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ETM Podcast – The SABRE Trial – Chris Partyka

In this episode of the ETM Course Podcast we talk to Dr Chris Partyka, Emergency Physician and Prehospital and Retrieval Specialist from Sydney and lead author for the recently published SABRE trial which compared Serratus Anterior Plane Blocks to a standard analgesia package for patients with rib fractures.

Also available on Apple Spotify YouTube iHeart Podchaser PlayerFM

This was a really well designed and executed study, and the results will be practice changing for anyone who treats trauma patients. In this episode we drill down into the design, execution and results of the study, and discuss the benefits of using this block as well as some tips on how to introduce this procedure into your ED in a structured and safe fashion.

You can access the article here: Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management The SABRE Randomized Clinical Trial

Huge thanks for Chris for taking time out of his busy schedule to talk to us!

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The Art of Making the Team Excel at Trauma with Andrew Petrosoniak & Chris Hicks

We’re posting this as a shout out to Andrew Petrosoniak and Chris Hicks from Advanced Performance, and Mark Bonta from Ditch The Labcoat podcast. This is a fantastic interview with some really interesting insights on trauma team leadership from a couple of the world leaders in this space.

It’s reassuring to hear that much of what we teach on ETM (task specific role allocation, labels, pre-brief, synthesis, communication) is reflected in their practice.

But the second half of this episode on ergonomics and design is where the gold is. Andrew and Chris talk in detail about the interplay between self, team, environment and the system as key elements of trauma reception and resuscitation. You can train the team and up-skill in human factors all you like, but if the trauma bay is laid out poorly, you can’t find what you need, or your internal systems are not geared toward getting the patient where they need to be in a timely fashion, then your team will perform poorly. On the flipside, if you design your workspace properly, many of the frustrations and barriers that lead to poor team performance will evaporate and performance will improve.

This episode will have you asking yourself “why do we do trauma the way we do?” And “why aren’t we doing it like they do?”

Highly recommended to anyone who treats trauma patients. For anyone considering redesigning their clinical workspace, or if you are lucky enough to be involved in a new ED design, you need to listen to this! We can only hope that the principles they discuss in this episode become the norm for ED resus/trauma team, environment and system design in the future.

5 stars.

Andy Buck
ETM Course Director.

And by the way, when you’re done with that episode, check out Andrew speaking to Erik Hein! Another great interview.

Posted in Podcast, Resus Room Management, Trauma Education, Trauma Reception & Resuscitation, Trauma Systems, UncategorizedLeave a Comment

ETM Online – Tox Course Module 2 is now live!

We are excited to announce the launch today of the second module of the Tox Course at ETM Online.

Module 2 contains the following topics:

Introduction to recreational drugs
Gamma Hydroxybutyrate (GHB)
MDMA and LSD
White powders
Inhalants
Cannabinoids
Cathinones
Vaping and Nicotine
Stimulant induced movement disorders

This is a fantastic module that covers all of the main recreational substance use presentations to the ED from a high level toxicology perspective, but also from a practical, “how we really do it, on the floor” perspective, in an easy to navigate online course format.

Huge shout out to the course authors Ingrid Berling and Nick Dafters who put in a massive amount of work to bring this module to life.

Interested in taking your emergency toxciology knowledge to the next level? Then head over to ETM Online and enrol in the Tox Course – Module 2 today!

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ETM Podcast Episode 15 – Ben Newell – Decision making

Trauma is all about decision making, so it’s tempting to think that knowing more about how we make decisions might help us do it better. There’s been a lot of hype around System 1 and System 2, metacognition and bias in the Emergency Medicine scene lately that might lead one to believe that we should all use this information to help us make better decisions.

But are we overthinking our “thinking about thinking”? Does knowing about different models of decision making, metacognition and the dozens of biases we are prone to help us make better clinical decisions?

Ben Newell, Professor of Cognitive Psychology and decision making expert, answers these and many more questions in this episode.

You can see Ben’s profile here.

You can get a copy of Ben’s awesome book, Straight Choices – The Psychology of Decision Making here.

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Traction splinting for fractured shaft of femur – why do we do it?

As the longest bone in the body, when it breaks a fractured shaft of femur is a very painful and potentially life threatening injury. One of the main initial treatments for this injury is application of some sort of traction splint, designed to apply distracting force between the lower leg and the relatively “fixed” base of the pelvis, which pulls the displaced and shortened femur back into a more anatomical position.

The Fare-Tec CT-6 splint. Image source

There are two main reasons for use of traction splinting for fractured shaft of femur.

