We see seat belt signs at our trauma center with some regularity. There are plenty of papers out there that detail the injuries that occur and the need for a low threshold for surgically exploring these patients. I have not been able to find specific management guidelines, and want to share some tidbits I have learned over the years. Yes, this is based on anecdotal experience, but it’s the best we have right now.
Tips for trauma professionals:
- Common injuries involve the terminal ileum, proximal jejunum, and sigmoid colon. My observation is that location in the car is associated with the injury location, probably because of the location of the seat belt buckle. In the US, drivers buckle on the right, and I’ve seen more terminal ileum and buckethandle injuries in this group. Front seat passengers buckle on the left, and I tend to see proximal jejunum and sigmoid injuries more often in them.
- Seat belt sign on physical exam requires abdominal CT for evaluation, regardless of age. The high incidence of significant injury mandates this test.
- Seat belt sign plus any anomaly on CT requires evaluation in the OR. The only exception would be a patient with minimal fluid only in the pelvis with an unremarkable abdominal exam. But I would watch them like a hawk.
- In patients who cannot be examined clinically (e.g. severe TBI), a rising WBC count or lactate beginning on day 2 after adequate resuscitation should prompt a trip to the OR. This is an indirect method for detecting injured bowel or mesentery.
- Laparoscopy may be used in patients with equivocal findings. Excessive blood, bile tinged fluid, succus, or lots of fibrin deposits on the bowel should prompt conversion to laparotomy. Tip: place all ports distant to the seat belt mark. The soft tissues are frequently disrupted, and gas may leak into this pocket prohibiting good insufflation of the peritoneal cavity.
- If in doubt, open the abdomen. It’s bad form to put in the scope, see something odd, and walk away. Remember, any abnormal finding after trauma is related to trauma until proven otherwise. It’s almost never pre-existing disease.
The new hot items in trauma care are thromboelastography (TEG) and ROTEM (thromboelastometry), a new spin on TEG from the TEM Corporation. These tools allow for in-depth assessment of factors that influence clotting. We know that rapidly recognizing and treating coagulopathy in major trauma patients can reduce mortality. So many trauma centers are clamoring to buy this technology, citing improved patient care as the reason.
But new technology is always expensive, and isn’t always all it’s cracked up to be. TEG and ROTEM require an expensive machine and a never-ending supply of disposable cartridges for use. Some hospitals are reluctant to provide the funds unless there is a compelling clinical need.
Surgeons at the University of Cincinnati compared the use of TEG with good, old-fashioned point-of-care (POC) INR testing in a series of major trauma patients seen at their Level I center.
Here are the factoids:
- This was a retrospective review of 628 major trauma patients who received both TEG and POC INR testing using an iSTAT device over a 1.5 year period
- Median ISS was 13, and there were many sick patients (20% in shock, 21% received blood, 11% died)
- INR correlated with all TEG values, with better correlation in patients in shock
- Both INR and TEG correlated well with treatment with blood, plasma, and cryoprecipitate
- Processing time was 2 minutes for POC INR vs about 30 minutes for TEG
- Charges for POC INR were $22,000 vs $397,000 for TEG(!!)
Bottom line: Point of care INR testing and TEG both correlate well with the need for blood products in major trauma patients. But POC INR is much cheaper and faster. Granted, the TEG gurus will say that you can tailor the products administered to meet the exact needs of the patient. But in all my travels, I have never visited a center that has fully and effectively incorporated TEG or ROTEM into their massive transfusion protocol. Before you make the financial leap to buy these new toys, make sure that you have a very good clinical reason to do so.
Reference: All the bang without the bucks: defining essential point-of-care testing for traumatic coagulopathy. Presented at EAST 2015, Paper 30.
Many busy trauma hospitals have equally busy trauma ICUs. Frequently, trauma patients who need critical care are backed up in the emergency department (ED) while awaiting a bed in such cases. This slows ED throughput for other patients, and increases the possibility of an adverse event while waiting for the ICU bed.
The group at the University of Kentucky in Lexington will present an abstract examining the impact of keeping an open bed in the ICU, as well as having a charge nurse in that unit without a patient assignment to help manage bed availability and staffing.
