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Trauma Top Ten - Part Deux!

Okay, still catching up on all the good stuff from the Northwest States Trauma Conference. Here's the second half of Dr. Richard Mullins' Trauma Top Ten studies from 2009 (first half here).

Etomidate and RSI -- already covered this one on full HERE. Basically, researchers have found that Etomidate causes changes in the adrenal system even when used as just a bolus for RSI. Studies compared Etomidate vs. Ketamine for RSI and found that -- particularly for septic patients -- there may be an advantage. Although they found differences in cortisol levels, however, they didn't find much change in outcome. Read the full blog post.

Dealing with Hip Fractures -- This study looked at whether in there was an increase in complications and hospital stay if patient's had to wait to have their hip fractures repaired.  Mullins also reviewed the best imaging to use when trying to identify hip fractures. In other words, find them faster and fix them faster to reduce mortality and morbidity.

Hip fractures in the elderly increase the risk of death in the months and years following the injury. Recently researchers have found that a 48 hour delay in the surgical repair or stabilization of a hip fracture increases risks of complications. Thanks to an aging population, we can expect to encounter twice as many hip fractures by 2040 with 15 percent of the population experiencing this injury by age 80.

However, finding them on plain films isn't always easy. One out of every twenty patients my not have a fracture that you can see on X-ray.

Researchers found MRI to be the gold standard for identifying occult hip fractures. Best practice would then be to get an MRI and to surgery if indicated in the first 24 hours following the injury.

Best Pressors: Dopamine or Norepinepherine - Researchers studied Dopamine vs. Norepinepherine for use in patients low blood pressure due to shock. The premise being that Dopamine will cause more heat problems. Indeed, twice as many patients developed atria fibrillation in the Dopamine group -- however the overall survival outcome was the same.

"A lot of dead patients in this study. This group of patients were all pretty sick ... there was a high risk they were going to die of something," Mullins told the conference. "That may be an indication that we're winning the battle but losing the war with these type of patients."

Mullins added that there is a lot variability in biochemistry that may increase the chances that a particular patient is susceptible to a particular medication. In the future, Mullins said, genetic testing may determine the optimal drug course. That discussion lead right into topic #2.

Genetic Variation Affects Mortality - The secret to a long life -- or at least surviving trauma -- may be as simple as picking your parents. In this study researchers studied trauma patients with genetic variation that changed the production of three specific proteins that have been shown to be crucial to survival when a patient goes into shock. About 20 percent of the population has a Single Nucleotide Polymorphism (SNP pronounced SNiP) where the change in just a single nucleotide is enough to change protein synthesis in a significant way.

Vanderbilt researchers found the death rate in trauma patients studied was half as much in the patients with the abnormal gene. Of the three proteins studied, the one associated with the Beta 2 adrendergic receptor was the most significant player.  Researchers found that the abnormal protein actually provided the patient with survival advantage.

Another study focused on SNPs involved in the complement cascade. Here again there was a significant difference in mortality observed for those with the SNP (20 percent) versus those without the genetic variation (11 percent.) The abnormal genome patients also had higher pneumonia rates.

"In the future, we'll be able to map our genes and decide which drug will have the best effect for you," Mullins said. "The other side of this of course is the privacy issue. I'm sure the insurance company will get a hold of this information and find a way to charge you more based on your genetic profile."

Using Morphine in Trauma to Prevent PTSD - Post Traumatic Stress Disorder (PTSD) can be a long term source of disability following major trauma. Studies have found that up to 25 percent of patients with serious injuries had some level of PTSD one year after the injury. The magnitude of pain, stress and anxiety experienced at the time of injury may create an exaggerated response to stress in the amygdala that potentiates for the development of PTSD long after the event is over. Could medications given at the time of the event decrease the psychiatric stress of the event two years later?

Since the amygdala has opiate receptors, researchers looked at service men and women injured in the war in Iraq to see if there was a difference for those who got morphine as part of their trauma resuscitation versus those who did not. The study excluded those with traumatic brain injuries. The results showed a significant increase in PTSD for those given morphine in the first 24 hours versus those who did not. In fact, the patients without PTSD were more likely to have more severe injury and/or amputation

 Another study supported these findings, demonstrating an inverse relationship between higher doses of morphine and less severe PTSD.

Mullins brought in a different study for perspective on the use of narcotics. A Dutch study looked at the medications given for pain for Dutch and American patients being treated for hip and ankle injuries. The study found that 85 percent of Americans and 58 percent of the Dutch received narcotics while in the hospital. Moreover, 77 percent of the Americans were sent home with narcotic perscriptions. None of the Dutch patients got narcs at home. Outcomes appeared to be similar.

"These studies seem to indicate that narcotics should be administered during the initial phase of evaluation following injury, "Mullins said. "Maybe we should be giving more earlier and less later."

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