In 252 mild traumatic brain injury patients seen at 3 level I centers that were given the Rivermead Post Concussion Symptoms Questionnaire within 24 hours of arrival, 3 month post concussive symptoms were significantly correlated with their score on the questionnaire. This questionnaire take 3 minutes to complete. This may be helpful in prognosticating who will have post-concussive symptoms and who will need additional follow up.
This group looked at 88 patients intubated for penetrating neck injury and found 95% received neuromuscular blocking agents, 73% were intubated using a bougie, and 95% were intubated on first pass.
The authors concluded; “Rapid sequence intubation with bougie use was an effective default approach to definitive airway management in ED patients with penetrating neck trauma.”
These authors followed 250 consecutive trauma activation patients over a one year period. In hospital elevated blood pressure and glucose level correlated with a new diagnosis of hypertension and diabetes respectively over that 1 year time line. Some of these patients also had a new diagnosis of HIV, substance use disorder and hepatitis C. Using their contact with the health system due to trauma can be a way to screen for undiagnosed medical problems such as diabetes and hypertension. Assuring outpatient follow up for these patients will have an effect on their long term morbidity and mortality.
In a German study comparing one EMS jurisdiction which used IV paracetamol (acetaminophen) in combination with nalbuphine (Nubian, opiate agonist/antagonist) to another jurisdiction which used piritramide (synthetic opioid similar to fentanyl) for prehospital traumatic pain, the combination worked better to decrease pain on a numerical scale. There were no differences in typical safety measures.
The use of an antagonist/agonist theoretically could precipitate withdrawal in non-opiate naive patients and could influence in hospital analgesic choices. The literature on this is mixed.
This study offers further evidence of the efficacy of multi-modal pain control, the feasibility of paramedics using IV paracetamol and the possibility of using rapid onset opioid agonist/antagonist in the prehospital setting.
Another paper emphasizing care for brain injured patients should include:
-pre-intubation preoxygenation to avoid hypoxia
-pre-intubation avoid extremes in blood pressure (hypotension kills)
-use hemodynamically neutral induction agents such as ketamine or etomidate
-post intubation target eucapnia on the ventilator. (do not aim for low CO2)
-post intubation maintain adequate sedation to avoid increased intercranial pressure
This paper reminds us older patients have higher mortality and worse outcomes overall if their injury includes a head injury. Any mechanism that results in head injury, including fall from standing, has a higher potential for death, disability, and long term cognitive decline in older patients. Triaging these patients to trauma centers can lead to better outcomes. The difficulty is knowing which patients to send to trauma centers vs. emergency departments. The authors write:
"clinicians should consider transporting to a trauma center in geriatric patients with head trauma, if feasible. However, given the frequency with which head injury occurs, transportation to a trauma center for all patients with head trauma is likely to overwhelm EMS systems and hospitals. Unfortunately, the existing literature does not delineate the subset of patients whose condition will benefit from this evaluation . Given these considerations, we recommend EMS clinicians consider abnormal mental status, presence of anti-coagulation, and loss of consciousness as considerations to transport to a trauma center in cases where the need for trauma center evaluation is not clear.”
This systematic review of the literature found four findings associated with intercranial hemorrhage in older patients after a fall. They were: focal neurologic findings, external signs of trauma on the head, loss of consciousness, and male sex.
We still need better studies as this is completely based on the quantity and quality of literature available to review. This information is not enough to change liberal CT imagining in older patients after a fall. It is the beginning of the study process.
The National Association of EMS Physicians, the American College of Surgeons Committee on Trauma, and the American College of Emergency Physicians recommends:
• Prehospital TXA administration may reduce mortality in adult trauma patients with hemorrhagic shock when administered after lifesaving interventions.
• Prehospital TXA administration appears safe, with low risk of thromboembolic events or seizure.
• The ideal dose, rate, and route of prehospital administration of TXA for adult trauma patients with hemorrhagic shock has not been determined. Current evidence suggests EMS agencies may administer either a 1-g intravenous/intraosseous dose (followed by a hospital-based 1-g infusion over 8 hours) or a 2-g intravenous/intraosseous dose as an infusion or slow push.
• Prehospital TXA administration, if used for adult trauma patients, should be given to those with clinical signs of hemorrhagic shock and no later than 3 hours post-injury. There is no evidence to date to suggest improved clinical outcomes from TXA initiation beyond this time or in those without clinically significant bleeding.
• The role of prehospital TXA in pediatric trauma patients with clinical signs of hemorrhagic shock has not been studied, and standardized dosing has not been established. If used, it should be given within 3 hours of injury.
• Prehospital TXA administration, if used, should be clearly communicated to receiving health care professionals to promote appropriate monitoring and to avoid duplicate administration(s).
• A multidisciplinary team, led by EMS physicians, that includes EMS clinicians, emergency physicians, and trauma surgeons should be responsible for developing a quality improvement program to assess prehospital TXA administration for protocol compliance and identification of clinical complications.
These authors reiterate principles that have been discussed previously regarding intubation in head/brain injured patients.
-Avoid hypoxia with preoxygenation
-Avoid hypotension by fluid resuscitation/vasopressors/blood in the correct clinical setting
-Use hemodynamically neutral induction agents such as Etomidate or Ketamine (it is ok use this in head injured patients!)
-Video laryngoscope gives best first pass success which minimizes hypoxia/raised ICP
-Post-Intubation aim for eucapnia (avoid hyperventilation)
-Use adequate post-intubation sedation to avoid raised ICP
In this retrospective study at 103 hospitals of patients over age 65 who received a head CT:
5948 total patients
3177 (53%) were on at least one anti-thrombotic (warfarin, direct oral anticoag, or anti-platelet agent)
781 (13%) had inter cranial hemorrhage. (ICH)
No form of AC showed an increased risk of ICH.
