Interesting Concept: The Abdominal Aortic & Junctional Tourniquet

February 27, 2014 The Trauma Pro Leave a comment

Tourniquets for extremity bleeding are definitely back in vogue. Our military experience over the past 20 years has shown us what a life saver this simple tool can be. It’s now carried by many prehospital trauma professionals for use in the civilian population. But what about bleeding from the nether regions? You know what I’m talking about, the so-called junctional zones. Those are the areas that are too proximal (or too dangerous) to put on a tourniquet, like the groin, perineum, axilla, and neck.

Traditionally, junctional zone injury could only be treated in the field with direct pressure, clamps, or in some cases a balloon (think 30Fr Foley catheter inserted and blown up as large as possible, see link below). In the old days, we could try blowing up the MAST trousers to try to get a little control, but those are getting hard to find.

An Alabama company (Compression Works) developed a very novel concept to try to help, the Abdominal Aortic and Junctional Tourniquet (AAJT). Think of it as a pelvic compression device that you purposely apply too high.

Note the cool warning sticker at the bottom of the device!

The developers performed a small trial on 16 volunteer soldiers after doing a preliminary test on themselves (!). The device was placed around the abdomen, above the pelvis, and inflated to a maximum of 250 torr. Here are the factoids:

All subjects tolerated the device, and no complications occurred
Flow through the common femoral artery stopped in 15 of the 16 subjects
The subject in whom it did not work exceeded the BMI and abdominal girth parameters of the device
Average pain score after application was 6-7 (i.e. hurts like hell!)

Here’s a list of the criteria that preclude use of this device:

Bottom line: This would seem to be a very useful device for controlling hemorrhage from pesky areas below the waist.

BUT! Realistically, it will enjoy only limited use in the civilian population for now. Take a closer look at the exclusion criteria above. Half of the population is ineligible right off the bat (women). And among civilians, more than a third are obese in the US. Toss in a smattering of the other criteria, and the unlikelihood of penetrating trauma to that area in civilians, it won’t make financial sense for your average prehospital agency to carry it. Maybe in high violence urban areas, but not anywhere else.

The company has received approval for use in pelvic and axillary hemorrhage control, so we’ll see how it works when more and larger studies are released (on more and larger people).

Related post:

Novel use of a Foley catheter for bleeding control

Reference: The evaluation of an abdominal aortic tourniquet for the control of pelvic and lower abdominal hemorrhage. Military Med 178(11):1196-1201, 2013.

Thanks to David Beversluis for bringing this product to my attention. I have no financial interest in Compression Works.

General

Warfarin Reversal For Emergent Surgery Using PCC

February 26, 2014 The Trauma Pro Leave a comment

Yesterday I published a protocol that Regions Hospital uses for rapid reversal of warfarin in patients with life-threatening bleeding. This is very useful in trauma patients, but a number of other specialties use it as well (GI, etc). But what about that patient who doesn’t have a major bleeding problem, but needs emergency surgery or some invasive procedure? If something isn’t done prior to the case, the surgeon or interventionalist may inflict life-threatening bleeding!

We use a variant of the protocol I posted yesterday. The differences arise from the fact that, in this case, there is a little bit of time to find out some of the patient’s medical history. Certain things may modify the protocol, or contraindicate it entirely, such as:

Is the patient in DIC?
Do they have heparin induced thrombocytopenia (HIT)?
Do they have a history of significant peripheral vascular disease or thrombotic tendencies?
Will they need to be re-anticoagulated afterwards?

Again, feel free to download this protocol and modify it as you wish. Comments and questions are welcome!

Download the warfarin reversal for emergent surgery protocol here

Related post:

Warfarin reversal for life-threatening bleeding protocol

General

Warfarin Reversal With Prothrombin Complex Concentrate

February 25, 2014 The Trauma Pro Leave a comment

Everybody is looking for good algorithms. They’re very helpful in standardizing care and they are a great teaching tool to show one good way to do something. All trauma centers have at least a few, like the Massive Transfusion Protocol.

