The Eastern Association for the Surgery of Trauma is in the process of updating their trauma practice guidelines for liver injury. The first set of guidelines was introduced in 2003, and several advances in management have occurred since. here is a summary of the current status of the guidelines:
Level I recommendations (best quality data):
Level II recommendations (good data):
- Initial management of hemodynamically stable patients should be nonoperative
- CT of the abdomen with IV contrast is the most reliable method to assess severity of liver injury in the hemodynamically stable patient
- Unstable patients should undergo operative or endovascular management of their injury, not imaging
- Patients with peritonitis should go to the operating room
- Age, grade of injury, amount of hemoperitoneum and age are not contraindications to nonoperative management. Only hemodynamic stability matters.
- Angiography with embolization should be considered if a contrast blush is seen on CT
- Angiography with embolization may also be considered if there is evidence of ongoing blood loss without blush on CT
- Nonoperative management should only be considered if continuous monitoring and serial exams can be carried out at your hospital, and if an operating room is immediately available if needed
Level III recommendations (weak data):
- Clinical status should dictate need and frequency of followup imaging (my interpretation: only do it if the patient condition changes for the worse)
- Interventional modalities may be used to treat complications (ERCP, percutaneous drainage, laparoscopy, etc)
- If a patient transiently responds to fluid initially, try angiography with embolization while they are still stable
On Monday, I’ll present the updated guidelines for management of spleen injury.
Reference: Trauma Practice Guideline Update, 24th Annual Scientic Assembly, Eastern Association for the Surgery of Trauma, January 2011.
Eight years ago, the National Association of Emergency Medical Services Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACS-COT) released guidelines regarding withholding or terminating resuscitation in traumatic cardiopulmonary arrest (TCPA). Survival rates were extremely low (<2%) and were thought to have poor outcomes. But validation of the guidelines has been challenging, and some even doubted that EMS personnel could accurately assess these patients in the field!!
Researchers at Mt. Sinai Hospital in Chicago performed a large retrospective study of all patients in TCPA brought to their hospital by the Chicago Fire Department over at 7.5 year period. These patients met exclusion criteria but had been resuscitated anyway. Their series was relatively large (294 patients), and looked not only at the ultimate outcome, but also at EMS performance and cost.
They found that field assessments by EMS were very accurate and consistent. Violation of the guidelines resulted in only 6 survivors, and they all were resuscitated to a neurologically devastated state (4 brain dead, 1 family withdrew support, 1 sent to TCU with long-term GCS 6). No loss of neurologically intact survivors would have occurred if the guidelines were followed. Finally, the cost of trying to resuscitate these patients was $385,000 per year.
Bottom line: EMS can and should apply the NAEMSP/ACS-COT criteria for traumatic cardiopulmonary arrest and withhold resuscitation for these patients. Tragically, it is an expensive waste of time to try to bring them back.
To review the NAEMSP guidelines, click here.
Reference: The consequences of violating current guidelines regarding resuscitation of patients in prehospital traumatic arrest. Presented at the 34th annual Residents Trauma Paper Competition at the 89th Annual Meeting of the ACS Committee on Trauma, March 10, 2011.
Trauma surgeons frequently place some type of drain in their patients, whether it be a chest tube, a damage control system, or a bulb suction drain near the pancreas. On occasion, nursing may become concerned with the character of the output, wondering if the patient is bleeding significantly. How can you tell if the output is too bloody?
First, most drains are in place to drain serous fluid which may have a little blood in it. Drainage that is mostly bloody is very uncommon from these drains, which are typically placed after orthopedic, spine or abdominal surgery. However, some drains are placed in areas where unexpected bleeding may occur, such as:
- Damage control drain systems – as patients warm up, arterial sources that were not surgically controlled may open up
- Pericardial drains – more common in cardiac surgery, not trauma
- Chest tubes in patients with penetrating trauma
What should you do if you have concerns about your patient’s drain output?
- Familiarize yourself with what kind of drain it is and what it should be draining
- Look at the volume of output – it takes 500cc of pure blood to drop the patient’s hemoglobin by about 1 gram. Low outputs are not dangerous, even if it is pure blood.
- Look at the change in output– if it is increasing significantly or changes color, call the physician to evaluate.
- Look at the color of the output – most drainage ranges from clear to something like cranberry juice and appears to be partially transparent. Look carefully if it appears to be darker or more opaque, and compare it to the blood that you would see in a blood collection tube. Even the darkest drain output usually looks a little watery compared to whole blood. Bright red output needs to be evaluated by a physician.
- If in doubt, check the fluid’s hematocrit. Whole blood has a hematocrit of 30% or more. Most bloody-looking drain output maxes out at about 5%. If the value is closer to whole blood, have a physician evaluate the patient.
One of the critical maneuvers that EMS providers perform is establishing initial vascular access. This IV is important for administering medications and for initiating volume resuscitation in trauma patients. Prehospital Trauma Life Support guidelines state that every trauma patient should receive two large bore IV lines. But is this really necessary?
The upside of having two IVs in the field is that the EMS provider can give lots of volume. However, a growing body of literature tells us that pushing systolic blood pressure up to “normal” levels in people (or animals) with an uncontrolled source of bleeding can increase mortality and hasten coagulopathy.
The downside of placing two lines is that it is challenging in a moving rig, sterility is difficult to maintain, and the chance of a needlestick exposure is doubled. So is it worth it?
A group at UMDNJ New Brunswick did a retrospective review of 320 trauma patients they received over a one year period who had IV lines established in the field. They found that, as expected, patients with two IVs received more fluid (average 348ml) before arriving at the hospital. There was no increase in systolic blood pressure, but there was a significant increase in diastolic pressure with two lines. The reason for this odd finding is not clear. There was no difference in the ultimate ISS calculated, or in mortality or readmission.
Bottom line: This study is limited by its design. However, it implies that the second field IV is not very useful. The amount of extra fluid infused was relatively small, not nearly enough to trigger additional bleeding or coagulopathy. So if another IV does not deliver significant additional fluid and could be harmful even if it did, it’s probably not useful. Prehospital standards organizations should critically look at this old dogma to see if it should be modified.
- Study of placing a second intravenous line in trauma. Prehospital Emerg Care 15:208-213, 2011.
Alright, here’s the final answer to the xray I posted last Friday. This patient was using a ThermaCare Menstrual HeatWrap by Pfizer. It was applied to her back, though, for relief from back pain. It was not apparent during the trauma activation exam, even with clothes off, until we logrolled her to examine her back.
Each pocket in the wrap contains a granular mixture of activated carbon, iron powder, salt and a few other ingredients. When the wrap is removed from its vacuum pouch it heats up to 104F (40C) and stays hot for up to 8 hours. The iron shows up on xrays. The regular pattern is a giveaway that this is not some other problem (stones, drug pouches in the colon).
Bottom line: Remember, conventional xrays collapse a 3D space onto a 2D image, so you can’t tell how deep objects are (anterior to posterior). This is another reminder to be thorough when examining your patient. They can hide things anywhere!
Disclaimer: I do not have any financial or other interest in Pfizer Inc.