Monthly Archives: May 2011

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ICP Monitoring: Less Is More?

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Management of severe traumatic brain injury (TBI) routinely involves monitoring and control of cerebral perfusion pressure. Monitoring is typically accomplished with an invasive monitor, with the extraventricular drain (EVD) and fiberoptic intraparenchymal monitors (IP) being the most common.

The extraventricular drain is preferred in many centers because it not only monitors pressures, but it can also be used to drain cerebrospinal fluid (CSF) to actively try to decrease intracranial pressure (ICP). But could less really be more? Surgeons at Massachusetts General reviewed 229 patients with one of these monitors, looking at outcomes and complications. They found the following interesting results:

  • There was no difference in mortality between the two monitor types
  • The EVD patients did not require surgical decompression as often, possibly because of the ability to decrease ICP through drainage
  • The EVD patients were monitored longer, and had a longer ICU length of stay. This was also associated with a longer hospital length of stay.
  • Complications were much more common in the extraventricular drain group (31%). The most common complications were no drainage / thrombosis (15%) and malposition (10%). Hemorrhage only occurred in 1.6% of patients. 
  • Fiberoptic monitors had a lower complication rate (8%). The most common was malfunction leading to loss of monitoring (12%). Hemorrhage only occurred in 0.6% of patients.

Bottom line: Don’t change your monitoring technique yet. Much more work needs to be done to flesh out this small retrospective study. But it should prompt us to take a critical look for better indications and contraindications for each type of monitor.

Reference: Intraparenchymal versus extracranial ventricular drain intracranial pressure monitors in traumatic brain injury: less is more? Presented at the 34th Annual Residents Trauma Papers Competition at the American College of Surgeons 89th Annual Meeting, March 10, 2011, Washington DC.

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http://c.brightcove.com/services/viewer/federated_f9?isVid=1

Trauma Prevention: Falls From Windows

It’s warm weather time (in the Northern hemisphere) and the windows are opening. Unfortunately, many parents forget that window screens are not strong enough to keep a child in if they put their weight against it. 

Please share the following prevention tips with your patients to keep their children safe:

  • Install window guards on all windows above the first floor
  • Windows without guards should only be opened from the top
  • Keep beds, cribs, sofas and other furniture away from windows so children can’t play near open windows
  • Lock closed windows and do not let children sit or play near open windows
(Source: http://c.brightcove.com/)
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Is It Really Safe To Observe Occult Pneumothorax?

Occult pneumothorax is the most common incidental finding on CT imaging, occurring in 2% to 10% of trauma patients. By definition, an occult pneumothorax is a pneumothorax that is seen only on CT and not a conventional chest x-ray. When detected, the question that comes to mind is, will this patient need a chest tube?

The AAST conducted a trial encompassing the experience at 16 Level I and II trauma centers around the US. They looked at injury severity, specific chest injuries, ventilator settings if on positive pressure ventilation (PPV) and size of pneumothorax. The size was calculated by measuring the largest air collection along a line perpendicular to the chest wall (see image above). Failure of observation meant that a thoracostomy tube was placed.

The 2 year study looked at a total of 448 occult pneumothoraces that were initially observed. Key findings of the study were:

  • Injury severity was no different between failure and non-failure groups
  • There was a 6% failure rate overall
  • PPV alone was associated with an increased failure rate of 14%
  • Surgical intervention requiring PPV was not associated with an increased failure rate
  • Pneumothorax size > 7mm, positive pressure ventilation, progression of the pneumothorax, respiratory distress and presence of hemothorax were associated with failure.
  • Pneumothorax size was not entirely reliable for predicting failure, since patients with sizes as small as 5mm on PPV and 3mm not on PPV failed in this series

Bottom line: Most blunt trauma patients with an occult pneumothorax can be safely observed. A followup chest x-ray should be obtained to look for progression. If the patient progresses, is placed on PPV, has a hemothorax or develops respiratory distress, have a low threshold for inserting a drainage tube. Maximum pneumothorax size may predict failure when large, but it can still happen with very small air collections.

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Reference: Blunt traumatic occult pneumothorax: is observation safe? – results of a prospective, AAST multicenter study. J Trauma 70(5):1019-1025, 2011.

CT image courtesy of Journal of Trauma

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Trauma PI: When Is A Peer Issue Really A System Issue? (Part IV)

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Yesterday I discussed loop closure for system issues. Today I’ll look at the interesting relationship between peer and system issues.

Although most PI issues that arise seem to be related to something done (or not done) by an individual, that doesn’t mean that the issue is peer-related. Frequently a significant portion of the problem is caused by a system issue. How can this be?

Let’s take the example of DPL. A physician performs a DPL in the trauma bay and the trauma PI program notes that it was performed without the requisite placement of an NG tube and urinary catheter first. At first look, this is a peer-related problem, right? Just counsel the doctor and everything will be better.

Wrong! Your PI program needs to assume that every apparent peer-related problem is a manifestation of one or more system issues. In my example, another DPL is performed 6 months later by a different physician, and once again the catheters are not inserted first. What gives?

I recently wrote that DPL was a dying art. Most institutions perform this procedure only a few times a year. People get rusty with uncommon procedures because they can’t practice. So instead of considering this a physician problem, look at it as a system problem. How can you keep them from forgetting something they seldom do? Simple! Attach a gastric tube and a urinary catheter directly to the DPL kit. When the physician grabs the kit, they will be instantly reminded of the need to insert them first. Problem solved.

Bottom line: always assume that people are doing their best to provide excellent care to their patients. Look closely for possible system problems that are keeping them from doing just that. Then put your thinking cap on and come up with some creative solutions.

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