Category Archives: carebundles

carebundles, Prehospital Trauma

Things to Do When Blunt Things Happen

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Continuing the series of sharing Carebundles, Alan Garner moves on to go through the stuff to include in multiple blunt trauma. 

OK, part 2 in our Carebundle series.  This time we will take a look at our multiple blunt trauma bundle.  This excludes isolated head injury which we dealt with in the previous post.  Why that order you may ask? Our Sydney service started life as a trial evaluating the management of severe head injury so TBI is front if mind for us.  It is also more straightforward as there are not the competing priorities that occur in multiple trauma.  And in the end we don’t just want survivors but neurologically intact survivors so starting with TBI and brain resuscitation makes sense.  The multiple blunt trauma bundle has conditional targets that are modified by the presence or absence of brain injury acknowledging that brain resuscitation is our major goal.

So multiple blunt trauma is next. This has many bits of intrigue to it. It is multiple. We’re moving into the bits of the body where the pathology can be buried in the large splodgy bit in the middle. The diagnostic stuff can be pretty challenging at the side of the road. Oh, and because it’s multiple there’s always that threat of a new competitor emerging in the pathophysiology parade.

We won’t touch on penetrating trauma, burns and immersion all of which have their own bundles of joy for another time.

The Common Touch

All of the mandatory items overlap with the TBI bundle so we won’t waste any time on them here:

  • Venous access – yes we reckon that still makes sense.
  • Analgesia – opioids/ketamine – yes we’re really trying to stress that analgesia is a vital component of care, pretty much every time.
  • Monitoring: SpO2, NIBP, ECG
  • Spine immobilisation – note we’re just sticking with immobilisation.
  • SpO2 > 93% by ED arrival
  • Scene time < 25 min – again, this isn’t always possible which is part of why Carebundles provide guidance but need clinician judgment on each job. What we’re aiming for is a background enthusiasm for keeping momentum throughout the time we’re looking after patients so we can get them to the hospital with all those eager people waiting.
  • Transport direct to trauma centre – this would be the house for the eager people.

The conditional items however vary from the TBI bundle and we will now go through these.

 Checking the Terms and Conditions

Long bone fractures splinted

There is no evidence I am aware of that this changes outcome but it is standard ATLS teaching and makes pain control easier. We carry lots of excellent drugs and the Carebundle makes a point of mentioning them but everything is easier if you manage the physical elements contributing to the painful situation. Really this is the original multimodal analgesia. It’s just that one of the modes is “physical things that stop hurting things from exercising a right to freedom of movement”.

 Massive external haemorrhage controlled

There is strong cohort level data that this saves lives, although more so in the penetrating trauma context where it is more common.  Certainly data from recent conflicts supports this as a primary aim of prehospital care. So we’re carrying tourniquets, dressings, chitosan gauze and granules (though the latter are more for penetrating wounds).

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Right here seems to be a point to salute the wondrous quality of the shells of prawns.

 TXA if episode of SBP < 90mmHg, or below normal for age

CRASH 2 inclusion criteria were felt to be a little vague to include in our bundle.  After all the inclusion criteria in this study was any trauma patient who was at risk of haemorrhage.  To make the bundle we felt the item needed to identify the cases where TXA really should have been given because the risk of life threatening haemorrhage is so high.  There is some evidence that just a single episode of documented hypotension is enough to identify a group of very high risk patients so we adopted this as our criteria. As another mental trigger point, some of our team have expressed a process when they consider packed cell transfusion – “If I’m reaching for blood, I should reach for that drug.”

 If shocked, SBP at ED arrival (refer fluid guideline)

  • No head injury: palpable central pulses/obeying command
  • With head injury: Palpable peripheral pulses, or SBP > 90mmHg / lower limit of normal for age

In setting our blood pressure targets we differentiated between those with and without head injuries.  Without a head injury permissive hypotension is our strategy.  With a head injury we adopted the lowest level identified in the Brain Trauma Foundation Guidelines i.e. SBP of 90mmHg as our target.  This is lower than our target for isolated severe TBI where our target is a MAP of 90mmHg or SBP of 110mmHg (see the TBI bundle post for further details). That last modification is obviously for paediatric patients where the guidelines are a little harder to attach specific numbers to.

 If GCS < 9:

  • Intubation and mechanical ventilation
  • EAM above JVP (head elevation)
  • ETCO2:
  • 30-35mmHg if no chest trauma/shock
  • 25-30mmHg if chest trauma/shock present

This is similar to our isolated severe TBI bundle but we finesse our etCO2 targets in the presence of other injuries that might affect the gradient between arterial and alveolar levels.  There is some evidence that adopting a lower prehospital etCO2 target in patients with chest trauma and/or shock is reasonable as these patients have predictably higher gradients.  My own personal experience is that in patients who have both chest trauma and shock the target needs to be even lower.  I have achieved an etCO2 by ED arrival in the mid-twenties in patients where both these factors are present only to find the first blood gas reveals an arterial level in the 50s.  I would certainly be interested in hearing other people’s experience on this one.  Of course in our rapid response urban trauma work we don’t carry a POC blood gas analyser like we do in our interfacility transport operations.  Actually measuring the arterial CO2 would be ideal but we don’t think this is practical for both time and weight reasons in our urban response service.

