Michael Gibbs

Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND The ABCs of trauma resuscitation begin with the airway evaluation, and effective airway management is imperative in the care of a patient with critical injury. The Eastern Association for the Surgery of Trauma Practice Management Guidelines committee aimed to update the guidelines for emergency tracheal intubation (ETI) published in 2002. These guidelines were made to assist clinicians with decisions regarding airway management for patients immediately following traumatic injury. The goals of the work group were to develop evidence-based guidelines to (1) characterize patients in need of ETI and (2) delineate the most appropriate procedure for patients undergoing ETI. METHODS A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov). RESULTS The search retrieved English-language articles published from 2000 to 2012 involving patients who had sustained blunt trauma, penetrating trauma, or heat-related injury and had developed respiratory system insufficiency or required ETI in the immediate period after injury (first 2 hours after injury). Sixty-nine articles were used to construct this set of practice management guidelines. CONCLUSION The data supported the formation of six Level 1 recommendations, four Level 2 recommendations, and two Level 3 recommendations. In summary, the decision to intubate a patient following traumatic injury is based on multiple factors, including the need for oxygenation and ventilation, the extent and mechanism of injury, predicted operative need, or progression of disease. Rapid sequence intubation with direct laryngoscopy continues to be the recommended method for ETI, although the use of airway adjuncts such as blind insertion supraglottic devices and video laryngoscopy may be useful in facilitating successful ETI and may be preferred in certain patient populations. There is no pharmacologic induction agent of choice for ETI; however, succinylcholine is the neuromuscular blockade agent recommended for rapid sequence intubation.

EMT Defibrillation Does Not Increase Survival From Sudden Cardiac Death in a Two-Tiered Urban-Suburban EMS System☆☆☆★★★♢

OBJECTIVE The use of automatic external defibrillators (AEDs) by EMS initial responders is widely advocated. Evidence supporting the use of AEDs is based largely on the experience of one metropolitan area, with effect on survival in many systems not yet proved. We conducted this study to determine whether the addition of AEDs to an EMS system with a response time of 4 minutes for first-responder emergency medical technicians (FREMTs) and 10 minutes for paramedics would affect survival from cardiac arrest. METHODS This prospective, controlled, crossover study (AED versus no AED) of consecutive cardiac arrests managed by 24 FREMT fire companies took place from 1992 to 1995 in Charlotte, North Carolina, a city of 455,000. Patients were stratified using the Utstein criteria. The primary endpoint was survival to hospital discharge among patients with bystander-witnessed arrests of cardiac origin. RESULTS Of the 627 patients, 243 were bystander-witnessed arrests of cardiac origin. Survival to hospital discharge was accomplished in 5 of 110 patients (4.6%; 95% confidence interval [CI] 0.6% to 8.4%) with AED compared with 7 of 133 (5.3%, 95% CI 1.5% to 9.1%) without AED (P = .8). Both groups were comparable with regard to age, gender, history of myocardial infarction, congestive heart failure or diabetes, arrest at home, bystander CPR, and whether or not ventricular fibrillation (VF) was the initial rhythm. For arrests of any cause, witnessed by bystanders or EMS personnel, with an initial rhythm of VF or ventricular tachycardia (VT), 5 of 77 (6.5%, 95% CI 1.0% to 12.0%) with AED survived compared with 8 of 105 patients (7.6%, 95% CI 2.5% to 12.7%) without AED (P = .8). Statistically significant differences were noted in race and EMS response times between the two groups, which did not affect survival. CONCLUSION Addition of AEDs to this EMS system did not improve survival from sudden cardiac death. The data do not support routinely equipping initial responders with AEDs as an isolated enhancement, and raise further doubt about such expenditures in similar EMS systems without first optimizing bystander CPR and EMS dispatching.

Thoracic aortic dissection secondary to crack cocaine ingestion

Thoracic aortic dissection is a rare but recognized complication of crack cocaine inhalation. It is thought to be triggered in some cases by transient severe elevations in blood pressure, causing a shear effect on the thoracic aorta. Unrecognized, it can result in high morbidity and mortality. A case of an unusual presentation of thoracic aortic dissection following crack cocaine ingestion is reported.

