I’m back in the Midlands at the excellent and great value TraumaUK conference. If you’ve not been to this conference then I’d strongly suggest you do next year. It’s an amazing program and incredible value for money.
As usual I’m in the emergency medicine stream bringing together the top 10 trauma papers from 2018-2019.
As ever it’s a bit disappointing to find relatively few papers to talk about as I try and focus on those papers that might lead to a change in practice. Although there are a lot of publications out there, once you start applying the filters of applicability, quality and interest that number plummets.
So here is my top 10 list based entirely on my own opinion. There is some repetition from past posts, but I’m OK with that as we can call it spaced repetition1.
Paper 1. PAMPER trial
Paper 1 is the PAMPER trial that looked at the use of prehospital plasma in patients suffering major trauma. The idea here is that we need to manage coagulopathy in the seriously injured and by getting ahead of the curve by giving FFP early. This large RCT based in the US showed a 9.8% increase in survival which is incredible. It is the sort of treatment effect that is so large that I’d like to see it repeated. You can read more about the PAMPER trial on the Bottom Line Website here.2,3
Paper 2: Bougie use in the ED
Paper 2 is an RCT comparing the routine use of a bougie in the ED against the use of a stylet. This is an important study for me as I’ve advocated the routine use of a bougie for as long as I can remember. However, others have suggested it takes more time, that it might cause injury or that a stylet (or nothing at all) is better.
This paper demonstrates that not only is the bougie safe, but also that it is quicker and easier to use. This is true irrespective of whether you think it’s going to be a difficult airway. The bottom line is use a bougie in most cases.4,5
Paper 3: Ventilation during RSI.
For many years I have seen some of my colleagues routinely ventilate patients at risk of desaturation in the time between induction and paralysis taking effect. We typically do this using a Water’s circuit with a bit of PEEP applied (that’s a Mapleson C circuit) which we use for pretty much all RSIs in Virchester). In pre-hospital care there is a preference for the BVM as it still works even if you lose your O2 supply. It’s done gently and carefully to avoid gastric insufflation, but it’s always felt a little odd as we I was originally taught that ventilating at this stage of the RSI was forbidden and dangerous. Notably because it was felt that it could induce aspiration. On the other hand there are the risks of desaturation, hypoxia and the associated consequences of cardiovascular instability and potential end organ damage. Thus the debate about whether ventilating the patient in the time between induction and intubation has been controversial and debated for years.
This paper is an ED based RCT showing that it is safe and advantageous to ventilate patients between induction and laryngoscopy. Far fewer patients desaturated and there was no increase in complications (aspiration and pneumonia). Read more about the paper here.6,7
Paper 4: Is hypotensive resuscitation evidence based?
Paper 4 is a systematic review of the principles of hypotensive resuscitation in trauma patients. The benefit of hypotensive resuscitation in trauma patients is a widely held belief and there are good pathophysiological arguments to support it. Is it a strategy with a strong evidence base though?
This year there have been two systematic reviews of the evidence base8,9 and it’s a bit of a surprise really. In my head I had imagined that there was a very strong evidence base in the literature, but having read the papers I’m less assured.
Across 722 papers reviewed the authors in one review found only 5 RCTs. One of these, and by far the largest is the Bickell trial from 1994 when trauma care was a little different and where the patients were all victims of penetrating trauma10.
Although the authors conclude that there is a benefit to hypotensive resuscitation strategies it’s unclear what the magnitude of the effect is. I am a little concerned that most of the evidence is historical and from a very different patient group to the one I see.
Paper 5: Late presenters with head injury. Do they need a scan?
No doubt you will be familiar with the NICE guidelines on the management of head injury11. They’ve been around for a while and they are well embedded in our practice. In practice I see them applied to all patients with head injury, even those who present late. However, most head injury guidelines were derived from patient cohorts that limited themselves to patients who presented within 24 hours of injury.
The bottom line is that we have far less evidence for patients who present late which has led to some interesting ideas around how we deal with them. We can of course use the guideline, or in some opinions the fact that the patient has survived 24 hours is an indicator in itself that they are fine. Remember that most of these patients are ‘walk-ins’ in the minor end of the department, presenting with relatively mild symptoms such as nausea, vomiting and headache.
