A PEM Adventure
Ranulf is a 14-year-old explorer.
He has already climbed Ben Nevis in Scotland, visited the Gobi desert (possibly from the comfort of his parents 4 x 4, but who’s judging) and has his bronze D of E nailed.
Whilst you were busy managing head injuries and drownings, Ranulf had been out with a group of boys from school this evening. They had been enjoying a celebratory dinner following their safe return from a trip to the Amazon rainforest. Spirits were running high amongst the young teenagers as they ate and drank, regaling their parents with tales from the trip.
Ranulf’s best friend, Tarquin, had particularly enjoyed their lesson in arctic spear-fishing and, in an attempt to demonstrate the native technique, grabbed a knife wedged into a nearby piece of stilton. Tarquin lifted the knife high above the remains of his fish course. But unfortunately for Ranulf, as Tarquin stood, he slipped on a blob of spilt quince jelly. Lurching awkwardly sideways, Tarquin fell towards his best friend, the knife lunging deep into the left side of his chest.
Ranulf went white with the shock.
Tarquin screamed and pulled the knife straight back out, but blood started to spurt from the decent-sized incision he had accidentally made.
Grabbing a pristine white table napkin to apply pressure to the wound, Ranulf’s class teacher and expedition leader called the ambulance as chaos descended on the restaurant.
All you know, back in ED, is that the ETA is 10 minutes, and there is a single stab wound to the chest.
The trauma call goes out.
You will be running the show today, and you want to use your preparation time well. So, what are your key priorities? A stab wound means there could be:
– Significant bleeding – you consider putting out a Major Haemorrhage call
– Significant chest injuries – you ask your general surgeon to get the chest drain kit prepared
– Significant intra-abdominal injuries – you are not sure until you see the patient exactly where the problem will be
– Significant pain – they are coming in un-intubated with a paramedic crew. You ask your anaesthetist to get ready to sedate or intubate depending on their status
– Significant risk to the department – you make sure security is aware
And your patient arrives.
Ranulf is quite a sweet, round-faced boy, accompanied by his traumatised-looking mother as he is wheeled to your trauma bay.
Smiling reassuringly at Ranulf and his mum, you turn around to take the ambulance handover, which is beautifully presented ATMIST style:
A – We have a 14-year-old male by the name of Ranulf
T – Ranulf was accidentally stabbed with a cheese knife at 735pm
M – HIs friend slipped while holding the knife, and it entered the left chest, just adjacent to the nipple. The knife was immediately removed, and significant blood loss was visible when we arrived on scene.
I – We suspect a left-sided haemothorax or haemopneumothorax, but there are no other injuries
S – HR has been 100-120, BP 110/78, borderline saturations 93% in air, but 98% % in 100% O2 via non-rebreathe. RR 25-30. Temperature 36.8C. GCS 15.
T – He’s got a single grey cannula in situ, and we’ve given him a 5 mg bolus of IiV morphine on the way in
The primary survey
Thanking the paramedic team, you ask the T&O SHO to proceed with a primary survey. She calls out her findings:
A – OK
B – 1 puncture mark to the anterior left chest wall, covered with a three-sided dressing. Actively oozing. There is decreased air entry, dull percussion at the left base, and minimal chest wall movement. RR 30 Sats 96% in 100% O2 via NRB
C – Tachycardic, feeling cold and clammy HR 124 BP 116/80, soft abdomen, no other signs of blood loss
D – eyes open, can obey commands, not talking much but can answer questions, GCS 15
E – T 36.8C
Right now, though, Ranulf’s’ Mum looks whiter than he does.
“Is he going to be OK?
You hate questions like this at the start of a trauma case
“He’s in the best place,” you tell her.
And it’s true. In 2021, Evans and colleagues (1) compared adolescent mortality rates in adult, children’s and mixed major trauma centres across the UK. 21 033 cases were included in the logistic regression analysis. They showed that even when controlling for injury severity, mechanism of injury and physiological parameters, crude 30-day trauma-related mortality was lowest for adolescents attending a dedicated children’s MTC at 2.5%, followed by a mixed centre at 4.4% and highest at 4.9% for adolescents up to the age of 25 attending an adult only MTC.
“I will sit down and have a proper chat with you shortly once we’ve stabilised him.”
Your priority is to decompress the chest and replace lost blood. So you ask that:
– A major haemorrhage call is put out
– 2 x wide bore IV access is obtained, blood is taken, and a dose of tranexamic acid is given.
Ranulf seems to be maintaining his airway – so what do you do next?
You turn to your anaesthetist, “We could put this drain in under ketamine sedation or, do you think it would be better to go ahead and intubate him now?
