Fluid Resuscitation, Treatment of Envenomation, Recognition of Major Injuries in Elder Trauma Patients - Literature review Example

Literature Review Questions Student’s Name Institutional Affiliation Literature Review Questions Question One You are called to attend to a hypotensive patient with a penetrating chest wound inflicted by a 25cm blade. What are the risks associated with treating this patient with crystalloid fluids and what alternative treatments could be implemented in pre hospital setting?! Fluid resuscitation is cornerstone to sustaining hemodynamic imbalances arising after fluid loss from the body. The patient in question is in hypotensive state after a probable blood loss through the wound inflicted by the blade. The patient is at risk of hemorrhagic shock if the bleeding source is not controlled and fluid resuscitation initiated as soon as possible (Krausz, 2006). Fluid resuscitation is significant in maintaining sufficient cardiac output and sustaining microvasculature perfusion to ensure vital organ function and tissue oxygenation (Krausz 2006). Among the possible fluids for volume replacement are volume expanders such as crystalloid fluids (Perel, Roberts & Ker, 2009). Use of crystalloid fluids for volume replacements has some risks that include development of tissue edema or interstitial edema (Smorenberg, Ince & Groeneveld, 2013). The body usually maintains fluid balance between the intravascular and the extravascular compartment through a balance of Sterling forces operating between the membranes of capillaries. An imbalance of these forces in addition to occasional increase in the permeability of proteins across microvasculature membranes enhances fluid movement into the interstitial space. When crystalloid fluids are used to correct hypotension or hypovolemia in patients, a large volume of these fluids is required to achieve the required systolic blood pressure or volume state. This is due to crystalloids such as 0.9% saline or Lactated Ringers being isotonic to blood plasma, therefore, they readily get distributed between the intravascular and interstitial spaces necessitating the use of huge volumes to restore a given intravascular volume (Boldt, 2008). The large crystalloid volumes lowers colloid oncotic pressure (COP) in the intravascular compartment, increases hydrostatic pressure, decreases the integrity of membranes, and alters factors that promote fluid flow across the microvasculature into the interstitium or extracellular compartment (Boldt, 2008). The increasing fluid movement may result in pulmonary edema that may complicate the patient's pulmonary circulation and gaseous exchange in the lungs (Murakami et al., 2007). In addition, tissue edema around the wound site may rupture the newly formed clots leading to more blood loss. Crystalloids such as the “physiologically unbalanced” 0.9% saline when administered in large volumes may result in hyperchloremic metabolic acidosis attributable to accumulating chloride load in the body that interferes with the optimal physiological environment for enzymatic activity in the body including the coagulation pathway (Roche & James 2009). Other risks associated with crystalloids include dilution of factors involved in coagulation and a possible elevation or exacerbation of intracranial pressure (Smorenberg, Ince, & Groeneveld, 2013). Dilution of coagulation factors may impair the clotting activity on the wound and aggravate or prolong bleeding. Colloids would be suitable alternatives to crystalloids in restoring the patient's blood pressure to recommended levels. Colloids significantly increase intravascular volume without resulting in edema associated with crystalloids. Albumin would be among the appropriate choices of colloids since it has been least linked with detrimental coagulation effects (Boldt 2008). Furthermore, use of hypertonic saline in combination with colloids has fewer risks compared to solely using huge volumes of crystalloids (Krausz 2008). Nevertheless, the first intervention should be to stop or prevent further bleeding from the wound site before proceeding with fluid replacement. Question Two Australians are susceptible to envenomation (poisoning from animal venom) from multiple sources. What treatments are available in the prehospital setting? Provide support for its use in the prehospital setting. Pre-hospital treatment is significant in saving lives of patients who have been envenomed from various animals, reptiles or any other invertebrate. It includes implementation of basic and advanced life support measures while ensuring adequate airways, breathing and circulation (Barnett, Durrheim, Speare & Muller, 2005). Among the implicated poisonous creatures in Australia include more than 50 species of snakes such as brown and black snakes, taipans