All posts by TheTraumaPro

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.

ACS vs State Trauma Verification / Designation

In the US, there are two major methods for gaining recognition as a trauma center: verification by the American College of Surgeons (ACS), and designation by a state or county authority. ACS verification is fairly rigorous and standardized, and is applied uniformly across the US. State or county designation is not nearly as uniform, with significant variability in the application of criteria, frequency of site visits, and quality of reviewers. A few states allow dual site visits which result in both ACS verification and state designation, but in general the processes are different.

A recent paper from the University of Pittsburgh sought to quantify some of these differences by using mortality as a barometer of trauma center quality and hence, verification/designation quality. It analyzed information from the 2007-2008 dataset of the National Trauma Data Bank. It specifically compared outcomes from ACS Level I and II centers to state designated centers that applied for but did not obtain ACS verification. Robust statistical models were used to address the usual shortcomings of using large datasets. Observed vs expected mortality was calculated using standard methodology. Here are the key results:

  • Over 900,000 records were analyzed (!) from a mix of academic, community, large, and small hospitals. Most (92%) were nonprofits.
  • There was no difference in survival outliers (either unexpected saves or unexpected deaths) in Level I ACS vs state trauma centers.
  • A significantly higher number of unexpected mortalities occurred in state designated Level II centers compared to ACS Level IIs. There was no difference in unexpected saves.
  • ACS verification was an independent predictor of survival at Level II centers

The equivalence in survival at Level I centers is likely due to the application of rigorous designation criteria by states for these flagship centers. Additionally, they usually attract personnel who are keenly interested in and dedicated to trauma care. Many state Level II centers have more variability in terms of commitment and resources. The surgeons may not be able to commit as much of their time to trauma care as at Level I centers. Other key resources may not be as readily available.

Bottom line: This study matches with my observations of both ACS and state trauma centers. Level I criteria are fairly rigorous for both, but there is much more variability in Level II criteria. Unfortunately, this study suggests that this situation is not good for our patients. It is not enough for states to just adopt ACS criteria into their own designation programs. Regular, standardized and rigorous reviews are important to ensuring quality.


Reference: American College of Surgeons trauma center verification versus state designation: Are Level II centers slipping through the cracks? J Trauma 75(1):44-49, 2013.