Thoracostomy in blunt traumatic arrest

37 patients with blunt traumatic cardiac arrest underwent attempted resuscitation by a HEMS crew over a four year period. Chest decompression was performed in 18 cases (17 thoracostomy, one needle decompression). The procedure revealed evidence of chest injury in 10 cases (pneumothorax, haemothorax, massive air leak) and resulted in return of circulation and survival to hospital in four cases. All four cases died of associated major head injury, although one became a heart beating organ donor. Only half of the cases found to have pneumothorax demonstrated clinical signs of one prior to chest decompression.
The authors state: ‘Relying on clinical signs of the thorax alone will not identify all patients with these injuries, and our data support extending the practice into all patients with a suitable mechanism of injury together with external evidence of chest injury.’
Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest
Emerg Med J. 2009 Oct;26(10):738-40

Not such a B.I.G. success in the field?

Success rates with the bone injection gun were 71% (10 out of 14) in children <16 years and 73% (19 out of 26) in adults. Less encouraging data than that seen with the EZ-IO device, and consistent with the experience of some other services.



Prehospital Intraosseus Access With the Bone Injection Gun by a Helicopter-Transported Emergency Medical Team
J Trauma. 2009 Jun;66(6):1739-41

Ballistic penetrating neck injury and the risk of immobilisation

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

Prehospital Hypocapnia and Poor Outcome After Severe Traumatic Brain Injury

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

No benefit from drugs in pre-hospital cardiac arrest

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

Is cervical spine protection always necessary following penetrating neck injury?

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

Spinal imaging and immobilisation may be unnecessary in many GSW patients

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