Keywords: appendicitis, delayed operating room, appendectomy (PubMed Search)
This Scandinavian study from the Lancet says yes. They randomized 1800 patients over age 18 to appendectomy either within 8 hours or 24 hours and found no difference in perforation rate or other complications.
Karoliina Jalava, Ville Sallinen, Hanna Lampela, Hanna Malmi, Ingeborg Steinholt, Knut Magne Augestad, Ari Leppäniemi, Panu Mentula,
Role of preoperative in-hospital delay on appendiceal perforation while awaiting appendicectomy (PERFECT): a Nordic, pragmatic, open-label, multicentre, non-inferiority, randomised controlled trial,
The Lancet, 2023
Keywords: rural, trauma, laparotomy, damage control (PubMed Search)
For rural emergency departments, the decision to transfer a trauma patient to a level one center involves multiple factors including the patient’s hemodynamic stability. Harwell et al. looked at 47 trauma patients transferred from a rural hospital to a level one center. They found: “Overall mortality was significantly different between patients who had damage control laparotomy at a rural hospital (14.3%), were unstable transfer patients (75.0%), and stable transfer patients (3.3%; P < 0.001).” They concluded: “Rural damage control laparotomy may be used as a means of stabilization prior to transfer to a Level 1 center, and in appropriate patients may be life-saving.”
Preplanning with emergency medicine, surgery, radiology, anesthesia, nursing, and the receiving trauma center on how to manage these patients is critical.
Harwell PA, Reyes J, Helmer SD, Haan JM. Outcomes of rural trauma patients who undergo damage control laparotomy. Am J Surg. 2019 Sep;218(3):490-495. doi: 10.1016/j.amjsurg.2019.01.005. Epub 2019 Jan 10. PMID: 30685052.
Keywords: arrest, trauma, pneumothorax, CT scan (PubMed Search)
In a study looking at 80 blunt trauma patients that died within 1 hour of arrival to a trauma center who underwent a noncontrast post mortem CT scan the following injuries were identified:
-40% traumatic brain injury
-25% long bone fracture
-25% cervical spine injury
- 18.8% moderate/large pneumothorax
-5% esophageal intubation
Blunt trauma arrest patients deserve decompression of the chest (preferred method is open with finger sweep). Intubation should be verified with end tidal CO2. Verification on arrival at the trauma center is also prudent.
Levin, Jeremy H. MD; Pecoraro, Anthony MD, MBA; Ochs, Victoria; Meagher, Ashley MD; Steenburg, Scott D. MD; Hammer, Peter M. MD, FACS. Characterization of fatal blunt injuries using postmortem computed tomography. Journal of Trauma and Acute Care Surgery 95(2):p 186-190, August 2023. | DOI: 10.1097/TA.0000000000004012
Keywords: liver laceration, trauma (PubMed Search)
Keywords: cardiac arrest, trauma, termination, blood, epinephrine (PubMed Search)
The authors of this paper suggest the following changes, supported by evidence, to the management of traumatic cardiac arrest:
1. Epinephrine, bicarbonate and calcium have limited if no role in traumatic cardiac arrest.
2. CPR may be harmful in traumatic cardiac arrest. Hypovolemia is the cause of death for most trauma patients and CPR cannot correct this.
3. Blood is the resuscitative fluid to be given and all other fluids do not have a role in traumatic cardiac arrest.
4. Correct hypoxia immediately.
5. Finger thoracostomy to decompress penumothoracies, not needles.
6. Utilize termination of resuscitation protocols to end resuscitations in the field.
Traumatic Cardiac Arrest (TCA): Maybe We Could Do Better?
Prehospital trauma care and outcomes have improved little in the past 50 years, the authors write. It’s time to change that.
Keywords: blood, transfusion, prehospital, pediatrics (PubMed Search)
In this small propensity matching study looking at prehospital blood transfusion vs. emergency department blood transfusion in trauma patients aged 0-17 these authors found a better 24 and in-hospital mortality for patients who received prehospital blood transfusion compared to those receiving blood on arrival to the emergency department.
“The number needed to transfuse in the prehospital setting to save 1 child's life was 5 (95% CI, 3-10).”
Morgan KM, Abou-Khalil E, Strotmeyer S, Richardson WM, Gaines BA, Leeper CM. Association of Prehospital Transfusion With Mortality in Pediatric Trauma. JAMA Pediatr. 2023 Jul 1;177(7):693-699. doi: 10.1001/jamapediatrics.2023.1291. PMID: 37213096; PMCID: PMC10203962.
