Bilateral fixed dilated pupils? Operate if extradural!

November 11, 2014 by  
Filed under All Updates, EMS, ICU, Kids, Resus, Trauma

Almost two-thirds of patients with extradural haematoma and bilateral fixed dilated pupils survived after surgery, with over half having a good outcome

 

pupilsiconNeurosurgeon, HEMS doctor, and all round good egg Mark Wilson was on the RAGE podcast recently and mentioned favourable outcomes from neurosurgery in patients with extradural (=epidural) haematomas who present with bilateral fixed dilated pupils (BFDP). Here’s his paper that gives the figures – a systematic review and meta-analysis.

A total of 82 patients with BFDP who underwent surgical evacuation of either subdural or extradural haematoma were identified from five studies – 57 with subdural (SDH) and 25 with extradural haematomas (EDH).

In patients with EDH and BFDP mortality was 29.7% (95% CI 14.7% to 47.2%) and 54.3% had a favourable outcome (95% CI 36.3% to 71.8%).

Only 6.6% of patients with SDH and BFDP had a good functional outcome.

Clearly there is potential for selection bias and publication bias, but these data certainly suggest an aggressive surgical approach is appropriate in some patients with BFDP.

The authors comment on the pessimism that accompanies these cases, which potentially denies patients opportunities for recovery:


“We believe that 54% of patients with extradural haematoma with BFDPs having a good outcome is an underappreciated prognosis, and the perceived poor prognosis of BFDPs (from all causes) has influenced decision making deeming surgery inappropriately futile in some cases.”


Scotter J, Hendrickson S, Marcus HJ, Wilson MH.
Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis.
Emerg Med J 2014 e-pub ahead of print Nov 11;:1–7


Primary objective To review the prognosis of patients with bilateral fixed and dilated pupils secondary to traumatic extradural (epidural) or subdural haematoma who undergo surgery.

Methods A systematic review and meta-analysis was performed using random effects models. The Cochrane Central Register of Controlled Trials and PubMed databases were searched to identify relevant publications. Eligible studies were publications that featured patients with bilateral fixed and dilated pupils who underwent surgical evacuation of traumatic extra-axial haematoma, and reported on the rate of favourable outcome (Glasgow Outcome Score 4 or 5).

Results Five cohort studies met the inclusion criteria, collectively reporting the outcome of 82 patients. In patients with extradural haematoma, the mortality rate was 29.7% (95% CI 14.7% to 47.2%) with a favourable outcome seen in 54.3% (95% CI 36.3% to 71.8%). In patients with acute subdural haematoma, the mortality rate was 66.4% (95% CI 50.5% to 81.9%) with a favourable outcome seen in 6.6% (95% CI 1.8% to 14.1%).

Conclusions and implications of key findings Despite the poor overall prognosis of patients with closed head injury and bilateral fixed and dilated pupils, our findings suggest that a good recovery is possible if an aggressive surgical approach is taken in selected cases, particularly those with extradural haematoma.

Early femur fixation recommended

November 2, 2014 by  
Filed under All Updates, Guidelines, ICU, Resus, Trauma

Comments Off

The Eastern Association for the Surgery of Trauma recommends early (<24 hours) open reduction and internal fracture fixation in trauma patients with open or closed femur fractures.

They acknowledge the strength of the evidence is low, but suggests a trend toward lower risk of infection, mortality, and venous thromboembolic disease.

They conclude: “the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients

Check out the rest of the EAST Trauma Guidelines

Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma

Journal of Trauma and Acute Care Surgery 2014;77(5):787-795


BACKGROUND
Femur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. Internal fixation with intramedullary nailing is the ideal method of treatment; however, there is no consensus regarding the optimal timing for internal fixation. We critically evaluated the literature regarding the benefit of early (<24 hours) versus late (>24 hours) open reduction and internal fixation of open or closed femur fractures on mortality, infection, and venous thromboembolism (VTE) in trauma patients.

METHODS
A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the earlier question. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development, and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables.

RESULTS
No significant reduction in mortality was associated with early stabilization, with a risk ratio (RR) of 0.74 (95% confidence interval [CI], 0.50–1.08). The quality of evidence was rated as “low.” No significant reduction in infection (RR, 0.4; 95% CI, 0.10–1.6) or VTE (RR, 0.63; 95% CI, 0.37–1.07) was associated with early stabilization. The quality of evidence was rated “low.”