 Thoracic decompression if hypoxic/shocked & clinical or US suspicion of pneumothorax

I don’t think this one is rocket science.  Even if we know a pneumothorax is present on ultrasound we usually leave it alone if they are not compromised.  If compromise is present however then we expect it to be decompressed.

 If GCS <13, BSL documented

All patients with an altered level of consciousness get their blood glucose documented.

 Pelvic binder if shock and:

  • possible AP compression / Vertical Shear injury or signs of pelvic #

 We don’t expect pelvic binders to be placed prophylactically.  There is no evidence to support such a practice.  We do however think that binders are helpful on AP compression and possibly vertical shear type injuries and the patient is shocked.

So that is it for our multiple blunt trauma bundle.  It’s what we came up with on a review of the evidence but we’re always open to clever thoughts from others. If you have comments or suggestions we would love to hear from you.

And next time we return to the Carebundles it might just be time to get to the pointy end of penetrating trauma.

 

Notes: 

As always, we’re very happy to hear other people’s clever takes on things that are worth doing. It helps us re-examine our thinking.

Here’s the PubMed link again for the “a single low blood pressure” matters paper linked above:

Seamon MJ et al. Just One Drop: The Significance of a Single Hypotensive Blood Pressure Reading During Trauma Resuscitations. J Trauma. 2010;68(6(:1289-94.

And here’s the one on capnography and major trauma:

Helm M, et al.  Tight control of prehospital ventilation by capnography in major trauma victims. Br J Anaesth. 2003 Mar;90(3):327-32

 

The image for this post came from flickr’s Creative Commons area. It is unchanged from the original posting by “Peter”

 

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carebundles, Governance, Prehospital Trauma

A Bundle for TBI

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Not that long ago Dr Alan Garner described the process for developing Carebundles as part of trying to deliver the best care and measure it at the same time. Here’s the first of the follow-up posts: on TBI.

The isolated severe traumatic brain injury bundle

As a follow up to our blog about Carebundles and their general utility in Prehospital and Retrieval Medicine we thought we might go through each of the bundles that we are using in Sydney and discuss our rationale for why we included the items we did and the evidence base for them.  We hope this process will provide us with some open peer review of our criteria across an international cohort of our colleagues which can only be good for us.

The first thing to note is simply a repeat of my previous post.  It is hard to get good evidence in the space we work in and much of the data is extrapolated forward from in-hospital practice.  Mere geography alone should not affect pathophysiology so this approach is biologically plausible but we acknowledge it is not ideal. To quote from the previous post:

“We then turned to the evidence based consensus guidelines, Cochrane reviews and good quality RCTs to define the Carebundle items.  This is a sobering process as you realise just how few interventions there are that have good evidence to back them up.  This is particularly true for prehospital care where we are often operating in an evidence free zone.  In many cases we had no choice but to go with the consensus (or best guess as I like to call it).  We decided that we would include intubation for unconscious trauma patients for example despite the evidence not being all that strong and in many cases contradictory.”

So let’s look at our bundle items for isolated severe head injury (GCS <9) and why we chose them:

Intubation and mechanical ventilation

As I have already stated the evidence here is not strong.  However it certainly allows better control of both oxygenation and ventilation (PaCO2) so it makes sense and is the in-hospital standard of care.  We also know that we can do this safely and extremely rapidly without delaying in-hospital care (CT scan in particular).  Given we are not delaying subsequent care it seems reasonable to intubate these patients on scene given the other advantages.

We carry a small ventilator to every case.  There is some observational evidence that PaCO2 outside of the normal range is bad for head injuries and that we are crap at providing consistent ventilation by hand so this made sense to us.

ETCO2 30-35mmHg

Again see Davis’ papers on this subject.  We are wanting low normal range (in the 35-40mmHg range) but we don’t have formal blood gases available to us in our rapid response urban operation in Sydney (we do in our longer distance transports in other parts of Australia and internationally).  We therefore assume there will be a small gradient from arterial to alveolar and aimed for an ETCO2 that was likely to get our arterial level in the zone we were aiming for.

Monitoring

Our minimum is ECG, SpO2, non-invasive blood pressure and waveform, quantitative ETCO2.  These are the minimum standards for managing an intubated patient in our part of the world as covered by the specialty colleges. .

