Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine - Latest Comments

Comment for the article: 'Avoiding iatrogenic thrombo-embolism: the 'KAPLIT' technique'

Sohan Solanki — 2012-06-11T14:26:57Z

Editor,
We read with interest the Letter to the Editor by Chaudhary K et al. [1] entitled `Avoiding iatrogenic thrombo-embolism: the 'KAPLIT' technique¿. This is a good technique for prevention of back flow of blood into intravenous tubing when non invasive blood pressure cuff and intravenous line are on same limb. This technique has been used routinely at many centers including ours for a long time by anesthesia providers. It cannot be labeled as an innovative technique precisely because there is nothing new in this technique, neither in terms of common awareness nor in terms of documentation in literature. This so called KAP-LIT technique (may be on the name of first two authors of this article) for prevention of backflow of blood into the intravenous tubing, has been mentioned in literature 2 decades ago first by Brin EN et al. [2] and later also by Wait CM [3]. Our concern is that authors of the article should have mentioned the original idea of the previous articles in there discussion and should not give their name to a technique well documented in literature and subject of general awareness.

We would rather appreciate Kondo M et al. [4] also describing an alternative interesting and innovative technique for prevention of back flow of blood into intravenous line that can be assembled from easily available means inside the operating room.

References:
1. Chaudhary K, Gupta L, Anand R. Avoiding iatrogenic thrombo-embolism: the 'KAPLIT' technique. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2010;18:53
2. Brin EN, Lewin TC, Brin JA. A simple method for reducing backup of blood into intravenous lines caused by inflation of a blood pressure cuff. Anesth Analg. 1990;71:569.
3. Wait CM. Blood pressure measurement and intravenous infusion. Anesthesia. 1992;47:1012.
4. Kondo M, Nomura R, Enoki T. A simple device to prevent back flow of blood into the intravenous line. Anesthesiology. 1998;88:1693.

Authors:
Sohan Lal Solanki, MD; Vipin Kumar Goyal, MD
Senior Residents, Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow-Uttar Pradesh (India)
Correspond to:
Sohan Lal Solanki, MD
Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow-Uttar Pradesh (India)
Email: me_sohans@yahoo.co.in
Phone: +918004904603

The benefit of additional active warming in trauma patients deserves further research.

Peter Lundgren — 2012-03-09T13:48:35Z

Authors: Peter Lundgren, Otto Henriksson, Peter Naredi and Ulf Bjornstig

Affiliation: Division of Surgery, Department of Surgery and Perioperative Sciences, Umea University, Sweden.

Admission hypothermia is an independent predictor of increased mortality and morbidity in trauma patients and early application of adequate insulation to reduce heat loss and prevent body core cooling is an important part of prehospital trauma care (1). In addition, most guidelines on protection against cold also suggest the application of active external warming, to aid in protection of further cooling during evacuation and transportation to definitive care (2). Previous laboratory studies on mildly hypothermic shivering subjects have found that exogenous skin heating attenuates shivering heat production by an amount equivalent to the heat donated (3-6). Thus, in a mildly hypothermic shivering victim, external warming is not likely to decrease afterdrop or increase rewarming rate, however it might provide other advantages including increased comfort, decreased cardiac work and preserved substrate availability.

Accordingly, in this study on lucid trauma patients with a mean initial body core temperature of 35.4 plus or minus 1.0 degree Celsius and preserved shivering capacity, additional active warming using a large chemical heat pad applied to the upper torso provided no advantage over passive warming alone on body core temperature rewarming during prehospital transportation. However, in accordance with the argumentation above, this does not mean that active warming is of no additional benefit to mildly hypothermic conscious trauma patients, as active warming is likely to reduce shivering metabolism, relieving both cardiac and respiratory demands and preserving oxygen availability for vital organs. The statistically significant reduction in heart rate and respiratory rate with additional active warming seen in this study might be an indicator of reduced cold stress, although we do agree on the fact that the clinical relevance of this small reduction might be limited.

Another possible beneficial effect from additional active warming is increased thermal comfort. Although body core temperature was increased in both groups, only 2/3 of the patients assigned to passive warming presented a decrease in cold discomfort whereas all patients assigned to additional active warming presented a decrease in cold discomfort during transportation. This beneficial effect on thermal comfort by application of a chemical heat pad to the upper torso is probably explained by a combination of reduction in shivering thermogenesis and increased skin temperature. There is, opposite to what is suggested in the letter, no reliable relation between cold discomfort and body core temperature (7). We agree that there might be a favourably biased effect on comfort from having a non-blinded additional active warming intervention, but since thermal comfort is a subjective measure, a possible favourably biased effect is desirable and a valuable part of the beneficial effect of active warming.