and tiger snakes, sea animals such as the blue-ringed octopus, jellyfish and stinging fish, arthropods that include spiders, wasps, ticks, bees, scorpions and stinging ants (Barnett et al. 2005; Hardy, Australian Venom Research Unit [AVRU], 2007; Cavazzoni, Lister, Sargent & Schibler, 2008). Some select few envenomation injury may require treatment using venom-specific interventions, but most of these injuries have a common pre-hospital forms of treatment. Objectives of the pre-hospital treatment include management of symptoms that are life-threatening, control and management of any other immediate symptoms and to slow the dissemination of the poison in the body (Chauhan et al. 2005; Ahmed et al. 2008). The initial measure when handling envenomed patients is to ensure that the source of the venom has been removed to prevent further threat to the patient or the paramedics attending to the patient (Cavazzoni et al., 2008). Thereafter, the patient's management shall be prioritized by following the ABC protocol. This includes endotracheal intubation for patients requiring ventilation and administration of oxygen via oxygen masks to sustain sufficient pulmonary oxygenation of blood (Cavazzoni et al. 2008; Cheng, 2013). The stress caused by the injury may precipitate underlying conditions such as asthma as was experienced in a case of jellyfish poisoning in Bernett et al.’s (2005) study, hence the need for the paramedic to be ready with medication to manage any acute complications. After life threatening symptoms have been controlled, immediate symptoms that include local symptoms such as aches, redness and swelling at the venom entrance site on the skin and systemic symptoms such as pain and others that may result from the activation of the parasympathetic system that include salivation, tearing, nausea and vomiting should be managed (Rahmani et al 2014) . Pain especially systemic pain can be managed using opioid analgesics such as morphine. However, if respiratory failure is imminent, narcotics should not be used for pain control (Rahmani et al. 2014). Supporting and reassuring the patient is also paramount to relieving anxiety and prevent further exacerbation of symptoms through anxiety induced sympathetic stimulatory activity that may increase muscle activity and heart rate and enhance further venom absorption in the body (Chauhan et al., 2005). The third goal when managing envenomed patients is to prevent the dissemination of the venom in the whole body. For envenomation on limbs, immobilization of the injured limb by bandages or clothing and positioning the limb at a level same to the heart's level would slow down venom spread (Ahmed et al. 2008). In addition, compression bandage or an elastic bandage at the injury site and wrapped around the limb slows lymphatic flow of blood, therefore, delay flow and absorption of the venom into tissues (Ahmed et al, 2008). Question Three Patients over the age of 55 who experience trauma are at risk of unrecognized major injury thus failing to receive or receive delayed care for injuries compared to younger trauma victims. Discuss the evidence related to recognition of major injuries in elder trauma patients. Elements of triage and diagnosis of trauma in older patients have, in most cases, been extrapolated from those used for triaging and diagnosing similar conditions in individuals of younger age group. This has resulted to an underestimation of the severity of major trauma in the older individuals aged more than 55 years and a higher major trauma related mortality in this age group (Kuhne, Ruchholtz, Kaiser & Nast-Kolb, 2005). Kuhne et al. (2005) noted a three times high severe trauma related mortality in individuals older than 55 compared to patients aged between 46 and 55 years. Among the reasons that may precipitating the under-triaging of elderly patients with major trauma include the physiological changes associated with old age that alter the predictability of some physiological variable used in triaging such patients and age bias during triaging (Lehmann, Beekley, Casey, Salim & Martin, 2009; Chang, 2008). A study by Lehmann et al. (2008) sort to demonstrate the impact that advanced age has on triaging and the outcome of such triage decisions. Study participants consisted of 65 and above year-old patients. The study outcome suggested that elderly patients were less likely to be attended with the attention they deserve including the activation of trauma team despite the severity and urgency of traumatic conditions experienced by such patients (Lehmann et al., 2008). The study also suggested that blood pressure and heart rate of patients older than 65 years may not be predictive of their degree of injury and hence the need of more specific physiological parameters that effectively indicate the