Multidisciplinary Trauma PI Committee is an essential part of all trauma centers verified by the American College of Surgeons. A lot happens in that one hour (or so) meeting. But efficiency hinges on being prepared, and we’ve all experienced meetings where the case presentations just weren’t crisp.
What to do? Here’s a set of guidelines to help your presenters do the best job possible. They rely on advance preparation and good communication with your trauma program.
Download a pdf copy of the guidelines here
And please comment with your own twists and turns on making trauma PI an efficient and meaningful process!
Thanks and a hat tip to Mary Carr MD for suggesting these guidelines!
Deep venous thrombosis has been a problem in adult trauma patients for some time. Turns out, it’s a problem in injured children as well although much less common (<1%). However, the subset of kids admitted to the ICU for trauma have a much higher rate if not given prophylaxis (approx. 6%). Most trauma centers have protocols for chemical prophylaxis of adult patients, but not many have similar protocols for children.
The Medical College of Wisconsin looked at trends prior to and after implementation of a DVT protocol for patients < 19 years old. They used the following protocol to assess risk in patients admitted to the PICU and to determine what type of prophylaxis was warranted:
The need for and type of prophylaxis was balanced against the risk for significant bleeding, and this was accounted for in the protocol. The following significant findings were noted:
- The overall incidence of DVT decreased significantly (65%) after the protocol was introduced, from 5.2% to 1.8%
- The 1.8% incidence after protocol use is still higher than most other non-trauma pediatric populations
- After the protocol was used, all DVT was detected via screening. Suspicion based on clinical findings (edema, pain) only occurred pre-implementation.
- Use of the protocol did not increase use of anticoagulation, it standardized management in pediatric patients
Bottom line: DVT does occur in injured children, particularly in severely injured ones who require admission to the ICU. Implementation of a regimented system of monitoring and prophylaxis decreases the overall DVT rate and standardizes care in this group of patients. This is another example of how the use of a well thought out protocol can benefit our patients and provide a more uniform way of managing them.
Reference: Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma 72(5):1292-1297, 2012.
Adult trauma patients are at risk for venous thromboembolism (VTE). Children seem not to be. The big question is, when do children become adults? Or, at what age do we need to think about screening and providing prophylaxis to kids? As of yet, there are no national guidelines for dealing with DVT in children.
Researchers at Johns Hopkins went to the NTDB to try to answer this question. They looked at the records of over 400,000 trauma patients aged 21 or less who were admitted to the hospital.
Here are the interesting factoids:
- Only 1,655 patients (0.4%) had VTE (1,249 DVT, 332 PE, 74 DVT+PE)
- VTE patients were older, male, and frequently obese
- VTE patients were more severely injured, with higher ISS and lower GCS
- Patients with VTE were more likely to be intubated and receive blood transfusions, and had longer hospital and ICU stays
The risk of VTE stratified by age was as follows:
Bottom line: Risk of VTE in pediatric trauma patients follows the usual injury severity pattern. But it also demonstrates a predictable age distribution. Risk increases as the teen years begin (13), and rapidly becomes adult-like at age 16. Begin your standard surveillance practices on all 16 year olds, and consider it in 13+ year olds if their injury severity warrants.
Reference: Venous thromboembolism after trauma: when do children become adults. JAMA Surgery online first October 31, 2013.
The Centers for Disease Control and Prevention (CDC) published a set of Guidelines for Field Triage two years ago. Click here to download them. They list 4 tiers of activation criteria to help prehospital providers triage patients appropriately to trauma centers.
Tier 1, which are physiologic criteria, and Tier 2 (anatomic criteria) are very accurate in predicting injury serious enough to require trauma team activation. Tier 3 contains mechanism criteria, and many centers who use these verbatim in their activation criteria end up with a fair amount of overtriage. Some centers even see a significant number of patients who meet Tier 3 criteria go home from the ED!
The Yale department of Emergency Medicine looked at intrusion into vehicle criteria (more than 12" near an occupant, more than 18" anywhere on the vehicle) to see if they are a valid predictor for admission or trauma center transport. It was a retrospective review of EMS transports to the Yale ED or to one satellite site.
Unfortunately, the number of vehicles that met intrusion criteria (48) was small compared to the number without significant intrusion (560). This makes the data a little less convincing than it may have been. The likelihood that intrusion would require trauma center admission (Positive Predictive Value) was only 26%. The likelihood that trauma center resources would be utilized (for issues like death, ICU stay, operation, spinal injury or intracranial hemorrhage) was only 13%. The authors recommend that the CDC guidelines be tweaked based on this data.
Bottom line: I think the numbers are far too small to convince the CDC to change their guidelines. But I would urge each trauma center that uses the intrusion criteria for activation to carefully study how many of those patients have minor injuries or go home from the emergency department. They may find that they can rely on other more accurate criteria and decrease their overtriage rate at the same time.
Reference: Motor vehicle intrusion alone does not predict trauma center admission or use of trauma center resources. Prehospital Emerg Care 15:203-207, 2011.
Alcohol abuse is a major problem worldwide, and provides trauma professionals with a never-ending stream of patients to take care of. A few of our patients partake so frequently that they are at risk for complications when they are forced to stop (e.g. admitted to the hospital).
In days gone by, one of the possible treatments for alcohol withdrawal was actual administration of ethanol in the hospital, by mouth or sometimes IV (!). For the most part, this has fallen by the wayside. However, I do get questions from readers about it from time to time, and I assume that this still happens at some hospitals. And I know of a few hospitals that still have beer on the formulary!
So what’s the answer? There is enough literature out there to convincingly say that the practice should be abandoned. Here are some factoids for you:
- Benzodiazepines are now the first-line treatment for withdrawal
- Benzos have anticonvulsant properties, which ethanol does not
- Benzos cause less respiratory depression than ethanol when dosed properly
- Using a CIWA protocol early minimizes over-medication events and can prevent progression to more serious withdrawal
- Lorazepam is a good choice because its metabolism is minimally affected by liver dysfunction
- The use of ethanol to treat withdrawal condones alcohol abuse and does not promote behavioral change or treatment
Bottom line: Don’t reach for the bottle when trying to prevent or treat alcohol withdrawal syndrome. Monitor at-risk patients closely, adopt a finely-tuned CIWA protocol (see below), and aggressively refer to treatment after your patient recovers.
Reference: Ethanol for alcohol withdrawal: end of an era. J Trauma 74(3):925-931, 2013.