Paper 5 looks at patients presenting after 24 hours to a UK trauma centre with a head injury12. They compared the CT incidence of significant injury with that of patients who were scanned within 24 hours. They identified 650 patients in the late presentation cohort. Note that they only included patients who had a scan, it is highly likely that some patients will have presented late and not received a CT scan. That may bias the results.
The bottom line is that the incidence of significant CT findings was the same (well slightly more) in the late presentation group. Over 10% of the patients presenting late (and who had a CT scan) had a significant finding, and several ended up with neurosurgical intervention (3%). What this means is that we cannot dismiss late presenting patients simply on the basis of time.
Paper 6: Trauma laparotomy mortality.
Paper 6 covers a really interesting paper that looks at mortality following trauma laparotomy. Whilst we all think that we’ve made great progress in trauma care13,14 there is a group of patients in whom mortality does not seem to be improving15,16.
Data from the Royal London and also from the UK military database shows that mortality has remained the same despite all the advances that we know have taken place. I think this paper links well with Karim Brohi’s paper on why trauma patients die17,18. That showed a shift to later deaths on the ICU as a result of as yet unknown mechanisms. The bottom line is that there is still work to be done in the management of torso trauma, and especially in non-compressible torso haemorrhage. Interesting to listen to Ed Barnard on exactly that issue of non compressible bleeding at the conference today.
Paper 7: Hypothermia in head injury
Hypothermia should work for lots of critical illness, but it doesn’t seem to in practice. Whilst lab data suggests and demonstrates the neuroprotective effect of hypothermia we’e failed to demonstrate it in several different areas (notably post cardiac arrest). What about head injury though? On the ICU the Eurotherm trial showed that it did not make a difference in patients with raised ICP, but that was criticised as the hypothermia was started late. What happens if we start it early?
In the POLAR trial patients were randomised as soon as possible to hypothermia after head injury19,20. In this large RCT there was little difference in outcome and more complications in the hypothermia group. Once again hypothermia fails to live up to the promise although it’s still unclear why. Read more on the blog here.
Paper 8: Beta blockers in the management of traumatic brain injury
We’ve reviewed a whole bunch of papers on the blog that aim to improve outcomes from medical or traumatic causes of brain injury. Hormones21,22, hypothermia20,23–25, EPO26,27 and more have been tried, but they have been disappointing. In fact there has been very little progress in the ICU/medical management of serious TBI.
One therapy that I was not familiar with is the use of Beta blockers for this group of patients. Paper 8 is an observational study that looks at outcomes related to Beta Blocker use in critical care patients in the US28.
In 15 US trauma centres and 2337 patients there was an association of beta blocker use and survival. The mechanism for this is a bit uncertain but may be related to control of catecholamine effects. Catecholamines surge post TBI and the magnitude of the rise is associated with outcome. Catecholamines cause inflammation and apoptosis with effects lasting for over a week. There is therefore some logic in the use of Beta Blockers in the management of these patients.
What they found is that there was a 4% difference in mortality and an unadjusted difference in GOS (favouring no BB).
There are always problems with observational studies of this type. There are many confounding factors and bias that may influence the result. Most notably here that patients who are suitable to receive a beta blocker may not have as much cardiovascular instability as those who do not (and with the associated mortality as a result). They did try to address this by adjusting for known factors, but that’s never perfect.
Having said that there is a fairly strong association between use and survival and also use and positive functional scores.
What we need is an RCT of this therapy to find out whether the association found in this paper is actually a causal relationship.
Paper 9: Paediatric Splenic Injury
Paper 9 is a paediatric paper looking at splenectomy results in UK trauma centres29. Using the TARN database the authors compared splenectomy rates between hospitals that were dedicated paediatric major trauma centres and those that are not. The results are really quite stark with almost a 5-fold difference in operative rates.
Now you might think that this is because patients in the non Paeds MTC were too sick to travel and thus more likely to need operative management. The authors helped explore this by comparing rates dependent on the severity of splenic injury as defined by AIS score.
So the bottom line here is that the differences exist irrespective of the splenic injury. That suggests that injury severity is not the main factor. Ross Fisher, our friend and resident paediatric surgeon has suggested that splenectomy rates can be used as a quality marker for the surgical management of major trauma30. On the basis of this paper he may well be right.