1) Analgesia

Movement is the main cause of fracture related pain, hence why splinting is part of the routine care of almost all fractures. However the anatomy of the femur makes application of the flexible aluminium/foam-padded splints, inflatable splints or plaster backslabs impractical and ineffective. Whilst none of the available traction splints support the thigh fully, application of traction will allow less movement than would occur with an unsupported leg. It also prevents the inevitable thigh muscle spasm from further displacing or moving the fracture (sometimes jamming the injured bone ends together) which can be very painful.

2) Haemorrhage control

There are many misconceptions and incorrect descriptions in online articles/blog posts about how and why traction splinting reduces blood loss from a fractured shaft of femur, however it is commonly accepted that fractured femurs can bleed a lot. How much? It seems no-one really knows and we’ve all been quoting a guesstimate.

I was unable to find any useful references that provide an accurate evidence base for the oft-quoted figure of 1500ml (or “4units… producing class III shock” – from the ATLS manual 8th edition which has no obvious reference for this figure) for the potential amount of blood that can be lost from a fractured femur. Searching on PubMed there is a paucity of studies that provide any accurate calculations or estimates for this number.

A small, retrospective chart review that relied on changes in hematrocrit and several estimates/assumptions (for example: estimated total blood volume based on weight, assumed ml of blood loss per percent drop in hematocrit, requirement for transfusion based on symptomatology) showed an average estimated blood loss of 1,276 ml, with a wide range of 740ml-2,620 ml. Reference. Interestingly the authors did not find an association between open, comminuted or segmental fractures (fracture types that have traditionally been assumed to result in higher blood loss) and estimated blood loss.

A paediatric study showed no significant haematocrit or haemodynamic change in children with isolated femur fractures, prompting the comment that even in cases of diagnosed femur fracture in children, dropping haematocrit or haemodynamic instability should prompt a search for bleeding elsewhere. Reference.

Perhaps the most useful demonstration of blood loss from a femoral fracture comes from Gunther’s ER:

NB: NSFW if you go past the 42:16 mark!

Suffice to say that yes, the medullary cavity of the femur is a highly vascular space that can bleed when fractured.

One can lose a moderate to large amount of blood which may potentially contribute to haemodynamic instability in adults, but probably not in children.

How does traction splinting reduce blood loss?

It’s a simple matter of geometry. The thigh is generally in the shape of an inverted conical frustum (a cone with the pointy end cut off).

When the femur fractures and the thigh begins to fill with blood, it becomes more spherical in shape.

As it fills even more, it becomes cylindrical.

For geometric shapes of equivalent upper radius dimensions, a sphere has 2/3 the volume of cylinder and a cone (or frustum) has 1/3 the volume of a cylinder. This increase in volume is still apparent even if some relative shortening of the broken bone is taken into account (although obviously the exact 1/3:2/3:1 proportions may be slightly different).

So traction splinting endeavours to draw the thigh back into its more anatomical, frustum (or inverted cone) shape, which minimises the potential space for blood loss.

X-ray source: Radiopaedia

Obviously this is a theoretical assumption and given we don’t have an accurate way to measure blood loss from fractured femurs, we’ll never be able to tell how much traction splinting reduces blood loss. But it’s a nice theory and given the other main benefit of stabilisation and analgesia and the lack of apparent serious harm (i.e. traction splints have not been shown to worsen blood loss), it is probably OK to continue using them for the purpose of haemorrhage control whilst remaining nascent of the limitations of the science behind the technique.

We haven’t touched on the best method or device for applying traction, complications of traction splinting, other methods of analgesia for femoral shaft fractures or other related issues but hopefully we can cover these in future posts.

Are there other benefits of traction splinting?

Do you have a reference that more accurately describes blood loss from femoral shaft fractures?

Feel free to leave a comment below.

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The trauma world mourns the loss of Dr John Hinds

Dr John Hinds whom many of you will know from his legendary appearances at SMACC, died yesterday from injuries sustained whilst providing medical cover at a motorsports event in Ireland.

All of us at ETM are deeply saddened by the loss of such an amazing trauma practitioner and educator.

The ETM flag is flying at half mast today.

Image courtesy of BBC News

John was campaigning for a HEMS service for Northern Ireland.

Please sign the petition started in his memory to help push this initiative forward.

Here’s some of the trauma education gold John left us with:

John’s superb talk on resuscitative thoracotomy from the recent SMACC Chicago conference

EMCrit Podcast 135 – Trauma Thoughts with John Hinds

The summary on this post is also worth a read, available here.

Cases from the races – John’s great presentation at SMACC Gold in 2014

NB: The audio was directly lifted from the RAGE Podcast site. Head over there to pay homage.

Click play on the player below, and then click through the slides.