Here are the factoids:
- The study examined highest level trauma activations in the ED requiring ICU admission before implementation of the open bed policy
- 303 patients pre-implementation were compared to 261 patients post-implementation
- The usual demographics were similar for both groups
- Time in the ED decreased from 4:17 to 2:34 after the open bed policy was instituted, which was highly significant
- ICU length of stay (LOS) for patients who were admitted after the policy was in place decreased despite an increase in ISS, but not significantly so
- There was no change in mortality
- There was a cost savings of about $1000 per patient due to increased nursing productivity and the decreased LOS
Bottom line: Making the effort to reserve a bed for an incoming trauma patient at all times seems to be well worth it. I have visited many hospitals with incredible logjams of these patients in the ED. Frequently, this has a disproportionate and negative impact on the throughput of other ED patients. Creating such a policy should serve to improve patient flow (and satisfaction: what family wants to spend hours sitting in the ED?) as well save money.
Reference: Maintaining an open ICU be for rapid access to the trauma intensive care unit is cost effective. Presented at EAST 2015, paper 28.
Most states have implemented graduated driver license laws for teen drivers over the past 10+ years. Typically, these laws place age limits, approved times of day for driving, and passenger restrictions on young drivers. There is a growing body evidence that these laws have decreased the number of crashes and injuries/fatalities involving new drivers.
A group at the University of Rochester looked at changes in injuries and deaths in new driver related crashes over an extended period in New York state. During this time, the state first implemented graduated licenses, then added further restrictions on passengers under age 21 six years later. Some interesting patterns emerged.
Here are the factoids:
- Before graduated licenses were implemented in New York, young drivers made up 4.2% of all fatal crashes and 3.3% of all personal injury crashes
- After implementation of graduated licenses (time of day restrictions), the numbers dropped to 2.9% of fatal crashes and 2.7% of personal injury crashes
- When the number of youthful passengers was further limited, the fatality rate for those young riders decreased from 43% to 37%. Injury rate also decreased from 41 to 37%.
- Driver fatalities and injuries also decreased further after the number of young passengers was limited (numbers not listed in abstract). [Fewer distractions?]
Bottom line: Graduated driver license laws have been passed in nearly every state (with the exception of Vermont [no night-time driving restrictions], and Florida, South Dakota, Virginia [no young passenger restrictions]). It appears that these laws have reduced the number of deaths and injuries in young drivers. But the unintended consequence is that it has also reduced those numbers in the few young passengers they are allowed to carry as well.
Reference: Impact of graduated driver’s license law on crashes involving young passengers in New York State. Presented at EAST 2015, paper 17.
The Centers for Disease Control (CDC) has developed a neatly packaged falls prevention program that clinicians can apply to their elderly patients. Of course, there’s a cute acronym (STEADI = Stopping Elderly Accidents, Deaths, and Injuries), and a lot of slickly packaged reference material. The trauma group at Parkland wondered if the application of this outpatient program on an inpatient population would be helpful.
They looked at elderly patients (age>65) who were admitted for falls. The patients went through STEADI evaluation and interventions, and were compared with a group of historical controls from the prior year.
Here are the factoids:
- 218 patients went through the STEADI process, and were compared with 194 controls
- The usual demographics appeared to be the same in both groups
- The fall rate in-hospital was 4.1% for both groups (!)
- The fall recidivism rate (fell after discharge) was also the same (2.8% STEADI vs 2.1% controls)
STEADI consists of a number of assessments, including looking for medical conditions and medications that may impair mobility, visual problems, gait and balance testing, footwear evaluation, cognitive screening, and home evaluation. This program was modified by the authors for inpatient use, although the exact modifications were not listed in the abstract.
Bottom line: The application of the CDC STEADI program did not appear to affect falls in-hospital or those after discharge. The authors question whether maintaining the resources ($) to implement this program is justified. The paper does raise that question, but it is not clear what modifications were made to the full program to tailor it to an inpatient population. The fact that nearly 1 in 20 elderly patients are falling in the hospital is concerning, with or without STEADI. What the abstract does confirm is that elderly falls are a huge problem. The CDC notes that 1 in every 3 patients age 65 and older will fall each year! Further evaluation of STEADI and other similar programs is essential to decrease the morbidity and mortality of falls in this age group.
Reference: UnSTEADI: Implementation of the CDC fall prevention program does not prevent in-hospital falls or reduce fall recidivism rates. Presented at EAST 2015, Paper 16.