1. Recent Articles In Trauma
Dr.JSK Chaitanya
DNB (Gen Medicine), IDCCM, EDIC
Consultant Intensivist
Royal Care Superspeciality Hospital,Coimbatore

2. PAMPER TRIAL
POLAR-RCT
Permissive hypotension in critically ill haemorrhagic shock patients
Betablockers in severe TBI
ATLS UPDATES
ZERO POINT SURVEY

3. PAMPER TRIAL
NEJM July 2018

5. What is already known
An initial, warmed fluid bolus of isotonic fluid. The usual dose is 1 liter for adults for patients in hemorrhagic shock – ATLS 10TH EDITION

6. PAMPER TRIAL
Why ?
To determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock.
How?
Pragmatic , multicenter, cluster-randomized, phase 3 superiority trial that compared the administration of thawed plasma with standard-care resuscitation during air medical transport.
What?
Primary outcome was mortality at 30 days.

7. PAMPER TRIAL Team in ambulances screened and enrolled patients
Randomisation was of air medical services (2 to 6 bases or helicopters per service), and not individual patients.
These were block randomized and assigned to the plasma arm or standard care (control) arm for 1 month at a time.
No blinding of prehospital and hospital staff, but trial assessors were blinded
Assuming a 1:1 randomization of 32 clusters or 16 patients each, 530 patients (504 eligible patients with complete data) would provide the trial with 88% power to detect a difference of 14 percent age points (8.0% vs. 22.0%) in 30-day mortality
Statistical significance for the primary analysis (P<0.038) was adjusted for two interim analyses by the external data safety monitoring board

8. PAMPER TRIAL Inclusion: Blunt or penetrating trauma patients, and
Transported from a scene of their injury or from an outside referral ED to a participating trauma centre, and
At risk of haemorrhagic shock, as defined by at least one episode of:
Hypotension (systolic blood pressure <90mmHg) and tachycardia (HR>108/min)
Severe hypotension (systolic blood pressure <70mmHg)

9. Exclusion: >90 years old or <18 years old
Unable to establish IV or IO access
Isolated fall from standing
Documented cervical cord injury
Known to be a prisoner
Pregnant
Traumatic cardiac arrest >5 minutes
Penetrating brain injury
Isolated drowning or hanging
>20% TBSA burns
Admitted to an outside referral hospital
Patient or family member objected to participation in the trial at the scene

10. PAMPER TRIAL A total of 501 patients were enrolled
390 enrolled directly at scene, while 111 transferred from a non-trauma centre emergency department
72.7% were men
Median age 45 years old
82.4% had blunt trauma
High risk trauma population
Median injury severity score 22 (13-30)
Median MAP 70 Median HR 116
Prehospital intubation in 51.1%
34.7% received prehospital red blood cells
58.4% had urgent operations in initial 24hours
Overall mortality 29.6%
Similar baseline demographics, prehospital vital signs, and injury scores in all areas except
Prehospital crystalloid was lower in plasma group median 500mls (0-1250) vs 900mls (0-1500)
Prehospital RBC transfusion was lower in plasma group 26.1% vs 42.1%

11. PAMPER TRIAL Intervention
Air medical bases randomized to the intervention were provided with 2 units of thawed plasma stored in coolers with a temperature between 1 to 10 degrees (either group AB (“universal donor”) or group A with a low anti-B antibody )
Plasma was initiated in prehospital setting by air transport team before other resuscitative fluids were given
The infusion was required to be completed once started
Following completion of the plasma, goal directed resuscitation as described below continued until arrival at trauma centre, including the infusion of crystalloids and or RBCs
Control
Goal-directed, crystalloid-based resuscitation targeting a systolic blood pressure of ≥90mmHg
This was not standardised, but was guided by local  air ambulance protocols
Management common to both groups
In addition to above crystalloid resuscitation, 13/27 air transport teams also carried 2 units of universal donor red cells
RBC transfusion was indicated if after 1L of crystalloid there was ongoing
Hypotension with systolic blood pressure <90mmHg
Changes in mental status
Tachycardia with heart rate >120 beats per minute
Capillary refill >2 seconds

12. Primary outcome
30 day Mortality -(23.2% vs. 33.0%; difference, −9.8% ;p = 0.03
The Kaplan– Meier survival curves showed an early separation of the two groups that began 3 hours after randomization and remained until 30 days (720 hours) after randomization P = 0.02

14. Secondary outcomes

15. Does it change the way I manage?
In patients at risk for hemorrhagic shock, the administration of thawed plasma during prehospital air medical transport was safe and resulted in lower 30-day mortality and a lower median prothrombin-time ratio than standard-care resuscitation.