The all-time classic cricoid debate with Brent May:

Rollcage Medic Podcast Episode 7

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London HEMS pre-hospital REBOA video

Just over a year ago London HEMS performed the first pre-hospital regtrograde endovascular balloon occlusion of the aorta (REBOA). This is a potentially lifesaving treatment pioneered by the US military¹ for patients with exsanguinating pelvic and lower limb haemorrhage. There are REBOA trials underway in major trauma centres in Australia currently, so it won’t be happening anytime soon in your local Aussie ED, but for an amazing closeup view of roadside REBOA, check out this episode of “An hour to save your life”.

Want to read the literature on REBOA? Here’s some references.

1. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011 Dec;71(6):1869-72 (full article free text)

2. Martinelli et al. Intra-Aortic Balloon Occlusion to Salvage Patients with Life-Threatening Hemorrhagic Shocks from Pelvic Fractures J Trauma 2010; 68(4): 942–8 (full article free text)

3. Norii, Crandall, Terasaka. Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma Acute Care Surg 2015 Apr;78(4):721-8

4. Brenner et al. A Clinical Series of Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhage Control and Resuscitation. J Trauma Acute Care Surg 2013; 75(3): 506–11

5. Morrison et al. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): A Bridge to Definitive Haemorrhage Control for Trauma Patients in Scotland? The Surgeon 2014 Jun;12(3):119-20

6. White et al. Endovascular Balloon Occlusion of the Aorta Is Superior to Resuscitative Thoracotomy with Aortic Clamping in a Porcine Model of Hemorrhagic Shock. Surgery 2011; 150(3): 400–9 (full article free text)

7. Avaro et al. Forty-Minute Endovascular Aortic Occlusion Increases Survival in an Experimental Model of Uncontrolled Hemorrhagic Shock Caused by Abdominal Trauma. J Trauma 2011; 71(3): 720–725

8. Morrison et al Aortic Balloon Occlusion Is Effective in Controlling Pelvic Hemorrhage J Surg Res 2012; 177(2): 341–7

9. Markov et al.Physiologic Tolerance of Descending Thoracic Aortic Balloon Occlusion in a Swine Model of Hemorrhagic Shock Surgery 2013; 153(6): 848–56

10. Scott et al. A Novel Fluoroscopy-Free, Resuscitative Endovascular Aortic Balloon Occlusion System in a Model of Hemorrhagic Shock. J Trauma Acute Care Surg 2013; 75(1): 122–8

11. Morrison et al. Use of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Highly Lethal Model of Noncompressible Torso Hemorrhage. Shock 2014; 41(2): 130–7

12. Morrison et al.The Inflammatory Sequelae of Aortic Balloon Occlusion in Hemorrhagic Shock. J. Surg. Res. 2014; pii: S0022-4804(14)00366-7

13. Hörer et al. Intraperitoneal Metabolic Consequences of Supraceliac Aortic Balloon Occlusion in an Experimental Animal Study Using Microdialysis. Ann Vasc Surg 2014; 28(5): 1286–95

Posted in Pelvic Trauma, Uncategorized, Vascular accessLeave a Comment

Emergency Radiology Course

Off the back of the very successful trauma radiology course last year, Andrew Dixon and Frank Gaillard from Radiopaedia and Andy Buck from the ETM Course are presenting a new, one day, Emergency Radiology course on Saturday May 16th at the Alfred Hospital in Melbourne.

This promises to be a great course that will cover common and life threatening conditions seen on plain x-ray and CT in the ED (and maybe a few MRI’s as well!)

If you are interested, click on the picture below. Tickets are already selling fast so get in quick to avoid disappointment!

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ETM Radiology: That’s not a knife!

In true Aussie trauma style, we pay homage to Crocodile Dundee, with a case of penetrating chest injury. Can you troubleshoot the chest in this tricky case?

A 49 year old man presents after being stabbed multiple times in the left anterior chest.

Paramedics state that en-route he was tachycardic to 125 bpm, his oxygen saturations were dropping to 88% despite supplemental oxygen, he had absent breath sounds on the left, and they therefore decompressed his left chest with a pneumocath/pleurocath, placed in the left anterior 2nd intercostal space attached to a heimlich valve.

On arrival the patient was alert, GCS 15, with a persistent tachycardia and persistently low sats around 90-92% despite supplemental oxygen. He had 3 x 2cm stab wounds to his left anterior precordium, and the pneumocath was in situ.

