Doing trauma right… in the right order… at the right time..

The folks at St Emlyn's blog in the UK just released a nice discussion of how to handle trauma patients. Apparently, there is a new quality marker on trauma care in UK major trauma centres: 30 minutes from ED presentation to Pan-Scan CT image acquisition on trauma patients with an ISS >15. 

http://stemlynsblog.org/ttl-podcast-1-getting-ct-30-minutes/

This new trauma quality indicator is different from the older pan-scan quality indicator of getting at pan scan report 1 hour after presentation. 

While the idea of getting this done in less than 30 minutes might seem crazy to many ED providers in New Zealand, it can certainly be done. Whether it is a beneficial, safe, and reasonable goal is a different question. However, I think it is a reasonable aspirational goal that could really focus people's thinking.

I'm not aware of any evidence that explicitly supports a 30 minute door-to-CT time, but I certainly believe that trauma systems that can get patients from ED to theatre in around 20 minutes are better than those that take longer. A 30-45min ED to CT timeframe is probably reasonable as well. I look forward to them publishing about their experience.   

Anyway, taking patients to CT in less time requires an enormous multidisciplinary effort. Sure, the scanner needs to be cleared, radiologists need to be ready to read, and the patient needs to be packaged, but what else needs to happen? What needs to NOT happen? 

Traditionally, before transporting a trauma patient, all sorts of crazy stuff got done to them: log-rolls, exposure, auscultations, 2 liters of saline, fingers and tubes shoved every-which-way. X-rays, ultrasounds, plasters, binders, and bandages. Once you start thinking about a 30min time-crunch, you start to think about which parts of that initial 30 minutes give you the best bang-for-the buck and which parts are just done because of tradition, ignorance, and PROVIDER comfort. 

These guys (Simon Carley and Iain Beardsell) do a great job is discussing the stuff that most everyone agrees could be removed from the urgent trauma resus before urgent pan-scan: c-spine x-rays, "springing" the pelvis, plaster splinting, and combing that patient's hair. They also question the utility of some other "historical" portions of the primary and secondary exam that may have limited value: auscultation the chest, tracheal palpation, the log roll, routine rectal exams, and the chest and pelvic x-ray. 

I totally support questioning the value these protocolized, insensitive, nonspecific, and time-wasting tests and procedures on sick blunt trauma patients who will be through the CT scanner in less than 30 minutes. Of course there are times when your want to use your clinical judgment and a focused exam to ADD a chest x-ray on hypoxic or dyspneic patients. However, these patients can almost always identified in seconds from the end of the bed.

This post reminds me of my favourite axiom in medicine:

"Don't do stuff that doesn’t impact patient outcome."

Especially: don't do bad tests (tests that take essential time and have poor sensitivity and specificity) if you're about to do a good test in the next 30 minutes. 

Anyway it is worth listening to, and, even through I mostly disagree with him, Andy Buck's comments are definitely worth a read as well. 

Andy

PS: They also briefly discussed some controversies surrounding common debates: CXR vs Lung US,  pelvic x-rays vs pelvic binders, crystalloid vs blood vs nothing, chest tube vs needle vs finger thoracostomies, but I suspect we'll cover those in future posts. 

 

 

 

QuizEM # 27 : Figure 1

Figure 1 : Image of the Week This photo was taken during a thromboendarterectomy for treatment of chronic thromboembolic pulmonary hypertension (CTEPH). Surgery is the only definitive therapy for this condition, which occurs in a small proportion of acute pulmonary embolism patients. Photo credit: Sean Love/Figure 1 Medical Images   1.  Do you know when […]

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Acute respiratory distress syndrome following intralipid emulsion therapy

intralipid2.5 out of 5 stars

Acute respiratory distress syndrome following verapamil overdose treated with intravenous lipid emulsion; A rare life-threatening complication. Martin C et al.  Ann Fr Anesth Reanim 2014 [Epub ahead of print]

Reference

This interesting French case report is a textbook example of how not to use intralipid emulsion therapy (ILE) in calcium-channel-block (CCB) overdose.

It describes a 51-year-old woman who present to the emergency room 8 hours after ingesting forty 240 mg verapamil, a total of 9.6 grams. She was hypotensive and bradycardic, although alert and oriented. Initial echocardiography showed good systolic function. She was given fluids and calcium, and a temporary transvenous pacemaker placed.

Six hours after presentation the patient was intubated after her oxygen saturation decreased and she required high-dose pressors. At that point, “A literature review suggested the use of lipid therapy as a possible antidote,” and an intralipid bolus was given followed by continuous infusion. After 4 hours of infusion, the patient developed signs of acute respiratory distress syndrome (ARDS). Echocardiography at this point showed impaired systolic function with an ejection fraction of 35%.

Veno-arterial extracorporeal membrane oxygenation (ECMO) and continuous veno-venous hemofiltration (CVVH) was started, as well as plasmapharesis. The patient slowly recovered. She was extubated on day 9 and discharged from the ICU on day 18, with intact pulmonary and neurological function.

In a recent column in Emergency Medicine News, I wrote about how CCB overdose produces a “perfusion salad.” with hypotension caused by impaired myocardial function, vasodilation, or a combination of the two. Apparently in this case systolic function was initially intact, which might be why high-dose insulin (HDI) was withheld and the clinical team relied on high-dose pressors. When these proved insufficient, it would have made sense to re-evaluate systolic function and move on to HDI if it was impaired. Most toxicologists would save ILE for a last-ditch effort if response to other modalities was inadequate. It is puzzling why the infusion was continued for 4 hours if the response was not sufficient.

The authors conclude that this paper is “the first one to our knowledge to report a case of ARDS induced by an ILE administration.” Although the authors do not do so, it is worth pointing out that, in terms of likelihood,  applying the Naranjo Algorithm reveals that this was only a possible or at best probable adverse drug reaction to ILE. A simple PubMed search would have determined that this was not true. A 1984 paper reported a similar case, although in that instance ILE was administered for nutritional purposes, not to treat a toxic overdose.

Bedside TEE with @arntfield Part 1.  Yes, you heard right.  Point of care providers doing TEE.  It just got real.  #foamed

At Castlefest 2014, Rob Arntfield blew our minds with his point of care TEE talk.  He showed us why and how we could and should be doing point of care TEE.  Then we all practiced on simulators.  It was a phenomenal experience, and he’s agreed to come back in 2015 and do it all again.  So if you haven’t signed up, do that NOW!
However, we think this is too important to just teach to Castlefestians, so we want to #foamed it out to all of you.  The truth is, this isn’t the hardest thing in the world to do.  It sounds scarier than it really is.  If you can get your hands on a simulator to practice, you can totally learn this……probably more quickly than TTE.  That’s the experience of most people who do this.  The windows are really much easier.
We’ll be getting part 2 out to you very soon.  In the meantime if you want to read more, then pick up Introduction to Bedside Ultrasound that has a chapter on this written by the man himself, Robert T. Arntfield.  Or hangout with him as part of the Ultrasound Leadership Academy or come practice with him and us at Castlefest.
Follow us:  @ultrasoundpod
Register:  Castlefest 2015
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