Monthly Archives: October 2014

General

Update: Can TBI Be Managed Without Neurosurgical Consultation?

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This paper was presented at EAST in 2013, and this is an update of that work using the entire manuscript which has now been published.

The standard of care in most high level trauma centers is to involve neurosurgeons in the care of patients with significant traumatic brain injury (TBI). However, not all hospitals that take care of trauma patients have immediate availability of this resource. The University of Arizona at Tucson looked at management of these patients by their acute care surgeons.

The authors did a retrospective cohort study of patients at their center who had a mild TBI and positive head CT, managed with or without neurosurgery consultation, over a two year period. They matched the patients with and without neurosurgical consultation for age, GCS, AIS-Head and presence of skull fracture and intracranial hemorrhage.

A total of 90 patients with and 180 patients without neurosurgical involvement were reviewed. Here are the factoids:

  • Hospital admission rate was identical for both groups (87-89%)
  • ICU admission was significantly higher if neurosurgeons were involved (20% vs 44%)
  • Repeat head CT was ordered more than 3 times as often by neurosurgeons (20% vs 86%)
  • Post-discharge head CT was ordered more often by neurosurgeons, but was not significantly different (5% vs 12%)
  • There were no surgical interventions, in-hospital mortality, or readmissions within 30 days in either group.
  • Cost of the hospital stay was significantly increased if neurosurgery was consulted. 

Bottom line: Can surgeons safely manage select patients with intracranial injury? Granted, this is a small, retrospective study, but the answer is probably yes. The majority of patients with mild to moderate TBI with small intracranial bleeds or skull fractures do well despite everything we throw at them. And it appears that surgeons use fewer resources managing them than neurosurgeons do. The keys to being able to use this type of system are to identify at-risk patients who really do need a neurosurgeon early, and having a quick way to get the neurosurgeon involved (by consultation or hospital transfer). Having a specific practice guideline for management is essential as well. As neurosurgery involvement in acute trauma declines, this concept will become more and more pertinent.

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Reference: The acute care surgery model: managing traumatic brain injury without an inpatient neurosurgical consultation. J Trauma 75(1):102-105, 2013.

General

Tech: Bandage Indicates Wound Tissue Oxygen Concentration

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Tissue oxygenation is critical to wound healing. But unfortunately, there is no easy way to “see” how healthy the wound is just by looking at it. A research team at the Massachusetts General Hospital is developing a spray-on “smart” bandage that determine, at a glance, shows a map of tissue oxygen levels.

Now, of course, the researchers had to get clever and come up with a lame acronym. So here it is: sensing, monitoring and release of therapeutics (SMART). Get it? SMART bandage. 

Here’s what it looks like:

Okay, so how does it work? There are three components: a sensor molecule that glows over a useful range of oxygenation values, a bandage material to bind it to, and an imaging device for capturing useful images.

The sensor molecule is a phospor derivative that glows longer and brighter as tissue oxygen decreases. The bandage is a viscous liquid that is painted on the skin and dries as a solid film within a minute (think NewSkin). It contains the sensor molecule. In order to keep room air from seeping into the bandage and interfering with the readings, a transparent barrier is placed over it (think Tegaderm). 

Finally, the detector is … a smartphone or camera! No need for other expensive equipment. The flash stimulates the phosphors as the image is recorded. The image can then be analyzed for brightness and color of the phosphors. 

What is this good for? Trauma professionals deal with soft tissue wounds on a regular basis. Some of the more complicated ones require skin grafts or flaps, and maintaining their health is very important. Imagine begin able to identify oxygenation problems early in the edges of a flap or from a small seroma under a skin graft. This could lead to earlier correction of any problems and an increase in graft salvage. And it may allow us to better predict which burns are getting worse or may need grafting. Here are images of burn vs normal skin:

Bottom line: Yet another cool (and probably inexpensive) tool in expanding our senses to appreciate factors that help wound healing. Once the kinks are worked out, expect this to move into clinical care fairly quickly.

