All posts by TheTraumaPro

Blunt Traumatic Arrest In Kids: Are They Little Adults?

Over and over, we hear that children are not just little adults. They are a different size, a different shape. Their “normal” vital signs are weird. Drug doses are different; some drugs don’t work, some work all too well.

But in many ways, they recover more quickly and more completely after injury. What about after what is probably the biggest insult of all, cardiac arrest after blunt trauma? The NAEMSP and the ACS Committee on Trauma previously released a statement regarding blunt traumatic arrest (BTA):

 “Resuscitation efforts may be withheld in any blunt trauma patient who, based on out-of-hospital personnel’s thorough primary patient assessment, is found apneic, pulseless, and without organized ECG activity upon arrival of EMS at the scene.“

The groups specifically point out that the guidelines do not apply to the pediatric population due to the scarcity of data for this age group.

The Children’s Hospital of Los Angeles and USC conducted a study of the National Trauma Data Bank, trying to see if children had a better outcome after this catastrophic event. Patients were considered as children if they were up to and including age 18.

Here are the factoids:

  • Of 116,000 pediatric patients with blunt trauma, 7,766 had no signs of life (SOL) in the field (0.25%)
  • The typical male:female distribution for trauma was found (70:30)
  • 75% of those without SOL in the field never regained them. Only 1.5% of these survived to discharge from the hospital.
  • 25% regained SOL with resuscitation, and 14% of them were discharged alive.
  • 499 patients underwent ED thoracotomy, and only 1% survived to discharge. There was no correlation of thoracotomy with survival.
  • It appeared that there was a tendency toward survival for the very young (age 0-4) without SOL, but statistical analysis did not bear this out

Bottom line: Children are just like little adults when it comes to blunt cardiac arrest after trauma. Although it is a retrospective, registry-based study, this is about as big as we are likely to see. And don’t get suckered into saying “but 1.5% with no vital signs ever were discharged!” This study was not able to look at the quality of life of survivors, but there is usually significant and severe disability present in the few adult survivors after this event.

Feel free to try to re-establish signs of life in kids with BTA. This usually means lots of fluid and/or blood. If they don’t respond, then it’s game over. And, like adults, don’t even think about an emergency thoracotomy; it’s dangerous to you and doesn’t work!

Reference: Survival of pediatric blunt trauma patients presenting with no signs of life in the field. J Trauma 77(3):422-426, 2014.

REBOA For Pelvic Fractures

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is one of the newer shiny toys that trauma professionals have adopted over the past 8 years or so. It is used to buy time for a patient who is near arrest in order to temporarily stop bleeding and get them to the operating room.

And as with all new toys, everyone wants one! I have always advised caution. Adopt a data-based approach to toy usage. Unfortunately information has been accumulating ever so slowly on this one. To help remedy this, the AAST created a registry in 2013 to consolidate the low REBOA experience numbers accruing across the US.

A group of seven surgeons representing higher-volume REBOA centers collaborated to review the AAST AORTA registry, which prospectively collects data on patients who undergo aortic occlusion. They retrospectively reviewed over six years of data on adult patients receiving REBOA for pelvic injury. They examined demographic, procedural, and outcome data in patients who underwent this procedure, both with and without other interventions like preperitoneal packing, angioembolization, or external fixation. For inclusion in the study, patients needed to have sustained blunt trauma and survived beyond the emergency department.

Here are the factoids:

  • Of the 207 patients with pelvic (Zone 3) REBOA in the registry, only 160 met inclusion criteria
  • Patients who only had REBOA suffered a mortality rate of 40% (5% in OR and 35% in the ICU)
  • Patients who had REBOA plus one of the other interventions had a 31% mortality rate (6% in OR and 25% in ICU)
  • Patients who had REBOA plus two other interventions also had a 31% mortality rate (12% in OR and 30% in the ICU)
  • Adding external fixation with or without another adjunct appeared to decrease mortality by half (from 50% to about 25%)
  • Complications were very common in all subsets, ranging from 35% to 86%
  • Patients receiving more interventions typically were more severely injured
  • No combination of REBOA and adjuncts was superior, but addition of an external fixator did appear to improve survival
  • Patients receiving angiographic embolization had a higher incidence of AKI, sometimes resulting in the need for dialysis
  • There were no significant outcome differences with REBOA use alone or with additional adjuncts

Bottom line: This was a primarily a descriptive study of how REBOA is integrated into pelvic fracture care at select US trauma centers. It was not really designed to compare the efficacy of REBOA vs preperitoneal packing vs angioembolization vs external fixation of the pelvis.

