Diagnostic imaging is a mainstay in diagnosing injuries in major trauma patients. But the big questions are, how much is enough and how much is too much? X-radiation is invisible but not inocuous. Trauma professionals tend to pay little attention to radiation that they can’t see in order to diagnose things they can’t otherwise see. And which may not even be there.
There are two major camps working in emergency departments: scan selectively and scan everything. It all boils down to a balance between irradiating enough to be satisfied that nothing has been missed, and irradiating too much and causing harm later.
A very enlightening study was published last year from the group at the University of New South Wales. They prospectively looked at their experience while moving from selective scanning to pan-scanning.They studied over 600 patients in each cohort, looking at radiation exposure, missed injuries, and patient injury and discharge disposition variables.
Here are the interesting findings:
Absolute risk of receiving a higher radiation dose increased from 12% to 20%. This translates to 1 extra person of every 13 evaluated receiving a higher dose.
The incidence of receiving >20 mSv radiation dose nearly doubled after pan-scanning. This is the threshold at which we believe that cancer risk changes from low (<1:1000) to moderate (>1:1000).
The risk of receiving >20 mSv was lower in less severely injured patients (sigh of relief)
There were 6 missed injuries with selective scanning and 4 with pan-scanning (not significant). All were relatively minor.
Bottom line: Granted, the study groups are relatively small, and the science behind radiation risk is not very exact. But this study is very provocative because it shows that radiation dose increases significantly when pan-scan is used, but there was no benefit in terms of decreased missed injury. If we look at the likelihood of being helped vs harmed, patients are 26 times more likely to be harmed in the long term as they are to be helped in the short term. The defensive medicine naysayers will always argue about “that one catastrophic case” that will be missed, but I’m concerned that we’re creating some problems for our patients in the distant future that we are not worrying enough about right now.
Autotransfusing blood that has been shed from the chest tube is an easy way to resuscitate trauma patients with significant hemorrhage from the chest. Plus, it’s usually not contaminated from bowel injury and it doesn’t need any fancy equipment to prepare it for infusion.
It looks like fresh whole blood in the collection system. But is it? A prospective study of 22 patients was carried out to answer this question. A blood sample from the collection system of trauma patients with more than 50 cc of blood loss in 4 hours was analyzed for hematology, electrolyte and coagulation profiles.
The authors found that:
The hemoglobin and hematocrit from the chest tube were lower than venous blood (Hgb by about 2 grams, Hct by 7.5%)
Platelet count was very low in chest tube blood
Potassium was higher (4.9 mmol/L), but not dangerously so
INR, PTT, TT, Factor V and fibrinogen were unmeasurable
Bottom line: Although shed blood from the chest looks like whole blood, it’s missing key coagulation factors and will not clot. Reinfusing it will boost oxygen carrying capacity, but it won’t help with clotting. You may use it as part of your massive transfusion protocol, but don’t forget to give plasma and platelets according to protocol. This also explains why you don’t need to add an anticoagulant to the autotransfusion unit prior to collecting or giving the shed blood!
Do you have any videos or wisdom to share of how a trauma call should run, from arrival to disposition to OR/ICU? Trauma team roles, positions, responsibilities, etc.
This is something that has to be individualized for every hospital. The team composition, positions, responsibilities is designed with the hospital size, type and trauma center level in mind. I have a few videos available about are team. Start with this one: https://www.youtube.com/watch?v=J8estsbxEWI
Last week I asked for your assistance in determining how big a trauma resuscitation room should be. Thanks to everyone who replied! As you might suspect, these rooms can range from the very spacious…
to very tight…
Most respondents indicated that their trauma bays were somewhere between 225 and 300 square feet (21-28 sq meters), although some were quite large (Rashid Hospital in Dubai at nearly 50 sq meters!).
Interestingly, I did manage to find a set of published guidelines on this topic. The Facility Guidelines Institute (FGI) develops detailed recommendations for the design of a variety of healthcare facilities. Here are their guidelines for adult trauma bays:
Single patient room: The clear floor area should be 250 sq ft (23 sq m), with a minimum clearance of 5 feet on all sides of the patient stretcher.
Multiple patient room: The clear floor area should be 200 sq ft (18.5 sq m) with curtains separating patient areas. Minimum clearance of 5 feet on all sides of the patient stretcher should be maintained.
The FGI “clear floor area” corresponds to my “Trauma Bay Working Area”, which is the area that excludes all the carts, cabinets, and countertops scattered about the usual trauma room. California’s guideline of 280 sq feet seems pretty reasonable as the “Trauma Bay Total Area”, if you can keep your wasted space down to about 30 sq feet.
Bottom line: Once again, don’t try to figure out everything from scratch. Somebody has probably already done it (designed a trauma bay, developed a practice guideline, etc). But remember, a generic guideline or even one developed for a specific institution may not completely fit your situation. In this case, the FGI guidelines say nothing about the trauma team size, which is a critical factor in space planning. Use the work of others as a springboard to jump start your own efforts at solving the problem.
This tip is for all trauma professionals: prehospital, doctors, nurses, etc. Anyone who touches a trauma patient. You’ve probably seen this phenomenon in action. A patient sustains a very disfiguring injury. It could be a mangled extremity, a shotgun blast to the torso, or some really severe facial trauma. People cluster around the injured part and say "Dang! That looks really bad!"
It’s just human nature. We are drawn to extremes, and that goes for trauma care as well. And it doesn’t matter what your level of training or expertise, we are all susceptible to it. The problem is that we get so engrossed (!) in the disfiguring injury that we ignore the fact that the patient is turning blue. Or bleeding to death from a small puncture wound somewhere else. We forget to focus on the other life threatening things that may be going on.
How do we avoid this common pitfall? It takes a little forethought and mental preparation. Here’s what to do:
If you know in advance that one of these injuries is present, prepare your crew or team. Tell them what to expect so they can guard against this phenomenon.
Quickly assess to see if it is life threatening. If it bleeds or sucks, it needs immediate attention. Take care of it immediately.
If it’s not life threatening, cover it and focus on the usual priorities (a la ATLS, for example).
When it’s time to address the injury in the usual order of things, uncover, assess and treat.
Don’t get caught off guard! Just being aware of this common pitfall can save you and your patient!
Yesterday I requested your help in figuring out how big a trauma resuscitation room should be. As promised, I brought in my trusty tape measure today to check out my trauma bays at Regions Hospital. I came up with several helpful measurements to help gauge the relative utility of the rooms.
Here are the indices that I came up with:
TBTA: Trauma Bay Total Area. This is the total square footage (meterage?) measured wall to wall.
TBWA: Trauma Bay Working Area. This is the area that excludes equipment carts next to a wall, and areas under countertops that extend away from the wall.
TBAA: Trauma Bay Available Area. This is the TBWA less any other unusable areas in the room. We have an equipment post near one corner that eats up 16.5 sq ft of space. Also remember to subtract the area taken up by the patient bed, as this area is not available to the trauma team, either.
