Journal of Trauma and Acute Care Surgery

Treatment


1. Ross SW, Christmas AB, Fischer PE, et al. Impact of common crystalloid solutions on resuscitation markers following Class I
hemorrhage: A randomized control trial. J Trauma Acute Care Surg. 2015 Nov;79(5):732-40. doi:
10.1097/TA.0000000000000833.

CONCLUSION: This study is one of the first human studies to prospectively demonstrate quantifiable differences in base deficit and lactate by type of crystalloid resuscitation. LR resuscitation elevated lactate levels, and NS negatively affected the base deficit. These findings are critical to the interpretation of trauma patient resuscitation with crystalloid solutions. PMID: 26496098

Comment: This was a cleverly designed study on blood donors to either not give fluid, give 2L LR, or 2L NS.  The type of fluid matters when interpreting lactate level and base deficit.

2. Schreiber MA, Meier EN, Tisherman SA, et al for the ROC Investigators. A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: results of a prospective randomized pilot trial.J Trauma Acute Care Surg. 2015 Apr;78(4):687-95; discussion 695-7. doi: 10.1097/TA.0000000000000600.

CONCLUSION: Controlled resuscitation (CR) is achievable in out-of-hospital and hospital settings and may offer an early survival advantage in blunt trauma. A large-scale, Phase III trial to examine its effects on survival and other clinical outcomes is warranted. PMID:25807399

Comment: Giving 250mL boluses and reassessing hemodynamic response vs. giving 2L was safe, did not cause renal dysfunction, and showed a trend toward improved mortality. Specifically, in the protocol, "CR patients received 250 mL of fluid if they had no radial pulse or an SBP lower than 70 mm Hg and additional 250 mL boluses to maintain a radial pulse or an SBP of 70 mm Hg or greater. The standard resuscitation (SR) group patients received 2 L initially and additional fluid as needed to maintain an SBP of 110 mm Hg or greater."  Interestingly, the mortality improvement was in blunt trauma patients; penetrating trauma patients showed no difference in mortality.  For me, the upshot is that smaller crystalloid volume is safe and at least as effective as large volume.

Diagnostic


1. Cason B, Rostas J, Simmons J, et al. Thoracolumbar spine clearance: clinical examination for patients with distracting
injuries. J Trauma Acute Care Surg. 2015 Oct 21. [Epub ahead of print]

CONCLUSIONS: In awake and alert blunt trauma patients with distracting injuries,  clinical examination is a sensitive screening method for significant TLS injury.  Radiological assessment may be unnecessary for safe clearance of the asymptomatic TLS in patients with distracting injuries. These findings suggest significant potential reduction of both healthcare cost and patient radiation exposure. PMID:26491795

Comment: I disagree with these conclusions based on the results, which state, "This yielded an overall clinical clearance sensitivity for injury of 75% and sensitivity for clinically significant injury of 89%." That's not nearly high enough to be an adequate screening instrument in my opinion.  The study by Inaba et al below under Clinical Prediction Rules agrees, stating, "Clinical examination alone is insufficient for determining the need for imaging in evaluable patients at risk of TL-spine injury."


2. Inaba K, Karamanos E, Skiada D, et al. Cadaveric comparison of the optimal site for needle decompression of tension
pneumothorax by prehospital care providers. J Trauma Acute Care Surg. 2015 Oct 15. [Epub ahead of print]

CONCLUSION: For prehospital care providers, the fifth intercostal space (ICS), anterior axillary line (AAL) can be localized and decompressed with a higher degree of accuracy than the traditional second ICS mid-clavicular line (MCL). It is rated as easier to perform and can be done just as quickly. Based on these data, the fifth ICS AAL should be considered as an equivalent first-line position for needle decompression in patients with clinical evidence of a tension pneumothorax. PMID: 26488319

Comment: It seems like prehospital 2nd ICS MCL decompression never works, likely because most catheters never enter the pleural space, as visualized on CT.  Train prehospital providers to aim for the 5th ICS AAL.  In this cadaver model, they were far more accurate here than 2nd ICS MCL (misplacement rate of only 22.0% versus 82.0%).


3. Rostas J, Cason B, Simmons J, et al. The validity of abdominal examination in blunt trauma patients with distracting
injuries. J Trauma Acute Care Surg. 2015 Jun;78(6):1095-100 ; discussion 1100 - 1. doi:
10.1097/TA.0000000000000650.

