trauma arrests - gathering of eagles

10/5/2012

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Most Important Non-EMS Articles

Corey M. Slovis, M.D.Vanderbilt University Medical Center

Metro Nashville Fire DepartmentNashville International Airport

Nashville, TN

2011-2012

EAGLES

Trauma Arrests

J Trauma 2011;71:1997-1002

• 294 trauma Arrests over 8 years

• Mount Sinai, Chicago

• Evaluated Survival

• Evaluated Costs

• Should we adhere to TOR protocols?

• Withhold Care in Blunt Trauma if:

Traumatic Cardiac ArrestsNAEMSP/ACS-COT Guidelines

– Apneic, Pulseless, Asystolic or PEA

• Withhold Care in Penetrating: if apneic, pulseless, asystolic, and no signs of life

• Do not transport if > 15 min of unsuccessfulCPR

• Transport penetrating trauma if: organized ECG activity (PEA > 40) +/or signs of life, including pupils

J Trauma 2011;71:1997-1002

• 294 patients met TOR criteria, but were transported

• 35% arrived with signs of life

• 12.6% got ROSC in ED

Results

ED and ROSC

35%

12.6%

37

103

J Trauma 2011;71:1997-1002

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Short Term Survival

55%

25.2%

74

164

J Trauma 2011;71:1997-1002

4.8%

142.7%

8

• 8 patients to ICU s/p OR

Overall Survival of 294 Patients

• 4 declared brain dead

• 2 died within 24 hrs

• 1 had care withdrawn

• No organ donors

1/294 Survival (0.3%)GCS of 6 to long-term care

• $8,424 – pronounced in ED

• $43,080 - if admitted to OR or ICU

Charges for Trying to Save Victims Who Qualify for TOR

• Asystole

NFD Trauma ArrestsBegin Ventilation

- Contact Medical Control for Termination

• PEA- Blunt

- Contact Medical Control

- Penetrating- If rate under 40 contact Medical Control

• VF- Treat Like Medical Arrest

• VF

• Penetrating EMD-PEA Arrests

Transport Trauma ArrestsONLY IF

if rate > 40

Tourniquets

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• 499 patients

• 862 tourniquets on 651 limbs

• 635/651 appropriately applied or used

• Evaluated survival benefits

J Emerg Med 2011;41:590-597

• Survival was 87%

• 1.6% rate for nerve palsies

• 1.7% first 6 months, 1.5% next 6 months

• 0.4% major limb shortening

J Emerg Med 2011;41:590-597

Effectiveness of Tourniquets

Tourniquet Take Homes

should be on all EMS units!Tourniquets

TXA

Lancet 2010;376-23-32

• Does TXA work in severe hemorrhage?

• 20,211 patients with major trauma

• 10,046 patients got TXA within 8 hours

• Hospitals in Africa, Asia, Eastern Europe

0

5

10

15

20

Dea

th (

%)

30d All Cause Mortality Crash-2

16% 14.5%

Lancet 2010;376:23-32

p=0.0035

Placebo TXA

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• Reanalyzes prior CRASH-2 data

• 20,211 trauma patients

• Randomized to TXA or placebo

• Administered up to 8 hours post trauma

Does time to TXA matter?

Lancet 2011;377:1096-1101

RR

0.68

0.79

1.44

Bleeding Death with TXA vs PlaceboLancet 2011;377:1096-1101

<1 hr 1-3 hr 3 hr

• Crash-2 showed early TXA reducedmortality from traumatic bleeding

• Could it really affect worldwidemortality?

• Should TXA only be used in thirdworld countries?

BMC Emerg Med 2012;12: 1-7

TXA Potential Benefits(if given within 3 hours)


Crash- 2

TXA reduces trauma mortality

if given within 3 hours

from bleeding by about 1/3

• At the present time both the US and British

Current TXA Use

• UK National Health Service recommends

Armies include TXA in trauma protocol

TXA for all major trauma victims

• TXA is now a WHO “ Essential Medication”