TBSI: Trauma Bay Space Index. This value is derived by dividing the TBAA by the number of team members in the room. It gives an indication of how much space is available for each one to work in.
Values in my trauma center:
TBTA: 291 sq ft
TBWA: 220.5 sq ft
TBAA: 186.5 sq ft
What does it all mean? Hard to say without more info from you for comparison. For my team, it means we each have a 4x4 foot square to move around in, on average.
Keep on sending info on your trauma resuscitation rooms! Leave comments below, or tweet/email me the values for the metrics listed above. Once I get a critical mass of them, I’ll write a detailed post on the results!
I was just asked the question: how big should a trauma bay be? Interestingly, the state of California requires any newly constructed/renovated trauma room to be at least 280 square feet in size (26 sq meters). Today, I’d like to get your opinion. How big is your trauma bay? And is that big enough?
I’d like all my readers to chime in on this one. Take a moment to look at your resuscitation room, measure it if you can, and then judge it.
Then take a moment to either leave a comment below, tweet you answers, or email me at firstname.lastname@example.org. I’ll compile the answers at the end of the week and see if there is a consensus to be had.
I need three pieces of information:
How big is the room (wall to wall)?
How big is the floor area excluding equipment carts (usually much smaller)?
How many people are on your team and in the room? (Don’t include the patient; I assume that’s why you are in there)
The shift in management of adult solid organ injury from primarily operative to mostly nonoperative began in the late 1980s. For the last decade or so, we’ve been refining this management, figuring out failure criteria, the role of interventional radiology, and developing practice guidelines. We know we’ve been able to reduce the number of people that undergo operative management, with an acceptably low failure rate. But is there a financial impact as well?
Surgeons at the MedStar Hospital Center in Washington DC tapped into a huge hospital discharge database from 1994 to 2010. They focused on patients with admitting diagnoses of spleen or liver injury. They looked at relative costs compared to 1994 practice patterns (still quite a bit of operative management), hospital length of stay, and mortality risk.
Here are the factoids:
Nearly 30,000 spleen injury records and 15,000 liver injury records were reviewed
Nonop management of spleen injury increased from 38% to 67%, and for liver injury from 62% to 81%
In-hospital cost of care decreased by over $8,000 for each patient over the study period
Hospital length of stay decreased by about 2 days for each patient
Mortality in high risk patients dropped significantly (from 64% to 18% for liver, 30% to 20% for spleen)
Mortality in low risk patients remained unchanged (2-3%)
Bottom line: Yes, this study suffers from the usual pitfalls of massaging any large multi-institutional database. But what impresses me is that significant changes have been identified, despite huge variations in how nonoperative management is delivered at so many hospitals. As I have mentioned before, at my hospital we were able to show that just adhering to a standardized solid organ injury protocol squeezes yet another $1000 in costs out of each patient treated, on average. Time to adopt a protocol and adhere to it. Your hospital administrators will love you even more!
Trauma Education: The Next Generation Coming Soon!
TE:TNG, version 2.0 is coming next month! Our fast-paced 4 hour program will be available live (but you have to come see me in St. Paul MN), or via LiveStream on Thursday, September 4.
Our guest speaker is Dr. Cliff Reid of the resus.me blog, live from Australia (via Skype), talking about "When ‘scoop and run’ is not an option: emergency medicine and trauma surgery outside the hospital."
We also have a number of other live presenters, delivering 20 minute fact-packed talks on trauma topics applicable to all trauma professionals. Topics include:
Complex dental trauma
Prehospital spine immobilization
Peppered among all the live presenters will be curbside consults, where we ask the specialists what you also wished you had asked. We’ll also show a variety of focused, 5 minute how-to videos on:
Trauma team activation: the patient perspective
For more information, or to make arrangements to join us live or electronically, please visit our website at www.tetng.org
Is it real, or just another one of those crazy things that radiologists like to add to their reports? I recently came across one of these for the first time in over 30 years of practice. What is it? And is it significant in your management of a trauma patient?
A rudimentary rib is simply an extra one (supernumerary). They can be found on vertebrae where ribs are not supposed to be present, typically C7 and L1. The most common supernumerary ribs are found at C7, and are a well documented cause of thoracic outlet syndrome.
Rudimentary ribs are less commonly found on lumbar vertebrae, and they tend to be longer than the transverse processes. This means that it is possible to break them given moderate to high energy blunt torso trauma. The image below shows a person with 2 rudimentary lumbar ribs on L1.
These are very rare congenital variants. It is more likely that your patient is showing abnormal bone formation after a previous fracture, so question them closely for a history of trauma.
What’s the clinical significance? There’s little chance of hemothorax or pneumothorax. But they cause pain like any other fracture. Just apply your usual routine for rib fracture management: analgesia and pulmonary toilet. Since it takes a relatively large amount of energy to break these short little ribs, be on the lookout for other occult injuries as well.
Bottom line: This isn’t just a weird radiology “red herring.” Rudimentary rib fractures can occur, although a history of previous injury should be ruled out. Manage like any other rib fracture, but beware of potential occult injuries.
In my last post, I presented the issue of dealing with a surprise patient who was both in arrest and contaminated with gasoline. They are brought into your resuscitation room without warning of the potential hazard. Now that they are here, what do you do?
Thanks for the many online and email responses. This is a tough question, because there are so many variables to think about. And you have to make decisions very quickly. Here’s a rundown on my thought processes.
First, if you get an indication that there might be any type of contamination, insist that your prehospital providers hold the patient outside the ED. Have part of your trauma team waiting at the ambulance dock to do a quick assessment there. Another minute or two of Lucas CPR will not make a difference. Use your best judgment as to how much of a hazard is posed by the fuel/mystery liquid/white powder. But err on the side of being conservative so you don’t end up shutting your entire ED down due to contamination. If in doubt, immediately move to your decontamination area.
If the patient ends up deep in your ED before anyone recognizes that there might be a contamination problem, you must heed three overarching principles:
Limit contamination to the rest of your facility. Close the doors to the resuscitation room. Notify security and your hazardous materials team so they can start working on containment and safety issues outside the room. Failure to do this can take your entire hospital offline. If the situation turns out to be a multiple or mass casualty event and your hospital was the only one able to respond, you’ve just created a catastrophe and delayed treatment for the other patients.
Ensure the safety of your team. This is a great reason to require and enforce that everyone on the team dress up completely for every resuscitation. You never know where your patients have been, and when one of these will sneak in.
Continuously assess the risk:benefit ratio. Is the contamination a minor irritant? What is the danger to the team? The ED/hospital? How likely are your efforts to save the patient to succeed? As soon as the ratio goes bad, rethink the options and act accordingly.
Bottom line: In situations like this, think fast and think globally. Don’t just consider the patient. There may be many more lives at stake, and this can and should factor into your decisions about where and how long to continue resuscitation.
In this case, we were certain it was only gasoline. We closed the doors and quickly stripped the patient, bagging the clothes tightly. We tried not to generate any sparks, but we are surrounded by all kinds of electrical equipment. Defibrillation was out of the question. After the event was finished, it was time to wash everything down and start thinking about what would have happened if this had been something more toxic than fuel!
