Category: Trauma

Ketamine For Acute Pain Control

So, there’s effective.  And then there’s effective, but insane.  I am aware that low-dose continuous infusions of ketamine are excellent adjunctive therapies to decrease narcotic use in trauma and orthopedic patients, but I have never seen ketamine used in bolus form to treat acute pain in the out-of-hospital setting.

But, that’s what we have.  After an initial 5mg IV bolus of morphine, patients were randomized to receive either additional morphine or ketamine boluses – 1 to 5mg of morphine every five minutes, or 10 to 20mg of ketamine every three minutes.  Pain medication was given per protocol until relief or adverse events.  And, the ketamine group was superior – pain scores dropped 5.6 points on the numerical verbal scale with ketamine and 3.2 with morphine.

However, the ketamine group also had a 39% incidence of adverse effects, compared with 14% of the morphine group.  The morphine group had mostly nausea, with one patient exhibiting a change in level of consciousness.  However, the ketamine group had multiple patients with decreased consciousness, disorientation, and emergence phenomena.  So, while the editor capsule summary states “Supplementing out-of-hospital opiods with low-dose ketamine is an effective strategy to mitigate trauma pain” he is technically correct, but the insanity of this strategy is trying to make an evidence-based decision about intracranial imaging after iatrogenically altering your patients prehospital.

What I appreciate best about this paper is how aggressive the paramedics were with treating pain – the patients receiving morphine averaged 14.4mg, with a standard deviation of 9.4mg!  I see my residents ordering 2mg at a time and it drives me nuts.

“Morphine and Ketamine Is Superior to Morphine Alone for Out-of-Hospital Trauma Analgesia: A Randomized Controlled Trial”
www.ncbi.nlm.nih.gov/pubmed/22243959

Observation For Anticoagulated Head Trauma

Coming in a future issue of Annals, the Editor’s capsule summary: “Delayed intracranial hemorrhage is common after minor head injury when patients are receiving warfarin. A minimum protocol of 24-hour observation followed by repeated scanning is necessary to detect most such occurrences.”

Now, this isn’t a terribly management agnostic statement.  It does not specifically state this is something we need to start doing – but it rather implies that, if you don’t, you’ll be missing this “common” phenomenon.  It isn’t an alien concept – since 2002, the European Federation of Neurological Societies has recommended admission for observation after minor head trauma – but it’s certainly not the standard of care here.  So, for the Annals editors to state that observation and repeat scanning is “necessary”, they must obviously have excellent evidence.

Or they have an observational case series consisting of 87 patients from Italy.

These authors present a prospective case series of all patients at their institution who were admitted for observation specifically for minor head trauma while on oral anticoagulation.  At the time of repeat CT scanning 24 hours later, the authors report five of them had new bleeding detected.  In addition, two patients who were discharged after two negative CT scans returned with symptomatic bleeding, one at two days, and one at eight days.

So, should we be observing and rescanning every anticoagulated minor head trauma patient as these authors suggest (and as they do in Europe)?  If you practice in a zero-miss litigation environment, this article and ACEP’s apparent embrace of the results will hamstring your decision-making.  This data is completely inadequate to change clinical practice, and inconsistent with prior literature documenting delayed hemorrhage in only 2 of 137 patients.

Clearly, some patients will have delayed bleeding – a subset of which will be clinically significant.  However, we simply cannot expose all anticoagulated patients with minor head trauma to the harms and costs of hospitalization.  Better studies are required to prospectively determine the risk profile of patients who require further observation in a hospital setting, rather than a watchful discharge home.

“Management of Minor Head Injury in Patients Receiving Oral Anticoagulant Therapy: A Prospective Study of a 24-Hour Observation Protocol”

So, NEXUS Is Invalid?

Another doom and gloom trauma article that wants to take one of our most cherished tools away from us regarding the evaluation of the blunt trauma patients.  Certainly, nothing is sacred, but these authors want to take NEXUS out to the woodshed and make sure every trauma patient gets a CT of the c-spine.

The premise of their argument is reasonable – NEXUS was derived in an era of plain films for radiographic clearance of the cervical spine, and now, many studies have observed that CT with 3D reconstruction picks up potentially significant injuries that could be missed by plain x-rays.  Therefore, the gold standard incorporating plain radiography for NEXUS renders it invalid due to missed injuries.

These authors performed a prospective evaluation of the NEXUS rules by applying them to 2,606 adult trauma patients, all of whom underwent 16 multidetector CT scanning with 2mm thick axial cuts.  They found 157 patients with a total of 258 fractures – and note that 26 patients had fractures identified despite meeting NEXUS criteria.  Of these 26, 16 were managed in a c-collar, 2 underwent operative stabilization, and 1 had a halo placed.  Therefore, they simply conclude that NEXUS is not externally valid to their trauma population and everyone should receive a CT of the c-spine based on mechanism.