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Authors Conclude

TXA has the potential to save between

112,000-128,000 lives per year worldwide


if given within 1-3 hours of trauma

Arch Surg 2012;147:113-114

• TXA vs. no-TXA

• US Troops in Afghanistan

• All pts required >1 unit blood

• Subgroup got > 10 units PRBC

• Retrospective study, 896 pts

5

10

15

20

25

30

Mortality %

TXA in US Military

23.9%17.4%

ISS25.2

ISS22.5

p =0.03

Arch Surg 2012;147:113-114

No TXA

N=603

TXA

N=293

5

10

15

20

25

30

Mortality %

TXA in Massive Transfusion

28.1%

14.4%

p =0.004

Arch Surg 2012;147:113-114

No TXA

N=196

TXA

N=125

• TXA dramatically decreased mortality

• Benefits greatest in those requiring

Conclusions

• TXA decreased coagulopathy

TXA in the Military

massive transfusion

• TXA increased survival by factor of 7.228 for those requiring massive transfusion

• Seems to decrease bleeding deaths acutely

• Need to give within 3 hours of event

TXA 2012-2013 Take Homes

• Role in Level 1 Trauma unclear

• Has potential to save 100,000 + lives

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TXA Take Homes

• No controlled US or English study yet done

• Evidence is very much in favor

• Complications not shown to be significant

• Cost is very low

on TXA in rapid transport trauma system.

Response Times

Circ J 2011;75:580-588

Is under 8 minutes for ALS really important

to decrease mortality?

• Used only Delta & Echo call who

• Evaluated In-hospital mortality

Circ J 2011;75:580-588

• 24% > 8 minutes from 911 answer till

were admitted to the hospital

• 7760 EMS responses, Alberta Canada

EMS arrival

Response TimesPrehosp Emerg Care 2012;16:142-151

Response Times and Mortality Prehosp Emerg Care 2012;16:142-151

• OR of 1.19 if less or greater than8 minutes is only variable

• Author concludes that ≥ 8 minutes for EMS does not significantly affect mortality

• Rapid responses may make a significantdifference in only a small number of cases

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Response Times and Mortality

• Large sums of money spent on EMSto get times under 8 minutes

may not be justified!

• Until more studies show where time is

Prehosp Emerg Care 2012;16:142-151

crucial we may be judged on a false “standard”

Pain Control

Is Ketamine plus Morphine superior to Morphine only in Prehospital Pain Relief ?

Ann Emerg Med 2012; 59:497-503 • 135 EMS patients, Melbourne, Australia

• Pain score > 5 after 5 mg Morphine

• Measured pain score s/p M + K vs M alone

• Evaluated complications including

Ann Emerg Med 2012; 59:497-503

nausea, sedation, BP

Injury Types

M% K+M%

Extremity 26 (37%) 29 (45%)

Soft Tissue Injury 17 (24) 15 (23)

Fracture, Other 14 (20) 13 (20)

Dislocation 11(16) 7 (11)

Burn 2(3) 1 (1)

Ann Emerg Med 2012; 59:497-503-5.6

-3.2

Ketamine + Morphine

Morphine Only

Pain Scale Change

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• No significant VS change differences• 2x Nausea with Morphine (9.2% vs

4.3%)• 3 patients had LOC with Ketamine

vs 1 with Morphine• 4 emergence reactions with Ketamine

vs 0 with Morphine

Ann Emerg Med 2012; 59:497-503

Complications

M K+M%

Extremity 6 (9.2%) 3 (4.3%)

Soft Tissue Injury 0 1

Fracture, Other 1 3

Dislocation 0 8 (11.4%)

Burn 0 4 (5.7%)

Take Home PointsKetamine + Morphine in EMS

• Ketamine does improve pain relief

• Is associated with increase in the usual “Ketamine Complications”

• Most complications mild

• Consider Ketamine + Morphine for longer transports and selected urban services

TASERS

• All completed intense exercise

• Then a prolonged TASER discharge

• Pre and Post ECGs evaluated

J Emerg Med 2011;41:466-472

• Medical Questionnaire

• 30 seconds of rapid pushups

• Then treadmill at 8 mph at 8 elevation

• When exhausted; PH 7.22

• Then TASER for 15 seconds lying down

J Emerg Med 2011;41:466-472

Methods

o

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• 24/25 ECGs WNL at start

• 1 with PVC’s

J Emerg Med 2011;41:466-472

Results

Post TASER all ECG’s were WNL

Circulation 2012;125:2417-2422

• Are Tasers really safe?