“I’m easy,” says your colleague,
“There’s probably no right or wrong answer,” he continues.”The priority is the drain and blood replacement. You could argue that sedation is safer as you won’t be manipulating the airway in a haemodynamically unstable patient. However, once intubated, you can do whatever interventions are needed for Ranulf and have full airway control”.
The ODP is caught up leaving theatres and has not yet made it down to ED. So, in the interests of time, you opt for ketamine now, intending to intubate later if required.
Would you like a pigtail catheter or a surgical chest tube?
a) Pigtail +/- lavage
Seldinger – Traditionally shunned in trauma, these small calibre tubes are growing in popularity due to ease and tolerability of insertion and the option to perform irrigation and lavage easily
b) Surgical
Although still preferred in many centres, these large tubes are painful for patients during and post-insertion. Recent evidence suggests they may not confer any additional benefit over smaller pigtail drains.
c) Doesn’t matter, just get one in
Ultimately, Ranulf needs his haemothorax drained quickly and safely. Evidence suggests this could be with a pigtail catheter or surgical chest tube.
In 2021, Kulvatunyou, Bauman and colleagues compared the insertion of traditional 28-32Fr chest tubes with 14Fr pigtail catheters for drainage of traumatic haemothorax. They looked at 119 adult patients from an (unspecified) number of trauma centres.
The primary outcome measure was chest drain failure, i.e., retained haemothorax requiring a secondary interventional procedure. They found NO difference in drain failure rates (11% pigtail vs 13% chest tube P=0.74), total daily volume drained or length of ICU stay between groups.
However, patients in the pigtail catheter group rated their experience and tolerability of the insertion procedure much better than the chest tube group. The major caveat was that they excluded patients ‘requiring emergent placement’ of the drain. This was determined by the treating physician, making it difficult to know whether or not we could extrapolate the findings to Ranulf.
With that in mind, you request a 30 FR chest tube and make a mental note to review the evidence in more detail, especially around irrigation, as it would make a great departmental QUIP.
You ask the paediatric SHO to write up a dose of antibiotics to reduce the risk of empyema formation and turn back around to see that the surgical reg appears to be drawing on the patient’s arm.
He notices your quizzical look and explains that he uses the mid-arm point technique to site the drain.
“We do it all the time in grown ups”, he says, “to identify a safe zone for pleural decompression. It’s much quicker and easier than counting rib spaces. He’s a big enough kid, I am sure it will work for him”.
Hmmmm… it’s a LEFT-sided wound, and you want to ensure you will be inside the triangle of safety.
Where and how should we decompress the chest?
a) Needle decompression, 2nd intercostal space
Needle decompression is no longer recommended, with failure rates as high as 60%.
In addition, a flimsy cannula is easily dislodged during ongoing resuscitation and easily clots off.
b) Thoracostomy 4th – 6th intercostal space
Thoracostomy 4-6th intercostal space can be challenging to feel in some kids.
There is also a high failure rate with up to 40% of catheters sited using this method outside the triangle of safety.
c) Thoracostomy mid-arm point
Using the Mid-Arm Point (MAP) to mark the chest, halfway between the patient’s acromion and olecranon process, is reliable and safe in adults.
But Ranulf is only 14. Is this the case in children?
d) Thoracostomy mid-arm point +1
Using the Mid-Arm Point (MAP) to mark the chest, halfway between the patient’s acromion and olecranon process, is reliable and safe in adults.
But Ranulf is only 14. Does one additional intercostal space make it any safer?
Enter Nuala Quinn’s team and their recent paper on using the Mid-Arm Point in Paediatrics.
They looked at 392 children across four sites who required chest X-rays. Before the x-ray, they marked the mid-arm point and used radiopaque markers at the corresponding chest level to identify where a drain could be inserted.
When they reviewed the x-rays, 83% of markers were within the ‘safe zone’ for pleural decompression (4th to 6th intercostal spaces). When outside the ‘safe zone’, markers were nearly always too caudal. By transposing the mid-arm point one intercostal space cranially in those ≥ four years, performance improved significantly. 91% of markers were in the ‘safe zone’. This was an X-ray-based study, and the rule hasn’t been tested in vivo, but the results look promising. What’s more, Nuala and her team have coined the handy Rule of Fours to help you make sure your drain insertion goes smoothly:
Rule 1: Four steps in a ‘good plan’
Rule 2: Fourth (or fifth) intercostal space as the basis for siting a ‘good hole’
Rule 3: 4× uncuffed endotracheal tube size (4× [age/4 + 4]) to guide the selection of a ‘good tube’
Rule 4: 4 cm mark for a ‘good stop’ to ensure the drain is in far enough but not too far.
Happily, the drain goes in smoothly. And blood comes out. Quite quickly. Time to get a transfusion started.
