Trauma Year in Review 2016 from SMACCdub
by Chris Hicks and Andrew Petrosoniak
The science of trauma resuscitation has undergone a fairly massive evolution in the past decade. This talk was our attempt to summarize the best-of-the-best in trauma literature from the past several years, and package it into a series of clinically useful recommendations (i.e., our evidence-based opinions). This talk was live peer reviewed by trauma surgery deity Karim Brohi, who gave us a thumb’s up (although you kind of had to be there).
Here’s a run-down of our take-home points:
Use the Clamshell
Unless you’re a thoracic surgeon, consider the bi-thoracotomy as your initial approach to resuscitative thoracotomy. Don't operate in a hole – give yourself the best exposure, and the best shot at fixing the problem.
- Ref: WJS 2013, 37: 1277-1285
- How-to guide: http://emj.bmj.com/content/22/1/22
Prognosticate with POCUS
Point-of-care ultrasound (POCUS) has an ever-expanding role in trauma resuscitation, including prognosticating in cardiac arrest. In this study, patients with no cardiac activity and no pericardial effusion had no survival.
- Ref: Ann Surgery 2015, 262(3): 512-518
Get with the Guidelines
The EAST thoracotomy guidelines might be the most useful and evidence-based set of recommendations for the management of traumatic cardiac arrest yet. Bottom line: VSA trauma patients with penetrating thoracic injuries and an arrest time of < 10 minutes deserve a resuscitative thoracotomy – these are salvageable patients, and deserve an aggressive approach.
- Ref: Critical Care 2013, 17:308, J Trauma 2015, 79(1): 159-173
- Compare and contrast – WEST guidelines (2012): http://bit.ly/2mFemtM
Skip the Films
Stable patients with a plan for CT imaging don’t need a chest x-ray or pelvis x-ray. Not all patients undergoing CT need the full “pan-scan”. In the middle are assessable patients with reassuring vital signs, POCUS +/- x-ray imaging: they can be admitted for observation, or discharged.
- Ref: http://bit.ly/292tAUm
- In the same spirit – local wound exploration for anterior abdo stab wounds can eliminate the need for CT imaging, admission: https://www.ncbi.nlm.nih.gov/pubmed/22182859
The paradigm of 1-2L of crystalloid boluses in hypotensive trauma patients is harmful and should be abandoned. If PRBCs aren’t immediately available, give small boluses (250 cc at a time) for patients with sBP < 70, altered mental status or loss of peripheral pulses. NICE guidelines restrict crystalloids to pre-hospital only.
- Ref: BJM 2012; 345: 38-42, http://bit.ly/292tAUm
PROPPR in a nutshell: A balanced ratio of blood products (approximating 1:1:1) is probably the optimal approach for patients who are bleeding to death; also, platelets are pretty important early in trauma resus.
- Ref: JAMA 2015, 313(5): 471-482
Who Needs Mass Trans?
Predicting the need for massive transfusion in trauma is tricky. Relying on gestalt alone is associated with under-resuscitation in about one third of patients, even when trauma experts are making the call. In tricky situations, use the ABC score or shock index to improve situation awareness.
- Ref: Injury 2015, 46: 807-813, J Trauma 2009, 66: 346-352
Drop the dose
Trauma patients in profound shock don’t need the Full Monty when it comes to induction agents for RSI. Even the all-mighty ketamine can have negative hemodynamic consequences, as predicted by a pre-induction shock index > 1.0. We suggest dropping the dose of whatever induction agent you choose by 25-50% in shocky trauma patients, in-line with aggressive volume resuscitation.
- Ref: Ann Emerg Med August 2016Volume 68, Issue 2, Pages 181–188.e2
- Further reading: A controlled resuscitation strategy is both safe and feasible, and might even yield a mortality benefit in blunt (yes, blunt) trauma patients: J Trauma Acute Care Surg 2015, 78(4): 687-95
ETCO2 is not about the PaCO2
In intubated trauma patients, end-tidal CO2 correlates with hemorrhage, hemodynamic instability and death: BMC Anesthesiol 2013, 11;13(1): 20
Blood in the Sky
Pre-hospital blood transfusions during aeromedial evacuation of trauma patients: Mil Med 2017, 182(S1): 47-52
Hemostatic resuscitation is neither hemostatic nor resuscitative: J Trauma Acute Care Surg 2014, 76(3): 561-7
We didn’t even go there:
- A recent review of REBOA in trauma: Curr Opin Crit Care 2016, 22(6): 563-571
- Why guess on blood component therapy? Visecoelastic Hemostatic Assays (VHAs) and major hemorrhage in trauma: Crit Care 2016, 12;20: 100
- The Dog’s Bollocks: UK slang – “the best of the best”; Queen Street pub and house of ill repute in Toronto, Canada