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Department of Emergency Medicine

Department of Emergency Medicine

2012 - May R3 Journal Review

 Hyacinthe AC, Payen JF, et al.. Diagnostic accuracy of ultrasonography in the acute assessment of common thoracic lesions after trauma. Chest. 2012 May;141(5):1177-83. This paper compared the accuracy of a clinical examination and portable CXR in a supine trauma patient to focused thoracic ultrasound exam in the acute assessment of pneumothorax, hemothorax and lung contusion. It was a prospective observational cohort study over 2 years at a Level 1 Trauma Center. They enrolled all comers sequentially. Patients were included if their admission to the ED indicated a thoracic CT scan within 6 hours of their initial trauma. If so, the patients required a focused clinical exam, CXR and thoracic ultrasound within 90 min of the CT scan. The examiners used their exam and CXR to determine a quartile answer to determine if they could diagnose a PTX, HTX or contusion (1=unlikely, 2= probably not, 3= likely & 4= definitely). A total of 137 consecutive patients were screened and 18 were excluded. (11 had CT’s not reviewed by the radiologist, two had no indication for a CT scan and five patients had the thoracic ultrasound after the CT examination or chest tube). The ultrasound operators had to have at least 50 thoracic scans previously and they compared their US results to CT chest or chest tube placement as the gold standard. 

The results were given as area under the curve plots and showed that using ultrasound to detect pneumothorax and lung contusion had a significantly greater area under the curve that clinical exam + CXR alone (P < .05) when CT was used as a gold standard. No significant difference was found for detection of hemothorax (P = .09) though. Of note, there were 25 PTX’s that were missed on US. Fifteen of them were only small pleural air bubbles, eight were not accessible (eg, retrosternal, in the posterior mediastinal region or beneath a bandage) and two occurred in lung fields with subcutaneous emphysema which they hypothesized limited the US ability. Only one pneumothorax was missed on thoracic ultrasonography that subsequently required a chest tube according to the CT scan; in that case, there was a 1-hour delay between thoracic US exam and the CT scan in a patient with subcutaneous emphysema, so likely it had grown from initial injury. There were 22 missed hemothoraces, 20 were minimal (although they don’t quantify what this means) and located posteriorly and two occurred in lung fields with subcutaneous emphysema. Only one hemothorax was missed by thoracic ultrasonography that subsequently required a chest tube according to the CT scan; in that case, the chest tube was initially placed to drain an anterior pneumothorax in a lung field with subcutaneous emphysema which the US did detect. Of the 57 undiagnosed lung contusions, 35 were minimal (again, unclear what counts as minimal) and/or posterior, 13 were not accessible to ultrasound (eg, retrosternal or paravertebral), and two lung contusions occurred in lung fields with substantial subcutaneous emphysema leaving a total of seven lung contusions that were missed by US. 

This paper supports the hypothesis that thoracic ultrasonography is more accurate than clinical examination and portable CXR when compared to CT scans in a supine chest trauma patient. Of note, hemothorax may elude diagnosis with US alone as using it to rule out pulmonary contusion should be considered, although it may be helpful in confirming suspected diagnoses of contusion.

- Hastings

Jalili M, Fathi M, Moradi-Lakeh M, Zehtabchi S.   Sublingual Buprenorphine in Acute Pain Management: A Double-Blind Randomized Clinical Trial.  Ann Emerg Med. 2012 April. 59(4):276-280. Acute pain is a common complaint in the Emergency Department.  Appropriate pain control has been shown to be delayed in significant percentage of ED patients for a number of reasons, and easy-to-administer and fast-acting medications are appealing to physicians, nursing staff, and for patient satisfaction.  Morphine Sulfate is the prototypic analgesic used in acute pain management in the ED, but has been associated with respiratory depression, CNS depression, hypotension, and GI problems, and it is usually administered in IV form.

Buprenorphine is an agonist-antagonist of opioid receptors with 25 to 40 times greater potency than that of morphine.  It has been used for opioid detoxification, cancer-related pain, and post-op pain control.  

This is a double-blind, placebo-controlled, randomized clinical triage that compares the efficacy and safety of sublingual buprenorphine with that of IV morphine sulfate in adult ED patients with acute fracture pain.  Included patients were 16 years or older, with acute extremity fracture(s) and pain numeric rating of higher than 3/10.  

143 patients randomly were assigned to either 0.4 mg SL buprenorphine tablet plus 5mL of saline, or 5mg IV morphine sulfate plus 1 SL placebo.  Their pain (0-10 pain scale) was assessed at baseline, and then at 30 and 60 minutes after analgesic was administered (Primary outcome =efficacy).  Adverse effects (secondary outcome) were also recorded including: respiratory depression (rate below 12 breaths/min) and CNS depression, hypotension (decrease of more than 20mmHg), nausea, vomiting, dizziness, and headache.  

Results showed that pain scores were similar between groups at 30 and 60 minutes after med administration.  Frequency of nausea and dizziness were similar between groups.  More hypotension was observed with the Morphine group (9 vs 2, P=0.02). In either group, they did not observe decreased LOC, respiratory depression, oxygen desaturation, seizure, or vomiting, and no naloxone was administered.  

Limitations include: that it was only conducted on patients who could actively participate and did not include intoxicated patients, multi-trauma patients.  Also, fixed doses of the medications were used, when it would have been preferable to use weight-adjusted doses.  It only looked at acute pain associated with bone fracture. 

In review, the study suggests that sublingual buprenorphine can decrease acute fracture pain in ED patients as effectively as IV morphine, with similar safety profile.  Because sublingual dosing allows for easier and quicker administration, this may be an attractive alternative to IV morphine for acute pain management in the ED.  This is also promising for patients with difficult IV access, who can experience a delay in adequate pain control.  Further studies need to be conducted to evaluate this medication in other settings such as abdominal pain, headache, or renal colic. 

