All posts by TheTraumaPro

Managing Mild TBI Without A Neurosurgeon

TBI is a very common injury, and neurosurgeons are relatively rare resources for trauma centers. That mismatch can create significant problems for trauma programs. Reflexively, we consult neurosurgeons for a wide variety of neurotrauma, ranging from the very severe to the extremely mild.

sah

Can we intelligently and selectively utilize the skills of our neurosurgeons, and not jeopardize patient safety? Surgeons at Baystate Medical Center in Springfield MA reviewed their own experience managing mild TBI.

They defined a mild TBI as one with patient GCS of 13-15. However, their study included only patients with “GCS>14”, which I presume means all patients with GCS=15 (unless this is a typo). They allowed patients with normal GCS and intoxication, epidural (EDH) or subdural hematoma (SDH)<4mm, small subarachnoid hemorrhage (SAH), and non-displaced skull fracture (Fx). Any patient taking any type of anticoagulant or anti-platelet drug was excluded. They looked at need for neurosurgical consultation or intervention, readmission, and 30 day mortality.

This prospective study spanned 13 months. This lower volume center admitted 1341 patients, of which 77 were included in the study. Average age was 55, and average ISS was 16. A total of 97% presented for a followup visit (!).

Here are the factoids:

  • 47% had SAH, 43% SDH, 16% intraparenchymal hemorrhage (not mentioned in inclusion criteria), 14% Fx, and no EDH
  • Only one patient required neurosurgery consult, and none required intervention
  • There were no mortalities
  • Most (62%) were admitted to a ward bed, and the average length of stay for all patients was 3 days
  • Cost savings was estimated at about $16,000

Bottom line: Yes there is no magic in getting a neurosurgical consult for most mild TBI. The study is small, but telling. A carefully crafted practice guideline can dramatically decrease the (over)use of our neurosurgeons, saving both time and money.

In reviewing their guideline, I would recommend shaving even one more point off the GCS (>14), but stipulating that any central subarachnoid hemorrhage require consultation because of the possibility of an aneurysm being the culprit.

Check out the guideline in use at my hospital below. Also, look at the first related post, which is similar in idea to this one, but you can see the difference in management by surgeons vs neurosurgeons.

Related posts:

Reference: Mild traumatic brain injuries can be safely managed without neurosurgical consultation: the end of a neurosurgical “nonsult”? AAST 2016, Poster 51.

Early Mobilization In Solid Organ Injury

Most trauma centers have some kind of practice guideline for managing solid organ injury. Unfortunately, the specifics at each center are all over the map. Here are a few common questions:

  • Should you keep the patient NPO?
  • How often should Hgb/Hct be repeated?
  • Should they be at bed rest?
  • What are their activity restrictions after they go home?

spleen-lac

As for activity, some earlier studies have shown that early ambulation is safe. The group at Hahnemann University Hospital in Philadelphia tried to determine if early mobilization would decrease time in ICU and/or the hospital, or increase complications.

Until 2011, their trauma service kept all patients with solid organ injury at bed rest for 3 days(!). They modified this routine to allow ambulation the following morning for Grade 1 and 2 injuries, and after 24 hours for Grade 3 and above, or those with hemoperitoneum. They examined their experience for 4 years prior (PRE) and 4 years after (POST) this change. They excluded patients with penetrating injury, or other significant injuries that would impact the length of stay.

Here are the factoids:

  • 300 solid organ injury patients were identified in the PRE period, and all but 89 were excluded
  • 251 were identified in the POST period, and all but 99 were excluded
  • Hospital length of stay was significantly shorter (5.9 vs 3.7 days) after implementation of the new guideline
  • ICU length of stay also decreased significantly, from 4.6 to 1.8 days
  • The authors extrapolated a cost savings of about $40K for the ICU stay, and $10K for the ward stay, per patient
  • There was one treatment failure in each group

Bottom line: It’s about time we recognized what a waste of time these restrictions are! Unfortunately, the study groups became very small after exclusions, but apparently the statistics were still valid. But still, it continues to become clear that there is no magic in keeping someone starving in their bed for any period of time.