severity of injuries in older patients (Lehmann et al., 2008). Another study done by Chang (2008) recognized under triaging in elderly patients especially “to State-designated trauma Centers” and resolved to ascertain if age-bias is implicated in the under triage and the possible reasons for such triaging decisions. The study results suggested that emergency service providers (ESP) were half as likely to recommend the transportation of elderly trauma patients to trauma centers than younger trauma patients (Chang, 2008). ESP exhibited poor compliance with stipulated triage protocol for trauma. The providers attributed the under triaging to lack or insufficient training on elderly trauma patients, in addition to unfamiliarity with protocol and a belief of unworthiness of transporting elderly patients to trauma centers. Moreover, it was reported that residents and some physicians at the receiving end of the trauma centers were unwelcoming to older patients influencing ESP to under triage this age group (Chang, 2008). A redefinition of certain physiological parameters used to gauge severity of injury may enable a better and appropriate triaging of older patients. This includes redefinition of hypotension in the elderly to reflect specific blood pressures of a given age group such that a systolic blood pressure of below 100mmHg should be restricted to define hypotension for patients below 50 years, 120 mmHg and 140 mmHg for elderly aged 0-59 and above 70 years respectively (Edwards et al., 2010). Venous lactate was also shown to be a better predictor of the prognosis of severe trauma in the elderly than vital signs (Salottolo, Mains, Offner, Bourg & Bar-Or, 2013). These measures alongside educating ESP, residents and physicians on elderly trauma triaging protocols may reduce cases of under triaging. Question Four "Paramedics adequately manage pain in the pre hospital setting." Support or refute this statement. Very briefly, outline one change that can be introduced to EMS that would improve pain management in the pre hospital setting. Pain that arises due to illness or procedures is a common presentation among patients presenting in a pre-hospital set-up (Weber, Dwyer & Mummery, 2012). Pain management by paramedics in the pre-hospital set-up should be timely and appropriate to enable administration of effective care. Effective pain management is enhanced by the presence of evidence-based practice guidelines through which the paramedics can rely on when pharmacologically or non-pharmacologically relieving pain (Lord, 2009). However, paramedics have not been effective in managing pain in patients presenting in the pre-hospital setting. A major setback to pain management in such settings is a failure in assessing the presence and degree of pain compounded by inadequate protocols, unavailability of pain relieving agents, inadequate provider education, the regulation of controlled substances, and patient transportation time to nearest appropriately equipped treatment centers (McManus, 2005). Moreover, paramedics’ attitude has been associated with inappropriate clinical care of patients in pain (Weber, Dwyer & Mummery, 2012). Kosinski, Bryja , Wojtaszowicz & Gorka (2014) authored a study done to investigate the frequency and features of pain experienced by patients in the pre-hospital setting including the pain alleviation method used by ESPs. It was noted that pharmacological analgesia were "extremely sparingly" used in the management of pain with very few patients receiving opioid analgesics. This was common with basic emergency teams involving paramedics and a driver. Emergency teams comprising specialist officers exhibited more, rightful use of pharmacological analgesia compared to teams comprising paramedics only (Kosinski et al. 2014). Kosinski et al. (2014) attributed paramedics' under management of pain to fears of side effects related to analgesics such as narcotics and insufficient experience in using potent analgesics. Weber, Dwyer & Mummery’s (2012) study was done to demonstrate the perception and attitude among paramedics associated with the administration of certain analgesics such as opioids. The outcome of the study suggested that the negative attitude in relation to the administration of morphine, an opioid analgesic was statistically significant. Furthermore, it was reported that paramedics' intention to treat pain using morphine was influenced by perceived behavior control (PBC) and subjective norm in addition to attitude as proposed by the Theory of Planned Behavior (Weber, Dwyer & Mummery, 2012). Inexperience and insufficient knowledge are associated with poor PBC among paramedics. Paramedics were occasionally noted to withhold pain management so that patients may get hastened treatment in the emergence department as the patients