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.
Early tracheostomy is generally accepted to be a good thing in critically injured patients. A number of papers have shown that it decreases ventilator days and hence ICU and hospital days, and also reduces pneumonia rates, sedation requirements, and saves quite a bit of money.
However, there has been one problematic group in whom critical care surgeons are often forbidden to do an early trach: patients with a recent anterior cervical fusion. These patients typically have unstable cervical fractures, with or without a concomitant spinal cord injury. The spine surgeons argue that doing a trach “too soon” leads to a higher infectious complication rate due to the proximity of the trach to their anterior surgical wound.
But is this really true? The trauma/critical care program at Thomas Jefferson University in Philadelphia looked at their experience. They are a federally sponsored spinal cord injury center, and have a vast experience compared to most trauma centers. They reviewed their experience over a 16 year period. Typically, they performed all of their tracheostomies within 10 days, so they arbitrarily defined “early” as within 4 days, and “late” as > 5 days after the cervical procedure.
Here are the factoids:
- A total of 98 patients with tracheostomy after anterior fusion were included in the study, some of whom also underwent a concomitant posterior fusion
- 39 cases were “early”, within 4 days of the anterior fusion procedure, and 59 were “late”
- Average time to fusion in the early group was 2 days, and 10 days in the late group
- There were no wound infections in the early group
- There were 5 wound infections in the late group, and 4 of them involved the posterior fusion site(!)
- The only infection of the anterior fusion site occurred in a late patient who suffered an esophageal perforation from the fusion hardware
Bottom line: Although the numbers are still small after 15 years of data, it’s probably the best we will ever get! It is clear that an anterior fusion wound is safe in these procedures. I am at a loss as to why the posterior fusion wounds tend to get infected, though. But the next time your spine surgeons balk about doing an early trach in one of their anterior fusion, show them this paper!
Most trauma centers have at least a few practice guidelines to help the standardize the way they manage common injuries. Solid organ injury. Elder trauma. Chest tube management. But they are all designed for use in patients who present shortly after their injury.
What about someone who presents a day or two, or more, after their injury? That changes the picture entirely. Most guidelines have a time component built in. A TBI protocol requires a repeat head CT after a certain period of time. Solid organ injury patients may have restricted activity or frequent vital signs for a while.
But all too often, trauma professionals treat the patient with delayed presentation exactly the same as fresh trauma. For example, a patient falls and bumps their head. They have a persistent headache, and after two days decide to visit their local ED. The CT scan shows a small amount of subarachnoid blood in the area of the impact. Your practice guidelines says to admit for observation, frequent neruo checks, and repeat head CT in 12 hours.
Or a young male playing sports took a hit to his left flank. After 3 days, he’s just tired of the pain and comes to the ED for some pain medication. CT scan shows a grade III spleen injury with a small amount of hemoperitoneum. Your protocol says to admit, make NPO, liimit activity, and observe for 2 days.
What would I do in these cases? Think about it! If the patients had presented right after the event, they would have gone through your guideline and would have been discharged already. So I would review the images, talk to the patients about their injuries, then send them home from the ED with followup. They’ve already passed!
Bottom line: Remember, practice guidelines are not etched in stone. Variances are possible, but need to be well thought out in advance. And hopefully documented in the chart to expedite the inevitable trauma performance improvement inquiry. If the requisite amount of time has gone by, and the history and exam are reasonable, the patient has already passed your protocol. Send them home.
Here’s another in my series of “When To Call” pieces. We sometimes overuse our consultants and call then at inappropriate times. So what if we diagnose an injury in their area of expertise at 2 am? Does it need attention or an operation before morning? If not, why call at that ungodly hour?
Let’s use our consultants wisely! I’ve listed most of the common eye diagnoses that trauma professionals will encounter. There is also an indication of what you need to do, and exactly when to call your consultant.
Unfortunately, this one won’t fit on a 3×5 index card that you can keep in your pocket. I’ve included a printable pdf file, as well as the original Microsoft Word file in case you want to make a few modifications to suit your own hospital.
When to call Ophthalmology reference card (pdf)
When to call Ophthalmology MS Wordfile (docx)