At my hospital, we adopted a practice guideline very similar to this one way back in 2004 (download it below). Hospital lengths of stay dropped to about 1.5 days for low grade injury, and to about 2.5 days for high grade.

And earlier this year, we eliminated the NPO and bed rest restrictions altogether! How many patients actually fail and end up going urgently to the OR? So why starve them all? And normal activity started immediately is no different than activity started a few hours or days later.

Don’t starve or hobble your patients, adults or children!

Related posts:

Reference: Early mobilization of patients with non-operative liver and spleen injuries is safe and cost effective. AAST 2016, Poster #5.

September Trauma MedEd Is Here! Topic: Field Amputation

Welcome to the current newsletter. This one tells you everything you always wanted to know about field amputation (and dismemberment). Here’s the scoop on what’s inside:

  • Indications
  • Who can perform it?
  • What about logistics
  • Equipment
  • Blow by blow about the procedure itself
  • Supplemental resources, include policies, equipment list, and bibliography

Just so you know, subscribers received this issue at the beginning of the month. If you want to subscribe and get it before everyone else, just click here.

Got a suggested theme for later issues? Just let me know what you’d like to read about by replying to this email!

To download the current issue, just click here! You can also enter this web URL directly into your browser: http://bit.ly/TME201609  (All caps! Case is important.)

Thanks for reading!

Predicting VTE Risk In Children

There’s a lot of debate about if and at what age injured children develop significant risk for venous thromboembolism (VTE). In the adult world, it’s a little more clear cut, and nearly every patient gets some type of prophylactic device or drug. Kids, we’re not so certain about at all.

The Children’s Hospital of Wisconsin tried to tease out these factors to develop and implement a practice guideline for pediatric VTE prophylaxis. They prospectively reviewed over 4000 pediatric patients admitted over a 6 year period.

It looks like the guideline was developed using some or all of this data, then tested using regression models to determine which factors were significant. The guideline was then tweaked and a final model implemented.

Here are the factoids:

  • 588 of the patients (14%) were admitted to the ICU, and 199 of these were identified as high risk by the guidelines
  • Median age was 10 (this is always important in these studies)
  • VTE occurred in 4% of the ICU patients, and 10% of the high risk ones
  • Significant risk factors included presence of central venous catheter, use of inotropes, immobilization, and GCS < 9

Bottom line: This abstract confuses me. How were the guidelines developed? What were they, exactly? And the results seem to pertain to the ICU patients only. What about the non-ICU kids? The abstract just can’t convey enough information to do the study justice. Hopefully, the oral presentation will explain all.

I prefer a very nice analysis done at the Oregon Health Science University in Portland. I wrote about this study earlier this year. The authors developed a very useful calculator that includes most of the risk factors in this model, and a few more. Input the specific risks, and out comes a nice score. The only issue is, what is the score threshold to begin prophylaxis and monitoring? Much more practical (and understandable) than this abstract. Check it out at the link below.

Related post:

References:

  1. Evaluation of guidelines for injured children at high risk for VTE: a prospective observational study. AAST 2016, Paper 68.
  2. A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients. JAMA Surg 151(1):50-57, 2016.

Confusion At The Trauma Professional’s Blog?

Many readers may have noticed that the blog site has looked different for the past week. The good news is that I’ve migrated all my content (and more) to a standalone website, TheTraumaPro.com.

But the bad news was that all of the search engines only know of the original site, regionstraumapro.com, the original blog hosted on Tumblr. So a lot of people ended up being directed to an old post (on the new site) and not knowing why or how they got there. Confusing! Furthermore, links to related posts on the Tumblr site took readers to the same old random post on the new site. Even more confusing!

In order to stem the confusion while the search engines catch up, I’ve decided to run both sites in parallel. All posts will be cross-posted to both sites simultaneously. The Twitter notification will link to the post on the new site, but it will still be on Tumblr as well.

Please check out all the extra content on the new site at:

TheTraumaPro.com

but just be aware that searches for content will probably direct you to Tumblr at:

regionstraumapro.com

Thanks for reading, whichever one you choose!

Michael