Trauma Review

May has proven to be a very eventful month in KSA with many international speakers dropping by from the world of emergency medicine. This week we had the pleasure of meeting Dr. Swaminatha V. Mahadevan, associate professor of surgery and emergency medicine and director of international emergency medicine in Stanford University to give us a talk on trauma. The discussion was very interesting as West meets East in comparing practices!

First stop was the use of video laryngoscopy. Should video laryngoscopy be standard of care or should it be used as an adjunct in the management of emergency medicine? Video laryngoscopy has proven to have no difference in mortality compared to direct even though it took on average 16 seconds longer (Yeats et all. 2013. J Trauma Acute Care Surg: 75:212-9). In teaching intubation, video laryngoscopy provides a more relaxed and in-control environment as performer and teacher have equal views. Even though direct laryngoscopy is not out of the window yet, video laryngoscopy is definitely taking over.

Next stop was the use of massive transfusion protocol. Massive transfusion protocol and giving blood, plasma and platelets at a ratio of 1:1:1 has really changed the practice of trauma resuscitation. Thanks to the PROMITT study which has decreased 6 hour mortality with the above ratio. Patients with ratios of 1:2 were 3-4 times more likely to die than patients with 1:1. When do you apply it? The definition of Massive transfusion is when the patient is anticipated to loose his blood volume in 24 hours, i.e., 10 units. The Europeans advocate to start the protocol after 4 units of PRBCs while other guidelines suggest to start with a base excess >5, INR ≥1.5, hemoperitoneum (Hsu et al. 2013. J Trauma Acute Care Surg: 75:359).  How to apply it? Dr Mahadevan shared with us Stanford’s protocol that , 1 unit of FFP can be given for every 1 unit PRBC, after 10 units of each, 6 units of platelets are given.

Next was a very heated debate of head trauma in the anti-coagulated patient. A headache to both the patient and EM physician! The CT comes back negative but you are not done! The medical literature is quite lacking here with many questions still not answered. How long to observe? Indications for serial CTs? Will it go from a negative CT to a neurosurgical emergency? Who do you reverse the INR? The literature has failed to identify which patients at low risk of ICH, even in the absence of clinical findings and therefore an initial CT is warranted (Joesph et al. 2014. Am Surg: 80:43-7). After that, observation of at least 24 hours is key. Any change in level of consciousness, alertness, and neurological function buys this person a CT brain. In the presence of an intracranial bleed INR reversal is achieved with 4 factor PCC and slow infusion of IV vitamin K with INR monitoring. The decision to reverse the coagulation though life saving should not be taken lightly as the patient was on warfarin to prevent thrombosis whether it is a recurrent PE or a metallic valve.

Last, was the use of Ultrasound in trauma. This topic does not need an introduction ultrasound is used extensively here. Procedures are safer with ultrasound. Ultrasound has proven to be more sensitive than a chest x-ray at detecting a pneumothorax (Nagarsheth et al 2011. Am Surg: 77: 480-4). And of course ultrasound for E-Fast is well established in the literature.

Thank you Dr. Mahadevan for taking time off to meet the residents of SPEM and we look forward to seeing you again.

Thoracic Trauma

Good afternoon all,

Here are some points from our last activity (Thoracic Trauma) that took place in 22-04-2014

1-The most common chest injury in pediatrics is lung contusion. While the presence of rib fracture means sever trauma.

2-1st and 2nd ribs fractures are not always an indication for angiography as it depends on clinical suspicion.

3-Lower ribs fractures (9-12) :

A-If on the right side:  3 × times increase in risk of liver injury.

B-If on the left side:  4× times increase in risk of spleen injury.

4-Any displaced rib fracture needs observation and monitoring for at least 3 hours and chest x-ray needs to be repeated before discharge.

5-Isolated sternum fracture does not reflect cardiac or aortic injury.

6-In blast injury (shock wave) pulmonary contusion can present even without any external evidence of chest injury.

7-ARDS vs lung contusion :

Contusion will appear within the first 6 hours while ARDS will take longer time to manifest.

8-80 %  of tracheobronchial injuries are within 2 cm above the carina, suspect it when you have a continuously leaking chest tube .

9-Myocardial concussion (Commotio Cordis): blunt injury to the chest produces a stunned myocardium and dysrhythmias (mostly  Vfib).

10-There is no single test that confirms the diagnosis of cardiac contusion except for autopsy.  Thus, the key point whenever it’s suspected is monitoring (serial ECG, cardiac markers).

11-In myocardial rupture the most common affected part is ventricles (Rt more than Lt).

12-Aortic injury is the most common vessel injury with 80-90% of injuries in the descending part just distal to the Lt subclavian artery.  The most indicative CXR finding is widened mediastinum .