Here’s some food for thought. Read through the scenario below, as well as the questions under it. I’m interested in some comments from prehospital providers, physicians and nurses in the ED on what you would do in this situation.
Scenario: Paramedics call ahead to activate your trauma team for a young male who was ejected from his car during a motor vehicle crash. He was quickly extricated and was found to be in pulseless electrical activity (PEA) arrest. IVs were inserted and the Lucas automated CPR device was attached. The patient is immobilized and will arrive at your hospital in 5 minutes.
You assemble your trauma team and are patiently awaiting when the medics arrive. The patient / Lucas / backboard are rapidly transferred over to the ED stretcher and mechanical CPR continues. At that point, you are overwhelmed by the odor of gasoline, and you note that the patient’s clothing is saturated with liquid.
What would you do?
Here are my questions for you:
Do you move the patient or keep him in your trauma bay?
What if your decontamination area is a short/moderate/longer distance from your ED?
What if this situation involved a farmer in arrest who smelled strongly of pesticide? Any different?
Or someone covered with mysterious white powder?
How do you balance patient survival and team safety?
What kind of performance improvement activities will be needed with regard to the team? The prehospital providers?
This discussion is not suited to the 140 character limitation of Twitter, so please click the Comments link below and let me know what you think. I’ll give my take on this next week.
Rapid airway control is key in critically injured trauma patients. But too many times, I’ve seen trauma professionals take far too much time to establish one. Here’s a good rule of thumb to use in these situations.
After pre-oxygenating the patient, your first pro gets a crack at it. They generally have the most time available, often 3-5 minutes before sats begin to drop.
In the unlikely situation that they are not successful, strike 1. Stop trying and resume bagging the patient. At this point, someone (trauma surgeon, lead medic) must get the crich set out. Then the next most experienced intubator gets a shot.
If they are not successful, strike 2. Resume bagging and open the crich set.
The most experienced intubator now gets their chance, using any advanced technology available. No success even now? Strike 3, use the crich set!
Bottom line: We should never allow more than 3 airway attempts, and sometimes clinical conditions will dictate fewer tries. Examples that come to mind are severe brain injury patients (hypoxia is bad) and patients who do not recover from oxygen desaturation when they are bagged. Don’t lose track of time and the number of attempts!
A number of studies have documented post-traumatic stress disorder in our trauma patients, pre-hospital providers, and combat veterans. A new study now suggests that PTSD symptoms are present in 41% of trauma surgeons(!). Can it be true??
The study was carried out using an email questionnaire that was sent to all EAST and AAST members. Respondents were directed to an online questionnaire that polled them for basic demographics, as well as a series of questions using a well-established PTSD checklist scale, the PCL-C.
Here are the factoids:
1104 questionnaires were distributed, and 453 were complete enough for analysis (41%)
Respondents tended to be younger (68% < 50 years old), male (76%) and white (80%)
The majority worked in Level I (71%) urban (90%) academic centers (81%) with resident coverage (83%)
85% took at least 4 in-house calls each month, 27% had 2 weeks or less of vacation each year (!), and 81% believed that trauma surgery was more stressful than other surgical subspecialties
40% of respondents had PCL scores consistent with PTSD (!)
The only independent predictor of having PTSD symptoms was managing 5 or more critical cases while on call
Bottom line: Hmm, be skeptical of this one. Yes, it does seem to show some possible issues with PTSD in a select group of trauma surgeons. However, I don’t believe this is easily generalized, and my personal contact with surgeons around the country does not really bear this out. The survey methodology, response rate, and the skewed demographics raise some serious questions about the quality of this data. And can self-reporting of PTSD symptoms from a group of trauma surgeons really be reliable?? It does appear that a subset of surgeons who work at very busy urban centers may be at risk, and this certainly deserves further scrutiny. But this study does not really apply to the majority of surgeons practicing trauma care in this country, who don’t work in that kind of environment.
It’s one of those time honored treatments that most hospital-based providers are familiar with. The banana bag, reserved for intoxicated patients presenting to the ED or admitted to the hospital. They’ve been around so long, we just take them for granted. But like most things that have become dogmatic, they are due to be questioned from time to time.
A banana bag is a proprietary mix of “good” stuff, including electrolytes and vitamins, especially thiamine and magnesium. The exact content varies from hospital to hospital. Thiamine and other B vitamins give the resulting solution the characteristic color, hence the term “banana.”
Does it actually do good things like ward off Wernicke’s encephalopathy and megaloblastic anemia? A paper from Jacobi Medical Center in the Bronx prospectively evaluated a series of intoxicated people entering their ED. They drew vitamin B12, folate, and thiamine levels to see if they were deficient enough to even need vitamin supplementation.
Here are the factoids:
These folks (only 77 patients) were very drunk! Average BAC was 280mg/dL.
Vitamin B12 and folate levels were not critically low in any patient
Thiamine was low in 15% of patients, but none had clinical evidence of a deficiency
Later review of prior visits revealed that some patients with low levels had received a previous banana bag within 1 month. Did it do any good?
Bottom line: Most of our intoxicated patients are not vitamin deficient, and don’t need supplementation. The real kicker is that we almost never really try to find out if the patient might be a chronic abuser and potentially at risk. We just hang the bag. Remember, everything we do in medicine has a potential downside. And if the patient really doesn’t need a banana bag in the first place, there is no benefit to balance that risk. The next time you ask for that little yellow bag, think again!
I’ve previously blogged about the flat vena cava sign as an indicator of low volume status in trauma patients. And I commented on this paper when it was presented at EAST, which had a surprisingly negative result. It’s now been vetted by peer reviewers and published, and I’ve had the opportunity to read through the entire manuscript (always important). So let’s take a second look now.
A retrospective study at George Washington University was carried out over a one year period. They looked at all of their highest level trauma activation patients who also underwent CT scan of the abdomen. Images were read by three radiologists and inter-rater reliability was reviewed. The transverse to anteroposterior diameter ratios were calculated to determine flatness.
Here are the factoids:
276 patients met enrollment criteria, and were mostly male and blunt trauma
The IVC was nearly round in 21% of patients and collapsed in 26%
There was no association between IVC shape and shock index, blood pressure, Hbg, lactate, urgent operation, angiography or length of stay
There was also no association between IVC shape and blood transfusion or death
Correlation of the reads between radiologists was good
So what gives? A paper I reviewed three years ago in the Journal of Trauma came to a different conclusion. They found that a flat IVC on CT scan (defined as a transverse to AP ratio of 4:1 or greater) was associated with a significantly higher chance of receiving more crystalloid or blood, as well as requiring an operation within 24 hours.
This newer paper was able to look at a larger group of patients, and they were able to tease out why it initially looked like the flat cava looked like a good predictor for bad things to come. The problem was statistical skewing from a few extreme outliers. When properly corrected, it completely changed things. And looking at the older study, it appears that outliers may have also been the reason for the positive result. This is why I encourage everyone to always read the entire paper! The older paper involved a smaller series (114 patients), but it was prospective and seemed to have reasonable statistical analyses.