The Police are in attendance and produce the weapon for inspection by the treating team. (iPhone used for size comparison)

[DDET What structures may be injured in stab wounds to the left anterior chest? Click for answer]

Stab wounds to the left anterior chest may cause:

Pneumothorax
Haemothorax: with bleeding from chest wall tissue or intercostal muscle, intercostal or internal mammary vessels, lung laceration, major vessel injury or cardiac injury
Cardiac injury with or without tamponade
Tracheo-bronchial injury

Depending on the length of the blade and angle of insertion, other structures that may be injured include:

Neck – airway, vessels & nerves
Thyroid (thymus in babies/kids)
Diaphragm (and sub-diaphragmatic organs)
Spine – it would have to be a very long knife!
Thoracic duct

[/DDET]

[DDET What rapid bedside investigations would you perform?(Click for answer)]
Chest x-ray
There is debate about the utility of chest x-ray in patients who will undergo a CT chest regardless of the x-ray findings, however it’s still recommended as a quick, low to no risk, non-invasive procedure, especially in penetrating chest trauma.

This is the patient’s first chest x-ray:

It shows an apparently inflated left lung (small residual apical pneumothorax) with a pneumocath in situ, and no haemothorax. The cardiac contour looks normal.
Do you notice anything else about this image?

Bedside ultrasound
E-FAST can detect pneumothorax, haemothorax and pericardial effusion/tamponade with greater sensitivity than chest x-ray.
However this is operator dependent and other factors such as obesity, subcutaneous emphysema and chest wall haemaotoma may hinder the views. In this case, there was poor views of the heart on bedside ultrasound. No massive pericardial effusion but we couldn’t exclude it.

[/DDET]

What happened next?
Given the obvious penetrating injuries, and pneumocath insertion, an intercostal catheter was inserted. Only 50 ml of blood drained on insertion.

[DDET Click to see the first post-chest drain x-ray]

Chest x-ray 2 - post ICC insertion — Chest x-ray 2 – post ICC insertion

It shows an apparently inflated lung, with a fairly well positioned chest tube (1 or 2 rib spaces higher is ideal)

[/DDET]

So he should get better now, right?

The patient remained tachycardic, the sats hovered around 92-94% on oxygen, and his blood pressure remained around 100 systolic. Not the fantastic response to decompression/ICC insertion we were hoping for!

[DDET What could be going on in this patient’s chest to explain the lack of improvement post chest tube insertion?]

1) Occult injury
Lung or treacheo-bronchial injury +/- ongoing air leak/tension could explain the ongoing hypoxia and haemodynamic compromise, but the lung looks well inflated! Doesn’t it?

Haemorrhage could explain the haemodynamic compromise but not the low sats. There’s no gross haemothorax on the film and only 50ml of blood was drained from the chest drain.

Tamponade? Could be causing the signs we’re seeing, but he’s remarkably “stably unstable”. i.e. He’s not deteriorating. One would expect a patient who is tamponading from a hole in the heart to deteriorate in front of you, or at least be more unstable. This patient’s vitals are relatively static.

2) Chest tube:
Malposition
The chest tube may not be in the pleural space, but the drain was seen to swing & bubble on insertion.

Malfunction
The drain was checked and it is filled/setup correctly.
Could it be kinked or blocked with clot? Possibly, but this is very rare.
Could the connection between tube and drain be loose? This was checked and found to be well connected with no leak/entrainment of air.

[/DDET]

What happened next?

The patient was taken to CT, and this is his scan

[radiologystack cats=18]

It shows a well positioned intra-pleural chest tube, a small haemothorax, and a persistent pneumothorax. Look closely at the pneumocath. It’s intra-ulmonary (i.e. it’s in the lung), possibly with the tip in a bronchus. This has created a fistula between the patient’s airway and the outside of the chest, which has impaired lung re-expansion. This also raises the possibility of an air leak from lacerated lung, that is allowing air to enter the pleural space faster than the chest tube can withdraw it. Look closely at the base of the heart as well. There is no large pericardial effusion, but there is some blood sitting near the apex.

[DDET The the lab rings. Can you guess what the troponin was?]

28,000! Yep, and that’s the new high sensitivity troponin (with a bad STEMI usually peaking around 2,000-3,000). Not only does this guy have a likely broncho-atmospheric fistula from the pneumocath, and/or lacerated lung causing a persistent air leak, but his myocardium is injured as well.

[/DDET]

On return to the resus cubicle, the pneumocath was promptly removed, the first chest drain was placed on suction with no effect, and a second chest tube was inserted. He went to theatre shortly thereafter for a median sternotomy.

[DDET Here’s the chest x-ray post 2nd chest tube insertion]

After the 2nd tube was inserted, the sats started coming up, the pulse slowed a bit, and the Thoracics Team arrived to whisk him off to theatre.

