Trauma (November2016)
Research:
AIR: Trauma
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
- Does reading this article change your practice? If so, how?
13 comments
Scotter et al.
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It’s easy to feel defeatist when you see bilat fixed dilated pupils when EMS brings them in. But studies like this show that there’s hope.
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But lets not get ahead of ourselves. This review is tiny in terms of number, and analyzes multiple even smaller retrospective cohort studies. So it’s subject to huge selection bias. Neurosurgery are very selective in terms of who they take to the OR. Likely only those with the BEST outcomes received the operation.
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So it’s still a terrible prognostic sign to see bilat fixed and dilated pupils, but in selective patients (epidurals, young), it’s important to be aggressive in resus and operative management.
Lyon et al.
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Not sure what to think of this one. I’m not convinced that the difference in this study in terms of improved intubating conditions and less hypertension using fentanyl, ketamine, and ronc is not just from the fentanyl itself.
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After all, the etomidate succs group did not use fentanyl. And perhaps the pain and discomfort without anesthesia was the cause of differences.
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I also don’t understand why fentanyl was used with ketamine when ketamine already has excellent anesthetic properties already.
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Keep in mind as well as this is a prehospital study, where paralytics wearing off too early (succs), is a bigger problem than in the trauma room where we can quickly sedate the patient post-intubation and provide staff and restraints when needed.
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In the end, I’m not sure what I would do different. Etomidate is still relatively HD stable, though ketamine is probably more so. We’re not worried about sepsis in trauma patients. Succs still kicks in earlier in emergent intubations, and the combination has been so effective and safe for so long, I’m not sure why we’d add more complexity.
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Hope we discuss this further below.
Lyon et al.
Personally I’m a fan of rocuronium for RSI. Roc kicks in as quickly if not more quickly using the higher recommended dosing for rocuronium for RSI dosing. It has a longer duration of action which, as Alex mentioned, can be beneficial in the field but also in the ED when people are furiously trying to perform procedures etc. and it has a specific reversal agent which is not available for succs.
Suggamadex (trade name: Bridion) is a reversal agent specifically made for rocuronium. When administered it binds the rocuronium molecule. We used it all the time as a reversal agent for Roc at the end of surgery. In my experience it completely reversed paralysis in 30 seconds or so (patients went from 0/4 train of 4 twitches to 4/4 upon administration). It was also available in the ED for the specific purpose of reversing paralysis if a difficult airway was encountered.
While succs is short acting, seconds count when faced with a situation where you cant intubate and cant ventilate a patient. While it sounds like I work for Merck in the above paragraph, I think that we should all really be using a paralytic that allows for rapid reversal if that option is available. I believe that this will eventually become the standard of care. That was certainly the feeling of the anesthesiologists I have worked with.
Most intubations: modified RSI or in a more controlled environment in Ireland used fentanyl immediately before the induction agent. The anesthesiologists were big fans of this addition as they felt that it improved conditions for intubation in many cases. They especially felt that this was true in younger patients – especially younger males. Their feeling was that young males require significantly higher doses of induction agent than other groups. Instead of employing 300mg of propofol or even etomidate to adequately sedate someone, the addition of 100-200mcg fentanyl depending on the patient’s size would result in increased ease of intubation. I think it works well.
Scotter et al.
As Alex mentioned in his post, its very easy to abandon hope when a patient comes in with fixed and dilated pupils. The neurosurgeons tend to be fairly cryptic in how they make decisions about who to bring to the OR….at least at BMC. Reading this article gives a small glimpse into their thought process.
I don’t think it will change my practice. We’re still going intubate these patients, tightly control their blood pressure, attempt to control their ICP as much as possible in the ED and defer to NSGY with regards to their ultimate dispo. It is useful to have an idea about who they might bring to surgery for an evacuation procedure and why though.
I was unaware of the significant difference in outcomes for patients with extra-dural hematomas versus sub-durals. Intuitively it makes sense but I was unaware about research reflecting this finding.
As Alex mentioned in his posting, this review carries with it the selection bias of neurosurgeons that we see on a daily basis. It would be interesting to see if there was improvement in clinical outcomes if NSGY intervened as aggressively as they do with patient’s who have hematomas in regions more amenable to surgical drainage (i.e. extradurals)
Scotter –
With regard to the reference article, and in agreement with Liam, I doubt any change in practice. In patients presenting in a state as described, the BFDP are just one component in our assessment in outcomes. As I doubt the presence of BFDP would be a sole determining factor in attempting resuscitation, knowing the prognosis is poor, rather than the organ bank does relatively little, especially since NSG will ultimately determine dispo if successful initial resuscitation. I too was unaware of the possible change in prognosis based on epi vs subdural. Limitations include small sample sizes and retrospective review to name a couple. Outcomes include mortality which is a bit broad, focus on ability to accomplish ADL would be nice addition.
thought it was great selection of pre-hospital patients. i think in the future this has the potential to more accurately define the majority of intubations as community based emergency medicine becomes more prevalent, in addition to increased drives to keep more patients at home. limited ext validity in the sense that these were trauma patients rather than medical.