Bottom line: It looks like the flat vena cava sign, as measured by a static CT, should be discarded as an indicator of impending shock. Whether or not a more dynamic look (using ultrasound) is valuable remains to be determined.
I recently wrote about this journal article from a couple of pediatric trauma programs in New York. The article tried to focus on reducing the rate of phlebotomy in children who are being observed for solid organ injury. I was more excited about the overall protocol being used to manage liver and spleen injury, as it was a great advance over the original APSA guideline. But let’s look at the phlebotomy part as well.
This is an interestingly weird study, and you’ll see what I mean shortly. Two New York trauma hospitals that take care of pediatric patients pooled 4 years of registry records on children with isolated blunt liver and/or spleen injuries. Then they did a tabletop excercise, looking at “what if” they had applied the APSA guideline, and “what if” they had applied their new, proposed guideline.
Interestingly, this implies that they were using neither! I presume they are trying to justify (and push all their partners) to move to the new protocol from (probably) random, individual choice.
Here are the factoids:
120 records were identified across the 2 hospitals that met criteria
Late presentation to the hospital, contrast extravasation, comorbidities, lack of imaging, operative intervention at an outside hospital excluded 59 patients, leaving 61 for analysis. Three of those patients became unstable and were also excluded.
None of the remaining patients required operation or angioembolization
Use of the “new” (proposed) protocol would reduce ICU admissions by 65%, reduce blood draws by 70%, and reduce hospital stay by 37%
Conclusion: use of the protocol would eliminate the need for serial phlebotomy (huh?)
Bottom line: Huh? All this to justify decreasing blood draws? I know, kids hate needles, but the data on decreased length of stay in the hospital and ICU is much more important! We’ve been using a protocol similar to their “new” one at Regions Hospital, which I’ve shared below. We’ve been enjoying decreased resource utilization, blood draws, and very short lengths of stay for over a decade. And our analysis showed that we save $1000 for every patient entering the protocol, compared to the old-fashioned and inefficient way we used to manage them.
Pediatric Solid Organ Injury Management: It's About Time!
There was an interesting article released in the Journal of Pediatric Surgery in May about spleen and liver injury management in children. It’s interesting because if you just look at the title, you might just skip over it. The title suggests that it describes reducing scheduled phlebotomy in kids who are undergoing solid organ injury management. But the real meat of this article has to do with the protocol they are using to treat the children.
Nonoperative management of these injuries in children started becoming popular 40 years ago (!). But for decades, everyone put their own spin on how to do it. Bed rest for a week (or more). NPO for days! Limited physical activity for extended periods. Then the American Pediatric Surgery Association (APSA) published a set of guidelines about 15 years ago that took some of the guesswork out of it.
Although nonoperative management of these injuries in kids preceded its adoption in adults by a nearly two decades, it has languished in the APSA format for quite some time. Many pediatric surgeons still use these guidelines, even though adult spleen and liver injury management have advanced to shorter and more streamlined care.
We adopted a solid organ management guideline at Regions Hospital over ten years ago, and have made a few minor tweaks over the years. Nowadays, our grade I-III injuries can be home as early as 36 hours after admission, and frequently are. Grades IV and V are eligible to be discharged after just 24 more hours if they have no other injuries to keep them in the hospital.There are very rare failures.
I’ll detail the factoids about the phlebotomy part of this paper in tomorrow’s post. But I do want to show you the more aggressive protocol the authors are using (one of whom authored the original APSA guideline).
Here it is:
Bottom line: Note how quickly children are allowed to get up, eat, and get out of the hospital using the “new” protocol. Many adult centers have been using similar ones for years. It’s nice to see that adult and pediatric protocols are finally beginning to converge. After all, we figured out our current adult management based on our experience with kids 30 years ago!
Kenji Inaba and colleagues have done a lot of work on tension pneumothorax (tPTX) in the past few years. They’ve looked for the best devices and the best positions on the chest to quickly and effectively treat this emergency. Now, they’ve published a study on using what looks like a “better mousetrap” for relieving tension physiology.
Previous work from this lab has shown that up to a quarter of needle thoracostomies fail within 5 minutes due to mechanical reasons. This leaves a small window for insertion of the real chest tube. And even though much of the pressure may be relieved, a significant amount of air may be left in the chest, impeding recovery from PEA arrest.
They looked at the use of a 5mm laparoscopy port for relief of tension pneumothorax in Yorkshire swine. The exact size of the pigs was not listed, but these animals weigh 25 pounds at 6 weeks of age, and the pictures in the article show a reasonable sized animal. I’m not sure they were 70kg, though.
Here are the factoids:
Five animals were used, and 30 episodes of tPTX and 27 episodes of PEA arrest from tPTX
Tension pneumothorax was created by insufflating the chest with CO2 using a 10mm laparoscopic trocar
tPTX was completely relieved by insertion of the 5mm trocar in 100% of trials, with all physiologic measures returning to baseline within 1 minute
Circulation was restored to normal within 30 seconds in 100% of trials
There was no damage to heart or lung from trocar placement in any of the 5 animals
Bottom line: Once again, Inaba and crew have added some interesting tidbits to our knowledge base. You already know I’m not a fan of animal studies like this, but this one lays the ground work for some work in humans. We still need to know how the “usual American body habitus” will affect the use of this device. The only downside is the expense of the trocar, which is a lot more than a simple long needle. But if it is as efficacious in humans as it is in pigs, it may be worth it!
Procedural Complications: Residents vs Advanced Practice Providers
With the implementation of resident work hour restrictions 10 years ago, resident participation in clinical care has declined. In order to make up for this loss of clinical manpower and expertise, many hospitals have added advanced clinical providers (ACPs, nurse practitioners and physician assistants). These ACPs are being given more and more advanced responsibilities, in all clinical settings. This includes performing invasive procedures on critically ill patients.
A recent study from Carolinas Medical Center in Charlotte NC compared complication rates for invasive procedures performed by ACPs vs residents in a Level I trauma center setting.
A one year retrospective study was carried out. Here are the factoids:
Residents were either surgery or emergency medicine PGY2s
ACPs and residents underwent an orientation and animal- or simulation-based training in procedures
All procedures were supervised by an attending physician
Arterial lines, central venous lines, chest tubes, percutaneous endoscopic gastrostomy, tracheostomy, and broncho-alveolar lavage performances were studied
Residents performed 1020 procedures and had 21 complications (2%)
ACPs performed 555 procedures and had 11 complications (2%)
ICU and hospital length of stay, and mortality rates were no different between the groups
Bottom line: Resident and ACP performance of invasive procedures is comparable. As residents become less available for these procedures, ACPs can (and will) be hired to take their place. Although this is great news for hospitals that need manpower to assist their surgeons and emergency physicians, it should be another wakeup call for training programs and educators to show that resident education will continue to degrade.
