Trauma / Immunology (November 2017)
AIR: Immunology
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?
8 comments
Finally! A RCT on pan scan vs. selective imaging!
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While this study showed no diff in mortality, it had a few interesting findings. Figure 3 showed that mortality trended JUST A LITTLE BIT towards favoring pan CT, despite confidence intervals overlapping no difference. Also, the radiation reduction in the selective imaging approach was only ~0.3 mSV. That’s significant, but pretty small difference overall. It did seem to save time to just pan scan on initial evaluation. Cost effective analyses were not done.
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Always take into account institutional practices that may affect practice. For instance, this study didn’t talk about how great the floor care was in the Netherlands and Switzerland or how closely patients are reassessed compared to our hospital.
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Regardless, it’s a interesting study to bring up in your discussions with our surgeons.
Bar-Or et al.
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This study was selected to give some background on why initial lactate and perhaps serial lactate can be helpful in managing select trauma patients. Such studies are the reason why trauma surgery is interested in these values
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I see the value of lactate in most trauma patients. However, I have a problem with this study defining “occult hypoperfusion” as lactate >2.5 Without any thought to the many other reasons the lactate could be elevated. The definition alone implies causality.
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As you know, lactate elevation is common in alcoholics because alcohol dehydrogenase uses the same cofactors as aerobic metabolism. When used up, it shunts towards anaerobic metabolism. It doesn’t mean the patient is super sick.
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At MGH, we used lactate and base deficits religiously and I felt like it had a lot more utility in the general trauma population without a huge portion who are severely intoxicated.
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We should not so easily apply these findings in patient populations different than the one in the study in CO. Especially as ours with a heavy alcoholic population. Now a nonintoxicated elderly patient with trauma, go crazy!
Total Body CT vs selective imaging study:
What are some strengths of the study?
Prospective RCT, and large-scale basis (N 1400). I’m not surprised that an immediate pan-scan saved time, which in theory should lead to improved mortality/morbidity outcomes.
What are the limitations?
They didn’t really comment on the cost difference of pan-scan vs selective imaging. And a significant portion of the patients in the “selective imaging” arm actually ended up having a pan-scan in the end.
What are the main outcomes of the study?
No mortality difference in immediate pan-scan vs selective imaging in severe trauma patients. I think the outcome may be different if there was more selection criteria as to which type of patients (based on mechanism of trauma and/or secondary survey) get pan-scanned vs just selective imaging.
Great point. If we saved all pan scans for intubated or severely intoxicated/altered trauma patients, we might pick up more pathology and make more of a difference.
Compared to stable, awake, reliable patients who are pan scanned purely for mechanism.
Strengths: randomized, large trial. Similar pt demographics and characteristics, similar trauma severity score
Limitations: “trauma population with potentially severe injuries.” They included patients with compromised vitals, clinical suspicion of life-threatening injuries, severe injury. Could not find the appendix online where they further elucidated on what severe mechanism meant. Also 46% of pts that had selective testing had further imaging later which resulted pan scan=bias
Outcome: no difference in in-hospital mortality btw pan scan and selective imaging
Bar-Or:
How has reading the article changed your practice?
Feel like I usually get lactates on elderly trauma @ BMC, it is definitely part of our trauma set so whoever is going through the trauma room will get it, so while it doesn’t change our practice here, it is important to keep in mind when practicing in a smaller shop
What information had you believed in previously that were debunked by reading this article?
Little research on lactate in geri trauma population
What new information did you learn from reading this article?
Associated improved mortality with serial lactate and early trauma involvement
What are current areas of uncertainty on this topic that can be potential areas for research?
Single center, prospective study, didn’t specify injury severity, presence of liver disease in the cohort would have affected lactate clearance
Bar-Or et al.
I tend to agree with Alex on this one. While an elevated lactate can be useful in the acute setting of the trauma room and almost all of our patient’s who pass into the trauma bays receive one, I think it may be a stretch to link an elevated lactate reading entirely with ischemia – overt or occult!
While an elevated lactate can be an indicator of poor tissue perfusion, it can also be elevated due to many other reasons (DKA, Alcohol, etc…). It’s pretty difficult to lump all of these patients together and attribute their lactatemia to occult trauma.
I was unaware that lactate could be trended towards resuscitation goals for “occult trauma”. It seems to me you aren’t fixing the problem in this situation by simply pouring fluids into them.
Bar-Or et al,
Strengths: RCT. Large N= 1400. Prospective.
Limitations:This study only looked at populations in Switzerland and the Netherlands…findings may not necessarily translate into different geographic regions with varying access to healthcare. A comparison of healthcare dollars in different countries.
Outcome: No difference in mortality in immediate pan-scan vs more selective imaging in severe trauma patients.