Keywords: Spleen, trauma, spleen injury grades (PubMed Search)
Splenic injury treatment depends on the grade of injury. In general, grades 1 and 2 are non-operatively managed. Grades 4 and 5 tend to be managed operatively. Interventional radiology is used commonly for grade 3 and grades 1 and 2 if active contrast extravasation is seen. Below is a refresher on splenic injury grading.
Adaptation of AAST Organ Injury Scale for Spleen
Description of injury
Subcapsular, <10% surface area
Subcapsular, 10% to 50% surface area
Capsular tear, 1 cm to 3 cm parenchymal depth that does not involve a trabecular vessel
Subcapsular, >50% surface are or expanding: ruptured subcapsular or parenchymal hematoma: intraparenchymal hematoma_>5 cm or expanding
Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen)
Completely shattered spleen
1. An update on nonoperative management of the spleen in adults. BMJ Trauma Surgery and Acute Care Open. Volume 2, Issue 1. Ben L Zarzaur, Grace S Rozycki
Category: Airway Management
Keywords: major adverse event, airway, management, cardiovascular collapse (PubMed Search)
This systemic review and meta analysis looked at major adverses events (hypoxia, cardiovascular instability, or cardiac arrest) in patients intubated in emergency departments, ICU’s, or medical floors. They found nearly 1/3 of patents had an event. ICU intubation and patients with pre-existing hemodynamic compromise had the highest rate of adverse outcomes. This study gives further support to the concept of maximizing resuscitation pre-intubation and to anticipate a major event peri-intubation. Be prepared and don't be surprised when something doesn't go as planned.
Keywords: Ortho, bohler angle, fracture. (PubMed Search)
"The normal value for the Böhler angle is between 25° and 40° . Although there is wide variation between individuals, there is relatively little variation between the left and right feet of a single individual . A reduced Böhler angle can be seen in displaced intra-articular calcaneal fractures. The degree of reduction in the Böhler angle is an indicator of the severity of calcaneal injury, and the degree to which the Böhler angle is restored at surgery is correlated with functional outcome ."
Amini B, Worsley C, Weerakkody Y, et al. Böhler angle. Reference article, Radiopaedia.org (Accessed on 27 Jul 2023) https://doi.org/10.53347/rID-1002
Keywords: radiology, transfer, trauma, imaging, rural (PubMed Search)
Evaluating trauma patients at Level 3 or 4 centers, rural hospitals, and non-trauma centers is difficult. Understanding the amount of work-up to perform prior to transfer is important. Summers, et al suggest less is more when it comes to imaging. The receiving facility often repeats imaging leading to time delays, additional radiation exposure, and increased costs. Chest X-ray and FAST exam may be all that is indicated in centers that do not have the resources to care for injures identified on CT imaging prior to transfer.
Summers LN, Harry ML, Colling KP. Evaluating our progress with trauma transfer imaging: repeat CT scans, incomplete imaging, and delayed definitive care. Emerg Radiol. 2021 Oct;28(5):939-948. doi: 10.1007/s10140-021-01938-x. Epub 2021 May 28. PMID: 34050410.
Keywords: access, IO, IV, resucitation (PubMed Search)
This study found that time to intraosseous was faster than time to peripheral IV. This lead to quicker resuscitation time. This was particularly true in pateints that arrived without a pre-hospital IV.