Paper 10: The Zero Point Survey
Cheekily I added the zero point survey paper that I co-authored in 201831–33. Why you may ask? It’s because of all the things I’ve done this year it’s the easiest, quickest, cheapest and most effective to deliver in practice.
We don’t have the evidence yet, but it makes sense and I’d strongly recommend you consider putting it into your practice. Read more about the ZPS here.
- 1.Carley S. Educational theories you must know. Spaced Repetition. St.Emlyn’s • St Emlyn’s. St.Emlyn’s. https://www.stemlynsblog.org/better-learning/educational-theories-you-must-know-st-emlyns/educational-theories-you-must-know-spaced-repetition-st-emlyns/. Published 2015. Accessed March 6, 2019.
- 2.PAMPer. The Bottom Line. https://www.thebottomline.org.uk/summaries/em/pamper/. Published August 3, 2018. Accessed March 6, 2019.
- 3.Sperry JL, Guyette FX, Brown JB, et al. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. July 2018:315-326. doi:10.1056/nejmoa1802345
- 4.Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation. JAMA. June 2018:2179. doi:10.1001/jama.2018.6496
- 5.Carley S. JC: Don’t blame it on the Bougie. St Emlyn’s • St Emlyn’s. St.Emlyn’s. https://www.stemlynsblog.org/jc-dont-blame-it-on-the-bougie-st-emlyns/. Published May 20, 2018. Accessed March 6, 2019.
- 6.Casey JD, Janz DR, Russell DW, et al. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. N Engl J Med. February 2019:811-821. doi:10.1056/nejmoa1812405
- 7.Carley S. JC: Should we continue ventilations during RSI? St Emlyn’s • St Emlyn’s. St.Emlyn’s. https://www.stemlynsblog.org/jc-ventilation-during-rsi-st-emlyns/. Published February 22, 2019. Accessed March 6, 2019.
- 8.Tran A, Yates J, Lau A, Lampron J, Matar M. Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock. Journal of Trauma and Acute Care Surgery. May 2018:802-808. doi:10.1097/ta.0000000000001816
- 9.Tran A, Yates J, Lau A, Lampron J, Matar M. Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trials. J Trauma Acute Care Surg. 2018;84(5):802-808. https://www.ncbi.nlm.nih.gov/pubmed/29370058.
- 10.Bickell W, Wall M, Pepe P, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331(17):1105-1109. https://www.ncbi.nlm.nih.gov/pubmed/7935634.
- 11.Overview | Head injury: assessment and early management | Guidance | NICE. NICE. https://www.nice.org.uk/guidance/cg176. Published 2019. Accessed March 6, 2019.
- 12.Marincowitz C, Allgar V, Townend W. CT head imaging in patients with head injury who present after 24 h of injury: a retrospective cohort study. Emerg Med J. April 2016:538-542. doi:10.1136/emermed-2015-205370
- 13.Moran CG, Lecky F, Bouamra O, et al. Changing the System – Major Trauma Patients and Their Outcomes in the NHS (England) 2008–17. EClinicalMedicine. August 2018:13-21. doi:10.1016/j.eclinm.2018.07.001
- 14.Grayson A. Trauma in the UK, who cares? St Emlyn’s • St Emlyn’s. St.Emlyn’s. https://www.stemlynsblog.org/trauma-in-the-uk-who-cares-st-emlyns/. Published December 31, 2018. Accessed March 6, 2019.
- 15.Marsden M, Carden R, Navaratne L, et al. Outcomes following trauma laparotomy for hypotensive trauma patients. Journal of Trauma and Acute Care Surgery. May 2018:1. doi:10.1097/ta.0000000000001988
- 16.Carden R. What’s the bleeding problem with trauma laparotomies?! • St Emlyn’s. St.Emlyn’s. http://www.stemlynsblog.org/whats-the-bleeding-problem-with-trauma-laparotomies/. Published December 28, 2018. Accessed March 6, 2019.
- 17.Carley S. JC: Why do bleeding trauma patients die? St Emlyn’s • St Emlyn’s. St.Emlyn’s. https://www.stemlynsblog.org/jc-why-do-bleeding-trauma-patients-die-st-emlyns/. Published February 13, 2019. Accessed March 6, 2019.
