G Model RESUS-5954; No. of Pages 2
ARTICLE IN PRESS Resuscitation xxx (2014) xxx.e1–xxx.e2
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Reply to Letter to the Editor Reply to letter: Requirement for a structured algorithm in cardiac arrest following major trauma: Epidemiology, management errors, and preventability of traumatic deaths in Berlin Sir, We are pleased to receive such a great response and vivid scientific discussion since we published our article.1 In response to Peters et al. we consider pre-hospital treatment possibilities significantly different from hospital settings. Presenting data of pre-hospital traumatic deaths with highest incidence of preventable deaths, we recommended focusing on improvement of pre-hospital trauma management2,3 ; nonetheless, we do not recommend resuscitating casualties with non-survivable injuries or transportation of every traumatic cardiac arrest (tCA) patient to hospital. Pre-hospital decision-making is the crucial factor, and anatomical injuries may mislead or be misinterpreted resulting in wrong decisions. Therefore, an algorithm including all potentially reversible reasons of tCA as well as further devices for enabling diagnosis of e.g. tension-pneumothorax or pericardial tamponade, is necessary Portable ultrasound devices are useful tools in the hand of experts. Emergency physicians not routinely using the portable ultrasound might be more confused in a tCA setting than benefit from the devices. Even resuscitation itself might be prolonged due to extended investigation times,4 with limited pre-hospital investigation conditions (less than 55%). Furthermore, we deal with the evident problem of misleading false-negative ultrasound in trauma. To our mind, pre-hospital ultrasound to assist in deciding to which hospital severe trauma patients should be transported is not mandatory. Patients with suspected internal bleeding are a time-critical mission. We need a more pragmatic way: every trauma patients should be admitted to a highly experienced level I trauma center. Furthermore, the use of pre-hospital ultrasound might lead to unnecessary delay or default of life saving procedures. We also strive for feasible techniques like Pneumoscan® to improve pre-hospital diagnostics, especially for most frequent definitely preventable cause of traumatic death, the tension pneumothorax.3,5 We totally agree that chest decompression via thoracostomy with or without chest tube insertion is the life-saving procedure. Bilateral chest decompression and periocardiocentesis should be performed always prior to termination of tCPR, also without pre-hospital ultrasound techniques – there is nothing to lose, but possibly a life at stake. As trauma surgeons we prefer emergency thoracotomy in pericardial tamponade rather than needle pericardiocentesis with all its potential problems, but comprehensive use and training of appropriate pre-hospital emergency thoracotomy, except for highly specialized trauma rescue helicopters (as in the Netherlands or London), is currently not practicable. We extensively discussed
this issue with reviewers and colleagues and confirmed the compromise that pre-hospital emergency thoracotomy in pericardial tamponade is gold standard, but, however, recently not daily practice, and that we need to provide a less invasive, potentially feasible alternative: the pre-hospital needle pericardiocentesis. As in all other subspecialties of medicine, emergency trauma care is subject to innovative pressures from the fields of science, practical medicine and industry, particularly concerning invasive techniques. In the light of maximum invasive measures such as use of portable extracorporeal membrane oxygenation (ECMO) in pre-hospital cardiopulmonary failure,6 we feel that needle pericardiocentesis should at least be considered in the pre-hospital situation of tCA, especially prior to termination of tCPR. The use of permissive hypotension in exsanguinating trauma victims without neuro-trauma is a standard procedure and recommended in several guidelines. We agree to Peters et al. that in future early blood or coagulation factor substitutions should be integrated in trauma algorithms. The field of pre-hospital traumatic coagulopathy treatment is currently in its childhood but will substantially change pre-hospital trauma management in the near future, e.g. use of tranexamic acid in severe trauma patients. To conclude, we are glad about the professional input for further advancement of our suggested pre-hospital traumatic CPR algorithm. We strive for an international meeting of all experts recently contacted us and all interested persons to improve the algorithm and set up a multicenter study to gain further evidence on traumatic cardiac arrest. Conflict of interest statement There is no conflict of interest. The corresponding author affirms that he has no relationships with a company whose product is mentioned in the article or with one that sells a competitive product. The presentation is impartial and the content is independent of commercial influence. References 1. Kleber C, Giesecke MT, Lindner T, Haas NP, Buschmann CT. Requirement for a structured algorithm in cardiac arrest following major trauma: epidemiology, management errors, and preventability of traumatic deaths in Berlin. Resuscitation 2013. 2. Kleber C, Giesecke M, Buschmann C. Overall distribution of trauma-related deaths in Berlin 2010: the weakest links of the chain of survival are emergency medicine and critical care: reply. World J Surg 2013;37:475. 3. Kleber C, Giesecke MT, Tsokos M, Haas NP, Buschmann CT. Trauma-related preventable deaths in Berlin 2010: need to change prehospital management strategies and trauma management education. World J Surg 2013. 4. Ketelaars R, Hoogerwerf N, Scheffer GJ. Prehospital chest ultrasound by a Dutch helicopter emergency medical service. J Emerg Med 2013;44:811–7. 5. Lindner T, Conze M, Albers CE, Leidel BA, Levy P, Kleber C, et al. Does radar technology support the diagnosis of pneumothorax? PneumoScan—a diagnostic point-of-care tool. Emerg Med Int 2013;2013:489056. 6. Arlt M, Philipp A, Zimmermann M, et al. Emergency use of extracorporeal membrane oxygenation in cardiopulmonary failure. Artif Organs 2009;33:696–703.