CONCLUSION
In trauma patients with open or closed femur fractures, we suggest early (<24 hours) open reduction and internal fracture fixation. This recommendation is conditional because the strength of the evidence is low. Early stabilization of femur fractures shows a trend (statistically insignificant) toward lower risk of infection, mortality, and VTE. Therefore, the panel concludes the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients.

SMACC Chicago – don’t miss the boat!

October 29, 2014 by  
Filed under All Updates, Resus

smacc chicago.002sm

If you’ve attended a SMACC conference or heard anything about them, you will be aware that it is the most exciting, inspiring, interesting, and educational critical care conference ever.

It is a non-profit venture dedicated to getting the best educators, clinicians, and researchers in intensive care, emergency medicine, prehospital/retrieval medicine and anaesthesia to share their knowledge, for free, through the medium of FOAM, embracing physicians, nurses, paramedics, and students.

You can access most of the content through podcasts after the event, but there is NOTHING like actually BEING THERE to experience the vibe.

And in 2015 it’s in Chicago. In the United States. It will be AMAZING.

You can’t look at the program without being blown away. Just look at the preconference workshops and you’ll become vertiginous trying to get your head around the the fact you can’t be in two places at once.

Why am I raving about this? What’s in it for me?

Like the other presenters I make no money from this – I dedicate my time, energy and passion for critical care and am so privileged to be a part of it. But as a do-everything-at-the-last-possible-minute emergency physician, registering for a conference is the kind of thing I’m often inclined to leave a few weeks until I can get round to it. But you CAN’T AFFORD to do that for SMACC Chicago. Not only will you waste money by missing the early registration discount, you might miss out completely: I anticipate registrations will be oversubscribed fast (this is the most anticipated conference EVER) and if you leave it too late you won’t be able to come and will be confined to the crowd who are forced to hear how great it was after the event from the people who were organised enough to actually get there.

So don’t miss out! You’ll feel like a muppet! Treat yourself to the best education at the best conference ever – pull your finger out now and register. And I’ll see you there.

Left Ventricular Assist Device for Cardiac Arrest?

October 7, 2014 by  
Filed under Acute Med, All Updates, ICU, Resus

Comments Off

LVADguyiconAn interesting case report by Dr Heidlebaugh and colleagues from the Department of Emergency Medicine at the William Beaumont Hospital describes a 72 year old marathon runner who arrested during cardiac catheterisation. It suggests a possible novel alternative to ECMO for cardiac arrest.

The patient became bradycardic then asystolic during catheterisation of his right coronary artery. High quality CPR was initiated and an Impella LV assist device was placed. This restored cardiac output which was followed by episodes of venticular fibrillation and then ROSC. His initial low ejection fraction of 15% recovered after targeted temperature management on ICU to 50% and he fully recovered neurologically.

This patient already had femoral arterial access for introduction of the Impella, since he was in a cath lab. He also had immediate CPR on arresting, and was an abnormally fit 72 year old. It remains to be seen whether this procedure can be applied to other patients in cardiac arrest. The authors state:

..until ECLS is readily available, poor survival and neurological outcome after cardiac arrest might be avoided in many patients by the use of pLVAD to offload the LV and enhance perfusion. Furthermore, there may be a subset of patients, in whom the support that pLVAD offers is sufficient to optimize hemodynamic parameters and bridge to ROSC, thus reducing the need for ECLS.

This video by Dr. I-Wen Wang from the Barnes-Jewish Hospital explains how the Impella is inserted and how it works.

 

 

Full Neurologic Recovery and Return of Spontaneous Circulation Following Prolonged Cardiac Arrest Facilitated by Percutaneous Left Ventricular Assist Device
Ther Hypothermia Temp Manag. 2014 Sep 3. [Epub ahead of print]


