Category Archives: General

Don’t Forget Trauma Education: The Next Generation!

TE:TNG is next week!

We’re breaking the mold for trauma talks! No more stodgy presenters reading from bullet-heavy PowerPoint slides! Away with the sore backside from sitting through an hour-long talk where the presenter goes over their time limit another 15 minutes!

The conference is now fast paced and to the point, with topics of interest to all trauma professionals (doctors, nurses, EMS, and anyone else who loves trauma). It consists of concise, 20 minute presentations interspersed with 5 minute videos of things you need to know. There are curbside consults, where we ask specialists the things you always wanted to. We’ll be taking questions for presenters from the audience and from Twitter using #TETNG13.

Here is a sample of some of the presentations:

  • Scott Weingart (EMCrit) joins us live from his studio in NYC, talking about finger thoracostomy
  • Michael McGonigal discusses why so much of what we think we know is wrong!
  • Felix Ankel talks about the future of trauma education
  • Field amputation, dislocated hip reduction, IO lines and more!

For those of you in the upper Midwest of the US, please join us live in St. Paul for this 4 hour program. It is located at the Minnesota History Center in a beautiful 300 seat auditorium. There is a fee to attend the live program to cover CME/CEU, food and parking. 

For those who cannot attend the live event, it will be streamed live on the internet beginning at 8am CST. Obviously, this is free but no CME/CEU’s will be offered. Park in your garage and get food from your own kitchen. 

And for anyone who just can’t tear themselves away from work on the morning of September 5, all content will be available for free on YouTube shortly after the conference.

For more information, and to register for the live event, go to TETNG.org 

Please feel free to email or comment with questions and suggestions!

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AAST 2013: Epidural Analgesia for Chest Trauma

This is my first in a series of reviews of abstracts for the coming AAST meeting in September. I’m going to pick some of the most interesting abstracts and discuss them here in advance of the meeting. I’ll be attending, so I can personally listen to the presentations to see if the work presented passes muster. I always encourage people to read the entire paper, or in this case listen to the whole presentation. Hopefully you’ve realized that the abstract does not always accurately portray what the research actually showed.

The first paper deals with the use of epidural analgesia for rib fractures. First off, this is a retrospective, cohort review of a large database (National Study of Cost and Outcomes of Trauma [NSCOT]). This means that there are shortcomings built in to the study from missing information and multiple submitters. Thankfully, many of these can be reduced using clever statistics.

The authors looked at records of patients with significant blunt trauma to the chest. They excluded all patients who had conditions that would have precluded epidural catheter placement (i.e. spine injury, coagulopathy). A total of 836 patients were identified as eligible for study, and 100 had epidurals placed. 

The following interesting findings were noted:

  • Epidural patients were older, had more rib fractures and were more likely to have a chest tube
  • Placement of an epidural catheter was much more likely if the patient was taken to a trauma center
  • Epidural placement was associated with a significant reduction in mortality at 30, 90 and 365 days. This is very interesting, especially since the study numbers are small.

Bottom line: Pain control for chest trauma using an epidural catheter is one of many items in our treatment toolbox. And although this abstract is more of a “this is how they do it” study, the mortality reduction is impressive. This occurred despite the epidural patients being older and with more rib fractures. In many centers, epidural catheters are used infrequently, and only in extreme cases. This study would seem to indicate that more aggressive usage, especially in the elderly (who are twice as likely to die from rib fractures), is warranted.

Related posts:

Reference: The effect of epidural placement after blunt thoracic trauma. AAST 2013, Paper 27.

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Autotransfusing Blood Lost Through The Chest Tube

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

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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!

Related post: Chest tubes and autotransfusion

Reference: Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood? Am J Surg 202(6):817-822, 2011.

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Trauma Mortality vs Cancer Mortality from CT Scans for Trauma

Trauma professionals worry about radiation exposure in our patients. A lot. There are a growing number of papers dealing with this topic in the journals every month. The risk of dying from cancer due to CT scanning is negligible compared to the risk from acute injuries in severely injured patients. However, it gets a bit fuzzier when you are looking at risk vs benefit in patients with less severe injuries. Is it possible to quantify this risk to help guide our use of CT scanning in trauma?

A nice paper from the Mayo clinic looked at their scan practices in 642 adult patients (age > 14) over a one year period. They developed dose estimates using a detailed algorithm, and combined them with data from the Biological Effects of Ionizing Radiation VII data. The risk level for injury was estimated using their trauma team activation criteria. High risk patients met their highest level activation criteria, and intermediate risk patients met their intermediate level activation criteria.

Key points in this article were:

  • Average radiation dose was fairly consistent across all age groups (~25mSv)
  • High ISS patients had a significantly higher dose
  • Cumulative risk of cancer death from CT radiation averaged 0.1%
  • This risk decreased with age. It was highest in young patients (< 20 yrs) at 0.2%, and decreased to 0.05% in the elderly (> 60 yrs)

Bottom line: Appropriate CT scan use in trauma evaluation is challenging. It’s use is widespread, and although it changes management it has not decreased trauma mortality. This paper shows that the risk of death from trauma in the elderly outweighs the risk of death from CT scan radiation. However, this gap narrows in younger patients with less serious injuries because of their very low mortality rates. Therefore, we need to focus our efforts to reduce radiation exposure on our young patients with minor injuries.

Related posts:

References:

  • Comparison of trauma mortality and estimated cancer mortality from computed tomography during initial evaluation of intermediate-risk trauma patients. J Trauma 70(6):1362-1365, 2011.
  • Health risks from low levels of ionizing Radiation: BEIR VII, Phase 2. Washington DC: The National Academies Press, 2006.
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Followup Cystogram After Bladder Injury

I’ve previously written about management of extraperitoneal bladder injuries. One of the tenets is that every injury needs to have a routine followup cystogram to ensure healing and allow removal of any bladder catheter. I routinely like to question dogma, so I asked myself, is this really necessary? A retrospective registry review from the Ryder trauma center in Miami helped to answer this question.

Over 20,000 records were screened for bladder injury and 87 were found in living patients. Fifty were intraperitoneal injuries, and half of them were caused by pelvic fractures (interesting). All were operated on, and 47 were classified as simple (dome disruption or through and through penetrating) and 3 were “complex” (involving trigone). All trackable patients (42 of the 50) had followup cystograms 9-16 days later. All of the simple injuries had a normal followup exam, but a leak was detected on one of the complex injuries.

There were 42 patients with extraperitoneal bladder injuries. All were due to blunt trauma, and 92% were associated with pelvic fractures. Most were found with CT cystogram. Two patients had operative repair, probably due to the need to fix the pubic bones with hardware. 37 of the 42 were available for followup, and 22% of repeat cystograms were positive (average study done on day 9). In the studies that showed a leak, repeat cystograms were done, and they took an average of 47 days to fully heal.

Bottom line: Patients with extraperitoneal or complex intraperitoneal bladder injuries (trigone) really do need a followup cystogram before removing the bladder catheter. Those who underwent a simple repair of their intraperitoneal injury do not.

Related posts:

Reference: Cystogram follow-up in the management of traumatic bladder disruption. J Trauma 60(1):23-28, 2006.

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