After taking a travel break last month, it’s back! The latest edition of the Trauma MedEd newsletter is now available for download. The subject is Abdomen. Included are articles on:
- How to close an abdominal stab laparoscopically - FAST is FAST and FAST is last! - FAST exam in children - Performance improvement for FAST - DPL: a dying art? - Less morbidity from negative trauma laparotomy?
The liver is one of the two most commonly injured solid organs after blunt trauma. There are a variety of ways to manage solid organ injury, and many trauma centers are adopting solid organ injury protocols to streamline and improve care. I am occasionally asked whether there is a place for liver function testing after hepatic injury.
In a previous post (see below), I cited some old literature refuting this idea. A more recent paper has now tried to answer this question. They retrospectively reviewed 3 years of data on patients admitted to a large hospital in Jiangsu, China. Only patients with blunt liver injury were included. They were interested to know if liver function testing helped identify the presence and severity of injury.
Here are the factoids:
182 patients who had blunt abdominal injury and liver function testing were identified in their registry (AST, ALT, GGT, Alk PHos, LDH, bili)
90 patients had liver injury and 92 did not
Grade of liver injury was fairly evenly distributed, with a few less grade IV and V
Elevated LFTs accurately predicted the presence of a liver injury. ALT > 57 U/L was the most accurate predictor.
There was no correlation between LFT values and severity of liver injury
Bottom line: Basically, routine liver function testing after blunt abdominal trauma is a waste of time. And obtaining LFTs after known liver injury is an even greater waste of time. You know your patient has the injury, and you know the grade from the CT scan you obtained (hopefully). And from personal experience, there is absolutely no value in “trending” liver functions to see how the liver is healing. If the patient develops an unexpected clinical finding at some point (new pain, jaundice, fever), then you may wish to order laboratory or imaging studies to help determine if a complication is developing.
One of the critical maneuvers that EMS providers perform is establishing initial vascular access. This IV is important for administering medications and for initiating volume resuscitation in trauma patients. Prehospital Trauma Life Support guidelines state that every trauma patient should receive two large bore IV lines. But is this really necessary?
The upside of having two IVs in the field is that the EMS provider can give lots of volume. However, a growing body of literature tells us that pushing systolic blood pressure up to “normal” levels in people (or animals) with an uncontrolled source of bleeding can increase mortality and hasten coagulopathy.
The downside of placing two lines is that it is challenging in a moving rig, sterility is difficult to maintain, and the chance of a needlestick exposure is doubled. So is it worth it?
A group at UMDNJ New Brunswick did a retrospective review of 320 trauma patients they received over a one year period who had IV lines established in the field. They found that, as expected, patients with two IVs received more fluid (average 348ml) before arriving at the hospital. There was no increase in systolic blood pressure, but there was a significant increase in diastolic pressure with two lines. The reason for this odd finding is not clear. There was no difference in the ultimate ISS calculated, or in mortality or readmission.
Bottom line: This study is limited by its design. However, it implies that the second field IV is not very useful. The amount of extra fluid infused was relatively small, not nearly enough to trigger additional bleeding or coagulopathy. So if another IV does not deliver significant additional fluid and could be harmful even if it did, it’s probably not useful. Prehospital standards organizations should critically look at this old dogma to see if it should be modified.
Study of placing a second intravenous line in trauma. Prehospital Emerg Care 15:208-213, 2011.
Trauma Activation Patients Staying Too Long In Your ED?
One of the long-held beliefs in trauma care relates to the so-called "golden hour." Patients who receive definitive care promptly do better, we are told. In most trauma centers, the bulk of this early care takes place in the emergency department. However, for a variety of reasons, throughput in the ED can be slow. Could extended periods of time spent in the ED after patient arrival have an impact on survival?
Wake Forest looked at their experience with nearly 4,000 trauma activation patients who were not taken to the OR immediately and who stayed in the ED for up to 5 hours. They looked at the impact of ED dwell time on in-hospital mortality, length of stay and ventilator days.
Overall mortality was 7%, and the average time in the ED was 3 hours and 15 minutes. The investigators set a reasonable but arbitrary threshold of 2 hours to try to get trauma activation patients out of the ED. When they looked at their numbers, they found that mortality increased (7.8% vs 4.3%) and that hospital and ICU lengths of stay were longer in the longer ED stay group. Hospital mortality increased with each hour spent in the ED, and 8.3% of patients staying between 4 and 5 hours dying. ED length of stay was an independent predictor for mortality even after correcting for ISS, RTS and age. The most common cause of death was late complications from infection.
Why is this happening? Patients staying longer in the ED between 2 and 5 hours were more badly injured but not more physiologically abnormal. This suggests that diagnostic studies or consultations were being performed. The authors speculated that the knowledge, experience and protocols used in the inpatient trauma unit were not in place in the ED, contributing to this effect.
Bottom line: This is an interesting retrospective study. It reflects the experience of only one hospital and the results could reflect specific issues found only at Wake Forest. However, shorter ED times are generally better for other reasons as well (throughput, patient satisfaction, etc). I would encourage all trauma centers to examine the flow and delivery of care for major trauma patients in the ED and to attempt to streamline those processes so the patients can move on to the inpatient trauma areas or ICU as efficiently as possible.
Reference: Emergency department length of stay is an independent predictor of hospital mortality in trauma activation patients. J Trauma 70(6):1317-1325, 2011.
Yesterday I posed a scenario where the surgeon needed to see an area of an open abdomen (trauma laparotomy) that could not easily be visualized. Specifically, there was a question as to whether the diaphragm had been violated just anterior to the liver, just under the costal margin.
Short of putting your head in the wound, how can you visualize this area? Or some other hard to reach spot? Well, you could have an assistant insert a retractor and pull like crazy. However, the rib cage might not bend very well, and in elderly patients it may break. Not a good idea.
Some readers suggested breaking out the laparoscopy equipment and using the camera and optics to visualize. This is a reasonable idea, but expensive. Shouldn’t there be some good (and cheap) way to do this?
Of course, and there is. Think low tech. Very low tech. You just need to see around a corner, right. So get a mirror!
Every OR has some sterile dental mirrors lying around. Get one and have your assistant gently hold the liver down while you indirectly examine the diaphragm. Since you’re probably not a dentist, it may take a minute or two to get used to manipulating the mirror to see just what you want. But if you can manage laparoscopic surgery, you’ll get the hang of it quickly.
And if you need more light up in those nooks and crannies? Shine the OR light directly into the abdomen, then place a nice shiny malleable retractor into the area to reflect light into the area in questions. Voila!
Bottom line: A lot of the things that trauma professionals need to do in the heat of the moment will not be found in doctor, nurse, or paramedic books. Be creative. Look at the stuff around you and available to you. Figure out a way to make it work, and make $#!+ up if necessary.
Let me present a scenario and first see how you might solve this problem.
A young man presents with a gunshot to the abdomen in the right mid-back. He is hemodynamically stable, and you get a chest xray. It shows a small caliber slug in the right upper quadrant, but no hemo- or pneumothorax. He has peritoneal signs, so you whisk him off to the OR for a laparotomy.
