All posts by The Trauma Pro

protocols

The CIWA Protocol Demystified

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What exactly is the CIWA protocol?

It is a tool used commonly in the US that helps clinicians assess and treat potential alcohol withdrawal. A significant amount of injury in this country is due to the overuse of alcohol. A subset of these patients are admitted and do not have access to alcohol. They may begin to withdraw within a few days, and this condition can lead to dangerous complications.

The Clinical Institute Withdrawal Assessment measures 10 items that are associated with withdrawal:

  • Nausea / vomiting
  • Anxiety
  • Paroxysmal sweats
  • Tactile disturbances (itching, bugs crawling on skin, etc)
  • Visual disturbances
  • Tremors
  • Agitation
  • Orientation
  • Auditory disturbances
  • Headache

All items are measured on a scale of 0-7 with the exception of orientation, which uses a scale of 0-4. All subscores are tallied to arrive at the final score.

The total score is used to determine whether benzodiazepines should be given to ameliorate symptoms or avoid seizures. Typically, a threshold is selected (8 or 10) and no medications are needed as long as the patient is under it. Once it is exceeded, graduated doses of lorazepam or diazepam are given and vital signs and CIWA scores are repeated regularly. The protocol is discontinued once the patient has three determinations that are under the threshold.

The individual dosing scale and monitoring routine varies by hospital. Look at your hospital policy manual to get specifics for your institution.

For a copy of the CIWA scoring criteria, click here.

Tomorrow, precautions when using the CIWA protocol.

Pharmacy

How Many Salt Tabs In A Liter Of Saline?

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Seems like a simple, silly question, right? I dare you to figure it out without reading this post!

horse-salt-block-lick2

On occasion, our brain injured trauma patients have sodium issues. You know, cerebral salt wasting. Trying to maintain or regain the normal range, without making any sudden moves can be challenging. There are a lot of tools available to the trauma professional, including:

  • Saline
  • Hypertonic saline
  • Salt tablets
  • Fluid restriction
  • Some combination thereof

Fun times are had trying to figure out how much extra sodium we are giving with any of the first three items. This is important as you begin to transition from the big guns (hypertonic), to regular saline, and then to oral salt tabs.

Below is a quick and dirty conversion list. I won’t make your heads explode by trying to explain the math involved changing between meq, mg, moles, sodium and sodium chloride.

  • The “normal saline” bags we use are actually 0.9% saline (9 gm NaCl per liter)
  • Hypertonic saline can be 3% or 5% (30 gm or 50 gm per liter)
  • Salt tabs are usually 1 gm each (and oh so yummy)

Therefore, a liter of 0.9% normal saline is the same as 9 salt tabs.

A liter of 3% hypertonic saline is the same as 30 salt tabs. The usual 500cc bag contains 15.

A liter of  5% hypertonic saline is the same as 50 salt tabs. The usual 500cc bag contains 30.

To figure out how many tablets you need to give to match their IV input, calculate the number of liters infused, then do the math! And have fun!

Complications

Incidental Appendectomy During Trauma Laparotomy?

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The debate over incidental appendectomy has waxed and waned over the years. And for the most part, it has nearly permanently waned in general surgical cases for now. But every once in a while, I am asked about incidental appendectomy during trauma laparotomy. Is it a good idea? What reasons could there possibly be for doing it?

In the old days, we would frequently do an incidental appendectomy because… well, just because we were there. The surgeon was in the midst of a general surgical case, typically an open one, and this normal little appendix was just staring us in the face. The justification was usually, “we’ll save him another operation in the future in case he develops acute appendicitis.”

Legitimate reason? It took many years for the literature to develop, but it finally did. Here were the reasons we figured out not to do it:

  • Despite how innocuous a procedure it seems to be, there is a measurable uptick in complication rates. This is true in the usual clean contaminated general surgery cases. Some papers also noted an increased mortality when the appendectomy was added to a cholecystectomy case. In a trauma procedure with bowel injury and contamination, it’s a bit harder to see the correlation. But any time we cut or staple something out, there is always the possibility that it might break down.
  • Cost increases in laparoscopic cases if additional ports and/or equipment is needed for the appendectomy. This doesn’t really apply to major trauma cases, since we better not be doing them laparoscopically!
  • The appendix is not the useless vestigial structure we originally thought. There is evidence that it is a repository for the gut microbiome, which can help repopulate the colon with bacteria after a serious insult like prolonged antibiotic administration. Unnecessary removal may ultimately interfere with gut health and disease.

Can acute appendicitis develop after trauma laparotomy? Sure, at any time. Thankfully, it’s not very common. The presenting complaints are the same as we learned in the doctor books. However, the location of the pain and tenderness may not be in the classic location depending on the post-trauma anatomy and presence of adhesions.

Bottom line: Incidental appendectomy is no longer indicated for just about anything, including trauma laparotomy. If one of your patients presents with abdominal pain at any time, both post-traumatic and other causes must be considered. CT has become the standard for appendicitis workup, and is extremely helpful in sorting out causes in the post-op trauma patient. Use it, and if it is one of the rare cases where appendicitis is actually present, then proceed with the usual and appropriate operative on nonoperative management.

