All posts by TheTraumaPro

The Three Strikes And You’re Out Airway Rule

Rapid airway control is key in critically injured trauma patients. But too many times, I’ve seen trauma professionals take far too much time to establish one. Here’s a good rule of thumb to use in these situations.

After pre-oxygenating the patient, your first pro gets a crack at it. They generally have the most time available, often 3-5 minutes before sats begin to drop.

In the unlikely situation that they are not successful, strike 1. Stop trying and resume bagging the patient. At this point, someone (trauma surgeon, lead medic) must get the crich set out. Then the next most experienced intubator gets a shot.

If they are not successful, strike 2. Resume bagging and open the crich set.

The most experienced intubator now gets their chance, using any advanced technology available. No success even now? Strike 3, use the crich set!

Bottom line: We should never allow more than 3 airway attempts, and sometimes clinical conditions will dictate fewer tries. Examples that come to mind are severe brain injury patients (hypoxia is bad) and patients who do not recover from oxygen desaturation when they are bagged. Don’t lose track of time and the number of attempts!

Best Of: Paging And The Trauma Pro

People who work in hospitals, particularly physicians, physician assistants, nurse practitioners and residents are throwbacks who still use old-fashioned paging technology. My colleague, the Skeptical Scalpel, recently lamented this fact in one of his blog posts. But they do seem to be a necessary evil, since cellular coverage is often limited deep inside of buildings.

But how much to trauma professionals get paged? An oral presentation at the recent Congress of Neurological Surgeons described a study that monitored paging practices between nurses and neurosurgical residents.

Medical students were paid to follow neurosurgical residents during 8 12-hour call shifts. They recorded the paging number and location, priority, and what the resident was doing when paged. The results were enlightening but not surprising:

  • 55 pages were received per shift, on average, ranging from 33 to 75
  • An average of 5 pages per hour were received, with a range of 2 to 7
  • A substantial number of pages were received during sleep times (4 per hour)
  • It took an average of 1.4 minutes to return the page
  • 68% of pages were non-urgent
  • 65% interrupted a patient care activity
  • An average of 1.1 hours was spent returning pages per shift

Bottom line: Yes, we are throwbacks using an old technology. But it does serve us well. Unfortunately, it’s an old technology being used in an inefficient manner. I recommend that nursing units make it a practice to maintain a “page list” of nonurgent items. The trauma professional can then stop by or call each unit periodically (every 2 hours or some other appropriate time interval) and deal with all of them at once. Obviously, urgent and emergent problems should still be called immediately. This will ensure that routine issues are taken care of in a timely manner and the trauma pro can attend to their other duties as efficiently as possible.

Related posts:

Reference: Oral Paper 113: An Observational Study of Hospital Paging Practices and Workflow Interruption Among On-call Junior Neurosurgery Residents. Presented at the Congress of Neurological Surgeons 2012.

State Laws And Pediatric Firearms Injuries

The US federal government records some basic statistics regarding firearm injuries, mostly related to deaths. However, the Agency for Healthcare Research and Quality maintains a database that contains detailed information on pediatric hospitalizations, including injury information. A group at Tufts University used this database to compare injury trends in pediatric firearm injury (age 0-20) in states with and without a Stand Your Ground law (SYG). Stand Your Ground laws, which many first became aware of after the death of Trayvon Martin in Florida, allow an individual to defend themelves from an unlawful threat without having to retreat first.