The objective of this study was to evaluate the effect of active warming intervention, and we choose the chemical heat pad as one of many possible warming devices. Effective heat transfer capacity is mainly dependent on surface area, heat content and duration (8). As pointed out the risk of burn injuries should be carefully considered and thus the surface temperature in contact with wet and cold skin should not be allowed to rise above 45 degrees Celsius (9). In optimal conditions, the chemical heat pad surface temperature reaches about 50 degrees Celsius within 2 minutes after activation and then gradually declines (8). Keeping a thin layer of clothing between the patient and the heat pad or as in this study placing the heat pad in an ordinary pillow-case effectively prevents the risk of a too high initial heat transfer and no adverse effects or events were reported from the use of the chemical heat pad during the study.

Another important factor affecting heat transfer is the thermal conductivity and pressure applied on the skin from the heating device (9). The weight of the chemical heat pad (1.400 g) thus possess an advantage over more lighter chemically or electrically heated thermal blankets or forced-air warming devices. If, in rare cases, this weight restricts breathing of a respiratory compromised patient or prevents assessment of the anterior chest wall, the heat pad can easily be replaced at other areas of high heat transfer capacity such as in the groins, axillae or under the torso. To assure a high protocol consistency we decided to use only one chemical heat pad in this study. However, in cases where an increased thermal transfer is desired, the results from our previous study using a human model for severe hypothermia support the use of an additional heat pad, possibly placed under the upper back (8).

We conclude that in mildly hypothermic trauma patients, with preserved shivering capacity, adequate passive warming (blankets alone) is an effective treatment to establish a slow rewarming rate and to reduce cold discomfort during prehospital transportation. However, the addition of active warming using a chemical heat pad applied to the torso will significantly improve thermal comfort even further and might also reduce the cold induced stress response.

Although recommended in most guidelines, active warming in prehospital trauma care has only been evaluated in a few previous clinical trials and the results are diverging (10,11). All studies are also relatively small and included patients suffer from not more than mild hypothermia. Thus, active warming in prehospital trauma care deserves further research, especially including more severely injured patients suffering from moderate or severe hypothermia.

References

1. Ireland S, Endacott R, Cameron P, Fitzgerald M, Paul E. The incidence and significance of accidental hypothermia in major trauma ¿ A prospective observational study. Resuscitation 2011 March; 82(3): 300-306.
2. Tisherman SA: Hypothermia, cold injury and drowning. In: Peitzman AB (editor). The Trauma Manual. 2. ed. Philadelphia: Lippincott Williams and Wilkins, 2002, pp 404-410.
3. Giesbrecht GG, Bristow GK, Uin A, Ready AE, Jones RA: Effectiveness of three field treatments for induced mild (33.0 degrees Celsius) hypothermia. J Appl Physiol 1987, 63:2375-79.
4. Sterba JA: Efficacy and safety of prehospital rewarming techniques to treat accidental hypothermia. Ann Emerg Med 1991, 20:896-901.
5. Giesbrecht GG, Sessler DI, Mekjavic IB, Schroeder M, Bristow GK: Treatment of mild immersion hypothermia by direct body-to-body contact. J Appl Physiol 1994, 76:2373-9.
6. Vanggaard L, Eyolfson D, Xu X, Weseen G, Giesbrecht GG: Immersion of distal arms and legs in warm water (AVA rewarming) effectively rewarms mildly hypothermic humans. Aviat Space Environ Med 1999, 70:1081-8.
7. Parsons KC. Human thermal physiology and thermoregulation. In: Parsons KC. Human thermal environments: the effects of hot, moderate, and cold environments on human health, comfort and performance. 2. ed. London, UK: Taylor and Francis; 2003, pp 31-70.
8. Lundgren JP, Henriksson O, Pretorius T, Cahill F, Bristow G, Chochinov A, Pretorius A, Bjornstig U, Giesbrecht GG: Field Torso Warming Modalities: A Comparative Study Using a Human Model. Prehosp Emerg Care 2009, 3:371-378
9. Parsons KC. Human skin contact with hot, moderate and cold surfaces. In: Parsons KC. Human thermal environments: the effects of hot, moderate, and cold environments on human health, comfort and performance. 2. ed. London, UK: Taylor and Francis; 2003, pp 350-387.
10. Kober A: Effectiveness of resistive heating compared with passive warming in treating hypothermia associated with minor trauma: a randomized trial. Mayo Clin Proc 2001, 76:369 375.
11. Watts DD: The utility of traditional prehospital interventions in maintaining thermostasis. Prehosp Emerg Care 1999, 3:115-122.

