications are being written about it. But, like many new things (think Factor VII), will it stand the test of time?
It has long been recognized that hemorrhage from trauma is bad. Mortality rates are high, and traditional management with crystalloids and then blood products leads to persistent coagulopathy, troublesome bleeding, tissue injury, and finally death. HR was devised to address the early coagulopathy. It concentrates on early coag correction with plasma and platelets, permissive hypotension, and rapid definitive correction of hemorrhage.
The end result of HR has been measured, and both organ perfusion and coagulopathy can be corrected with it. Unfortunately, these measurements are typically taken once hemorrhage control has been achieved. Is looking at (or beyond) the endpoint really the best way to gauge its effectiveness?
A robust multicenter study scrutinized looked at coagulopathy correction and organ perfusion during active hemostatic resuscitation. They used ROTEM to gauge the former, and lactate levels for the latter. Values were measured on arrival and after administration of every 4 units of blood. Only patients who received at least 4 units were included (106 subjects).
Here are the factoids:
- Average admission lactate was 6.2 meq/L, so these patients were sick
- Patients with a lactate > 5 did not clear it until after hemorrhage was controlled and no further blood was needed
- 43% of patients were coagulopathic by ROTEM on arrival.
- Coagulopathy increased for every 4 units of blood given, despite a plasma infusion ratio of close to 1:1 throughout their resuscitation
Bottom line: This was a well-done study on a relatively large number of patients, although a number of weaknesses and potential improvements are pointed out in the discussion. There’s a lot of data in the paper, and I urge you to read it in depth. But it seems to show that hemostatic resuscitation is not necessarily doing what we want it to do during the acute phase of hemorrhage. Both bleeding AND transfusions must be stopped before it appears to work. And even then, there is a delay before ROTEM and lactate parameters return to normal. For now, rapid control of hemorrhage is of utmost importance. We still need to figure out how tools like ROTEM or TEG and various serum markers will help us while we accomplish it.
Reference: Hemostatic resuscitation is neither hemostatic nor resuscitative in trauma hemorrhage. J Trauma 76(3):561-568, 2014.
Members of the trauma team must frequently protect the cervical spine when moving the patient or performing certain procedures. In most cases, a cervical collar is placed which does a fine job of this. Occasionally, though, the collar must be removed to provide access to areas near or under the collar.
When the collar is off, someone must be charged with immobilizing the cervical spine. Sometimes this is incorrectly referred to as providing inline traction and not inline stabilization.There is a big difference!
Inline traction is used to try to realign cervical vertebra that are malpositioned due to fracture or ligamentous injury. This should only be performed under the guidance of a neurosurgeon!
Inline stabilization merely means that the patient (or trauma professional) is restrained from moving the cervical spine. This is commonly needed while intubating the patient, so that the intubator does not extend the neck when trying to visualize the cords.
Why is this important? Check out the images below. If a severe injury has already occurred, traction on the neck may have devastating consequences! Inline stabilization is the only way to go.
The March Trauma MedEd Newsletter will be released to subscribers late next Monday. The topic is Imaging. Articles include:
- Contrast tips and tricks
- Imaging before transferring patients
- Radiation exposure
- And more!
Anyone on the subscriber list as of 8AM Monday (CST) will receive it by email later that night. I’ll release it to everyone else next Friday via the blog. So sign up for early delivery now by clicking here!
Pick up back issues here!