All posts by TheTraumaPro

G&A Open Fracture Classification System

The Orthopaedic Trauma Association (OTA) Open Fracture Study Group has published a proposal for an updated system for classification of open fractures. So far, I don’t know of anyone who is actually using the new system, but I wanted to publicize it for your comments. Today, I’ll discuss the current classification standard in most trauma centers. Tomorrow, I’ll review the newly proposed one.

The most widely used system was developed by Gustilo and Anderson (G&A), with work starting in 1969. A number of modifications have been made over the years. Here’s the current classification system:

  • Grade I: Clean wound, <1cm in length
  • Grade II: Wound >1cm, but no extensive soft tissue injury, flaps or avulsions
  • Grade III: Extensive soft tissue laceration or damage, or open segmental fracture. Three subtypes were later developed:
  • Grade IIIa: Adequate periosteal coverage of the fracture
  • Grade IIIb: Extensive soft tissue loss, periosteal stripping, bone damage. Usually includes massive contamination.
  • Grade IIIc: Vascular injury requiring repair, regardless of degree of soft tissue injury

A few minor modifications have been made by others over the years, but they are not in general use. 

So what’s the problem with G&A? Here are a few. Is the injury classified before or after debridement? Preop classification or intraop? Can you use this system for treatment when it is already based on treatment? How reproducible is it? Is there good data on outcomes? Do outcomes rely on other factors, such as the level of trauma hospital treating the fracture? To name a few. In it’s favor, it is in widespread use and nearly all orthopaedic surgeons are well versed in it.

Tomorrow I’ll discuss how the new OTA system addresses some of the shortcomings in the G&A system.

Related posts:

References:

  • Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 58:453–8, 1976.
  • Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma  24:742–6, 1984.

Why Create Practice Guidelines?

Practice guidelines are everywhere. More and more organizations have developed processes to create high quality ones. But why should we care? Do they improve what we already do?

Here are my reasons for using practice guidelines:

  • They provide a consistent way of approaching a clinical issue. Everybody working with the patient knows how things will be done, so they don’t have to remember the nuances that particular doctors or providers like.
  • They (hopefully) use the best and most valid scientific data to address the care issue, thus giving trauma professionals the opportunity to provide the best care we know of.
  • They decrease errors and complications by narrowing the number of choices available to providers.
  • They decrease waste for the same reason. For example, drawing blood every 6 hours vs daily for solid organ injuries can add up to three unneeded tests every day.
  • They provide our trainees with one good way to deal with the clinical issue. This is important when they move on to independent practice, and sometimes when taking standardized tests (boards).

Bottom line: If 10 trauma professionals deal with a given clinical problem 10 different ways, then none of them are doing it right! Develop a guideline that all of them can live with, based on current literature (if any). That way they can all be right for once, and our patients will reap the benefits.

The following link illustrates a protocol we developed for chest tube management. There is no literature that details when and how to remove a chest tube, so this one was hammered out by our group of trauma surgeons. We now all do it the same, and our length of stay has decreased since we eliminated much of the arbitrary variability in this process.

But The Radiologist Made Me Do It!

The radiologist made me order that (unnecessary) test! I’ve heard this excuse many, many times. Do these phrases look familiar?

  1. … recommend clinical correlation
  2. … correlation with CT may be of value
  3. … recommend delayed CT imaging through the area
  4. … may represent thymus vs thoracic aortic injury (in a 2 year old who fell down stairs)
Some trauma professionals will read the radiology report and then immediately order more xrays. Others will critically look at the report, the patient’s clinical status and mechanism of injury, and then decide they are not necessary. I am firmly in the latter camp.
But why do some just follow the rad’s suggestions? I believe there are two major camps:
  • Those that are afraid of being sued if they don’t do everything suggested, because they’ve done everything and shouldn’t miss the diagnosis
  • Those that don’t completely understand what is known about trauma mechanisms and injury and think the radiologist does
Bottom line: The radiologist is your consultant. While they are good at reading images, they do not know the nuances of trauma. Plus, they didn’t get to see the patient so they don’t have the full context for their read. First, talk to the rad so they know what happened to the patient and what you are looking for. Then critically look at their read. If the mechanism doesn’t support the diagnosis, or they are requesting unusual or unneeded studies, don’t get them! Just document your rationale clearly in the record. This provides best patient care, and minimizes the potential complications (and radiation exposure) from unnecessary tests.
Related post: 

Reference: Pitfalls of the vague radiology report. AJR 174(6):1511-1518, 2000.