Asymptomatic Isolated Celiac Artery Dissection After a Fall

Isolated injury to mesenteric vessels in blunt trauma is uncommon. Most patients with these injuries present with abdominal pain, shock, or laboratory evidence of bowel and/or liver ischemia. We report herein the case of a man with asymptomatic isolated celiac artery dissection after blunt trauma suspected by screening abdominal computed tomography and confirmed by catheter-based angiography. The patient was treated with 3 months of oral anticoagulation alone.

Impact of common crystalloid solutions on resuscitation markers following Class I hemorrhage: A randomized control trial.

BACKGROUND Resuscitation after hemorrhage with crystalloid solutions can lead to marked acidosis and iatrogenically worsen the lethal triad. The effect of differing solutions on base deficit and lactate has been sparsely prospectively studied in humans. We sought to quantify the effect of normal saline (NS) and lactated Ringer’s (LR) resuscitation in voluntary blood donors as a model for Class I hemorrhage. METHODS A prospective randomized control trial was conducted in conjunction with blood drives. Donors were randomized to receive no intravenous fluid (noIVF), 2-L NS, or 2-L LR after blood donation of 500 mL. Lactate and base deficit were measured before and after fluid administration using an iSTAT. The mean laboratory values were compared between groups first using a global test followed by pairwise testing between groups using the Wilcoxon rank-sum and Kruskal-Wallis tests. The Bonferroni correction was used and a statistical significance of p < 0.0167 was set. RESULTS A total of 157 patients completed the study. The mean (SD) age was 39.2 (12.7), and 65.0% were female. Patients in each group lost equivalent amounts of total blood volume, and a similar amount was replaced in the crystalloid group (p > 0.0167). Donors had comparable increases in lactate and base deficit after donation regardless of the group (p > 0.0167). After resuscitation with 2-L crystalloid, the lactate level increased higher in the LR group than in the noIVF or the NS group (1.36 mmol/L vs. 1.00 mmol/L vs. 1.54 mmol/L, p < 0.0001). In addition, the resuscitation base deficit increased in the NS group more than in the noIVF or LR group (−0.65 vs. −3.06 vs. −0.34, p < 0.0001). CONCLUSION This study is one of the first human studies to prospectively demonstrate quantifiable differences in base deficit and lactate by type of crystalloid resuscitation. LR resuscitation elevated lactate levels, and NS negatively affected the base deficit. These findings are critical to the interpretation of trauma patient resuscitation with crystalloid solutions. LEVEL OF EVIDENCE Therapeutic study, level II.

Sonographic intraperitoneal fluid in patients with pelvic fracture: two cases of traumatic intraperitoneal bladder rupture

Two patients who presented to the Emergency Department (ED) in shock with severe pelvic fractures were evaluated for intra-abdominal injury with a focused assessment with sonography in trauma (FAST) examination. Free intraperitoneal fluid was identified in the hepato-renal recess of both patients. At laparotomy both patients were found to have extensive uroperitoneum resulting from intraperitoneal bladder rupture and no other intra-abdominal injuries. The source of shock in both cases was ultimately determined to be arterial hemorrhage from pelvic vessels. The utility of FAST examinations in the setting of major pelvic injury is relatively unstudied. Coincident injuries make the evaluation for source of hemorrhage in this subset of patients challenging. This is a report of sonographic intraperitoneal fluid in the setting of major pelvic injury and hemodynamic instability found to be uroperitoneum and not hemoperitoneum.

Electrocardiographic manifestations of severe hyperkalemia

Severe hyperkalemia is a hazardous condition that warrants urgent intervention. In critically ill patients, the electrocardiogram (ECG) can be the most immediately available diagnostic tool in identifying patients with potentially lethal hyperkalemia. Peaking of the T waves, the most widely appreciated ECG sign, is actually rarely a manifestation of life-threatening hyperkalemia. In this review, we provide several clinical-electrocardiographic manifestations that can help identify those patients with hyperkalemia who require prompt intervention.

