Brian Burns: Trauma before and beyond the hospital – from SMACC 2013

From the SMACC 2013 conference – this podcast is Dr Brian Burns (Greater Sydney Area HEMS) speaking about managing trauma patients in extremis and in extreme conditions

Click HERE for the podcast (right click to save)

Accompanying slides:

Click here for Brian Burns (@HawkmoonHEMS) on twitter

Click here for Brian Burns (@HawkmoonHEMS) on twitter

Does every patient who gets pre-hospital needle decompression need a chest tube?

The authors of a recent study tried to answer this question. The authors evaluated patients who got needle decompression in the field using prospective, observational methodology (though I wonder if truly prospective given the lack of data). Anyways, they noted that in their population very few patients (5/52 decompressions) escaped without requiring a follow-up chest tube. Only 1/15 penetrating trauma patients did not get a chest tube.  A few important questions remain including how many of the needle decompressions actually reached the pleural cavity or the technique used for decompression (appears later in Q&A that it was probably anterior axillary line). 

The authors conclude to have a low threshold for chest tube insertion based on CXR however, not shockingly a CT chest will provide more information. This study certainly doesn’t support withholding a chest drain if needle decompression is performed in the field. There was a nice suggesting by another surgeon who commented they leave all the needles in place during CT scan to see if it actually reached the pleural cavity. For the stable patient that doesn’t need immediate intervention, this is probably sound advice. Wait for the CT then make decision based on clinical and radiographic data.

There should probably be further study on this topic but for now, this is all we have! Here’s the abstract below.

Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax? KM Dominguez et al. Am J Surg 2013; 205(3): 329-332 

BACKGROUND:

Thoracic needle decompression is lifesaving in tension pneumothorax. However, performance of subsequent tube thoracostomy is questioned. The needle may not enter the chest, or the diagnosis may be wrong. The aim of this study was to test the hypothesis that routine tubethoracostomy is not required.

METHODS:

A prospective 2-year study of patients aged ≥18 years with thoracic trauma was conducted at a level 1 trauma center.

RESULTS:

Forty-one patients with chest trauma, 12 penetrating and 29 blunt, had 47 needled hemithoraces for evaluation; 85% of hemithoraces required tube thoracostomy after needle decompression of the chest (34 of 41 patients [83%]).

CONCLUSIONS:

Patients undergoing needle decompression who do not require placement of thoracostomy for clinical indications may be assessed using chest radiography, but thoracic computed tomography is more accurate. Air or blood on chest radiography or computed tomography of the chest is an indication for tube thoracostomy.

Paediatric prehospital trauma care resources

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With over half the Auckland HEMS team coming from a hospital that serves age 15 and up (and therefore not dealing with children on a daily basis), prehospital management of paediatric patients is a field to which we must pay considerable attention in our training. Simulation exercises have included paediatric scenarios on several occasions – our thanks to Mike Shepherd and Trish Wood from Starship Hospital for their assistance!

Below are some useful resources regarding prehospital care of paediatric trauma patients:

Podcasts from Dr Jeffrey Guy, Medical Director of PHTLS (right-click to download)

(he has also produced other PHTLS podcasts – found here)

A 2012 review of prehospital paediatric trauma from the Harbourview Medical Centre in Seattle can be found here. Take-home messages:

  • falls and MVA are the most common causes of paediatric trauma morbidity
  • despite a lot of research and intervention paediatric trauma patients are under-resuscitated on arrival compared to their adult counterparts
  • children have very different airways anatomically to adults; with full cervical spine immobilisation airway view can be improved with a towel under the shoulders to bring the neck into a neutral position
  • with a higher surface area/size ration children are more prone to hypothermia
  • due to their smaller blood volume a small amount of blood lost can represent a large percentage of their blood volume
  • contrary to traditional teaching, cuffed ETT are increasingly used at half a size smaller than the appropriate uncuffed ETT

 

 

 

Tranexamic acid podcast and resources

In this post Andrew Petrosoniak discussed the use of tranexamic acid in the prehospital trauma setting, and  Auckland HEMS is currently developing a prehospital protocol its use in our service.

About a year ago, Scott Weingart from emcrit.org interviewed Dr Tim Coats, one of the lead authors of the CRASH 2 trial. The interview, which covers a lot of practical territory, became a podcast on emcrit.org in early 2012.

The podcast is here.

Dr Weingart’s ‘show notes’, which include a link to a draft protocol by Minh Le Cong for tranexamic acid in the prehospital setting, are here.