- 18.Brohi K, Gruen RL, Holcomb JB. Why are bleeding trauma patients still dying? Intensive Care Med. February 2019. doi:10.1007/s00134-019-05560-x
- 19.Carley S. JC: What’s the target temperature for OOHCA cooling. St.Emlyn’s • St Emlyn’s. St.Emlyn’s. https://www.stemlynsblog.org/whats-target-temperature-oohca-cooling-st-emlyns/. Published November 18, 2013. Accessed March 6, 2019.
- 20.Cooper DJ, Nichol AD, Bailey M, et al. Effect of Early Sustained Prophylactic Hypothermia on Neurologic Outcomes Among Patients With Severe Traumatic Brain Injury. JAMA. December 2018:2211. doi:10.1001/jama.2018.17075
- 21.Carley S. JC: Progesterone’s pleiotropic failure in head injury. St.Emlyn’s • St Emlyn’s. St.Emlyn’s. http://www.stemlynsblog.org/jc-progesterones-pleiotropic-failure-head-injury-st-emlyns/. Published December 29, 2014. Accessed March 6, 2019.
- 22.Wright DW, Kellermann AL, Hertzberg VS, et al. ProTECT: A Randomized Clinical Trial of Progesterone for Acute Traumatic Brain Injury. Annals of Emergency Medicine. April 2007:391-402.e2. doi:10.1016/j.annemergmed.2006.07.932
- 23.Carley S. JC. Pre-hospital therapeutic hypothermia: The RINSE trial. St.Emlyn’s • St Emlyn’s. St.Emlyn’s. http://www.stemlynsblog.org/pre-hospital-therapeutic-hypothermia-the-rinse-trial-st-emlyns/. Published September 13, 2016. Accessed March 6, 2019.
- 24.Bernard SA, Smith K, Finn J, et al. Induction of Therapeutic Hypothermia During Out-of-Hospital Cardiac Arrest Using a Rapid Infusion of Cold Saline. Circulation. September 2016:797-805. doi:10.1161/circulationaha.116.021989
- 25.Horner D. JC: EuroTHERM or EuroBURNED. St.Emlyn’s • St Emlyn’s. St.Emlyn’s. http://www.stemlynsblog.org/jc-eurotherm-or-euroburned-st-emlyns/. Published November 7, 2015. Accessed March 6, 2019.
- 26.Cariou A, Deye N, Vivien B, et al. Early High-Dose Erythropoietin Therapy After Out-of-Hospital Cardiac Arrest. Journal of the American College of Cardiology. July 2016:40-49. doi:10.1016/j.jacc.2016.04.040
- 27.Carley S. JC: Does EPO improve OOHCA outcomes? St.Emlyn’s • St Emlyn’s. St.Emlyn’s. http://www.stemlynsblog.org/jc-epo-improve-oohca-outcomes-st-emlyns/. Published July 3, 2016. Accessed March 6, 2019.
- 28.Ley EJ, Leonard SD, Barmparas G, et al. Beta blockers in critically ill patients with traumatic brain injury. Journal of Trauma and Acute Care Surgery. February 2018:234-244. doi:10.1097/ta.0000000000001747
- 29.Warwick AM, Jenks T, Fisher R, Garrett‐Cox R, Lecky F, Yates D. Disparities in the management of paediatric splenic injury. Br J Surg. October 2018:263-266. doi:10.1002/bjs.10996
- 30.Development P. Ross Fisher on the management of UK Paediatric trauma. St Emlyn’s podcast. https://www.stemlynspodcast.org/e/ross-fisher-on-the-management-of-uk-paediatric-trauma/. Published 2016. Accessed March 6, 2019.
- 31.Carley S. JC: The Zero Point Survey. Optimising resuscitation teams in the ED. St Emlyn’s • St Emlyn’s. St.Emlyn’s. https://www.stemlynsblog.org/jc-the-zero-point-survey-optimising-resuscitation-teams-in-the-ed-st-emlyns/. Published September 30, 2018. Accessed March 6, 2019.
- 32.Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med. https://www.ceemjournal.org/upload/pdf/ceem-17-269.pdf. Published 2018. Accessed March 6, 2019.
- 33.Reid C, Brindley P, Hicks C, et al. Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med. September 2018:139-143. doi:10.15441/ceem.17.269