Predicting Escalation Of Domestic Violence
Most trauma professionals will have the opportunity to provide care for victims of domestic violence some time during their career. We are on the front lines and can unfortunately see the damage first hand. From time to time, the abuse escalates to a point where the woman (typically) is murdered. Is there a way to predict this fatal progression so it can be avoided?
The answer is yes! The Danger Assessment Tool (DAT) was developed 25 years ago and has been validated. Even though the instrument is old, it remains extremely helpful. The unfortunate thing is that at least half of the women involved do not recognize the grave peril they are in.
Some key points that were uncovered in the development of the DAT:
- If a gun or other weapon is used to threaten, the risk of being murdered increases 20-fold
- If there is merely a gun in the house, the risk of murder increases 6 times
- If the abuser threatens murder, the risk of being killed increases 15-fold
- Other indications of increased risk of death include heavy substance abuse, extreme jealousy, stepchild in the household, attempts to choke and forced sex
Bottom line: Domestic violence is criminal. We must go beyond the physical treatment and make sure these individuals are safe. Use the Danger Assessment Tool routinely to help identify women most at risk of losing their lives and bring all your social services resources to bear to keep them safe!
Download: Danger Assessment Tool
- Campbell, Jacquelyn C., Assessing Dangerousness: Violence by Sexual Offenders, Batterers, and Child Abusers, Newbury Park, CA: Sage Publications, 1995.
- Campbell, Jacquelyn C. , Phyllis W. Sharps, and Nancy Glass, “Risk Assessment for Intimate Partner Violence,” in Clinical Assessment of Dangerousness: Empirical Contributions, ed. Georges-Franck Pinard and Linda Pagani, New York: Cambridge University Press, 2000: 136–157.
Predicting Bleeding In Patients With Stable Pelvic Fractures
Bleeding is a well-recognized complication of severe pelvic fracture. Certain fracture patterns, usually with significant involvement of the posterior portions of the ring, are associated with significant bleeding. Most of these fractures are unstable to some degree.
Stable pelvic fractures (those that do not require internal or external fixation) are not generally prone to a large amount of bleeding. However, it can occur on occasion, and surgeons at the Massachusetts General Hospital have devised a simple prediction system so patients more likely to bleed can be identified and monitored more closely.
They retrospectively looked at their stable pelvic fracture population over 5+ years. A total of 391 patients with stable pelvic injury were identified. Of those, 280 never required transfusion and 111 did. Of the latter, only 15 bled from their stable pelvic fractures.
The authors found the following three significant indicators of bleeding from stable pelvic fractures:
- Admission hematocrit < 30%
- Pelvic hematoma on CT
- Any systolic blood pressure < 90 mm Hg
Bottom line: This is a simple, retrospective study with low numbers. However, the three indicators commonly indicate significant early bleeding in any trauma patient, so it makes sense to apply it here, too. If a patient meets one or two criteria, consider monitoring in the ICU and consider angiography. If all three or met, strongly consider appropriate intervention (angiography if good blood pressures can be maintained, or fixation and/or preperitoneal packing if not).
Reference: Predictors of bleeding from stable pelvic fractures. Arch Surg 146(4):407-411, 2010.
Using Your ABCs To Predict Massive Transfusion
It’s nice to have blood available early when major trauma patients need it. Unfortunately, it’s not very practical to have several units of O neg pulled for every trauma activation, let alone activate a full-blown massive transfusion protocol (MTP). Is there any way to predict which trauma patient might be in need of enough blood to trigger your MTP?
The Mayo Clinic presented a paper at the EAST Annual Meeting today that looked at several prediction systems and how they fared in predicting the need for massive transfusion. Two of the three systems (TASH - Trauma Associated Severe Hemorrhage, McLaughlin score) are too complicated for practical use. The Assessment of Blood Consumption tool is simple, and it turns out to be quite predictive.
Here’s how it works. Assess 1 point for each of the following:
- Heart rate > 120
- Systolic blood pressure < 90
- FAST positive
- Penetrating mechanism
A score >=2 is predictive of massive transfusion. In this small series, the sensitivity of ABC was 89% and the specificity was 85%. The overtriage rate was only 13%.
The investigators were satisfied enough with this tool that it is now being used to activate the massive transfusion protocol at the Mayo Clinic.
Bottom line: ABC is a simple, easy to use and accurate system for activating your massive transfusion protocol, with a low under- and over-triage rate.
Reference: Comparison of massive blood transfusion predictive models: ABC, easy as 1,2,3. Presented at the EAST 24th Annual Scientific Assembly, January 26, 2011, Session I Paper 4. Click here to view the abstract.
How to Predict the Need for Massive Transfusion in the ED
Massive transfusion is needed in about 3-5% of trauma patients. All Level I and II trauma centers are required to have a massive transfusion protocol.However, the protocol must be triggered in a timely manner to best benefit the major trauma patient.
Trauma surgeons at Vanderbilt validated a simple scoring system that allows accurate prediction of the need for massive transfusion in patients as they arrived in the ED. The system was called the ABC score (Assessment of Blood Consumption). It consists of the following 4 yes/no parameters:
- Penetrating mechanism (0=no, 1=yes)
- ED SBP <= 90 (0=no, 1=yes)
- ED heart rate >= 120 (0=no, 1=yes)
- Positive FAST (0=no, 1=yes)
The results of ABC when applied to trauma patients in the ED was as follows:
ABC Score % requiring massive transfusion
This scoring system is simple, easy to use and easy to remember. No laboratory tests are needed, and the information needed can be gathered quickly.
Bottom Line: This is a simple and accurate prediction system for determining the need for massive transfusion in trauma patients. Recommended!
Reference: Cotton et al. J Trauma 66(2) 346-352, 2009.