16. POLAR TRIAL
JAMA, October 2018

18. What is already known
Lewis SR, Evans DJW, Butler AR, Schofield-Robinson OJ, Alderson P.Hypothermia for traumatic brain injury.Cochrane Database of Systematic Reviews2017, Issue 9. Art. No.: CD

19. POLAR TRIAL
Why?
To determine the effectiveness of early prophylactic hypothermia compared with normothermic management of patients after severe traumatic brain injury.
How?
Multicenter randomized trial in 6 countries that recruited 511 patients both out-of-hospital and in emergency departments after severe traumatic brain injury.
What?
Favorable neurologic outcomes or independent living (Glasgow Outcome Scale–Extended score, 5-8) obtained by blinded assessors 6 months after injury.

20. POLAR TRIAL INCLUSION CRITERIA EXCLUSION CRITERIA
Eligible patients with head injuries were estimated to be
aged 18 to 60 years
had a GCS of less than 9
actual or imminent endotracheal intubation
EXCLUSION CRITERIA
Significant bleeding suggested by systolic hypotension (<90 mm Hg) OR Sustained tachycardia (>120/min)
Suspected pregnancy
Possible uncontrolled bleeding,
GCS – 3 and unreactive pupils
Destination hospital not a study site

21. POLAR TRIAL BASELINE CHARACTERSTICS Predominantly men
Mean age of 34.5 years (SD, 13.4)
Median Glasgow Coma Scale score of 6
The majority of patients (70.6%) had diffuse brain injury (brain swelling or hemorrhages, without subdural or extradural brain hematomas),
The median time from injury to randomization was 1.9 hours

22. POLAR TRIAL INTERVENTION HYPOTHERMIA INDUCTION MAINTENANCE
patient exposure,
a bolus of up to 2000 mL intravenous ice-cold (4°C) 0.9% saline
surface-cooling wraps targeting an initial core temperature of 35°C and 33 °C after excluding significant risks for bleeding.
MAINTENANCE
Maintained at 33°C (or 35°C if bleeding concerns persisted) with a Gaymar Meditherm 3 console with surface-cooling wraps for at least 72 hours after randomization.
Can be rewarmed to 35 °C if hemodynamic instability or bleeding occurs.

23. POLAR TRIAL REWARMING NORMOTHERMIA
If the ICP <20 mm Hg, gradual controlled rewarming was commenced at a target rate up to 0.25°C/h.
If the ICP> 20, recooled , assessed again for reduction in ICP
Maximum duration of 7 days.
patients were maintained normothermic with automated surface-cooling wraps for up to 7 days postrandomization
NORMOTHERMIA
Temperature target was 37°C ― 0.5°C.
Surface-cooling wraps could be used to manage pyrexia or refractory intracranial hypertension
General managent based on international TBI guidelines

24. POLAR TRIAL
No significant differences in primary outcomes or in secondary outcomes

25. Does it change the way I manage?
Among patients with severe traumatic brain injury, early prophylactic hypothermia compared with normothermia did not improve neurologic outcomes at 6 months.
These findings do not support the use of early prophylactic hypothermia for patients with severe traumatic brain injury.

26. Permissive Hypotension vs
Permissive Hypotension vs. Conventional Resuscitation Strategies in Adult Trauma Patients with Hemorrhagic Shock: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

28. What is already known
In patients with hemorrhagic shock, permissive hypotensive resuscitation is adviced prior to achieving hemostasis when ICP is not raised.- ATLS 10TH edition
Level of Evidence –III

29. only randomized studies
Studies evaluating adult patients with penetrating or blunt traumatic injury and suspicion of hemorrhage
Both civilian and military
Isolated head injuries excluded.
only randomized studies

30. 4 of the studies showed reduced mortality but for only one study with significance.

