Naughty but NICE: clinical conundrums in trauma care but NICE: clinical conundrums in trauma care...
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@STHJournalClub Dr Matt Wiles Sheffield Teaching Hospital NHS Foundation Trust Editor, Anaesthesia http://sthjournalclub.wordpress.com/ Naughty but NICE: clinical conundrums in trauma care
Transcript of Naughty but NICE: clinical conundrums in trauma care but NICE: clinical conundrums in trauma care...
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DrMattWilesSheffieldTeachingHospitalNHSFoundationTrust
Editor,Anaesthesiahttp://sthjournalclub.wordpress.com/
NaughtybutNICE:clinicalconundrumsintraumacare
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NICESpinalInjuryGuidelines2016
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NICETraumaGuidelines2016
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Guidancevs.Rules
“Aguidelineisastatementbywhichtodetermineacourseofaction.Aguidelineaimstostreamlineparticularprocessesaccordingtoasetroutineorsoundpractice.Bydefinition,followingaguidelineisnevermandatory.Guidelinesarenotbindingandarenotenforced.”U.S.DepartmentofVeteranAffairs(http://www.va.gov/trm/TRMGlossaryPage.asp)
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Winningheartsandminds…Newman.JEmerg Med2007;50:476-77
Semmelweiss Reflex“Thereflex-liketendencytorejectnewevidenceofknowledgebecauseitcontradictsestablishednorms,beliefsorparadigms”
Pseudoaxioms“Falseprinciplesorruleshandeddownthroughgenerationsofmedicalprovidersandacceptedwithoutseriouschallengeorinvestigation”
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TheThreeCommandmentsofITU
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Assumptions1. Traumapatientsareatriskofunstablespinalinjuries
2. Anyspinalinjurywhichhasbeensustainedmaybeworsenedbyfurthermovement(s)
3. Theapplicationofasemi-rigidcervicalcollarandspinalimmobilisation devicepreventspotentiallyharmfulmovementofthespine
4. Cervicalcollarapplicationandspinalimmobilisationarebenigninterventions,andthereforecanbeappliedtolargenumbersofpatientsasaprecautionarymeasure
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Assumption1
“Traumapatientsareatriskofunstablespinalinjuries”
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EpidemiologyofSCIHasler RMetal.JTrauma2011;72:975-981
• Medianage47.2years• 66%male• 3.5%hadcervicalspineinjuries– 10.3%inthosewithGCS3to8– only23%hadneurologicalsymptoms[0.8%oftotal]
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EpidemiologyofSCIHasler RMetal.JTrauma2011;72:975-981
• Medianage47.2years• 66%male• 3.5%hadcervicalspineinjuries– 10.3%inthosewithGCS3to8– only23%hadneurologicalsymptoms[0.8%oftotal]– 25%hadinjuriestootherregions• 16%head• 16%extremities• 14%chest
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AsymptomaticcervicalspinediseaseBrinjikji Wetal.AmJNeuroradiol 2015;36:811-16
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Assumption2
“Anyspinalinjurywhichhasbeensustainedmaybeworsenedbyfurthermovement(s)”
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ImmobilisationandCordInjurySundstrømTetal.JNeurotrauma2014;31:531-40CrosbyET.Anesthesiology 2006;104:1293-1318
• Mostspinalinjuriesarestable;thosethatareunstablehavealreadycausedirreversibledamage
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ImmobilisationandCordInjurySundstrømTetal.JNeurotrauma2014;31:531-40CrosbyET.Anesthesiology 2006;104:1293-1318
• Mostspinalinjuriesarestable;thosethatareunstablehavealreadycausedirreversibledamage
• Improvementsinmortalityratessince1973attributedtoimmobilisation
• “Missed”injurieswithdeterioration(10-29%)arehistoricalandpredominatelyduetoimagingissues
• 2-10%ofcordinjuriesworsenregardless• ExaggeratedrateofsecondarySCIwithoutcollars
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TraumaticSpinalCordInjuryAmerica/CanadaSinghAetal.ClinicalEpidemiology2014;6:309-331
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TraumaticSpinalCordInjuryinDevelopingCountriesRahimi-Movaghar Vetal.Neuroepidemiology2013;41:65-85
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Assumption3
“Theapplicationofasemi-rigidcervicalcollarandspinalimmobilisation devicepreventspotentiallyharmfulmovementofthespine”
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EfficacyofCollarsHollaMetal.Eur SpineJ2016;25:2023-2036
0% 20% 40% 60% 80%
• Flexion/Extension42%-78%• Lateral13%-40%• Rotation13%-40%
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ManualIn-lineStabilisationManoach S&PaladinoL.AnnEmerg Med2007;50:236-45
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ManualIn-lineStabilisationManoach S&PaladinoL.AnnEmerg Med2007;50:236-45
• Originuncertain– ATLSguidance1984• Datafromcadavericstudies,healthyvolunteersandcaseseries(n=96)
• SeveralstudiessuggestMILShasnoeffectoncervicalsegmentmovementStudy Method Grade1 GradeII GradeIII GradeIVNolan&Wilson.Anaesthesia1993;48:630-33
Optimalposition 129 26 2 -
MILS 75 48 34 -
Heath.Anaesthesia1994;49:843-45
Optimalposition 46 4MILS 12 27 11Collar/tape/sandbags 2 16 25 7
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Assumption4
“Cervicalcollarapplicationandspinalimmobilisation arebenigninterventions,andthereforecanbeappliedtolargenumbersofpatientsasaprecautionarymeasure”
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CollarsmayworseninjuriesBen-Galim PGetal.JournalofTrauma2010;69:447-50
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TransportDelayswithImmobilisationHaut ERetal.JournalofTrauma2010;68:115-120
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Mvs.EHertfordshireHA1991Athanassoglou Vetal.TrendsAnaes Crit Care2015;5:57-60
“Wecannotassertthatcricoidpressureisnoteffectiveuntiltrialshavebeenperformed,(i.e.wemustassumeitsefficacy)especiallyasitisanintegralpartofanaesthetic technique…thathasbeenassociatedwithareducedmaternaldeathratefromaspirationsincethe1960s."
