March 2009

Ventilator-associated tracheobronchitis: the impact of targeted antibiotic therapy on patient outcomes

Chest. 2009 Feb;135(2):521-8

http://www.ncbi.nlm.nih.gov/pubmed/18812452

Ventilator associated pneumonia (VAP) is a well recognised complication of ICU care, but colonisation and infection further up the respiratory tract may be a risk factor for VAP that is worth identifying and treating. Ventilator-associated tracheobronchitis (VAT) has similar diagnostic criteria to VAP, but without the radiographic infiltrates.

A systematic review of controlled studies: do physicians increase survival with prehospital treatment?

Scand J Trauma Resusc Emerg Med. 2009 Mar 5;17(1):12

http://www.ncbi.nlm.nih.gov/pubmed/19265550

This systematic review by Scandinavian authors examined controlled studies comparing physician with non-physician treatment in pre-hospital care. Fourteen of the 26 studies identified demonstrated significantly improved survival in the intervention (physician-treated) group. Most survival benefit has been demonstrated in trauma and cardiac arrest, reflecting the fact that these two areas are the most studied. The authors rightly remind us of the paucity of pre-hospital controlled studies of sufficient quality and strength.

Full text available at http://www.sjtrem.com/content/pdf/1757-7241-17-12.pdf

Comparison of use of the Airtraq with direct laryngoscopy by paramedics in the simulated airway.

Prehosp Emerg Care. 2009 Jan-Mar;13(1):75-80

http://www.ncbi.nlm.nih.gov/pubmed/19145529

Paramedics intubated simulated patients positioned supine on the floor by direct laryngoscopy (DL) and by using the Airtraq device. Ventilation was achieved more quickly with the Airtraq in a difficult airway scenario (tongue oedema), and after a short training period the Airtraq was faster at intubating a ‘normal’ airway.

A prospective study of the time to evacuate acute subdural and extradural haematomas.

Anaesthesia. 2009 Mar;64(3):277-81

http://www.ncbi.nlm.nih.gov/pubmed/19302640

Further evidence from the UK shows that patients with acute traumatic brain injury suffer delays in the neurosurgical evacuation of intracranial haematomas which are increased from an average of 3.7 hours to 5.4 hours if they have to undergo interhospital transfer. Coordinated regional trauma systems please!

Bispectral index monitoring in helicopter emergency medical services patients

Prehosp Emerg Care. 2009 Apr-Jun;13(2):193-7

http://www.ncbi.nlm.nih.gov/pubmed/19291556

Bispectral index monitoring (BIS) was applied to 57 intubated patients transported by a Helcopter Emergency Medical Service (HEMS), demonstrating (1) that the patients were adequately sedated, (2) BIS works in helicopters, and (3) there is enormous scope for publishing work related to the retrieval environment - anything is of interest!

Early packed red blood cell transfusion and acute respiratory distress syndrome after trauma.

Anesthesiology. 2009 Feb;110(2):351-60

http://www.ncbi.nlm.nih.gov/pubmed/19164959

Blood transfusion in trauma is a risk factor for acute respiratory distress syndrome (ARDS). An analysis of 14070 patients in a trauma database showed that 521 (4.6%) developed ARDS. Logisitc regression analysis demonstrated that, independent of injury type, injury severity, or pneumonia, (1) early PRBCs transfusion of more than 5 units during the first 24 h of hospital admission predicted ARDS and (2) each unit of PRBCs transfused early after admission increased the risk of ARDS by 6%.

Is external defibrillation an electric threat for bystanders?

Resuscitation. 2009 Apr;80(4):395-401

http://www.ncbi.nlm.nih.gov/pubmed/19211180

No rescuer or bystander has ever been seriously harmed by receiving an inadvertent shock while in direct or indirect contact with a patient during defibrillation. New evidence suggests that it might even be electrically safe for the rescuer to continue chest compressions during defibrillation if self-adhesive defibrillation electrodes are used and examination gloves are worn. This paper reviews the existing evidence, but warns more definite data are needed to make absolutely sure that there is no risk before defibrillation safety recommendations are changed.

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Routine use of oxygen in the treatment of myocardial infarction: systematic review

Heart. 2009 Mar;95(3):198-202

http://www.ncbi.nlm.nih.gov/pubmed/18708420

Hyperoxia may reduce coronary artery blood flow, increase systemic vascular resistance, and decrease cardiac output. This paper argues that if the baseline arterial oxygen saturations are >90%, high concentration oxygen does not increase oxygen transport, as the reductions in cardiac output are in excess of the increase in oxygen content. The balance of the limited evidence that exists suggests that the routine use of oxygen in uncomplicated MI (no failure or shock) may increase infarct size and possibly increase the risk of mortality, owing to its haemodynamic effects, including a reduction in coronary blood flow.

Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography

Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7

http://www.ncbi.nlm.nih.gov/pubmed/19145519

This CT study of 110 trauma patients showed: ‘the standard 4.4-cm angiocatheter is likely to be unsuccessful in 50% (95% confidence interval = 40.7–59.3%) of trauma patients on the basis of body habitus. In light of its low predicted success, the standard method for treatment of tension pneumothorax by prehospital personnel deserves further consideration’. Consistent with several other Ultrasound and CT-based studies published on the same subject then.

Performance of endotracheal intubation and rescue techniques by emergency services personnel in an air medical service

Prehosp Emerg Care. 2009 Jan-Mar;13(1):44-9

http://www.ncbi.nlm.nih.gov/pubmed/19145523

In contrast to literature showing high intubation failure rates by ground paramedics, a review over eight years of 369 intubations by flight paramedics and nurses showed successful tracheal intubation in 92.1% cases. Of the 369 intubation encounters, rapid sequence medications were given in 345. The authors ascribe their success to both initial training and mandatory ongoing practice and demonstration of competencies.

Should the digital rectal examination be a part of the trauma secondary survey?

Ann Emerg Med. 2009 Feb;53(2):208-12

http://www.ncbi.nlm.nih.gov/pubmed/19177638

A comprehensive review of the literature, the findings of which showed ‘compelling’ consistency: digital rectal examination (DRE) as a screening test had sensitivities ranging from 0% to 50%, had consistently high false-positive and false-negative rates, and did not improve the predictive value of the other components of a typical trauma examination.

Based on case reports of five patients, the authors suggest DRE may be of value during trauma evaluation in the following settings: (1) patients with evidence of penetrating trauma in the vicinity of the rectum, (2) cases in which the presence of neurologic injury is neither completely supported nor refuted by the clinical findings, and (3) before pharmacologic paralysis. A selective approach is therefore recommended. Some good news for your patients if this will persuade you to discard another piece of longstanding dogma perpetuated in basic trauma teaching.

Answers to March CME Questions:

1) F 2) T 3) T 4) T 5)F