Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries. Evans CD, Petersen A, Meier EN, Buick JE, Schreiber M, Kannas D, Austin MAA. J Trauma Acute Care Surg. 2016 August 81(2): 285-93.
Survival following prehospital traumatic cardiac arrest has historically been poor, with only 2% of patients surviving to hospital discharge. Given that 50% of all traumatic arrests occur in the prehospital setting, this large, prospectively collected dataset sought to describe the contemporary management and outcomes of prehospital traumatic arrests as well as to identify if any Advanced Life Support (ALS) procedures performed in the prehospital setting affected survival.
Using two databases, the ROC Epistry-Trauma and the Prospective Observational Prehospital and Hospital Registry for Trauma (PROPHET), the authors identified 2,300 patients who sustained prehospital hospital traumatic arrest as defined by receipt of cardiopulmonary resuscitation performed by EMS providers. This population was predominantly young (mean age 39-40 years old), male (79%), and sustained mainly motor vehicle collisions, gunshot wounds, and falls. Median scene times and transport times were short (17 minutes scene time, 8-10 minutes transport time). Initial vital signs on EMS arrival was an important predictor of survival (23% vs 1.8% in Epistry and 11% vs 1.6% in PROPHET).
Interestingly, this study found that traumatic arrest patients who sustained falls were most likely to survive to discharge (11%) as compared to gunshot wounds (2.1%), and those sustaining blunt injuries more likely to survive than penetrating. Patients who received a supraglottic airway insertion or intubation experienced decreased odds of survival compared to those patients who received bag-mask ventilation. Overall, 6.3% of patients who sustained prehospital cardiac arrest survived to discharge, a higher rate than historically reported (2%). This study concluded that witnessed prehospital traumatic cardiac arrests deserve aggressive resuscitative efforts.
Timing of pharmacologic venous thromboembolism prophylaxis in severe traumatic brain injury: a propensity-matched cohort study. Byrne JP, Mason SA, Gomez D, Hoeft C, Subacius H, Xiong W, Neal M, Pirouzmand F, Nathens AB. J Am Coll Surg. Oct;223(4):621-631.e5.
Patients sustaining severe traumatic brain injury (sTBI) with GCS<8 are at high risk for venous thromboembolism (VTE) complications, but limited evidence exists regarding the timing and type of VTE chemoprophylaxis in this patient population. This study is a retrospective cohort study of patients with isolated sTBI treated at TQIP-participating level I or II trauma centers, to compare patients who received early (<72 hours) or late (>72 hours) DVT chemoprophylaxis. They also compared unfractionated heparin (UH) versus low molecular weight heparin (LMWH). The primary outcome was VTE as defined by PE or DVT, with secondary outcomes of mortality and late neurosurgical interventions, defined as craniotomy/craniectomy or ICP monitor/drain insertion after 72 hours from admission. Early deaths (<5 days) were excluded.
A total of 3,632 patients with sTBI from 186 participating centers were included, with 43% receiving early prophylaxis. LMWH was used in 55% as compared to UH in 45%. Overall, PE occurred in 1.7% and DVT occurred in 6.5%. While there was no difference in mortality or need for additional neurosurgical interventions between groups that received early or late VTE prophylaxis, those patients who received early VTE prophylaxis had significantly lower rates of DVT and PE as compared to those >72 hours. In addition, LMWH was associated with significantly lower odds of VTE and mortality as compared to UH. “Screening centers” were defined as those trauma centers who reported vascular ultrasound for >10% of their patients, and were a minority of the centers (13%). While limited in its retrospective nature, as well as by the inability to analyze other TBI-related complications including hemorrhage progression on repeat CT, this study is the largest study to date demonstrating the benefits of both early VTE prophylaxis and use of LMWH in high-risk patients with sTBI.
Effect of Pelvic Binder Placement on OTA Classification of Pelvic Ring Injuries Using Computed Tomography: Does it Mask the Injury? Swartz J, Vaidya R, Hudson I, Oliphant B, Tonnos F. J Orthop Trauma. 2016 June 30(6): 325-330.
