Monthly Archives: December 2012

Prehospital management of pelvic fractures

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Will a pelvic binder help this?

Will a pelvic binder help this?

In the New Zealand trauma setting, blunt trauma is by far the most common mechanism. In the Auckland region it is not uncommon for us to manage patients with major pelvic trauma in ED (most commonly as a result of road trauma), and with the advent of the HEMS service our team are now dealing with this in the prehospital setting as well. The most notable case transported by the Auckland HEMS service in the last year involved a middle aged patient with a free-floating pubic symphysis (open bilaterally with actively bleeding groin wounds), a sacral fracture, and an ED arrival blood pressure of 66/40…)

This paper, published in 2007 by a UK trauma service, provides a nice overview of the prehospital management of pelvic trauma.

Take-home messages:

  • In patients who are obtunded (and therefore have an utterly unreliable clinical assessment) a pelvic fracture should be assumed to be present and a splinting device placed
  • in conscious patients, the presence of pelvic pain is a more reliable indicator of a fracture than palpation or compression of the pelvis
  • Reduction and stabilisation of pelvic fractures should occur as soon as possible after injury, while clotting mechanisms are still intact
  • Bleeding from pelvic fractures should be considered to be non-compressible, and therefore permissive hypotension (resuscitation to the presence of a radial pulse only) should be considered as a resuscitation strategy; NICE guidelines recommend 250mL boluses titrated to the radial pulse
  • There is a risk of patients becoming haemodynamically unstable following full log-rolls for spinal assessment (this has been reported in the ED setting); in the prehospital setting a roll to 15 degrees only will allow placement of a scoop
  • the handover to medical staff in ED should include advice not to remove the splint until a significant injury is excluded, including the fact that pelvic splints can provide excellent anatomical reduction leading to fractures potentially being missed and displacing once the splint is removed

The following is an instructional video showing the use of the SAM Sling, which is carried as standard kit on our helicopters:

 

 

Prehospital Management of Traumatic Brain Injury

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extradural-haematoma

To date, the most significant procedural capability the the addition of doctors to the ARHT Westpac Rescue Helicopter has provided has been RSI capability. Of the RSIs performed so far,  a significant proportion have been for severe traumatic brain injury (TBI).

With the exception of surgical intervention (which is required in a minority of cases of severe TBI), most other essential elements of severe TBI management can be provided in the prehospital setting – airway protection, optimisation of oxygenation, prevention of hyper- or hypo-carbia, support of cerebral perfusion pressure, and ICP control.

This paper, published in the Journal of Neurosurgery in 2008, reviews the evidence around the various elements of the pre-hospital severe TBI care ‘package’.

Take-home messages:

  • a period of hypoxia (PaO2<60mmHg) is associated with a 50% mortality rate and a 50% severe disability among survivors
  • in previous studies hypoxia has been a common complication of prehospital intubation for severe TBI, with up to 57% of patients experiencing transient hypoxia lasting a mean of 2.3 minutes (note – these studies frequently involved neither an RSI as we know it nor personnel who were appropriately trained and qualified; more recent evidence points to a benefit for prehospital RSI for severe TBI provided it is done well by appropriate people)
  • Tight control of CO2 after intubation has a significant effect on survival – in one large series patients with normal CO2 on arrival to ED had a 21% mortality, those with CO2 outside the normal range had a 34% mortality
  • Manual ventilation is associated with hypocarbia
  • A single episode of hypotension (systolic BP less than 90mmHG) doubles mortality
  • Management of hypotension in the field improves outcome
  • Transport by helicopter for patients with severe TBI improves odds of survival compared with ground transport (OR 1.6-2.25) – this may reflect the presence of more skilled personnel on the helicopter, careful attention to post-intubation ventilatory parameters, and transport to a trauma centre.

Have we been taught all wrong?…A new location of needle decompression?

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Where do you insert the needle for pneumothorax decompression?

Easy!

Is it time to rethink 2nd intercostal space, mid clavicular line for site of needle decompression?

Is it time to rethink 2nd intercostal space, mid clavicular line for site of needle decompression?

“2nd intercostal space (ICS), mid-clavicular line (MCL)” – this has been drilled into all of us since we began training and caring for critically ill patients. Ever since we began as pre-hospital care providers or took our first  Advanced Trauma Life Support have we used the 2nd ICS, MCL and assumed it to be optimal.

Well recently some studies have started looking at whether we should consider an alternative location. There is some evidence to suggest that the traditional anterior approach may reduce kinking and in the combat environment, it might be preferred (Beckett A et al. J Trauma 2011). However, if it will never enter into the pleural space then kinking becomes irrelevant.  While the utility of needle decompression vs. simple finger thoracostomy followed by chest tube insertion can be debated, in the pre-hospital setting, needle decompression remains within the realm of paramedics and may at times be most practical. Also, unless you’re rapidly prepared to perform a chest tube with sterility in mind, needle decompression may be a better option. Thus, such studies remain important.

A recently published study (from the USC trauma surgeons in Los Angeles who seem to publish everything related to trauma) compared the 2nd ICS , MCL with the 5th intercostal space, anterior axillary line (AAL).

CT chest exams of 120 trauma patients were used in the study. Measurements were taken at both sites and compared. Interestingly, the authors stratified patients into 4 BMI categories then analyzed the data based on these groupings.