Dumas, Ryan P. MD; Vella, Michael A. MD; Maiga, Amelia W. MD; Erickson, Caroline R. MD; Dennis, Brad M. MD; da Luz, Luis T. MD, MSc; Pannell, Dylan MD; Quigley, Emily BSN; Velopulos, Catherine G. MD; Hendzlik, Peter; Marinica, Alexander DO; Bruce, Nolan MD; Margolick, Joseph MD; Butler, Dale F. MD; Estroff, Jordan MD; Zebley, James A. MD; Alexander, Ashley MD; Mitchell, Sarah MD; Grossman Verner, Heather M. MS; Truitt, Michael MD; Berry, Stepheny MD; Middlekauff, Jennifer BSN; Luce, Siobhan MD; Leshikar, David MD; Krowsoski, Leandra MD; Bukur, Marko MD; Polite, Nathan M. DO; McMann, Ashley H. MD; Staszak, Ryan MD; Armen, Scott B. MD; Horrigan, Tiffany MD; Moore, Forrest O. MD; Bjordahl, Paul MD; Guido, Jenny MD; Mathew, Sarah MD; Diaz, Bernardo F. MD; Mooney, Jennifer MD; Hebeler, Katherine MD; Holena, Daniel N. MD. Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review. Journal of Trauma and Acute Care Surgery 95(1):p 87-93, July 2023. | DOI: 10.1097/TA.0000000000003958
Keywords: pelvic fracture, binder, hemorrhage (PubMed Search)
Pelvic fractures can be a major source of life threatening hemorrhage. Suspect fracture with significant force/mechanism. Signs are pelvic tenderness (no need to “rock” the pelvis), bruising at perineum, and hypotension in the setting of major trauma. Major classifications of pelvic fractures are lateral compression, anterior posterior (wide public ramus, open book), and vertical sheer (fall from height). An appropriately applied pelvic binding device can be lifesaving. The biggest mistake in applying these devices is to apply them too high. Maximum pressure is achieved with application directly across the greater trochanters.
2. Bonner TJ, Eardley WGP, Newell N, et al. Accurate placement of a pelvic binder improves reduction of unstable fractures of the pelvic ring. J Bone Joint Surg Br. 2011;93-B(11):1524-1528. doi:10.1302/0301-620X.93B11.27023
Keywords: shock index, trauma, pre-hospital (PubMed Search)
Shock index (heart rate/systolic blood pressure) has been used to predict trauma outcomes. This study from American Journal of Emergency Medicine looked at 89,000 pre-hospital patients who had a normal shock index on arrival at an emergency department. They then looked for those with abnormal pre-hospital shock index vs. those without an abnormal shock index and compared outcomes. Those with an abnormal pre-hospital shock index had worse outcomes than those with normal pre-hospital shock index.
Bottom line: A good handoff from pre-hospital to emergency department staff is critical because any abnormal shock index predicts a worse outcome than those with a normal shock index.
Yoshie Yamada Sayaka Shimizu, et al Prehospital shock index predicts 24-h mortality in trauma patients with a normal shock index upon emergency department arrival Am J Emerg Med 2023 May 10;70:101-108 doi: 10.1016/j.ajem.2023.05.008.
Keywords: Optho. (PubMed Search)
What is this called? What does it indicate? Treatment?
Tear Drop pupil. Globe rupture/corneal laceration. Protect the eye with a commercially available shield (Fox, etc) or if none is available use a paper/sytroform cup that can be cut to length to allow taping in place. Start IV antibiotics and emergency opthamology referal.
Keywords: predictive rule, EHR, utilization, AI (PubMed Search)
Author- Steve Schenkel, MD MPP Professor of Emergency Mediciner at UMEM:
A recent Annals of Emergency Medicine Publication (here https://www.annemergmed.com/article/S0196-0644(22)01276-8/fulltext) tested a predictive rule for Likelihood to Occupy an Inpatient Bed associated with a common Electronic Health Record.
At the individual patient level, the score performed ok. Depending on the chosen threshold, it traded off sensitivity and specificity and generally became more accurate the longer the patient was in the ED.
The authors and the associated editorial (here https://www.annemergmed.com/article/S0196-0644(22)01401-9/fulltext) suggest a different, potentially more beneficial use: to allow aggregate prediction of admissions across an entire department and therefore prompt earlier planning to prevent crowding on account of boarding.
The takeaway: Administrative prediction rules oriented toward individual patients may be more meaningfully used to predict resource needs, including in-patient beds, across the ED population.