But what are you going to give…
Do you want to transfuse with?
a) A balanced ratio of 1:1:1 (platelets: FFP: packed red cells)
The PROPPR trial showed us that balanced ratios are important. This was a randomised controlled multisite study comparing resuscitation of trauma patients requiring massive transfusion using either 1:1::1 or 1:1:2 ratios of platelets to plasma to red blood cells.
Significantly more patients achieved haemostasis in the balanced ratio group (86% vs 78% p = .006), and they were less likely to die from exsanguination in the first 24 hours (9.2% vs 14.6% in 1:1:2 group; difference, −5.4% [95% CI, −10.4% to −0.5%]; P = 0.03.).
Importantly, there were no differences between the groups regarding complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications.
But this was all done in adults, and no comparable prospective trials in children exist.
b) A balanced ratio of 1: 1:2 (platelets: FFP: packed red cells)
The PROPPR trial showed us that balanced ratios are important. This randomised controlled multisite study compared resuscitation of trauma patients requiring massive transfusion using either 1:1::1 or 1:1:2 ratios of platelets to plasma to red blood cells.
Significantly more patients achieved haemostasis in the balanced ratio group (86% vs 78% p = .006), and they were less likely to die from exsanguination in the first 24 hours (9.2% vs 14.6% in 1:1:2 group; difference, −5.4% [95% CI, −10.4% to −0.5%]; P = 0.03.).
Importantly, there were no differences between the groups regarding complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications.
But this was all done in adults, and no comparable prospective trials in children exist.
c) Any available ratio, just get some products in quick
The PROPPR trial showed us that balanced ratios are important. This randomised controlled multisite study compared resuscitation of trauma patients requiring massive transfusion using either 1:1::1 or 1:1:2 ratios of platelets to plasma to red blood cells.
Significantly more patients achieved haemostasis in the balanced ratio group (86% vs 78% p = .006), and they were less likely to die from exsanguination in the first 24 hours (9.2% vs 14.6% in 1:1:2 group; difference, −5.4% [95% CI, −10.4% to −0.5%]; P = 0.03.).
Importantly, there were no differences between the groups regarding complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications.
But this was all done in adults, and no comparable prospective trials in children exist.
d) Something else
The PROPPR trial showed us that balanced ratios are important. This randomised controlled multisite study compared resuscitation of trauma patients requiring massive transfusion using either 1:1::1 or 1:1:2 ratios of platelets to plasma to red blood cells.
Significantly more patients achieved haemostasis in the balanced ratio group (86% vs 78% p = .006), and they were less likely to die from exsanguination in the first 24 hours (9.2% vs 14.6% in 1:1:2 group; difference, −5.4% [95% CI, −10.4% to −0.5%]; P = 0.03.).
Importantly, there were no differences between the groups regarding complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications.
But this was all done in adults, and no comparable prospective trials in children exist.
There is evidence for using balanced ratios in children, but this comes from retrospective case note reviews.
A recent review was conducted on Trauma Quality Improvement Program data between 2014 and 2016. This generated a sample of 1233 paediatric trauma patients who had received at least 1 unit PRBC and FFP. They stratified patients according to the ratio of FFP: PRBC received (1:1, 1:2, 1:3 and 1:3+) and performed logistic regression analyses for various outcomes.
Blood product ratios made no difference to complications such as ARDS and AKI. However, patients in the 1:1 group had the lowest 24-hour mortality (14% vs 18% vs 22% vs 24%; p = 0.01), and in-hospital mortality (32% vs 36% vs 40% vs 44%; p = 0.01). In addition, the 1:1 group had the lowest overall PRBC transfusion requirements (p < 0.01).
So, while we await a prospective trial in children, the evidence looks to be stacked in favour of keeping the blood product ratios balanced.
But what about fibrinogen replacement?
Fibrinogen is crucial in achieving hemostasis, and most major haemorrhage protocols widely advise early replacement. CRYOSTAT-1 showed us that early fibrinogen replacement with cryoprecipitate almost halved mortality from traumatic haemorrhage.
However, CRYOSTAT-2 suggests that empirical use of up-front cryoprecipitate may cause harm. In this phase III multicentre randomised controlled trial of nearly 1500 adult trauma patients, there was no benefit to 28-day all-cause mortality amongst patients receiving upfront cryoprecipitate, and a trend towards increased mortality if given within the first hour. (34% 28-day mortality if given under 45 mins; 29% in the first hour vs 26% standard care, non-significant).
This tells us (as if we didn’t already know) that clotting in trauma is complex, and one size does not necessarily fit all when it comes to replacing blood products.
Trauma-induced coagulopathy (TIC) is characterised by widespread microvascular haemorrhage. Traditionally thought to result from the dilutional effects of massive transfusion, acidaemia or hypothermia, trauma-induced coagulopathy is now known to be triggered at the time of injury, long before these factors have developed or any medical intervention has taken place.