[/DDET]

Injuries found at operation:

Lacerated lung from knife wounds – repaired

Hole in lung from pneumocath – repaired

Lacerated myocardium – heart chambers not penetrated – repaired

Lessons from this case:

1) Chest X-ray has limitations in trauma
Go back to the initial chest x-ray. What’s wrong with it? It’s supine. In fact all of them are. In pentrating chest trauma with a systolic BP > 90, don’t be afraid to sit the patient up for the chest x-ray. It may have shown the non-inflated lung, and moved the team to the 2nd chest tube more quickly. Supine chest x-rays can easily miss a pneumo or haemothorax. Ultrasound is better, however in this case, it didn’t help due to the overlying tissue damage, and subcutaneous emphysema.

For a great discussion on the utility of chest x-rays in trauma – head over to St Emlyn’s where Simon Carley does a great podcast, and engages in some lively debate in the comments section on ditching superfluous, low sensitivity, time-wasting procedures and processes in resus.

If you’re going to bother to get a chest x-ray in penetrating chest trauma, and the patient can tolerate sitting up without fainting from hypotension – sit them up!

2) A non-inflating lung with an adequately positioned chest tube means there’s an air leak

A broncho-pleural connection will allow air to continue to enter the pleural space, sometimes faster than a chest tube can get it out. The management for this is to apply wall suction to the drain (NOT the tube!), and if this doesn’t work, insert a 2nd chest drain. A broncho-atmospheric connection (eg from a pneumocath) means the inhaled air will bypass the pleural space, and the trapped pleural air won’t escape, rendering the pneumocath useless. If there is a hole in the chest wall that has not closed over you can get a broncho-atmospheric connection, however the pressures in the airway and atmosphere should be roughly the same, so you shouldn’t get tension. Without a broncho-pleural connection, a non-sealed chest wall hole will act as an open pneumothorax, and draw air from outside inwards during inspiration, (the “sucking chest wound”), and you may see bubbling from the wound on exhalation as some of the air in the pleural space is expelled. The treatment for this is either a 3-sided dressing (which are notoriously hard to get to work), or insert a chest tube elsewhere in the hemithorax (not in the hole) and repair/close/seal the sucking wound.

3) Knives are dangerous

As the London HEMS know all to well, with their case series of roadside thoracotomies for penetrating chest injury, knives vs chests all too often ends in tragedy. As demonstrated by the lack of utility of chest x-rays in this case, your threshold for getting a CT scan for anyone stabbed in the chest should be very low. Wound exploration of thick chest walls with intercostal muscles that close over the tract can be falsely reassuring. Patients can bleed and deteriorate slowly, so initially normal vital signs can be falsely reassuring. And as in this case, chest x-ray (even with an adequately positioned ICC) can fail to detect significant pneumothoraces.

4) Pneumocaths/pleurocaths don’t always work, and may cause problems

There are various commercially available pleural drainage kits used by ambulance and pre-hospital services. Most involve a seldinger type kit, usually fitted to a heimlich valve (a one way valve with a rubber sleeve inside a clear plastic chamber). Complications of pneumocaths/pleurocaths include:

Too shallow – failure to reach the pleural space – subcutaneous air may be aspirated giving a false positive result without treating the pneumothorax
Too deep – can penetrate the lung/other organs
They can get blocked with blood or kink – leads to re-accumulation of pneumothorax
Intercostal vessel injury – haemorrhange

In this case the intrapulmonary insertion rendered the pleurocath ineffective.

pleurocath heimlich

Posted in Trauma Radiology, Trauma Resuscitation, Uncategorized2 Comments

ETM Journal Club: Pressure, perfusion, and compartments

This is a review article (available free online over at The Journal of Trauma and Acute Care Surgery) that covers compartment syndrome by body region, reviewing the latest evidence and challenging some dogma related to this fascinating condition.

Ivatury RR. Pressure, perfusion, and compartments: Challenges for the acute care surgeon. J Trauma Acute Care Surg. 2014 Jun;76(6):1341-8

As the article is available free online, I won’t do a full analysis of it, but anyone who manages trauma, burns, or other critically ill patients should read this article as there’s some great learning points about compartment syndrome.

Take home messages:

