All posts by TheTraumaPro

Best of AAST #12: Embolization Of Splenic Pseudoaneurysm

The management of blunt spleen injury has evolved significant over the time I’ve been in practice. Initially, the usual formula was:

Spleen injury = splenectomy

This began to change in the late 1980’s, and beginning in the early 90’s nonoperative management became the rage. We spent the next 10-15 years tweaking the details, gradually reducing bed rest and NPO times, and increasing the success rate through smart patient selection and discovering new adjuncts.

One of these adjuncts was angiography with embolization. The ShockTrauma Center in Maryland was an early adopter and protocolized its use in patients with high-grade injuries.

But now, they are questioning the utility of this tool in certain patients: those with splenic pseudoaneurysms (PSA). They theorized that modern, high resolution CT identifies relatively unimportant pseudoaneurysms. They conducted a 5-year retrospective review of their experience.

Here are the factoids:

  • They identified 717 splenic injuries, of whom 155 were embolized but only 140 patients had adequate records and imaging for review
  • The majority of patients had high grade injury: 31% Grade 3, 61% Grade 4, 1% Grade 5
  • Extravasation was seen in 17% and PSA in 52%
  • About 44% of patients went to angiography within 6 hours, but the mean was 17 hours indicating quite a few outliers
  • Among the 73 patients with an initial PSA , a third of them did not have a detectable lesion during angiography
  • Patients who underwent embolization for PSA had a followup CT 48-72 hours afterwards, persistently perfused PSA were seen in 40% (!)
  • No patients with PSA who were only observed required delayed splenectomy

The authors conclude that a third of pseudoaneurysms may be clinically insignificant, and that 40% of them persist after embolization. They do not, however, offer any recommendations based on their data.

Here are my comments: This is an interesting study. My read of the abstract and slides would indicate that this group routinely sends all Grade 3 and 4 injuries to angio, and Grade 5 could go to either angio or OR. They take their good time going to interventional radiology (mean 17 hours from arrival), and get a routine followup CT 48-72 hours from hitting the door if they didn’t go to the OR.

If I were to play the devil’s advocate, I might think that interventional radiology was being de-emphasized for some reason. Was there some reluctance to send patients there, or limited availability? This might explain the long access times. And how are the radiologists not shutting down 40% of PSA that are seen?

I am intrigued by the study, but there are a lot more details needed to get some good takeaways from it.

Here are my questions for the presenter and authors:

  • Please explain why it takes so long to send patients to angiography. Less than half got there in less than 6 hours, and the mean of 17 hours means that many didn’t get there until the next day.
  • Does this small study have the statistical power to say that some PSA are benign? The groups are very small, and I would speculate that the group size needed to show significance is in the high hundreds.
  • What was the reason for splenectomy in the 2 patients who underwent embolization? Was it related to the pseudoaneurysm or something else?
  • How can you be sure that these PSA are insignificant? Frequently, pseudoaneurysms don’t explode for 7-10 days. Do you have any data on patients who returned to a hospital with delayed bleeding?
  • If you believe that many pseudoaneurysms are benign, how do you propose to manage the patients? Observe until they explode? Repeat a contrast CT scan, with the associated contrast and radiation re-dose? And how long would you wait to do this? What would your new protocol be?

I’ll be all ears on Friday when this abstract is presented live.

Best Of AAST #11: Hard Signs Of Vascular injury

The next abstract in this series poses a challenge to long-held dogma. More than three decades ago, examination of vascular injuries was divided into “hard signs” vs “soft signs.” Hard signs consisted of findings like pulsatile hemorrhage, expanding hematoma, absent distal pulses, thrill, or bruit. These were believed to be absolute indications to proceed directly to the operating room for exploration and repair.

But now, in this day and age of CT angiography  (CTA)and all manner of endovascular techniques and tools, things seem to be changing. There is more reliance on CTA, and a willingness to image patients with hard signs before considering an operation. But is this prudent?

The AAST established the Prospective Observational Vascular Injury Treatment (PROOVIT) database as a multi-institutional effort involving major trauma centers around the country in 2013. A group based at the Massachusetts General Hospital massaged the data to study current patterns in assessment and management of patients with penetrating extremity vascular injury. Specifically, they were interested in examining the presence of hard signs and the outcomes after initial imaging and operative management.

Here are the factoids:

  • A total of 1,910 database records were reviewed, of which 1108 (58%) presented with hard signs of injury
  • 83% of the patients with hard signs had either active hemorrhage or expanding hematoma; only 15% had ischemia
  • CTA was used in a quarter of patients with hard signs (24% hemorrhagic, 40% ischemic)
  •  Two thirds of patients with hard signs were taken to OR without imaging (70% hemorrhagic, 45% ischemic)
  • Open repair was performed in about two thirds of hemorrhagic and ischemic patients both with and without imaging, but endovascular  or hybrid repairs were 5x more likely (2% vs 10%) in patients who underwent imaging first
  • There were no differences in outcomes (amputation, mortality, blood transfusions, reoperation) between the open and endovascular/hybrid repair groups

The authors concluded that stable patients with hard signs of vascular injury may benefit from preop imaging to help plan the specific mode of repair to be performed (open vs endovascular / hybrid).

