Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

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#1: Heat Stroke – The Fastest Cooling Methods

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Cold water immersion resulted in significantly faster cooling rates for patients with exertional hyperthermia compared to passive cooling measures.

Why does this matter?
Exertional heat stroke is defined as hyperthermia with core temperature greater than 40°C/104°F associated with central nervous system dysfunction after strenuous activity. Exertional heat stroke is among the leading causes of death in young athletes, and the incidence of exertional heat related illness is expected to continue to rise due to global climate change. Management is focused on immediate removal from any heat sources and rapid cooling measures. However, what cooling measures are best supported by the current evidence?

Is cold water immersion the best way to chill?
This was a systematic review and meta-analysis of 63 studies of adults with exertional hyperthermia. Water immersion techniques appeared to be the most efficacious methods to rapidly lower core body temperature [cold water (14-17 °C/57.2-62.6 °F), colder water (8-12 °C/48.2-53.6°F) and ice water (1-5 °C/ 33.8-41 °F)] and were significantly faster than passive cooling. Figure 2 from the article below nicely summarizes the cooling rates for the different cooling techniques that were studied.

From cited article

From cited article

There were several limitations in this study, and the amount of evidence for exertional heat illness is still quite limited. However, based on low to very low certainty of evidence, water immersion techniques (1-17 °C water) rapidly lowered core body temperatures and should be considered first line treatment for exertional hyperthermia when possible.

Source
First aid cooling techniques for heat stroke and exertional hyperthermia: A systematic review and meta-analysis. Resuscitation. 2020 Mar 1;148:173-190. doi: 10.1016/j.resuscitation.2020.01.007. Epub 2020 Jan 22.

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#2: Blunt Cerebrovascular Injury – When to CTA

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Use a screening protocol to determine which trauma patients to order CTA of the head and neck. It detects more blunt cerebrovascular injuries (BCVI), which leads to more treatment, which reduces risk of stroke and mortality.

Why does this matter?
It’s often a quandary which patient to order CTA of the neck in the setting of blunt trauma. There is no easy rule to remember. Even if we scan, does finding these injuries make a difference?

Pick a protocol and use it.
This was a meta-analysis with 23 studies of BCVI. They found the more you look with CTA, the more you find. OR was 4.7 for detecting injuries with vs without a screening protocol in place. Also, CTA was more likely to show BCVI with high-risk (such as fractures through neuroforamina) vs low-risk c-spine injury (OR 12.7). Antithrombotic therapy vs none reduced stroke and mortality: risk of stroke, OR 0.20; mortality, OR 0.17; both were highly statistically significant. Patients with stents did no better than those treated medically. So, what protocol should you use? Two are put forward: Denver and Memphis. Denver criteria are extensive and impossible to remember. It’s more a question of who does not warrant a CTA. What I take away is that I should probably be doing more neck CTA scans than I’m currently doing. Here are the Denver Criteria for your reference.

Denver Criteria

Signs/Symptoms of BCVI

  • Potential arterial hemorrhage from neck/nose/mouth

  • Cervical bruit in patient < 50 years old

  • Expanding cervical hematoma

  • Focal neurologic defect: TIA, hemiparesis, vertebrobasilar symptoms, Horner’s Syndrome

  • Neurologic deficit inconsistent with head CT

  • Stroke on CT or MRI

Risk factors for BCVI

  • High energy transfer mechanism

  • Displaced mid-face fracture (LeFort II or III)

  • Mandible fracture

  • Complex skull fracture/basilar skull fracture/occipital condyle fracture

  • Severe traumatic brain injury with GCS < 6

  • Cervical spine fracture, subluxation or ligamentous injury at any level

  • Near hanging with anoxic brain injury

  • Clothesline type injury or seat belt abrasion with significant swelling, pain, or altered mental status

  • TBI with thoracic injuries

  • Scalp degloving

  • Thoracic vascular injuries

  • Blunt cardiac rupture

  • Upper rib fractures

Source
EVALUATION AND MANAGEMENT OF BLUNT CEREBROVASCULAR INJURY: A PRACTICE MANAGEMENT GUIDELINE FROM THE EASTERN ASSOCIATION FOR THE SURGERY OF TRAUMA.  J Trauma Acute Care Surg. 2020 Mar 14. doi: 10.1097/TA.0000000000002668. [Epub ahead of print]

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