Quik-what?

An inadvertent leader in trauma research..!

An inadvertent leader in trauma research..!

There have been significant changes in the delivery of acute trauma care as a result of the military conflicts in Iraq and Afghanistan. One of the recent advances has been the advent of haemostatic dressings for haemorrhage control, which are now being used in the civilian as well as the military setting.

Auckland HEMS carries a product called Quikclot Gauze. This is an inert mixture of oxides of silica, sodium, magnesium, aluminium, and quartz. The compounds absorb water in a physical (not chemical) reaction, which concentrates platelets and clotting factors at the site of administration.

In 2008 the Journal of Trauma published a case series of the first 103 documented uses of Quikclot, including uses in military and civilian prehospital and hospital settings. The majority of uses involved extremity haemorrhage, often when direct pressure and tourniquets and direct pressure had failed. First responders found Quikclot to be 100% effective. Quikclot was ineffective in a handful of hospital cases, which involved moribund coagulopathic massively-injured patients. Heat generation from the physical reaction was an issue, with 3 patients sustaining burns, and a quarter of concious patients reporting ‘moderate to severe’ pain.

Wound from helicopter rotor blade, with Quikclot applied

Wound from helicopter rotor blade, with Quikclot applied

There is also evidence from an animal model that Quikclot may allow sufficient haemostasis to reduce tourniquet time. This study involved a pig model of extremity haemorrhage and found that after haemostasis of a bleeding extremity had been acheived with a tourniquet and Quikclot, bleeding occurred only 20% of the time after tourniquet release, compared to a 100% failure rate with standard gauze dressings.

A systematic review of literature regarding haemostatic dressings was published in Injury in 2011, and can be found here. Overall data is scant and mostly observational/retrospective, but what is available suggests that haemostatic dressings like Quikclot should be a useful tool for controlling significant haemorrhage in our prehospital setting.

Full text pdfs for this post are here (secure area limited to ADHB staff only – ADHB has online subscription access to these journals through the Philson Library at the University of Auckland School of Medicine)

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

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

Errors in prehospital paediatric resuscitation

paeds

When compared to adult resuscitation, paediatric resuscitation has anatomical, pharmacological, procedural, social, and emotional differences that may make it more difficult and therefore more prone to error.

The authors of this study (full text pdf – NOT hosted on this site) used a simulated paediatric emergency (infant with altered mental status, seizures, and respiratory arrest) to look at errors in paediatric resuscitation by two person EMS teams.

What emerged were issues regarding equipment familiarity/use/misuse, failure to check BSL, and drug errors. Calculations of drug doses were difficult under stress. Failure rates in some of these domains exceeded 50%.

This study, coupled with our low incidence of significant paediatric resuscitation, suggests that we must have ongoing training in paediatric emergencies (simulation and otherwise) to mitigate these risks, and consider new ways of avoiding error. Given the high rate of smartphone use by HEMS personnel, this app is possibly a good start!

 

Algorithm for traumatic cardiac arrest

tension

While traditional teaching is that resuscitation on scene in traumatic cardiac arrest is futile, recent studies have demonstrated higher survival rates than previously thought.

The authors (UK emergency medicine and aeromedical specialists) of this paper have reviewed the literature regarding traumatic cardiac arrest and generated an algorithm that is applicable to both pre-hospital and hospital settings.

“The algorithm aims to rapidly identify and correct reversible causes of TCA. Transport of TCA patients from the pre-hospital to hospital setting with on-going cardiopulmonary resuscitation is usually futile and key interventions need to be performed as soon as possible, usually on-scene. Patients arriving at a hospital in traumatic peri- or cardiac arrest need reversible causes immediately excluded and managed prior to transfer for diagnostic imaging or surgical intervention. The treatment priorities in this algorithm have been applied by a physician-led pre-hospital trauma service to over a thousand TCA’s attended over an eighteen year period. Published results demonstrate that adherence to these principles can result in good survival rates from TCA.”

The algorithm focuses on treatment of reversible pathology that may have led to an arrest:

  • Correction of hypovolaemia
  • Oxygenation
  • Decompression of tension pneumothorax
  • Thoracotomy in the setting of penetrating chest/epigastric trauma
  • Consideration of non-traumatic causes of cardiac arrest

Full text pdf of this paper is available here (secure area limited to ADHB staff only – ADHB has online subscription access to this journal via the Philson Library at the University of Auckland School of Medicine)