All posts by TheTraumaPro

The ICU Bounce Back

We’ve all experienced it. A seriously injured trauma patient is admitted to the ICU and begins the process of recovery. Everything looks well, and after a few days they are transferred to a ward bed. But then they languish, never really doing what we expect. Finally (and usually in the middle of the night), they begin to look bad enough where we have to transfer them back to the ICU.

What’s the problem here? A failure of the ICU team? Did we all miss something? Is there any way we can avoid this problem? The major issue is that these “bounce backs” tend to do poorly compared to patients who successfully stay in their ward bed. Estimates are that mortality for patients successfully and finally discharged from the ICU range from 4-8%, whereas the mortality in bounce back patients is 20-40%!

Researchers at the Medical University of South Carolina in Charleston looked at the characteristics that defined the bounce back patient. They looked at nearly 2000 patients discharged from the trauma ICU and analyzed the variables that predicted an unplanned bounce back. They noted the following interesting findings:

  • More than two thirds of bounce backs occurred within 3 days
  • Males, patients with an initial GCS < 9, transfer during the day shift, and the presence of comorobidities
  • More comorbidities was associated with a higher chance of bounce back
  • Mortality in the bounce back group was 20%
  • The most common factors causing bounce back were respiratory failure or bleeding

Bottom line: This is an intriguing single-institution study that supports my own personal observations. Fewer bounce backs occur at night because staffing tends to be lower and there is more resistance to transfers out of the ICU to make room. Both the ICU team and the ward team need to scrutinize every transfer carefully. Significant head injury or the presence of medical comorbidities should trigger a careful assessment to make sure that the transfer is appropriate. Otherwise, your patient may be placed in unnecessary jeopardy.

Related posts:

Reference: Intensive care unit bounce back in trauma patients: An analysis of unplanned returns to the intensive care unit. J Trauma 74(6):1528-1533, 2013.

The Robert Jones Dressing

The Robert Jones dressing is a thick, padded bandage classically applied to the thigh and leg. It is thought to reduce swelling by applying even pressure to the extremity, which in turn should promote healing. And since it is a soft dressing, as opposed to a cast, there is less chance of developing skin breakdown from direct pressure. Here’s a compression-type dressing described in 1937 using stockinette, cotton wool, and elastic cloth, although it was not attributed to Jones at that point.

Charnley provided a detailed description of the bandage in 1950, and was the first to refer to Jones.

Interestingly, Robert Jones never really referred to the dressing by name. There were references to a “pressure crepe bandage over copious wool dressing” in his operative logs, but it wasn’t until much later that his name became associated with it. Because of this, the composition of the bandage has varied greatly over time.

But who was Robert Jones? We in the States are fairly ignorant, but my UK readers are very familiar. Jones was a British surgeon who practiced through the late 1800s and past the end of World War I. He learned about fractures from his uncle, and became one of the few surgeons of the time to be interested in fracture care. Until then, orthopaedics was focused primarily on correcting deformities in children. He received his FRCS in 1889. After being appointed Surgeon-Superintendent of the Manchester Ship Canal, he established the first comprehensive accident service in the world to take care of injured workers. He founded the British Orthopaedic Society in 1894, and introduced the concept of military orthopaedic hospitals during World War I. His innovations led to significant decreases in morbidity and mortality from fractures in the war, particularly of the femur.

And does his eponymous dressing actually work? There has been little research in this area. There is one study that I have found that actually measured compartment pressures to see if the loss of edema from compression caused a noticeable pressure decrease. Here are the factoids:

  • This was a very small prospective study from 1986 of 9 patients (!) who had just undergone knee arthroplasty
  • Slit catheters were placed into the compartment 10 cm below the knee joint (but they didn’t say which compartment)
  • Thick cotton-wool from a roll was applied over the surgical dressings twice, each with a thickness of two inches. An elastic bandage was then applied snugly.
  • Much to the researchers’ surprise, compartment pressures did not fall as expected over time. They were basically constant until the dressing was removed. Then the pressures fell significantly.

Bottom line: Robert Jones’ fame is well deserved. However, his dressing (which he did not name, and may not even be what he used), did not have the pressure-reducing effect on an injured limb that surgeons thought. No studies on edema and healing have been done. It’s basically a fluffy dressing. However, that is a good thing. It keeps the leg padded, protecting the skin, and immobilized. It’s like a very well padded cast, without the risk of skin breakdown. And because of its simplicity, it will probably be used for quite some time to come.

Related posts:

References:

  • The Robert Jones bandage. JBJS 68B(5):776-779, 1986.
  • The treatment of fracture without plaster of Paris. Closed Treatment of Common Fractures, E&S Livingstone 1950, pg 28-29.
  • Handbook of Orthopaedic Surgery. CV Mosby 1937, pg 418.