Well, as the population ages and more of our elders are placed on drugs like warfarin, they run the risk of life-threatening bleeding if an accident occurs. Why reinvent the wheel? Don’t spend the time combing through the literature and designing your own protocol if someone else has already done the leg work!

Here’s a copy of our protocol for rapid reversal of warfarin with prothrombin complex concentrate (PCC) when life-threatening bleeding is present (e.g. blood in the head). Please note that the INR must be 2 or above to use this protocol, or the risks of giving the drug begin to outweigh the benefits.

Once the patient is found to be eligible, a single dose of PCC based on INR is given, as well as 10mg of vitamin K. The INR usually returns to near normal within about 30-45 minutes. If it’s still elevated, then begin administering plasma.

Feel free to copy and share. Also, any and all comments are welcome!

Download the protocol by clicking here

Related post:

Managing TBI in patients on warfarin

General

Video February 24, 2014 The Trauma Pro Leave a comment

Formalizing The Prehospital to In-Hospital Handoff

I’ve written quite a bit about the benefits and pitfalls of the handoff process. Handoffs involving critical trauma patients is particularly important, because the receiving team needs to know a lot of information about what happened before patient arrival. All too often, the patient gets moved to the bed, and the medics are pushed to the side as the team descends upon him.

A number of hospitals around the US and the world have come up with solutions to strengthen this process. The regional trauma advisory committee here in the Twin Cities codified and implemented a formal handoff process to be used by emergency medical services providers any time they deliver a trauma activation patient to one of the area trauma centers.

I’d like to share our solution with you. This 4 minute video describes and demonstrates the process. Our expectation is that once things really get going, EMS will want to do this with just about every patient they deliver to the hospital.

Have a look, and feel free to comment or describe what you do!

Here’s a link to a Word document with the contents of the poster that can be placed in your trauma bay. Feel free to add your logos or change it in any way you wish. Download the poster here.

I first started writing about this project over a year ago. See these related posts on how it progressed:

(Source: https://www.youtube.com/)

General

Can You Teach A Trauma Surgeon To Insert An ICP Monitor?

February 21, 2014 The Trauma Pro Leave a comment

You’ve heard the statistics about the graying of our society. The proportion of older people is growing rapidly. Well, there are only about 4400 neurosurgeons in the US, and they are aging as well. Nearly a third are older than 55 years.

This leaves a relatively small number of neurosurgeons tasked with helping to take care of trauma patients. Many Level II centers are hard pressed to maintain their neurotrauma services. Even basic procedures like ICP monitor placement may require transfer to another center.

The group at Miami Valley Hospital in Dayton looked at their experience with training surgeons to insert intraparenchymal ICP monitors (not EVD devices) over a 6 year period. Their trauma surgeons, as well as surgical residents were trained by watching a video, practicing in a cadaver lab under the supervision of a neurosurgeon, and being proctored by a neurosurgeon while placing them in three patients. Surgical residents could place the monitor if directly supervised by a surgeon.

Here are the factoids:

Of 410 monitors placed, 298 were placed by surgeons and 112 by neurosurgeons
The surgeons placed 188 Licox monitors and 91 Caminos. The type was not recorded in 19.
Surgeon complication rate was 3% (9 patients), and the neurosurgeon rate was 0.8% (1 patient). None were major of life-threatening.
Most of the complications were malfunction of the device. There were 2 dislodgements in the surgical group, and 1 in the neurosurgeon group.

Bottom line: This one’s a little tough to interpret. Yes, the number of complications (malfunction) is higher with the surgeons. But the numbers are small, and this difference does not reach statistical significance. I do worry that the training is a bit too sketchy. But I think that this procedure will soon enter the skillset of many acute care surgeons, especially those working at hospitals in more rural settings. This will be the quickest way to begin high quality neurotrauma care for patients who are injured in areas not served by highest level trauma centers.

Related post:

ICP monitor placement by non-neurosurgeons

Reference: Successful placement of intracranial pressure monitors by trauma surgeons. J Trauma 76(2): 286-291, 2014.

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