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Clinical Updates

What’s New in Trauma Resuscitation—Should ABC Become CAB?

by Paula Ferrada, MD, FACS, FCCM

To have a positive impact on outcomes for critically injured patients, health care professionals should have an in-depth understanding of the physiology and treatment of hemorrhagic shock and the consequences of massive hemorrhage such as trauma-induced coagulopathy.

The treatment of trauma patients traditionally has prioritized care of the airway first. We refer to this sequence as the ABCs of trauma. However, several physiological effects as well as data support prioritizing circulation before intubation on patients who are in severe hypovolemic shock (CAB).

The trauma patient who has bled significantly presents in a pre-arrest state (Manole and Hickey 2006). Gasping, also known as agonal respirations, is the terminal pattern that occurs after severe ischemia. Some evidence shows that the frequency of gasping can predict the success of resuscitation maneuvers, as it increases venous return and cardiac output (Noc, Weil, et al 1994; Yang, Weil, et al 1994; Xie, Weil, et al 2004). In addition, the patient who presents in hypovolemic shock has a profound adrenergic response characteristic of peripheral vasoconstriction and then tachycardia. This response is a physiological attempt to preserve the perfusion to vital organs, including the heart and brain (Dorlas, Nijboer, et al 1985).

When a patient is breathing spontaneously, the negative pressure phase of inspiration increases venous return, eases the pressure on the pulmonary capillaries, and improves flow and perfusion. When we place a patient in positive pressure ventilation, intrathoracic pressure increases during inspiration, causing a drop in venous return, thereby decreasing right ventricular output and pulmonary blood flow (Mitaka, Nagura, et al 1989; van den Berg, Grimbergen, et al 1997).

When intubating bleeding patients, we often sedate and paralyze them, blocking the natural protective responses of gasping and vasoconstriction. Furthermore, after intubation we initiate positive pressure ventilation. By blocking the physiological protective responses in these patients who already are in shock with a significant oxygen debt, we cause further metabolic derangements that can deepen the hypotension and cause cardiac arrest (Bochicchio, Ilahi, et al 2003; Aufderheide, Sigurdsson, et al 2004; Min, Chai, et al 2010; Mayglothling, Duane, et al 2012).

In fact, postintubation hypotension (PIH) has proven to be common in trauma and is associated with increased mortality (Green, Butler, et al 2017). Green et al found on retrospective review of 444 patients an incidence of 38 percent of PIH with an added mortality of 29 percent for patients who experience this phenomenon. In a meta-analysis the author and colleagues found similar results (Ferrada, Manzano-Nunez, et al 2019). We reviewed four studies reporting results in 2,044 patients; 36.8 percent (n = 753) developed PIH. The mortality in all patients was 24.6 percent (n = 503) and was significantly higher in patients who developed PIH [PIH = 250/753 (33.2 percent) versus 253/1291 (19.6 percent), P < 0.001]. We also performed a retrospective review of patients in hypovolemic shock at our institution. This review showed 78 percent mortality in hypotensive trauma patients treated with the traditional sequence of ABC versus 50 percent mortality in patients treated with the initial trauma sequence reversed to CAB (Ferrada 2018).

Subsequently, we have performed a retrospective multicenter trial with the American Association for the Surgery of Trauma, which showed no difference in mortality. However, this study showed that trauma surgeons already are prioritizing circulation first in trauma patients with profound hypovolemic shock, with 44 percent of the patients reviving when treated with CAB instead of ABC (Ferrada, Callcut, et al. 2018).

The Eastern Association for the Surgery of Trauma is leading a multicenter study on this topic.

The jury is still out regarding the correct sequence of trauma resuscitation. Research is being conducted regarding prioritizing circulation and perfusion and the impact of these maneuvers on patient outcomes. Several adjuncts for the treatment of severe bleeding, such as faster proximal bleeding control and volemic and hemostatic resuscitation with either whole blood or in a 1:1:1 fashion, are other factors that may improve the early care of trauma patients.

Physician Visits Rebound for Some Specialties

Researchers at Harvard University, Cambridge, MA, and Phreesia, a New York, NY, health care technology company, analyzed data on changes in visit volume for the more than 50,000 providers that are Phreesia clients. The following findings, published by the Commonwealth Fund, illustrate that declines in visits vary by patient type, geographic area, clinical specialty, insurer, and size of provider organization.