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Reference: Non-invasive transdermal two-dimensional mapping of cutaneous oxygenation with a rapid-drying liquid bandage. Biomedical Optics Express 5(11):3748-3764, 2014.

General

What Is: The LisFranc Injury?

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Medicine is full of conditions with eponyms. Trauma is no exception. There’s the Mattox maneuver and the Cushing response, to name two. Many times, the name is just a kind of vanity plate for the discoverer of the condition. But in the case of the LisFranc injury (or fracture), it makes some sense. This injury is tough to describe in a sentence or two, let alone a few words. 

Jacques LisFranc de St. Martin was a French surgeon and gynecologist (!) who described this condition in about 1815. It entails the fracture of the heads of the metatarsal bones and possible dislocation from the tarsals (the cuboid, navicular, and three cuneiform bones). This area is known as the LisFranc joint complex.

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The injury can involve any or all of the metatarsals. The typical mechanism applies high energy across the midfoot, which can often be seen in head-on motor vehicle crashes. Crush injury to the proximal foot can also do this, such as running the foot over with a car. Occasionally, this injury pattern is produced with lower energy during sports play. In this case, the top of the foot is typically contacting the ground, plantar flexing it. At the same time, another player steps on the heel, grinding the foot into the ground (ouch). Interestingly, LisFranc did not describe the injury pattern or mechanism. His name is associated with the joint complex, and it is an injury to his joint complex.

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Most of the time, the injury is obvious. There is usually notable pain and swelling of the foot. X-ray findings are generally not subtle. However, lower energy mechanisms may not cause much displacement, and initial imaging may not show the injury. If your patient starts to complain of pain in the midfoot when they begin to ambulate, think of LisFranc.

Treatment depends on the degree of displacement and the amount of disruption of the tarso-metatarsal joints. If minimal, a trial of nonoperative, non-weight bearing may be sufficient. But frequently, surgical reconstruction is required. 

protocols

The Value of Protocols in Trauma

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Most trauma centers have a book of practice protocols or guideleines. Actually, it is required by the American College of Surgeons verification standards. All centers must have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question sometimes arises: why do we need another protocol? Can we show some benefit to using a protocol?

I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols.

In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues.

  • They allow us to build in adherence to any known practice guidelines or literature.
  • They help conserve resources by standardizing care orders and resource use.
  • They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
  • They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
  • They promote team building, particularly when the protocol components involve several different services within the hospital.
  • They teach a consistent, workable approach to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.

A number of years ago, we implemented a solid organ injury protocol here at Regions Hospital. I noted that there were large variations in simple things like time at bedrest, frequency of blood draws, how long the patient was kept without food and whether angiography should be considered. Once we implemented the protocol, patients were treated much more consistently and we found that costs were reduced by over $1000 per patient. Since we treat about 200 of these patients per year, the hospital saved quite a bit of money! And our blunt trauma radiographic imaging protocol has significantly reduced patient exposure to radiation.

Bottom line: Although the proof is not necessarily apparent in the literature, protocol development is important for trauma programs for the reasons outlined above. But don’t develop them for their own sake. Identify common problems that can benefit from consistency. It will turn out to be a very positive exercise and reap the benefits listed above.

General

… And The Ultimate Retained Foreign Bodies

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Sponges are unfortunately one of the most common retained foreign bodies. This is due to their small, flimsy nature. The surgeon usually looks at the obviously visible areas of the abdomen or other body cavity before closing. She can also feel around in the “nooks and crannies”, but sponges feel very similar to the other organs surrounding it.

But what about more substantial items, like surgical instruments? Surely these are so obvious as to not leave behind?

Unfortunately, not so. Take a look at these items. This is a large pari of surgical forceps.

This is a malleable retractor, a long, thin sheet of pliable metal that can be bent to any desired shape.

And finally, a pair of Metzenbaum scissor, a common surgical instrument for cutting tissue.

Bottom line: It doesn’t matter how small or large, anything can and will be left behind in emergent and trauma cases. Recognizing that this can occur, no matter how confident you are that it has not, is the key. Always count, but followup with an x-ray that covers all areas of the surgical field before closing.

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