All posts by The Trauma Pro

Technique

The Evolution Of Penetrating Neck Trauma Management – Part 1

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“When the facts change, I change my mind. What do you do, sir?”

This is a famous quote from John Maynard Keynes. (Or is it? There is some debate over its authenticity, but you get the idea it tries to convey.) Our knowledge base continually changes, so we must be willing to change our minds (and practices) based on new, reliable information.

The management of penetrating neck injury is one of those facets in trauma care that has undergone slow but steady progress over the past 40 years of my career. In the old days, we quickly identified the zone of injury and proceeded to the operating room for Zone II injuries. We had to think a little harder about the other zones to be certain that we needed to be in the OR. But overall, the threshold for surgery was low.

Things have been changing. Five years ago, I published a post detailing new work by Inaba et al. at LAC+USC. This started a move toward using more straightforward criteria and advanced imaging to assist decision-making with these injuries.

In this post, I’ll summarize the original paper. In the next section, I will describe the group’s paper, which is currently in press and outlines the full framework for workup or penetrating neck injury.

The advance that makes this new method possible is based on the high degree of accuracy that CT angiography of the neck provides. It is very sensitive for identifying even minor injuries to the aerodigestive tract and vascular system.

The trauma group at LAC+USC organized a prospective, multicenter study using a multidetector CT angiography of the neck for initial screening of penetrating neck injury. This allows the evaluation of the neck as a single unit, not as three zones. It also solves the problem of trying to apply zones to injuries that cross several of them.

The new algorithm that was tested utilized an initial physical exam, first looking specifically for “hard signs” of injury.  The following were considered the hard signs:

  • Active hemorrhage
  • Expanding or pulsatile hematoma
  • Bruit or thrill over the injured area
  • Unresponsive shock
  • Hemoptysis or hematemesis
  • Air bubbling from the wound

These patients were immediately taken to the OR and explored through an appropriate incision.

Patients with no signs or symptoms were admitted and observed for at least 24 hours. All other patients were considered to have “soft signs.” They underwent multidetector CT angiography of the neck, with a scanner having at least 40 slices. Further evaluation of these patients was based on the exam and CT scan.

Here are the factoids:

  • 453 patients with penetrating neck injuries were identified during the 31-month study period
  • 9% had hard signs and were taken to the OR; 50% had soft signs and underwent CT; 41% had no signs and were observed
  • For soft sign patients, 86% of scans were negative, and all were true negatives after observation
  • 12% of soft sign patients had a positive scan, and of those, 81% were true positives
  • four patients (2%) with soft signs had too much artifact for an accurate CT, and other tests were performed; 1 of the 4 had an injury
  • Sensitivity of CTA was 100%, and specificity was 97.5% in the soft sign patients
  • The authors concluded that CTA is very reliable for identifying injuries in patients with soft signs and that patients with no signs do not require scanning, only observation

Bottom line: This was an intriguing paper that utilized both physical examination and CT angiography. The results were impressive, and they supported the argument that CTA is not required in all stable patients. With additional numbers and time, it has become clear that we can safely adopt this algorithm. My next post will flesh out the details.

Reference: Evaluation of multidetector computed tomography for
penetrating neck injury: A prospective multicenter study. J Trauma 72(3):576-584, 2012.

Abdomen, Technique, Video

Video: Minimally Invasive Repair Of Rectal Injuries

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Extraperitoneal rectal injury repair has evolved considerably over the past 40 years. Way back when, this injury automatically triggered exploration, diverting colostomy with washout of the distal colon, and presacral drain insertion (remember those?).

We eventually backed off on the presacral drains (pun intended), which didn’t make a lot of sense anyway. And we gave up on dissecting down deep into the pelvis to approach the injury. This only served to contaminate an otherwise pristine peritoneal cavity. Ditto for the distal rectal washout. So we have been performing a diverting colostomy as the primary method of treatment for years.