Alex, i agreed, interesting choice of combinations to compare, utilizing fentanyl in only one group. outcome measures appropriate for what we are concerned about and was nice they included hemodynamic measurements rather than just intubation success.
liam, good point about the standard of care and the desire to have a specific reversal agent. looking at NOACs too, you can see how much interest it generates
maybe it will change my practice once im allowed to intubate. if i read this when i was rotating as an away medical student where i was allowed to intubate it could have been a real game changer :-P
Lyon. The strengths are prospective comparison of RSI medications. The numbers of patients are actually strong for such a study. The outcome measures were well chosen to be clinically significant. The weakness are that although statistically significant, the differences in outcome are small. The other weakness was that the paper could not make the final claim that the rocuronium, fentanyl and ketamine would be safe in all patients. An ideal RSI regimen could be used without any specific knowledge of comorbidities. The main outcome was that group 2 did showed less hemodynamic changes during intubation, likely secondary to fentanyl blunting the main response. The first pass intubation success was quite good in both, but better in group 2.
I think that this paper will make me more likely to use fentanyl and rocuronium during intubations. I am not sure that I will routinely use ketamine.
Lyon et al.
1. What are some strengths of the study? Spurs conversation on RSI medications and whether use of premedication is beneficial. I think this is an important topic that should be studied and clarified.
2. What are the limitations? The study states that its two main hypotheses are that rocuronium is equivalent to sux and that fentanyl improves hemodynamics during intubation. To better prove these hypotheses the study should not have added another variable — ketamine. For example, maybe the better hemodynamics are due to ketamine and not fentanyl. Ketamine acts as a confounding variable. Also it would have been nice to have randomized patient selection.
3. What are the main outcomes of the study? Main outcomes are intubation success, and presence of acute hemodynamic changes (hypertension, hypotension, or tachycardia) during intubation. Secondary outcomes are laryngoscopy view, and survival to hospital discharge.
4. Does reading this article change your practice? Not really. I have premedicated with fentanyl in the past and would still consider using it. I also use ketamine for RSI in asthma patients and will continue to do so. I probably won’t be switching to roc unless there is a contraindication to succ. I would have liked to see a paper that compared two randomized groups of premedicated with fentanyl vs no fentanyl.
Scotter et al.
1. How has reading the article changed your practice? I would be more likely advocate for surgical management of an acute traumatic epidural hematoma if consultants are reluctant to take the patient to the OR.
2. What information had you believed in previously that were debunked by reading this article? This paper states that prehospital thoracotomy for cardiac arrest in penetrating trauma is associated with a 15% rate of “good outcome.” This is the highest percentage I have seen quoted in an article.
3. What new information did you learn from reading this article? Patients with extradural (epidural) hematomas tend to have better outcomes and respond better to surgical management than patients with subdural hematomas.
4. What are current areas of uncertainty on this topic that can be potential areas for research? Factors that predict good neurologic outcomes for patients with ICH and which patients would benefit from aggressive surgical management.
Lyon et al.
1. They attempted to add to the RSI data with hopes of one day standardizing RSI protocols. They compared 2 RSI protocols to one another. Took the additional step off stratifying groups into full dose vs reduced dose.
2. Not randomized or powered enough (ie, type 2 error). Did not check for emergence phenomena in group 2. Similarly, subsequent CV changes not assessed. The heterogeneous group of pts with different pathology may have influenced the study’s results given the small population and lack of randomization. Data is from single hospital.
3. Compared to etomidate/sux, ketamine/fentanyl/roc is a/w better views, better 1st pass intubation success, better hemodynamic stability in RSI I the pre-hospital setting.
4. I like that new RSI protocols are being studied, particularly those involving ketamine. Given my lack of RSI experience and the study’s limitations, I can’t say my practice to jump to anything else not etomidate/sux has changed. I will say that the more I see attendings use ketamine in the ED, the more I feel comfortable using it in future circumstances.
Scotter et al.
1. Will be more quickly get NSY involved in these types of cases considering a major factor a/w better outcomes was time to surgery.
2. I actually was unaware of the data behind these “heroic” measures. Prior to reading this I associated trauma related BFDP w/ pretty much the end game. Not too sure that I would call a Glasgow score of 4-5 a favorable outcome.
3. I was unaware of the data relating to survival s/p NSY intervention in these cases and how epidural fared better than subdural hematomas.
4. As with many areas of NSY, there’s still a lot of unknown out there. The mannitol vs HTS vs nothing debate is always fraught with more opinion than research. Future studies that can aid EM docs in resuscitating severe intracranial pathology is always welcome.
Scotter et al.
1+2. I was previously under the impression that bilateral fixed and dilated pupils were a very poor prognostic sign ISO head trauma and known bleed, but now I will press more for emergent NSY intervention
3. I learned that the majority of epidural hematomas w/ bilateral fixed and dilated pupils actually have favorable outcomes after NSY intervention
4. Future areas of research could include prognostication scores to determine who would benefit from emergent NSY intervention in this population, and how quickly that intervention should occur
Lyon et al
1+2. I personally did not like this article at all. I think there were far, far too many confounding factors and they drew conclusions that aren’t supported at all by their data. The sample size was very small, and the injuries and baseline anatomy of their population confounded results significantly – both hemodynamically and as it relates to airway views.
3. The outcomes of this study were that ketamine/fentanyl/roc for RSI provided better views and better hemodynamic stability than traditional etomidate/succ
4. This article did not change my practice at all as I do not think it was a well conducted study.