Trauma Year in Review 2016 from SMACCdub

by Chris Hicks and Andrew Petrosoniak

The science of trauma resuscitation has undergone a fairly massive evolution in the past decade.  This talk was our attempt to summarize the best-of-the-best in trauma literature from the past several years, and package it into a series of clinically useful recommendations (i.e., our evidence-based opinions).  This talk was live peer reviewed by trauma surgery deity Karim Brohi, who gave us a thumb’s up (although you kind of had to be there).

 

Here’s a run-down of our take-home points:

Use the Clamshell

Unless you’re a thoracic surgeon, consider the bi-thoracotomy as your initial approach to resuscitative thoracotomy. Don't operate in a hole – give yourself the best exposure, and the best shot at fixing the problem.

* Ref: WJS 2013, 37: 1277-1285

* How-to guide: http://emj.bmj.com/content/22/1/22

Prognosticate with POCUS

Point-of-care ultrasound (POCUS) has an ever-expanding role in trauma resuscitation, including prognosticating in cardiac arrest. In this study, patients with no cardiac activity and no pericardial effusion had no survival.

* Ref: Ann Surgery 2015, 262(3): 512-518

Get with the Guidelines

The EAST thoracotomy guidelines might be the most useful and evidence-based set of recommendations for the management of traumatic cardiac arrest yet. Bottom line: VSA trauma patients with penetrating thoracic injuries and an arrest time of < 10 minutes deserve a resuscitative thoracotomy – these are salvageable patients, and deserve an aggressive approach.

* Ref: Critical Care 2013, 17:308, J Trauma 2015, 79(1): 159-173

* Compare and contrast – WEST guidelines (2012): http://bit.ly/2mFemtM

Skip the Films

Stable patients with a plan for CT imaging don’t need a chest x-ray or pelvis x-ray. Not all patients undergoing CT need the full “pan-scan”. In the middle are assessable patients with reassuring vital signs, POCUS +/- x-ray imaging: they can be admitted for observation, or discharged.

* Ref: http://bit.ly/292tAUm

* In the same spirit – local wound exploration for anterior abdo stab wounds can eliminate the need for CT imaging, admission: https://www.ncbi.nlm.nih.gov/pubmed/22182859

Crystalloids kill

The paradigm of 1-2L of crystalloid boluses in hypotensive trauma patients is harmful and should be abandoned. If PRBCs aren’t immediately available, give small boluses (250 cc at a time) for patients with sBP < 70, altered mental status or loss of peripheral pulses. NICE guidelines restrict crystalloids to pre-hospital only.

* Ref: BJM 2012; 345: 38-42, http://bit.ly/292tAUm

Be Propper PROPPR

PROPPR in a nutshell: A balanced ratio of blood products (approximating 1:1:1) is probably the optimal approach for patients who are bleeding to death; also, platelets are pretty important early in trauma resus.

* Ref: JAMA 2015, 313(5): 471-482

Who Needs Mass Trans?

Predicting the need for massive transfusion in trauma is tricky. Relying on gestalt alone is associated with under-resuscitation in about one third of patients, even when trauma experts are making the call. In tricky situations, use the ABC score or shock index to improve situation awareness.

* Ref: Injury 2015, 46: 807-813, J Trauma 2009, 66: 346-352

Drop the dose

Trauma patients in profound shock don’t need the Full Monty when it comes to induction agents for RSI. Even the all-mighty ketamine can have negative hemody...