Results

  • Overall, the 5th ICS AAL was a superior site for needle decompression based on chest wall measurement
  • Chest wall thickness was thicker at the 2nd ICS MCL compared to the 5th ICS AAL (by 0.5cm)
  • As only 16% of patients had chest walls thicker than the standard 5cm needle commonly used. Compared to 42% probable failures if placed at the 2nd ICS MCL.
  • Based on BMI stratification, needle decompression at the 5th ICS AAL would be possible for all but the highest BMI while at the 2nd ICS MCL would likely fail except in the lowest group

Take home message – given this was not a clinical study (only based on CT scans) it’s not quite practice changing. We don’t know the potential risks of cardiac injury using the 5th ICS AAL or whether it can be feasibly performed without kinking. However, this technique could be considered if the 2nd ICS MCL fails, especially in high BMI patients and clearly any benefits outweigh the risks – for instance if the patient has already arrested.

STUDY ABSTRACT

Inaba K et al Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg 2012;147:813-8

OBJECTIVE: To compare the distance to be traversed during needle thoracostomy decompression performed at the second intercostal space (ICS) in the midclavicular line (MCL) with the fifth ICS in the anterior axillary line (AAL).

DESIGN: Patients were separated into body mass index (BMI) quartiles, with BMI calculated as weight in kilograms divided by height in meters squared. From each BMI quartile, 30 patients were randomly chosen for inclusion in the study on the basis of a priori power analysis (n = 120). Chest wall thickness on computed tomography at the second ICS in the MCL was compared with the fifth ICS in the AAL on both the right and left sides through all BMI quartiles.

SETTING: Level I trauma center.

PATIENTS: Injured patients aged 16 years or older evaluated from January 1, 2009, to January 1, 2010, undergoing computed tomography of the chest.

RESULTS: A total of 680 patients met the study inclusion criteria (81.5% were male and mean age was 41 years [range, 16-97 years]). Of the injuries sustained, 13.2% were penetrating, mean (SD) Injury Severity Score was 15.5 (10.3), and mean BMI was 27.9 (5.9) (range, 15.4-60.7). The mean difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL was 12.9 mm (95% CI, 11.0-14.8; P < .001) on the right and 13.4 mm (95% CI, 11.4-15.3; P < .001) on the left. There was a stepwise increase in chest wall thickness across all BMI quartiles at each location of measurement. There was a significant difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL in all quartiles on both the right and the left. The percentage of patients with chest wall thickness greater than the standard 5-cm decompression needle was 42.5% at the second ICS in the MCL and only 16.7% at the fifth ICS in the AAL.

CONCLUSIONS: In this computed tomography-based analysis of chest wall thickness, needle thoracostomy decompression would be expected to fail in 42.5% of cases at the second ICS in the MCL compared with 16.7% at the fifth ICS in the AAL. The chest wall thickness at the fifth ICS AAL was 1.3 cm thinner on average and may be a preferred location for needle thoracostomy decompression

The first ARHT case-based learning session!

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This past week, we conducted the first ARHT case-based learning session for the duty crew!

While “case-based learning” may seem like a bunch of educational jargon…it can be rephrased to “sit around the table, discuss a previous job and consider the “what if” “.

I think at this point I was trying to convince people that I wasn't full of BS!

I think at this point I was trying to convince people that I wasn’t full of BS!

We assembled the team for the day which included the crewman, paramedic and doctor for a 45-50 minute session in the board room.  A huge thanks to Russell C, Leon, and Scott O. who all participated and they generated a great discussion about several aspects of this case. (next time we’ll be looking to get our pilot involved too!)

I had the opportunity to facilitate the session which was based on a relatively straight forward job that I had selected. The job involved a patient with a head injury and the focus was on the management of traumatic brain injury in the pre-hospital setting. But amazingly, the discussion covered tons of ground and we discussed all different aspects from before we leave the base, to the time we arrive at the hospital. Much of the discussion focused on CRM ideas which was very interesting.

Our team's paramedic and crewman in deep thought! We must have just been getting to the interesting part! At least the team isn't asleep!

Our team’s paramedic and crewman in deep thought! We must have just been getting to the interesting part! At least the team isn’t asleep…

Here’s a summary of our lively discussion!

Pre-job briefing: unless it was a water job (or extra equip is required) that this could/should be done en route
On scene time: Something we need to address as a team given some growing evidence that scene time doesn’t impact mortality in blunt trauma
Decision making for RSI: time to hospital played considerable role in whether to perform an RSI
Role assignment in RSI: crewman should probably be tasked with RSI checklist and scene management rather than involved in being hands-on during RSI. The doctor should hand the bougie & endotracheal tube to paramedic though  good discussion resulted about this and may be situation dependent
Team position in flight: discussion whether person who intubated should remain at head of bed (even if it was MD) during flight. Consensus that if patient is requiring infusions etc…then MD should be at the side, with paramedic at the head and crewman to his right.

We’ll be looking to roll out a few more sessions in the new year.

Some feedback from the session regarding logistics

  • Using previous jobs to generate discussion is good
  • Focus will be on picking jobs at random to improve learning but this will NOT be a means of quality assurance or control
  • Short sessions will be the goal: 20-30 minutes
  • Getting the whole team together is best, that includes the pilots!
  • All members felt this was a valuable exercise and would participate in future sessions

Again, thanks to the duty crew that day and Scott O for the pictures. See you all in the New Year.