Assessing the prediction of arterial CO2 from end tidal CO2 in adult blunt trauma patients.

BACKGROUND: The control of PaCO2 in ventilated patients is known to be of particular importance in the management and prognosis of trauma patients. Although EtCO2 is often used as a continuous, non-invasive, surrogate marker for PaCO2 in ventilated trauma patients in the emergency department (ED), previous studies suggest a poor correlation in this cohort. However, previous data has predominantly been collected retrospectively, raising the possibility that the elapsed time between PaCO2 sampling and EtCO2 recording may contribute to the poor correlation. As such this study aimed to analyse the correlation of PaCO2 to EtCO2 in the ventilated blunt trauma patient presenting to the ED through contemporaneous sampling. METHODS: This study was conducted as a prospective observational study analysing the near simultaneous recording of EtCO2 and Arterial Blood Gas sampling of ventilated adult trauma patients in the ED of a Level 1 trauma centre over a 12-month period. Data was analysed using linear regression and subgroup analysis by Injury Severity Score (ISS) and Abbreviated Injury Score (AIS) of the Chest. RESULTS: Linear regression of EtCO2 vs PaCO2 demonstrated a moderate correlation with r = 0.54 (p < 0.01, n = 51, 95 % CI 0.31-0.71). Subgroup analysis by ISS, revealed a stronger correlation in those with minor ISS (0-11) (r = 0.76, p < 0.01, n = 13, 95 % CI 0.36-0.92) compared to those more severely injured patients (ISS > 15) (r = 0.44, P < 0.01, n = 38, 95 % CI 0.14-0.67). Analysis by AIS Chest demonstrated similar correlation between patients without chest injuries (AIS 0) (r = 0.55, n = 29, p < 0.01, 95 % CI 0.23-0.76) and those with an AIS >1 (r = 0.51, n = 22, p = 0.02, 95 % CI 0.11-0.77). In patients with traumatic head injuries who had an EtCO2 between 30 and 39 mmHg, only 57 % had a measured PaCO2 within 5 mmHg. CONCLUSIONS: As patients transition from minor to seriously injured, a decreasing strength of PaCO2 to EtCO2 correlation is observed, decreasing the reliability of EtCO2 as a surrogate marker of PaCO2 in this patient group. This inconsistency cannot be accounted for by the presence of chest injuries and worryingly is frequently seen in those with traumatic brain injuries.

Increased distance or time from a major trauma centre in South Australia is not associated with worse outcomes after moderate to severe traumatic brain injury.

OBJECTIVE: Considerations in traumatic brain injury (TBI) management include time to critical interventions and neurosurgical care, which can be influenced by the geographical location of injury. In Australia, these distances can be vast with varying degrees of first-responder experience. The present study aimed to evaluate the association that distance and/or time to a major trauma centre (MTC) had on patient outcomes with moderate to severe TBI. METHODS: A retrospective cohort study was conducted using data from the Royal Adelaide Hospital's (RAH) Trauma Registry over a 3-year period (1 January 2018 to 31 December 2020). All patients with a moderate to severe TBI (Glasgow Coma Scale [GCS] ≤13 and abbreviated injury score head of ≥2) were included. The association of distance and time to the RAH and patient outcomes were compared by calculating the odds ratio utilising a logistic regression model. RESULTS: A total of 378 patients were identified; of these, 226 met inclusion criteria and comprised our study cohort. Most patients were male (79%), injured in a major city (55%), with median age of 38 years old and median injury severity score (ISS) of 25. After controlling for age, ISS, ED GCS on arrival and pre-MTC intubation, increasing distance or time from injury site to the RAH was not shown to be associated with mortality or discharge destination in any of the models investigated. CONCLUSION: Our analysis revealed that increasing distance or time from injury site to a MTC for patients with moderate to severe TBI was not significantly associated with adverse patient outcomes.

Longer times in computed tomography for trauma patients result in a decrease in body temperature.

OBJECTIVE: To determine if lower ambient temperatures in computed tomography (CT) rooms contribute to accidental hypothermia (≤35°C) in trauma patients. METHODS: Prospective, observational study of trauma patients undergoing a CT scan at the Royal Adelaide Hospital. RESULTS: Among a cohort of 81 trauma patients, 54 met level 1 call-out criteria. Mean time in CT was 11 min. Longer time spent in CT contributes to greater decrease in body temperature (∆T/t = -0.1483°C/min, P = 0.0026). CONCLUSION: Increasing time spent in CT leads to a decrease in body temperature in trauma patients. Clinicians should actively reduce time spent in the CT room and take active warming measures.

Introduction of point-of-care ROTEM testing in the emergency department of an Australian level 1 trauma centre and its effect on blood product use.

