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.