Finding flaws with NEXUS – excellent, let’s identify the subset at higher-risk so we can prevent missed injuries.  However, this article doesn’t help us at all.  They don’t do any sort of descriptive analysis of the NEXUS-negative patients who end up with significant injuries with which to educate our practice.  They simply conclude with the blanket statement that the dollar cost of performing all the CTs is less than the dollar cost of potential malpractice payouts.

In an era where we’re trying to cut healthcare costs and reduce the practices of defensive medicine, this is precisely the sort of article that we don’t need.  This is fantastic data presented in a non-constructive fashion that will likely, as the authors seem to intend, ensure the 97% of NEXUS-negative patients who had no injuries get their CT of the c-spine.

“National Emergency X-Radiography Utilization Study Criteria Is Inadequate to Rule Out Fracture After Significant Blunt Trauma Compared With Computed Tomography”
http://www.ncbi.nlm.nih.gov/pubmed/21610391

Who Knows If Older Platelets Are More Harmful

It might be true, but there’s no way to know from this study – another illuminating example of just how difficult it is to perform trauma research.

Given that increased platelet transfusion in trauma has been linked to sepsis, ARDS, and other untoward outcomes, these authors decided to retrospectively evaluate whether the age of the platelet had any effect on sepsis, ARDS, ARF, liver failure, and mortality.  And, the answer – like I said, who knows?  The group that received four-day old platelets had the highest ISS – mostly attribute to head AIS >3 – in addition to an unlimited number of accounted for and unaccounted for confounding variables.

If you believe their adjustments, their proportional hazard regression model shakes out platelet and blood product age-related variables as significant associations with complications – most of which is sepsis.  So, while the authors are probably right, there are limitations.

“Impact of the Duration of Platelet Storage in Critically Ill Trauma Patients”
http://www.ncbi.nlm.nih.gov/pubmed/22182887

TYRAPS69S6HZ claim code (don’t ask).

Too Many Traumatic Arrests Are Transported

Traumatic arrest in the field – except in the narrowest of circumstances – has universally dismal outcomes.  Yet, As the authors of this study observe, a great number of these patients continue to be transported to hospitals.

This is a retrospective review of a prospective trauma registry at Sinai in Chicago in which all traumatic patients with pre-hospital arrest were considered.  Patients were excluded for pediatrics, medical causes, drowning/electrocution injuries, and if the prehospital time was less than 15 minutes.  Essentially, they were looking at guidelines from the ACS Committee on Trauma for termination of resuscitation in the out of hospital setting – pulseless, apneic, no organized ECG activity, or unresponsive to 15 minutes of resuscitation.

They identified 428 patients in their cohort – and found that 294 of them were transported in violation of guidelines.  Of the inappropriately transported patients, 93% were declared dead in the ED and the remaining 6.8% (20 patients) survived the ED.  Of those 20, 12 died in surgery, 8 made it to the ICU, and 7 died.  A single, neurologically devastated, patient survived to discharge to a long-term care facility with a GCS of 6.

The total hospital charges incurred for the futile resuscitation of these patients totaled $3.8 million – a figure that excludes the EMS charges as well as the long-term care facility charges for the patient with GCS 6.

And this is just a single hospital.

“The Consequences of Noncompliance With Guidelines for Withholding or Terminating Resuscitation in Traumatic Cardiac Arrest Patients”
http://www.ncbi.nlm.nih.gov/pubmed/21986740

TEG and Dabigatran

An interesting mini-letter from my institution regarding dabigatran, thromboelastography, and poor outcomes.

It simply notes and reinforces the fact that conventional coagulation studies in patients on dabigatran will be normal – and therefore conventional reversal options are unlikely to be of value.  The only abnormality detected was prolongation of the activated clotting time, corresponding to inhibition of enzymatic clotting.

Multiple patients have presented after traumatic injury to our institution, and they have universally had poor outcomes.

“Acutely Injured Patients on Dabigatran”
http://www.nejm.org/doi/full/10.1056/NEJMc1111095

Do/Don’t Scan the Trauma Patient

In a study attempting to build consensus, they discovered philosophical differences between the trauma team and the emergency physician.

This is a prospective observational study in which 701 blunt trauma activations at LAC-USC were enrolled, with the EP and the trauma team each giving an opinion on which CT studies were necessary.  The authors then reviewed which scans were obtained, sorted out the scans that were undesired by one or both physicians, and determined whether any injuries would be missed.

