Teaching Methods Utilized During Medical Resuscitations in an Academic Emergency Department.

INTRODUCTION: One important skill that an emergency medicine trainee must learn is the resuscitation of the critically ill patient. There is research describing clinical teaching strategies used in the emergency department (ED), but less is known about specific methods employed during actual medical resuscitations. Our objective was to identify and describe the teaching methods used during medical resuscitations. METHODS: This was a prospective study involving review of 22 videotaped, medical resuscitations. Two teams of investigators first each reviewed and scored the amount and types of teaching observed for the same two videos. Each team then watched and scored 10 different videos. We calculated a Cohen's kappa statistic for the first two videos. For the remaining 20 videos, we determined means and standard deviations, and we calculated independent two-tailed t-tests to compare means between different demographic and clinical situations. RESULTS: The Cohen's kappa statistic was K=0.89 with regard to number of teaching events and K=0.82 for types of teaching observed. Of the resuscitations reviewed, 12 were in coding patients. We identified 148 episodes of teaching, for an average of 7.4 per resuscitation. The amount of teaching did not vary with regard to whether the patient was coding or not (p=0.97), nor based on whether the primary learner was a junior or senior resident (p=0.59). Questioning, affirmatives and advice-giving were the most frequently observed teaching methods. CONCLUSION: Teachers use concise teaching methods to instruct residents who lead medical resuscitations. Further research should focus on the effectiveness of these identified strategies.

FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation.

OBJECTIVE: The objective of this study was to examine the ability of Focused Assessment Using Sonography for Trauma (FAST) to discriminate between survivors and nonsurvivors undergoing resuscitative thoracotomy (RT). BACKGROUND: RT is a high-risk, low-salvage procedure performed in arresting trauma patients with poorly defined indications. METHODS: Patients undergoing RT from 10/2010 to 05/2014 were prospectively enrolled. A FAST examination including parasternal/subxiphoid cardiac views was performed before or concurrent with RT. The result was captured as adequate or inadequate with presence or absence of pericardial fluid and/or cardiac motion. A sensitivity analysis utilizing the primary outcome measure of survival to discharge or organ donation was performed. RESULTS: Overall, 187 patients arrived in traumatic arrest and underwent FAST. Median age 31 (1-84), 84.5% male, 51.3% penetrating. Loss of vital signs occurred at the scene in 48.1%, en-route in 23.5%, and in the ED in 28.3%. Emergent left thoracotomy was performed in 77.5% and clamshell thoracotomy in 22.5%. Sustained cardiac activity was regained in 48.1%. However, overall survival was only 3.2%. An additional 1.6% progressed to organ donation. FAST was inadequate in 3.7%, 28.9% demonstrated cardiac motion and 8.6% pericardial fluid. Cardiac motion on FAST was 100% sensitive and 73.7% specific for the identification of survivors and organ donors. CONCLUSIONS: With a high degree of sensitivity for the detection of potential survivors after traumatic arrest, FAST represents an effective method of separating those that do not warrant the risk and resource burden of RT from those who may survive. The likelihood of survival if pericardial fluid and cardiac motion were both absent was zero.

Thromboelastogram evaluation of the impact of hypercoagulability in trauma patients.

INTRODUCTION: Admission hypocoagulability has been associated with negative outcomes after trauma. The purpose of this study was to determine the impact of hypercoagulability after trauma on the need for blood product transfusion and mortality. METHODS: Injured patients meeting our level I trauma center's highest activation criteria had a thromboelastography (TEG) performed at admission, +1 h, +2 h, and +6 h using citrated blood. Hypercoagulability was defined as any TEG parameter in the hypercoagulable range, and hypocoagulability as any parameter in the hypocoagulable range. Patients were followed up prospectively throughout their hospital course. RESULTS: A total of 118 patients were enrolled: 26.3% (n = 31) were hypercoagulable, 55.9% (n = 66) had a normal TEG profile, and 17.8% (n = 21) were hypocoagulable. After adjusting for differences in demographics and clinical data, hypercoagulable patients were less likely to require un-cross-matched blood (11.1% for hypercoagulable vs. 20.4% for normal vs. 45.7% for hypocoagulable, adjusted P = 0.004). Hypercoagulable patients required less total blood products, in particular, plasma at 6 h (0.1 [SD, 0.4] U for hypercoagulable vs. 0.7 [SD, 1.9] U for normal vs. 4.3 [SD, 6.3] U for hypocoagulable, adjusted P < 0.001) and 24 h (0.2 [SD, 0.6] U for hypercoagulable vs. 1.1 [SD, 2.9] U for normal vs. 8.2 [SD, 19.3] U for hypocoagulable, adjusted P < 0.001). Hypercoagulable patients had lower 24-h mortality (0.0% vs. 5.5% vs. 27.8%, adjusted P < 0.001) and 7-day mortality (0.0% vs. 5.5% vs. 36.1%, adjusted P < 0.001). Bleeding-related deaths were less likely in the hypercoagulable group (0.0% vs. 1.8% vs. 25.0%, adjusted P < 0.001). CONCLUSIONS: Approximately a quarter of trauma patients presented in a hypercoagulable state. Hypercoagulable patients required less blood products, in particular plasma. They also had a lower 24-h and 7-day mortality and lower rates of bleeding-related deaths. Further evaluation of the mechanism responsible for the hypercoagulable state and its implications on outcome is warranted.

Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax.

OBJECTIVE: To compare the distance to be traversed during needle thoracostomy decompression performed at the second intercostal space (ICS) in the midclavicular line (MCL) with the fifth ICS in the anterior axillary line (AAL). DESIGN: Patients were separated into body mass index (BMI) quartiles, with BMI calculated as weight in kilograms divided by height in meters squared. From each BMI quartile, 30 patients were randomly chosen for inclusion in the study on the basis of a priori power analysis (n = 120). Chest wall thickness on computed tomography at the second ICS in the MCL was compared with the fifth ICS in the AAL on both the right and left sides through all BMI quartiles. SETTING: Level I trauma center. PATIENTS: Injured patients aged 16 years or older evaluated from January 1, 2009, to January 1, 2010, undergoing computed tomography of the chest. RESULTS: A total of 680 patients met the study inclusion criteria (81.5% were male and mean age was 41 years [range, 16-97 years]). Of the injuries sustained, 13.2% were penetrating, mean (SD) Injury Severity Score was 15.5 (10.3), and mean BMI was 27.9 (5.9) (range, 15.4-60.7). The mean difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL was 12.9 mm (95% CI, 11.0-14.8; P < .001) on the right and 13.4 mm (95% CI, 11.4-15.3; P < .001) on the left. There was a stepwise increase in chest wall thickness across all BMI quartiles at each location of measurement. There was a significant difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL in all quartiles on both the right and the left. The percentage of patients with chest wall thickness greater than the standard 5-cm decompression needle was 42.5% at the second ICS in the MCL and only 16.7% at the fifth ICS in the AAL. CONCLUSIONS: In this computed tomography-based analysis of chest wall thickness, needle thoracostomy decompression would be expected to fail in 42.5% of cases at the second ICS in the MCL compared with 16.7% at the fifth ICS in the AAL. The chest wall thickness at the fifth ICS AAL was 1.3 cm thinner on average and may be a preferred location for needle thoracostomy decompression.

Hyperfibrinolysis elicited via thromboelastography predicts mortality in trauma.

BACKGROUND: The acute coagulopathy of trauma has been identified as a critical determinant of outcomes. Antifibrinolytic agents have recently been demonstrated to improve outcomes. This prospective study was designed to assess coagulopathy in trauma patients using thromboelastography. STUDY DESIGN: Trauma patients meeting our institution's highest tier of trauma team activation criteria were prospectively enrolled during a 5-month period ending April 1, 2011. Thromboelastography was performed at admission, +1 hour, +2 hours, and +6 hours using citrated blood. Hyperfibrinolysis was defined as estimated percent lysis ≥15%. Patients were followed throughout their hospital course to collect clinical data and outcomes. RESULTS: One hundred and eighteen patients were enrolled (77.1% were male, 51.7% had penetrating trauma, 7.6% had systolic blood pressure <90 mmHg, 47.5% had Injury Severity Score >16, and 23.7% had Glasgow Coma Scale score ≤8). Hyperfibrinolysis was present in 13 patients (11.0%), with a mean time to detection of 13 minutes (range 2 to 60 minutes). By the 6-hour sampling, 8 (61.5%) of the hyperfibrinolytic patients had expired from hemorrhage. Survivors at this point demonstrated correction of coagulopathy, however, 12 patients (92.3%) ultimately expired (75% hemorrhage, 25% head injury). On stepwise logistic regression, hyperfibrinolysis was a strong predictor of early (24 hours) mortality (odds ratio = 25.0; 95% CI, 2.8-221.4; p = 0.004), predicting 53% of early deaths. Compared with patients without hyperfibrinolysis, patients with hyperfibrinolysis had a greater need for massive transfusion (76.9% vs 8.7%; adjusted odds ratio = 19.1; 95% CI, 3.6-101.3; p < 0.001) and had a greater early mortality (69.2% vs 1.9%; adjusted odds ratio = 55.8; 95% CI, 7.2-432.3; p < 0.001) and in-hospital mortality (92.3% vs 9.5%; adjusted odds ratio = 55.5; 95% CI, 4.8-649.7; p = 0.001). CONCLUSIONS: In this prospective analysis, hyperfibrinolysis on thromboelastography developed in approximately 10% of patients and was considerably more likely to require massive transfusion. Hyperfibrinolysis was a strong independent predictor of mortality. Additional evaluation of the role of thromboelastography-directed antifibrinolytic therapies is warranted.

