All posts by TheTraumaPro

Best Of EAST #12: The Lasting Effect Of Trauma

Trauma professionals are keenly aware of the impact of traumatic injury on their patients. And they are particularly aware of the impact during their own phase of care. Prehospital providers know everything about the situation on scene and in their rig. Inpatient providers are experts in the trauma team activation process and other facets of inpatient care. Physiatrists excel at helping their patients overcome the immediate effects of injury.

But what happens later, three or six or more months down the road? A huge amount of data is collected during the acute care processes and maintained in local or national registries. But once the patient leaves the hospital, there is much less information available about long-term progress and outcomes.

The trauma group at the University of Pennsylvania examined longer-term physical, emotional, and social outcome information on their own patients over a two year period. They administered a set of test instruments and screens, including substance use, employment, living situation, PTSD, and PROMIS-29, a comprehensive evaluation of pain and seven health domains. This battery was given on admission, and then six months after discharge.

Here are the factoids:

  • A total of 618 patients underwent the initial screen, and 129 (21%) completed the six-month followup
  • Demographics of the pre- and post-followup groups were nearly identical
  • The incidence of penetrating trauma was high, about 25%
  • Half of patients had been previously hospitalized for an injury
  • There were statistically significant decreases in the ability to participate in social roles and activities, and a significant increase in anxiety and depression
  • PTSD was common, occurring in 28% of patients
  • Patients reporting only occasional employment or unemployment increased from 45% to 68%

The authors concluded that effects of injury extend beyond the initial pain and disability, impacting several areas for at least six months post-injury. They suggest that there is a need for screening and intervention protocols for post-injury patients.

Bottom line: This is an intriguing paper that focuses attention beyond the areas where most clinicians are aware. It points out the longer lasting impact from trauma, which may have a significant effect on the rest of the patient’s life. Any issues relating to mental or emotional health, or employment and livelihood may have a far ranging impact on that person’s life.

The sample size is small, and the attrition between initial interview and six month followup resulted in an even smaller analysis group. However, the similar demographics imply that the sample is reasonably valid. The screening tools were selected appropriately, and the statistical analyses seem to be appropriate.

This abstract points out the need to look beyond discharge to really find out how our patients are doing. We will probably not like what we see, and it should prompt us to develop more robust screening to figure out who is in trouble. Ultimately, this should move us to incorporate screening and appropriate interventions into the bigger trauma care picture, just as the authors suggest.

Here are my questions for the authors and presenter:

  • Are you confident that your data is representative of your patients given the steep attrition between admission and six month followup?
  • Can your results be generalized to other non-urban trauma patients? The number of patients suffering penetrating trauma or previously hospitalized for injury is very high. Might this group of patients suffer a disproportionately higher likelihood of disturbances at six months?
  • Although your screening test changes are statistically significant, are they clinically relevant? I have seen many numerically different results in other studies that have only questionable clinical significance (e.g. a decrease in ICU length length of stay of 0.4 days).
  • Has your work prompted you to design and implement the type of screening and interventions you are presenting?

This is important work, and will serve to increase awareness of the non-anatomic issues we absolutely must address in order to get our patients back to being healthy again.

Reference: BEYOND PAIN AND DISABILITY: THE LASTING EFFECTS OF TRAUMA ON LIFE AFTER INJURY. EAST 35th ASA, oral abstract #7.

Best Of EAST #11: Rib Fracture Fixation vs Epidural Analgesia

Rib fracture fixation has really taken off over the past five years for management of select rib fracture patterns. There are probably two mechanisms by which it improves pain control and speeds recovery.

The first is purely mechanical. In patients with flail chest, there is impairment of chest wall mechanics that decreases ventilatory efficiency and often leads to prolonged intubation and pulmonary complications. The other is the control of pain associated with multiple or displaced rib fractures.

The trauma group at the Brown University Alpert Medical School performed a TQIP database analysis that attempted to tease out the pain component in this equation. They compared outcomes from patients who underwent rib fixation or epidural analgesia within 72 hours of admission. They looked at a single year of TQIP data for adults with rib fractures, and excluded those who had TBI or died within 24 hours. Specific outcomes were pulmonary complications, lengths of stay, and mortality.

Here are the factoids:

  • There were just over 1,000 patients in each of the rib fixation and epidural analgesia groups
  • A much larger percentage of patients undergoing fixation had a diagnosis of flail chest (43% vs 13%) and a higher ISS (17 vs 14)
  • Early rib fixation was associated with an added 1.5 day length of stay, but this was not statistically significant
  • Early fixation was significantly associated with a higher risk of unplanned intubation
  • There were no differences in respiratory failure, VAP or mortality between the groups

The authors concluded that rib fracture fixation was associated with longer hospital length of stay but less risk of unplanned intubation. They suggest that patients should receive early referral to centers where both interventions are available so appropriate candidates can undergo fixation.

Bottom line: I’m struggling a bit here. When I read the title I thought I might learn something more about my therapeutic choices for patients with more complicated rib fractures. But this was not even a “how we did it” paper, but a “how hundreds of other centers did it” study. For a subject like this, a database study like this injects quite a bit of selection bias that just can’t be removed. 