32. 3 trials recorded lesser blood product tx
2 trials recorded higher crystalloid requirement in control arm
2 trials recorded lesser blood loss estimates

33. Does it change the way I manage
Based on the pooled findings of five randomized controlled trials, a survival benefit for lower blood pressure targets as compared to conventional resuscitation thresholds is noted.
Patients receiving permissive hypotension have
lower reported blood loss volumes
reduced blood product utilization
lower volumes of crystalloid administration
Ideal blood pressure target for such a strategy remains unclear.
Level of evidence – level II

34. ATLS
TENTH EDITION

38. What is already known
TBI management guidelines emphasize on prevention of secondary injuries like hypoxia or hypothension.
Evidence in prevention of progression of secondary injuries so far have not yielded much of results

39. What?
Hypothesis that beta blocker use after TBI is associated with lower mortality, and secondarily compared propranolol to other beta blockers.
How ?
Multi - institutional,prospective, observational trial in which adult TBI patients who required ICU admission were compared based on beta blocker administration

40. Inclusion criteria
Age > 18 years
Blunt traumatic injury
CT of the brain demonstrating an acute TBI
ICU admission at presentation.
Sample size calculation was based on an overall mortality of 10% for a similar group of TBI patients who survived until ICU admission

41. Fishers test
Student's t test or Mann-Whitney U-test
Multivariate logistic regression analysis
p < 0.05 was considered statistically significant
The primary outcome was 30-day mortality.
Secondary outcomes – GOS (4-5 VS 1-3 ) , HOSPITAL LENGTH OF STAY

44. Limitations of the study
Management of TBI was not uniform among study sites.
The optimal type and dose required has yet to be delineated.
Differences in the baseline characteristics of the cohorts - addressed by multivariate regression
Selection bias
Lack of data on other interventions.

45. Does it change the way I manage?
Administration of beta blockers after TBI was associated with improved survival, before and after adjusting for the more severe injuries observed in the treatment cohort
Level of Evidence : Level III

46. Zero point survey
Clin Exp Emerg Med 2018;5(3):

48. Current understanding
Standard resuscitation teaching begins with the primary survey.
No technical skills- rarely taught
Environmental aspects- often left out.

49. COGNITIVE ROADMAP FOR RESUSCITATION
PRIMARY SURVEY
IDENTIFY
PRIORITISE threats to life
TEMPORIZE
TEAM
ENVIRONMENT
EQUIPMENT
COGNITIVE ROADMAP FOR RESUSCITATION

50. Why is it important? More complex frail patients Large teams
Changing personnel
Diagnostic ambiguities
Cognitive bias
FACILITATE PROBLEM IDENTIFICATION
ERROR AVOIDANCE
SITUATION AWARENESS
BETTER PLACEMENT OF EQUIPMENT
SAFE ENVIRONMENT
ZERO POINT SURVEY
BETTER TEAM RESILIENCE
SUCCESFUL OUTCOME

51. When and where? When? Where? Start of the shift
Prior to arrival of the patient
During resuscitation in dynamic scenarios
Where?
Emergencies
ICU’s
OT’s
Rapid response teams
Code Blue teams

53. Self check physical Personal readiness Cognitive TEAM LEADER
Illness
Medication/drugs
Stress
Alcohol
Fatigue
Eating/elimination
Cognitive
BREATHE
TALK
SEE
FOCUS
Team readiness
TEAM LEADER
ASSIGNMENT OF ROLES

54. TEAM BRIEF
TASK WORK
What needs to be done?
TEAM WORK
How the team works ?
UPDATES
PRIORITIES

55. “Is there enough space to safely manage this patient?
ENVIRONMENTAL SCAN
DANGERS
COMBATIVE PATIENT
EXPOSED BODY FLUIDS
TRIP/FALL HAZARDS
SPACE
“Is there enough space to safely manage this patient?
LIGHT
NOISE
CROWD

56. PS could also benefit from a prequel
Take home
Non-technical skills and human factors are increasingly recognized as critical ingredients in the success or failure of acute care delivery .
Increase the likelihood of patient rescue and to help create and maintain robust resuscitation teams.
PS could also benefit from a prequel
ZERO POINT SURVEY

57. TEAM WORK WORKS
THANK YOU