But it does show that survival remains dismal in these patients and the complication rates of REBOA + adjunct use are considerable. The authors correctly conclude that REBOA is being used in the treatment of pelvic fractures, frequently with the addition of other adjuncts. They state that the benefit of more interventions must be balanced against the potential for complications. And finally, they note that there is a need to fill in the evidence base if we are ever to adopt REBOA as a standard of care for select pelvic fractures.

What does this mean to all of you who are thinking of playing with this toy? Proceed with caution! The learning curve is steep. The complication rate is high. The opportunity for mayhem is great. This means that you must proceed deliberately. Get some advanced training with this technique. Use your performance improvement program to impartially critique its use with every deployment. And submit your experience to the national registry so we can all learn from your experience and figure out how to optimize use of this tool.

Reference: Patterns and outcomes of zone 3 REBOA use in the management of severe pelvic fractures: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database. J Trauma 90(4):659-665, 2021.

 

Preperitoneal Packing vs Angioembolization For Pelvic Fracture

In my last post, I laid out the various options available for initial management of major pelvic fracture bleeding. Today, I’ll compare two of the newer tools: embolization (AE) and preperitoneal packing (PPP). In the next post, I’ll look at the data available for REBOA.

Interestingly, the use of AE and PPP vary geographically. Angioembolization has been a mainstay in the US for some time, and PPP has been more commonly used in Europe. The use of both is becoming more widespread, and each has its pros and cons.

Angioembolization requires the presence of a special interventional radiology team and a reasonably stable patient. The procedure can take some time, and the IR suite is not really the place to house an unstable patient. Preperitoneal packing requires a reasonably stable pelvis to hold the packs in place for optimal tamponade, which may require application of an external fixator at the time of the procedure.

But is one better than the other? A number of relatively small studies have been performed, which means that it is time to synthesize them and see if some clearer answers can be found. The trauma group in Newcastle, Australia did just this. They performed a systematic search of the literature, analyzing the impact of each procedure on in-hospital mortality.

Here are the factoids:

  • A total of 18 studies met the authors’ inclusion criteria: 6 studies on AE, 9 studies of PPP, and 3 that compared them to each other
  • ISS was significantly higher in the PPP group vs AE (41 vs 36)
  • Average time to OR in the PPP patients was 60 minutes vs 131 minutes to IR in the AE group (statistically significant)
  • A quarter (27%) of the PPP patients did not get adequate hemorrhage control and required AE
  • In-hospital mortality in the PPP papers was 23% vs 32% in the AE research
  • Mortality in the papers that compared AE directly to PPP wasno different

Bottom line: What does this all mean? Is packing “better” than embolization? The simple answer is that we don’t know yet. Due to the way this study was performed, it is not possible to tease out all of the possible confounders. 

We are taught that control of hemorrhage is paramount. The time to definitive management in the AE group was twice that of the PPP patients. This could have a major impact on mortality. Two hours of bleeding can certainly kill. And the lower mortality in the PPP group occurred even though their injury severity was higher.

Many trauma centers have both of these interventions available to choose from. How should we approach their use? Unfortunately the literature is still to scarce to come to strong conclusions. Until we have better research to learn from, I suggest the following:

  • Time is of the essence. Which procedure can you get the fastest? In many cases, this will be preperitoneal packing since it’s just a trip to your trauma OR, which should be ready and waiting. If you have an IR team standing by or available very quickly, you could consider them first.
  • Pay attention to hemodynamic stability. An IR suite is no place for an unstable patient. The resuscitation equipment is not on par with the OR, and one never knows exactly how long the procedure will last.
  • If you have a hybrid room, use it! This is the ideal situation. The surgeon can start the PPP while the orthopedic surgeon applies a fixator. And the radiologist can be preparing to finish it off with a quick squirt as soon as they move away from the groin.
  • The use of one does not rule out the other. If one fails and the patient has increasing fluid and blood requirements move immediately to the other procedure to try to get control.

Reference: Preperitoneal packing versus Angioembolization for the initial management of hemodynamically unstable pelvic fracture – A Systematic Review and Meta-Analysis. J Trauma, publish ahead of print, Jan 4 2022, doi: 10.1097/TA.0000000000003528.

 

Options For Hemorrhage Control From Pelvic Fracture

We’ve come a long way in our available treatments to slow or stop bleeding from pelvic fractures. Let’s work our way through the list in today’s post, then look critically at two of the newcomers in the next one.

Pelvic binders. Long ago, these were just sheets wrapped around the patient and secured with clamps.

They were rather crude, as you can see. So of course, several enterprising companies began to offer commercial binders that were easier to place and secure.