Recent evidence suggests that the relationship between intracranial pressure (ICP), cerebral perfusion pressure (CPP), cerebral blood flow and the risk of death is not as simple as once postulated, and there are likely pathologic processes in the injured brain that do not directly involve increases in ICP and decreases in CPP.
Orbital compartment syndrome occurs in facial trauma, but may also occur in major burns patients who receive too much crystalloid fluid during resuscitation.
Post cardiac surgery (for example open heart surgery, or post repair of penetrating cardiac injury), too much intravenous fluid causes cardiac dilation, which causes raised intra-thoracic pressures if the chest is closed, resulting in impaired cardiac filling and hypotension. This may manifest intra-operatively during closure, or days later in ICU with increasing airway pressures and haemodynamic instability.
World Society of the Abdominal Compartment Syndrome (WSACS) have published clinical practice guidelines for the management of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), available free open access at Intensive Care Medicine. The guidelines cover issues such as abdominal pressure monitoring, sedation and paralysis, role of renal replacement therapy, decompressive laparotomy, open abdomen management, negative pressure wound therapy and more. You can also download free algorithms on ACS assessment and management from WSACS.
Poly-compartment syndrome reflects the interplay between pressures in the intracranial, thoracic and abdominal compartments. Examples include increasing ventilator pressures to manage injured lungs which can increase intracranial pressure (negatively impacting on concurrent brain injury), and the relatively new technique of reducing intracranial pressure by opening the abdomen. (There is a great lecture by the pioneer of this technique, Thomas Scalea, over at EMCrit).
The classic clinical signs of compartment syndrome in the extremities are specific but not sensitive and the definitive way to diagnose it is with invasive compartment pressure monitoring. However the threshold pressure or exact indication for fasciotomy remains unclear! What is very clear is that delays to fasciotomy result in worse outcomes if the diagnosis is delayed or missed.
Newer techniques such as Near Infra-Red Spectroscopy and Raman Spectroscopy are showing promise in being able to diagnose extremity compartment syndrome, but are likely to only be available in tertiary centres.
There is an extensive discussion about compartment syndrome in the extremities in the article – well worth a read.

This is a succinct, up to date review that has some very salient learning points for anyone who manages critically ill or injured patients.

ETM Rating: Highly recommended

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ETM Journal Club: Shock Index for prediction of critical bleeding post-trauma: A systematic review

I thought it prudent to start the new ETM Journal Club with a local article (from my alma mater as it were), and from none other than the famed (ex) Red Rag, EMA.

We all know that bleeding is bad in trauma. Bleeding until you’re shocked is bad. If you’re bleeding and you’re shocked to the point where you need a blood transfusion, you are more likely to have more serious injuries, get sicker, and die as a result. The more blood you need to get you out of shock, the worse off you are. Wouldn’t it be great if we had a single, easy to calculate number that told us whether you were likely to need a massive transfusion? We could act on this from the pre-hospital notification, notify blood bank, get the MTP down and warm up the blood warmer. We may even detect your need for blood earlier in the ED resus phase. So welcome back Shock Index. Is this the magic number it’s being held up as? Read on to find out.

Reference:

Review article: Shock Index for prediction of critical bleeding post-trauma: A systematic review. Olaussen A, Blackburn T, Mitra B, Fitzgerald M. Emerg Med Australas. 2014 Jun;26(3):223-8

What’s this article about?

[DDET Click for answer]

This article is about use of an easily calculated clinical sign, the Shock Index (SI), or heart rate divided by systolic blood pressure in predicting critical bleeding. Critical bleeding was defined as that which required at least 4 units of packed red blood cells or whole blood in 24 hours.

SI = HR / SBP

[/DDET]

Who did the study and can we trust them?

[DDET Click for answer]

This article has been written by well-known Australian researchers from Monash University, The Alfred Hospital (largest volume trauma centre in Australia) and Ambulance Victoria. Pretty reasonable credentials!

No conflicts of interest were identified.

[/DDET]

How was this study conducted?

[DDET Click for answer]

This is a systematic review article, which looked at 5 papers related to the use of the Shock Index in predicting critical bleeding. Interpreting advice from a review article can be difficult without pulling all of the individual references and analysing them.

In general, the higher the level of evidence (RCT > Cohort > Case Control > Case series) and homogeneity of the referenced articles, the higher the quality of the review, and the increased chance that meta-analysis of the studies will have meaning.

This is a review of mostly retrospective, heterogenous studies, therefore drawing conclusions from the data should be done with caution, and due to this, meta-analysis was not possible. This is acknowledged by the authors.

Heterogeneity issues in this paper include:

Definitions of massive transfusion, shock index, and critical bleeding varied between studies
The proportion of blunt vs penetrating trauma is not clear

[/DDET]

What did it find?

[DDET Click for answer]

In the reviewed studies, there was a positive correlation between degree of Shock Index, and critical bleeding/need for massive transfusion, however this varied from 3.4% to 39.6%.