The mechanisms behind TIC are complex and interrelated, but all stem from the impact of endothelial activation on the clotting system. ROTEM – or thromboelastography – allows us to examine a patient’s coagulation profile in real-time and target transfusion products based on specific deficits. This is helpful for a TIC patient whose needs may not match the products or ratios written into our trauma protocols. The next few years are likely to see us move away from blind, empirical prescribing to a targeted transfusion pathway that can potentially improve outcomes in paediatric trauma.
Back in ED with Ranulf, and pack two has gone through.
But when you reassess your patient, things are getting worse. His heart rate is creeping up, now 140. You do a gas to check the base excess and calcium and move on to pack three…
Five minutes later, however, the BP reading starts to alarm, now reading at 90/67.
What are you going to do?
You know you need to “turn off the tap”, but this is a non-compressible torso haemorrhage; you need to open the chest.
“What about REBOA?” asks that brainy surgical registrar.
Really, in a 14-year-old? You are not sure.
How should we deal with Ranulf’s bleeding?
a) REBOA
Let’s be clear: YOU will not be doing any of this. These procedures require an experienced operator. But even when you have one of those, the evidence is mixed.
The UK REBOA trial has been designed to answer your clinical conundrum. Owing to equipoise in the trauma literature, the trial, which is currently recruiting, aims to compare standard care with standard care plus REBOA in managing uncontrolled torso bleeding at major trauma centres across the UK.
Interim results presented earlier this year show that REBOA performed within the Emergency Department increased mortality. REBOA increased deaths due to bleeding at three hours and 90 days and substantially delayed time to definitive haemorrhage control.
A joint statement released by the American College of Surgeons/American College of Emergency Physicians recommends that zone 1 REBOA should only be performed if the anticipated time to start the operation is less than 15 minutes.
b) Emergency thoracotomy
Let’s be clear: YOU will not be doing any of this. These procedures require an experienced operator. But even when you have one of those, the evidence is mixed.
The UK REBOA trial has been designed to answer your clinical conundrum. Owing to equipoise in the trauma literature, the trial, which is currently recruiting, aims to compare standard care with standard care plus REBOA in managing uncontrolled torso bleeding at major trauma centres across the UK.
Interim results presented earlier this year show that REBOA performed within the Emergency Department increased mortality. REBOA increased deaths due to bleeding at three hours and 90 days and substantially delayed time to definitive haemorrhage control.
A joint statement released by the American College of Surgeons/American College of Emergency Physicians recommends that zone 1 REBOA should only be performed if the anticipated time to start the operation is less than 15 minutes.
c) Or, do both?
Let’s be clear: YOU will not be doing any of this. These procedures require an experienced operator. But even when you have one of those, the evidence is mixed.
The UK REBOA trial has been designed to answer your clinical conundrum. Owing to equipoise in the trauma literature, the trial, which is currently recruiting, aims to compare standard care with standard care plus REBOA in managing uncontrolled torso bleeding at major trauma centres across the UK. Interim results presented earlier this year show that REBOA performed within the Emergency Department increased mortality. REBOA increased deaths due to bleeding at three hours and 90 days and substantially delayed time to definitive haemorrhage control.
A joint statement released by the American College of Surgeons/American College of Emergency Physicians recommends that zone 1 REBOA should only be performed if the anticipated time to start the operation is less than 15 minutes.
The trauma surgeon arrives, and you agree to proceed to the theatres. Ranulf has an RSI intubation and is transferred upstairs with ongoing volume resuscitation.
Multiple bleeding intercostal vessels are tied off at thoracotomy, and the pleural cavity is washed out. Ranulf spends the next few days in PICU and a week in the children’s ward but fully recovers.
After extensive exposure to the fabulous trauma team, he makes a substantial donation to the local air ambulance, invests and develops a ‘cheese safety knife’ and becomes a world leader in the Swiss cheese model of human factors.
Brie-liiant!
This post is part of the PEM Adventure at NEPTUNE 2023, hosted by Dani, Kat, Costas and Sarah. NEPTUNE 2023 was inaugural UK PEM trauma conference, hosted by Nottingham University Hospitals Trust, one of the largest major trauma centres in the UK.
References
Akl M, Anand T, Reina R, El-Qawaqzeh K, Ditillo M, Hosseinpour H, Nelson A, Obaid O, Friese R, Joseph B. Balanced hemostatic resuscitation for bleeding pediatric trauma patients: A nationwide quantitative analysis of outcomes. J Pediatr Surg. 2022 Dec;57(12):986-993.
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https://www.nhsbt.nhs.uk/clinical-trials-unit/current-trials-and-studies/cryostat-2/