OBJECTIVE: To assess whether the introduction of point-of-care rotational thromboelastometry (ROTEM) analysis influences blood product transfusion and coagulation management in a modern Australian level 1 trauma centre. METHODS: Retrospective blood transfusion data collection from all level 1 trauma patients with an Injury Severity Score (ISS) >12 presenting to the Royal Adelaide Hospital in 2016 and 2018. Evaluation of changes in blood product administration with the addition of point-of-care viscoelastic testing in the ED in 2018. RESULTS: A total of 774 patients were analysed with 380 in 2016 and 394 in 2018. Almost a quarter of all 2018 trauma patients (93/394) had ROTEM performed within 24 h of ED arrival, 42% of these having an ISS >25. There was a significant increase in the number of patients receiving cryoprecipitate following the introduction of ROTEM (P = 0.01). In those receiving cryoprecipitate, there was a significant reduction in subsequent platelet and fresh frozen plasma use (P < 0.001). Overall, there was a reduction in expenditure on red cells, platelets and fresh frozen plasma from 2016 to 2018. CONCLUSION: Point-of-care ROTEM was performed in a small proportion of patients, mainly those with a higher ISS. ROTEM introduction in the ED altered blood product transfusion practices for major trauma patients with an ISS >12, leading to a potentially safer transfusion strategy and cost savings for key blood products.

Acute traumatic coagulopathy and the relationship to prehospital care and on-scene red blood cell transfusion.

OBJECTIVE: To identify the incidence of acute traumatic coagulopathy (ATC) in trauma patients presenting to the Royal Adelaide Hospital, analyse prehospital contributors, including red blood cell transfusion and assess the clinical significance of ATC. METHODS: A retrospective database review was undertaken using conventional coagulation assays and viscoelastic testing (ROTEM) for diagnosis of ATC. RESULTS: Baseline ATC incidence is 10% in trauma patients, increasing to over 80% among those where the prehospital team has attended and given a transfusion of red cells. ATC was significantly associated with higher severity of trauma (odds ratio [OR] 1.11, P < 0.0001), prehospital (OR 11.8, P < 0.0001) and in-hospital blood transfusions (OR 17.9, P < 0.0001), and massive transfusions (P < 0.001). CONCLUSIONS: Prehospital blood transfusions are given to the most severely injured trauma patients and the incidence of ATC in this group is more than 80%. There is an association with prehospital blood transfusion and increased ATC in part related to patient selection and severity of trauma, with the contribution of red cell transfusions to ATC unclear. This association should allow earlier identification of patients at increased risk of ATC to ensure rapid correction of coagulopathy to decrease the morbidity and mortality of trauma.

Impact of COVID-19 social restrictions on trauma presentations in South Australia.

OBJECTIVE: To review the impact of COVID-19 social restrictions on trauma presentations in South Australia. METHODS: Retrospective database review. RESULTS: During the period of social restrictions, there was a reduction in presentations of trauma and major trauma by 17% and 33%, respectively. The reduction in presentation rates was due to a large decrease in those aged over 40, with an increase in presentations in those younger than 40. Review by mechanism and location of injury revealed a reduction in road trauma, yet an increase in pedestrian trauma and trauma at home. CONCLUSION: Social restrictions alter the characteristics of trauma presentations.

Ketamine reduces the need for intubation in patients with acute severe mental illness and agitation requiring transport to definitive care: An observational study.

OBJECTIVES: The aim of this study was to review mental health patients transported by a dedicated statewide critical care retrieval team before and after the implementation of a ketamine sedation guideline. METHODS: This is a a retrospective cohort study of mental health patients with acute behavioural disturbance, transported between January 2010 and December 2015. RESULTS: A total of 78 patients were transported in the study period, 50 before and 28 after implementation of the ketamine guideline in June 2013. The introduction of the ketamine guideline was associated with a significant reduction in intubation for transport (36.00 vs 7.14%) (odds ratio 0.14, 95% confidence interval 0.02-0.71, P < 0.01). The likelihood of utilising ketamine for non-intubated patients (n = 58) was higher in the period after implementation (37.50 vs 84.62%, odds ratio 9.17, 95% confidence interval 2.54-33.08, P < 0.005). The incidence of complications in our series was low. CONCLUSIONS: The implementation of a ketamine clinical practice guideline for agitated mental health patients was associated with an increase in the number of patients receiving ketamine as part of their sedation regime and a reduction in the number of patients requiring intubation for transport. Appropriately trained critical care retrieval teams should consider ketamine as part of the sedation regime for agitated mental health patients.

Aeromedical transfer to reduce delay in primary angioplasty.