It is nice to have options.

I n this month’s Academic Emergency Medicine, Fitch and Kuhn present an evidence-based review comparing intraarticular lidocaine (IAL) to procedural sedation in the reduction of glenohumeral dislocation. This is not an insignificant clinical problem, because shoulder dislocation has been reported to be responsible for approximately 1.5% of all emergency department (ED) visits. As a result, emergency physicians (EPs) have become the ‘‘experts’’ in the treatment of this common injury that is seldom managed by our orthopedic surgery colleagues. In this expert role, it is our responsibility to develop a sophisticated and comprehensive understanding of the diverse treatment options currently available. In parallel with our maturation in the management of orthopedic injuries, we have also developed considerable expertise with procedural sedation. The days of ‘‘brute force and a little Versed’’ are fortunately long gone and the ED care of fractures and dislocations can be accomplished safely with minimal discomfort and anxiety for the patient. At the same time, procedural sedative does come at a cost. Considerable resources are required, and while small, the risk is definitely not zero. As busy clinicians, it is important to be open to changing the way we practice if it can result in improved patient-centered outcomes and faster throughput times. Evidence-based medicine reviews such as this one help to provide structure to evaluate current literature and put it into a frame of reference for the practicing EP. As the authors of this article point out, the default in many clinical arenas is to reduce shoulders with the aid of procedural sedation. In our institution, that means we need to find a nurse who can help with the procedure, find a monitored room in which to watch the patient during the sedation, get an intravenous line and all the requisite monitoring equipment in place, consent the patient for both procedures, fill out the requisite hospital-mandated presedation checklist (including the always-useful anesthesia-based American Society of Anesthesiologists [ASA] and Malampatti classification), enter the orders for the required medications into the computer so the PIXUS system can spit them out, push the medications ourselves (nurses are not licensed to push propofol in our state), perform the procedure, and then wait for the patient to wake up. We do all this despite evidence that the authors review demonstrating that IAL can be used in lieu of such procedural sedation with no signification change in reduction success rates, pain ratings on a visual analog scale, or ease of reduction. Added to this is their finding of a lower complication rate with IAL, as well as an overall shorter ED stay. That being said, as the authors point out in their study limitations, the six studies they utilized in this analysis were done with older procedural sedation agents (e.g., Pethidine, Valium, and Demerol). There are at present no head-to-head studies using more current sedation agents such as propofol or etomidate versus IAL in the reduction of shoulders. Current well-done studies on the use of these agents supports a much lower incidence of significant complications (5% or less) as well as faster emergence times due to the agents used. The authors of the present article also cite potential concerns regarding the fasting state of the patient undergoing procedural sedation. Again, recent well-done work by Green et al. has clarified this issue and has shown that traditional guidelines for operative fasting state (e.g. NPO for 6–8 hours) are not necessarily applicable to ED procedural sedation. Last, other ED-based literature supports the concept that many (up to 30%) repeat dislocaters may be reduced without the aid of any adjunct, further shortening ED stays as well as eliminating complications from either procedural sedation or IAL. The authors of the current review noted that in these six studies they could not discern how many were presenting with first-time dislocation versus repeat dislocation. So, predicated on this evidenced-based review in 2008, what is the right answer for the next shoulder dislocation that comes through your ED? Given the limitations noted above, we believe that there are several options:

16. First Responder Defibrillation Does Not Increase Survival from Sudden Cardiac Death in a Two-Tiered Urban-Suburban EMS System

Purpose: The use of automatic external defibrillators (AED) by emergency medical service (EMS) first responders (FR) is widely advocated based largely on reports from one metropolitan area, but widespread impact on survival remains unproven. We hypothesized that the addition of AEDs to an EMS system with short FR and prolonged paramedic response times (4 vs. 10 minutes) would improve survival from sudden cardiac death.