Keywords: lidocaine, trauma, rib fractures (PubMed Search)
Use of intravenous lidocaine has been proposed as an adjunct/replacement for opioids in trauma patients with rib fractures. These small studies show a signal that the use of lidocaine decreased the need for opiate pain medication in this cohort of patients. Larger studies are needed, however, trauma surgeons maybe reaching for intravenous lidocaine in patients they are admitting with rib fractures. Also, transdermal lidocaine patches have been shown to have a similar effect in this patient cohort. “In admitted trauma patients with acute rib fractures not requiring continuous intravenous opiates, lidocaine patch use was associated with a significant decrease in opiate utilization during the patients’ hospital course.” 3
1. Patton, Petrease MD, MSc; Vogt, Kelly MD, MSc; Priestap, Fran MSc; Parry, Neil MD; Ball, Ian M. MD, MSc. Intravenous lidocaine for the management of traumatic rib fractures: A double-blind randomized controlled trial (INITIATE program of research). Journal of Trauma and Acute Care Surgery 93(4):p 496-502, October 2022. | DOI: 10.1097/TA.0000000000003562
2. Jeff Choi , Kirellos Zamary, Nicolas B. Barreto, Lakshika Tennakoon, Kristen M. Davis, Amber W. Trickey, David A. Spain. Intravenous lidocaine as a non-opioid adjunct analgesic for traumatic rib fractures. Published: September 28, 2020 https://doi.org/10.1371/journal.pone.0239896
3. Johnson M, Strait L, Ata A, et al. Do Lidocaine Patches Reduce Opioid Use in Acute Rib Fractures? The American SurgeonTM. 2020;86(9):1153-1158. doi:10.1177/0003134820945224
Keywords: corneal perforation (PubMed Search)
Keywords: spinal trauma, injury, spine (PubMed Search)
Keywords: thoracotomy, survival, prognosis (PubMed Search)
Recognizing that the studies discussing emergency department thoracotomy (ERT) in traumatic injuries are performed at large institutions where surgical back-up is available, emergency physicians should be familiar with the indications of emergency department thoracotomy in the setting of trauma. An informed decision should be made based on resources available along with the limited literature available to make the best decision for the patient and staff present.
Adding to last week’s pearl of no cardiac activity and no pericardial fluid on FAST exam, what else prognosticates intact survival? A 2020 paper concluded “ERT had the highest survival rates in patients younger than 60 years who present with signs of life after penetrating trauma. None of the patients with blunt trauma who presented with no signs of life survived.” 1A review in Trauma last month recommended: “Based on our scoping review of existing literature, we can conclude three major findings in the context of RT: (1) Resuscitative Thoracotomies (RT) performed in the setting of blunt trauma have a worse prognosis compared to patients undergoing RT for penetrating injuries, (2) procedures that have the potential to delay patient transport to hospital, such as intubation, may significantly increase the risk of mortality and (3) the presence of signs of life or hemodynamic stability in the prehospital or in-hospital setting are positive survival predictors in the setting of RT” 2 The best outcome is in patients brought immediately to an ED (preferably a trauma center) with limited on scene time. Police transport had a major association with survival in these patients. Stab wounds have the highest rate of intact survival.
For those at non-trauma centers, have a conversation within your ED group as well as with general surgeons (if available) to decide ahead of time if this procedure will be utilized in the setting of traumatic cardiac arrest and in which patient population.
1. Vahe S Panossian , Charlie J Nederpelt , Majed W El Hechi , David C Chang , April E Mendoza , Noelle N Saillant , George C Velmahos Haytham M A Kaafarani Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility J Surg Res. 2020 Nov;255:486-494. doi: 10.1016/j.jss.2020.05.048. Epub 2020 Jul 1.
2. Radulovic N, Wu R, Nolan B. Predictors of survival in trauma patients requiring resuscitative thoracotomy: A scoping review. Trauma. 2023;0(0). doi:10.1177/14604086231156265
Category: Airway Management
Keywords: hypotension, pharmacology, RSI (PubMed Search)
Take away: Be prepared (with blood products and/or vasopressors) for hypotension in trauma patients post-intubation particularly the elderly and severely injured. Pre-intubation tachycardia predicts post-intubation hypotension. Resuscitation with saline in traumatically injured patients is inferior to blood products or permissive hypotension.
A UK study retrospectively looked at trauma patients undergoing helicopter based emergency medicine intubation using induction agents of fentanyl, ketamine, and rocuronium for hypotensive episodes. “This study demonstrates that more than one in five patients who undergo PHEA have a new episode of significant hypotension within the first ten minutes of induction. Increasing patient age, multi-system injuries, a higher baseline heart rate, and intravenous crystalloid administration by the ambulance service before HEMS arrival were all significantly associated with PIH, whereas the addition of fentanyl to the induction drug regime was not.”
Price, J., Moncur, L., Lachowycz, K. et al. Predictors of post-intubation hypotension in trauma patients following prehospital emergency anaesthesia: a multi-centre observational study. Scand J Trauma Resusc Emerg Med 31, 26 (2023). https://doi.org/10.1186/s13049-023-01091-z