13-Esophageal rupture:  almost 100%  mortality if the diagnosis has been delayed for more than 24 hours.  Gold standard test is gastrografin esophagram but it will be suboptimal in case of multiple trauma where the patient is only in supine position as it needs different views while standing in different positions, i.e. AP, oblique and lateral so in this case  you need to add endoscopy to support the diagnosis and if esophageal rupture is still suspected go to surgery .

14-The most common side of diaphragmatic rupture is the Lt side and it is mostly caused by a blow to the abdomen that raises the intrabdominal pressure too high to a limit that causes the diaphragm to burst.

MERSCoV suspected ? what type of precaution !? (WHO) advice is ….

 

 

 

Salam

Hi dear emerg folks!!

  You are resuscitating a patient who came to your ED with a history of acute dyspnea, cough, preceded by flu-like illness for the last 5-7 days and he is febrile > 38.5 C . The patient is extremely tachypnic, desating on 15 L NRM, septic and started to be agitated as he is removing the Oxygen non-rebreather mask!!  So you decide to go to maintain the patient’s airway and you are doing your checklist for RSI. BUT nowadays with the clusters of MERSCoV reported in our region you think: what type of (Personal Protective Equipments – PPE) should be used ? Standard ? Droplet ? Airborne precautions ?

mmmmm 😕 ?? 

Middle East Respiratory Syndrome coronavirus or MERSCoV is a disease that has arisen in the last couple of  years in the Middle East with majority of cases in our country, Saudi Arabia. It is a threat to both, the community and healthcare workers. Knowledge about MERSCoV is evolving and lots of information is still lacking!! Many researches and reports are ongoing by WHO and Saudi Ministry of Health.

We are, as front liners emergency physicians, should be aware of all threat to both community and health care providers .

While reading the World Health Organization (WHO) update on MERSCoV that was released yesterday, 10 April 2014. I noticed that the (WHO) advice is “Airborne precautions should be applied when performing aerosol generating procedures” (along with Standard and droplet precaution).  Although its not clear yet but less likely MERSCoV is an airborne transmitted disease!  Here is the link for WHO update on MERSCoV :

http://who.int/csr/don/2014_04_10_mers/en/ or click here 

The summary of ” what type of precautions ? ” is advised by WHO :

  • Droplet precautions should be added to the standard precautions when providing care to all patients with symptoms of acute respiratory infection.
  • Contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection.
  • Airborne precautions should be applied when performing aerosol generating procedures.

 

merscov1

 

 

merscov2

 

merscov3

 

merscov4

 

Hereby, I focused on the precautions for the healthcare workers. Yet it is as important also to educate the community.  So please do not forget that we should care about what’s threatening not only our community but the whole world. We as emergency physicians, with other healthcare providers, should have a role to educate and increase the awareness of  our community about this evolving threat. 

May ALLAH protect all humanity and make a speed recovery for those who are infected. Peace and mercy for those who passed away.

References:

– Word Health Organization – Global Alert and Response. Middle East respiratory syndrome (MERSCoV) – Update. 10 April 2014.    click here

– http://www.cdc.gov/

 

Regards

 

Educational day pearls A-1

Hi folks,  these are the main points of our discussion in the last academic activity day, enjoy!

  • Kayexalate,, Never think about it in the ED. Its effect -If any- only starts after 4 hours .
  • There is some published evidence on severe GI complications secondary to the administration of Kayexalate such as colonic necrosis or perforation, whether accompanied with the administration of Sorbitol or not.
  • Insulin with dextrose and Albuterol nebulizer have synergistic effect when treating hyperkalemia.
  • In case of hypernatremia: Start with correcting the underlying shock, hypoperfusion or significant hypovolemia with normal saline.
  • Most patients presenting to the ED with hyponatremia are stable and require NO emergent therapy.
  • For asymptomatic patients with sodium values of 115 to 135 mEq/ L, free water restriction is typically the single most important treatment in ED.
  • For Asymptomatic hyponatremia cases send: Serum and Urine osmolality, TSH, Random cortisol level, Uric Acid and urine electrolytes before starting fluids.
  • Many case reports addressed fatality from iatrogenic hypermagnesemia in elderly ( with or without renal impairment). Dose and infusion rate should be reviewed cautiously.

 

Journal club Extra session

Greetings. After getting an approval from Dr. Majed Alsalamh, we are going to have an extra-session of our journal club on Monday 17th March 2014 @ 7 – 9 p.m. This will take place in Radisson Blu Hotel-Riyadh. We are going to have a tutorial session of miscellaneous EBM concepts, for 1 hour, then we are going to have a 10 minute presentation by the sponsoring company representative. Then we will have Dinner at the end of the session. The aim of this extra-session is to refresh our EBM knowledge and to have an enjoying social gathering. Hope that everyone will attend and enjoy. For any inquiries, please don’t hesitate to contact me at any time.