Top 10 papers for trauma uk conference. widescreen version copy
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Paper review for the trauma care UK conference 2017
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Top 10 papers for trauma uk conference. widescreen version copy
- 3. 2 Minutes
- 7. 48% vs 26.9% survival
- 8. Of 100 patients 22 more survivors 8 in vegetative state 8 severe disability 8 moderate disability 0 more good outcomes
- 15. 5475 patients Mortality 22% vs. 25%
- 16. Cut or Push in TCA?
- 17. ETCO2?
- 18. six vs roc for TBI
- 19. six vs roc for TBI Mortality in severe injury 44% vs. 23%
- 20. location of needle for decompression
- 23. needle length obese patients
- 26. weekend mortality effect There isn’t not (for trauma)
- 29. IBA is real Brain Surgery is good for survival …but it may be bad for disability TCA is rare and as important as MCA Think again about thoracotomy Don’t sweat about WBCT Roc might be better Anterior axillary line prob best If big go yellow There is no weekend effect for trauma
Notas del editor
- The RESCUE-ICP4 trial looked at the use of the use of decompressive craniotomy for patients with refractory intracranial hypertension post head injury. They only got into the trial if levelk 1 and 2 treatments had failed (and interestingly that included hypothermia in some - and we know that does not work5). It was a trial I was vaguely involved in in the past and although conducted in 20 countries, 71% of patients were recruited here in the UK. Unsurprisingly the 408 patients randomised were largely young men with diffuse injury accounting for 2/3rds of patients. The results of this trial have been really quite controversial and I'm sure your interpretation will have more to do with your personal values than the numbers. In brief there was a clear survival advantage to craniotomy with 48.9% of patients surviving vs. 26.9%. However, there was no improvement in good outcomes. All the patients who would otherwise would have died were left with disability. Our fabulous friends at thebottomline have crunched the numbers and shown that for every 100 patients treated with craniotomy you would expect 22 more survivors, 6 would be in a vegetitive state, 8 would have a lower severe disability and 8 would have an upper severe disability or better (on GOS-E scale6). So the question is, should we swap death for disability, and in many cases severe disability. These are tough ethical questions and it's far from clear whether we know who best to offer this therapy.
- The RESCUE-ICP4 trial looked at the use of the use of decompressive craniotomy for patients with refractory intracranial hypertension post head injury. They only got into the trial if levelk 1 and 2 treatments had failed (and interestingly that included hypothermia in some - and we know that does not work5). It was a trial I was vaguely involved in in the past and although conducted in 20 countries, 71% of patients were recruited here in the UK. Unsurprisingly the 408 patients randomised were largely young men with diffuse injury accounting for 2/3rds of patients. The results of this trial have been really quite controversial and I'm sure your interpretation will have more to do with your personal values than the numbers. In brief there was a clear survival advantage to craniotomy with 48.9% of patients surviving vs. 26.9%. However, there was no improvement in good outcomes. All the patients who would otherwise would have died were left with disability. Our fabulous friends at thebottomline have crunched the numbers and shown that for every 100 patients treated with craniotomy you would expect 22 more survivors, 6 would be in a vegetitive state, 8 would have a lower severe disability and 8 would have an upper severe disability or better (on GOS-E scale6). So the question is, should we swap death for disability, and in many cases severe disability. These are tough ethical questions and it's far from clear whether we know who best to offer this therapy.
- The STITCH trial7 is a randomised controlled trial of initially conservative management of patients with intracranial traumatic bleeds. The patients were those where the treating clinician was in equipoise about whether a craniotomy was indicated or not. Patients were randomised either to early surgery (within 12 hours) or conservative management. The trial was sadly stopped early because of recruitment issues, but an analysis of the available data showed a non statistically significant benefit in terms of Glasgow Outcome Score for early surgery (10.5% so an NNT of 10) at 6 months. The secondary outcome of mortality was better with an 18% difference and this did reach statistical signifance and an NNT of 6 (though wide confidence intervals on this). However, like the RESCUE-ICP trial there was little improvement in patients with a good outcome. All the additional survivors were left with disability (though less severe than in RESCUE-ICP). It's a great shame this trial was stopped early, that there were changes to the protocol as it ran and that many patients did not receive treatment as randomised. It looks as though we might have to do this again, BUT it does tell us that conservative management may not be as safe as some (in my experience) referrals to neurosurgery suggest!