As you prep the patient for the case, you can feel a small mass just above the right costal margin. You incise the area and produce a 22 caliber bullet. Of course, you follow the chain of evidence rules and pass it off for the police. As you explore the abdomen, it appears that there are no gross injuries. You are concerned, however, that there may be an injury to the diaphragm in proximity to the bullet.
So here’s the question: how can you visualize the diaphragm in this area? The bullet was located below the right nipple. But the diaphragm in this area is covered by the liver, and is parallel to the floor. You can’t seem to feel a hole with your fat finger. But short of putting your whole head in the wound, you just can’t get a good angle to see the area in question.
How would you do it? Please tweet or leave comments with your suggestions. I’ll provide the answer(s) tomorrow!
As usual, the simplest things are often the best. A recent paper looked at the newest and greatest “drug” to use for providing postoperative analgesia: the good, old-fashioned ice pack!
This concept is obviously not new. Cold is known to quiet inflammation, which is inevitable when tissues are incised. Athletes and their trainers have used ice packs forever. Surgical studies have evaluated their use in orthopedic extremity procedures as well as hernia repairs.
The current paper, from several surgical departments at Emory in Atlanta, randomly allocated patients to have an ice pack placed on their laparotomy incision. Only patients undergoing open abdominal procedures were included. Ice packs were maintained in place for 24 hours, and were then allowed as long as the patient wanted it. Pain, as judged by the analog pain scale, narcotic use, and hospital length of stay were measured. A power analysis was actually performed, and the number of patients required to detect a 15% difference were enrolled (!).
Here are the factoids:
55 patients were enrolled, and were truly randomized
Most operations were for pancreatic, gastric, liver, and colorectal cancers
The usual demographics of the two groups were identical
Pain score was decreased as measured twice later in the day on day 1, and once on day 3
Narcotic use was lower on day 1
Length of stay was the same for both groups
Patients in the cryotherapy group requested to keep the ice packs for an average 2.75 days. None requested removal at the end of day 1.
Most stated that they would request an ice pack the next time they had surgery
Bottom line: For once, a nicely done study! Simple and to the point. It reinforces the concept that cheap and simple can still be good. The ice packs in this study were plain old refillable bags filled with ice cubes, not fancy gel or chemical packs that cost lots of money. And the decrease in narcotic use is huge! The side effects of these drugs (constipation, urinary retention, allergic reaction, etc.) create the need for interventions that introduce another whole world of complications.
Consider adding the simple old ice pack to your armamentarium of postop pain relief. But remember, you’ve got to start it as early as possible for best effect, ideally as the surgical dressing is placed.
Governmental agencies everywhere collect trauma related data. The US federal government maintains a number of databases, such as the Fatal Accident Reporting System (FARS), the Census of Fatal Occupational Injuries (CFOI) and many others. States collect similar but smaller datasets. Even towns and municipalities collate injury information in the form of prehospital run sheets.
But reams of data are of no use unless you can learn something from it. Unfortunately, most of this data is tucked away in database management systems, or in some cases just stacks of paper forms locked up somewhere. In order for humans to make sense of it and do useful things with it, we need to transform it into forms that we can easily interpret and make sense of.
Fortunately, there are lots of visual, electronic tools available to help us do just that. One of the most helpful tools is the programmable geographic information system (GIS). An example of this is Google Maps. Most of us have used this or a similar tool in some form, usually to get directions from here to there. But you may not be aware that Google provides a programming interface so a savvy user can place any type of geography-related data on the map, creating what is called a mashup.
Imagine crossing the FARS database, which contains extensive data points on every fatal road accident in the US, with a mapping system. This would allow creation of a map showing where every person lost their life in a road accident, along with additional pertinent information about the event. A great example of this is demonstrated below. It was created by ITO World Ltd., based in the UK. They crossed fatality information with geographic map data in both the US and the UK.
This map shows fatal road events around Minneapolis from 2001 to 2009. The type of event (pedestrian struck, motor vehicle crash, etc.) is displayed along with age, year and sex. It is movable and zoomable so it can be viewed it in great detail. Click on the map above to open a new window to the full map.
Bottom line: Using trauma data / map mashups is a great way to visualize complex information. It also allows us to plan meaningful prevention activities based on local information (a requirement for ACS trauma center verification). Imagine looking over such a map of your city, and identifying a cluster of pedestrian fatalities. Then you notice that this cluster is 2 blocks away from an elementary school. This could prompt you to work with the school to implement automobile awareness programs for the children, have the city review signage and obstructions to view in the area, and optimize the number and placement of crossing guards. Then redo the map afterwards to judge the impact. Wow!
To summarize: stab to the back, prone position, stable vitals, awake and alert and breathing easily. The patient had a chest xray which showed some likely hemothorax. He was sent to CT (prone) and the image obtained looked like this:
They key points to note are:
The injury is completely above the diaphragm. No need to worry about an intra-abdominal problem.
The amount of hemothorax is moderate. It is not enough to mandate a thoracotomy. At least for now.
There is a significant pneumothorax. You can’t see it due to the windows used, but the lung has separated from the chest wall by about 3cm.
The track of the knife was directed laterally.
No significant vascular structures were involved, and there is no contrast extravasation.
Final management: The patient was returned to the ED, and the knife was deftly removed and processed properly as evidence. The patient was then turned supine and a 40 Fr chest tube was inserted using procedural sedation. About 400 cc of blood was drained and reinfused. A repeat chest xray was obtained, which showed some residual hemothorax and near resolution of the pneumothorax. He was then admitted for frequent vital signs and drainage measurements for two shifts. Afterwards, he was placed in our chest tube management protocol. The tube was removed and he was discharged two days later. There were no complications.
I’m currently in Montreal, and just finished some presentations at McGill University / Montreal General Hospital on pediatric trauma. I’ll be wandering around the city today and will finish the stab to the back case tomorrow. Looking for fans!
So yesterday, we found that our patient was hemodynamically stable, with a knife in his back, positioned prone. An initial chest xray shows the knife (plainly) and haze in the right side of the chest. Obviously, this is a hemothorax.
Key points to note are that the amount of blood present is modest and the knife point is relatively medial, as is the entry seen on the outside. Combined, these data points indicate that you have time to gather more information.
My choice was to go to CT to get the ultimate anatomic information. What, you say, the patient is prone! Well, the scanner doesn’t care. As long has his torso AND the knife fit through, it works. Here’s the representative scan result:
What do you do now? Where do you do it? Answer tomorrow. Tweet or comment your decision!
Yesterday, I presented a case of a young man with a knife in his back. He was brought to your ED in the prone position. The question was, what to do next?
With any trauma patient, regardless of size, shape, or position, the first question is always, “does this patient belong in the ED?" And usually, that question is answered by checking hemodynamic stability.
This patient stays prone while you quickly assess vital signs. If vitals are abnormal, he needs to get rolled to the operating room immediately, while still prone. There is no time to figure out how to reposition, or if the knife can be removed. Get him out of your ED.
