Trio of Trauma - Journal Club Recap
/The care of trauma patients is constantly evolving. From the time of injury to OR or ICU, there are dozens of management decisions that can improve the care and outcome for your patients. In our most recent journal club we took a look at 3 articles that looked at the management of trauma patients in the ED and ICU. Should we be adding vasopressin to our massive transfusion protocols? Is DL dead for trauma patients? Should we move to use IO’s early in traumatic arrests? Take a listen to the podcast and read the summaries below.
Sims, C., Holena, D., Kim, P., Pascual, J., Smith, B., Martin, N., Seamon, M., Shiroff, A., Raza, S., Kaplan, L., Grill, E., Zimmerman, N., Mason, C., Abella, B., Reilly, P. (2019). Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial JAMA Surgery 154(11), 994-1003. https://dx.doi.org/10.1001/jamasurg.2019.2884
Why we chose this article
Vasopressors are not part of ATLS and with the current state of COVID-19 affecting the amount of people donating blood, any literature to support decreasing the amount of blood needed should be evaluated.
Why is it important
Potential to reduce complications associated with massive blood transfusions and preserve the limited blood supply most places have in place currently.
Study details
Randomized double-blind placebo-controlled clinical trial over a span of 4 years
Included 100 adult trauma patients (18-65yrs) who received at least 6 units of any blood product (PRBCs, FFP, Platelets) within 12 hours of injury.
Excluded pts with prehospital cardiopulmonary resuscitation, emergency department thoracotomy, corticosteroid use, chronic renal insufficiency, coronary artery disease, traumatic brain injury requiring any neurosurgical intervention, pregnancy, prisoner status, or AVP administration before enrollment.
Subjects were randomized to receive either arginine vasopressin bolus and infusion or placebo (normal saline) bolus and infusion for 48hrs.
Group assignment was performed by an independent investigational drug service using a computer-generated randomization scheme in blocks of 6. Study kits containing AVP or placebo were prepared off-site. The clinical team, research personnel, patients’ families, and patients were blinded to group assignment for the duration of the trial
The primary outcome of the study was total volume of blood product transfusion.
Secondary outcomes were assessing total volume of crystalloid transfused, estimated blood loss, overall fluid balance, and total vasopressor requirement within the first 48hrs. Outcomes at 30 days included mortality, length of stay and complications such as ARDS, AKI etc.
Results
At 48hrs, patients who received AVP required significantly less blood products (1.4L) which is about 3U PRBC or 4U of FFP.
The AVP group had less deep vein thrombosis however, there was no difference in the secondary outcomes such as requirements for crystalloids, vasopressor requirements, mortality or total complications.
Limitations
Small Sample size
It was a single center study with mostly penetrating trauma
Study underpowered for clinically relevant outcomes such as complications, morbidity and mortality.
Whole blood used more commonly now thus less individual components needing to be transfused.
Take home point
This is a promising study, and it has set a nice precedent in the approach to massive transfusion. More studies involving more institutions will be needed to address those secondary outcomes listed above such as mortality, morbidity and secondary complications that were not powered for and thus did not have any conclusive results. Until clinical outcomes are focal endpoints, then not much changes with ATLS protocol in most places.
Michailidou, M., O’Keeffe, T., Mosier, J., Friese, R., Joseph, B., Rhee, P., Sakles, J. (2015). A Comparison of Video Laryngoscopy to Direct Laryngoscopy for the Emergency Intubation of Trauma Patients World Journal of Surgery 39(3), 782-788. https://dx.doi.org/10.1007/s00268-014-2845-z
Over the last several years, we have moved to a VL-first airway management strategy for trauma patients at the University of Cincinnati. With a focus on trauma resuscitation for this month’s journal club, I wanted to review some of the evidence for this practice. I chose the article by Michailidou, et al, published in the World Journal of Surgery in 2015, which compared the overall success rate of video laryngoscopy to direct laryngoscopy in the emergent intubation of trauma patients. The study was conducted at the University of Arizona, an academic level 1 trauma center, over a period of 3.5 years from 1/2008 to 6/2011. Data was conducted prospectively on 709 patients during that time period via a post-intubation questionnaire, with nearly all intubations performed by EM residents. Study allocation was not randomized; rather, the device used and the decision to switch to a different device were at the discretion of the EM attending. The primary endpoint was successful intubation with the first device used, regardless of number of attempts. Secondary endpoints included first-pass success, Cormack-Lehane view, complications, and reason for first-attempt failure.