A Brief Report in the British Medical Journal Open shows us what may very well be the next stage in treating these injuries. Whereas they were previously left to heal on their own followed by colostomy closure after a few months, these authors from Sunnybrook Health Sciences Centre in Toronto are promoting a minimally invasive approach to definitive management.

They detail two cases, one an impalement by a steel rod through the rectum and bladder, and one stab to the buttock. The authors dealt with the non-rectal injuries using conventional techniques. The rectal injuries were repaired using trans-anal minimally invasive surgery (TAMIS). Both were discharged without complications.

Here is a video of the technique used in the stab victim (no audio):

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Bottom line: It’s about time! As long as there is not a destructive injury to the extraperitoneal rectum, this seems like a great technique to try. It may very well eliminate the need for a diverting colostomy.

But remember, this is only a case report. We don’t know about antibiotic duration, followup imaging, longer term complications, or anything really. A larger series of cases is warranted to provide these answers. This will take some time due to the low frequency of this injury. So if you try it, build your own series and publish it so we all can learn!

Reference: Minimally invasive approach to low-velocity penetrating extraperitoneal rectal trauma. Trauma Surg Acute Care Open. 2020 May 12;5(1):e000396. doi: 10.1136/tsaco-2019-000396. PMID: 32426526; PMCID: PMC7228675.

Device

Death Knell For The IVC Filter

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IVC filter insertion has been one of the available tools for preventing pulmonary embolism for decades—or so we thought. Its popularity has swung back and forth over the years and has been in the waning stage for quite some time now. This pendulum-like motion offers an opportunity to study effectiveness when coupled with some of the large datasets that are now available to us.

IVC filters have been used in two ways: prophylactically in patients at high risk for pulmonary embolism (PE) who cannot be anticoagulated for some reason and therapeutically once a patient has already suffered one. Over the years, guidelines have changed and have frequently been in conflict. Currently, the American College of Chest Physicians does not recommend IVC filters in trauma patients, and the Eastern Association for the Surgery of Trauma just released a new practice guideline for them.

A previous study from Boston University reviewed its own experience retrospectively over a 9-year period. This cohort study looked at patients with and without filters, matching them for age, sex, race, and injury severity. The authors specifically looked at mortality and used four study periods during the 9-year interval.

Here are the factoids:

  • Over 18,000 patients were admitted during the study period, resulting in 451 with an IVC filter inserted and 1343 matched controls
  • The patients were followed for an average of 4 years after hospitalization
  • Mortality was identical between patients with filters vs the matched controls

dvt-study

  • There was still no difference in mortality, even if the patients with the filter had DVT or PE present when it was inserted
  • Only 8% ever had their “removable” filter removed (!)

And now, there is a paper in press from the Eastern Association for the Surgery of Trauma with their newest practice guideline on IVC filters. They examined the literature on patients with or at risk for venous thromboembolism (VTE) and sought to determine whether IVC filters should be used prophylactically or therapeutically in these situations. They reviewed twenty-one studies, most of which were of the usual low quality.  They drew the following conclusions:

  • IVC filters should not be placed routinely for prophylaxis in patients without DVT who cannot receive chemoprophylaxis.
  • EAST conditionally recommends that IVC filters not be placed in patients with DVT who cannot receive prophylaxis. This recommendation was conditional due to the very poor quality of the few papers available to answer this question.

Bottom line: It looks like the end is near for the IVC filter. However, I can still foresee a few situations where there might be some utility. Consider the case where a patient has DVT, cannot be anticoagulated, and is showering emboli to the lungs. Otherwise, it appears that this device is on its last legs!

References:

  1. Association Between Inferior Vena Cava Filter Insertion
    in Trauma Patients and In-Hospital and Overall Mortality. JAMA Surg, online ahead of print, September 28, 2016.
  2. Role of Vena Cava Filter in the Prophylaxis and Treatment of Venous Thromboembolism in Injured Adult Patients: A  Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery, Publish Ahead of Print DOI: 10.1097/TA.0000000000004289, 2024.
Education

ChatGPT And Your Research Paper

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Generative artificial intelligence (AI) is the newest shiny toy. The best-known example, ChatGPT, burst onto the scene in November 2022 and caught most of us off guard. The earliest versions were interesting and showed great promise for a variety of applications.