But let’s say he is hemodynamically normal and talking to you. You need more information. So start with a physical exam. With him in the prone position! It works. In this case, there are no other puncture wounds, and the anterior part of the body can be examined by carefully logrolling him onto his side. Breath sounds are decreased over the right chest, otherwise there are no other anomalies.
So now what? Well, let’s get some more info! How about a chest xray? Best position? Prone! It’s the easiest, because the patient does not need to be held up next to an xray plate, which would also have to be held manually. The lateral view doesn’t add anything but hassle. Here’s the result:
Now what? What do you see, what do you do? Tweet or comment; more to follow tomorrow.
Here’s an interesting case to consider. A young male is assaulted and stabbed to the back. Paramedics bring him to your ED as a trauma team activation, and the full team is assembled prior to his arrival.
He is brought into the room on the stretcher in the prone position. Here is a representative picture. This is not the actual patient, just a picture I found on another blog site that looks pretty close to the real case.
Let’s walk through the thought processes of managing this over the next few days.
First, what do you need to know right now to navigate your critical decision points? And what are you going to do regarding positioning, evaluation, and imaging?
Tweet or comment with your replies! More on Monday.
We’ve all been faced with injured patients who are taking some kind of anticoagulant, and it complicates their care. Many trauma professionals just say, “they just shouldn’t take this stuff any more.” Why can’t we just stop them in patients at risk for injury (e.g. an elderly patient who falls frequently)?
Two major risk groups come to mind: those taking the meds who have DVT (or a propensity to get it), and patients with atrial fibrillation who take them to decrease stroke risk. I was not able to find much info (yet) on the former category. But there is a series of nicely done studies based on work from the Framingham Heart Study.
The Framingham study started in 1948, and has been following over 5,000 people for the development of cardiovascular disease. In this particular analysis, 5070 patients who were initially free of disease were analyzed for development of atrial fib and occurrence of stroke. Anticoagulants were seldom used in this group.
The authors found that the prevalence of stroke increased with age in patients with atrial fib. The percentage that could be attributed to a-fib also increased. The following summarizes their numbers:
Age 50-59: 0.5 strokes per 100 patients, attributable risk 1.5%
Age 60-69: 1.8 strokes per 100 patients, attributable risk 2.8%
Age 70-79: 4.8 strokes per 100 patients, attributable risk 9.9%
Age 80-89: 8.8 strokes per 100 patients, attributable risk 23.5%
Bottom line: The risk of having a stroke just because a patient has atrial fibrillation goes up significantly with age. So setting an age cutoff for taking an anticoagulant doesn’t make sense. Unfortunately, increasing age also means increasing risk of injury from falls. Warfarin definitely cuts that risk, and it happens to be relatively easily reversbile. However, the newer non-reversible drugs change the equation, shifting the risk/benefit ratio too far toward the dark side. We need some good analyses to see if it really makes sense to move everybody to these new (expensive) drugs just to make it easier to dose and monitor. The existing studies on them only look at stroke, but don’t take injury morbidity and mortality into account.
Reference: Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 22:983-988, 1991.
This is a perfect example of why you cannot just simply read an abstract. And in this case, you can’t just read the paper, either. You’ve got to critically think about it and see if the conclusions are reasonable. And if they are not, then you need to go back and try to figure out why it isn’t.
A study was recently published regarding bleeding after nonoperative management of splenic injury. The authors have been performing an early followup CT within 48 hours of admission for more than 12 years(!). They wrote this paper comparing their recent experience with a time interval before they implemented the practice.
Here are the factoids. Pay attention closely:
773 adult patients were retrospectively studied from 1995 to 2012
Of 157 studied from 1995 to 1999, 83 (53%) were stable and treated nonoperatively. Ten failed, and all the rest underwent repeat CT after 7 days.
After a “sentinel delayed splenic rupture event”, the protocol was revised, and a repeat CT was performed in all patients at 48 hours. Pseudoaneurysm or extravasation initially or after repeat scan prompted a trip to interventional radiology.
Of 616 studied from 2000-2012, after the protocol change, 475 (77%) were stable and treated nonoperatively. Three failed, and it is unclear whether this happened before or after the repeat CT at 48 hours.
22 high risk lesions were found after the first scan, and 29 were found after the repeat. 20% of these were seen in Grade 1 and 2 injuries. All were sent for angiography.
There were 4 complications of angiography (8%), with one requiring splenectomy.
Length of stay decreased from 8 days to 6.
So it sounds like we should be doing repeat CT in all of our nonoperatively managed spleens, right? The failure rate decreased from 12% to less than 1%. Time in the hospital decreased significantly as well.
Wrong! Here are the problems/questions:
Why were so many of their patients considered “unstable” and taken straight to OR (47% and 23%)?
CT sensitivity for detecting high risk lesions in the 1990s was nothing like it is today.
The accepted success rate for nonop management is about 95%, give or take. The 99.4% in this study suggests that some patients ended up going to OR who didn’t really need to, making this number look artificially high.
The authors did not separate pseudoaneurysm from extravasation on CT. And they found them in Grade 1 and 2 injuries, which essentially never fail
472 people got an extra CT scan
4 people (8%) had complications from angiography, which is higher than the oft-cited 2-3%. And one lost his spleen because of it.
Is a 6 day hospital stay reasonable or necessary?
Bottom line: This paper illustrates two things:
If you look at your data without the context of what others have done, you can’t tell if it’s an outlier or not; and
It’s interesting what reflexively reacting to a single adverse event can make us do.
The entire protocol is based on one bad experience at this hospital in 1999. Since then, a substantial number of people have been subjected to additional radiation and the possibility of harm in the interventional suite. How can so many other trauma centers use only a single CT scan and have excellent results?
At Regions Hospital, we see in excess of 100 spleen injuries per year. A small percentage are truly unstable and go immediately to OR. About 97% of the remaining stable patients are successfully managed nonoperatively, and only one or two return annually with delayed bleeding. It is seldom immediately life-threatening, especially if the patient has been informed about clinical signs and symptoms they should be looking for. And our average length of stay is 2-3 days depending on grade.
Never read just the abstract. Take the rest of the manuscript with a grain of salt. And think!
Reference: Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma: early screening leads to a decrease in failure rate. J Trauma 76(6):1349-1353, 2014.
The serial hemoglobin (Hgb) determination. We’ve all done them. Not only trauma professionals, but other in-hospital clinical services as well. But my considered opinion is that they are not of much use. They inflict pain. They wake patients up at inconvenient hours. And they are difficult to interpret. So why do them?
First, what’s the purpose? Are you looking for trends, or for absolute values? In trauma, the most common reason to order is “to monitor for bleeding from that spleen laceration” or some other organ or fracture complex. But is there some absolute number that should trigger an alarm? If so, what is it? The short answer is, there is no such number. Patients start out at a wide range of baseline values, so it’s impossible to know how much blood they’ve lost using an absolute value. And we don’t use a hemoglobin or hematocrit as a failure criterion for solid organ injury anymore, anyway.