• Reviews 8 cases of Loss of Consciousness

• Attempts to determine cause and effect

Circulation 2012;125:2417-2422

Immediate LOC then Arrest Taser Cases

• Ages: seven were 16-33 yo; one 48

• ΔT to ECG: usually 5-10 minutes

• Rhythm: VT/VF in 7; one AS

• Drug Screen: Two negative, others with

Circulation 2012;125:2417-2422

ETOH* or THC

• Autopsy: 7/8 died, 1 WNL, othersvariable findings(2 at > 300 mg%)

• X26 can cause capture in pigs and sheep

• Tasers can induce VF in pigs

• Epinephrine increase likelihood of capture

• Capture is usually at 200-240 BPM

• ↑ HR + ↓ BP presumed to cause

EP Data with Tasers

VT/VF arrests

Circulation 2012;125:2417-2422

ConclusionsThe animal and clinical data support the conclusion that ECD shocks from a TASER model X26 delivered via probes to the chest can cause cardiac electrical capture. Furthermore, if the capture rate increases sufficiently or if R on T occurs, the development of VF, either directly or via a transition through VT, occurs in animals and, in my opinion, in humans as well.

Douglas P. Zipes, MD

10/5/2012

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There is no reliable data that shows

TASERs to be dangerous in normal patients,

even if performed after high levels

of physical activity.

TASER Take Homes Taser Take Homes

• Safe in normals

• Associated with deaths

• May induce VF

• Repeat taser is drugs bad

• We are still unsure

Repeat ECG’s• Do repeat ECGs make a difference?

Prehosp Emerg Care 2012; Early Online: 1-6

difference in STEMI diagnosis?• Do repeat prehospital ECGs make any

• Canadian Study from Toronto

• 325 prehospital STEMIs

• Retrospective study

• ECG on scene

• Repeat en route

• Repeat pre ED entry

Prehosp Emerg Care 2012; Early Online: 1-6

If STEMI positive, diversion to STEMI Center.

Pos

itiv

e S

TE

MI

84.6%

93.8%

100%

STEMI ECG

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90% of STEMIs requiring

more than 1 ECG are diagnosed

within 25 minutes of first ECG.

• Encourage more than 1 ECG

Repeat Prehospital ECGsTake Home

in high risk patients

• Repeat ECG in ED per AHA recommendations

• Repeat prehospital ECGs seem reasonableat 10-20 minutes

• Repeat sooner if patient has a significantchange in BP, pulse or chest pain.

• Encourage more than 1 ECG

Repeat Prehospital ECGsTake Home

in high risk patients

• Repeat ECG in ED per

• Repeat prehospital ECGs seemreasonable at 10-20 minutes

• Repeat sooner if patient has a significant change in BP,

AHA recommendations

pulse or chest pain

One ECG Begets Another

GIK • Can it decrease ACS → AMI

• Can we affect AMI survival ?

EMS Glucose-Insulin-Potassium

• Does EMS GIK work ?

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• Meta-analysis of 9 trials

• 1,932 patients randomized

• GIK reduced hospital mortality

Circulation 1997;76;1152-1156

• Authors recommend large randomized trial

• 28% reduction (p=0.004)

(16.1% vs. 21% ; p=0.004)

• Large multicenter GIK in STEMI Trial

• 470 centers, 20,201 pts

• Patients treated within 12 hrs

JAMA 2005;293:437-446

• GIK should work, does in lab

• IMMEDIATE is randomized blinded trial

• 13 cities, 36 EMS Agencies

• 871 patients, D5W vs. GIK

• Primary Outcome: ACS → AMI

JAMA 2012; 307;1925-1933 • D30% W ( 300 g/ Liter)

GIK Solutions

• 50 units/Liter Insulin

• 80 mcg KCL/ Liter

• Run at 1.5 ml/kg/hr

• Run at 100 ml/hr in 70 kg pi

1015

2025

3035

4045

50

5560

Progression of MIJAMA 2012;307: 1925-1933

52.6%

48.7%

D5W GIK

p=ns

30d Mortality and Cardiac Arrest

0

1

2

3

4

5

6

7

8

9

D5W GIK

6.1%

8.7%

p = ns

4.4%4.4%

JAMA 2012;307: 1925-1933

p = 0.01

Mortality Mortality or Cardiac Arrest

D5W GIK

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• Large multicenter GIK in STEMI Trial

• 470 centers, 20,201 pts

• Patients treated within 12 hrs

JAMA 2005;293:437-446

No differences at 30d in mortality, arrests, cardiogenic shockHF or re-infarction

• EMS GIK may be coming

• May be a cheap and effective ACS Rx

• Safe, cheap, easy to give

• Move to come in next 1-2 years

Glucose, Insulin, and PotassiumGIK Take Homes

Seizure Management• IM Midazolam vs. IV Lorazepam

• 893 prehospital seizing children and adults

• Is either more effective?