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• 10casereportsofworseningSCIafterintubation– Littletoimplicatelaryngoscopyascause
• ClosedClaimsAnalysis:– 1970-2007(n=7740)– 48casesidentified(0.9%ofGAclaims)– Majority(>75%)hadstablec-spinespriortoprocedure– Ninehadunstablecervicalspines
• Twocasesofcordinjurywithdirectlaryngoscopyimplicated• TwocasesoccurreddespiteAFOI
RiskofLaryngoscopyHindman etal.Anesth 2011;114:782-795McLeod&Calder.BrJAnaes 2000;84:705-9
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AnatomyofSpinalCordInjuryCrosby.Anesth 2006;104:1293-318
Spaceavailableforspinalcord(SAC):1/3odontoid;1/3cord;1/3space
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CervicalSpine&DirectLaryngoscopyMcCahon etal.Anaesthesia2015;70:452-61
• Odontoidpegfractureincadavers
• Minimalglottic exposure• MILS• Assessed“spaceavailableforspinalcord”
• Airtraq,McCoy&Mac3– nosignificantdifference
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CervicalSpine&AirwayManoeuvresDonaldsonetal.Spine1997;22:1215-18Donaldsonetal.Spine1993;18:1220-23
• CadaverswithunstableC1-2– MILS– Glottic viewachievednotstated– Spaceavailableforcordassessed
• Jawthrust>chinlift>laryngoscopy• CadaverswithunstableC5-6– NoMILS– Glottic viewachievednotstated– Cervicalspinemotionassessed
• Chinlift/jawthrust≈cricoidpressure≈laryngoscopy
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MaskA MaskB Miller3 MacIntosh3
FOIOral FOINasal
CervicalSpine&BVMVentilationHauswald etal.AmJEmerg Med1991;9:535-8
• Cadaversstudiedwithin40minofdeath– Collar,spinalboard,tape– Glottic viewachievednotstated– Neckmaintainedinneutral
• Maskventilation>>trachealintubation[P=0.00004]
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CervicalSpine&OtherAirwayTechniques• LMA[Kilic etal.AmJEmerg Med2013;31:1034-36]– Doneincervicalcollars– LMA&iLMA similartoMacintosh
• GlideScope [Robitailleetal.Anesth Analg 2008;106:935-41]– MILS– NodifferencebetweenMacintoshandGlideScope
• Fibreoptic intubation[Sahin etal.EJA2004;21:819-23]– NoMILS– Bestpossibleglottic viewachieved– FOIsignificantlylessmovementatC1/2(8°)butnotC2/3comparedtodirectlaryngoscopy
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Assumptions1. Permissivehypotensionreducesmortalityfollowing
trauma2. Normalisation ofbloodpressurewillworsen
uncontrolledhaemorrhage aftertrauma
3. PermissivehypotensionisappropriateforUKpatientsmanagedinaMTC
4. Shortperiodsoflowcerebralperfusionarewell-toleratedbytraumapatients
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Assumption1
“Permissivehypotensionreducesmortalityfollowingtrauma”
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FluidadministrationintraumatichaemorrhageKwanIetal.CochraneLibrary2014;3:CD002245
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Assumption2
“Normalisation ofbloodpressurewillworsenuncontrolledhaemorrhage aftertrauma”
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PermissivehypotensionintraumatichaemorrhageMorenoDHetal.CochraneLibrary2015;5: CD011664Penn-Barwell JGetal.J Trauma2015;78:1014–20.
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Assumption3
“PermissivehypotensionisappropriateforUKpatientsmanagedinaMTC”
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Assumption4
“Shortperiodsoflowcerebralperfusionarewell-toleratedbytraumapatients”
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HypotensionintraumaticbraininjuryBerryCetal.Injury2012;43:1833–7.
BrennerMetal.JournalofTrauma2012;72:1135–9.
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Summary• Maximalinsulttothespinalcordoccursatthetimeofinjury
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Summary• Maximalinsulttothespinalcordoccursatthetimeofinjury
• Securetheairwaycarefullywithwhatevertechniquethatworksbestinyourhands
• Permissivehypotensionisnotatreatmentbutawarning
• UnlesspenetratingtraumaMAP>80mmHgmaybeoptimalifTBIsuspected
