Ballistic penetrating neck injury and the risk of immobilisation

Posted on December 21, 2009 by Cliff Reid

British military physicians reported the outcomes of patients sustaining penetrating neck injury from the Iraq and Afghanistan conflicts. Three quarters were injured in explosions, one quarter from gunshots.

Of 90 patients, only 1 of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury. The authors conclude that penetrating ballistic trauma to the neck is associated with a high mortality rate, and their data suggest that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk, and cervical collars may hide potential life-threatening conditions.

Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma
Injury. 2009 Dec;40(12):1342-5

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Prehospital Hypocapnia and Poor Outcome After Severe Traumatic Brain Injury

Posted on December 21, 2009 by Cliff Reid

Patients admitted to a level 1 trauma centre with traumatic brain injury whose end-tidal CO2 was kept with the Brain Trauma Foundation recommended limits of 30-35 mmHg (3.9-4.6 kPa) had a lower mortality than those whose CO2 was outside this range. The group in which the target was not achieved had a greater injury severity, which may have contribute to the difficulty in optimising ETCO2.

Prehospital Hypocapnia and Poor Outcome After Severe Traumatic Brain Injury
J Trauma. 2009 Jun;66(6):1577-82

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No benefit from drugs in pre-hospital cardiac arrest

Posted on December 17, 2009 by Cliff Reid

A Norwegian randomised controlled trial over five years compared out-of-hospital nontraumatic cardiac arrest outcomes between ACLS protocols with and without access to intravenous drugs (epinephrine/adrenaline, atropine, amiodarone).

Patients randomised to the drug group had a higher rate of hospital admission with return of spontaneous circulation, but there was no significant difference in survival to discharge, survival with favourable neurological outcome, or one year survival.

Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest
JAMA. 2009 Nov 25;302(20):2222-9

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Characteristic ECG signs of LAD occlusion without ST elevation

Posted on December 14, 2009 by Cliff Reid

In a single centre observational study over 10 years of patients undergoing acute PCI of the left anterior descending (LAD) artery, 35 of 1890 (2%) had a distinct non-ST elevation ECG pattern.

The ECG showed ST-segment depression at the J-point of at least 1 mm in the precordial leads with upsloping ST-segments continuing into tall, symmetrical T-waves. Patients also showed a mean J-point elevation of approximately 0.5 mm in lead aVR.

This novel ECG pattern resolved after reperfusion in all included patients.

The authors caution that these electrocardiographic changes may be missed or misdiagnosed as reversible ischaemia, which might substantially delay the transportation to a PCI centre or the start of reperfusion therapy

The authors conclude: “It is important for cardiologists and emergency care physicians to recognise this distinct ECG pattern, so they can triage such patients for immediate reperfusion therapy.”

Image from Dr Smith's ECG Blog

Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion
Heart. 2009 Oct;95(20):1701-6

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Is cervical spine protection always necessary following penetrating neck injury?

Posted on December 10, 2009 by Cliff Reid

This short cut review in the Best Bets format attempted to answer the question: “is cervical spine protection always necessary following penetrating neck injury?”

From the available evidence they draw the following conclusions:

  1. In stab wounds to the neck (with or without neurological deficit) an unstable spinal injury is very unlikely and c-spine immobilisation is not needed
  2. In gunshot wounds the value of cspine immobilisation is limited: for gunshot wounds without neurological deficit no immobilisation is required, while in cases of gunshot wounds with neurological deficit, or where the diagnosis cannot be made (ie, altered mental status), a collar or sandbag is advised once ABCs are stable, with close observation and intermittent removal to inspect and reassess.
  3. In the rare event of penetrating injury with combined blunt force trauma, a collar or sandbag is advised if possible, once ABCs are stable, with intermittent removal to reassess.

Emerg Med J. 2009 Dec;26(12):883-7

Full text at BestBets.org

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Spinal imaging and immobilisation may be unnecessary in many GSW patients

Posted on December 9, 2009 by Cliff Reid

A retrospective review of 4204 patients sustaining gunshot wounds (GSW) to the head, neck or torso examined the incidence of spinal cord injury and bony spinal column injury required operative spinal intervention. None of the patients demonstrated spinal instability requiring operative intervention, and only 2/327 (0.6%) required any form of operative intervention for decompression. The authors concluded that spinal instability following GSW with spine injury is very rare, and that routine spinal imaging and immobilisation is unwarranted in examinable patients without symptoms consistent with spinal injury following GSW to the head, neck or torso.
The role of routine spinal imaging and immobilisation in asymptomatic patients after gunshot wounds
Injury. 2009 Aug;40(8):860-3

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Cuffed tracheal tubes for children

Posted on December 3, 2009 by Cliff Reid

In a prospective randomised controlled multi-centre trial, cuffed tracheal tubes were compared with uncuffed tubes in 2246 children aged from birth to five years undergoing general anaesthesia. There was no significant difference in post-extubation stridor but the need for tube exchange was 2.1% in the cuffed and 30.8% in the uncuffed groups (P<0.0001).

From the resuscitation point of view, there remain few if any arguments for using an uncuffed tube.

Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children

Br J Anaesth. 2009 Dec;103(6):867-73

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First Aid for Burns

Posted on December 2, 2009 by Cliff Reid

A review of burn first aid treatments highlights the paucity of evidence on which to make firm recommendations. The authors recommend using cold running tap water (between 2 and 15 degrees C) and to avoid ice or alternative therapies. The optimum duration of first aid application and the delay after the injury for which first aid can still be effective are two areas of research which need further exploration.

A review of first aid treatments for burn injuries
Burns. 2009 Sep;35(6):768-75

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Physicians didn't improve outcome from nontraumatic cardiac arrest

Posted on November 24, 2009 by Cliff Reid

A Norwegian study retrospectively compared outcomes from non-traumatic cardiac arrest between ambulances staffed by physicians (PMA) and non-physician ambulances (non-PMA). There were no differences in any of the clinical outcome measures used in this study of 977 patients, in which 13% (PMA) and 11% (non-PMA) survived to hospital discharge.

Out-of hospital advanced life support with or without a physician: Effects on quality of CPR and outcome
Resuscitation. 2009 Nov;80(11):1248-52

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Fluids for cooling post cardiac arrest

Posted on November 24, 2009 by Cliff Reid

Large volume cold fluid resuscitation after return of spontaneous circulation can contribute to effective cooling but does it impair cardiac or respiratory function? A retrospective review of 52 resuscitated cardiac arrest patients suggests that the infusion of large volumes of cold fluid does not cause a further significant reduction in  respiratory function beyond that normally seen after cardiac arrest despite significantly reduced LV function.

Effects of large volume, ice-cold intravenous fluid infusion on respiratory function in cardiac arrest survivors
Resuscitation. 2009 Nov;80(11):1223-8

In the same issue of Resuscitation, a prospective study of cardiac arrest survivors in positive fluid balance from cold fluid cooling showed frequent evidence of hypovolaemia as determined by serial ultrasound assessment.

An accompanying editorial suggests this may be due to the systemic inflammatory response syndrome that follows successful cardiac arrest resuscitation; large volumes are tolerated well and myocardial dysfunction should not lead to restriction of fluids after cardiac arrest.

Assessment of intravascular volume by transthoracic echocardiography during therapeutic hypothermia and rewarming in cardiac arrest survivors
Resuscitation. 2009 Nov;80(11):1234-9

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