All posts by The Trauma Pro

protocols

TEG And Your Massive Transfusion Protocol

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Thromboelastography (TEG) and its fraternal twin rotational thromboelastometry (ROTEM) are relatively new toys in the trauma community. They allow for (somewhat) rapid assessment of clotting function, and allow the trauma professional to surmise what products might push abnormal clotting characteristics back toward normal.

Many trauma centers already own this technology due to its use by non-trauma services. But there have been a growing number of research presentations on the topic over the last five years, and many centers are clamoring to buy these units for use in their MTP.

But remember, new technology is usually expensive, and isn’t always all it’s cracked up to be. TEG and ROTEM require a (often-times) new machine and a never-ending supply of disposable cartridges for use, like your ink jet printer. Some hospitals are reluctant to provide the funds unless there is a compelling clinical need.

Surgeons at the University of Cincinnati compared the use of TEG with good, old-fashioned point-of-care (POC) INR testing in a series of major trauma patients seen at their Level I center.

Here are the factoids:

  • This was a retrospective review of 628 major trauma patients who received both TEG and POC INR testing using an iSTAT device over a 1.5 year period
  • Median ISS was 13, and there were many sick patients (20% in shock, 21% received blood, 11% died)
  • INR correlated with all TEG values, with better correlation in patients in shock
  • Both INR and TEG correlated well with treatment with blood, plasma, and cryoprecipitate
  • Processing time was 2 minutes for POC INR vs about 30 minutes for TEG
  • Charges for POC INR were $22,000 vs $397,000 for TEG(!!)

Bottom line: Point of care INR testing and TEG both correlated well with the need for blood products in major trauma patients. But POC INR is much cheaper and faster. Granted, the TEG gurus will say that you can tailor the products administered to meet the exact needs of the patient. But in all my travels, I’ve see very few centers that have fully, effectively, and contemporaneously incorporated TEG or ROTEM into their massive transfusion protocol from start to finish.

The area where TEG and ROTEM are most helpful are in the “mop up” phase at the tail end of the MTP. These tools allow trauma professionals to determine exactly which products are needed to normalize parameters, and they frequently diverge from the 1:1:1 to 1:1:2 ratios at that point to achieve this.

If you don’t have one of these toys yet, make sure that you have a very good clinical reason to do so. If you do, think very carefully about how you can meaningfully incorporate it in the massive transfusion process and write it into your protocol.

Reference: All the bang without the bucks: defining essential point-of-care testing for traumatic coagulopathy. J Trauma 79(1):117-124, 2015.

protocols

What Is The Ideal Blood Product Ratio?

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Back in the day when I was a resident when a massively bleeding patient came in, we gave crystalloid. And frequently, a lot of it. The books in those days said slam in two liters of saline or lactated Ringer’s solution. It was believed that there was little downside to crystalloid. Consequently, quite a bit of it was given before we ever thought about blood products.

And there were no systems in place to standardize how blood was requested, what was sent, or how much was used. We generally started off with a bunch of packed red cells. Yes, every now and then we might remember to ask for some plasma, and even less commonly some platelets or cryoprecipitate. Ratios? We didn’t really pay attention. In reality, there were probably four red cell packs to one unit of plasma, on average. And the ratio to platelets was so low it was hard to even measure!

By now, we have plenty of data showing that this crystalloid-heavy resuscitation contributed to coagulopathy and poor outcomes. We’ve adopted a more balanced concept of resuscitation, which of course we call “balanced resuscitation.” What does this term mean? Basically, it’s a combination of restricted crystalloid use, more optimized ratios of blood products, and some degree of permissive hypotension in select patients.

