All posts by TheTraumaPro

Are “Routine” Vital Signs Really So Routine?

Trauma professionals, particularly physicians, tend to take vital signs for granted on patients who are admitted to the hospital. And we tend to assume that our patients won’t ask questions, either. Unfortunately, they usually don’t.

“Routine” vital signs tend to get measured by the nurses once a shift. But think about that for a minute. In the US, the typical shifts run from 7 am to 3 pm, 3 pm to 11 pm, and 11 pm to 7 am. This means that at some point in the night, they will be disturbed to take their blood pressure and pulse. At least! And what if they need to have a neuro exam, pulse checks, or to have that beeping pulse oximeter hooked up?

And even though the shift runs from 11 pm to 7 am, does that mean the vitals will be take at the beginning or end of shift? No way! The nurse has to receive report for a safe handoff and get organized at the start of the shift. And how many patients does he or she have? They may not be able to check vitals on everybody until after midnight. And what if vitals are ordered to be taken more than once a shift? How can any patient get decent sleep? 

Bottom line: Once again, think carefully about the orders! It’s no wonder some of our elderly patients sundown when they are admitted to the hospital. How can anyone get a good night’s sleep there? 

Don’t just reflexively write for a frequency. Think about how often your patient really needs to be disturbed, especially at night. If they are recovering uneventfully from an orthopedic procedure, why bother them at all at night? And nurses, make it your responsibility to advocate for your patient and bring up these crazy orders so they can be fixed.

A Simple Tool To Predict The Need To Operate On A Subdural Hematoma

Trauma centers in the US are seeing lots of elderly patients, and falls are a major mechanism in the patient group. A significant number sustain a traumatic brain injury. Extra-axial bleeding is fairly common, but because of the increased space available inside the skull, the patient may not become overtly symptomatic. 

So what objective criteria can be used to determine if evacuation of a subdural hematoma (SDH)is needed? A study from the University of Manchester in the UK sought to figure this out. They speculated that the size of the lesion and the amount of displacement it caused might be objective enough. So they set out to see if any specific numbers would provide a reliable method.

Here are the factoids:

  • Two neurosurgeons reviewed four years of head CT scans and determined if they should be treated surgically or nonsurgically.
  • Measurements of the maximum thickness of the lesion, its volume, and the degree of midline shift were taken.
  • Reasonable attempts were made to ensure inter-rater reliability.
  • The total pool of scans studied was 483. 44% were judged to need surgical management.
  • Maximum SDH thickness of 10mm or more, or a midline shift of 1mm or more were found to accurately predict 100% of surgical lesions.
  • The best predictor of the need for surgery was midline shift.
  • Adding hematoma thickness did not significantly improve the ROC curve.

Bottom line: This study is somewhat limited because it is the experience of only one hospital, and the number of clinicians involved in decision making is small. It does echo other similar studies, but in my opinion it omits the use of the mental status exam.

Using a lesion thickness of 10mm or shift of 1mm does not necessarily mean the patient needs surgery if there mental status is completely normal. But these criteria can certainly identify a subset of patients who are at risk, and should be monitored very carefully for any deterioration. A change in GCS by even a single point should then send them straight to OR.

Related posts:

Reference: A simple tool to identify elderly patients with a surgically important acute subdural haematoma. Injury 46(1):76-79, 2015.

What Is: A Morel-Lavallee Lesion?

Anyone who takes care of blunt trauma has seen the Morel-Lavallee lesion (M-L). Here’s an obvious one because it’s acute:

The M-L lesion is essentially a closed degloving injury in which the skin remains intact. The subcutaneous tissue is sheared off of the underlying fascia, and typically blood accumulates in the potential space that is created. This picture shows a less acute lesion; the bruising and ecchymosis on the surface have resolved. Note the collection on the lateral thigh:

These injuries may take a very long time to resolve and may leave some residual deformity. The definitive management has never been very clear: needle drainage vs incision, timing, compression wraps, etc.

The Mayo Clinic reviewed their 8 year experience with 87 of these lesions to try to shed some light on proper management. They treated their patients in four different ways: needle drainage, incision and drainage, compression wraps, and debridement with vacuum drainage devices. Here are the factoids from their study:

  • Motor vehicle crash was the most common etiology for this lesion, which makes sense due to the energy needed to shear the tissues
  • The most common locations were thigh, hip and flank
  • The incidence of pre-existing conditions that might influence outcome (diabetes, obesity, smoking history, use of anticoagulants) did not seem to influence outcomes
  • Lesion location did not change the recurrence rate (even over joints)
  • Aspiration suffered the highest recurrence rate (56%) vs only 15-19% in the other groups
  • Aspiration of more than 50cc of fluid was more common in lesions that recurred (83%) vs those that did not (33%)

Their experience led them to develop the following practice guideline:

Bottom line: The Morel-Lavallee lesion can be challenging to treat. Although this study has limited numbers, it provides enough guidance to suggest a consistent way of managing it. I recommend adopting this algorithm to provide a standard pathway for dealing with it.

