Monthly Archives: March 2011

Performance Improvement

What Is The Cribari Grid?

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What Is The Cribari Grid?

I’ve spent some time discussing undertriage and overtriage. I frequently get questions on the “Cribari grid” or “Cribari method” for calculating these numbers. Dr. Cribari is currently the chair of the Verification Review Subcommittee of the ACS Committee on Trauma. He developed a table-format grid that simplifies calculation of these numbers.

I’ve simplified the process even more and provided a Word document that automates the task for you. Just fill in four numbers in the table, update the formulas and voila, you’ve got your numbers! Instructions for manual calculation are also included.

Click this link or the image above to download the file.

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Trauma 20 Years Ago: ED Intubation For Head Injury Is Safe

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How far we have come! It’s now commonplace to intubate trauma patients in the ED using rapid sequence induction followed by orotracheal tube placement. However, 20 years ago we were still gnashing our teeth about safety.

In 1991, the group at UMDNJ Newark looked at 100 consecutive trauma patients with suspected head injury who were paralyzed and intubated in the ED. Half of the intubations were performed by a surgeon, the other half by an anesthesiologist. Fifty seven patients were intubated orally and 40 nasally(!). Three required cricothyroidotomy after failure to intubate due to facial fractures.

The majority of these patients had head scans performed; 59% were positive and 15 required emergent neurosurgical procedures. No patients were found to have a neurologic deficit from the intubation even though seven were eventually found to have cervical spine injuries. Only one patient developed an aspiration pneumonia.

The authors concluded that paralysis and intubation in the ED was safe. It helped facilitate the diagnostic workup because they could control combative patients. Up to that time, the only alternative was heavy sedation, which carried its own risks. 

Interesting points on how far we have advanced:

  • Intubation in the ED did not used to be routine. There was a great deal of anxiety before this procedure
  • Nasal intubation was still fairly commonplace
  • The cricothyroidotomy rate was high
  • Intubation was usually performed by a surgeon or anesthesiologist 
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Need CPR? There’s An App For That!

The San Ramon Valley Fire Protection District has released an iPhone app that gives users a window into their 911 dispatch center. When you install the app, you can indicate that you are trained in CPR. Your phone then provides your GPS location, and you can be notified of any sudden cardiac arrest events in your area. You can then proceed to the incident and render assistance, if appropriate.

App users can view all active incidents and the status of dispatched units. If an ambulance passes you or you are stuck in a traffic jam, just tap the screen to find out the details. They can also be notified of incidents by type, and monitor live emergency radio traffic. 

The only downside is that leaving GPS location apps active in the background can significantly shorten your battery life. I think we can expect more communities to begin offering services like this in the near future.

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The FAST Exam in Children

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FAST is a helpful adjunct to the initial evaluation of adult trauma patients. Unfortunately, due to small numbers the usefulness is not as clear in children. In part, this is due to the fact that many children (particularly small children < 10 years old) have a small amount of fluid in the abdomen at baseline. This makes interpreting a FAST exam after trauma more difficult.

Despite this, use of FAST in children is widespread. A survey of 124 US trauma hospitals in 2007 showed an interesting pattern of ultrasound usage. In adult-only institutions 96% use FAST, and at hospitals that see both adults and kids, 85% use it. Most of these centers that use FAST have no lower age limit, and the physician most commonly performing the exam was a surgeon. However, only 15% of children’s hospitals do FAST exams, and they were usually done by nonsurgeons! The reasons for this are not clear. It appears that the pediatric surgeons have not embraced this technology as much as their adult counterparts.

What about that confusing bit of fluid found in kids? Several groups have looked at this (retrospectively). Fluid in the pelvis alone appears to be okay, but fluid anywhere else is a good predictor of solid organ injury. Fluid seen outside the pelvis had a 90% sensitivity and 97% specificity for injury, and positive and negative predictive values were 87% and 97% respectively.

Bottom line: FAST exam is useful in pediatric victims of blunt abdominal trauma. Fluid in the pelvis alone is normal in most children, but fluid seen anywhere else indicates a high probability of solid organ injury.

References: 

  1. Use of focused abdominal sonography for trauma at pediatric and adult trauma centers: a survey. J Pediatric Surgery 44:1746-1749, 2009.
  2. Minimal pelvic fluid in blunt abdominal trauma in children: the significance of this sonographic finding. J Pediatric Surgery 36(9):1387-1389, 2001.
  3. Clinical importance of ultrasonographic pelvic fluid in pediatric patients with blunt abdominal trauma. Ulus Travma Acil Cerrahi Derg 16(2):155-159, 2010.
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Trauma is Deadlier Than We Think

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Everyone knows that trauma is the number one killer of anyone age 1-44. The assumption is that if you sustain major injury and survive through discharge from a trauma center, you are home free. Unfortunately, this does not appear to be the case.

Arbabi and others from Harborview in Seattle looked at long term outcomes of 124,000 adult trauma patients treated over a 14 year period at any of Washington’s designated trauma centers.

During this period of time, in-hospital deaths decreased from 8% in 1995 to 4.9% in 2008. However, deaths after discharge increased from 4.7% to 7.4% during the same time interval. It appeared that older patients and those discharged to skilled nursing facilities (SNF) did particularly poorly after discharge. The risk of death after discharge to a SNF was 1.5 to 2x higher than normal. Yet mortality after discharge to an inpatient rehab facility was similar to that of patients sent home.

Bottom Line: Higher mortality in major trauma patients sent to a skilled nursing facility is likely a reflection of their age and severity of injury, as well as the services available there. Although patients with severe injuries may be sent to a rehab center, they typically must be able to participate in therapy for several hours a day. Those with more severe injuries that do not meet rehab criteria are typically sent to a SNF. This also explains why the authors found that patients with high ISS, low GCS, poor Functional Independence Measure and Medicare insurance had a higher likelihood of dying. This association should prompt us to look more thoroughly at these facilities to determine if they need additional oversight, more money or better rehab services.

Reference: Long-term survival of adult trauma patients. JAMA 305(10):1001-1007, 2011.