The database used was fairly robust. Data were submitted from 44 states, and 4 years were reviewed for the study. Over 19,000 pediatric firearm injury records were analyzed. The following interesting reslts were uncovered:

  • Nearly two thirds were assualts, and 27% were accidental injury.
  • Average length of stay for both mechanisms was about 3 days
  • Hospital cost for assault was $61,000 and for accidental injury was $46,000, per child
  • Children were about 10% more likely to suffer a firearm assault in SYG states
  • Kids in SYG states were also more likely to suffer accidental firearm injury and commit suicide with a firearm(?!)
  • Statistical association of firearm injury with the usual culprits (race, age > 16, male sex, socioeconomic status) was also noted

Bottom line: At best, this is a weak observational study. And of course, it is impossible to say that Stand Your Ground laws are the cause of a greater number of pediatric firearm injuries. The fact that (even greater) increases in accidental injury and suicide were noted points out this weakness even better. Although it is tempting to blame SYG laws on this perceived increase in injuries, it’s not correct. Much better analyses need to occur before we can really draw any actionable conclusions on the effects of these laws..

States with Stand Your Ground laws: AL, AK, AZ, CA, FL, GA, IA, IL, IN, KS, KY, LA, ME, MI, MS, MO, MT, NH, NC, ND, OH, OK,, PA, RI, SC, SD, TN, X, UT, WV, WI, WY

Pigtail Cathers Instead Of Chest Tubes?

I reviewed this abstract a few months ago, and now I’ve had the opportunity to hear it and see the data. Here’s an update on whether this is worthwhile..

This was a relatively small, prospective study, and only 40 of 74 eligible patients were actually enrolled over 20 months at a Level I trauma center in the US. Pain was measured using a standard Visual Analog Scale, as was complication and failure rate, tube duration and hospital stay.

The following interesting findings were noted:

  • Chest wall pain was similar. This is expected because the underlying cause of the pneumothorax, most likely rib fractures, is unchanged.
  • Tube site pain was significantly less with the pigtail
  • The failure rate was the same (5-10%)
  • Complication rate was also the same (10%)
  • Time that the tube was in, and hospital stay was the same

There were a few questions regarding blinding of the pain scale raters, but other than the small sample size, the study was nicely done.

Bottom line: There may be some benefit in terms of tube site pain when using a smaller catheter instead of a chest tube. But remember, this is a very small study, so be prepared for different results if you try it for your own trauma program. If you do choose to use a smaller tube or catheter, remember to do so only in patients with a pure pneumothorax. Clotted blood from a hemothorax will not be completely evacuated.

Related posts:

Reference: A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, Jan 17, 2013.

Angiography And Splenic Salvage

Variations in the way we deal with trauma can have a significant impact on patient outcome. This has been documented most recently in the use of angioembolization when dealing with patients with spleen injuries. The first paper presented at EAST 2013 looked at outcomes at hospitals that use angio more heavily vs those who don’t.

They analyzed 1275 patients presenting to 4 Level I trauma centers. Two centers were high-use (11% and 19% usage) and the other 2 were low-use (1% and 4%). The outcomes studied were the splenic salvage rate and success in nonoperative management. And although patients at the low angio use centers had a higher ISS, the splenic injury grade was the same.

Interesting findings included:

  • Admission splenectomy rate was the same, meaning that both types of centers used the same criteria when the patient rolled through the door
  • High angio use centers had higher overall salvage rates (82% vs 77%)  and greater success with nonoperative managment (96% vs 92%)
  • In high grade injury (grade 3 and 4) the salvage rate was still better (67% vs 56%) and nonop success rates were much better (92% vs 80%)
  • In patients who were initially managed nonoperatively, use of angio was associated with salvage
  • Patients in high angio centers were more likely to leave the hospital with their spleen where it should be
  • There was no analysis of complications from angiography
  • There was no comment on how these patients were managed on a day to day basis

Bottom line: There is a considerable amount of variation in how trauma centers use angiography for spleen injury. Unfortunately, this variability is allowing people to lose their spleens at centers who don’t use it as much. The overall success rate in managing spleen injury (all comers) has historically been about 93%. More aggressive use of angiography is now shown to improve that to 97%. Given this new data, angio needs to be considered in patients with grade 3+ injury and in any with contrast extravasation. And the overall management should be standardized as well.

Reference: Variation in splenic artery embolization and spleen salvage: a multicenter analysis. Paper 1, EAST annual scientific assembly, Jan 15, 2013.