Bafflingly, 7% of the 2,804 scans obtained during the study period were deemed unnecessary by both the emergency physician and the trauma attending – yet were still performed.  The remaining 794 undesired scans were desired by the trauma team but not the emergency physician.  Their question – would anything of significance been missed if the scans had been more selectively ordered?

The answer is – yes and no.  The trauma surgeon authors state yes, and justify that by saying that many of the abnormalities missed on CT required closer monitoring – just because none of the missed injuries deteriorated during the study period does not mean they were not significant.  The emergency physician authors point to a 56% reduction in pan-scanning, the benefits of radiation and cost reductions, and hang their hats on the fact that none of the hypothetically missed injuries changed management.

So, who is right?  Both, and neither, of course.  Emergency physicians and trauma teams should work on developing evidence-based clinical decision rules to support selective scanning in blunt trauma – and then try this study again to see if they can generate results they can agree on.

Definitely a fun read.

As far as medical literature goes, of course.

“Selective Use of Computed Tomography Compared With Routine Whole Body Imaging in Patients With Blunt Trauma.”
www.ncbi.nlm.nih.gov/pubmed/21890237

C-Collars Cannot Stabilize Unstable Injuries

This is another cautionary anatomic study that demonstrates cervical collars are not adequate immobilization devices – except in patients who already do not need them.

This is a cadaveric spinal immobilization study in which C5/C6 instability was induced, and the Ambu extrication collar, the Aspen collar, and no collar were evaluated for range of bending and rotation during a bed transfer simulation.

The results are pretty straightforward.  Before the instability was induced, patients had minimal neck movement, whether immobilized or not.  After instability was induced, the patients all had significant bending and rotation – nearly the same for the patients in the collars as in no collar at all.

This is consistent with the small amount of prior work done in actual unstable spines; most of the cervical collar data is in healthy volunteers.  The limitations of a cervical collar should be recognized, and patients should have their cervical spine evaluated and cleared or intervened on immediately.

“Cervical collars are insufficient for immobilizing an unstable cervical spine injury.”
www.ncbi.nlm.nih.gov/pubmed/21397431

MRI After Negative CT in Obtunded Trauma

In contrast to the recently reviewed study showing 5 surgical injuries in 174 patients complaining of neck pain after a negative CT c-spine, this study of MRI in obtunded trauma patients with a negative CT c-spine showed no surgical injuries.

Specifically, this is a retrospective review from U.C. Davis in which they looked at 512 patients who underwent both CT c-spine and MRI c-spine.  They found 150 patients who were confused/obtunded, had otherwise normal neurologic examination, and had a negative initial CT c-spine.  Half of these patients had an injury identified on their MRI, but none of them were unstable ligamentous injuries or structural abnormalities requiring surgical intervention.

This is more relevant to our trauma colleagues who need to mobilize people in the ICU to prevent other complications, and external validity is limited in a single-center study, but it’s a mark on the side of keeping the standard of care at CT and not proceeding to MRI in an irrational manner.

“The Value of Cervical Magnetic Resonance Imaging in the Evaluation of the Obtunded or Comatose Patient With Cervical Trauma, No Other Abnormal Neurologic Findings, and a Normal Cervical Computed Tomography.”
www.ncbi.nlm.nih.gov/pubmed/21857257

More Platelets In Massive Transfusion

Where are we going to get all these blood products?  The rapidly growing body of literature backing early transfusion of FFP and platelets in massive transfusion protocols continues to tilt towards the 1:1:1 ratio.

This is a retrospective review of whether platelet transfusion impacts survival in trauma.  They identify three categories of ratios of platelets to RBCs (>1:20, 1:2, and 1:1) and measure a variety of different outcomes.  Briefly, more platelets helped with survival to 24 hours, but more platelets also increased multi-organ failure.  In the end, the initial survival differences were great enough that they outweighed the additional multi-organ failure for a significant survival benefit (52% vs. 57% vs. 70%).

They exclude 25 patients who died within an hour in an effort to mitigate survival bias.  However, looking at the breakdown of survival times, it looks as though almost all the mortality benefit to increased platelet ratios was realized in the first 6 hours – and then the mortality numbers worsen in tandem after that.  The authors state they were unable to truly quantify retrospectively whether the patients survived because they received more platelets vs. whether patients surviving longer were able to receive more platelets, and note that prospective trials will need to be performed.

I would also note that a significant portion of their high ratio patients also received Factor VII, for whatever that’s worth.

So, we continue to await high quality prospective trials that specifically address the impact of survival bias.

“Increased Platelet:RBC Ratios Are Associated With Improved Survival After Massive Transfusion.”
http://journals.lww.com/jtrauma/Abstract/2011/08003/Increased_Platelet_RBC_Ratios_Are_Associated_With.2.aspx