All posts by The Trauma Pro

General

Can Lead Poisoning Occur After A Gunshot?

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This is a fairly common question from victims of gunshots and their families. As you know, bullets are routinely left in place unless they are superficial. It may cause more damage to try to extract one, especially if it has come to rest in a deep location. But is there danger in leaving the bullet alone?

One of the classic papers on this topic was published in 1982 by Erwin Thal at Parkland Hospital in Dallas. The paper recounted a series of 16 patients who had developed signs and symptoms of lead poisoning (plumbism) after a gunshot or shotgun injury. The common thread in these cases was that the injury involved a joint or bursa near a joint. In some cases the missile passed through the joint/bursa but came to rest nearby, and a synovial pseudocyst formed which included the piece of lead. The joint fluid bathing the projectile caused lead to leach into the circulation.

The patients in the Parkland paper developed symptoms anywhere from 3 days to 40 years after injury. As is the case with plumbism, symptoms were variable and nonspecific. Patients presented with abdominal pain, anemia, cognitive problems, renal dysfunction and seizures to name a few.

Bottom line: Any patient with a bullet or lead shot that is located in or near a joint or bursa should have the missile(s) promptly and surgically removed. Any lead that has come to rest within the GI tract (particularly the stomach) must be removed as well. If a patient presents with odd symptoms and has a history of a retained bullet, obtain a toxicology consult and begin a workup for lead poisoning. If levels are elevated, the missile must be extracted. Chelation therapy should be started preop because manipulation of the site may further increase lead levels. The missile and any stained tissues or pseudocyst must be removed in their entirety.

Reference: Lead poisoning from retained bullets. Ann Surg 195(3):305-313, 1982.

Performance Improvement

DOA vs DIE: What Does It Mean?

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When a trauma patient is delivered to the emergency department but ends up in the morgue, two acronyms are typically thrown around. The first is DOA, which many people (think they) know about. This stands for “dead on arrival.” The other is DIE, which many are less familiar with. It stands for “died in ED,” and is less familiar to some.

What do they really mean, and why is the difference important?  It can be quite confusing. All US trauma centers report data to the National Trauma Data Bank (NTDB). This database actually recognizes three types of ED death:

  • DOA. This is defined as declared dead on arrival with no or minimal resuscitative attempts. This is usually construed to mean no invasive procedures.
  • Died after failed resuscitation. This is a death within 15 minutes of arrival and does include invasive procedures.
  • DIE. These deaths occur in the ED but outside the 15 minutes in the previous category. Obviously, invasive procedures will have been performed.

The ACS Trauma Quality Improvement Program (TQIP) lumps the last two together when constructing reports for subscribing trauma centers. The objective is to exclude truly nonsalvageable patients from analysis to allow us to learn from patients who actually may have some chance of survival. Incorrectly classifying a DOA patient as DIE can significantly and adversely impact the mortality numbers for a center within TQIP.

Unfortunately, DOA is frequently misunderstood by those collecting data for their hospital’s trauma registry. What is an invasive procedure? Inserting an IV? Mechanical CPR? Intubation? REBOA?

The confusion typically occurs because the trauma team has a certain sequence of life-saving maneuver that they carry out based on ATLS principles. They must do this at the same time patient salvageability is being assessed. What denotes that transition from DOA to DIE?

Unfortunately, there is no literature that really dissects this. Here are my thoughts:

  • Mechanical CPR. This is commonplace to offload some of the work prehospital providers are doing during transport of the critical patient. DOA
  • IV insertion. This is a routine procedure and is something that could have been done in the prehospital setting. DOA
  • IO insertion. Same as IV insertion. DOA
  • Fluid administration. Again, this is a continuation of prehospital care. DOA
  • IV drug administration. This one is tricky. If one cycle of ACLS drugs are given while quickly assessing signs of life, DOA. Otherwise, DIE.
  • Intubation. This is pretty invasive, right? But again, EMS may have done this in the field. So if it is done while assessing signs of life and then the patient is quickly pronounced, DOA. Otherwise, DIE
  • Pelvic splint. Wrapping the pelvis should be routine in initial management of blunt traumatic arrest. DOA
  • Central line insertion. This is invasive and takes a little time. DIE
  • REBOA. Really? DIE

Bottom line: This is a difficult concept, and I’m sure some will disagree with my opinions above. I look at whether the cares provided are a continuation of prehospital support, are minimally invasive, AND ensure that they are only routinely applied while a rapid search for signs of life is in progress. Anything above and beyond this should be considered DIE.