Before we dive more deeply into ratios, let’s agree on the nomenclature. You may hear people talking about a 1:1 ratio, or 2:1:1, or even 1:1:2. Which product is which? Always read the paper or text carefully, as there is no real standard here. Typically, if only two numbers are specified, RBCs are first and plasma second. But when three are given, you must determine whether the red cells are first or last. Here are the most common configurations:

  •               RBC : plasma : platelets
  •               Plasma : platelets: RBC

Many papers have been written examining the ratio puzzle. Mortality, complications, renal or lung injury, deep venous thrombosis and pulmonary embolism, lengths of stay, transfusion reactions (of all types), and much more have all been investigated.

The most helpful literature covering transfusion ratios are systematic reviews. The main focus seems to be finding the magic ratio of red cells to everything else. The old-time higher ratios (1:?:4) were generally considered to be inferior, so most research has focused on comparing 1:1:1 to 1:1:2. Here are the main factoids, and all keep to the plasma:platelets:RBC format:

  • There was no discernible difference in 24-hour or 30-day mortality between groups with ratios of 1:1:1 or 1:1:2
  • Patients with a 1:1:1 ratio received significantly more platelets and plasma that the 1:1:2 patients
  • Giving cryoprecipitate or fibrinogen concentrate early had no effect on mortality

Although systematic reviews try to make up for shortcomings of individual studies, they introduce their own problems. However, they overall seem to indicate that the “magic” ratio lies between 1:1:1 and 1:1:2. Most centers strive for the former, but due to many reasons (e.g. no thawed plasma, delivery issues) more realistically try to stay under the latter.

Bottom line: Think about the logistics in your own trauma center, and design your massive transfusion protocol so that you can maintain a ratio somewhere between 1:1:1 and 1:1:2. Every MTP activation should be analyzed by your trauma performance improvement process and must review your final ratios. One thing I’m sure of is that we will continue to refine this over the coming years, so stay tuned!

Reference: Optimal Dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a Systematic Review. Transfus Med Rev 32(1):6-15, 2018.

CNS

Redefining Mild TBI: Who Needs To Be Transferred?

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One of the more common reasons for transfer to a higher level trauma center these days is the “mild or minimal TBI.” Technically, this consists of any patient with a Glasgow Coma Scale score of 14 or 15. A transfer is typically requested for observation or neurosurgical consultation, or because the clinicians at the initial hospital are not comfortable looking after the patient.

Is this really necessary? With the number of ground level falls approaching epidemic proportions, transferring all these patients could begin to overwhelm the resources of high level trauma centers. The surgical group at Carolinas Medical Center examined their experience with a simple scoring system they designed to predict high risk minor TBI patients, and thus suitability for transfer. Here is their checklist:

Category A
  • Traumatic SAH
  • Tentorial or falcine SDH < 4mm thickn
  • Convexity SDH < 4mm thick
  • Solitary IPH < 1cm
  • Isolated intraventricular hemorrhage < 4mm
Category B
  • Any Category A lesion greater than the allowed size
  • Midline shift
  • Skull fracture
  • Compression of basal cisterns
  • Diffuse SAH or SAH involving basal cisterns
  • Subacute or chronic SDH
SAH = subarachnoid hemorrhage, SDH = subdural hemorrhage, IPH = intraparenchymal hemorrhage

Patients were considered to be low risk if they had only one or two category A lesions. If they had more than two, or any Category B lesions, they were higher risk and transfer was considered justified.

The authors retrospectively reviewed their experience with these patients over a three year period. They followed patients to see if they needed neurosurgical intervention, and evaluated the cost savings of avoiding selective transfers based on their criteria.

Here are the factoids:

  • A total of 2120 patients were studied, with 68% low risk and 32% high risk
  • Two of the low risk patients (0.14%)  ultimately required neurosurgical intervention, compared to 21% of high risk patients
  • Mean age (56), and patients taking anticoagulants or antiplatelet agents were the same in the two groups, about 2-3% for each
  • System saving by avoiding EMS transfer costs would have been $734K had the low risk patients been kept at the initial hospital

Bottom line: This study was presented as a Quick Shot paper at this year’s Eastern Association for the Surgery of Trauma meeting, so there are some key details missing. Was there an association between anticoagulation or antiplatelet agent and two failures in the low risk group? What were they, and what intervention did they require?