The study revealed the following:

  • Overall visit counts for the week of June 14 remain substantively lower than baseline. The cumulative deficit in visits in March 15–June 20 is nearly 40 percent.
  • The number of visits to ambulatory practices had declined nearly 60 percent by early April. Since then, the numbers have rebounded, though the rebound may be beginning to plateau.
  • The rebound in visits is occurring across the U.S. The initial decrease in visits was most evident in the New England, Mid-Atlantic, and Pacific regions.
  • The decline in visits was greatest in states that had an early surge in COVID-19 cases. Visits remain more depressed in these states.
  • Initially, as in-person visits dropped, telemedicine visits increased rapidly. Since the peak in mid-April, telemedicine use has begun to decline, although it remains considerably higher than before to the pandemic.
  • Visits to some clinical specialties, such as dermatology and rheumatology, have returned to their baseline rates. The cumulative decline in visits from the start of the pandemic is greatest among pediatricians, pulmonologists, and several surgical specialties.
  • Since the nadir of visits in late March, the number of visits among Medicare beneficiaries has rebounded, whereas the rebound among people covered by Medicaid has lagged.
  • The difference between adult and pediatric visits is strikingly different.
  • Among smaller practices—one to five clinicians—both the initial decline in visits in early March and the subsequent rebound in visits were smaller.

AAMC Report Projects U.S. Could Experience a Shortage of Up to 28,700 Surgeons in 2033

A report from the Association of American Medical Colleges (AAMC) further underscores the projected physician shortage in the U.S., indicating that there could be anywhere from 54,000 to 139,000 fewer physicians in the nation by 2033. The projected shortage for 2033 is between 17,100 and 28,700 surgeons; it was previously estimated at between 14,300 and 23,400 by 2032.

The report predicts a primary care physician shortage of up to 55,200. Medical specialties, including surgical specialties, also could experience a deficit of more than 86,000 physicians in the next 13 years. If communities that currently have trouble accessing medical care are able to gain access at rates equal to more privileged communities, physician demand could increase by an additional 145,500. An aging workforce continues to be the primary driver of the shortfall, the report suggests, as more than 40 percent of physicians now in practice will be 65 or older within the next decade.

Based on current trends, the supply of surgeons is not projected to change substantially over the next 15 years, as future attrition offsets the number of newly trained surgeons. Demand continues to grow, with projected demand exceeding projected supply under all scenarios modeled. The 2018 higher shortage estimates result mainly from updated retirement rates, which suggest lower future supply than previously reported.

New from JAMA: STOP THE BLEED Conference Participants Identify Path Forward in Bleeding Control Training for Public

A JAMA article published July 6 reveals the findings from a two-day National STOP THE BLEED® (STB) Research Consensus Conference February 27−28, which was designed to identify and achieve consensus on research gaps that need to be filled to provide laypeople with the skills they need to assist in prehospital hemorrhage control. The 45 participants included subject matter experts, professional society leaders, and representatives from the federal government and private foundations. Before the conference, participants received a scoping review on layperson prehospital hemorrhage control. A three-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items were identified and became part of the national STB research agenda.

Participants came to consensus on high-priority questions within five themes: epidemiology and effectiveness, materials, education, global health, and health policy. The top 24 highest-ranked research questions, based on participant voting, constitute the National STB Research Agenda. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.

An accompanying commentary states that, facing a future with multiple looming threats and clear economic constraints, it is more important than ever to evaluate the effectiveness of these large-scale health initiatives. The participants in this consensus conference have provided a path forward in evaluating the implications of this prehospital intervention and creating a framework for a learning trauma care system.

CMSS Issues Statement on Wearing Masks to Avert the Spread of COVID-19

The Council of Medical Specialty Societies (CMSS) issued a statement, Respect Science, Wear Masks, last week. The statement calls on the federal government to implement a national mandate to wear a mask or other face covering in public. This mandate would require mask wearing when people cannot maintain physical distancing. Covering the nose and mouth are essential to prevent further spread of COVID-19, to support restarting the U.S. economy, and to reopen schools, colleges, and universities in the fall, according to the statement.