http://dx.doi.org/10.1016/j.resuscitation.2014.03.311 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Kleber C, et al. Reply to letter: Requirement for a structured algorithm in cardiac arrest following major trauma: Epidemiology, management errors, and preventability of traumatic deaths in Berlin. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.03.311
G Model RESUS-5954; No. of Pages 2 xxx.e2
ARTICLE IN PRESS Reply to Letter to the Editor / Resuscitation xxx (2014) xxx.e1–xxx.e2
C. Kleber ∗ M.T. Giesecke N.P. Haas Center for Musculoskeletal Surgery, AG Polytrauma, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany C.T. Buschmann Institute of Legal Medicine and Forensic Sciences, Charité – Universitätsmedizin Berlin, Turmstrasse 21 (Building N), 10559 Berlin, Germany
∗ Corresponding author at: Center for Musculoskeletal Surgery, AG Polytrauma, Charité – Universitätsmedizin, Berlin-Brandenburg Center for Regenerative Therapies, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail address: [email protected] (C. Kleber)
30 March 2014
Please cite this article in press as: Kleber C, et al. Reply to letter: Requirement for a structured algorithm in cardiac arrest following major trauma: Epidemiology, management errors, and preventability of traumatic deaths in Berlin. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.03.311
ARTICLE IN PRESS Resuscitation xxx (2014) xxx.e1–xxx.e2
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Reply to Letter to the Editor Reply to letter: Requirement for a structured algorithm in cardiac arrest following major trauma: Epidemiology, management errors, and preventability of traumatic deaths in Berlin Sir, We are pleased to receive such a great response and vivid scientific discussion since we published our article.1 In response to Peters et al. we consider pre-hospital treatment possibilities significantly different from hospital settings. Presenting data of pre-hospital traumatic deaths with highest incidence of preventable deaths, we recommended focusing on improvement of pre-hospital trauma management2,3 ; nonetheless, we do not recommend resuscitating casualties with non-survivable injuries or transportation of every traumatic cardiac arrest (tCA) patient to hospital. Pre-hospital decision-making is the crucial factor, and anatomical injuries may mislead or be misinterpreted resulting in wrong decisions. Therefore, an algorithm including all potentially reversible reasons of tCA as well as further devices for enabling diagnosis of e.g. tension-pneumothorax or pericardial tamponade, is necessary Portable ultrasound devices are useful tools in the hand of experts. Emergency physicians not routinely using the portable ultrasound might be more confused in a tCA setting than benefit from the devices. Even resuscitation itself might be prolonged due to extended investigation times,4 with limited pre-hospital investigation conditions (less than 55%). Furthermore, we deal with the evident problem of misleading false-negative ultrasound in trauma. To our mind, pre-hospital ultrasound to assist in deciding to which hospital severe trauma patients should be transported is not mandatory. Patients with suspected internal bleeding are a time-critical mission. We need a more pragmatic way: every trauma patients should be admitted to a highly experienced level I trauma center. Furthermore, the use of pre-hospital ultrasound might lead to unnecessary delay or default of life saving procedures. We also strive for feasible techniques like Pneumoscan® to improve pre-hospital diagnostics, especially for most frequent definitely preventable cause of traumatic death, the tension pneumothorax.3,5 We totally agree that chest decompression via thoracostomy with or without chest tube insertion is the life-saving procedure. Bilateral chest decompression and periocardiocentesis should be performed always prior to termination of tCPR, also without pre-hospital ultrasound techniques – there is nothing to lose, but possibly a life at stake. As trauma surgeons we prefer emergency thoracotomy in pericardial tamponade rather than needle pericardiocentesis with all its potential problems, but comprehensive use and training of appropriate pre-hospital emergency thoracotomy, except for highly specialized trauma rescue helicopters (as in the Netherlands or London), is currently not practicable. We extensively discussed