September Trauma MedEd Newsletter Released This Weekend!

The September Trauma MedEd Newsletter will be released to subscribers this weekend. This month, I’m concentrating on imaging, and specifically image transfer from referring to receiving hospitals. Articles will deal with:

  • Repeat imaging
  • Cloud services
  • Tips on image transfer
  • And more!

Anyone on the subscriber list as of midnight (CST) Saturday will receive it on Sunday. Everybody else will have to wait for me to release it here on the blog late next week. So sign up for early delivery now by clicking here!

Pick up back issues here!

ABC: A Quick & Dirty Way to Predict Massive Transfusion

It’s nice to have blood available early when major trauma patients need it. Unfortunately, it’s not very practical to have several units of O neg pulled for every trauma activation, let alone activate a full-blown massive transfusion protocol (MTP). Is there any way to predict which trauma patient might be in need of enough blood to trigger your MTP?

The Mayo Clinic presented a paper at the EAST Annual Meeting a few years ago that looked at several prediction systems and how they fared in predicting the need for massive transfusion. Two of the three systems (TASH – Trauma Associated Severe Hemorrhage, McLaughlin score) are too complicated for practical use. The Assessment of Blood Consumption tool is simple, and it turns out to be quite predictive.

Here’s how it works. Assess 1 point for each of the following:

  • Heart rate > 120
  • Systolic blood pressure < 90
  • FAST positive
  • Penetrating mechanism

A score >=2 is predictive of massive transfusion. In this small series, the sensitivity of ABC was 89% and the specificity was 85%. The overtriage rate was only 13%.

The investigators were satisfied enough with this tool that it is now being used to activate the massive transfusion protocol at the Mayo Clinic. Although the abstract is no longer available online, it appears to be remarkably similar to a paper published in 2009 from Vanderbilt that looks at the exact same scoring systems. Perhaps this is why it never saw print? But the results were the same with a sensitivity of 75% and a specificity of 86%.

Here’s a summary of the number of parameters vs the likelihood the MTP would be activated:

ABC Score         % requiring massive transfusion
0                                1%
1                               10%
2                               41%
3                               48%
4                             100%

Bottom line: ABC is a simple, easy to use and accurate system for activating your massive transfusion protocol, with a low under- and over-triage rate. It doesn’t need any laboratory tests or fancy equations to calculate it. If two or more of the parameters are positive, be prepared to activate your MTP, or at least call for blood!

Related post:

References: 

  • Comparison of massive blood transfusion predictive models: ABC, easy as 1,2,3. Presented at the EAST 24th Annual Scientific Assembly, January 26, 2011, Session I Paper 4. (No longer available online)
  • Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma 66(2):346-52, 2009.

Admission To Nonsurgical Service = Longer LOS?

Previous studies have shown that higher hospital costs are associated with longer length of stay (LOS). This makes sense, because the longer a patient stays in the hospital, the more that is “done” for them, and more daily charges are incurred. Obvious savings can occur if we look globally at services, medications, etc while the patient is in the hospital.

But does the admission service make a difference in LOS or cost? It shouldn’t if care is fairly uniform. A group of orthopedic surgeons at Vanderbilt in Nashville looked at a large group of isolated hip fracture patients (n=614) to see if LOS (used as a surrogate for cost) was significantly different. They also tried to control for a host of factors that could affect time in the hospital between the two groups.

Here are the factoids:

  • About half of the patients were admitted to the orthopedics service, and half to medicine
  • Median length of stay was way different! 4.5 days on Ortho vs 7 days on Medicine
  • Readmission rates were also significantly higher on Medicine, 30% vs 23%
  • After controlling for factors such as medical comorbidities, age, smoking and alcohol, ASA score, obesity, and others, a regression model showed that patients were still likely to stay about 50% longer if admitted to a medicine service.

Bottom line: Obviously, this is the experience of a single institution. But the difference in length of stay, and hence costs, was striking. As the US moves toward a bundled payment system, this will become a major problem. The initial LOS is more costly on the medicine service, and readmission for the same problem will not be reimbursed. Why the difference? Coordination of care between two services? Lack of familiarity with surgical nuances? This study did not look at that.

But it does point out the need to more closely integrate the care of the elderly in particular, and patients with a broad range of needs in general. An integrated team with orthopedic surgeons and skilled geriatricians is in order. And a set of protocols for standard preop evaluation and postop management is mandatory.

Related posts:

Reference: 

Does Admission to Medicine or Orthopaedics Impact a Geriatric Hip Patient’s Hospital Length of Stay? J Orthopedic Surg epub Sep 14, 2015.