Letter to the Editor

Brian Burns — 2011-10-25T04:11:28Z

Letter to the Editor
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Dear Editor,

I congratulate Dr. Ciapetti et al. for their recently published article in the Journal. (1). It is difficult to make robust conclusions from such a small case series, but this paper does highlight two important points. Firstly, ECMO retrieval can be done safely where there is a well-organised system with appropriately trained medical personnel with large experience in retrieval medicine and ECMO. Secondly, the authors reported 2 episodes of hypoxia (SpO2 less than 90%) in the conventionally transported group. The CESAR trial highlighted the dangers of transporting such patients by conventional ventilation. In that study 3 died prior to transport and 2 died in transport by conventional means. (2) Patients with severe ARDS should often be deemed unsafe for transport without ECMO, particularly where long journeys are envisaged, as in our jurisdiction.
Lastly, the authors stated that ¿little has been written on transport while on ECMO for ARDS in adults; it has been described only in one case report for ARDS-related H1N1¿. This is not the case. We have published on the logistics and safety of ECMO retrieval on 17 patients during the H1N1 pandemic (3) and also on our experience of ECMO retrieval since the ECMO program (4) was established in New South Wales, Australia¿s most populous state. In the latter study, we retrieved 40 patients on ECMO of whom 16 were confirmed or suspected H1N1. These patients had comparable Murray scores (median 3.75[3.5-3.75]) to Dr. Ciapetti¿s cohort over a median distance of 250km. Overall survival to hospital discharge was 85%. We believe that retrieval of patients on ECMO will increase in the future as this lifesaving therapy is brought out of the specialised ECMO centre and to the patient¿s side, wherever that may be.

Yours sincerely,

Dr Brian Burns, Dr. Karel Habig, Dr. Cliff Reid
Greater Sydney Area HEMS,
Ambulance Service of NSW,
Australia.

References

1. Feasibility of inter-hospital transportation using extra-corporeal membrane oxygenation (ECMO) support of patients affected by severe swine-flu (H1N1)-related ARDS. Marco Ciapetti, Giovanni Cianchi, Giovanni Zagli et al, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:32

2. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Peek GJ, Mugford M,Tiruvoipati R et al. Lancet 2009 374:1351-1363

3. Logistics and safety of extracorporeal membrane oxygenation in medical retrieval. Burns BJ, Habig K, Reid C et al. Prehosp Emerg Care. 2011 Apr-Jun;15(2):246-53. Epub 2011 Feb 4.

4. Retrieval of critically ill adults using extracorporeal membrane oxygenation: an Australian experience. Intensive Care Med. 2011 May;37(5):824-30. Epub 2011 Feb 26. Forrest P, Ratchford J, Burns B et al.

Hyperbaric oxygen could be harmful

Heikki Savolainen — 2011-08-20T07:32:09Z

Dear Editor,

The excellent study on delayed neuropsychological sequels after a grave carbon monoxide poisoning (1) does not offer support for a treatment with hyperbaric oxygen gas. It may even be harmful (2).

It is true that oxygen given under pressure shortens the half-life of the CO in the circulation. At ambient pressure (21 % oxygen) it varies 4-5 h while at a 2 atmosphere pressure 100 % oxygen, it is shortened to 30 min.

The benefit of this can be questioned as the neurological complication characterized by central demyelination (3) coincides with glial cell reaction probably due to peroxidative events in an animal model (4). Thus, large oxygen concentrations could aggravate this.

1 Pepe G et al. Delayed neuropsychological sequelae after carbon monoxide poisoning: predictive risk factors in the emergency department. A retrospective study. Scand J Trauma Resusc Emerg Med 2011; 19:16

2 Scheinkestel CD et al. Hyperbaric or normobaric oxygen for acute carbon monoxide poisoning: a randomised controlled trial. Med J Austr 1999; 170: 203

3 Savolainen H, Elovaara E. Effect of carbon monoxide on protein metabolism in mouse brain. Exp Neurol 1977; 57: 374

4 Savolainen H et al. Biochemical effects of carbon monoxide poisoning in rat brain with special reference to blood carboxyhemoglobin and cerebral cytochrome oxidase activity. Neurosci Lett 1980; 19: 319

Comment on 'control' arm of the study

Tim Coats — 2011-04-06T10:35:28Z

I think that it is not good to regard the 0.9% saline dilution as a "control" - this terminology implies that normal saline has no effect on coagulation, which is incorrect.

