Background: Alcohol and drug intoxication is common in trauma patients and a significant proportion of cervical spine (c-spine) injuries occur in patients with intoxication. A standard approach to both intoxicated and sober patients with suspected c-spine injury in many trauma centers includes the placement of a rigid cervical collar for spinal immobilization until the c-spine can be “cleared.” Even after a negative CT, intoxicated patients often are immobilized for prolonged periods of time until a reliable exam can be performed due to concern for missed findings on CT scan, specifically unstable ligamentous injuries. This practice is less than ideal, as prolonged c-spine immobilization is associated with DVT, atelectasis, aspiration pneumonia, and elevated intracranial pressures. In 2015, the Eastern Association for the Surgery of Trauma (EAST) demonstrated that CT imaging of obtunded patients due to any cause would miss approximately 9% of cervical spine injuries, most of which are clinically insignificant. They additionally found no benefit to prolonged immobilization. Read more →
Tag Archive for: Trauma
Background: Etomidate and ketamine are both routinely used as induction agents during rapid sequence intubation (RSI) in trauma patients. It is well established that etomidate transiently suppresses the adrenal gland through inhibition of the 11-beta hydroxylase enzyme. Though adrenal suppression in theory can cause deleterious outcomes, there is no high-quality evidence demonstrating a change in patient centered outcomes with it’s use in comparison to alternate agents. Ketamine has long been an alternative induction agent to etomidate but historical concerns, though disproven in more recent literature, limited it’s use due to concerns over increasing intracranial pressure. Read more →
Background: Currently the Advanced Trauma Life Support (ATLS) guidelines recommend initial treatment of decompression of a tension pneumothorax, as needle thoracostomy (NT) using a 5cm angiocatheter at the 2nd intercostal space (ICS2) in the mid clavicular line (MCL). With the growth of size in our population worldwide, there has been increasing evidence about two things:
- A 5cm angiocatheter may not be long enough to reach the pleural space
- The 2nd intercostal space at the mid clavicular line (ICS2-MCL) may not be the ideal location for needle decompression
“I’ve been in this game for years, it made me an animal
There’s rules to this sh*t; I wrote me a manual”
— Notorious BIG
You know, whether you sling crack rocks or not, there are some sage words of wisdom in the late Notorious BIG’s Ten Crack Commandments. Life pearls like “Never let ‘em know your next move” and “Never keep no weight on you” have helped guide me through some challenging life decisions.
1. Never let no one know how much dough you hold
2. Never let ‘em know your next move
3. Never trust nobody
4. Never get high on your own supply
5. Never sell no crack where you rest at
6. That Goddamn credit, forget it
7. Keep your family and business completely separated
8. Never keep no weight on you
9. If you ain’t getting bags stay the f*ck from police
10. A strong word called consignment; If you ain’t got the clientele say hell no
Table 1. The ten crack commandments.
While not much is new in the world of hustlin’, when it comes to trauma resuscitation, the game done changed*. It was easier in the old days: 2L of crystalloid for a hypotensive patient, and then blood. While new science on trauma resuscitation has helped us understand how flawed that paradigm is, the new school can be some tricky water to navigate. From damage control to fibrinogen, from TXA to thromboelastometry, there is no doubt that resuscitating a bleeding trauma patient is a more nuanced endeavor than we originally envisioned it.
So, inspired by Biggie’s Descartesian ten-point discourse on method, I present the ten rules of the contemporary trauma resuscitation game as I see them – backed by science, and occasionally editorialized with personal opinion.
In the United States, trauma is the leading cause of death among patients between the ages of 1 and 44 years of age and the third leading cause of death overall. Approximately 20 to 40% of trauma deaths occur after hospital admission and are a result of massive hemorrhage. There have been no large, multi-center, randomized clinical trials with survival as a primary end point that support optimal trauma resuscitation practices with approved blood products and therefore there are many conflicting recommendations. The Prosective Observational Multicenter Major Trauma Transfusion (PROMMT) Trial demonstrated that many clinicians were transfusing patients with blood products in a ratio of 1:1:1 or 1:1:2 and that early transfusion of plasma was associated with improved 6-hour survival after admission.
The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial was designed to address the effectiveness and safety of 1:1:1 transfusion ratio vs 1:1:2 in patients with trauma who were predicted to receive a massive transfusion.