The easiest way to think about this technology is to compare it to the auto-complete feature in your search engine. When you start to type a query, the search engine will show a list of commonly entered queries that begin the same way.

Generative AI does the same thing, just on a vastly expanded level. It looks at the question the user posed and displays its best guess on how to complete it based on the huge amount of data it has trained on. As the algorithms get better and the training data more extensive, the AI continues to improve.

However, there are drawbacks. Early iterations of ChatGPT demonstrated that the AI could very convincingly generate text that didn’t really match reality.  There are several very public cases of this. One online sports reporting service used AI extensively and found that nearly 50% of the articles it produced were not accurate. A lawyer submitted a legal brief prepared by AI without checking it. The judge determined that the cases cited in the brief were totally fabricated by the algorithms.

One of the most significant controversies facing academics and the research community is how to harness this valuable tool reliably. College students have been known to submit papers partially or fully prepared by AI. There is also a concern that it could be used to write parts or all of research papers for publication. Some enterprising startups have developed tools for spotting AI-generated text. And most journals have adopted language in their guidelines to force authors to disclose their use of this tool.

Here’s some sample language from the Elsevier Guide for Authors on their website:

“Where authors use generative artificial intelligence (AI) and AI-assisted technologies in the writing process, authors should only use these technologies to improve readability and language. Applying the technology should be done with human oversight and control, and authors should carefully review and edit the result, as AI can generate authoritative-sounding output that can be incorrect, incomplete, or biased. AI and AI-assisted technologies should not be listed as an author or co-author, or be cited as an author. Authorship implies responsibilities and tasks that can only be attributed to and performed by humans, as outlined in Elsevier’s AI policy for authors.

Authors should disclose in their manuscript the use of AI and AI-assisted technologies in the writing process by following the instructions below. A statement will appear in the published work. Please note that authors are ultimately responsible and accountable for the contents of the work.

Disclosure instructions
Authors must disclose the use of generative AI and AI-assisted technologies in the writing process by adding a statement at the end of their manuscript in the core manuscript file, before the References list. The statement should be placed in a new section entitled ‘Declaration of Generative AI and AI-assisted technologies in the writing process’.

Statement: During the preparation of this work the author(s) used [NAME TOOL / SERVICE] in order to [REASON]. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.”

But apparently, some researchers don’t heed the guidelines. Here is a snippet of text from a case report published in an Elsevier journal earlier this year. I’ve highlighted the suspicious text at the end of the discussion section. Click the image to make it readable in full size:

It appears the author tried to use AI to generate this text, but its disclaimer logic was triggered. This represents a failure on many levels:

  • The authors apparently used AI to generate one or more parts of their manuscript.
  • The authors did not thoroughly proofread the final copy before submission to the journal.
  • The authors did not disclose their use of AI as required.
  • The editors and reviewers for the journal did not appear to read it very closely either.
  • And it’s now in the wild for everyone to see.

The big question is, how reliable is the rest of the text? How much is actually just a bunch of stuff pulled together by generative AI, and how accurate is that?

Bottom line: First, use generative AI responsibly. Some excellent tools are available that allow researchers to gather a large quantity of background information and quickly analyze it. However, it ultimately needs to be fact-checked before being used in a paper.

Second, refrain from copying and pasting AI material into your paper. After fact-checking the material, write your own thoughts independent of the AI text.

Finally, if you do use AI, be sure to follow the editorial guidelines for your journal. Failure to do so may result in your being banned from future submissions!

Reference: Successful management of an Iatrogenic portal vein and hepatic artery injury in a 4-month-old female patient: A case report and literature review. Radiology Case Reports 19(2024):2106-2111.

