Debate has forever swirled around how to clear the cervical spine. Clear clinically? CT scan plus exam? CT only? Flexion/extension views? Distracting injury?
This last one has been problematic for a long time. What is a distracting injury? Is there a difference between lower extremity wounds vs upper chest/shoulder wounds from a distraction standpoint? Is it possible to clinically clear the cervical spine if one of these injuries exist?
Finally, a multi-institutional trial was performed that strives to answer this question. Seven Level I US trauma centers participated in this 3.5 year long study. All patients with GCS > 14 underwent a standard clinical exam regardless of whether a possible distracting injury was present. Then all underwent CT evaluation of the entire cervical spine.
Here are the factoids:
- Distracting injuries were classified into three regions: head, torso, and extremities, but no further analysis was presented in the abstract
- Nearly 3,000 patients were enrolled and 70% had a potential distracting injury
- A total of 233 patients (8%) had a cervical spine injury identified by CT
- 136 patients had a cervical injury AND distracting injury, and 14 were missed by clinical exam (10%)
- 87 patients had a cervical injury BUT NO distracting injury, and 10 were missed by clinical exam (13%)
- Only one injury missed by clinical exam required operation
Bottom line: This study shows the usual prevalence of cervical spine injury after blunt trauma, but adds some interesting information regarding distracting injury. Basically, clinical examination will miss about 1% of patients with a negative exam, regardless of distracting injury status. Therefore, the study suggests that clinical clearance should be attempted on all patients first, regardless of “distracting injury.”
Reference: Clearing the cervical spine for patients with distracting injuries: an AAST multi-institutional trial. Session I Paper 3, AAST 2018.
The annual meeting of the American Association for the Surgery of Trauma (AAST) begins in two weeks. Today, I will kick off a series of commentaries on many of the abstracts being presented at the meeting. All readers should be aware that I have only the abstracts to work with. As I always caution, final judgement cannot be passed until the full paper has been reviewed. And many of these will not make the jump to light speed and ever get published. So take them with a grain of salt. They may point to some promising developments, but then, maybe not.
First up is a nice analysis on the price of being a trauma center. One of my mentors, Bill Schwab, always used to say that trauma centers are always in a state of “high-tech waiting.” It costs money to keep surgeons in house, other medical and surgical specialists at the ready, and an array of services and equipment available at all hours. Any hospital administrator can tell you that trauma is expensive. But how expensive, exactly?
The trauma group at the Medical Center of Central Georgia in Macon did a detailed analysis of the cost of readiness for trauma centers in the year 2016. The Georgia State Trauma Commission, trauma medical directors, trauma program managers, and financial officers from the Level I and II centers in Georgia determined the various categories and reported their actual costs for each. An independent auditor reviewed the data to ensure reporting consistency. Significant variances were analyzed to ensure accurate information.
Here are the factoids:
- Costs were lumped into four major categories: administrative, clinical medical staff, in-house OR, and education/outreach
- Clinical medical staff was the most expensive component, representing 55% of costs at Level I centers and 65% at Level II
- Only about $110,000 was spent annually on outreach and education at both Level I and II centers, representing a relative lack of resources for this component.
- Total cost of being a Level I center is about $10 million per year, and $5 million per year for Level II
Here is a copy of the table with the detailed breakdown of each component:
Bottom line: Yes, it’s expensive to be a trauma center. It’s a good idea for any trauma center wannabe to perform a detailed analysis to make sure that it makes sense financially. This is most important in areas where there are plenty of trauma centers already. Tools have been developed to determine how many trauma centers will fit within a given geographic area (see below). Unfortunately, very few if any states use this tool to determine how many centers are reasonable. In come cities, it’s almost like the wild west, with centers popping up at random all over the place. This abstract suggests that an additional analysis is mandatory before taking the plunge into this expensive business.
Reference: How much green does it take to be orange? Determining cost associated with trauma center readiness. Podium abstract #18, session VIII, AAST 2018.
Welcome to the current newsletter. This is part 1 of 2 issues where I discuss the massive transfusion protocol (MTP). Here are some of the things I cover:
- Introduction to MTP
- Building your own MTP
- Key factors in the MTP
- When to activate it
- How to analyze it
The September issue will be released to subscribers late this month and will cover the product ratio question, using TEG in the MTP, TXA, and that old yet new thing, whole blood. I’ll release it to everyone in October, so subscribe now if you want it sooner!
To download the current issue, just click here! Or copy this link into your browser: http://bit.ly/TME201808a.
Level I and II trauma centers that are verified by the American College of Surgeons are required to have a method for ensuring that urgent orthopedic cases have good access to an operating room (OR). Some hospitals (that have room availability) have achieved this by dedicating an OR for this purpose. In a few hospitals, the room is available 24/7, but most provide daily block time that has a reasonable release time (typically about 6am). This allows procedures to reliably get done the next morning.