this issue with reviewers and colleagues and confirmed the compromise that pre-hospital emergency thoracotomy in pericardial tamponade is gold standard, but, however, recently not daily practice, and that we need to provide a less invasive, potentially feasible alternative: the pre-hospital needle pericardiocentesis. As in all other subspecialties of medicine, emergency trauma care is subject to innovative pressures from the fields of science, practical medicine and industry, particularly concerning invasive techniques. In the light of maximum invasive measures such as use of portable extracorporeal membrane oxygenation (ECMO) in pre-hospital cardiopulmonary failure,6 we feel that needle pericardiocentesis should at least be considered in the pre-hospital situation of tCA, especially prior to termination of tCPR. The use of permissive hypotension in exsanguinating trauma victims without neuro-trauma is a standard procedure and recommended in several guidelines. We agree to Peters et al. that in future early blood or coagulation factor substitutions should be integrated in trauma algorithms. The field of pre-hospital traumatic coagulopathy treatment is currently in its childhood but will substantially change pre-hospital trauma management in the near future, e.g. use of tranexamic acid in severe trauma patients. To conclude, we are glad about the professional input for further advancement of our suggested pre-hospital traumatic CPR algorithm. We strive for an international meeting of all experts recently contacted us and all interested persons to improve the algorithm and set up a multicenter study to gain further evidence on traumatic cardiac arrest. Conflict of interest statement There is no conflict of interest. The corresponding author affirms that he has no relationships with a company whose product is mentioned in the article or with one that sells a competitive product. The presentation is impartial and the content is independent of commercial influence. References 1. Kleber C, Giesecke MT, Lindner T, Haas NP, Buschmann CT. Requirement for a structured algorithm in cardiac arrest following major trauma: epidemiology, management errors, and preventability of traumatic deaths in Berlin. Resuscitation 2013. 2. Kleber C, Giesecke M, Buschmann C. Overall distribution of trauma-related deaths in Berlin 2010: the weakest links of the chain of survival are emergency medicine and critical care: reply. World J Surg 2013;37:475. 3. Kleber C, Giesecke MT, Tsokos M, Haas NP, Buschmann CT. Trauma-related preventable deaths in Berlin 2010: need to change prehospital management strategies and trauma management education. World J Surg 2013. 4. Ketelaars R, Hoogerwerf N, Scheffer GJ. Prehospital chest ultrasound by a Dutch helicopter emergency medical service. J Emerg Med 2013;44:811–7. 5. Lindner T, Conze M, Albers CE, Leidel BA, Levy P, Kleber C, et al. Does radar technology support the diagnosis of pneumothorax? PneumoScan—a diagnostic point-of-care tool. Emerg Med Int 2013;2013:489056. 6. Arlt M, Philipp A, Zimmermann M, et al. Emergency use of extracorporeal membrane oxygenation in cardiopulmonary failure. Artif Organs 2009;33:696–703.
http://dx.doi.org/10.1016/j.resuscitation.2014.03.311 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Kleber C, et al. Reply to letter: Requirement for a structured algorithm in cardiac arrest following major trauma: Epidemiology, management errors, and preventability of traumatic deaths in Berlin. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.03.311
G Model RESUS-5954; No. of Pages 2 xxx.e2
ARTICLE IN PRESS Reply to Letter to the Editor / Resuscitation xxx (2014) xxx.e1–xxx.e2
C. Kleber ∗ M.T. Giesecke N.P. Haas Center for Musculoskeletal Surgery, AG Polytrauma, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany C.T. Buschmann Institute of Legal Medicine and Forensic Sciences, Charité – Universitätsmedizin Berlin, Turmstrasse 21 (Building N), 10559 Berlin, Germany
∗ Corresponding author at: Center for Musculoskeletal Surgery, AG Polytrauma, Charité – Universitätsmedizin, Berlin-Brandenburg Center for Regenerative Therapies, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail address: [email protected] (C. Kleber)
30 March 2014
Please cite this article in press as: Kleber C, et al. Reply to letter: Requirement for a structured algorithm in cardiac arrest following major trauma: Epidemiology, management errors, and preventability of traumatic deaths in Berlin. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.03.311