For example, look at the huge (3x) difference in flail chest between the groups. Clearly, patients with a flail have a higher ISS and hospital length of stay, and are much more likely to selected for fixation. Thus, that diagnosis alone will skew the data more than the choice of procedure. I would suggest that simple descriptive and regression analyses is not adequate to answer your questions. Some type of propensity matching for ISS or at least AIS chest is probably required.

The only statistically significant result in the abstract was the decreased risk in unplanned intubation. Again, it’s difficult to say whether this is related to the larger percentage of patients who had flails who had their risk decreased by the procedure.

Here are my questions for the authors and presenter:

  1. Did you exclude all patients with TBI? Why not keep those with mild TBI (GCS 14-15), since they should behave similar to those without head injury?
  2. Why did you restrict your dataset to patients who underwent either procedure within the first 72 hours? This seems like an arbitrary time frame. Do you have a sense of the distribution of time interval until either procedure? As a thought experiment, let’s say that the mean (or median) time to either of the procedures was 5 days. You would be sampling the small, early tail of patients who had an intervention before day 3. In that case, your study might not be representative of of real life.
  3. Did you analyze the chest diagnoses and/or AIS  chest? Controlling or propensity score matching for this may have yielded additional information.
  4. You concluded that patients should be referred to centers where the best care can be provided. Isn’t this what we do already?

This is an interesting paper, and I’m hoping that you have more data to present than would fit in the abstract!

Reference: COMPARISON OF SURGICAL STABILIZATION OF RIB FRACTURES VS EPIDURAL ANALGESIA ON EARLY CLINICAL OUTCOMES. EAST 35th ASA, oral abstract #29.

Best Of EAST #10: (F)utility Of ICP Monitoring In Geriatric Patients?

Patients with severe TBI are typically managed using staged protocols based on the Brain Trauma Foundation (BTF) guidelines for ICP monitoring. There have been a number of papers over the past six years that question the utility of ICP monitoring, at least using the procedures in the BTF guidelines.  Most of these studies do not specifically break out elderly patients.

The group at the Westchester Medical Center in NY used the TQIP database to review the impact of ICP monitoring for severe TBI in patients > 65 years old. They performed a four year database study on these patients with an isolated head injury (no other body regions with AIS > 2), initial GCS < 8, and a length of stay > 24 hours. The examined the presence or absence of an ICP monitor, AIS head score, GCS, and a number of outcome measures.

Here are the factoids:

  • A total of 4,433 patients met the above criteria, and 17% had an ICP monitor placed
  • After propensity matching for those with and without an ICP monitor, mortality was nearly identical in both groups at 49%
  • ICU length of stay, hospital length of stay, and ventilator days were significantly longer in the monitor group

The authors concluded that ICP monitoring in this elderly group of patients did not improve survival and increased length of time in the ICU, hospital, and on the ventilator. The recommend that the current guidelines be improved to recognize these facts.

Bottom line: This is a nice, simple study that sought to answer just a few nice, simple questions. The mortality results are convincingly equal between the groups with and without an ICP monitor. The lengths of stay and ventilator days are statistically significantly longer with p values < 0.001. However, the actual numbers are not provided. I have seen many studies where statistically different numbers are not clinically relevant.

There are a number of papers that have come to similar conclusion on other or broader groups of TBI patients. Although we have specific guidelines on who gets a monitor and what we do with the numbers, there is growing doubt that their use actually helps. Perhaps it is time for us to review the data and make appropriate revisions!

Here are my questions for the authors and presenter:

  • Tell us about your propensity score matching. This will help us understand how similar the patient groups really were, with the exception of their ICP monitors.
  • Please provide the actual numbers for your lengths of stay and ventilator days. We need to be sure these are clinically and/or financially significant.
  • Have the results of this work prompted you to rework your own practice guidelines for treatment of severe TBI? I’m always interested if the group feels strongly enough about their work that they would consider changing their practice based on it.

Reference: ROLE OF ICP MONITORING IN GERIATRIC TRAUMA PATIENTS. EAST 35th ASA, oral abstract #33.

 

Best Of EAST #9: Routine Repeat Head CT For TBI Patients On Antithrombotic Agents

The data we use as guidance for repeat head CT in elderly patients who sustain mild TBI while taking antithrombotic therapy remains limited. There is a slowly growing consensus that the need is limited, but there is still a very wide variation in practice patterns.

The group at HCA Healthcare Nashville collected data from 24 system hospitals on this very specific cohort of patients: elderly (age > 55), head trauma with GCS 14-15, an initial head CT, and no other injuries with AIS > 2. They divided these patients into two groups based on whether they were currently taking antithrombotic (AT) therapy. Rate of delayed intracranial hemorrhage (ICH), need for neurosurgical intervention, and mortality were compared.