A large number of limitations are identified in this paper, including:

Shock Index will be inaccurate in:

Geriatric patients (reduced physiologic compensatory mechanisms)
Pre-existing hypertension (baseline blood pressure will be higher, will have to drop more to raise SI)
Athletes (lower resting heart rate, higher stroke volume/cardiac output)
Pregnant (larger blood volume, faster resting heart rate)
Illicit substance use (eg sympathomimetics – faster resting heart rate)
Cardiopaths (beta-blockers/Ca2+ blockers, pacemakers, transplant)
Spinal cord injury (neurogenic shock from sympathetic disruption)
Hypotermia (causing bradycardia)

Eg:

Fit, healthy 24yo man, fall off horse onto right side, yelling in pain, RUQ tender ++, FAST positive, pink & well perfused (from all the yelling). HR = 100 BP = 120 SI = 0.83

75yo pedestrian vs car, amputated lower leg, you’re standing in a pool of blood that’s running off trolley. HR 110 SBP = 130 SI = 0.84 (On beta blocker, usual BP 180/110)

[/DDET]

Should this article change my practice?

[DDET Click for answer]

In short – No.

Whilst there are some interesting observations in this paper, the heterogeneity of the studies, the small number of papers reviewed (only 5 articles met inclusion criteria), their mostly retrospective nature, and the large number of variables and limitations that affect shock index means this “vital sign” should not be used to determine whether your patient has critical bleeding or will need massive transfusion, or at least it should be used with caution.

Until the defintions are tightened, and the end points clarified, (and potentially studied prospectively), I’d be cautious about using a single number to determine need for massive transfusion.

I think it falls into the “general interest” category, in that you knew your patient was bleeding (either externally or internally) from your excellent assessment, so you were already going to give blood instead of saline, and part of your decision included looking at their blood pressure and pulse, and their trends pre-hospital and while the patient was in the ED, and you weighed up other issues like haemostatic resuscitation principles (target SBP 90-100mmHg, regardless of pulse), time delay to surgery, co-morbidities, age, and blood results (e.g. haemoglobin which is usually available very rapidly from a blood gas).

i.e. “Look, my patient’s bleeding, I can’t stop it as quick as I’d like, they are clinically shocked so I better give them blood, and oh, by the way their SI is greater than 1.

It may come in handy as the authors suggest when comparing SI’s temporally, (eg from pre-hospital to ED, and during the ED resus. If the SI is going up over 1 or 1.1, especially if it rises despite fluid/blood administration, they have anywhere from a 3-40% chance of needing large volume transfusion, but hopefully you will have already realised that from other parameters, signs and detected injuries).

I’m also no good calculating percentages in my head. I’d have to get my calculator out on my phone, and that’s one more thing to remember to do in a busy resus!

[/DDET]

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ETM Course is accredited for ACRRM PDP

For our rural and remote colleagues, the Emergency Trauma Management Course is accredited for PDP/MOPS with the Australian College of Rural and Remote Medicine, as follows:

Activity Title:
Emergency Trauma Management Course – ETM – 2017-2019

Code:
E1401ETMC

Points + MOPS:
30 PRPD points
30 Emergency Medicine MOPS points
1 Anaesthetics Emergency Response

Procedural Grant
ETM Course is also recognised as a Tier 1 Emergency Medicine course and eligible for 3 days of Procedural Grant funding for eligible doctors, under the Anaesthetics or Emergency components. Refer to the Procedural Grants Program for further information.

We look forward to welcoming more ACRRM practitioners to our course, so check out our course dates and register today!

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ETM Recommends: SWAN XXII Trauma Conference

Now in its 22nd year, the South West Area Network (SWAN) Trauma Conference at Liverpool Hospital promises to be yet another great conference. I attended my first SWAN conference last year, and was thoroughly impressed by the sheer calibre and world-class trauma experience of the speakers. With a range of local and international Surgical, ED, ICU, Anaesthetic and Radiology experts, and some great case-based panel discussions, you’d struggle to find a better cutting edge trauma education experience.

Low on hype, with minimal razzle-dazzle, but packed with more interdisciplinary trauma pearls than you’ll find anywhere else (in this hemisphere at least), I can’t recommend it highly enough. The only downside is that Liverpool Hospital is a pain in the backside to get to, and the surrounding suburbs are not renowned for their safety, but that just adds to the gritty trauma feel of the event. You know you’re going somewhere where they see real trauma, every day!

Check out the brochure here, and download the registration form here. Earlybird registration finishes on the 30th of April.

If you’re going, be sure to let me know (best to tweet me) as I’d love to meet up and talk trauma!

Andy

DISCLOSURE:
I have no interest, financial or otherwise in this event, I just think it’s great!

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ETM & The Vortex – SMACC Gold Presentation

I’ve just returned from the amazing SMACC Gold Conference on the Gold Coast, and what an amazing conference it was. 3 days of powerhouse Emergency and Critical Care from the cream of the medical education crop.