If this data holds up to publication, then it may provide a useful tool for deciding to keep minimal TBI patients at the local hospital. This is usually far more convenient for the patient and their family, but would require additional education of the clinicians at that hospital to help them become comfortable managing these patients. 

We use a similar tool within our Level I trauma center to decide which patients require a neurosurgical consultation. Since the low risk patients almost never require intervention, our trauma service provides comprehensive management while in hospital, and arranges for TBI clinic followup post-discharge. You can view and download a copy using the link below.

Link: Regions Hospital SAH/IPH/Skull fracture practice guideline

Reference: Redefining minimal traumatic brain injury (MTBI): a novel CT criteria to predict intervention. Quick Shot Paper #48, EAST 2019.

Survey

Participate In A Survey: The Trauma PI Coordinator

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Trauma performance improvement (PI) is a very complicated business, and more trauma centers fail their verification visits due to PI problems than for any other reason. The amount of information reviewed in the trauma PI program and the volume of documentation required can be quite onerous, but is necessary to assure the highest quality trauma care.

Many centers are now hiring trauma PI coordinators (TPIC) to free up other personnel from this time consuming task. Do you have a trauma PI coordinator, or do you wish you did? Please take two minutes to fill out a quick survey. I am trying to determine how many centers do and how many do not have a PI coordinator. I’d also like to correlate the center demographics with PI coordinator presence or absence.

For that reason, you must have one key piece of information before you fill out the survey. I need the total number of trauma registry admits for your center. You can find this out from your trauma program manager (TPM) or the lead registrar. Or better yet, have your TPM fill out the survey!

I’ll let the survey run for about two weeks, and then I will publish the results here. I’ll show TPIC FTEs vs center level and type, trauma volume, and other fun tidbits that might help those have-nots out there get one of their own!

You can access the survey by clicking here

Thanks for participating!

Education

Are Graduating General Surgery Residents Qualified To Take Trauma Call?

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Trauma training during general surgery residency has changed dramatically over the past two decades. Although we like to blame the 80-hour work week rule on everything, there are other factors that may be at play. Increasing use of nonoperative management, availability and increasing scope of interventional radiologists, and the increasing number of surgical subspecialists are certainly significant.

The surgical group at LAC+USC looked at changes in operative caseloads, type of surgery performed, and the impact that concurrent subspecialty training has had on trauma operative volumes. The authors reviewed 16 years of ACGME data on resident surgical procedures in various body regions by year of training. They specifically looked at the impact of implementation of the 80-hour work week.

Here are the factoids:

  • There was a trend only (p=0.07) toward decreased operative trauma cases
  • The number of trauma laparotomies increased, vascular procedures decreased, and neck explorations and thoracotomies remained stable
  • Trauma vascular procedures decreased for surgical residents, but increased for vascular fellows
  • Individual resident operative volumes in chest, abdomen, solid organ, and extremities decreased after implementation of the 80-hour work week
  • Based on this, the authors recommend residents who are interested in a career in trauma and acute care surgery have fellowship training (??)

Bottom line: Well, it was a catchy title, at least. Or is it a promotion for trauma fellowships? The differences between pre-80 hour and post-80 hour in the table are not that impressive, and although a number of the operative case comparisons reach statistical significance, they represent a difference of only 1 case! Not clinically relevant! And other than the number of laparotomies going up, the other numbers looked fairly constant. 

The exposure to operative cases overall appeared to remain constant for most procedures with the exception of laparotomies increasing and vascular cases decreasing. In my opinion, one of the most apparent changes is in resident comfort with critical decision making. I don’t believe that this is due to any change in operative experience, but rather to closer oversight by attending surgeons and less opportunity to independently come to those decisions.

Reference: Is your graduating general surgery resident qualified to take trauma call? A 15-year appraisal of the changes in general surgery education for trauma. J Trauma 82(3):470-480.