Here are my comments: This was a retrospective review of prospectively collected data. The database has a wealth of detail, and this is a simple and clean analysis of a specific question. The results and analyses were straightforward and easy to follow.

What this study does is to call into question the old dogma of rushing straight to the operating room with any patient who has hard signs of vascular injury. The advent of endovascular tools and techniques has allowed us to more easily address some vascular injuries that were previously problematic due to their location and accessibility.

Being a descriptive study only, it showed us “what we did” with vascular injuries during the time period of the database. And it also showed that the surgeons were more likely to use endovascular techniques if they were able to take the time for preop imaging. Most importantly, it demonstrated that gross outcomes like death, reoperation, and amputation were not increased by the delay needed to obtain that imaging.

I consider this to be a pilot project. And the authors correctly state that the next step is a true prospective study to confirm that this should be the new way of thinking about hard signs in the future.

Here are some questions for the presenter and authors.

  • Please provide more information on the database records used. Which years were included? What were the inclusion criteria? Were any patients excluded?
  • What was the definition of a vascular injury to the extremity? Did it include the very proximal brachial artery or the distal subclavian? These may increase the likelihood of choosing an endovascular repair.
  • Did you stratify by type of penetrating injury (stab vs gunshot) or velocity (assault rifles and shotguns)? These will increase the likelihood of proceeding directly to OR and potentially skew the data.
  • Some data from the abstract is missing, typically p values. This appears to be a glitch with the abstract entry system, since it is a problem in other abstracts as well.
  • How long do you think it will take to collect adequate data from a prospective study so that preop imaging in stable patients becomes the new standard of care?

This was a fun abstract to read! I’m looking forward to the presentation next week.

Best Of AAST #10: The Hybrid ER Room?

The next abstract is an interesting demonstration of the use of technology is trauma resuscitation. Pretty much all technology imaginable. It details the use of a “hybrid ER” room, which combines resuscitation space with all sorts of imaging and even interventional angiographic procedures. Here’s an image of the room when it was first written about in 2012.

A = CT scanner   B = CT exam table   C = movable C-arm   D = monitor screen   E = ultrasound   F = ventilator

This setup was installed at Osaka General Medical Center in Japan nearly 10 years ago. The authors have written occasional papers about it, and have now performed a study on its impact on trauma patient survival. They studied major trauma patients during two time periods. The first was pre-installation (2007-2011), and the second started immediately after installation (2011-2020). They specifically looked at 28-day mortality, and tried to tease out the relation to injury severity.

Here are the factoids:

  • About a thousand patients were studied, 348 in the pre (conventional) group and 702 in the post (hybrid) group
  • 28-day mortality was significantly lower in the hybrid group
  • Using a fancy statistical test (cubic spline analysis), they showed that 28-day mortality sharply decreased 200 days after installation of the hybrid ER
  • Mortality decreased disproportionately more in the hybrid ER as the injury severity score (ISS) increased

The authors concluded that the hybrid ER may have improved survival, especially in the more severely injured patients.

Here are my comments: Hmm. This is an association study that only looks at one variable, the new hybrid ER room. How many other variables may have a potential impact on survival? And how have those variables changed over the past 11 years? I worry that the study premise is too simplistic, but it certainly makes this unique resource look good.

Here are some questions for the presenter and authors:

  • How did you select your patients? You describe about 1,000 patients over 11 years, which is only about 100 per year. What about all the others?
  • What is it about the hybrid room that you think confers such a survival benefit to your patients? It seems to work for all patients, blunt or penetrating, badly hurt or not. What’s the magic?
  • Do you see the same effect for patients who were treated at other hospitals first and then transferred? The extra time that passed could decrease survival in severely injured patients.
  • Please explain cubic spline analysis clearly. I always worry when super-fancy statistical tests are needed to detect a difference. Why was it needed in this case?
  • Why did it take 200 days to see an effect from the installation of the hybrid ER? What happened at that point in time?
  • Please explain how the actual survival is so much better than predicted for ISS=75 patients. Your graph shows an actual survival of about 22%, as opposed to the 3% in your conventional ER. That is a massive improvement! How do you do it?

As you can see, I’m a bit uncertain about how this works and how the lessons can be applied to other centers. This is a unique resource, and the rest of the world needs to know a lot more about it before deciding to try it out themselves.

Best Of AAST #9: Blunt Carotid And Vertebral Injuries

Blunt carotid and vertebral artery injuries (BCVI) are an under-appreciated problem after blunt trauma. Several screening tools have been published over the years, but they tend to be unevenly applied at individual trauma centers. For an unfortunate few, the only indication of BCVI is a stroke while in hospital.