Please share your opinions via comments here or by Twitter!

Hospital

Adding A Hospitalist To The Trauma Service

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Hospitals are increasingly relying on a hospitalist model to deliver care to inpatients on medical services. These medical generalists are usually trained in general internal medicine, family medicine, or pediatrics and provide general hospital-based care. Specialists, both medical and surgical, may be consulted when needed.

In most higher level trauma centers in the US (I and II), major trauma patients are admitted to a surgical service (Trauma), and other nonsurgical specialists are consulted based on the needs of the patients and the competencies of the surgeons managing the patients. As our population ages, more and more elderly patients are admitted for traumatic injury, with more and more complex medical comorbidities.

Is there a benefit to adding medical expertise to the trauma service? A few studies have now looked at this, and I will review them over the next few days. The Level I trauma center at Christiana Care in Wilmington, Delaware embedded a trauma hospitalist (THOSP) in the trauma service. They participated in the care of trauma patients with coronary artery disease, CHF, arrhythmias, chronic diseases of the lung or kidneys, stroke, diabetes, or those taking anticoagulants.

The THOSP was consulted on appropriate patients upon admission, or during admission if one of the conditions was discovered later. They attended morning and afternoon sign-outs, and weekly multidisciplinary rounds. A total of 566 patients with hospitalist involvement were matched to controls, and ultimately 469 patients were studied.

Here are the factoids:

  • Addition of the THOSP resulted in a 1 day increase in hospital length of stay
  • Trauma readmissions decreased significantly from 2.4% to 0.6%
  • The number of upgrades to ICU status doubled, but ICU LOS remained the same
  • Mortality decreased significantly from 2.9% to 0.4%
  • The incidence of renal failure decreased significantly
  • Non-significant decreases in cardiovascular events, DVT/PE and sepsis were also noted
  • There was no difference in the number of medical specialty consults placed (cardiology, endocrinology, neurology, nephrology)

Bottom line: This paper shows some positive impact, along with some puzzling mixed results. The decrease in mortality and many complications is very positive. Was the increase in ICU transfers due to a different care philosophy in medical vs surgical personnel? And the failure to decrease the number of specialty consults was very disappointing to me. I would expect that having additional medical expertise on the team should make a difference there.

Was the THOSP really “embedded” if they were not involved in the regular daily rounds? In this case, they were present only for handoffs and for weekly multidisciplinary rounds. I believe that having them on the rounding team daily would be of huge benefit, allowing the surgeons and hospitalists to learn from each other. Plus, there should be a benefit to the residents in a Level I center, helping them broaden their ability to care for these complicated patients.

Reference: Embedding a trauma hospitalist in the trauma service reduces mortality and 30-day trauma-related readmissions. J Trauma 81(1):178-183, 2016.

Extremity

Giving Vitamin D After Fracture

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The role of Vitamin D in fracture healing is well known. So, of course, trauma professionals have tried to promote Vitamin D

supplementation to counteract the effects of osteoporosis. A meta-analysis of of 12 papers on the topic relating to hip and other non-vertebral fractures showed that there was roughly a 25% risk reduction for any non-vertebral fractures in patients taking 700-800 U of Vitamin D supplements daily.

Sounds good. So what about taking Vitamin D after a fracture occurs? Seems like it should promote healing, right? A very recent meta-analysis that is awaiting publication looked at this very question.

Unfortunately, there was a tremendous variability in the interventions, outcomes, and measures of variance. All the authors could do was summarize individual papers, and a true meta-analysis could not be performed.

