Rectal exam has lousy test characteristics

March 21, 2009 by  
Filed under All Updates, Resus, Trauma

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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.

Should the digital rectal examination be a part of the trauma secondary survey?
Ann Emerg Med. 2009 Feb;53(2):208-12

Air medical intubation success

March 21, 2009 by  
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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.

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

Chest needle too short

March 21, 2009 by  
Filed under All Updates, EMS, Resus, Trauma

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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.

Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography
Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7

Is defib danger overstated

March 21, 2009 by  
Filed under Acute Med, All Updates, EMS, ICU, Resus

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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.

Is external defibrillation an electric threat for bystanders?
Resuscitation. 2009 Apr;80(4):395-401

Transfusion and ARDS

March 21, 2009 by  
Filed under All Updates, ICU, Resus, Trauma

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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%.

Early packed red blood cell transfusion and acute respiratory distress syndrome after trauma.
Anesthesiology. 2009 Feb;110(2):351-60

BIS+HEMS

March 21, 2009 by  
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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!

Bispectral index monitoring in helicopter emergency medical services patients
Prehosp Emerg Care. 2009 Apr-Jun;13(2):193-7

Delays to neurosurgery

March 21, 2009 by  
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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!

A prospective study of the time to evacuate acute subdural and extradural haematomas.
Anaesthesia. 2009 Mar;64(3):277-81

Airtraq use by paramedics

March 21, 2009 by  
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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.

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

Physicians in pre-hospital care

March 21, 2009 by  
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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.

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

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

 

Ventilator-associated tracheobronchitis

March 21, 2009 by  
Filed under All Updates, ICU

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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.

Ventilator-associated tracheobronchitis: the impact of targeted antibiotic therapy on patient outcomes
Chest. 2009 Feb;135(2):521-8

 

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