Equipment

How To Design Your Trauma Bay

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In the last two posts, I discussed the size of your trauma bay and how to measure it. This can obviously be helpful if you are updating or building new resuscitation rooms. But what about all the stuff that goes into it? Where is the best place to put it? If you are in the enviable position of being able to stock a brand-new room, here are some tips.

Figure out what you really need in the trauma bay. You don’t have to put everything and the kitchen stove in there. It’s fine to have less commonly used equipment somewhere else, but it must be close! You don’t want someone to have to walk 50 yards to look for something you need right now.

Here’s a list of the critical stuff:

  • Temperature and light controls.  These must be inside the room for easy and rapid access. And the doors should close to contain the heat. Resus rooms that are used frequently should be kept warm, doors closed, at all times.
  • Personal protective equipment. This should be located just inside the room (if space is available) or just outside. It absolutely must be near the entrance and easily accessible or no one will wear it.
  • Airway cart and video laryngoscope. These items must always be located near the head of the bed for immediate availability.
  • Difficult airway cart. These are not used frequently, so need not be placed inside the room. But make sure it is close by.
  • Travel ventilator. This can be stored outside unless you have lots of space available.
  • IV start/blood draw carts. One of these should be stationed on either side of the patient.
  • Rapid infuser. This may be located inside or outside of your trauma room based on the number of times it is typically needed.
  • Procedure packs. These should be located inside the trauma bay, and clearly organized inside cabinets.
  • Medication dispenser. This must be inside the room. Period.
  • Other commonly used equipment/supplies.  These should be placed intuitively in the bay and/or cabinets depending on frequency of usage of each item. Clear marking is essential.
  • Scribe stand. Don’t forget the scribe. They obviously have to be in the room, and need some space for the (preferably) paper trauma flow sheet.
  • Pediatric cart. This can be stored inside or outside the resus room, but should be nearby. Make sure that the measuring card that translates child size into equipment size is easily located.
  • Blood refrigerator. This item is optional, but is becoming more common. It can be located inside or close outside the trauma bay depending on space available.
  • Blanket and sheet warmer. These are nice to have, wherever you have room to put one. The patients will appreciate it.
  • Procedure lights. Ceiling mounted are best because they don’t take up floor space. However, these are notorious for developing a mind of their own as they age. After a while, they never seem to stay focused on your field.
  • Forced air warming blanket unit. This is important here in Minnesota, but also anywhere your patients can get cold. Which is pretty much everywhere. The airflow unit itself is relatively small and can usually be tucked under a counter somewhere. Otherwise, keep it nearby.
  • Linens hamper. You need to get rid of that gown / those sheets and blankets / or whatever. There’s no reason to take up space in the room for this. Park it outside.
  • Laundry basket. This is a valuable item that is generally overlooked. What do you usually do with all that stuff you cut off the patient? Drop it on the floor, right? This is setting you up to lose your patient’s stuff. Get a cheap plastic laundry basket from Target and put it under one of the counters. Toss clothing, shoes, etc in it as they are removed.
  • Cast cart. These are typically huge. They can be anywhere else but inside the trauma bay. Roll it outside the door when needed.

Now where do you put all this stuff? Most trauma centers already have an established layout and flow in their existing trauma bays. When you are moving to a new one, plan ahead! Hopefully you will have more room, so you’ll have some additional flexibility as to where to place everything.

But designing the placement and flow on paper alone is of limited use. You must try it out in advance! How do you do this? Have your contractor mock up a space exactly the size of your new resuscitation room. Move actual carts, cabinets, and equipment into it. If it’s not possible to cart the exact stuff into it, have the contractor build mock-ups of them and place them in the bay.

Now have actual trauma team members practice simulations of common types of resuscitation: basic no frills, basic with intubation, basic with splinting/casting, advanced with all of the above plus multiple procedures. Take careful notes of flow and any glitches that arise. Then move your stuff around to fix any problems, and try again!