Here are the factoids:

  • About 3,000 patients were enrolled and only 10% had a repeat head CT
  • Of those who were rescanned, 10% of patients on meds had a new ICH vs 6% in those not taking meds (not statistically significant)
  • Extrapolating those numbers to all patients, the rate of delayed ICH would be 0.7% in patients not taking AT vs 1.0% for those who were (also not significant)
  • Mortality attributable to a head bleed occurred in only one patient who was made comfort care
  • There were no neurosurgical procedures performed in either group

The authors concluded that this specific subset of patients has a very low rate of delayed ICH, and that there are minimal clinical consequences in those that do. They do not support repeat head CT.

Bottom line: This abstract adds to the growing body of literature that shows little benefit to repeat head CT scan after a negative initial study, even if the patient is on blood thinners. Many previous studies involve only a single center and/or have smaller numbers. This one is larger because of the size of the HCA trauma system, and answers a simple set of questions on a limited subgroup of patients: elderly, mild TBI, with limited other injuries.

My back of the envelope power calculations show the authors may be a little short of the number of subjects to be able to show that the difference in the number of delayed ICH (0.7% vs 1.0%) is statistically significant. But the numbers are close enough and the p value so large (0.3) that they are probably right. This is completely offset by the absence of necessary neurosurgical interventions and the single attributable death.

Many trauma centers, including my own, have adopted a “no repeat scan” policy after a negative initial scan, even on thinners. In fact, unless the patient has some other injury that requires admission, they are discharged home with a responsible adult.

Here are my questions for the authors and presenter:

  • Did you do any type of power analysis to determine if the large number of patients included was actually large enough?
  • The term “antithrombotic therapy” is used broadly; which agents were considered in this category? Traditional warfarin therapy? Aspirin and other antiplatelet agents? DOACS?
  • Have you changed your system guidelines to reflect your work?

This is important and practical work! I’m looking forward to hearing all the details.

Reference: ROUTINE REPEAT BRAIN CT SCANNING IS UNNECESSARY IN OLDER PATIENTS WITH GCS 14-15 AND A NORMAL INITIAL BRAIN CT SCAN REGARDLESS OF PREINJURY ANTITHROMBOTIC USE: A MULTICENTER STUDY OF 3033 PATIENTS. EAST 35th ASA, oral abstract #31.

Best Of EAST #8: Timing Of Reimaging For BCVI

There are still many questions regarding optimal management of blunt carotid and vertebral arterial injury (BCVI). We know that they may ultimately result in a stroke. And we kind of know how to manage them to try to avoid this. We also know that the grade may change over time, and many vascular surgeons recommend re-imaging at some point.

But when? There are still many questions. A multi-center trial has been collecting observational data on this issue since 2018. The group reviewed three years of data to examine imaging characteristics and stroke rate during the study period.

Here are the factoids:

  • A total of 739 cases were identified at 16 trauma centers
  • The median number of imaging studies was 2, with a range of 1-9 (!). Two thirds received only one study.
  • Injury grade distribution was as follows:
    • Grade 1 – 42%
    • Grade 2 – 30%
    • Grade 3 – 10%
    • Grade 4 – 18%
    • Grade 5 – <1%
  • About 30% changed in grade during the hospitalization, with 7% increasing and 24% decreasing.
  • Average time to change in grade was 7 days
  • Nearly 75% of those that decreased actually resolved. All of the grade 1 lesions resolved.
  • Stroke tended to occur after about one day after admission, although the grade 1 lesions took longer at 4 days
  • Strokes occurred much earlier than grade change

The authors concluded that there should be further investigation about the utility of serial imaging for stroke prevention.

Bottom line: This is basically a “how we did it” study to tease out data on imaging and stroke after BCVI. It’s clear that there is no consensus across trauma centers regarding if and when repeat imaging is done. And it’s not really possible to make any recommendations about repeat imaging based on this study.

However, it does uncover one important fact. It takes a week for the injury grade on CT to change, but strokes occur much earlier and usually within 24 hours! This is important because it makes it clear that it’s crucial to actually make the diagnosis early. Average stroke occurrence was 9% overall. Grade 1 injuries had only a 3% rate, but grades 2-4 were in the 12-15% range. Grade 5 had a 50% stroke rate!

These facts reinforce the importance of identifying as many of these BCVI as possible during the initial evaluation. The abstract I reviewed yesterday confirmed that the existing screening criteria (Memphis, Denver) will miss too many. More liberal imaging is probably indicated. If you missed the post, click here to view it in a new window.

Here are my comments for the authors and presenter:

  • The “change in BCVI grade over time” charts in the abstract are not readable. Please provide clear images during your presentation and explain what they mean. I was confused!
  • Based on your data, do you have any recommendations regarding the utility of re-imaging? Is it necessary in the same hospitalization at all? These patients will receive treatment anyway, and it doesn’t appear to have any impact on stroke rate.
  • Do you have any recommendations regarding the (f)utility of existing screening systems given the early occurrences of stroke in the study? Are you a fan of using energy / mechanism rather than a bullet list of criteria?

This is important work and I can’t wait to look at the data up close.

Reference: BLUNT CEREBROVASCULAR INJURIES: TIMING OF CHANGES TO INJURY GRADE AND STROKE FORMATION ON SERIAL IMAGING FROM AN EAST MULTI-INSTITUTIONAL TRIAL. EAST 35th ASA, oral abstract #34.