We were lucky enough to be invited to speak in the education forum, and rather than dish out a boring old Powerpoint presentation, we teamed up with the guys from the Vortex, and did a live scenario, demonstrating some of the trauma resus skills you learn on the ETM Course, as well as the Vortex approach to the unanticipated difficult airway, live on stage, followed by a brief feedback session with the audience.

The scenario demonstrated the team approach to trauma resuscitation taught on the ETM Course, and how this helps manage multiple, complex, simultaneous events that are proceeding at different rates, rather than the traditional, linear A/B/C/D approach. This Resus Room Management approach is one of the key things that differentiates ETM from other trauma courses.

I’m guessing by some of the feedback we got that it was pretty well received. This is compliment from Rob Rogers, (of iTeachEM fame, and one of the most highly regarded Emergency Medicine educators on the planet), made my day!

And here’s the “Awesome Card”:

UPDATE: Here’s Rob’s synopsis of the SMACC Conference over at iTeachEM.

So thanks to everyone who came along and attended our session, and I’d very much like to thank Chris Nickson and the rest of the SMACC Team for offering us the oppourtunity to showcase the course at the conference, as well as our assistants on the day, including:

Tim Gray (@timgray61)

Noush Perera (@noushperera)

Tim Leeuwenburg (@KangarooBeach , KIDocs & Rural Doctors Net)

John Dyett (@johndyett)

Robert Simpson (@AmboFOAM & AmboFOAM blog)

There are already multiple blog posts summarising the rest of the conference, and you can check some of them out here, here, and here.

Suffice to say, this was without a doubt the best conference I’ve been to, and only promises to be bigger and better next year when SMACC launches overseas, as the 2015 conference will be held in Chicago in May. So start planning your leave now!

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Step Back Think

I recently posted about the JMB Foundation, and the personal connection I had with this story and the organisation. Some friends of James have also started the Step Back Think campaign to raise awareness of the dangers of street violence. I’d encourage you to like them on Facebook, follow them on Twitter and support their efforts to reduce the number of people we see in ED with alcohol related violence injuries.

Here’s an excellent video they’ve made about traumatic brain injury. Please tweet it or share it any way you can, and maybe one of us will see one less person with a severe head injury this weekend in the ED.

httpv://www.youtube.com/watch?v=m0xuJtVVK8A

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Help support patients with acquired brain injury through the JMB Foundation

In 2006, I worked for 6 months as the Clinical Forensic Medicine Registrar at the Victorian Institute of Forensic Medicine (VIFM). This job involved seeing “live” people with forensic issues, often victims and occasionally perpetrators of assaults, to document their injuries and take forensic samples. One case stuck a particular chord with me – the night I was called by the Police to come into the Melbourne CBD to examine a young man who was covered in blood after he and his friend had been assaulted, late on a Saturday night.

This was the friend of James Macready-Bryan. James had been the victim of a “king-hit” while out celebrating his 20th birthday in the city that night, had fallen to the ground striking his head, and as it turned out, the friend that was with him was covered in blood – from James’ head injury – as he did mouth to mouth on him as instructed over the phone by the 000 operator. James survived, but has a severe acquired brain injury requiring full time care. The random, senseless nature of this incident, and the frequency with which we see patients with similar injuries in the ED has stayed with me over the last 7 years, and prompted me recently to look up his story again. That’s when I discovered the JMB Foundation.

As James was the victim of an assault, and not injured at work or in a vehicle, there was no insurance or government funding to pay for his care. The JMB Foundation was started to help raise funds, provide services for, and to raise awareness of the many young Australians who suffer acquired brain injury each year, many of whom face life in a nursing home.

Last week Amit & I had the honour of meeting James’ father Andrew, and Helen Sykes, the Chair of the JMB Foundation. Their work to improve the lives of young people with acquired brain injury, through fundraising, provision of care and support services, and lobbying for the National Disability Insurance Scheme is amazing. At ETM we have pledged to make a donation of a portion of the funds from each ETM Course to the JMB foundation, in an effort to support the care of young people with acquired brain injury, as we feel this is directly related to our role in teaching medical practitioners about the acute management of traumatic brain injury on the ETM Course.

I can still remember the night I was called out to see James’ friend. I remember the look of shock on his face, and I remember calling the hospital to get an update on James’ condition, and the sinking feeling I had when I spoke to the ED doctor who told me “he had a massive bleed, he went straight to theatre”, knowing full well from that limited amount information that his life, the lives of his friends and their families had just changed drastically for the worse, forever.

So please join us in supporting the JMB Foundation. You can donate through the Everyday Hero website, if you’re an athlete you can fundraise for them by participating in various fun runs and the Melbourne Marathon, or you can donate directly to the JMB Foundation.

Andy Buck
ETM Course Director

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How Can ETM Help Me Manage Trauma Better?