Trauma coagulopathy & Head and Spinal injury prediction
Posted by Matthew Mac Partlin on Saturday, January 18, 2014 Under: Clinical topics
Posted by Matthew Mac Partlin on Wednesday, August 1, 2012
If you keep an eye on some of the great critical care blog sites, at some point you will have come accross Cliff Reid's Resus M.E. site. Recently he has put up 2 great posts that should be of interest to all of us who practice medicine and rescue in motor sports.
The first is a presentation given by HEMS doctor, Pete Sherren, on the bleeding trauma patient. He outlines an illustrative pre-hospital case and follows through to the ICU admission. He then follows on with a concise overview of the pathogenesis and management of the Acute Coagulopathy of Trauma Shock (ACoTS or ACT), along with a summary of current and future developments. It's worth stopping at the MIST slide of the case presentation and substituting in a competitive motorbike rider at a circuit or off-road event and then taking a minute or two to consider how you would have managed this case as the first on scene or as the event CMO. What interventions could you have initiated with your current kit? What would have been your evacuation plan? What other concerns might you have had?
The second post is a quick review of 2 papers that evaluated a European trauma dataset to attempt to identify predictors of whole and cervical vertebral and spinal cord injury. You might notice that our motor sport population fit at least 3 of the predictive associations (Age <45yo, sports injuries and road traffic collisions) with male gender probably also being over-represented.
Medicine and Rescue at motorsport events is often provided at two levels. There's the well-meaning and enthusiastic volunteer who shows up with a variable level of trauma experience and equipment, usually to the local club or state event, but may also join a rescue agency for a particular event. Then there's the dedicated motor sport rescue agencies that generally cover state, national and international events, but also some club races. These agencies are usually composed of people with at least some level of pre and/or in-hospital trauma experience and more tailored clinical and rescue equipment. Both intend to provide the best service that they can and commonly link up with the local state ambulance provider, but there are limitations.
Skill level - Having some level of ATLS or EMST training is desirable, but not often mandated. Regardless, while the ambulance crew will usually have some degree of pre-hospital trauma training and experience, the attending doctor or nurse may not. Practicioners are generally good at what they do often. That does not mean that you have to be a trauma surgeon or anaesthetist to be a good motor sport medic, but it is important to be aware of the knowledge and skill set needed to be an effective provider of clinical care at a motor sport event.
Equipment - This can be highly variable, depending on whether the provider is an ambulance crew (General versus Paramedic), a local volunteer or a dedicated rescue agency. It includes clinical equipment (airway, circulation, trauma gear such as found in a well stocked Thomas pack) and rescue tools (stabilising devices, cutting tools, fire suppression, etc). Factors which influence the available kit include cost, weight and volume, pharmacology administrative and logistical considerations. There is no national standard in Australia, though some work has begun to addres this, which has its own implications for providers. Pete Sherren's presentation should prompt us to think about strategies such as carrying a few vials of Tranexamic acid (see the CRASH-2 trial and the MATTERS trial), a military grade tourniquet (CAT, EMT, SOFT-T, etc), or an EnFlow fluid warmer. We should also be thinking about simple things, like ejecting colloids and starch based resuscitation fluids from the medical pack.
Evidence based practice is lacking in motor sport practice and filters through slowly from hospital and pre-hospital practice. There is often an assumption that civilian trauma management can be extrapolated across and, in most circumstances, this is probably true; but untested. There are some key differences though, in terms of the speeds involved, types of protective equipment such as tailored impact absorption, rollcage structure, helmet and neck restraint device assemblies and the logistics of providing clinical care in a competitive event scenario. The threshold for injury is arguably higher in motor sports than for civilian motor vehicle collisions, though this varies with the competitive level, but when it does occur it usually means much greater forces are involved with the potential for much more serious injuries. As a simple example, applying the Canadian or NEXUS cervical spine rules for clinical clearance to motor sports competitors cannot be assumed to be valid, as the population involved is vastly different to the populations used to geerate and test these decision algorithms. Again, there is some work being done by several groups, but as yet any outcomes are not widely available to practicioners and there is a need to resolve this particular issue. The two posts on Cliff's site, amongst others, should also encourage us to start adopting strategies that could lead to improved outcomes for our patient group, such as using elements of the TASH score to pre-alert the retrieval service and the receiving hospital of a potential need for a massive blood transfusion, or aligning components of our practice with those that have been shown to enhance damage control resuscitation.
In the meantime, sites like Resus M.E. and P.H.A.R.M., along with other emergency and critical care sites and the more traditional journals that cover trauma and acute care practice, while largely valid for civilian and military settings, will continue to be the main source of influence for motor sport medical and rescue practice. It is then up to us to start putting them into practice and, just as importantly, evaluate their impact on outcomes.