- Schutz

 Galvagno SM, Elliott RH, Zafar SN, et al. Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma.  JAMA. 2012 Apr 18; 307(15): 1602-1610. This retrospective cohort study involved 223,475 patients older than 15 years old, having an injury severity score higher than 15, and sustaining blunt or penetrating trauma that required transport to US level I or II trauma centers between 2007-2009 whose data were recorded by the American College of Surgeons National Trauma Data Bank (NTDB).  The use of the NTDB, which collects data from more than 900 centers in the US, makes it a multi-center study.  Patients were eligible for inclusion if they had certain trauma-related ICD-9-CM codes, were older than 15 years old, were admitted to a level I or II trauma center, and had an Injury Severity Score (ISS) higher than 15.  Analysis was restricted to records with complete information regarding transportation and disposition information.  Patients were excluded if they died prior to reaching the ED, or came by private vehicle, walked-in, or came by police.  Primary intervention was transport by either helicopter or ground EMS.  Primary outcome was survival to hospital discharge, with evaluation by three different multivariate logistic regression models, one standard (Model 1), one with robust variance calculations to control for clustering by trauma center (Model 2), and one other incorporating the results of propensity score matching (Model 3).

Unadjusted mortality was significantly higher for those transported by helicopter than by ground, however a higher proportion of both level I and level II patients transported by helicopter had an ISS higher than 24.  These patients also had statistically significantly higher heart rates, lower GCS motor scores, lower respiratory rates, and lower systolic blood pressures compared with patients transported by ground EMS.  However, in all regression models, helicopter transportation was associated with a statistically significantly greater odds of survival (Model 1: OR 1.31, 95% CI 1.27-1.38, P<.001, Model 2: OR 1.38, P<.001; Model 3:OR 1.16, P<.001).  Secondary results showed that fewer patients in the helicopter groups were discharged home without services, and that a higher proportion of the helicopter group was discharged to rehabilitation or intermediate facilities.  Also fewer patients in the helicopter group left the hospital AMA.

The overall impact of this study is limited, especially given its many limitations: observational study, non-randomized, data from trauma registry (described as convenience sample, may not represent a population-based sample), lots of missing data in the NTDB, possibly not at random.  It is interesting to note that despite having generally sicker trauma patients in the helicopter, these sick patients tended to do better than their ground-based EMS counterparts.  The reason is not yet clear, whether it is due to faster transport times, better trained crew, or otherwise, and future studies may better elucidate this.  This study is applicable to our patient population, but unlikely to change how we do anything in the department itself.

- Ang

Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012 Jun;59(6):460-468.e7. The use of anticoagulants and antiplatelets (warfarin and clopidogrel) is increasing. Previous studies show patients on warfarin are at increased risk for traumatic ICH on initial CT scan, but there is limited data on risk of delayed traumatic ICH as well as limited data on risk of traumatic ICH for patients on clopidogrel. This study’s aim was to determine the prevalence of immediate traumatic intracranial hemorrhage and the incidence of delayed traumatic intracranial hemorrhage in patients taking clopidogrel or warfarin who have blunt head trauma. This was a prospective, observational, multicenter study conducted at 2 trauma centers and 4 community hospitals in northern California. Adults ≥18 years ED patients with blunt head trauma and pre-injury warfarin of clopidogrel use (within the previous 7 days) were enrolled. Patients were excluded when they were transferred from outside facilities with known traumatic ICH, or if there were on both warfarin and clopidogrel. Imaging All patients had 14 day follow-up to assess for documented of clinical evidence of delayed traumatic ICH.  If patients were unable to be contacted, the Social Security Death Index was reviewed to evaluate for death.

1,101 patients were enrolled in the study between April 2009 and January 2011. 37 patients were excluded for being on both clopidogrel and warfarin, leaving 1,064 patients for analysis. 1,000 of these patients received initial head CT. 70 of the 1,000 patients had immediate ICH. Prevalence of immediate traumatic ICH was higher in patients receiving clopidogrel (12%) than warfarin (5.1%).  Follow-up was obtained for 63/64 patients who did not have initial head CT and none had a follow-up diagnosis of traumatic ICH. The prevalence of immediate traumatic ICH was higher at the Level I trauma center (12.6%) when compared with the Level II trauma center (5%), and the 4 community centers (5.4%). Delayed traumatic ICH was identified in 0.6% of patients receiving warfarin and 0% of patients receiving clopidogrel. Stratified and sensitivity analyses were performed assess validity of results—they confirmed an increased risk of immediate traumatic ICH in patients receiving clopidogrel compared with warfarin. Limitations of this study include that it was an observational study and not all patients underwent CT imaging—therefore there are patients with potentially undiagnosed initial traumatic ICH—even though none were identified in follow-up. Also, since no imaging was mandatory there were potentially patients with initial negative head CT who may have eventually developed and undiagnosed delayed traumatic ICH. Also, aspirin use was not included in this study and concomitant use of aspirin and clopidogrel may have attributed to higher prevalence of traumatic ICH.            

This study has a large impact on our day-to-day practice. It showed that the prevalence of immediate traumatic ICH in patients on clopidogrel is higher when compared to patients on warfarin. There are no current guidelines for patients on clopidogrel and this study can help base evidence based practice. In addition, this study is also useful because it included both trauma centers and actually majority of patients were from community hospitals, therefore is a realistic patient population for most practicing physicians. It also showed that the incidence of delayed traumatic ICH is very low, therefore it would suggest that patients with normal head CTs who are anticoagulated, d/c home from the ED with follow-up and return precautions is reasonable.

- Rockford