In this episode of the St Emlyn's podcast, Ian Beardsell and Simon Carley review the top 10 trauma papers of the year, highlighting key findings and their implications for trauma care. The selection includes significant studies published in high-profile journals such as The Lancet and the New England Journal of Medicine, offering valuable insights for healthcare professionals in emergency and trauma medicine.

1. Whole Body CT Scanning: REACT-2 Study

The REACT-2 study explored the impact of whole-body CT (WBCT) scanning on trauma patients, particularly its effect on mortality rates. The study involved 1400 patients and found no significant difference in mortality between those who received WBCT and those who underwent more selective CT scanning. The difference in radiation exposure was minimal, suggesting that WBCT's comprehensive imaging might be more beneficial than harmful, especially in elderly patients where missed injuries can complicate outcomes. This study reassures trauma team leaders that current scanning practices are appropriate and highlights the importance of a patient-centred approach based on clinical presentation.

2. Impact Brain Apnea (IBA)

Impact brain apnea, characterized by apnea and a catecholamine surge following a severe head blow, has been increasingly recognized in trauma care. The paper, co-authored by John Hines and Mark Wilson, provides a detailed explanation of IBA's pathophysiological mechanisms. This condition can lead to cardiac arrest if not promptly addressed, emphasizing the need for immediate intervention in cases of traumatic brain injury (TBI). Understanding IBA helps emergency care providers identify and treat potentially life-threatening conditions that may not be immediately apparent.

3. Decompressive Craniectomy for Raised ICP: RESCUE-ICP Trial

The RESCUE-ICP trial examined the outcomes of decompressive craniectomy in patients with refractory intracranial pressure (ICP) due to severe TBI. The study found that while the procedure increased survival rates, many survivors experienced significant disability. This raises ethical considerations about the quality of life post-intervention. The trial underscores the importance of informed consent and discussions about potential outcomes with patients' families, aligning treatment with patient values.

4. STITCH Trial: Surgery Timing for Intracranial Bleeds

The STITCH trial focused on the timing of surgical intervention in patients with traumatic intracranial bleeds. Although the trial faced recruitment challenges and was terminated early, results suggested better outcomes with early surgery. This finding, while not statistically conclusive, supports the notion that timely intervention can reduce mortality and improve recovery. Emergency physicians and neurosurgeons should consider these findings when deciding on surgical timing in TBI cases.

5. Traumatic Cardiac Arrest: Epidemiology and Outcomes

Using data from the Trauma Audit and Research Network (TARN), this study examined traumatic cardiac arrest (TCA) cases, revealing a 30-day survival rate of 7.5%. This rate, similar to medical cardiac arrests, challenges the perception that TCA is almost always fatal. The study highlights the importance of aggressive resuscitation efforts and underscores the need for ongoing training to retain skills in managing these rare but critical events.

6. Open vs. Closed Chest Compressions in TCA

The effectiveness of open chest (thoracotomy) versus closed chest compressions in TCA was explored, with findings indicating similar outcomes in terms of end-tidal CO2 levels, a marker for effective CPR. This challenges the notion that thoracotomy should always be performed in TCA cases. The study suggests that standard advanced life support (ALS) protocols may suffice in certain scenarios, especially where thoracotomy is not practical.

7. Rocuronium vs. Succinylcholine for RSI in Severe Brain Injury

The choice between rocuronium and succinylcholine for rapid sequence intubation (RSI) in severe brain injury remains debated. An observational study found no significant overall difference in mortality between the two drugs, though succinylcholine was associated with higher mortality in severe head injury cases. This suggests a possible preference for rocuronium in such scenarios, though the evidence is not strong enough to mandate a change in practice.

8. Intraosseous Needle Length in Obese Patients

As obesity becomes more prevalent, appropriate intraosseous (IO) needle length is crucial for effective vascular access. The study recommended using longer yellow IO needles for patients with a BMI over 43, as standard blue needles may not reach the marrow. This is particularly important in emergency situations where IV access is difficult, ensuring proper drug administration and preventing complications like compartment syndrome.

9. Optimal Site for Needle Decompression in Tension Pneumothorax

A systematic review recommended the anterior axillary line as the preferred site for needle decompression in tension pneumothorax, aligning with standard chest drain placement. The review also noted significant complication rates associated with needle decompression, suggesting that alternative methods like thoracostomy may be necessary in certain cases. This finding emphasizes the need for precise technique and careful consideration in managing tension pneumothorax.

10. Weekend Effect in Major Trauma Care

The study examined the "weekend effect" in major trauma care, finding no significant difference in mortality between weekend and weekday admissions. This suggests that well-resourced, consultant-led trauma care can provide consistent outcomes regardless of the day. The findings advocate for the 24/7 availability of senior emergency physicians and trauma teams, ensuring high-quality care at all times.

Conclusion

This year's top trauma papers provide valuable insights into current practices and emerging trends in trauma care. While there may not have been groundbreaking changes, the studies reinforce the importance of evidence-based decision-making, ongoing training, and ethical considerations in patient management. As the field evolves, staying informed about the latest research is crucial for improving patient outcomes and delivering high-quality trauma care. For further details and access to the studies, visit the Sentemlin site and related FOAMed resources.

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Ep 90 - Top Ten Trauma Papers 2016