Of note in the photo above, the wrap on the left is totally wrong. It is too wide and extends too high, so will not provide effective compression. The image on the right shows proper placement low across the greater trochanters. It is also not secured using metal clamps which may interfere with x-ray imaging.

External fixation of the pelvis. This usually involved a call to your friendly orthopedic surgeon. It could be applied in either the trauma bay or the operating room.

This image also shows improper technique. The horizontal bar should be angulated downwards over the pubis so it will not interfere with the trauma surgeon’s approach to laparotomy.

Internal pelvic packing + internal iliac artery ligation. Since surgeons didn’t have many other good tools, they could actually operate! Unfortunately, neither of these worked terribly well. The laparotomy pads could decompress upwards out of the pelvis and the internal iliac arteries have lots of collateral branches that permit ongoing bleeding from pelvic bones.

Angioembolization. Arterial bleeding from the pelvis occurs more often than you think (upwards of 50% of major pelvic injuries). Angiography and embolization can work very well. Unfortunately they are not suitable for unstable patients since IR suites are poor resuscitation areas. Many trauma centers do not have hybrid operating rooms where hemodynamically compromised patients can be taken for combined IR and open procedures if needed. So unstable patients must go to a regular OR first to attempt stabilization.

Preperitoneal packing. This is the new OR procedure kid on the block. Instead of placing packs in the pelvis, they are placed next to the broken pelvic bones but just outside the peritoneum. This permits better tamponade, and the intraperitoneal viscera push out against the packs to help decrease bleeding.

Zone 3 REBOA. And this is the very newest kid on the block. The balloon tipped catheter is inserted to a level above the aortic bifurcation but below the visceral and renal vessels. This is essentially a non-selective, temporary ligation of not just the internal iliac arteries, but everything distal to the aorta. It can be performed in the ED to dramatically slow blood loss, providing more time to get the patient to the OR where more definitive hemorrhage control can be provided (using many of the above techniques).

In my next post, I’ll take a closer look at the effectiveness of preperitoneal packing vs angioembolization.

Best Practice: Use of CT Scan In Trauma Activations – Part 2

In my last post, I described how the unscheduled and random use of CT scan in trauma activations can interfere with normal radiology department workflow, creating access problems for other emergency and elective patients. Today, I’ll detail a project implemented at my hospital to analyze the magnitude of this problem and try to resolve it.

We started with a detailed analysis of how the scanner was being used for trauma activation patients. Regions Hospital has a single-tier trauma activation system, with no mechanism of injury criteria other than penetrating injury to the head, neck, and torso. There were usually about 850highest-level activations per year at the time, and traditionally the CT scanner had been “locked down” when the activation is announced. The CT techs would complete the current study on the table, then hold the scanner open until called or released by the trauma team.

Since we are a predominantly blunt trauma institution, we scan most stable patients. Our average time in the trauma bay is a bit less than 20 minutes. Add this time to the trauma activation prenotification time of up to 10 minutes, and the scanner has the potential to sit idle for up to half an hour. And in some cases when scan is not needed (minor injuries, rapid transport to OR) the techs were not notified and were not aware they could continue scanning their scheduled cases.

A multidisciplinary group was created and started with direct observation of the trauma activation process and a review of chart documentation and radiology logs. On average it was calculated that the scanner was held idle for an average of 17.9 minutes too long. This is more than enough time to complete one, or even two studies!

A new process was implemented that required the trauma team leader to call out to the ED clerk placing orders for the resuscitation 5 minutes before the patient would be ready for scan. I still remember the first time this happened to me. I was so used to just packing up and heading to scan, I got a little irritated when told that I hadn’t made the 5-minute call. But it’s a good feedback loop, and I never forgot again!

We studied our workflow and results over a 9-week period. And here are the factoids:

  • The average CT idle time for trauma activations before the project was 17.9 minutes
  • This decreased to an average idle time of 6.4 minutes during the pilot project
  • Total idle time for all activations was 8.3 hours, but would have been 36 hours under the old system
  • A total of 28.6 hours were freed up, which allowed an additional 114 patients to be scanned while waiting for the trauma activation patients

This was deemed a success, and the 5-minute rule is now part of the routine flow of our trauma activations. We rarely ever have to wait for CT, and if we do it’s usually due to the team leader not thinking ahead.

Bottom line: This illustrates the processes that should be used when a quality problem surfaces in your program:

  • Recognize that there is a problem
  • Convene a small group of experts to consider the nuances
  • Generate objective data that describes the problem in detail
  • Put on your thinking caps to come up with creative solutions
  • Test the solutions until you find one that shows the desired improvement
  • Be prepared to modify your new systems over time to ensure they continue to meet your needs