Venous access

There is definitely no randomised controlled trial that shows that prehospital venous access improves outcome from severe head injury (or anything else that I know of either).  However it really goes with intubation as above.  We aim for pharmacologically smooth intubations without desaturation or hypotension.  We need a line to achieve this.

C-spine immobilisation

Note that this does not say a rigid collar, just immobilisation which can be achieved in a number of ways.  There is of course evidence that collars impede venous return and therefore it is possible they have an adverse effect mediated by effects on cerebral perfusion pressure.  The consensus guidelines still cite the evidence of C spine injury associated with severe head injury so neck immobilisation made our list. We’re actively reviewing what to do when we arrive at a patient already with a rigid collar in place.

Analgesia

No evidence that I am aware of that prehospital analgesia changes outcome for patients with severe TBI, even in terms of subsequent post traumatic stress disorder in survivors. Unconscious (but not completely obtunded patients) still feel and respond to pain however.  Of course it may also mitigate the risk of hypertension potentially exacerbating intracranial haemorrhage so again a biologically plausible mechanism for a benefit.  I think we mainly included this one as it is what we would want for ourselves & our families.

Head elevation (External Auditory Meatus above JVP)

This is again extrapolated forward from standard in-hospital care.  We need to get the brain above the effect of venous pressure to maximise cerebral perfusion.  No prehospital studies on outcome (recurrent theme) but seems reasonable.

SpO2 >93%

All the large observation data sets about this quote 90% as the magic number (See Randal Chestnut and Michael Fearnside’s classic papers on this topic for example).  We were simply conservative and aimed a bit higher at the inflection point of the Hb dissociation curve as desaturation occurs so rapidly below this point.  I note that the Germans (ADAC) are aiming for 95% presumably due to similar thinking.

Systolic Blood Pressure >110mmHg

Again the classic papers talk about 90mmHg for this item, although if you look at the Brain Trauma Foundation guidelines, they suggest a preference for a higher target, even though they can’t say exactly where to land.  Guidelines out of Italy have also recommended this sort of target previously. Again this seems to make sense from a cerebral perfusion pressure point of view.

Blood sugar level

We mandate that this be documented for all patients.  Our trauma population like most other parts of the developed world is becoming older and co-morbidities are increasingly common.  This one is too embarrassing to miss.

Scene time <25 mins

One fifth of patients with severe head injury have a drainable haematoma.  We want to maintain a sense of urgency among our teams. Again, we recognise that there are times when circumstances stop the team achieving this. The key thing is maintaining that sense that forward momentum can be significant for the patient.

Transport direct to trauma centre

All based on observational data but taking severe trauma patients direct to designated specialist trauma centres is standard of care internationally.  Even the UK have got in on the act recently.

Conditional item

Hypertonic saline if neurologically deteriorating or lateralising signs

This one is going to be controversial.  Again based on beneficial effects on ICP in the ICU setting rather than hard evidence of improved outcomes.  We chose hypertonic saline over mannitol as there is less electrolyte disturbance and hypotension.  We are targeting the neurologically deteriorating and lateralising signs group as they may have drainable lesions and we are trying to buy time to surgical evacuation.  That is the theory anyway.

This is our audit sheet that the doctors complete post mission.  You will note that it contains space for the team to comment on variations from the bundle so that we can identify the reasons that we are unable to meet our management targets.

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Here it is in all its documentation glory.

 

Although the bundle is designed for patients with GCS<9 in reality we intubate a lot of head injury patients with GCS 9-12 as well for various reasons.  We do not consider application of the bundle mandatory in this group but if they do intubate the patient we encourage our teams to apply all the bundle items as well as completing an audit sheet post mission.

Did we get it right? As I said the lack of good evidence makes this process very sobering, so we would particularly welcome feedback.  Next time I will have a look at our blunt multiple trauma bundle.

 

Notes and References:

One of the papers suggesting letting CO2 rise isn’t great:

Davis DP, Hoyt DB, Ochs, M, et al. The Effect of Paramedic Rapid Sequence Intubation on Outcome in Patients with Severe Traumatic Brain Injury. J Trauma Infect Crit Care. 2003;54:444-53.

and

Davis DP, Peay J, Sise MJ, et al. The Impact of Prehospital Endotracheal Intubation on Outcome in Moderate to Severe Traumatic Brain Injury. J Trauma Infect Crit Care. 2005;58:933-9.

Here’s the Pubmed page for the paper on issues with manual ventilation which no one seems to have repeated:

Hurst JM, Davis K JR, Branson RD, Johannigman JA. Comparison of blood gases during transport using two methods of ventilatory support. J. Trauma. 1989;29:1637-40.

Do you remember this classic paper relating to hypoxia:

Chestnut RM, Marshall LF, Glauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34:216-222.

And here are those BTF guidelines.

 

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