UMEM Educational Pearls - By Robert Flint

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Category: Ultrasound

Title: Does IV contrast help identify injuries in blunt abdominal trauma patients?

Keywords: Abdomen, ultrasound, trauma, contrast (PubMed Search)

Posted: 5/23/2024 by Robert Flint, MD (Updated: 5/25/2024)
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This very small study looked at the utility of using IV contrast media to enhance abdominal sonography in identifying injuries in blunt abdominal trauma patients. The comparison was CT scanning of the abdomen to identify injuries. The study concluded:

“With the addition of contrast and careful inspection of solid organs, abdominal sonography with contrast performed by the emergency physician improves the ability to rule out traumatic findings on abdominal CT. CEUS performed by emergency physicians may miss injuries, especially in the absence of free fluid, in cases of low-grade injuries, simultaneous injuries, or poor-quality examinations.”

To me, this is a limited study and the technique is not ready for wide spread use but further study is warranted.

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Category: Trauma

Title: Vasopressors in hemorrhagic shock

Keywords: vasopressor, hemorrhage, shock, trauma (PubMed Search)

Posted: 5/19/2024 by Robert Flint, MD (Updated: 5/25/2024)
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In this podcast, the concept of vasopressor use in hemorrhagic shock is discussed.  Key take away points:

  1. US and UK literature is much less supportive of vasopressor use in hemorrhagic shock than continental European literature.
  2. Concept is while filling the tank with blood, getting some squeeze in the venous system to keep it circulating.
  3. If a young trauma patient has cool extremities, they are already vasogenic and unlikely to benefit from vasopressors. Warm extremities mean they may benefit from vasopressors.
  4. Norepinephrine is the drug of  choice. Aim for a maintenance dose of 3-5 mcg/min and no need to titrate because you are not looking for arterial constriction, just venous tone.
  5. Low dose Vasopressin drip may be beneficial as well, however more literature is needed. 
  6. Blood is still the answer in these patients! Vasopressors are an adjunct to creating a balanced resuscitation.

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This retrospective study looked at patients diagnosed with urinary tract infections receiving an IV dose of antibiotics  prior to discharge and compared ED length of stay and return visit rate. They found:

“Parenteral antibiotic administration in the ED was associated with a 60-minute increase in ED LOS compared with those who received an oral antibiotic (P < 0.001) and a 30-minute increase in ED LOS compared with no antibiotic (P < 0.001). No differences were observed in revisits to the ED at 72 hours”

Appears no benefit to the practice of IV antibiotics prior to discharge in UTI patients.

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Category: Trauma

Title: Brain Injury Associated Shock

Posted: 5/12/2024 by Robert Flint, MD (Updated: 5/25/2024)
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Hemodynamic instability in trauma patients is most often associated with hemorrhagic shock, however, there is an entity known as brain injury associated shock (BIAS). BIAS is thought to be associated with catecholamine surges secondary to brain injury.  BIAS is found in both isolated head injury pts as well as multi-trauma patients. Studies have identified BIAS in 13% of adult  trauma patients and up to 40% of pediatric major trauma patients.  
We know hypotension in brain injury worsens outcome.  We should assume hemorrhagic etiology until we prove otherwise. Once we suspect BIAS and have excluded hemorrhagic etiology our strategy should switch to  blood pressure support using non-blood product management.

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Category: Trauma

Title: Blunt Cardiac Injury

Keywords: trauma, blunt, cardiac injury, shock, thoracic (PubMed Search)

Posted: 5/5/2024 by Robert Flint, MD
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Blunt Cardiac Injury is a continuum from asymptomatic, not clinically relevant to catastrophic, life ending disease . Consider blunt cardiac injury in patients with significant force to the chest wall or sudden deceleration injuries (motor vehicle crashes, motorcycle crashes, falls from height etc.). This algorithm is helpful when working up patients suspected of having significant blunt cardiac injury. 