The goal of this study was to assess the diagnostic sensitivity of computed tomography (CT) after placement of a pelvic binder or pelvic circumferential compression device (PCCD). In order to assess this question, the authors retrospectively identified all patients with an AO/OTA Type B or C pelvic fracture (partial or complete posterior instability) during the period from 2003-2010. Of the 867 identified, they selected 43 patients for analysis that had: 1) an initial pelvic radiograph prior to PCCD placement; 2) a CT with PCCD in place; and, 3) a fluoroscopic stress examination under anesthesia (FEUA), which was considered to be the diagnostic gold standard. A senior orthopedic resident and two fellowship trained orthopedic traumatologists separately classified all images independently. Pelvic plain films and CT were viewed separately and initial findings were not adjusted based upon interpretation of the companion study.
Among the group with Anterior-Posterior Compression and/or Vertical Shear, sensitivity of CT+PCCD was only 50% for correctly identifying the entire injury complex compared to 69% on pre-PCCD plain film. Overall, the difference in sensitivity for anterior injury was more notable between plain film and CT (89% vs 64%,p=0352); while posterior injury was more difficult to detect with both pre-radiograph and post-CT (72% vs 78%,NS). When utilized in combination, the sensitivity of the two modalities was greater than 87% for all types of injury. Overall, 17 injuries were misidentified due to pelvic binder placement (2 posterior APC, 13 anterior APC, 2 LC). The authors conclude that pelvic binders have the potential to mask the clinically severity of pelvic fractures on computed tomography. They recommend that FEUA should be considered when pre-PCCD imaging is not available. While the article focuses on the potential misinterpretation of CT images in these severely injured patients, the remarkable degree of fracture reduction achieved with the PCCD is notable and the authors appropriately advocate for the widespread and early use of PCCD in all settings, regardless of the timing of imaging.
Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers. Inaba K, Karamanos,E, Skiada D, Grabo D, Hammer P, Martin M, Sullivan M, Eckstein M, Demetriades D. J Trauma Acute Care Surg. 2015 Dec;79(6):1044-8.
Needle thoracostomy with 14 gauge 5cm angiocatheter at the 2nd intercostal space (2MCL) along the mid-clavicular line has long been recommended as the emergent treatment for tension pneumothorax. However, unacceptably high failure rates have led to a growing body of literature supportive of longer catheters, alternative placement at the 5th intercostal space along the anterior axillary line (5AAL), and alternative decompression devices. This paper adds further support to the argument for the use of the 5AAL as a primary site for needle decompression of tension pneumothorax, in lieu of the 2MCL.
The authors compare both the anatomic accuracy and comfort level following placement when needle thoracostomy was performed by US Navy corpsmen on fresh cadavers. 25 corpsmen inserted 100 needles on 25 cadavers. 82% of 2MCL insertions compared to 22% of 5AAL insertions were misplaced (+/-5cm margin of error, p<0.001). When ease of placement was rated on a Likert scale, 88% defined placement at 5AAL as Very Easy/Easy and none as Difficult/Very Difficult. Comparatively, only 32% felt 2MCL placement was Very Easy/Easy and 44% stated that it was Difficult or Very Difficult. Bilateral thoracotomy and laparotomy were performed on all cadavers and no significant injuries were noted at either location. The authors conclude that the 5AAL can be more accurately localized and decompressed than 2MCL and should be considered as an alternative first-line position for decompression of tension pneumothorax.
Additional tension pneumothorax articles for reference when reviewing Article 4:
Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV, Vu TD, Thiels CA, Pandian TK, Schiller HJ, Murad MH, Aho JM. Injury. 2016 Apr;47(4):797-804.
Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter. Aho JM, Thiels CA, El Khatib MM, Ubl DS, Laan DV, Berns KS, Habermann EB, Zietlow SP, Zielinski MD. J Trauma Acute Care Surg. 2016 Feb;80(2):272-7.