- More survivors but they are dependent survivors. No increase in good survival. Question of ethics.
- UK Traumatic Cardiac Arrest stats8 are up next with an excellent review of the epidemiology and outcomes here in the UK. Ed Barnard and colleagues have put together a great paper using the TARN database from 2009-2015. In that period 705 patients out of 227,944 on the database had a traumatic cardiac arrest with an overall 30-day survival of 7.5%. Interestingly the success rate of survival prehospital was greater than that in hospital (not sure why) and no patients survived who were in cardiac arrest at scene and in the ED. These stats can look pretty depressing but it's not a million miles away from the success rates of medical causes of cardiac arrest. There may well be a question of inclusion bias in this study as some prehospital cardiac arrests won't make it into the TARN database but despite this it's fair to say that we should be aggressive in our management of these patients.
- “Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial” http://www.ncbi.nlm.nih.gov/pubmed/27371185
- “Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial” http://www.ncbi.nlm.nih.gov/pubmed/27371185 The key point about this study is that although the radiation dose was smaller it was pretty much insignificantly so.
- In terms of what to do, then controversy exists about whether closed chest compressions are effective in traumatic cardiac arrest. The logic is that if the heart is empty and/or there are bits of broken rib/chest around then there is no point and indeed a likelihood of harm. Looking at the stats above one suspects that an RCT is not going to happen anytime soon (too few patients) and so we must use wisdom and observational data to decide what to do. Here at St.Emlyn's we've advocated thoracotomy and direct cardiac massage for traumatic cardiac arrest9, but a paper in the Journal of Trauma questions this. In an observational study in a US level 1 trauma centre researchers used ETCO2 to determine the effectiveness of closed vs open cardiac massage. ETCO2 is a widely used marker of CPR effectiveness and interestingly the authors found no difference, and no difference in survivors either. So what should we do? I suspect we should carry on as we are, onthe basis of the pathophysiological arguments until something better comes along. As Rich Carden suggests on the St.Emlyn's blog, that may be REBOA, but we don't really have the evidence for that either as yet!
- If you want to start a fight on Twitter then mention something about emergency RSIs..... a whole plethora of opinions will gush forth and to be honest most of it is just that, opinion. I've gotten a little bored of it at times, but that does not stop the St.Emlyn's team looking out for any evidence that can help us make better decisions about issues such as drug choice. A regular 'firestarter' issues is the Roc vs Sux debate. You will no doubt have heard the phrase 'Roc Rocks, Sux Sucks'... well maybe. We could do with some evidence and there is some out there on BestBets10 , Cochrane11 and #FOAMed sites12,13 Unsurprisingly they all sort of disagree with each other. There are no fabulous RCTs out there and so we have to look at observational data such as this paper reviewed by Swami from Pantawala in the US14. It is observational but in 260 patients with traumatic brain injury they saw a signficant difference in mortality amongst those with severe head injury (44% vs 23%). It's interesting and will get the Roc fans excited, but in all honesty, and even though there is a plausible pathophysiological mechanism, this may well just be association rather than causation.
- If you want to start a fight on Twitter then mention something about emergency RSIs..... a whole plethora of opinions will gush forth and to be honest most of it is just that, opinion. I've gotten a little bored of it at times, but that does not stop the St.Emlyn's team looking out for any evidence that can help us make better decisions about issues such as drug choice. A regular 'firestarter' issues is the Roc vs Sux debate. You will no doubt have heard the phrase 'Roc Rocks, Sux Sucks'... well maybe. We could do with some evidence and there is some out there on BestBets10 , Cochrane11 and #FOAMed sites12,13 Unsurprisingly they all sort of disagree with each other. There are no fabulous RCTs out there and so we have to look at observational data such as this paper reviewed by Swami from Pantawala in the US14. It is observational but in 260 patients with traumatic brain injury they saw a signficant difference in mortality amongst those with severe head injury (44% vs 23%). It's interesting and will get the Roc fans excited, but in all honesty, and even though there is a plausible pathophysiological mechanism, this may well just be association rather than causation.