Sudden cardiac arrest is associated with high early mortality, which is largely related to postcardiac arrest syndrome characterized by an acute but often transient decrease in left ventricular (LV) function. The stunned LV provides poor cardiac output, which compounds the initial global insult from hypoperfusion. If employed early, an LV assist device (LVAD) may improve survival and neurologic outcome; however, traditional methods of augmenting LV function have significant drawbacks, limiting their usefulness in the periarrest period. Full cardiac support with cardiopulmonary bypass is not always readily available but is increasingly being studied as a tool to intensify resuscitation. There have been no controlled trials studying the early use of percutaneous LVADs (pLVADs) in pericardiac arrest patients or intra-arrest as a bridge to return of spontaneous circulation. This article presents a case study and discussion of a patient who arrested while undergoing an elective coronary angioplasty and suffered prolonged cardiopulmonary resuscitation. During resuscitation, treatment included placement of a pLVAD and initiation of therapeutic hypothermia. The patient made a rapid and full recovery.
Image is of M. Joshua Morris, a happy LVAD recipient (not the patient in the described study) who kindly alerted me to this article. Used with permission.

ARISE study: EGDT no better than standard care

October 4, 2014 by  
Filed under Acute Med, All Updates, Guidelines, ICU, Resus

Comments Off

periph-vasoactive-iconThe second of three major trials assessing early goal directed therapy (EGDT) in sepsis – the Australasian ARISE Trial – has been published.

ARISE tested the hypothesis that EGDT, as compared with usual care, would decrease 90-day all-cause mortality among patients presenting to the emergency department with early septic shock in diverse health care settings.

There was no difference in all-cause mortality at 90 days between EGDT and standard care, in keeping with the results from ProCESS.

Why are the results so different from Rivers’ original EGDT study? The authors explain:


“although our results differ from those in the original trial, they are consistent with previous studies showing that bias in small, single-center trials may lead to inflated effect sizes”

This cautions us all against making major practice changes based on one single centre study. In critical care we’ve learned this before with subjects like tight glycaemic control and Activated Protein C. However I do believe that the things we know to be of benefit – early recognition, source control, antibiotics, and fluids – are effective in making ‘standard’ care “as good as” EGDT because of heightened awareness of the condition and its treatment, and Rivers’ initial study and the subsequent Surviving Sepsis Campaign Guidelines have played a major role in raising that awareness.

The ARISE study is appraised by Wessex’s The Bottom Line and discussed on the one and only EMCrit podcast.

The ARISE Investigators and the ANZICS Clinical Trials Group.
Goal-Directed Resuscitation for Patients with Early Septic Shock
N Engl J Med. 2014 Oct;:141001063014008.Full Text


Background
Early goal-directed therapy (EGDT) has been endorsed in the guidelines of the Surviving Sepsis Campaign as a key strategy to decrease mortality among patients presenting to the emergency department with septic shock. However, its effectiveness is uncertain.

Methods In this trial conducted at 51 centers (mostly in Australia or New Zealand), we randomly assigned patients presenting to the emergency department with early septic shock to receive either EGDT or usual care. The primary outcome was all-cause mortality within 90 days after randomization.

Results Of the 1600 enrolled patients, 796 were assigned to the EGDT group and 804 to the usual-care group. Primary outcome data were available for more than 99% of the patients. Patients in the EGDT group received a larger mean (±SD) volume of intravenous fluids in the first 6 hours after randomization than did those in the usual-care group (1964±1415 ml vs. 1713±1401 ml) and were more likely to receive vasopressor infusions (66.6% vs. 57.8%), red-cell transfusions (13.6% vs. 7.0%), and dobutamine (15.4% vs. 2.6%) (P<0.001 for all comparisons). At 90 days after randomization, 147 deaths had occurred in the EGDT group and 150 had occurred in the usual-care group, for rates of death of 18.6% and 18.8%, respectively (absolute risk difference with EGDT vs. usual care, -0.3 percentage points; 95% confidence interval, -4.1 to 3.6; P=0.90). There was no significant difference in survival time, in-hospital mortality, duration of organ support, or length of hospital stay.

Conclusions In critically ill patients presenting to the emergency department with early septic shock, EGDT did not reduce all-cause mortality at 90 days.

Non-ST-Elevation Acute Coronary Syndromes

September 29, 2014 by  
Filed under Acute Med, All Updates, EMS, Guidelines, ICU, Resus

Comments Off

The latest AHA/ACC guidelines on NSTEACS have been published ahead of print in Circulation.

Full text is available, and the Executive Summary is available here

Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, et al.
2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation. 2014 Sep 23. [Epub ahead of print]

Blunt traumatic arrest in kids

September 24, 2014 by  
Filed under All Updates, EMS, Kids, Resus, Trauma

Comments Off

Traumatic cardiac arrest outcomes are not great, but they’re not so bad that resuscitation is futile – a subject I’ve ranted about before.