Risk factors for ICH were: “a high-level fall, a Glasgow coma scale of 14, a cutaneous head impact , vomiting, amnesia, a suspected skull vault fracture or of facial bones fracture”
To me this really begs the question are we ordering head CTs on the right patients? Was there any indication of head injury in these patients or did the mere presence of a patient on AC prompt the imaging order? More work should be done to prevent needless imaging cost, patient time in the emergency department and radiologist work load/turn around time.
Over 300 ml of blood on a chest CT in a traumatically injured patient requires a tube thoracostomy. How do you calculate 300 ml of blood on a chest CT?
This review article answers the basic question: when does a traumatic pneumothorax require tube thoracostomy?
“A pneumothorax greater than 20% of the thoracic volume on chest x-ray or greater than 35 mm on CT, measured radially from the chest wall to the lung parenchyma, should be treated with tube thoracostomy. Pneumothoraces smaller than this may be observed; approximately 10% of these will fail observation and require tube thoracostomy treatment.”
This paper outlines the long term effects of surviving a gunshot wound. The authors conclude:
“Firearm injury survivors frequently experience chronic pain, nerve injury, retained bullet fragments that may cause lead toxicity, physical limitations, and PTSD and are at risk for reinjury. In addition to supportive medical and psychiatric care, survivors of firearm injury may benefit from health care–based violence intervention programs.”
Looking at a trauma database of over 3 million patients, 1% presented with prehospital hypothermia (<35 degrees C). These patients had longer hospital stays, higher resource utilization and higher mortality. Even isolated head injury patients with hypothermia had worse outcomes. Rewarming did increase survival slightly for all patients.
Take away: rewarm hypothermic trauma patients as soon as possible to improve mortality.
Looking at 140 patients retrospectively who had abdominal gunshot wounds with associated fractures, prophylactic antibiotics longer than three days did not offer any benefit in preventing fracture infection. Only two patients experienced fracture related infections and 65 total experienced any infection related complications.
From and ED standpoint, it appears reasonable to give a dose of antibiotics in this very rare subset of gunshot wound patients.
A retrospective, single Australian center review of 300 patients who had blunt cerebral vascular injuries found:
-9.8% had an inpatient CVA
-Most occurred in first 72 hours
-Those receiving no anti coagulation or antiplatelets had 28% CVA incidence.
-Those treated had a 3.6% CVA incidence (anti platelets were better than anti coagulation)
-Carotid artery injury was less common than vertebral artery but had higher frequency of CVA
-associated factors: low GCS, rib fractures, severe trauma
Take away: non-treatment of blunt cerebral vascular injuries had higher inpatient stroke risk. Antiplatelet agents such as aspirin and Clopidogrel performed better than anticoagulants
This paper looked at the literature regarding missed injuries in trauma patients. Missed injuries was defined as an injury discovered after the patient was discharged. Most of the missed injuries and causes are not novel but are worthy of remembering.
They suggest a Trauma Tertiary Survey helps prevent missed injury. “Tertiary Survey (TTS), which includes a thorough in-hospital re-examination and a review of diagnostic investigations within the first 24 h, has been shown to significantly reduce the occurrence of missed injuries (1–9 %) in severe trauma patients found after a primary and secondary survey.” This concept is similar to a discharge time out in emergency medicine where all data is reviewed, viral signals are confirmed normal and a team discharge is performed.
The paper offers these suggestions to avoid missed injuries:
1.
Standardize Tertiary Trauma Surveys (TTS).
2.
Be Cognizant of Cognitive Biases (e.g., Anchoring Bias).
3.
Repeat Imaging When Clinically Indicated.
4.
Use Protocolized Imaging Techniques (CT/MRI).
5.
Ensure Radiology-Trauma Communication.
6.
Prioritize High-Risk Populations.
7.
Implement Peer Review or Double-Check Systems.
8.
Encourage a Culture of Collaboration and Humility.
9.
Limit Provider Fatigue and Overload.
10.
Create Tailored Checklists for Subtle Injuries.
Outcomes in traumatic brain injury are improved when physiologic homeostasis is achieved as soon as possible after injury. Here are the American College of Surgeons’ recommendations. Note SBP over 110 and a hemoglobin over 7. A study looking at a more liberal transfusion target showed worse ARDS and no mortality benefit.
This study from Great Britain compared fatalities for pedestrians and cyclist struck by motor vehicles based on vehicle body type. They found :
“We conclude that in Great Britain, being hit by an SUV as opposed to a passenger car increases injury severity among pedestrians and cyclists, with the strongest effect in children.“
These authors looked at 5958 trauma patients arriving at their trauma center with a systolic blood pressure greater than 90. They calculated shock index (heart rate /sbp) for all of these and then looked at who received a blood transfusion within one hour of arrival. 211 patients received blood in that time frame. “Patients were stratified by SI using the following thresholds: ? 0.7, > 0.7 to 0.9, > 0.9 to 1.1, > 1.1 to 1.3, and > 1.3.”
“A main effect was observed for shock index with increased risk for required transfusion for patients with admission shock index >0.7 (P < 0.001). In comparison to shock index of ? 0.7, odds ratios were 2.5(1.7 - 3.8), 8.2(5.4 - 12.2), 24.9(15.1 - 41.1), 59.0(32.0 - 108.6) for each categorical increase in SI.”