Here are the factoids:

  •  81 papers made the cut for final review
  • A whopping 70% of the population with fractures had low Vitamin D levels
  • Vitamin D supplementation in hospital and after discharge did increase serum levels
  • Only one study, a meeting abstract which has still not seen the light of day in a journal, suggested a trend toward less malunions following a single loading dose of Vitamin D

Bottom line: Vitamin D is a great idea for people who are known to have, or are at risk for, osteoporosis and fractures. It definitely toughens up the bones and lowers the risk of fracture. However, the utility of giving it after a fall has not been shown. Of the 81 papers reviewed, none showed a significant impact on fracture healing. The only good thing is that Vitamin D supplements are cheap. Giving them may make us think that we are helping our patient heal, but it’s not. 

References:  

  • What is the role of vitamin D supplementation in acute fracture patients? A systematic review and meta-analysis of the prevalence of hypovitaminosis D and supplementation efficacy. J Orthopaedic Trauma epub Sep 22 2015.
  • Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA 293(18):2257-2264, 2005.
Solid organ

APSA Activity Restrictions After Solid Organ Injury: Aren’t We Done With That Yet?

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Nearly 20 years ago, the American Pediatric Surgical Association (APSA) published a clinical guideline for management of solid organ injury in children. Part of the guideline included activity restrictions, specifically for a period of time after injury. This was generalized by many clinicians to include a period of in-hospital bed rest.

A paper has just been published that examines the usefulness of restricting activity in pediatric patients with solid organ injury. It was authored by a consortium of 10 Level I pediatric trauma centers, and included all patients through age 18 who did not have a concomitant significant renal injury and no pancreatic injury. All injuries were diagnosed by CT scan over a 33 month period.

Activity restrictions were given to all patients upon discharge, which limited sports, wheeled recreational activities, and anything else requiring two feet off the ground. A phone survey was conducted 60 days post-discharge to judge compliance. Unplanned return to ED, readmission, and complications were also assessed.

Here are the factoids:

  • A total of 1007 patients were studied, and 99 were excluded due to concomitant pancreatic or high grade renal injury. An additional 79 were excluded due to missing injury grade or operative management.
  • Of the remaining patients, only 366 were available for 60-day followup
  • 279 claimed to adhere to activity restrictions; 13% returned to the ED and 6% were readmitted.
  • 49 admitted that they did not pay attention to the restrictions, and only 4 (8%) returned to the ED. None were hospitalized.
  • Even in the high-grade injury patients, there was no difference between compliant or noncompliant groups
  • No patient in either group bled post-discharge

Bottom line: Due to the nature of this study (specifically the phone survey component), there will be degradation of the data. Some patients do not want to admit that they didn’t follow the doctor’s orders. In theory, this could increase the number of complications / returns to ED in the “compliant” group. But it did not. 

The other issue I have with this study is that it was not stratified by age. The spleen of an 18 year old is very different than that of a 6 year old. Sixty years ago, we used to take spleens out in adults with a diagnosed injury. The reason we moved toward nonoperative management in adults was the very favorable experience we had in children. Unfortunately, nowhere in this paper is age broken out. Typically, the number of older children (who are really adults) with the injury far outnumber the younger ones, which also tends to increase the number of complications seen. But once again, we did not. Small numbers? Possibly. 

So what are we to make of all this? Basically, it tells us that we’ve been trying to restrict activity in our patients with liver and spleen injury for no good reason. And this applies especially to the children. Look at your own clinical experience, and try to recount how many “failures” you’ve seen due to failure to follow activity restrictions. More typically, failures are due to undiagnosed or untreated pseudoaneurysms. 

It’s time to rethink your solid organ management protocol, if you haven’t already. Do you really need a period of NPO status? Or bedrest? Or activity restriction? And have you ever tried to restrict activity in a 6-year old? Have a look at the guideline we’ve used at my hospital for nearly 20 years! We got rid of the NPO and bedrest restrictions a while ago. Now it’s time to start reducing the activity restrictions!

References:

  • Evidence-Based Guidelines for Resource Utilization in Children With
    Isolated Spleen or Liver Injury. J Ped Surg 35(2):164-169, 2000.
  • Adherence to APSA activity restriction guidelines and 60-day clinical outcomes for pediatric blunt liver and splenic injuries (BLSI). J Ped Surg in Press, 2018.