This excellent review article discussing damage control resuscitation in traumatically injured children highlights several points including:
-”Damage-control resuscitation (DCR) consists of rapid control of bleeding, avoidance of hemodilution, acidosis, and hypothermia; early empiric balanced transfusions with red blood cells, plasma and platelets, or whole blood when available, and the use of intravenous or mechanical hemostatic adjuncts when indicated.”
-”he 30-day mortality in children with traumatic hemorrhagic shock is estimated to be 36% to 50% compared with the 25% reported mortality in similar adults. The early stages of hemorrhagic shock after injury in children can be more challenging to recognize because of their remarkable compensatory mechanisms. In children unlike adults, blood pressure alone is an insensitive indicator of hemorrhagic shock as hypotension is a late sign often not occurring until blood volume is reduced by >40%.”
-”Based on the current literature, the challenges health care providers must focus on are the early recognition of shock in the pediatric patient, moving the hemostatic resuscitation forward to the prehospital phase when feasible, improvement in times to first blood product, balanced resuscitation and efficiency of massive transfusion protocols (MTPs).”
This UK study randomized 90 trauma patients suspected of having major life threatening torso hemorrhage to receive standard resuscitative care vs. standard care plus resuscitative endovascular occlusion of the aorta (REBOA). Mortality was 54% in the REBOA group and 42% in the standard care group. This calls into question the routine use of REBOA in trauma resuscitations.
This article reminds us that using a small bore chest tube to drain traumatic hemothorax is supported by small studies and the Easterm Society for the Surgery in Trauma.
"The main findings were the following: (1) there was no evidence of an effect of HTS compared with other agents (mainly mannitol) on long-term neurological outcome in patients with raised ICP; (2) similarly, there was no evidence of a beneficial effect of HTS on all-cause mortality, uncontrolled ICP, length of hospital or ICU stay, and ICP reduction; and (3) HTS may be associated with increased risk of adverse hypernatremia.”
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.
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.
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
-22.5% hemoperitoneum
-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.
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.
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).”
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.
Table 1
Adaptation of AAST Organ Injury Scale for Spleen
| Grade | Injury type | Description of injury |
|---|---|---|
| I | Hematoma | Subcapsular, <10% surface area |
| II | Hematoma | Subcapsular, 10% to 50% surface area |
| Laceration | Capsular tear, 1 cm to 3 cm parenchymal depth that does not involve a trabecular vessel | |
| III | Hematoma | Subcapsular, >50% surface are or expanding: ruptured subcapsular or parenchymal hematoma: intraparenchymal hematoma_>5 cm or expanding |
| IV | Laceration | Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) |
| V | Laceration | Completely shattered spleen |
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.
"The normal value for the Böhler angle is between 25° and 40° 1. Although there is wide variation between individuals, there is relatively little variation between the left and right feet of a single individual 2. 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 3."
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.
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.
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.
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.
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.
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