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In a cohort of  93,512 ED patients discharged with a diagnosis of hypertension there were 4400 who received a prescription for antihypertensives. The group receiving a prescription had fewer 30 day revisits and adverse events such as MI, CHF, etc. 

Previous study’s have found it is safe to prescribe antihypertensives from the ED. 

 This study is limited by the fact it is not a randomized control trial and there are many variables as to why the select patients received prescriptions  

The authors conclude: “Prescription antihypertensive therapy for discharged ED patients is associated with a 30-day decrease in severe adverse events and ED revisit rate.”

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A small study retrospectively looking at recorded calls to a level 1 trauma center transfer line specifically looking at patients who died or were discharged to hospice without surgical intervention found only 10% had goals of care discussed prior to transfer. Most were brain hemorrhage patients. 
As a transferring facility, clearly outlining goals of care and addressing futility of care can have a major impact on trauma transfers and the cost and family burden associated with transfers.

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PECARN  has a decision tool to identify blunt trauma patients under age 18 who are low probability for important intra-abdominal injuries. The questions to ask are:

  1.  Evidence of abdominal wall trauma/seatbelt sign
  2. GCS <14 with abdominal trauma
  3. Abdominal tenderness
  4. >1 of thoracic wall trauma, vomiting, complaint of abdominal pain, decreased breath sounds

Answering no to all yields  <0.1% chance of intra-abdominal trauma requiring intervention.  (See MedCalc link for other calculations)

A prospective validation study in the Lancet yielded 100% sensitivity and negative predictive value in 7542 patients under age 18  

This tool can likely be used to guide imaging choices in pediatric blunt abdominal trauma patients

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This study looked at survival pre and post implementation of an airway guideline for prehospital traumatic brain injury (TBI) patients who received positive pressure airway interventions.  The guideline “focused on the avoidance and aggressive treatment of hypotension and 3 airway-related goals: (1) prevention or treatment of hypoxia through early, high-flow oxygen administration; (2) airway interventions to optimize oxygenation or ventilation when high-flow oxygen was insufficient; and (3) prevention of hyperventilation or hypocapnia by using ventilation adjuncts (ie, rate timers, flow-controlled ventilation bags, end-tidal carbon dioxide monitoring).”

Post implementation, survival to admission increased in all severity levels of TBI and in the most severely injured, survival to discharge improved. 

Useful for those involved in prehospital education and as a reminder for in hospital airway management  in TBI patients.

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Category: Trauma

Title: Is a systolic blood pressure of 90 the best measure of illness in trauma patients?

Keywords: Trauma, blood pressure, shock index, predictor, mortality (PubMed Search)

Posted: 4/8/2024 by Robert Flint, MD
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Traditionally, a systolic blood  pressure (SBP) of 90 has been used as a marker of severe illness in trauma patients. This study looked at a large database and found shock index (SI) and systolic blood pressure were the best predictors of early mortality in trauma patients. 
They found: 

prehospital SI 0.9 and SBP 110,

ED SI 0.9 and SBP 112,

and

in elderly 

prehospital SI 0.8 SBP 116 

ED SI 0.8 SBP 121 

were the cutoffs to predict early mortality.  
We should rethink our protocols and approach to trauma patients using a higher systolic blood pressure than 90. Also note elderly had a different number than younger trauma patients.

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Category: Trauma

Title: No evidence to support use of markers for penetrating trauma radiographs

Keywords: Marker, penetrating trauma, radiopaque (PubMed Search)

Posted: 4/7/2024 by Robert Flint, MD (Updated: 5/25/2024)
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Using radiopaque markers such as paperclips to mark penetrating wounds prior to radiographs has been taught in trauma bays for decades. This article points out there is no evidence to support this practice and is purely based on expert opinion. With the heavy use of CT imaging to assess wound tracks, the use of markers on plain films appears to be of limited utility.