The largest study on blunt traumatic arrest in children to date has been published, showing that 340 / 7766 kids without signs of life in the field survived to hospital discharge. Neurological status at discharge was not documented. However, this represents 4.4%, or in other words for every 22 blunt traumatically arrested children who underwent prehospital resuscitation, one survived to discharge. The authors describe this survival as ‘dismal’. It’s not great, but my take on it is that survival is possible and in most cases resuscitation should be attempted.

The authors state:

Based on these data, EMS providers should not be discouraged from resuscitating blunt pediatric trauma patients found in the field with no signs of life

While the major focus should be on injury prevention, it is worthwhile considering whether more advanced resuscitation in the field could be provided to further increase the number of neurologically intact survivors.

Survival of pediatric blunt trauma patients presenting with no signs of life in the field
J Trauma Acute Care Surg. 2014 Sep;77(3):422-6


BACKGROUND: Prehospital traumatic cardiopulmonary arrest is associated with dismal prognosis, and patients rarely survive to hospital discharge. Recently established guidelines do not apply to the pediatric population because of paucity of data. The study objective was to determine the survival of pediatric patients presenting in the field with no signs of life after blunt trauma.

METHODS: We conducted a retrospective analysis of the National Trauma Data Bank research data set (2002-2010). All patients 18 years and younger with blunt traumatic injuries were identified (DRG International Classification of Diseases-9th Rev. codes 800-869). No signs of life (SOL) was defined on physical examination findings and included the following: pulse, 0; respiratory rate, 0; systolic blood pressure, 0; and no evidence of neurologic activity. These same criteria were reassessed on arrival at the emergency department (ED). Furthermore, we examined patients presenting to the ED who underwent resuscitative thoracotomy (Current Procedural Terminology code 34.02). Our primary outcome was survival to discharge from the hospital.

RESULTS: There were a total of 3,115,597 pediatric patients who were found in the field after experiencing blunt trauma. Of those, 7,766 (0.25%) had no SOL. Seventy percent of the patients with no SOL in the field were male. Survival to hospital discharge of all patients presenting with no SOL was 4.4% (n = 340). Twenty-five percent of the patients in the field with no SOL were successfully resuscitated in the field and regained SOL by the time they arrived to the ED (n = 1,913). Of those patients who regained SOL, 13.8% (n = 265) survived to hospital discharge. For patients in the field with no SOL, survival to discharge was significantly higher in patients who did not receive a resuscitative thoracotomy than in those who did.

CONCLUSION: Survival of pediatric blunt trauma patients in the field without SOL is dismal. Resuscitative thoracotomy poses a heightened risk of blood-borne pathogen exposure to involved health care workers and is associated with a significantly lower survival rate.

Resuscitationist lessons from a self-protection master

August 28, 2014 by  
Filed under All Updates, Fascinomata, Resus

UCIt’s better to have it and not need it, than to need it and not have it

My great friend and fellow Brit Lee Morrison is in Sydney again, teaching people how to save lives. Like a resuscitationist. But Lee isn’t a health care worker. He is a professional self protection instructor and martial athlete. The lives he is teaching people to save are their own and those of their friends and families. Lee has travelled the world and taught a diverse range of professionals including law enforcement and military special forces personnel. His current world tour will include the Czech Republic, USA, France, Russia and Germany after Australia.

What does this have to do with resuscitation? In my experience, almost everything. Hitting someone in self defence is technically very easy. Doing a resuscitative hysterotomy is technically very easy. Being able to do either of those things under stress can be difficult or impossible for some people.

Those who strive to understand and cultivate the Mind of the Resuscitationist know the importance of preparation through simulation under stress; the need to acknowledge and control the physiological and emotional response to stress; the necessity to train outside ones comfort zone and minimise the gap between simulated and real situations by optimising the cognitive fidelity of training scenarios; and the requirement to access the right mental state in an instant in which failure is not considered to be an option.

People who do not wish to witness the discussion or demonstration of violence or who cannot stand swearing should stop now. Those of you who want to see mastery in action watch the video below of Lee teaching in Germany.