BACKGROUND: Aeromedical transfer can reduce transfer times for primary percutaneous coronary intervention (PPCI). Delays in dispatch of the helicopter and landing-reperfusion can reduce the benefits of air travel. The ad hoc nature of these transfers may compound delays. A formal aeromedical transfer service, with rapid dispatch protocols and rapid landing to balloon times could significantly reduce reperfusion times. METHODS: A standard operating procedure (SOP) was developed using a field assessment team (doctor, aircrew paramedic) and a cardiologist-led multidisciplinary team meeting the incoming aircraft. The aeromedical SOP for STEMI care was implemented when anticipated land journey >30 min to the nearest PPCI centre. Reperfusion times for actual air travel and estimated virtual land journeys from the same location were compared. RESULTS: Between April and December 2009, 8 patients were managed according to the aeromedical SOP. Median air distance 49 miles and road, 40 miles. All subsequent data shown in median minutes (range). Call-balloon time 109 (97-116). Call-aeromedical activation 13 (9-26). Aeromedical activation-arrive scene 12 (9-16). Time at scene 29 (24-52). Call-depart scene 57 (45-75). Air journey 25 (18-30) and landing-balloon 21 (8-22). Call-arrive at PPCI centre for air 85 (70-95); estimated virtual road call-arrive at PPCI centre 102 (85-104). CONCLUSIONS: This SOP delivered sub 120 min call-balloon times in all cases undergoing PPCI from difficult locations where anticipated land journeys were >30 min. With longer anticipated land journeys (or more remote locations) the proportional gains with air transfer will be greater. Subject to a formal SOP and very rapid landing-balloon times, aeromedical transfer can significantly reduce the number of patients suffering long reperfusion delays in acute myocardial infarction.

Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: essential safety measure or a hindrance to rapid safe intubation?

OBJECTIVES: This is the first study to look at the effects of cricoid pressure/laryngeal manipulation on the laryngeal view and intubation success in the emergency or pre-hospital environment. Cricoid pressure is applied in the hope of reducing the incidence of aspiration. However the technique has never been evaluated in a randomized trial and may adversely affect laryngeal view. In order to improve intubating conditions cricoid pressure may be released and the larynx manipulated into a more favourable position. METHODS: We carried out a prospective observational study to evaluate the effects of cricoid pressure and laryngeal manipulation on laryngeal view in our physician led pre-hospital trauma service. RESULTS: 402 patients were included over a 16-month period. We intubated 98.8% patients on the first or second attempt. In 61 intubations (in 55 patients, 13.6%) the larynx required manipulation to facilitate intubation. In 22 intubations cricoid pressure was removed with the laryngeal view improving in 50%. Bimanual laryngeal manipulation was used in 25 intubations and the larynx better visualised in 60% of these. Backwards upwards rightwards pressure was applied to the larynx in 14 intubations and the laryngeal view improved in 64%. Two patients regurgitated when cricoid pressure was released. Both had prolonged periods of bag valve mask ventilation and difficult intubations. DISCUSSION: The results suggest that cricoid pressure should be removed if the laryngeal view obtained is not sufficient to allow immediate intubation. Further manipulation of the larynx is likely to improve the chances of successful tracheal tube placement.

Magen David Adom--the EMS in Israel.

Israel is a small country with a population of around 7 million. The sole EMS provider for Israel is Magen David Adom (MDA) (translated as 'Red Shield of David'). MDA also carries out the functions of a National Society (similar to the Red Cross) and provides all the blood and blood product services for the country. Nationwide, the organisation responds to over 1000 emergency calls a day and uses doctors, paramedics, emergency medical technicians and volunteers. Local geopolitics has meant that MDA has to be prepared for anything from everyday emergency calls to suicide bombings and regional wars. MDA also prides itself in being able to rapidly assemble and dispatch mobile aid teams to scenes of international disasters. Such a broad range of activities is unusual for a single EMS organisation.

Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis.

Cricoid pressure is considered an integral part of patient safety in rapid sequence tracheal intubation and emergency airway management. Cricoid pressure is applied to prevent the regurgitation of gastric contents into the pharynx and subsequent aspiration into the pulmonary tree. This review analyzes the published evidence supporting cricoid pressure, along with potential problems, including increased difficulty with tracheal intubation and ventilation. According to the evidence available, the universal and continuous application of cricoid pressure during emergency airway management is questioned. An awareness of the benefits and potential problems with technique allows the practitioner to better judge when cricoid pressure should be used and instances in which it should be removed.

Prehospital rapid-sequence intubation of patients with trauma with a Glasgow Coma Score of 13 or 14 and the subsequent incidence of intracranial pathology.

AIM: To identify the incidence of intracranial pathology in a population of patients with trauma with an on-scene Glasgow Coma Score (GCS) of 13 or 14, and the proportion that required prehospital intubation and ventilation. METHOD: A retrospective review of a prehospital trauma database was carried out over a 12-month period, and 81 patients were reviewed. All had a traumatic mechanism of injury and had an on-scene GCS of 13 or 14 recorded by a prehospital doctor. 43 patients required prehospital rapid-sequence intubation. Overall, 31.5% of patients with a GCS of 13 or 14 had an abnormal computed tomography scan of the head and 20.5% had an intracranial haemorrhage. RESULTS: For this group of patients with trauma with a drop of only one or two points on the GCS, the incidence of intracranial pathology was almost one in three and that of intracranial haemorrhage was one in five.