What about trends, then? First, you have to understand the usual equilibration curve of Hgb/Hct after acute blood loss. It’s a hyperbolic curve that reaches equilibrium after about 3 days. So even if your patient bled significantly and stopped immediately, their Hgb will drop for the next 72 hours anyway. If you really want to confuse yourself, give a few liters of crystalloid on top of it all. The equilibration curve will become completely uninterpretable!
And how often should these labs be drawn? Every 6 hours (common)? Every 4 hours (still common)? Every 2 hours (extreme)? Draw them frequently enough, and you can guarantee eventual anemia.
Bottom line: Serial hemoglobin/hematocrit determinations are nearly worthless. They cost a lot of money, they disrupt needed rest, and no one really knows what they mean. For that reason, my center does not even make them a part of our solid organ injury protocol. If bleeding is ongoing and significant, we will finding it by looking at vital signs and good old physical exam first. But if you must, be sure to explicitly state what you will do differently at a certain value or trend line. If you can’t do this and stick to it, then you shouldn’t be ordering these tests in the first place!
Again, I’m not a fan of animal studies. But this one, presented at EAST 2012 and now published, involves both pigs and humans and is so intriguing I just have to share it. The authors have a track record of studying coagulation issues with thromboelastography (TEG) in both animals and people. They previously showed that hypercoagulability detectable by TEG occurs after insertion of pulmonary artery catheters in swine and critically ill humans.
In this follow-on study, they looked at TEG profiles in 16 healthy swine and 8 critically ill humans after insertion of a central venous catheter (CVC). They found that CVC insertion induced the same type of hypercoagulable state. TEG clotting time and initial clot formation time decreased, and fibrin cross-linking accelerated. The changes were somewhat less in humans, but were still significant in both groups. All coag tests (PT, PTT, INR) and measured coag factors (von Willebrand, AT III) were unchanged.
Interestingly, in the animal group the hypercoagulable state persisted for at least 3 hours after CVC removal. And the hypercoagulability could be prevented with enoxaparin, but not heparin.
Bottom line: The idea that hypercoagulability could be induced by central arterial or venous catheter placement is intriguing, although this work has not been replicated by others yet. What if hypercoagulability occurs with any invasion of the vascular system? We may eventually discover that the increased incidence of DVT we have been fighting in the hospital setting is in part due to our ubiquitous use of IVs and routine blood draws.
Reference: Insertion of central venous catheters induces a hypercoagulable state. J Trauma 73(2):385-390, 2012.
Best Of: What You Need To Know About Falls From a Height
Falls from a height can be either accidental or intentional (suicide attempt). There are several prognostic factors for survival that have been identified:
Type of surface
Body part that touches the ground first
Two other factors are important, but do not have a significant effect on mortality:
Circumstances of the fall (suicide, accident, escape)
Initial impact with an object before impacting the ground
Height. Overall, about half of victims die at the scene, and a total of 70% die before they reach the hospital. The median height leading to death is about 49 feet, or about 4 to 5 storeys. 100% of victims die after falling 85 feet, or about 8 storeys.
Age. Mortality increases with age due to pre-existing medical conditions and decreased physiologic reserve.
Type of surface. The type of surface struck (i.e. grass, water, construction debris) can also have an effect on secondary injuries and survival. Mortality after striking a hard surface is nearly double that of hitting a soft one (39% vs 22%)
Body part touching the ground first. The highest mortality is seen when the victim lands in a prone position (57%). Striking head first has the next highest mortality at 44%. The best striking position is feet first, with a mortality of 6%.
Circumstances of the fall. Suicide attempts have the highest death rate at 46%. This may be attributable to pre-planning, and the increased likelihood that the fall may lead to additional trauma mechanisms (struck by car after jumping from land bridge, drowning after jumping from bridge over water). Accidental falls have a lower 17% mortality.
Initial impact before final impact. Striking wires or scaffolding before the final impact is protective, decreasing the death rate from 37% to 15%.
It is important for the trauma professional to obtain as much information from bystanders or EMS as possible about the fall details. This will ultimately enable to trauma physician to pursue appropriate diagnostic techniques to pinpoint specific injuries associated with various types of falls.
Spinal cord injuries are typically devastating injuries with profound consequences for function and life expectancy. However, a small percentage result in rapidly reversible symptoms. Because these temporary injuries are rare, they tend to cause confusion among clinicians.
Technically, a spinal cord concussion (a “zinger” or “stinger” is an example) is a mild cord injury that results in transient neurologic disturbances. The deficits can be sensory, motor or both, and typically resolve in less than 48 hours. The injuries tend to involve the mid-portion of the cervical cord or the cervico-thoracic junction, since these are the areas of maximum mobility. In a few cases, the athlete has congenital narrowing of the spinal canal which predisposes them to injury. In most cases, the injury probably occurs due to the flexibility of the young spine.
The usual management consists of an MRI of the spine followed by admission and frequent neurologic checks to ensure ongoing resolution. MRI is typically negative in a true concussion. If a signal change is seen, then technically a cord contusion is present. Management is the same for both. There is no indication to give steroids. Evaluation of the ligaments is critical to determine if a collar will be necessary.
Recovery is rapid and complete. But what is the answer to the inevitable question, “when can he/she return to play?” In adult players, the literature suggests that it may be safe to return once they have fully recovered. There is little guidance for kids.
Here’s what I tell the parents: This event has shown that, given the right force applied to your child’s neck, the bones can move enough to injure their spinal cord. This time, the cord was just tickled a little bit. But if the bones had moved just another millimeter or two, this injury could have been permanent and they would never have walked again. I recommend that they do not play this sport again.
Some of you may disagree. I’d be very interested in hearing your comments.
First mention: About concussion of the spinal cord. Wein Med Jahrb 34:531, 1879.
The radiologist made me order that (unnecessary) test! I’ve heard this excuse many, many times. Do these phrases look familiar?
… recommend clinical correlation
… correlation with CT may be of value
… recommend delayed CT imaging through the area
… may represent thymus vs thoracic aortic injury (in a 2 year old who fell down stairs)
Some trauma professionals will read the radiology report and then immediately order more xrays. Others will critically look at the report, the patient’s clinical status and mechanism of injury, and then decide they are not necessary. I am firmly in the latter camp.
But why do some just follow the rad’s suggestions? I believe there are two major camps:
Those that are afraid of being sued if they don’t do everything suggested, because they’ve done everything and shouldn’t miss the diagnosis
Those that don’t completely understand what is known about trauma mechanisms and injury and think the radiologist does
Bottom line: The radiologist is your consultant. While they are good at reading images, they do not know the nuances of trauma. Plus, they didn’t get to see the patient so they don’t have the full context for their read. First, talk to the rad so they know what happened to the patient and what you are looking for. Then critically look at their read. If the mechanism doesn’t support the diagnosis, or they are requesting unusual or unneeded studies, don’t get them! Just document your rationale clearly in the record. This provides best patient care, and minimizes the potential complications (and radiation exposure) from unnecessary tests.