Overall, 55% of patients were intubated with VL and 45% with DL. There was no difference in patient age, gender, mechanism of injury, indication for intubation, or intubator experience level between groups. Patients intubated with VL were more severely injured, had more difficult airway predictors, and were more often in c-spine precautions. There was a significant difference in the reported reason for device selection, with DL most often chosen based on the presence of a standard airway and VL chosen for anticipated difficult airways (p<0.001). There was no difference in first-pass success or number of attempts between the DL and VL groups; however the rate of overall success, defined as successful intubation without changing devices, was significantly higher for VL (88% vs. 83%, p=0.05). Success rates with VL were also significantly higher than with DL in patients in c-spine precautions (87% vs. 80%, p=0.03). There was no significant difference in complications between groups, though there was a trend toward more esophageal and mainstem intubations with DL, and more desaturation events (SpO2 <90%) with VL. In a multivariate analysis controlling for gender, presence of shock, head/facial injuries, difficult airway predictors, and intubator experience, the odds ratio for failed intubation with DL vs. VL was 1.82 (p=0.01). The authors concluded that VL in trauma patients is associated with higher overall success rates than DL, especially in patients with c-spine immobilization.
Chreiman, K., Dumas, R., Seamon, M., Kim, P., Reilly, P., Kaplan, L., Christie, J., Holena, D. (2018). The intraosseous have it Journal of Trauma and Acute Care Surgery 84(4), 558-563. https://dx.doi.org/10.1097/ta.0000000000001795
Performed at University of Pennsylvania
Police are allowed to bring penetrating trauma patients to the ED, so many of them arrive without IV access
Question: How does speed and success of placement vary between PIVs vs. IOs. vs. CVCs for trauma patients in extremis?
Method: Reviewed video recordings of resuscitative thoracotomies from April 2016 - July 2017 (total of 38 patients)
Results: IOs and PIVs equally as fast, but IOs 2x as likely to be successful (CVCs with similar success rates to PIVs but the longest insertion times)
Limitations: Difficult to generalize results from this patient population (those undergoing thoracotomy) to more stable trauma patients
Bottom line: IOs may be useful in trauma patients in extremis as first line IV access given their speed of insertion and high success rates. They may also be helpful in allowing for volume resuscitation, therefore making subsequent PIV or CVC attempts more successful
References
Sims, C., Holena, D., Kim, P., Pascual, J., Smith, B., Martin, N., Seamon, M., Shiroff, A., Raza, S., Kaplan, L., Grill, E., Zimmerman, N., Mason, C., Abella, B., Reilly, P. (2019). Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial JAMA Surgery 154(11), 994-1003. https://dx.doi.org/10.1001/jamasurg.2019.2884
Chreiman, K., Dumas, R., Seamon, M., Kim, P., Reilly, P., Kaplan, L., Christie, J., Holena, D. (2018). The intraosseous have it Journal of Trauma and Acute Care Surgery 84(4), 558-563. https://dx.doi.org/10.1097/ta.0000000000001795
Michailidou, M., O’Keeffe, T., Mosier, J., Friese, R., Joseph, B., Rhee, P., Sakles, J. (2015). A Comparison of Video Laryngoscopy to Direct Laryngoscopy for the Emergency Intubation of Trauma Patients World Journal of Surgery 39(3), 782-788. https://dx.doi.org/10.1007/s00268-014-2845-z
Authorship
Sims, et al - Eddie Irankunda, MD PGY-3 University of Cincinnati Department of Emergency Medicine
Chreiman, et al - Kathryn Connelly MD PGY-3 University of Cincinnati Department of Emergency Medicine
Michailidou, et al - Allie Hunt MD PGY-3 University of Cincinnati Department of Emergency Medicine
Editing and Posting - Jeffery Hill, MD MEd