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This retrospective population cohort study looked at  first time ED visits for adolescents and young adults comparing those with visits related to alcohol to those not related to alcohol. Patients in the alcohol related visit group had  a threefold increased one year mortality rate.  Cause of death was trauma, poisoning by drug and alcohol. Risk factors include being male, age 20-29, history of mental health and having a visit for withdrawal.  

Adolescents and young adults presenting to an emergency department for an alcohol related complaint are high risk for one year mortality and deserve intervention and appropriate referral.

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Category: Trauma

Title: A benzodiazepine sparing protocol for alcohol withdrawal in trauma patients

Keywords: Alcohol, withdrawal, trauma, protocol, sparing (PubMed Search)

Posted: 3/24/2024 by Robert Flint, MD (Updated: 5/25/2024)
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This study compared  admitted trauma patients with alcohol withdrawal or those at risk of withdrawal before and after a  benzodiazepine sparing protocol (using clonidine and gabapentin) was initiated. They found a lower daily CIWA score and significantly less lorazepam use in the benzodiazepines sparing group. This sparing protocol appears to be safe and effective.

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Category: Trauma

Title: Use of hospice for discharge in geriatric trauma patients

Keywords: Geriatric trauma, outcome, hospice (PubMed Search)

Posted: 3/17/2024 by Robert Flint, MD (Updated: 5/25/2024)
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This was a database study of nearly 2 million trauma patients over age 65 who were discharged looking at all levels of trauma centers. The authors found:

“Dominance analysis showed that proportion of patients with Injury Severity Score of >15 contributed most to explaining hospice utilization rates (3.2%) followed by trauma center level (2.3%), proportion White(1.9%), proportion female (1.5%), and urban/rural setting (1.4%).”

 Level one centers had the lowest level of discharge to hospice. The authors felt: “As the population ages, accurate assessment of geriatric trauma outcomes becomes more critical. Further studies are needed to evaluate the optimal utilization of hospice in end-of-life decision making for geriatric trauma.”

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This secondary analysis of the NEXUS head injury data found patients over 65:

-sustained more significant injuries than younger pts

-presented more frequently with occult injuries

-when they required neurosurgery intervention only 16% went home, 32% were discharged to rehab facility and 41%  died

-mechanism of injury was most commonly fall from standing

-mortality rates were highest for fall from ladder and auto vs. pedestrian injuries

The authors concluded: “Older blunt head injury patients are at high risk of sustaining serious intracranial injuries even with low-risk mechanisms of injury, such as ground-level falls. Clinical evaluation is unreliable and frequently fails to identify patients with significant injuries. Outcomes, particularly after intervention, can be poor, with high rates of long-term disability and mortality.”

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This is a retrospective study looking at traumatic brain injury patients comparing those with and without  pre-existing psychiatric illness at the time of injury. Those with pre-existing illness had longer hospital stays, longer ICU stays and more frequent readmissions.

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This meta analysis did not find convincing evidence for or against seizure prophylaxis for admitted moderate to severe traumatic brain injury pts. They recommend Levetiracetam over other medications again on weak evidence.

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Category: Trauma

Title: Geriatric Hip fractures: when is a low hgb detrimental.

Keywords: Hip fracture l, hemoglobin l, mortality (PubMed Search)

Posted: 2/25/2024 by Robert Flint, MD (Updated: 5/25/2024)
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In this study, geriatric hip fracture patients with a hemoglobin less than 7.1 had higher mortality, especially in those over age 79, even when controlling for other factors such as ASA Physical status class, anti-platelet use, etc.

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This research letter notes: “The Rural Emergency Hospital is a new Medicare payment model available to hospitals with 50 or fewer beds in rural areas. Rural hospitals converting to this model will have emergency department (ED), observation, and outpatient services.”. Their study concludes that the majority of these hospitals already transfer the vast majority of their admissions to larger hospitals and this designation is a recognition of already established practices.

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