CONCLUSION: Distracting injuries do not seem to diminish the efficacy of clinical abdominal examination for the diagnosis of clinically significant abdominal injury. These data suggest that clinical examination of the abdomen is valid in awake and alert blunt trauma patients, regardless of the presence of other injuries. PMID: 26151507

Comment: I can already hear some of our trauma surgeons now, "This study proves our point - everyone needs a traumagram (i.e. pan-scan CT).  There would have been 5 missed injuries."  In this study, "sensitivity and negative predictive value of abdominal examination for patients with distracting injuries were 90.0% and 97.0%, respectively."  None of the injuries required surgery or transfusion.  I think this shows that a careful abdominal exam is able to rule out clinically significant injury, even if other distracting injuries are present.


4. Patel MB, Humble SS, Cullinane DC, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Feb;78(2):430-41. doi: 10.1097/TA.0000000000000503.

CONCLUSION: In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. PMID: 25757133

Comment: In obtunded patients, if a high quality CT has been done and shows no injury, the chance of having an unstable ligamentous injury leading to paralysis is near zero.


5. Brown JB, Gestring ML, Forsythe RM, et al. Systolic blood pressure criteria in the National Trauma Triage Protocol for
geriatric trauma: 110 is the new 90. J Trauma Acute Care Surg. 2015 Feb;78(2):352-9. doi: 10.1097/TA.0000000000000523.

CONCLUSION: SBP of less than 110 mm Hg increases sensitivity. SBP of less than 110 mm Hg has discrimination as good as that of SBP of less than 90 mm Hg, with superior improvements in undertriage relative to overtriage in geriatric patients. Geriatric patients newly triaged to be positive under this change have a risk of mortality similar to those under the current SBP criterion. This change in SBP criteria may be merited in geriatric patients, warranting further study to consider elevation to a Step 1 criterion in the National Trauma Triage Protocol. PMID: 25757122

Comment: I love this title!  "Hypotension" appears to need a redefinition to 110 systolic in geriatric patients, or as the authors say, "110 is the new 90."

Review


1. Miller J, Lieberman L, Nahab B, et al. Delayed intracranial hemorrhage in the anticoagulated patient: A systematic
review. J Trauma Acute Care Surg. 2015 Aug;79(2):310-3. doi: 10.1097/TA.0000000000000725.

CONCLUSION: The incidence of delayed intracranial hemorrhage is low among patients on warfarin with minor head injury. Trauma centers should consider the characteristics of the population they serve compared with the published studies when determining management strategies for these patients. PMID: 26218702

Comment: Rates of delayed bleeding are 0 - 72 /1000, which is a wide range. For the U.S., the rate is probably about 2 - 15 /1000. Elderly patients without support or secure follow would benefit from observation in the hospital.


2. Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department
thoracotomy: A practice management guideline from the Eastern Association for the
Surgery of Trauma. J Trauma Acute Care Surg. 2015 Jul;79(1):159-73. doi:
10.1097/TA.0000000000000648.

CONCLUSION: We strongly recommend that patients who present pulseless with signs of life after penetrating thoracic injury undergo EDT. We conditionally recommend ED thoracotomy (EDT) for patients who present pulseless and have absent signs of life after penetrating thoracic injury, present or absent signs of life after penetrating extrathoracic injury, or present signs of life after blunt injury. Lastly, we conditionally recommend against EDT for pulseless patients without signs of life after blunt injury. PMID: 26091330

Comment: EDT has a role, but even in the best case scenario, neurologically intact survival is abysmal (4-12%).  Blunt trauma patients with no signs of life should not be considered for EDT.

Clinical Prediction Rules

1. Inaba K, Nosanov L, Menaker J, et al for the AAST TL-Spine Multicenter Study Group. Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: An American Association for the Surgery of Trauma Multi-Institutional Trials Group Study. J Trauma Acute Care Surg. 2015 Mar;78(3):459-65; discussion 465-7. doi: 10.1097/TA.0000000000000560.

CONCLUSION: Clinical examination alone is insufficient for determining the need for imaging in evaluable patients at risk of TL-spine injury. Addition of age [60 or older] and high-risk mechanism results in a clinical decision-making rule with a sensitivity of 98.9% for clinically significant injuries. PMID: 25710414

Comment: This needs to be externally validated. Also, take note, "high-risk mechanism" is broadly defined and excludes a lot, including: "fall, crush, motor vehicle crash with ejection/rollover, unenclosed vehicle crash, auto vs. pedestrian."  In patients under 60 without high risk mechanism, as defined above, clinical clearance of the T and L-spine may be safe if this is externally validated.