What’s The Best Test For Blunt Cerebrovascular Injury?

Blunt injury to the carotids or vertebrals (BCVI) is a little more common than originally thought, affecting about 1% of blunt trauma patients. We have many tools available to help us diagnose the problem: duplex ultrasound, CT angiography (CTA), MR angiography (MRA), and even good old conventional 4 vessel angiography

But which one is “best?” This is a tough question, because there is always some interplay between clinical accuracy and cost. The surgical group at the Medical College of Wisconsin – Milwaukee did a nice job teasing some answers from existing literature on the topic. The authors tried to take a comprehensive look at costs, including money spent to prevent stroke, the cost of complications of therapy, and the overall cost to society if the patient suffers a stroke.

Here are the factoids:

  • For patients at risk for BCVI, the stroke rate is 11% without screening, 6% with duplex ultrasound screening, 4% with MRA, and 1% with either CTA or conventional angiography
  • From a societal standpoint (includes the lifetime costs of stroke for the patient), CTA is the most cost effective at $3,727 per patient
  • From the hospital standpoint (does not include lifetime cost), no screening is the most cost effective, but has the highest stroke rate (11%)
  • CTA prevents the most strokes, and costs about $10,000 per patient while decreasing societal costs by about $32,000 per patient screened

Bottom line: The “best” test for patients at risk for blunt cerebrovascular injury is the CT angiogram. It minimzes the stroke rate, and provides information on all four vessels supplying the brain, which is probably why the duplex ultrasound has a higher miss rate (can’t see the vertebrals or into the skull). But how do you decide who is at risk for this problem. Tune in tomorrow!

Reference: Screening for Blunt Cerebrovascular Injuries is Cost-Effective. J Trauma 70(5):1051-1057, 2011.

Procedural Complications: Residents vs Advanced Practice Providers

With the implementation of resident work hour restrictions 10 years ago, resident participation in clinical care has declined. In order to make up for this loss of clinical manpower and expertise, many hospitals have added advanced clinical providers (ACPs, nurse practitioners and physician assistants). These ACPs are being given more and more advanced responsibilities, in all clinical settings. This includes performing invasive procedures on critically ill patients.

A recent study from Carolinas Medical Center in Charlotte NC compared complication rates for invasive procedures performed by ACPs vs residents in a Level I trauma center setting.

A one year retrospective study was carried out. Here are the factoids:

  • Residents were either surgery or emergency medicine PGY2s
  • ACPs and residents underwent an orientation and animal- or simulation-based training in procedures
  • All procedures were supervised by an attending physician
  • Arterial lines, central venous lines, chest tubes, percutaneous endoscopic gastrostomy, tracheostomy, and broncho-alveolar lavage performances were studied
  • Residents performed 1020 procedures and had 21 complications (2%)
  • ACPs performed 555 procedures and had 11 complications (2%)
  • ICU and hospital length of stay, and mortality rates were no different between the groups

Bottom line: Resident and ACP performance of invasive procedures is comparable. As residents become less available for these procedures, ACPs can (and will) be hired to  take their place. Although this is great news for hospitals that need manpower to assist their surgeons and emergency physicians, it should be another wakeup call for training programs and educators to show that resident education will continue to degrade.

Reference: Comparison of procedural complications between resident physicians and advanced clinical providers. J Trauma 77(1):143-147, 2014.

Why Is So Much Published Research So Bad?

Yesterday, my colleague the Skeptical Scalpel wrote about an interesting (?) paper published in Emergency Medicine Australasia. It was a small study that concluded that ED wait times decreased as the number of people presenting to be seen decreased. Where’s the mystery in that? Overstating the obvious?

But if you look through almost any journal today, you will find studies that leave you wondering how they ever got published. And this is not a new phenomenon. Look at any journal a year ago. Five years ago. Twenty years ago. And even older. The research landscape is littered with their carcasses. 

And on a related note, sit down with any serious clinical question in your field you want to answer. Do a deep dive with one of the major search engines and try to get an answer. Or better yet, let the professionals from the Cochrane Library or other organization do it for you. Invariably, you will find hints and pieces of the answer you seek. But never the completely usable solution you desire. 

Why is it so hard? With tens of thousands of articles being published every year?

Because there is no plan! Individuals are forced to produce research as a condition of their employment. Or to assure career advancement. Or to get into medical school, or a “good” residency. And in the US, Level I trauma centers are required to publish at least 20 papers every three years to maintain their status. So there is tremendous pressure across all disciplines to publish something

Unfortunately, that something is usually work that is easily conceived and quickly executed. A registry review, or some other type of retrospective study. They are easy to get approval for, take little time to complete and analyze, and have the potential to get published quickly.

But what this “publish or perish” mentality promotes is a random jumble of answers that we didn’t really need. There is no planning. There is no consideration of what questions we really need to answer. Just a random bunch of easy to get published thoughts that never get cited by anyone else. 

