All posts by TheTraumaPro

Pedestrian Struck!

The pedestrian struck by a car presents challenges to trauma professionals for a number of reasons. Due to the size mismatch between the two, serious injuries are fairly common. And unfortunately, many injuries are occult, so it’s easy to dismiss patients who may be hiding serious problems.

The National Highway and Traffic Safety Administration (NHTSA) recently published its Traffic Safety Facts report for 2011. This 232 page tome contains a wealth of interesting and thought-provoking data. One of the more interesting tidbits that caught my eye had to do with pedestrians struck by cars.

Most normal people do not get hit by cars. There is nearly always some additional factor that allows this to occur:

  • Don’t understand cars – this is a typical reason for small children, and I’ve also seen foreign visitors from countries with little auto traffic fall victim to this one. The developmentally disabled also fall into this category.
  • Not paying attention – this category is growing rapidly due to smart phone use
  • Can’t clear the intersection in time – this one gets the elderly. Due to physical constraints, they can’t move fast enough (4 ft/sec for most intersections) to get across in time
  • Intoxicated – this basically puts an adult back into the first category above. These incidents tend to be clustered around bars, and the numbers peak at night, typically from midnight to 3am.

The NHTSA report has always detailed the age breakdown of pedestrians struck, but now they are reporting the number of “impaired walkers” as well.

  • Overall, death by motor vehicle (occupants and pedestrians) involved alcohol 31% of the time (!!)
  • 4,432 pedestrians were killed and about 69,000 were injured
  • About one third of pedestrians killed tested positive for alcohol, and most were legally intoxicated!
  • 14% of the nonintoxicated pedestrians were struck by an intoxicated driver vs 19% of intoxicated pedestrians

Bottom line: There are many reasons for getting hit by a car, and being intoxicated is an entirely avoidable one. These patients can be seriously injured, so don’t just shrug off complaints as being due to intoxication. Additional prevention efforts should be developed using the interesting patterns outlined in the NHTSA report.

Reference: NHTSA Traffic Safety Facts 2011

Hare Traction – Putting It On, Taking It Off

Femoral traction devices have been around for a long time. One reader has asked about the timing of removal of these devices after they arrive at the hospital. I learned a number of things while reviewing the literature to answer this question.

Most importantly, there is really only one indication for applying a traction splint to the femur: an isolated, relatively mid-shaft femur fracture. Unfortunately, there are lots of contraindications. They consist of other injuries or fractures that could sustain further damage from traction. Specifically, these include:

  • Pelvic or hip fracture
  • Hip dislocation
  • Knee injury
  • Tib/fib, ankle or foot fracture

I did find one interesting study from 1999 that looked at how useful these splints really were. Of 4,513 EMS runs, only 16 had mid-thigh trauma and 5 of these appeared to have a femur fracture. Splint application was attempted in 3, and only 2 were successful. This was the experience in only one city (Evanston, IL) for one year. However, it mirrors what I see coming into our trauma center.

Unfortunately, when it comes to removal, there are very few guidelines out there. My advice is to have your orthopedic surgeon evaluate as soon as imaging is complete. They can help decide whether converting to some type of definitive traction is necessary, or whether it can be changed to a more conventional splint. In any case, the objective is to minimize the total amount of time in the traction splint to avoid any further injury to other structures.

Reference: Prehospital midthigh rauma and traction splint use: recommendations for treatment protocols. Am J Emerg Med, 19:137-140, 2001.

New Trauma MedEd Newsletter Released Sunday Night To Subscribers!

The July issue of Trauma MedEd is ready to go! Subscribers will receive it overnight Sunday night. This issue is devoted to Xrays. 

Included are articles on:

  • Trauma team radiation exposure
  • Repeating images in the trauma bay
  • Using lateral chest xrays and CT for chest trauma
  • and more!

As mentioned above, subscribers will get the issue delivered tomorrow night to their preferred email address. It will be available to everybody else on next Wednesday’s blog post.

Check out back issues, and subscribe now! Get it first by clicking here!

Tired Of Waiting For The Ambulance To Arrive With Your Trauma Patient?

When trauma patients are enroute to the hospital, accurate arrival times are crucial. If the patient arrives later than announced, the trauma team waits and wastes time. If the patient gets there early, it’s really a form of undertriage and they may not be able to immediately get the critical services they need. A Portland study noted that more than half of transport time estimates were off by at least 10 minutes, and over a quarter were wrong by 10 minutes or more! Surely there must be a way to predict transport time more accurately!

Harbor-UCLA Medical Center developed a simulation using transport data from a single Oregon county for an entire year. Their goal was to determine the factors that influenced transport time and develop a Google Maps application that would be more accurate than current estimates. Route mapping software was used, with inclusion of variables such as patient demographics, use of lights and siren, time of day, and weather. Individual variables that were statistically found to be insignificant were removed, one at a time, until the best model was derived.

Nearly 50,000 transports were analyzed to create the Google Maps application. Here’s what it looks like:

image

And here are the interesting findings:

  • Without a model, baseline accuracy was only 16% within 5 minutes of predicted
  • Transport times were longer during daytime and rush hour (gee!)
  • Shorter times occurred with use of lights and siren (gee whiz!)
  • Age, sex, wet roads, and trauma system entry had no effect on times
  • Use of the model within the Google Maps app increased accuracy to 73% within 5 minutes. Use of lights and siren boosted the accuracy to 78%

Bottom line: Yes, it is possible to enhance the accuracy of arrival predictions of your ambulances. This method should be adopted everywhere! Not only can it improve trauma team use and trauma patient treatment, it can improve ED resource usage for any incoming patient.

Rreference: Predicting Ambulance Time of Arrival to the Emergency Department Using Global Positioning System and Google Maps. Prehospital Emergency Care online first, doi:10.3109/ 10903127.2013.811562.

Stuff You Sterilize Other Stuff With May Not Be Sterile??

When one works in the trauma field, or medicine in general, we deal with the need for sterility all the time. We use equipment and devices that are sterile, and we administer drugs and fluids that are sterile. In surgery, we create sterile fields in which to use this sterile stuff.

In the past few years, we’ve come to the realization that the sterility we take for granted may not always be the case. There have been several cases of contaminated implanted hardware. And most recently, supposedly sterile injectable steroids were found to be contaminated with fungus, leading to several fatal cases of meningitis.

An article in the New England Journal of Medicine brings a bizarre problem to light: microbial stowaways in the topical products we use to sterilize things. Most drugs and infused fluids are prepared under sterile conditions. However, due to the antimicrobial activity of topical antiseptics, there is no requirement in the US that they be prepared in this way.

A number of cases of contamination have been reported over the years:

  • Iodophor – contamination with Buckholderia and Pseudomonas occurred during manufacture, leading to dialysis catheter infection and peritonitis
  • Chlorhexidine – contaminated with Serratia, Buckholderia and Ralstonia by end users, leading to wound infections, catheter infections, and death
  • Benzalkonium chloride – contaminated with Buckholderia and Mycobacteria by end users, causing septic arthritis and injection site infections

Bottom line: Nothing is sacred! This problem is scarier than you think, because our most basic assumptions about these products makes it nearly impossible for us to consider them when tracking down infection sources. Furthermore, they are so uncommon that they frequently may go undetected. The one telltale sign is the presence of infection from weird bacteria. If you encounter these bugs, consider this uncommon cause. Regulatory agencies need to get on this and mandate better manufacturing practices for topical antiseptics.

Reference: Microbial stowaways in topical antiseptic products. NEJM 367:2170-2173, Dec 6 2012.