Achieving adequate pain control after injury and minimizing opioid dependence is imperative. Ketamine, an NMDA antagonist, has seen a recent resurgence and has been shown to reduce postoperative opioid requirements. However, its role specifically in trauma remains poorly defined. A previous study demonstrated that low-dose ketamine does not reduce opioid requirements in patients with rib fractures but was beneficial in a subset of patients with severe injuries, defined as ISS > 15. The aim of this specific study was to investigate the impact of adjustable dose ketamine (ADK) infusions in severely injured patients.
The investigators conducted a double-blinded, randomized controlled trial in which patients with an estimated ISS > 15 (which was determined by imaging and clinical findings) received either ADK or placebo, in addition to a patient-controlled analgesia, and both opioid and non-opioid agents. The study drug was administered within 24 hours of arrival and continued for 48 hours. The primary outcome was the difference in oral morphine equivalents (OME) at 24 hours. Secondary outcomes included OME reduction from 24 to 48 hours, during the 48-hour infusion period, and throughout the entire hospitalization.
There was no difference in the median OME during the first 24 hours, between 24 and 48 hours, or at 48 hours. Similarly, no differences in total OME were observed throughout the hospitalization or at hospital discharge. Numeric pain scores were comparable. This study raises questions about the efficacy of ketamine in achieving pain control.
In this prospective, observational EAST multicenter trial, the authors sought to evaluate whether prioritizing circulation over airway was associated with improved survival after exsanguinating injury. Patients presenting to six trauma centers between January 2018 and April 2022 who had a systolic blood pressure less than 90mmHg and were intubated within 30 minutes of arrival were included. The authors defined prioritizing circulation over airway (CAB group) as delaying intubation until blood products were started and/or bleeding control was performed. Prioritizing airway over circulation (ABC group) was defined as intubating before resuscitation or obtaining hemorrhage control. 278 patients were included, of whom 171 (61.5%) were in the CAB group. CAB patients were more likely to have sustained a penetrating injury (28.1% vs 15.9%) and more likely to be intubated in the operating room (39.2% vs 0%). 75.4% of CAB patients received blood products before intubation, compared with 60.8% of ABC patients. CAB patients had a lower systolic blood pressure before intubation (median 71 vs 76mmHg), but had a higher SBP post-intubation (median 67 vs 57 mmHg). The primary outcome was 24-hour mortality, which was significantly lower in CAB patients (11.1% vs 69.2%). This mortality difference persisted to 30-days (17.5% vs 72.0%). On multivariate analysis, CAB patients had a 91% decrease in the odds of mortality at 24 hours and an 89% decrease at 30 days.
This study demonstrates that the patients in the CAB group had improved survival at 24 hours and 30 days compared to the patients in the ABC group and hypothesized this mortality benefit was due to a lower rate of post-intubation hypotension. The authors used this finding to conclude that prioritizing circulation over airway in a trauma resuscitation is associated with lower mortality. Initiating blood transfusion or obtaining hemorrhage control prior to intubation was used as a surrogate marker for prioritizing circulation over airway, but it is unclear whether these markers are truly indicative of a different philosophical approach to resuscitation, or whether they reflected a different pathophysiology between groups. There also appears to be substantial heterogeneity within the ÅBC group: although receiving blood prior to intubation was inclusion criteria for the CAB group, 60% of patients in the ABC group also received blood prior to intubation. It is unclear why these patients were included in the ABC group, and the authors do not separately report the outcomes of these patients. There is also no information about the time to hemorrhage control or time to intubation in each group, the type of hemorrhage control needed, or the indication for intubation. Although this study appears to support a growing body of evidence that supports addressing hemorrhagic shock before intubation, these methodological limitations impact its generalizability.
This study is particularly compelling. Traumatic cardiac arrest (TCA) typically carries a grim prognosis, yet as the authors aptly highlight, certain reversible causes such as massive hemorrhage, cardiac tamponade, and pneumothorax can yield favorable outcomes if managed promptly, especially before hospital arrival. Resuscitative thoracotomy (RT) remains a go-to maneuver for the management of patients suffering traumatic cardiac arrest. It has been shown to improve survival in a subset of patients, especially those with penetrating cardiac injuries. Often, this is done upon arrival to the emergency department, limiting this time-sensitive intervention to a “door to intervention” interval rather than the more critical injury to intervention time.
Perkins and colleagues conducted a robust retrospective analysis examining outcomes for civilian patients undergoing prehospital RT performed by the London Air Ambulance (LAA) over a span of 21 years. Their primary outcome was survival to hospital discharge. Notably, the LAA has been pioneering prehospital RT since the 1990s, aiming to address traumatic cardiac arrest as rapidly as possible. Comprising a physician-paramedic team, the LAA provides advanced critical care en route to one of four major trauma centers in Greater London. The indication for RT was initially for penetrating injuries to the chest or epigastrium but expanded approximately 13 years after the beginning of the study period to include penetrating injuries in other body regions and select cases involving blunt injury.
Over the study period, the LAA encountered 3223 patients who had prehospital traumatic cardiac arrest. Of those, 601 (1.3%) had a prehospital resuscitative thoracotomy. The study population was mostly young adults aged 25 (20-37) years, male 538 (89.5%), and suffering from penetrating injuries 529 patients (88.0%). Overall, 30 patients (5.0%) survived to hospital discharge. Of the survivors, 76% had a favorable neurological outcome based on the Cerebral Performance Categories score. Of the nonsurvivors, 160 patients (26.6%) survived transport to the trauma center.
Timeliness proved crucial: median intervals from emergency call to TCA, trauma team arrival, and RT initiation were notably short, at 12, 20, and 22 minutes, respectively. Hemorrhage was the most common cause of TCA (70%) and primarily thoracic in origin (270 patients [65%]), followed by cardiac tamponade (17.6%). Notably, patients with cardiac tamponade showed the highest survival rate (21%), with approximately three-quarters achieving favorable neurological outcomes. Conversely, survival rates for severe hemorrhage were markedly lower (1.9%), and none survived beyond five minutes of cardiac arrest duration compared with cardiac tamponade where no survivors to discharge beyond 15 minutes of TCA. None of the patients with combined cardiac tamponade and severe hemorrhage survived to hospital discharge.
The authors conclude that prehospital RT significantly enhances survival potential, especially among patients with penetrating cardiac injuries causing tamponade. However, broader application of these findings must be approached cautiously, given the unique capabilities of the LAA's specialized physician-paramedic teams, which are rare in many trauma systems. Additionally, substantial changes in trauma care practices over two decades may influence these outcomes. Lastly and interestingly (my two cents), the reported scene arrival time of 12 minutes contrasts with a more recent prehospital multicenter trial by Crombie et al. (2016-2021) investigating prehospital blood product vs crystalloid resuscitation, involving the same LAA service, which recorded 30 minutes to scene arrival and an additional 26 minutes to initiate prehospital blood transfusion interventions. This discrepancy invites reflection on evolving prehospital care logistics.
Ultimately, this provocative study strongly supports further prospective research into the effectiveness and broader feasibility of prehospital resuscitative thoracotomy.
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