The overall incidence of BCVI is thought to be small, on the order of 1-2%. But how do we know? Well, the group at Birmingham retrospectively reviewed every CT angiogram (CTA) of they did in a recent two year period. They did this after adopting a policy of screening all their major blunt trauma patients. Each patient chart was also evaluated to see if they met any of the criteria for the three commonly used screening systems.

Here are the factoids:

  • 5,634 of 6,800 blunt trauma patients underwent BCVI screening with CTA of the neck
  • 471 patients (8.4%) were found to have BCVI
  • Here are the accuracy statistics for the three screening systems

Here are my comments: The authors found that the incidence of BCVI is about 8x what we previously thought. What we don’t know is the percentage of these patients that go on to cause stroke or other neurologic deficits. But this is somewhat frightening.

Even more frightening is that the screening systems that we rely on fare so poorly. The Denver and Modified Memphis criteria have a true positive rate that is the same as a coin toss. And even if the patient meets none of the criteria in any system, about 5% BCVI will sneak through (NPV 95%).

So the question becomes, do we all perform universal screening for blunt trauma? Or do we still use one of the three systems and keep our fingers crossed that the ones we miss will not progress? Or maybe just give everybody an aspirin a day for a while. And still keep our fingers crossed!

Here are some questions for the presenter and authors:

  • Why did you decide to implement a universal screening protocol in the first place? Bad experience(s)?
  • Do you have any screening recommendations other than to screen everybody? How do you decide which blunt trauma patients to screen? Every car crash? What level of fall? The devil is in the details!

This is an easy to follow paper with a solid analysis and real world implications. Excellent work!

Best Of AAST #8: Duplex Screening For DVT

To screen on not to screen, that is the question. If you do more testing, you will find more cases. But does it make a difference clinically? Sounds like some of the questions coming up in our current discussion of the Coronavirus. But that’s what we really need to know.

The group at Intermountain Medical Center in Salt Lake City performed a 2 ½ year randomized, prospective study of screening duplex ultrasound of the lower extremities vs no screening study. They used the Risk Assessment Profile (RAP) developed by Greenfield, first published in 2000. Any patient at moderate or higher risk for DVT (RAP score >5) was enrolled in the study. They were randomized into two groups: a screening group who received duplex scans on days 1, 3, 7, and then weekly, and a “no routine screening” group. All patients received chemoprophylaxis per the trauma service’s existing protocol.

The RAP score is a 17 factor scale that assigns a specific number of points based on underlying medical conditions, iatrogenic factors like central lines or transfusions, injury-related factors, and age.

Here are the factoids:

  • A total of 3,236 trauma patients were identified, and the 1,989 who were at moderate or higher risk for DVT were evenly randomized to screening vs no screening
  • There were no differences in age, sex, BMI, mechanism, ISS, or length of stay between the two groups
  • The incidence of DVT was 15% in the screened group vs 1.7% in the no screening group

The authors concluded that screening diagnoses more DVT, most of which is below the knee. And they also noted that screening identified DVT more often than clinical exam alone, but does not result in fewer PE or deaths. They suggest that more work needs to be done to identify exactly who benefits from duplex screening the most.

Here are my comments:

Finally, an easy to follow and well-designed study! But I think some of the results may be missing from the abstract. That section cuts off in the middle of some of the statistics, and there is no mention of the clot location or PE/mortality rates mentioned in the conclusion.

I also worry that a thousand patients in each group may not be enough. We are working with low incidence end points like PE and death, and this is an association study with many potential confounders/factors that may not have been recorded. I generally like to see the ability to detect a minimum of a 2x effect. So if the incidence of PE is 1.5%, I like to see the ability to detect a difference if the other group is 3%.

And speaking of study size. The RAP score was first described in 1997 and was a pilot study. They drew their conclusions from only 53 patients, and the only risk factor that they could show that was a statistically significant predictor of DVT was age. They concluded that surveillance of patients with RAP > 5 was warranted. This abstract builds upon this work, but is trying to say that maybe we don’t need to do duplex scans.

Here are my questions for the presenter and authors:

  • Is there some text missing from the end of the results section of the abstract? It seems to end unexpectedly, and some things are mentioned in the conclusions that are not in the results.
  • Why did you choose the RAP score? There are other risk assessment tools available out there. What is so special about RAP?
  • Is your sample size large enough to detect differences in incidence of PE or death? My back of the envelope calculations suggest at least 1,500 patients would be needed in each group.
  • How long did you follow patients to determine if they had PE or death? Until they were discharged? Later than that?  This makes a big difference in the eventual incidence of these outcomes.
  • Based on what you found, is there any value to treating asymptomatic proximal DVT? It sounds like you are saying that screening is not needed at all because PE and death are the same. Isn’t there value in treating proximal DVT if you find it?

This abstract certainly got me thinking! I am looking forward to the presentation and discussion of this abstract!

Reference: Head in the sand? The value of routine duplex ultrasound screening for venous thromboembolism in the trauma patient: a randomized Vanguard trial. AAST 2020, Oral Abstract #16.