would be assessed to have higher scores on triage. Therefore, to enhance pre-hospital, adequate management of pain, development or review of pain management protocols such that systems requiring paramedics to consult or contact physicians in hospitals the paramedics are based in should be relaxed to allow paramedics to make decisions regarding use of analgesics in the field and speed up administration of analgesics to deserving patients (McManus, 2005). Research suggest that with appropriate pain management education, protocols or national guidelines, paramedics can administer analgesics, including narcotic analgesics, efficiently and appropriately with better outcome and limited adverse events (Mcmanus, 2005; Kosinski et al. 2014). French, Chan & Ramaker (2010) also demonstrated that initial and continuous education on management of pain improves paramedic’s perception, attitude and management of pain in the field. References Ahmed, S.M., Ahmed, M., Nadeem, A., Mahajan, J., Choudhary, A. & Pal, J. (2008). Emergency treatment of a snake bite: Pearls from literature. Journal of Emergence Trauma and Shock, 1(2), 97-105. Australian Venom Research Unit. (2007). Australia's venomous creatures. Retrieved October 17, 2014, from http://www.avru.org/compendium/biogs/A000152b.htm Barnett, F.I., Durrheim, D.M., Speare, R. & Muller, R. (2005). Management of Irukandji syndrome in northern Australia. Rural and Remote Health, 5(369), 1-10. Boldt, J. (2008). Fluid choice for resuscitation in trauma. International TraumaCare, 18(1), 57-65. Cavazzoni, E., Lister, B., Sargent, P. & Schibler, A. (2008). Blue-ringed octopus (Hapalochaena sp.) envenomation of a 4-year-old boy: A case report. Clinical Toxicology, 46, 760-761. Chang, D.C. (2008). Undertriage of elderly trauma patients to state-designated trauma centers. American Medical Association, 143(8), 776-781. Chauhan, S., Faruqi, S., Bhalla, A., Sharma, N., V Bali, J. (2005). Pre-hospital treatment of snake envenomation in patients presented at a tertiary care hospital in Northwestern India. Journal of Venomous Animals and Toxins Including Tropical Diseases, 11(3), 275-282. Cheng, D. (2013). Brown snake envenomation treatment & management. Retrieved October 17, 2014, from http://emedicine.medscape.com/article/772066-treatment Edwards, M., Ley, E., Mirocha, J., Hadjibashi, A.A., Margulies, D.R. & Salim, A. (2010). Defining hypotension in moderate to severely injured trauma patients: raising the bar for the elderly. The American Surgeon, 76(10), 1035-1038. French, S.C., Chan, S.B. & Ramaker, J. (2012). Education on pre hospital pain management. A follow -up study. Western Journal of Emergency Medicine, 14(2), 96-102. Krausz, M.M. (2006). Initial resuscitation of hemorrhagic shock. World Journal of Emergency Surgery, 1(18), 1-5. Kuhne, C.A., Ruchholtz, S., Kaiser, G.M. & Nast-Kolb, D. (2005). Mortality in severely injured elderly trauma patients-When does age become a risk factor. World Journal of Surgery, 29, 1476-1482. Lehmann, R., Beekley, A., Casey, L., Salim, A. & Martin, M. (2009). The impact of advanced age on trauma triage decisions and outcomes: A statewide analysis. The American Journal of Surgery, 197(5), 571-575. Lord, B. (2009). Paramedic assessment of pain in the cognitively impaired adult patient. BMC Emergency Medicine, 9(20), 1-7. MacManus, J.G. (2005). Pain management in the prehospital environment. Emergency Medicine Clinics of North America, 23, 415-431. Murakami, S., Suwa, M., Morita, H., Murakami, T., Ito, T.Soyama, A. ... & Katsumata, T. (2007). Localised pulmonary edema after blunt chest trauma. Circulation, 115, e206-e207. Perel, P., Roberts, I. & Ker, K. (2009). Colloids versus crystalloids for fluid resuscitation in critically ill patients (Review). Cochrane Database of Systematic Reviews, 28(2), 1-59. Rahmani, F., Khojasteh, S.M., Bakhtavar, H.E., Rahmani, F., Shahsavari, K. & Faridaalaee, G. (2014). Poisonous spiders: bites, symptoms, and treatment; an educational review. Emergency, 2(2), 54-58. Roche, A.M. & James, M.F. (2009). Colloids and crystalloids: does it matter to the kidney? Current Opinion in Critical Care, 15, 520-524. Salottolo, K.M., Mains, C.W., Offner, P.J., Bourg, P.W. & Bar-Or, D. (2013). A retrospective analysis of geriatric trauma patients: venous lactate is a better predictor of mortality than traditional vital signs. Scandinavian Journal of trauma, Resuscitation and Emergency Medicine, 21(7), 1-5. Smorenberg, A., Ince, C. & Groeneveld, J. (2013). Dose and type of crystalloid fluid therapy in adult hospitalized patients. Perioperative Medicine, 2(17), 1-10. Weber, A., Dwyer, T. & Mummery, K. (2012). Morphine administration by paramedics: An application of the theory of planned behaviour. Injury International of the Care of the Injured, 43, 1393-1396. Read More