• Also evaluated complications

• Double Blind, Randomized, Non-inferiority

NEJM 2012;366:591-600

20

30

40

50

60

70

IV Ativan IV Versed

Seizures Stopped by ED Arrival

63.4%

73.4%

329448

282485

NEJM 2012;366:591-600

p < 0.001for non inferiority

0

1

2

3

4

5

6

7

AT Ver AT Ver

Min

utes

4.8

1.2

Time to Treat and Stop SeizureNEJM 2012;366:591-600

Time to Treat Time to Stop

1.2(6.0)

3.3(4.5)

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• Similar times to stop seizures

NEJM 2012;366:591-600

Results

(Ativan: 6 min vs. Versed: 5 min; p = NS)

• Need for intubation the same

• Recurrent seizures the same

• Less hospital admissions with IM Versed(57.6% vs. 65.6%; p = 0.01)

Pediatric Care

• 45 EMS Crews; Simulated Peds Care

• 6 month old: AMS, SZ, Resp Arrest

• Crews used own equipment

• Two observers rated video observation

• Root cause analysis → 5 error themes

Acad Emerg Med 2012;19:37-47

• Don’t use peds equipment often

• Bags often sealed & tagged; not checked

• If stored with adult equip, not found

• If separate, often lacking equipment

Pediatric Error Themes Equipment Organization & Use


Pediatric Error ThemesGlucose Measurement


• Crews often forget to check glucose• Sepsis, AMS, OD:

all may be hypoglycemic

• Incorrect weight estimates

• Incorrect Broselow use

• Drug Calculation Errors

• 64% did not cross check dosages

Pediatric Error Themes Drug Administration


they were often confused• If IV, IM, IN doses all different,

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Pediatric Error ThemesInappropriate CPR


• Compressions with pulse present (<100 BPM)

• No pulse check per CPR

• Did not bring O2 to patients

• Could not find peds equipment

• Failed to use OPA in infants

• Poor ventilatory technique

Pediatric Error Themes O2 Delivery


Expert Pediatric Emergency CareTake Homes

• We need to pay attention to paramedics

• Simulations great for diagnosing training

• Simulations great for teaching

• Pediatric EMS is rarely practiced

pediatric skills and skill retention

(1-2% for many services)

needs Anaphylaxis

• Online survey, 3357 NREMTs

• 98.9 recognized classic case

• Evaluated Epi use

• Evaluated routes of admin

Prehosp Emerg Care 2012 in press

Epinephrine in Anaphylaxis

Only 46.2% said Epi was initial drug in a classic case of a hypotensive, wheezing, tachycardia patient with tingling in his throat & hands, and hives on his chest.


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Epinephrine in Anaphylaxis

• An almost equal number (40%) started

• More gave Epi SQ (58.4%) than

• 1.7% gave Epi IV!


with Benadryl as started with Epi (46.2%)

IM (38.9%)

• One of the most important EMS

• Half of our paramedics may not give

Anaphylaxis Care

• Too many in EMS (and Medicine) think

Take Home Points

Epi when they should • More than half of our paramedics give

Epi SQ rather than IM

Benadryl is the first line drug for

emergencies

anaphylaxis

J Emerg Med 2012 in press

without increasing morbidity

• Excellent literature review

• 407 articles screened; 15 evaluated

• TPA is safe and effective

• Use 3-4.5 hrs post stroke improves outcome

In Summary

Atropine No, Epi Early

2 inches at 100-120 BPM

20 seconds or less for perishock pause

Mechanical CPR benefits still unproven

SGA’s may decrease cerebral flow and survivalFollow closely

Decrease transports of pulseless patients

Tasers still controversial

Repeat ECG’s

IM Versed for seizures

Anaphylaxis and Peds needs more teaching

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VanderbiltEM.com

trauma arrests - gathering of eagles

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