Surgeons Who Operate Post-Call

Fatigue is a big deal for trauma professionals. I previously devoted a week of posts to detailing research on fatigue, and dedicated the June 2012 Trauma MedEd newsletter to the topic. So I just reviewed a paper suggesting that it might not be such a big deal for attending (consultant) surgeons who operate after they’ve been on call.

The whole idea came about because residents in the US (registrars) have had restrictions to their work hours in place for 10 years, limiting them to only 80 hours per week. Yet the attending physicians, who are older and more likely to show the effects of fatigue, have no such limits. They can work as long as they want. Maybe their greater experience or long-established habits of occasional sleep deprivation are protective?

The group in Memphis looked at this phenomenon, performing a retrospective review of patients operated on by surgeons post-call and those who were not. They looked at 737 patients over 3.5 years, of which 15% were performed by post-call staff surgeons. Here are the key points:

  • Only cholecystectomy, hernia and intestinal procedures for bowel obstruction, ischemia or bleeding were evaluated
  • The authors used complications and readmission as outcomes to monitor
  • Complications occurred in about 13% of both post-call and no-call groups. No difference.
  • Readmissions within 30 days occurred in about % of both groups. Again, no difference.

So it looks like it’s okay to operate after the surgeon’s been up at night, right? Wrong! This is another perfect example of why it’s so important to read the whole paper, not just the abstract. Major problems:

  • The actual amount of sleep or fatigue levels are not quantified, so it’s a mix.
  • It’s a teaching hospital, so the surgeons always operate with a trainee at some level. The residents either do the work, or can “double check” the surgeon’s work to prevent any significant errors.
  • Complications and readmission rates are very crude indicators of error. Only the most egregious problems would manifest as one of these.

Bottom line: There is plenty of non-medical literature out there that shows that fatigue is bad (aviation, trucking, marine operations). And as much as we’d like to believe it, surgeons and other physicians are in no way immune to its effects. What this paper really showed is that if you are supervising a well-rested trainee and looking at outcomes that aren’t directly related to fatigue, everything looks great! It’s not, and all trauma professionals need to be aware of the fact that, even though they feel invincible and that they can do anything after sleep deprivation, it’s just their fatigue talking. Protect your patients and make sure that everyone who takes care of them is in tip-top shape.

Reference: Outcomes of operations performed by attending physicians after overnight trauma shifts. Journal Am Coll Surg, in press 11 Jan 2013.

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CIWA Demystified

What exactly is the CIWA protocol?

It is a tool used commonly in the US that helps clinicians assess and treat potential alcohol withdrawal. A significant amount of injury in this country is due to the overuse of alcohol. A subset of these patients are admitted and do not have access to alcohol. They may begin to withdraw within a few days, and this condition can lead to dangerous complications.

The Clinical Institute Withdrawal Assessment measures 10 items that are association withdrawal:

  • Nausea / vomiting
  • Anxiety
  • Paroxysmal sweats
  • Tactile disturbances (itching, bugs crawling on skin, etc)
  • Visual disturbances
  • Tremors
  • Agitation
  • Orientation
  • Auditory disturbances
  • Headache

All items are measured on a scale of 0-7 with the exception of orientation, which uses a scale of 0-4. All subscores are tallied to arrive at the final score.

The total score is used to determine whether benzodiazepines should given to ameliorate symptoms or avoid seizures. Typically, a threshold is selected (8 or 10) and no medications are needed as long as the patient is under it. Once it is exceeded, graduated doses of lorazepam or diazepam are given and vital signs and CIWA scores are repeated regularly. The protocol is discontinued once the patient has three determinations that are under the threshold.

The individual dosing scale and monitoring routine varies by hospital. Look at your hospital policy manual to get specifics for your institution.

For a copy of the CIWA scoring criteria, click here.