Reference: The Mayo Clinic experience with Morel-Lavallee lesions: establishment of a practice management guideline. J Trauma 76(2):493-497, 2014.

Do We Need All Those Trauma Centers In The US?

There are a lot of trauma centers in the US. Unfortunately, they are not very evenly distributed. An example of this disparity can be found in Washington state. Harborview Medical Center is the only Level I trauma center serving all of Washington, Alaska, Montana, and Idaho. Yet in other metropolitan areas, there can be multiple Level I’s, II’s, and III’s. And in some other areas, new centers seem to be popping up right and left.

Unfortunately, there is such a thing as too many trauma centers. Opening a new center is a zero sum game, however. No more trauma patients will miraculously appear. They will only get redistributed from other centers, decreasing the number of their trauma admissions. Until the next one opens and begins to take patients away from the last new one, as well. Frequently, the “need” for the new center is strictly an economic one for its parent organization, not an actual population need.

The American College of Surgeons Committee on Trauma (ACSCOT) released a position statement on this phenomenon early this year. They promote the following guidelines:

  • Designation responsibility falls to the governmental agency that oversees the regional trauma system. This body needs leadership and statutory authority to enforce reasonable guidelines on how many centers may exist.
  • Trauma professionals must advocate for their patients in educating the lead agency about what the needs really are. The interests of the patients must supersede the interests of the providers and their health care organizations.
  • The designation process should be guided by a concrete regional trauma plan.
  • Needs should be assessed using concrete measures like the number of centers per 100,000 people, population location with respect to these centers, EMS transport times, trauma mortality, and frequency of diversion status.
  • Trauma center allocation should be reassessed on a regular basis.
  • Regional variability must be taken into account.

Bottom line: A super-abundance of trauma centers already exists in several cities around the US (and you know who you are). Unfortunately, the cat is out of the bag, and few if any designating agencies have stepped up to the plate to deal with this. The sad truth is that little will happen until hastily and poorly resourced centers start to close unexpectedly, straining established trauma centers and jeopardizing patient safety. When this crisis finally hits, our state and regional trauma systems will finally seek and wield the authority to designate more intelligently.

Reference: Statement on trauma center designation based upon system need. ACSCOT January 2015.

Are We Wasting Valuable Helicopter EMS Resources?

The use of helicopters for transporting injured patients dates back to World War II. Thirty years later, this concept was translated into civilian practice. Today, there are hundreds of helicopter EMS (HEMS) services across the US, and thousands world-wide. Unfortunately, the indications for using this service are not strictly defined, and it is very expensive compared to ground EMS transport. In the US alone, there are over 400,000 HEMS transports per year. This creates the opportunity for use in patients who are not seriously injured, as well as the potential for wasted resources.

The University of Arizona at Tucson examined 6 years of transport data to their center, by both ground and air. They were interested to see if they could identify a group of HEMS-transported patients that could have safely and more reasonably been transported by ground ambulance. They defined this group of “minimally injured” as having an injury severity score (ISS) of 5 or less.

Here are the factoids:

  • A total of 5,202 patients were transported, 19% by air and 77% by ground
  • Overall, the hospital length of stay was significantly longer for HEMS patients (3 vs 2 days), as was ICU length of stay (2 vs 1 days) [Hmm..]
  • ISS was significantly higher in the HEMS group as well (9 vs 5) [Hmmmmm…]
  • There was [of course] no difference in mortality between the two groups
  • By their definition, 28% of HEMS patients were minimally injured, compared to 39% of ground transfers
  • The average charge for a HEMS transport was $18,000

Bottom line: This is another paper that just doesn’t deliver on what it’s title suggests. But this one is an underestimation of the result, not an overestimation, for once. From personal experience, I see lots of examples of patients who don’t need air transport but get it anyway. But if you dive more deeply into the data in this paper, you can see why it’s just not good enough. Sure, they’ve got a lot of patients. But if you look at the clinical reality of the numbers, none of the patients were really that sick. The maximum ISS in the HEMS group was 17! The GCS for every patient in the study was 14 or 15. The maximum hospital LOS was 7 days. And the clinical significance of a 3 day vs a 2 day hospital stay is negligible.

These were just not very sick patients. It looks to me like none of their patients needed HEMS transport, other than for extreme distance issues. The authors needed to set a better definition of minimally injured patients, and if they had, they would have found that most of their HEMS transfers could have been shifted to ground ambulance.

This paper really points out (more than the authors anticipated) the potential resources being wasted. There are already some suggested rules for optimal use of HEMS. But unfortunately, we tend to ignore them! It’s time to start a concerted effort to more wisely use this valuable and expensive resource.

Related posts:

Reference: Overuse of helicopter transport in the minimally injured: a health care system problem that should be corrected. J Trauma 78(3): 510-515, 2015.