Bottom line: How do we fix this? Not easily. Instead of focusing on the quantity of publications, the “authorities” need to focus in on their quality. Extra credit should be given to multicenter trial involvement, prospective studies, and other higher quality projects. The actual number of publications should not matter as much as how much high quality work is in progress. Sure, the sheer number of studies published will decline, but the quality will increase exponentially!

Don’t Ignore The Naughty Bits

A major part of any patient encounter is the physical exam. This is particularly true in the trauma patient, because it allows trauma professionals to identify potential life and limb threatening injuries quickly and deal with them. Unfortunately, we tend to mentally block out certain parts of the body, typically the genitalia and perineum, and may not do a complete exam of the area. I call these areas the naughty bits. For those of you who don’t get the reference, here’s the origin of this phrase:

Specifically, the naughty bits are the penis, vagina, perineum, anus and natal cleft (aka the butt crack or arse crack). These areas are more likely to remain covered when the patient arrives, and are less likely to be examined thoroughly.

In penetrating trauma, a detailed exam of these areas is extremely important in every patient to avoid hidden injuries and to determine if nearby internal structures (rectum, urethra) might have been injured.

Here are some tips for each of the areas:

  • Penis – Always look for any blood at the meatus (or a little blood in the underwear) as a possible sign of urethral injury. This is frequently associated with pelvic fractures.
  • Scrotum – Blood staining here is usually from blood dissecting away from pelvic fractures. Patients with this finding are more likely to need angiographic embolization of pelvic bleeding.
  • Vagina – external exam should always be done. Internal and/or speculum exam should be done in pregnant patients, and those with external bleeding or pelvic fractures
  • Perineum – Also associated with pelvic fracture and significant bleeding. Skin tears in this area are usually lacerations indicating an open pelvic fracture. Alert your orthopaedic surgeons early, and do a good, clean rectal exam (carefully wipe away all external blood). Rectal injuries are common with this finding, and a formal proctoscopic will probably be required.
  • Anus – Skin tears virtually guarantee that a deeper rectal injury will be found. Proctoscopic exam in the OR is mandatory.
  • Natal cleft – Usually not a lot going on in this area, except in penetrating injury. This is the only area of the naughty bits that can be safely examined in the lateral position.

Bottom line: The naughty bits are important because the occasional missed injury in this area can be catastrophic! Do your job and force yourself to overcome any reluctance to examine them.

EAST Practice Guideline: Rectal Trauma

EAST just published their newest practice management guideline, which pertains to rectal trauma. They sought to answer three questions that pertain to nondestructive penetrating trauma to the extraperitoneal rectum. 

Trauma dogma from the 80′s and 90′s mandated that these injuries undergo three things: proximal diversion, distal rectal washout, and presacral drainage. The latter two have had waning interest over the intervening years, and questions have even been raised as to whether diversion is really necessary.

Practice Guideline Committee members at EAST performed a thorough and well documented review of the existing literature to determine what we really should be doing with these injuries.

Here are the factoids:

  • Proximal diversion. The major fear that prompts surgeons to divert is the possibility of infectious complications in the area of the rectal injury itself, or death. The literature consisted of 14 papers, most of which were retrospective and observational. Although there was no difference in mortality (about 0%), the incidence of infections doubled in patients without diversion. The recommendation was that patients with these injuries receive a proximal diverting colostomy.
  • Presacral drains. Only 17 papers addressed this question, and they were of low quality with few patients. There is not enough evidence to recommend this practice. And from a logistical standpoint, I could never figure out why this should work. The drain is placed in the presacral space, adjacent to the posterior rectum. How can this do anything for an anterior injury?
  • Distal rectal washout. In the good old days, this was performed through the distal portion of the newly created colostomy. There were all kinds of fancy ways to do it, and it required converting to lithotomy position and stationing someone (hint: intern) with a bag or bucket to catch the effluent. Very messy and unpleasant. Only 13 papers addressed this practice, and could not convincingly demonstrate a benefit. Not recommended.

Some additional tips of my own:

  • Do not violate the peritoneal reflection in the pelvis while doing the laparotomy. If the injury is isolated to the distal rectum, you will create a conduit for infection in the deep pelvis. You will have a hard time repairing an injury from above, especially in the usual narrow male pelvis. Don’t look at it; just let it heal on its own.
  • Create a standard end colostomy. Surgeons argue that a loop colostomy is convenient because it may be possible to close it later without reopening the midline incision. This is not always the case, and the bridge that is necessary to keep the loop above the skin makes colostomy care very difficult. Patients frequently complain about smelly leaks.

Bottom line: EAST guidelines are helpful in figuring out what to do in certain clinical situations, but they do not provide detailed guidance. This guideline provided answers (as best they could) to just three questions about rectal trauma. They justify not doing things that most surgeons have not been doing for some time. But don’t try to talk yourself out of not doing the diverting colostomy.

Reference: 

Management of penetrating extraperitoneal rectal injuries: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma 80(3):546-551, 2016.