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.

2 thoughts on “Trauma Review”

  1. Thanks Selma for summersing Dr. Mahadevan talk , that unfortunately i couldn’t attend as I’m out of Saudi Arabia,,

    i would like to comment on some of the points discussed
    1- I think C mac I have no would be the best for both the learner & the supervisor as learner can use it as DL and supervisor is seeing what is going on as it would be for VL , so the learner will be trained as if it is DL without jeopardising the patient.
    by the way ,, “I have no relevant financial or nonfinancial relationships to disclose about C mac ”

    2- the study is called PROMMTT not PROMITT study http://www.ccm.pitt.edu/sites/default/files/calendar_event_articles/liepert.pdf
    and showed the closer to 1:1:1 the better pt did in 1st 24 hrs after that it didn’t matter in both group.

    PROPPR study is an ongoing study looking for
    ratio vs non ratio based , so stay tuned and will know what it’ll show

    3- tow studies , first looked for pt with minor head inj on Warfarin the other study included pt on clopidogrel or warfarin but not aspirin

    first study –>
    Menditto VG et al. Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Ann Emerg Med. 2012 Jun;59(6):451-5 PMID: 22244878.
    This study only included patients on warfarin and did not study other anticoagulation agents
    87 patients – 6% of pt who had an initially negative head CT and a GCS of 14 or 15, had findings on repeat head CT. Only 1 of these had any neurologic changes
    Of the patients who went home after two negative head CTs and a period of observation, two patients later returned with symptomatic subdural hematomas. one after 2 days & one after 8 days !!
    what we can came out with this study ? Patients with an INR greater than 3 and those who were elderly were at higher risk of delayed bleed.

    the other study –>
    Nishijima DK et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012 Jun;59(6):460-8 PMID: 22626015.

    They looked at the incidence of acute and delayed bleeds.
    revalence of a bleed on the initial study? About 12% in the clopidogrel group and only 5% in the warfarin group.
    They found the incidence of delayed bleed was 0% in the clopidogrel group and 0.6% in the warfarin group

    So the question now is what u’ll do after negative initial head CT ?
    Observation, a repeat CT head or sending them home with good return precautions are all reasonable options.
    come up with your own conclusion of what to do. If the patient has risk factors such as a high INR or elderly, it may be worth admitting them for observation and a repeat CT.
    TAKE HOME : remember that there is still the possibility of a delayed bleed several days later.

    I gather some of my above mentioned studies from #EMU2014 & EMRAP.org ,,,

    thanks again Selma and hope to see you all soon

    regards

    1. Thank u abdulrahman for the discussion! A lot of interesting points!
      C MAC vs. Glidoscope…there are many articles that cover the success rates in the ED (Moiser et al.Ann Emerg Med. 2013.61:414-420)but not as a teaching tool. Sounds like you have good grounds for a study there!
      I agree about anticoagulated patients and head trauma. The initial CT is key as pointed in my review. As the literature is not clear cut on observation vs a close follow up, it depends on the patient and practice. The next question is in patients that do have ICH how many needed neurosurgical intervention? This is without any mention newer generation anticoagulants.
      Each point mentioned in the review is a review in its own right! Stay tuned…

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