References:

  • Incidental appendicectomy with laparotomy for trauma. Br J Surg 62(6):487-9, 1975
  • Appendicitis following blunt abdominal trauma. Am J Emerg Med 35(9):1386.e5-1386, 2017.
  • Systematic review of blunt abdominal trauma as a cause of acute appendicitis. Ann R Coll Surg Engl 92(6):477-82, 2010.
Philosophy

The Tenth Law Of Trauma

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Several years ago, I ran a series of posts on my Laws of Trauma. I assembled them into  newsletter that contained all nine that existed at the time. If you’d like to download it, just click this link.

I’ve  been struck by another pattern, and I think it’s about time to add the tenth law. Weirdly enough, it was inspired by Dancing With The Stars. You’ll see what I mean.

Here is the Tenth Law of Trauma:

“In trauma, it generally takes two to tango”

So what does this mean? When dealing with injury, there are a few broad quantitative categories.

  • Single person mechanism. This is one extreme. Common examples would be the elderly fall, a single vehicle car crash, or a self-inflicted stab or gunshot. There is a single “point of failure” that only the individual involved can manage, but for various reasons they do not or cannot. This law does not apply.
  • Multiple person mechanism. This is the other extreme, and thankfully is not seen very often at all. Examples are a tour bus crash, house explosion, or mass casualty event. Once again, those involved usually have little ability to recognize or avoid the imminent event, and the tenth law is null and void.
  • Two person mechanism. This one is very common, and is exemplified by the two car crash, pedestrian struck, or the various flavors of assault. And this is the one that the tenth law applies to.

When two people are involved in an event that leads to traumatic injury, there is usually (but certainly not always) a set of checks and balances that is present. And frequently there is at least one opportunity to avoid the event.

In the case of a two vehicle crash, one driver may have “gone off the reservation” and ignored the usual traffic laws for whatever reason. But the second driver usually has an opportunity to recognize this and change their behavior in order to avoid the situation. However, if they are distracted, impaired, or making assumptions about how other driver behave they can still get into trouble. Thus, it takes two.

What about the pedestrian struck? Likewise, the driver or the pedestrian may have done something nonstandard. Wear dark clothes at night. Glance at their phone while driving. Look at their passenger a bit too long while having a conversation. Once again, the other participant may have an opportunity to see the result of this unexpected behavior and jump or swerve out of the way.

Interpersonal violence it a bit more tricky. Sure, one of the potential participants may get wind that something is up and try to avoid or defuse the situation. But not always. And this situation is heavily charged with emotion and social pressures and is much more difficult to change or avoid.

Bottom line: Many, but certainly not all,  “two-person” mechanisms of injury are avoidable if both of the individuals involved are mentally present and attentive to their surroundings. Look at your own patient population and see how often this applies. You may be surprised!

Complications

More On Lead Poisoning And Retained Bullets

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Trauma professionals frequently have to leave bullets in patients. It is often more disruptive to go digging the projectiles out than to just leave them in place. But patients always want to know why and what the consequences might be.

In my last post, I discussed a very old paper on what we know about lead levels and retained bullets. Very recently, a meta-analysis was published that provides a better picture of this topic. They somehow managed to find over 2000 articles dealing with lead toxicity and bullets out there. But after someone had the pleasure of reviewing each of them, they found only 12 that had any meaningful or actionable information.

Here are the factoids:

  • All studies were observational (duh! It would be difficult to get your IRB to approve a study where patients were shot on purpose)
  • There were five cross-sectional studies, four case-control studies, and three prospective cohort studies
  • The studies were small, with a median of only 26 patients (range 15-120)
  • Eleven of the twelve studies showed an association with retained bullets and elevated blood lead levels
  • Three studies showed elevated blood levels if a fracture was present
  • The higher the number of retained fragments, the more likely lead levels were to be high
  • Higher lead levels were associated with retained fragments near a bone or joint
  • There were no good correlations with number of fragments and location vs actual lead toxicity

Bottom line: Even using meta-analysis, it is difficult to tease out meaningful answers to this question. That speaks to the low numbers of papers and their quality. However, this study does provide a little bit of guidance.

Retained bullet fragments are probably not a big worry in most patients. The bothersome cases are those where the fragments are in or near a bone or joint. And even though few patients actually developed lead toxicity, lead levels approaching 5 micrograms/dL can have physiologically significant negative effects. 

Recommendation: If your patient has a retained bullet fragment near a bone or joint, or they have “multiple” retained fragments (no good definition of this), they should have blood lead levels measured every three months for a year. If the level is rising, and certainly if it reaches the 5μ/dL level, attempts should be made to remove the fragments.

Reference: Lead toxicity from retained bullet fragments: A systematic review and meta-analysis. J Trauma 87(3):707-716, 2019.