If you keep an eye on some of the great critical care blog sites, at some point you will have come accross Cliff Reid's Resus M.E. site. Recently he has put up 2 great posts that should be of interest to all of us who practice medicine and rescue in motor sports.
The first is a presentation given by HEMS doctor, Pete Sherren, on the bleeding trauma patient. He outlines an illustrative pre-hospital case and follows through to the ICU admission. He then follows on with a concise overview of the pathogenesis and management of the Acute Coagulopathy of Trauma Shock (ACoTS or ACT), along with a summary of current and future developments. It's worth stopping at the MIST slide of the case presentation and substituting in a competitive motorbike rider at a circuit or off-road event and then taking a minute or two to consider how you would have managed this case as the first on scene or as the event CMO. What interventions could you have initiated with your current kit? What would have been your evacuation plan? What other concerns might you have had?
The second post is a quick review of 2 papers that evaluated a European trauma dataset to attempt to identify predictors of whole and cervical vertebral and spinal cord injury. You might notice that our motor sport population fit at least 3 of the predictive associations (Age <45yo, sports injuries and road traffic collisions) with male gender probably also being over-represented.
Medicine and Rescue at motorsport events is often provided at two levels. There's the well-meaning and enthusiastic volunteer who shows up with a variable level of trauma experience and equipment, usually to the local club or state event, but may also join a rescue agency for a particular event. Then there's the dedicated motor sport rescue agencies that generally cover state, national and international events, but also some club races. These agencies are usually composed of people with at least some level of pre and/or in-hospital trauma experience and more tailored clinical and rescue equipment. Both intend to provide the best service that they can and commonly link up with the local state ambulance provider, but there are limitations.
Skill level - Having some level of ATLS or EMST training is desirable, but not often mandated. Regardless, while the ambulance crew will usually have some degree of pre-hospital trauma training and experience, the attending doctor or nurse may not. Practicioners are generally good at what they do often. That does not mean that you have to be a trauma surgeon or anaesthetist to be a good motor sport medic, but it is important to be aware of the knowledge and skill set needed to be an effective provider of clinical care at a motor sport event.
Equipment - This can be highly variable, depending on whether the provider is an ambulance crew (General versus Paramedic), a local volunteer or a dedicated rescue agency. It includes clinical equipment (airway, circulation, trauma gear such as found in a well stocked Thomas pack) and rescue tools (stabilising devices, cutting tools, fire suppression, etc). Factors which influence the available kit include cost, weight and volume, pharmacology administrative and logistical considerations. There is no national standard in Australia, though some work has begun to addres this, which has its own implications for providers. Pete Sherren's presentation should prompt us to think about strategies such as carrying a few vials of Tranexamic acid (see the CRASH-2 trial and the MATTERS trial), a military grade tourniquet (CAT, EMT, SOFT-T, etc), or an EnFlow fluid warmer. We should also be thinking about simple things, like ejecting colloids and starch based resuscitation fluids from the medical pack.
Evidence based practice is lacking in motor sport practice and filters through slowly from hospital and pre-hospital practice. There is often an assumption that civilian trauma management can be extrapolated across and, in most circumstances, this is probably true; but untested. There are some key differences though, in terms of the speeds involved, types of protective equipment such as tailored impact absorption, rollcage structure, helmet and neck restraint device assemblies and the logistics of providing clinical care in a competitive event scenario. The threshold for injury is arguably higher in motor sports than for civilian motor vehicle collisions, though this varies with the competitive level, but when it does occur it usually means much greater forces are involved with the potential for much more serious injuries. As a simple example, applying the Canadian or NEXUS cervical spine rules for clinical clearance to motor sports competitors cannot be assumed to be valid, as the population involved is vastly different to the populations used to geerate and test these decision algorithms. Again, there is some work being done by several groups, but as yet any outcomes are not widely available to practicioners and there is a need to resolve this particular issue. The two posts on Cliff's site, amongst others, should also encourage us to start adopting strategies that could lead to improved outcomes for our patient group, such as using elements of the TASH score to pre-alert the retrieval service and the receiving hospital of a potential need for a massive blood transfusion, or aligning components of our practice with those that have been shown to enhance damage control resuscitation.
In the meantime, sites like Resus M.E. and P.H.A.R.M., along with other emergency and critical care sites and the more traditional journals that cover trauma and acute care practice, while largely valid for civilian and military settings, will continue to be the main source of influence for motor sport medical and rescue practice. It is then up to us to start putting them into practice and, just as importantly, evaluate their impact on outcomes.
In : Clinical topics
Tags: "trauma coagulopathy" "coagulopathy of trauma" "spinal cord injury" "spinal injury" "evidence based practice in motor sport"
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