All posts by TheTraumaPro

The 8 Hour Rule For Open Fractures: We’re So Over That

For decades, the standard of care for irrigation and debridement (I&D) of open fractures has been within 8 hours of injury. There is a growing body of orthopedic literature that says this isn’t necessarily so.

A paper being presented at the AAST meeting in Chicago next week retrospectively looked at their experience with early (<8hrs) vs late I&D in a series of 248 patients. They looked at infection rates stratified by time and upper vs lower extremity.

They found that the infection rates overall were not significantly different. However, when subgrouped by extremity and higher Gustilo type >= III, they noted that both delayed I&D and Gustilo type correlated with infection risk. For the upper extremity, only Gustilo type >= III correlated with a higher infection rate.

The authors concluded that all lower extremity open fractures should be dealt with in the 8 hour time frame, whereas upper extremity fractures can be delayed for lower Gustilo classes.

Bottom line: I don’t necessarily buy into all the results from this small study. The orthopedic literature has already refined this concept. At Regions Hospital, we allow up to 16 hours to I&D for open fractures up to and including Gustilo class IIIA. Above that, the 8 hour rule is followed. We periodically review our registry data on all open fracture patients to make sure that the extended time frame patients are not experiencing an increase in wound complications. And they haven’t in our 8 year experience in handling them this way.

Refresher on the Gustilo classification system:

  • Class I – open fracture, clean wound, <1cm laceration
  • Class II – clean wound, laceration >1cm with minimal soft tissue damage
  • Class IIIA – clean wound, more extensive soft tissue damage or laceration, periosteum intact, minimal contamination
  • Class IIIB – extensive soft tissue damage with periosteal stripping or bone damage, significant contamination
  • Class IIIC – arterial injury without regard for degree soft tissue injury

Reference: Open extremity fractures: does delay in operative debridement and irrigation impact infection rates? AAST 2011 Annual Meeting, Paper 22.

AAST 2011: Video-Assisted Intubation Edges Out Direct Lanyngoscopy

Intubation is the one procedure that provokes the most anxiety for trauma professionals. What about those facial fractures? What if you can’t get it? Video-assisted intubation is now readily available and at a reasonable cost. And it seems like a great idea, but does it make intubation easier?

A paper to be presented at the AAST next week looked at intubation success among relatively inexperienced users, junior residents. They compared success rates of video assisted (VA) intubation in an ICU (74 patients) with direct laryngoscopic (DL) intubation performed in an ED (54 patients).

All patients were successfully intubated by the junior resident, or by a more senior backup if they were unsuccessful (fellow or attending). The junior residents were successful in 96% of the VA intubations, but in only 76% of DL intubations. Less experienced residents (<20 intubations) were successful in all 96% of the VA intubations but in only 40% of the DL. And the least experienced, those who had done less than 5 intubations, obtained an airway with VA 37% of the time vs 7% for DL. The number of desaturations to less than 80% and hospital mortality was the same for the two groups.

Bottom line: Video assisted intubation is superior to the old-fashioned direct laryngoscopic technique. Even inexperienced providers have a better success rate with the video assisted technique. Over the next few years, it will become the standard for intubating patients, both in the field by medics and in the hospital.

Related posts:

Reference: The emergent airway: video-assisted intubation is superior to direct laryngoscopy for teaching junior residents. AAST 2011 Paper #65.

AAST 2011: The Initial Hematocrit Matters

Traditional teaching is that we bleed whole blood, and it takes time to pull volume out of the interstitial space to replace it. Therefore, the initial hematocrit should be normal when a fresh, bleeding trauma patient rolls through the doors.

An observation I have made over the years is that this is not necessarily so. A few patients have low initial hemoglobin or hematocrit readings, and they tend to be bleeding briskly from somewhere. A paper to be presented at next week’s AAST meeting in Chicago shows just that.

The authors retrospectively reviewed 198 trauma patients requiring emergency surgery at a Level I trauma center. Patients with lower initial hematocrits tended to have lower systolic blood pressure, lower GCS, lose more blood, and require infusion of more blood products during surgery. They also had a higher ISS and mortality. The biggest jump in these indicators occurred when the Hct dropped below 37.

Bottom line: A low hematocrit on the first blood drawn during trauma resuscitation is more helpful that previously thought. Be sure to check those lab values early, and if the hematocrit value is in the mid-30s or lower, start looking for significant sources of bleeding.

Reference: The initial hematocrit matters in trauma: a paradigm shift? AAST 2011 Annual Meeting, Paper 38.

Another Anticoagulant To Watch Out For

In May, I wrote about a new direct thrombin inhibitor named dabigatran (Pradaxa). This drug appears beneficial for patients who need ongoing anticoagulation without the hassle of blood testing to check drug levels. The danger for trauma patients is that there is no antidote or rapid reversal possible. This means that significant traumatic bleeding, particularly in and around the brain, cannot be stopped! At Regions Hospital, we have seen a few patients on this drug, but luckily they have not had bleeding from trauma.

Late last month, Bristol-Myers Squibb and Pfizer announced that a new drug has shown very favorable results in preventing strokes in patients with atrial fibrillation (apixaban, Eliquis). Indeed, it cut the relatively low risk of stroke in half, compared to warfarin. It also had about a third fewer bleeding complications. It looks like it may also give dabigatran a run for its money.

This drug is a Factor Xa inhibitor, and also has no antidote other than time. There is some evidence that activated charcoal given orally within 3 hours of apixaban dosing may be somewhat helpful in reducing blood concentrations.

Trauma professionals need to be on the lookout for patients who use this drug. Any trauma patient who admits to being on a “blood thinner” needs to be questioned carefully to determine which one it is. If it is one of the newer drugs without an antidote, they need to be monitored continuously for signs of bleeding (read: ICU), especially if they have experienced head trauma.

Bottom line: Be on the lookout for these drugs. If any patients who have fallen are taking this drug (elderly, frequently intoxicated, etc.), contact their primary physician so that the risks vs benefits of continuing it can be considered.

Related posts

 

References

Weird Trauma: Pruning Shears to the Head and Neck

This case made the national news yesterday, and I wanted to make a few comments on the ideal management of this type of injury.

An 86 year old Arizona man was trimming plants in his back yard and fell on his pruning shears. One of the handle grips pushed into his orbit and through his pharynx into his neck. How do you think through something like this?

First, always check vital signs. If the patient is hypotensive, they must go to the operating room. Even if vital signs are stable, ongoing bleeding necessitates an operation before anything else.

If vital signs are stable, then a road map showing vial structures is essential. The patient should be taken to CT so the exact position of the object can be determined. Any involved structures (carotid artery, esophagus) can be identified and a proper plan can be developed. 

Then and only then can a stable patient be taken to the OR. Appropriate incisions should be placed so that key portions of the foreign object can be viewed as they are removed. In this case, incisions were made under his lip and into the maxillary sinus wall to monitor the removal process. The carotid artery had been cleared by CT. Once removed, any remaining bleeding can be addressed. 

A final point: any problem like this that has the potential to involve the airway requires that a skilled anesthesiologist be present with appropriate airway management equipment, and the surgeon needs to have all equipment ready to place a tracheostomy on short notice.

This patient did well after removal and was treated with about 3 weeks of antibiotics for his sinus injuries. His inferior orbital wall was rebuilt, and overall he did well postoperatively. He is seriously reconsidering doing any gardening again.