Ten years of mechanical complications of central venous catheterization in trauma patients.

The study purpose was to determine the incidence of mechanical complications (MC) associated with central venous catheterization (CVC) and to evaluate their impact on outcomes. This was a retrospective review of trauma morbidity and mortality records at a Level I trauma center (1999 to 2009). Demographics and outcomes were extracted for all trauma patients with CVC. Patients developing MC were compared with those who did not. Four thousand eight hundred eighteen lines were placed in 2935 patients. Of these, 1.5 per cent (n = 73) had MC. A total of 64.4 per cent (n = 47) were pneumothoraces followed by arterial cannulation at 8.2 per cent (n = 6) and thrombosis at 6.8 per cent (n = 5). The rate of MC by access site was: subclavian 1.8 per cent (n = 52), internal jugular 1.2 per cent (n = 10), and femoral 0.3 per cent (n = 3) (P value for trend = 0.001). Change in management was required in 31.5 per cent (n = 23). Number of lines (P < 0.001), Injury Severity Score (P < 0.001), body mass index less than 20 kg/m(2) (P = 0.036), and chest Abbreviated Injury Score greater than 3 (P = 0.034) were significant predictors of MC. Patients with MC had a longer intensive care unit length of stay (18.8 ± 25.7 vs 11.4 ± 13.3; adjusted odds ratio, 5.75; 95% confidence interval, 2.24-9.25; P = 0.001). Incidence of MC was 1.5 per cent. Complications were clinically significant in 31.5 per cent and resulted in longer intensive care unit stays.

Venous thromboembolic events in isolated severe traumatic brain injury.

OBJECTIVE: The purpose of this study was to investigate the effect of prophylactic anticoagulation on the incidence of venous thromboembolic events (VTE) in patients suffering from isolated severe traumatic brain injury (TBI). MATERIALS AND METHODS: Retrospective matched case-control study in adult patients sustaining isolated severe TBI (head AIS ≥3, with extracranial AIS ≤2) receiving VTE prophylaxis while in the surgical intensive care unit from 1/2007 through 12/2009. Patients subjected to VTE prophylaxis were matched 1:1 by age, gender, glasgow coma scale (GCS) score at admission, presence of hypotension on admission, injury severity score, and head abbreviated injury scale (AIS) score, with patients who did not receive chemical VTE prophylaxis. The primary outcome measure was VTE. Secondary outcomes were SICU and hospital length of stay (HLOS), adverse effects of anticoagulation, and mortality. RESULTS: After propensity matching, 37 matched pairs were analysed. Cases and controls had similar demographics, injury characteristics, rate of craniotomies/craniectomies, SICU LOS, and HLOS. The median time of commencement of VTE prophylaxis was 10 days. The incidence of VTE was increased 3.5-fold in the controls compared to the cases (95% CI 1.0-12.1, P=0.002). The mortality was higher in patients who did not receive anticoagulation (19% vs. 5%, P=0.001). No adverse outcomes were detected in the anticoagulated patients. CONCLUSION: Prophylactic anticoagulation decreases the overall risk for clinically significant VTE in patients with severe isolated TBI. Prospective validation of the timing and safety of chemical VTE prophylaxis in these instances is warranted.

Rapid Sequence Intubation from the Patient's Perspective.

INTRODUCTION: This study assesses the efficacy of the rapid sequence intubation (RSI) protocol in preventing patient recollection of resuscitative events and patient discomfort during intubation, as subjectively determined by the patient. METHODS: This was a prospective study of all patients intubated at Los Angeles County, University of Southern California Medical Center from July 2009 to January 2010. Extubated patients were interviewed using a standard questionnaire and data collection tool. RESULTS: Of 211 airway codes, 201 were excluded due to death before extubation, transfer, or persistent vegetative state, leaving 10 awake, alert subjects who were interviewed regarding their recollection of the RSI and resuscitation. Five had recollection of the event. Most patients recalling RSI described the event as painful or uncomfortable despite receiving the recommended doses of sedation/induction agents. CONCLUSION: In this cohort of 10 patients intubated using typical agents, 5 remembered some details of their intubation and 2 described pain that was 10/10 on a verbal pain scale. Further work is indicated to ensure that the medications used during this procedure provide the appropriate sedation and amnesia.