I want you to appreciate the following:

  • Presentation style – how to connect with an audience and fully engage them through humour, passion, emphasis, intelligent discourse, and detailed explanations that connect emotionally and physically as well as intellectually.
  • The loss of fine motor skill under stress (2 min 13 sec)
  • The mindset of determination (2 min 48 sec) – consider how this relates to the perspective of the resuscitationist prepared to do a resuscitative thoracotomy under stress
  • How to influence and win arguments in a conflict situation by being assertive but providing a face-saving get-out for the aggressor. I have applied this multiple times in the resus room and in retrieval situations. (4 min 11 sec)
  • Training honestly – maintaining safety but ‘doing it like you f—-ing mean it’. Get out of your comfort zone and make the discomfort as real as possible. (7 min 37 sec)
  • How to minimise the gap between your training and what you’re training for, when legal, moral, and safety restrictions prevent you from doing the actual task for real as a training exercise. Using fatigue, pain, and disorientation as perturbations so you learn to recognise and mitigate their effects. (9 min 19 sec)
  • Accessing a single mental state that provides focus and prevents distraction from discomfort (11 min 40 sec)

If the video made you feel uncomfortable ask yourself why. If it’s because you consider yourself to be above violence and find the subject matter, language, and humour to be distasteful, that’s your right to feel like that. But try to dig a little deeper and ask yourself whether there are potential situations in your life that could confront you with fear or pain that you could be better prepared for if you trained with a different mindset.

When the situation arises that demands life-saving action and you are tired, hungry, scared, and discouraged by opposing advice or opinion, do you have the self-knowledge and resilience to see it through? If you don’t know the answer to that, isn’t it time you found out?

You can find out more about Lee at Urban Combatives

Hexagonal storm on Saturn’s North Pole

August 11, 2014 by  
Filed under All Updates, Fascinomata

Comments Off

Our solar system is amazing and beautiful and the wondrous discoveries continue. Watch this video from the NY Times on Saturn’s northern storm, shaped like a hexagon and larger than Earth:

This line from the video is inspiring:

Rings of ice, in a dancing ribbon of Aurora, sitting smack on top of a six-sided hurricaine. Another jewel in the crown of the solar system’s most photogenic planet.

 

Not Your Average Conference

August 3, 2014 by  
Filed under All Updates

Comments Off

DevEM2014

An amazing conference program, amazing speakers, in an amazing part of the world:

Imagine a line-up that includes FOAM Master Joe Lex and Matt & Mike from the Ultrasound Podcast, and it isn’t even a SMACC event!

I wish I was going, but I already committed to speaking at a great conference elsewhere!

Listen to organisers Mark and Lee talk about this and last year’s fantastic DevelopingEM conference in Cuba:

Here Mark and Lee explain how it works and what to expect:

After the success of our last two conferences in Sydney and Havana we’re taking the DevelopingEM concept to Brazil where Emergency Medicine is quickly evolving as a new specialty.

Our core focus remains the provision of high quality clinically relevant critical care information and with an expanded program and the addition of Sambafest, a 2 day Ultrasound Workshop, run by the team at Ultrasound Podcast, we think this will be our best conference to date.

With an expanded program covering Adult Emergency Medicine and Critical Care, Paediatrics, Trauma, Global Health, Emergency Medicine in Brazil, a LLSA session covering a review of EM and Critical Care Literature and a unique Communication and De-escalation workshop we’re sure there’s something for everyone in our program.

Our 42 hours of education is accredited by ACEM and ACRRM and DevelopingEM is endorsed by IFEM and supported by ASEM so time will be a valuable addition to your yearly continuing professional development.

We’re also repeating the highly successful local delegate sponsorship system that allowed 65 Cubans clinicians to attend DevelopingEM 2013 free of charge. With our connections in the Brazilian Association of Emergency Medicine (ABRAMEDE), presentations on Emergency Medicine in Brazil by some of the leading EM practititioners in Brazil and continuous real time translation of presentations we hope to once again have a distinct local flavour to DevelopingEM 2014.

We have maintained our not for profit financially unsponsored model so you know your education will be untainted ’cause we know you like it that way.

 

Check out the program and register here

These guys are my prehospital & retrieval medicine colleagues and run the DevelopingEM project in a not-for-profit capacity. I have no financial interest in this or any other conference.

Next Page »