Previous papers have documented many of the benefits of this practice: decreased length of stay, fewer surgical revisions, decreased cost, and of course, fewer after-hours operations. But by definition, this adds a delay of several hours to the case. If the patient comes in at 7pm, the case may not start for 12 hours or more.
Could this increase the risk of infection or other complications? The orthopedic group at Stormont Vail in Topeka KS (Level I) looked at their retrospective experience over a 6 year period. They specifically examined cases in which a time delay could increase the infection rate: open tib/fib fractures. They recorded the usual demographics, time to procedure, and broke the data down by Gustilo grade of the fracture.
Here are the factoids:
- The authors treated 297 patients with a total of 347 open fractures
- About half were treated before a dedicated ortho OR was implemented, and half after
- Average time to debridement in the dedicated OR was 13 hours, vs 5 hours in the on-call system
- Overall, the number debrided within 24 hours was the same in both groups
- Primary fracture union was significantly higher in the dedicated room group (73% vs 57%)
- Patients treated initially in the dedicated room were significantly less likely to need an unplanned procedure later (for malunion or infection)
- There was no difference in infection, non-union, or amputation rates
Bottom line: Let your orthopedic surgeon sleep if you have a dedicated OR so the work can get done first thing the next day! It saves wear and tear on the hospital infrastructure that occurs when cases are done in the middle of the night, as well as the surgeon. Besides saving time and money, final outcomes are better, too!
Reference: Use of the Dedicated Orthopaedic Trauma Room for Open Tibia and Femur Fractures: Does It Make a Difference? J Ortho Trauma 32(8):377-380, 2018.
This is a perfect example of why you cannot just simply read an abstract! And in this case, you can’t just read the paper, either. You’ve got to critically think about it and see if the conclusions are reasonable. And if they are not, then you need to go back and try to figure out why it isn’t.
A study was published a few years ago regarding bleeding after nonoperative management of splenic injury. The authors have been performing an early followup CT within 48 hours of admission for more than 12 years(!). They wrote this paper comparing their recent experience with a time interval before they implemented the practice.
Here are the factoids. Pay attention closely:
- 773 adult patients were retrospectively studied from 1995 to 2012
- Of 157 studied from 1995 to 1999, 83 (53%) were stable and treated nonoperatively. Ten failed, and all the rest underwent repeat CT after 7 days.
- After a “sentinel delayed splenic rupture event”, the protocol was revised, and a repeat CT was performed in all patients at 48 hours. Pseudoaneurysm or extravasation initially or after repeat scan prompted a trip to interventional radiology.
- Of 616 studied from 2000-2012, after the protocol change, 475 (77%) were stable and treated nonoperatively. Three failed, and it is unclear whether this happened before or after the repeat CT at 48 hours.
- 22 high risk lesions were found after the first scan, and 29 were found after the repeat. 20% of these were seen in Grade 1 and 2 injuries. All were sent for angiography.
- There were 4 complications of angiography (8%), with one requiring splenectomy.
- Length of stay decreased from 8 days to 6.
So it sounds like we should be doing repeat CT in all of our nonoperatively managed spleens, right? The failure rate decreased from 12% to less than 1%. Time in the hospital decreased significantly as well.
Wrong! Here are the problems/questions:
- Why were so many of their patients considered “unstable” and taken straight to OR (47% and 23%)?
- CT sensitivity for detecting high risk lesions in the 1990s was nothing like it is today.
- The accepted success rate for nonop management is about 95%, give or take. The 99.4% in this study suggests that some patients ended up going to OR who didn’t really need to, making this number look artificially high.
- The authors did not separate pseudoaneurysm from extravasation on CT. And they found them in Grade 1 and 2 injuries, which essentially never fail
- 472 people got an extra CT scan
- 4 people (8%) had complications from angiography, which is higher than the oft-cited 2-3%. And one lost his spleen because of it.
- Is a 6 day hospital stay reasonable or necessary?
Bottom line: This paper illustrates two things:
- If you look at your data without the context of what others have done, you can’t tell if it’s an outlier or not; and
- It’s interesting what reflexively reacting to a single adverse event can make us do.
The entire protocol is based on one bad experience at this hospital in 1999. Since then, a substantial number of people have been subjected to additional radiation and the possibility of harm in the interventional suite. How can so many other trauma centers use only a single CT scan and have excellent results?
At Regions Hospital, we see in excess of 100 spleen injuries per year. A small percentage are truly unstable and go immediately to OR. About 97% of the remaining stable patients are successfully managed nonoperatively, and only one or two return annually with delayed bleeding. It is seldom immediately life-threatening, especially if the patient has been informed about clinical signs and symptoms they should be looking for. And our average length of stay is 2-3 days depending on grade.
Never read just the abstract. Take the rest of the manuscript with a grain of salt. And think!
Reference: Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma: early screening leads to a decrease in failure rate. J Trauma 76(6):1349-1353, 2014.