Different resuscitation fluids (including saline) have different effects on the coagulation system, see:
Impairment of coagulation by commonly used resuscitation fluids in human volunteers. Coats TJ, Brazil E, Heron M, MacCallum PK.
Emerg Med J. 2006 Nov;23(11):846-9).

Resuscitation. 2004 Jan;60(1):101-4.
The effect of hypertonic saline dextran on whole blood coagulation
Coats TJ, Heron M

The effects of commonly used resuscitation fluids on whole blood coagulation.
Coats TJ, Brazil E, Heron M.
Emerg Med J. 2006 Jul;23(7):546-9.

Does calcium cause the different effects of Gelofusine and Haemaccel on coagulation?
Coats TJ, Heron M.
Emerg Med J. 2006 Mar;23(3):193-4.

What is presented in the current paper is actually "The difference between the effects of saline and Hypertonic Saline Hydroxyethyl Starch on coagulation" not "the effect of Hypertonic Saline Hydroxyethyl Starch".

The literature in this area is confusing partly because different investigators have used different 'control' fluids, but not taken into account the effect of the control on coagulation. So it may appear pedantic to object to the word 'control' - but I think that it is an important point if we are to understand the effects of our resuscitation fluids on blood coagulation.

There is a Role of Pre-hospital Advance Life Support in Military Trauma Care

kithsiri senanayake — 2011-01-06T08:14:20Z

It is well proven that there is no benefit of pre-hospital advance life support for the out hospital cardiac arrest by a multicenter randomised control trial that included 5638 patients (1).

However our experience in the military trauma is that the pre-hospital advance life support saves the lives significantly in trauma setting. Sri Lanka successfully eradicated the terrorism by a military mission recently and we experienced as medical personal involving the management of military trauma. In the front line of the battle field injured are rescued, canulated and resuscitated. Needy patients were incubated and CPR given before the hospital. Main priorities were arrest of bleeding, fluid resuscitation and air way management especially intercostal tube insertion. If we were given only the BLS before hospital we would have lost many lives.

References
1. Stiell IG, George A, Brian F, et al. Advanced Cardiac Life support in Out-of-Hospital Cardiac Arrest. N Engl J Med 2004; 351:647-656

Observation on Article

Rick Goulet — 2010-12-01T09:47:22Z

The article is a great read and makes many valid points. However I have read many articles on this in my country as well and it is used I beleive to suppress the advancement of pre-hospital care by missing some very valid points. For example pre-hospital providers witness much pain, N/V seizure activity, drug overdoses, hypoglycemia and the like and in may cases are ill equipped to manage these presentation effectively. I am interested in and never read an article that addressed these issues. I believe BLS providers can be trained to administer such drugs as fentynal, morphine, benedryal, gravol or phenergen, narcan, EPI in Cardiac Arrest. To this end if BLS providers were trained in the above it would save many a dollar in training and the high cost to run a high performance ALS system. I would suggest at least in Canada there is not much movement towards up training BLS prociders to administer simple meds for simple on going everday medical problems in the pre-hospital environment, A thought. Thank YOu

A potential patient's point of view

William Richey — 2010-12-01T09:46:27Z

If I ever need emergency defibrillation, I hope to be in a hospital where the training for nurses proposed in this article has been implemented.

Revised Utstein Trauma Template - User manual

Kjetil G. Ringdal — 2008-12-12T12:35:21Z

The User Manual of the revised Utstein Trauma Template has now been completed and is available for download at http://www.scantem.org/

Kjetil G. Ringdal

Correction: Reference 7 / Pre-hospital airway management guidelines

Harald Genzwuerker — 2008-10-09T17:46:52Z

Unfortunately, there is a small mistake regarding reference 7 ("Pre-hospital airway management: guidelines from a task force from the Scandinavian Society for Anaesthesiology and Intensive Care Medicine."), which is not published in Anesth Analg but rather in Acta Anaesthesiol Scand.

Published in the mean time, the correct reference is:

Berlac P, Hyldmo PK, Kongstad P, Kurola J, Nakstad AR, Sandberg M. Pre-hospital airway management: guidelines from a task force from the Scandinavian Society for Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2008;52:897-907

http://www.ncbi.nlm.nih.gov/pubmed/18702752?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum