Category Archives: General

General

Does Hemostatic Resuscitation Really Work?

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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.

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General

Blunt Traumatic Arrest In Kids: Are They Little Adults?

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Over and over, we hear that children are not just little adults. They are a different size, a different shape. Their “normal” vital signs are weird. Drug doses are different; some drugs don’t work, some work all too well. 

But in many ways, they recover more quickly and more completely after injury. What about after what is probably the biggest insult of all, cardiac arrest after blunt trauma? The NAEMSP and the ACS Committee on Trauma recently released a statement regarding blunt traumatic arrest (BTA):

 “Resuscitation efforts may be withheld in any blunt trauma patient who, based on out-of-hospital personnel’s thorough primary patient assessment, is found apneic, pulseless, and without organized ECG activity upon arrival of EMS at the scene.“

The groups specifically point out that the guidelines do not apply to the pediatric population due to the scarcity of data for this age group.

The Children’s Hospital of Los Angeles and USC conducted a study of the National Trauma Data Bank, trying to see if children had a better outcome after this catastrophic event. Patients were considered as children if they were up to and including age 18.

Here are the factoids: 

  • Of 116,000 pediatric patients with blunt trauma, 7,766 had no signs of life (SOL) in the field (0.25%)
  • The typical male:female distribution for trauma was found (70:30)
  • 75% of those without SOL in the field never regained them. Only 1.5% of these survived to discharge from the hospital.
  • 25% regained SOL with resuscitation, and 14% of them were discharged alive.
  • 499 patients underwent ED thoracotomy, and only 1% survived to discharge. There was no correlation of thoracotomy with survival.
  • It appeared that there was a tendency toward survival for the very young (age 0-4) without SOL, but statistical analysis did not bear this out

Bottom line: Children are just like little adults when it comes to blunt cardiac arrest after trauma. Although it is a retrospective, registry-based study, this is about as big as we are likely to see. And don’t get suckered into saying "but 1.5% with no vital signs ever were discharged!” This study was not able to look at the quality of life of survivors, but there is usually significant and severe disability present in the few adult survivors after this event.

Feel free to try to re-establish signs of life in kids with BTA. This usually means lots of fluid and/or blood. If they don’t respond, then it’s game over. And, like adults, don’t even think about an emergency thoracotomy; it’s dangerous to you and doesn’t work!

Related posts:

Reference: Survival of pediatric blunt trauma patients presenting with no signs of life in the field. J Trauma 77(3):422-426, 2014.

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General

A Tourniquet For Your Abdomen???

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Tourniquets for extremity bleeding are definitely back in vogue. Our military experience over the past 20 years has shown us what a life saver this simple tool can be. It’s now carried by many prehospital trauma professionals for use in the civilian population. But what about bleeding from the nether regions? You know what I’m talking about, the so-called junctional zones. Those are the areas that are too proximal (or too dangerous) to put on a tourniquet, like the groin, perineum, axilla, and neck.

Traditionally, junctional zone injury could only be treated in the field with direct pressure, clamps, or in some cases a balloon (think 30Fr Foley catheter inserted and blown up as large as possible, see link below). In the old days, we could try blowing up the MAST trousers to try to get a little control, but those are getting hard to find. 

An Alabama company (Compression Works) developed a very novel concept to try to help, the Abdominal Aortic and Junctional Tourniquet (AAJT). Think of it as a pelvic compression device that you purposely apply too high.

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Note the cool warning sticker at the bottom of the device!

The developers performed a small trial on 16 volunteer soldiers after doing a preliminary test on themselves (!). The device was placed around the abdomen, above the pelvis, and inflated to a maximum of 250 torr. Here are the factoids:

  • All subjects tolerated the device, and no complications occurred
  • Flow through the common femoral artery stopped in 15 of the 16 subjects
  • The subject in whom it did not work exceeded the BMI and abdominal girth parameters of the device
  • Average pain score after application was 6-7 (i.e. hurts like hell!)

Here’s a list of the criteria that preclude use of this device:

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Bottom line: This would seem to be a very useful device for controlling hemorrhage from pesky areas below the waist.

BUT! Realistically, it will enjoy only limited use in the civilian population for now. Take a closer look at the exclusion criteria above. Half of the population is ineligible right off the bat (women). And among civilians, more than a third are obese in the US. Toss in a smattering of the other criteria, and the unlikelihood of penetrating trauma to that area in civilians, it won’t make financial sense for your average prehospital agency to carry it. Maybe in high violence urban areas, but not anywhere else.

The company has received approval for use in pelvic and axillary hemorrhage control, so we’ll see how it works when more and larger studies are released (on more and larger people). 

Related post:

Reference: The evaluation of an abdominal aortic tourniquet for the control of pelvic and lower abdominal hemorrhage. Military Med 178(11):1196-1201, 2013.

I have no financial interest in Compression Works.

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General

Below Knee DVT: Worse Than We Thought

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Deep venous thrombosis (DVT) has become the bane of trauma professionals over the past 15+ years. We agonize about how to screen properly, the best ways to prevent, and why it has become such a problem. It’s fairly clear that clot in the veins of the thighs and higher have significant potential to cause major problems, specifically pulmonary embolism (PE).

But what about below the knee DVT? For a long time, we were not as concerned because it was not clear that it actually caused significant complications. I wrote about a study from OHSU last year that addressed this. Now, a recent study published from Scripps Hospital in San Diego confirms the answer to the question.

All trauma patients who were screened for DVT by duplex ultrasound over a 5 ½ year period were enrolled in a retrospective study of the progression and/or complications of this diagnosis. Patients who were at bed rest for 72 hours or who were considered at moderate or higher risk for DVT by American College of Chest Physicians guidelines were screened. Ward patients were screened by duplex weekly, and ICU patients were screened twice a week.

Here are the factoids:

  • Nearly 3,000 of over 11,000 trauma patients were screened (25%)
  • 251 (9%) had DVT or DVT+PE
  • It took an average of 6 days for DVT to appear, and 9 days for PE
  • Two thirds had below knee DVT, one third had above knee disease
  • 4.4% of below knee DVT developed PE
  • Below knee DVT progressed to above the knee in 13% of patients
  • 86% of above knee clot was treated with anticoagulation vs only 24% with below knee DVT
  • 64% of the patients who developed PE were not receiving prophylaxis

Bottom line: Below knee DVT is more significant than we thought, frequently progressing above the knee or throwing off pulmonary emboli. Duplex ultrasound needs to be performed from groin to ankle in at risk patients according to a protocol determined by your hospital. As for what to do when you find below the knee clot, the answer is not yet clear. If the patient has not been receiving chemical prophylaxis, they should at least be started. If they have been receiving prophyaxis, a change to therapeutic dosing is probably warranted. 

Related posts:

Reference: Below-knee deep vein thrombosis: An opportunity to prevent pulmonary embolism? J Trauma 77(3):459-463, 2014.

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Cool Video Alert: The Day Everything Changed…

Ever wonder what it’s like to be a patient involved in a major traumatic event? Here’s a video shot from their perspective. It starts from the moment of a motorcycle crash, and includes first responders, aeromedical response, trauma team activation, and more. We trauma professionals take for granted what goes on, but it’s eye-opening to view it from the patient point of view.

This video is 10 minutes long, not including the ending credits. It was shown at the Trauma Education: The Next Generation conference last week. Enjoy!

(Source: https://www.youtube.com/)
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