- On a similar theme debates about the 'right' location for the decompression of tension pneumothoraces has raged for years. Personally my approach is to find a needle big enough to reach the pleural cavity and to just go for it, though I recognise that's a little unscientific. A number of trials have been published on this and so it is good to see a collation of them in a systematic review and meta-analysis on this in 201616. Overall we have 34.642 patients to look at with 15 studies examining chest wall thickness and 13 looking at the effectiveness of needle thoracostomy at mid clavicular line, anterior axillary line and mid axillary line. The bottom line is that you are least likely to fail in the anterior axillary line (13% for AAl, 31% for MAL, 38% for MCL). For me it was also fairly sobering to read the complication rates from this technique which are as high as 9%, maybe the big needle and a good strong arm technique is not so wise after all. Read a more detailed review from Salim here17.
- If you're working in the UK or US then you will know that Bariatric trauma is a real issue. The larger patient can present problems in assessment and management and it's something we are seeing more frequently. It even affects our ability to do procedures due to a change in body size. Access to the chest is a notable problem, as it's notably easier to get a chest drain in a skinny male than a very large female, I'm not making any judgements here, it just is. Similarly getting access using the Intra-osseous route can also be challenging. Swami (on the REBELEM site) found an interesting paper15 this year looking at exactly this which shows that as your patient approaches a BMI of 43, or you can't feel the tibial tuberosity then a standard 25mm (blue) IO may not be adequate and you should reach for the 45mm (yellow) one.
- Lastly, and because the conference is being held on the Friday I think it's appropriate for us to have a look at the weekend effect in major trauma.Unless you've been living under a rock then you will know that the idea of a 'weekend effect', in that you are more likely to die if admitted during the weekend is somewhat controversial. What about trauma patients though? Is there an effect for those patients with severe injury? David Metcalfe and colleagues looked across 22 UK major trauma centres and found no difference in mortality irrespective of whether the patient is admitted at night or during the day18. This was leapt upon by the more politically minded as evidence that there is no weekend effect for any patients, arguably that's not the case, and may be precisely the opposite. Trauma centres have been designed to deliver 24 hour cover, 7 days a week. In Virchester it now means that as a consultant I am resident on call and respond to all trauma patients within 10 minutes of arrival. Perhaps this paper tells us that if you have a well resourced system, with consultant involvement (from all specialities) early in the disease process then you get better outcomes. So watch this space for all our emergency care, not just trauma, perhaps the revelation is that if you fund and support an urgent care system things get better..... now who could possibly have believed that!
- Lastly, and because the conference is being held on the Friday I think it's appropriate for us to have a look at the weekend effect in major trauma.Unless you've been living under a rock then you will know that the idea of a 'weekend effect', in that you are more likely to die if admitted during the weekend is somewhat controversial. What about trauma patients though? Is there an effect for those patients with severe injury? David Metcalfe and colleagues looked across 22 UK major trauma centres and found no difference in mortality irrespective of whether the patient is admitted at night or during the day18. This was leapt upon by the more politically minded as evidence that there is no weekend effect for any patients, arguably that's not the case, and may be precisely the opposite. Trauma centres have been designed to deliver 24 hour cover, 7 days a week. In Virchester it now means that as a consultant I am resident on call and respond to all trauma patients within 10 minutes of arrival. Perhaps this paper tells us that if you have a well resourced system, with consultant involvement (from all specialities) early in the disease process then you get better outcomes. So watch this space for all our emergency care, not just trauma, perhaps the revelation is that if you fund and support an urgent care system things get better..... now who could possibly have believed that!
- In this somewhat bizarre study researchers used a coagulation model by diluting whole blood with saline