Appropriately, a great deal of time and energy is being expended to educate on the use of tourniquets to prevent mass hemorrhage. Are the current generation of tourniquets the best that we can have? These authors performed a Delphi study to assess needs with tourniquet design.
They concluded the next generation of tourniquets should have the following: “Capable of being used longer than 2 hours, applied and monitored by anyone, data displays, semiautomated capabilities with inherent overrides, automated monitoring with notifications and alerts, and provide recommended actions.”
This study used the modified Brain injury Guidelines retrospectively to assess whether the guidelines would have saved transfers to their level one facility safely. They concluded the guidelines would have effectively prevented unnecessary mBIG 1 and mBIG2 transfers with no patient harm.
TABLE 1 - Modified Brain Injury Guidelines Radiologic Stratification, as per Kahn et al.
| mBIG 1 | mBIG 2 | mBIG 3 | |
|---|---|---|---|
| Skull fracture | No | Non-displaced | Displaced |
| SDH | ?4 mm | 4–7.9 mm | ?8 mm |
| EDH | No | No | Yes |
| SAH | ?3 sulci and <1 mm | Single hemisphere or 1–3 mm | Bihemisphere or >3 mm |
| IVH | No | No | Yes |
| IPH | ?4 mm | 4–7.9 mm | ?8 mm or multiple |
EDH, epidural hematoma; IPH, intraparenchymal hemorrhage; IVH, intraventricular hemorrhage; SAH, subarachnoid hemorrhage.
In this Scandinavian study looking at 2,362 head injury patients on oral anticoagulants, the authors found only 5 cases of delayed hemorrhage and none of the five underwent neurosurgery. The authors concluded:
“In patients with head trauma, on oral anticoagulation, the incidence of clinically relevant delayed intracranial hemorrhage was found to be less than one in a thousand, with detection occurring four days or later after initial presentation.”
It would appear based on this study and others that it is safe to discharge these patients with a normal head CT and giving strict return precautions for headache, nausea, vomiting or other changes.
On exam, assess for facial instability and airway patency. CT scan is the imaging of choice. The higher the number, the more complex the fracture, the more unstable and the more difficult the airway managment will be. Look for open lacerations or blood in the sinuses and treat with antibiotics if these are found. Consult ENT or plastics urgently for further management.
The reference is a nice review of these fractures
In this podcast, the concept of vasopressor use in hemorrhagic shock is discussed. Key take away points:
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.
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.
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.
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:
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
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.
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.
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.
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.
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.”
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.”
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.
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.
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.
This retrospective study of 66 trauma patients who had pelvic fractures attempted to determine if prehospital applied pelvic binders had an impact on mortality. There were 3 cohorts: appropriately applied binders (14), inappropriately applied (14 not at the level of the greater trochanter), and none applied (38). Survival for applied was 92% and those without was 81% which was not statistically significant. The authors concluded: “In conclusion, our study found that the use of prehospital pelvic binders did not show a significant effect on patient outcomes for those with unstable pelvic fractures. Instead, injury severity score (ISS) emerged as the most significant predictor of survival.”
Previous studies have shown regular education is needed on proper use of binders. We should continue to educate on appropriate positioning and the use of pelvic binders. For me, this study is not large enough to convince that we should go away from binder use. We need more data before we abandon the pelvic binder.
In this prospective study looking at geriatric patients with unknown head injury vs. known head injury, the unknown head injury group had an ICH 1.5%, neurosurgical intervention 0.3% and delayed ICH 0.1% when compared to known head injury (10.5%, 1.2% and 0.7% respectively). The authors concluded that the risk of ICH was high enough in uncertain head injury patients to warrant scanning.
