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Philosophy

When Is It Too Late To Call A Trauma Activation?

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This is a related, follow-on post from yesterday, where I discussed activating your trauma team after transfer from another hospital. What about patients presenting directly to your hospital, but some time after their injury?

Admit it. It’s happened to you. You get paged to a trauma activation, hustle on down to the ED, and get dressed. The patient is calmly and comfortably lying on a cart, staring at you like you’re from Mars. Then you hear the story. He has a grade V spleen injury. But he just got back from CT scan. And his car crash was yesterday!

Is this appropriate? The answer is no! But, as you will see, the answer is not always as obvious as this example. The top thing to keep in mind in triggering a trauma activation appropriately is the reason behind having them in the first place.

The entire purpose of a trauma activation is speed. The assumption must be that your patient is dying and you have to (quickly) prove that they are not. It’s the null hypothesis of trauma.

Trauma teams are designed with certain common features:

  • A group of people with a common purpose
  • The ability to speed through the exam and bedside procedures via division of labor
  • Rapid access to diagnostic studies, like CT scan
  • Availability of blood products, if needed
  • Immediate access to an OR, if needed
  • Recognition in key departments throughout the hospital that a patient may need resources quickly

Every trauma center has trauma activation triage criteria that try to predict which patients will need this kind of speed. Does the patient in the example above need this? NO! He’s already been selected out to do well. Why, he’s practically finished the nonoperative solid organ management protocol on his own at home.

Here are some general rules:

  • If the patient meets any of your physiologic and/or anatomic criteria, they are or can be sick. Trigger immediately, regardless of how much time has passed.
  • If they meet only mechanism criteria and it’s been more than 6 hours since the event, they probably do not need the fast track.
  • If they only meet the “clinician / EMS judgment” criteria, think about what the suspected injuries are based on a quick history and brief exam. Once again, if more than 6 hours have passed and there are no physiologic disturbances, the time for needing a trauma activation is probably past.

If you do decide not to trigger an activation in one of these cases, please let your trauma administrative team (trauma medical director, trauma program manager) know as soon as possible. This may appear to be undertriage as they analyze the admission, and it’s important for them to know the reasoning behind your choice so they can accurately document under- and over-triage.

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Philosophy

Do I Have To Call My Trauma Team For Incoming Transfers?

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I had a great question sent in by a reader last week:

Some trauma centers receive a number of transfers  from referring hospitals. Much of the time, a portion of the workup has already been done by that hospital. If the patient meets one or more of your trauma activation criteria, do you still need to activate your team when they arrive?

And the answer is: sometimes. But probably not that often.

Think about it. The reason you should be activating your team is that you suspect the patient may have an injury that demands rapid diagnosis and treatment. The purpose of any trauma activation is speed. Rapid evaluation. Fast lab results. Quick access to CT scan or OR. If a significant amount of time has already passed (transported to an outside hospital, worked up for an hour or two, then transported to you), then it is less likely that a trauma activation will benefit the patient.

There are four classes of trauma activation criteria. I’ll touch on each one and the need to activate in a delayed fashion if present, in priority order.

  • Physiologic. If there is a significant disturbance in vital signs while in transit to you (hypotension, tachycardia, respiratory problems, coma), then you must activate. Something else is going on that needs to be corrected as soon as the patient arrives. And remember the two mandatory ACS criteria that fall into this category: respiratory compromise/need for an emergent airway, and patients receiving blood to maintain vital signs. But a patient who needed an airway who is already intubated and no longer compromised does not need to be a trauma activation.
  • Anatomic. Most simple anatomic criteria (e.g. long bone or pelvic fractures) do not need a trauma activation unless the patient is beginning to show signs of physiologic compromise. However, anatomic criteria that require rapid treatment or access to the OR (proximal amputations, mangled or pulseless extremities, spinal cord injury) should be activated.
  • Mechanism. Most of the vague mechanistic criteria (falls, pedestrian struck, vehicle intrusion) do not require trauma activation after transfer to you. But once again, if the mechanism suggests a need for further rapid diagnosis or treatment (penetrating injury to abdomen), then activate.
  • Comorbidities. This includes underlying diseases, extremes of age, and pregnancy. In general, these will not require trauma activation after they arrive.

Bottom line: In many cases, the patient transferred in from another hospital will not need to be a trauma activation, especially if they have been reasonably assessed there. The patient should be rapidly eyeballed by your emergency physicians, and if there is any doubt about their condition, activate then.

However, if little workup was done at the outside hospital (my preference), and the injuries are “fresh” (less than a few hours old), then definitely call your team. 

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Prehospital

Can Prehospital Providers Accurately Estimate Blood Loss?

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EMS providers are the trauma professional’s eyes and ears when providing transportation from the scene of an accident. We rely on their assessment of the mechanism of injury and the amount of blood lost. We tend to believe in the accuracy of those assessments.

A study was carried out that tested EMS personnel on their ability to accurately estimate specific amounts of blood that were left at a simulated accident scene. The blood volumes tested were 500cc, 1000cc, 1500cc and 2100cc. A total of 92 professionals participated, and there was an even split into basic EMTs (34%), intermediate/critical care EMTs (33%) and paramedics (31%). Experience levels were as follows: 0-5 years 43%, 6-10 years 30%, >10 years 31%.

The results were as follows:

  • 87% underestimated the quantity of blood
  • 9% overestimated
  • 4% guessed the exact amount
  • Experience or credentialing level did not matter

Only 8% of the subjects were within 20% of the actual volume, and an additional 19% were within 50%. In general, most medics underestimated the amount of blood lost, and their guesses were worse with higher volumes. The median guess for the 2100cc loss group was only 700cc!

EMS Blood Loss Estimates

Bottom line: Visual estimates of blood loss are extremely inaccurate, and are most likely  underestimates. Physicians in the ED should rely on exam and physiology to help determine the amount of blood loss. For safe measure, multiply the reported blood loss of the EMT or paramedic by 2 or 3 to get a realistic number.

Reference: Patton et al. Accuracy of Estimation of External Blood Loss by EMS Personnel. J Trauma 50(5), 914, 2001.

What the heck?

What The Heck? CT Imaging Problem: The Answer

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I received some good guesses about this image yesterday, but no one got the right answer.

The patient had sustained blunt trauma and was undergoing CT imaging. The scout for the abdominal CT showed some kind of weird debris that interfered with the image, but when we uncovered and looked at the patient, nothing was visible:

What the heck? If you look carefully at the left side of the image, you can see that the “debris field” is on the surface of the patient. We can’t see in 3-D on images, but the difference in appearance on the left and right sides looks like it this stuff is wrapping around the patient.

She was brought in by EMS with a warming blanket in place. On closer inspection, this was a thin, disposable blanket that heats up when removed from an airtight plastic pouch. These blankets contain thin pockets of a mineral mixture that looks like gravel. When exposed to air it heats up.

But on CT it looks like bone density material! When we looked at the patient, we were just lifting off the blanket that contained the offending material. Hence, we couldn’t find it.

Here’s a picture of one of these products. Note the six mineral pouches embedded in it., Don’t let this happen to you!