Fix PTSD with "A Jab to the Neck"

With the incidence of PTSD expected to rise with increased combat and military deployment during the past ten years, research into alternative ways to treat this disease are likely to keep appearing in the literature.

As reported in the current issue of Pain Practice, researchers at  Walter Reed Army Medical Center have tried a Stellate Ganglion nerve block instead of anti-anxiety drugs to treat the disorder. As far as I can tell the sample size was all of two, but the research was based on prior reports of success by a Chicago based anesthesiologist, Dr. Eugene Lipov. The authors of the study concluded:

 Selective blockade of the right stellate ganglion at C6 level is a safe and minimally invasive procedure that may provide durable relief from PTSD symptoms, allowing the safe discontinuation of psychiatric medications.

Traditional treatment with therapy and antidepressants can take months to relieve PTSD symptoms, and can cause side effects such as impotence, weight gain, and sedation, Lipov told ABCnews.com. But the block offers another way -- it works within 30 minutes and does not have those side effects. 

While these local nerve blocks have been around for almost a century, they are not without risk. 

Why would a local nerve block work in treating an mental health problem rooted in a traumatic experience? Lipov speculates that traumatic events cause a spike in nerve growth factors.

Other experts cautioned that more research is needed - with a sample size of two, I'd hope so.  Although the ABCnews.com report states the study was placebo controlled, the abstract of the journal article says both subjects got SGB and reported relief. (maybe there's a different study ABC news if referring to, but I'm not seeing it.)

For his part, Lipov is hoping the neve blocks prove a cheap, quick and easy way to address PTSD.

With so many veterans returning from combat plagued by psychological disorders like PTSD, Lipov told ABCnews.com  "I think it's going to be huge in addressing the 'reverse surge' -- all these vets coming back to the country with these psychological problems."

Abstract of the article HERE

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).

#5
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.

#4
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.

#3
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.

#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."

#1
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."

Dr. Mullins Trauma Top Ten (part one)

Day two of the 21st Annual Northwest States Trauma Conference here in Sunriver and we get an early start counting down some of the latest research in trauma care. OHSU Trauma Surgery Eminence Dr. Richard Mullins held forth on the following hot topics.

#10
CT versus Laparotomy with penetrating wounds to the abdomen - The question: how do we best find injuries in the abdomen with patients presenting with penetrating abdominal wounds? Do we CT them? Open them up and look around or do serial, noninvasive physical exams.

The OAKLAND group found that CT was a great way find to triage abdominal injuries if "mandatory laparotomy signs" weren't present. Out of 306 patients, half of which got CT exams and only two false negatives were found. "That's pretty good," said Mullins, "but I think those guys probably missed a few more holes in the diaphragm." In any case, the Oakland group was dealing mostly with gunshot wounds and a lot of them.

The WESTERN just focused on stab wounds and defined the abdomen as below the costal margin. This group did wound exploration. Positive findings bought the patient 23 hours of serial physical exams. If they weren't showing signs of peritonitis, bleeding and were still hemodynamically stable, they got to go home.

The EASTERN trauma surgeons agree that serial physical exam is reliable IF there is a system to follow for the exams and a systematic way to record any changes. In otherwords, observation only works if you pay attention.

Mullins said he likes a delayed CT with oral contrast after six hours if there is still the possibility of damage to the bowel.

#9
 Using CT to determine which kidney injuries require intervention - One 5th of cardiac output is going to the renal system, so trauma can cause rapid exsanguination.  So who needs surgical intervention or angioembolization to control bleeding? Who will get better if you just observe them? Researchers found that injury scales are valid, correlating highly with outcomes. We also know now that there are three features of grade 3 and 4 renal injuries that require intervention to control bleeding. Most can be managed -- and managed earlier with angioembolization rather than later surgery and need for blood transfusions.

#8
 Surrogate and Doctor Expectations regarding ICU patient's long term Outcomes - This study was fascinating and sad. Surgeons managing a ICU patient on long term ventilation go to family members to ask for permission to put in a tracheostomy. Twenty percent of the patients died after the trach and of those that lived, only one out of 10 patients was doing well one year after discharge from the hospital to long term care. When asked of expected outcomes, neither the doctors, nor the surrogate decisionmakers were anywhere close to the reality of the outcomes. Worse, when the surrogates and family members were asked what had happened in the past year, 49 percent reported more stress in their lives and 84 percent had to quit their jobs to take care of the patient.

"We are looking at an enormous burden of families, and we need to communicate that accurately when we ask for persmission."

#7
Using procrit and other Erythropoiesis stimulating agents (ESAs) in patients with traumatic brain injuries - Usually ESAs are given to cancer patients to stimulate the growth of new red blood cells. However, this research looked at ten years of the drug's use in patient's with traumatic brain injuries. The death rate for those getting ESA was 8 percent compared to 24 percent in the other group. Strangely those getting the ESA had a lower hemoglobin on average than the control group.

#6
 Using Warm Fresh Whole Blood for trauma - Recent studies have shown that "old blood is bad blood" Mullins says. "Older than 29 days and you have two times the risk of infection. Yet the FDA says that blood can be kept for 42 days."

This study looked at the use of warm fresh whole blood in trauma patients in Iraq. While fresh whole blood in almost never given in the US these days due to screening restriction, in Iraq, pre-screening of military donors allowed 6,000 units of fresh whole blood to be given right after donation.  The results seem to be better trauma survival outcomes.

Why?

Even though the total red blood cells is the same, fresh blood has the plasma included.
"I think maybe the frozen plasma and platelets we give are not as good a coagulation cocktail as fresh warm blood," Mullin said. Studies in Japan have shown that trauma activates a coagulation cascade which consumes coagulation factors. Of the non-surviving trauma patients studied 87 percent had evidence of DIC. Fresh Warm Blood may stave off DIC in major trauma. "Some day blood donors will be part of the level one trauma team activation," Mullins concludes.

Read the Rest of the Top Ten HERE