Traumatic brain injury (TBI) is a common injury world-wide, but neurosurgeons are scarce. Traditionally, neurosurgeons are the ones to place invasive monitors to watch intracranial pressure (ICP). But what about injured people who are taken to a hospital where there is no available neurosurgeon?
A group at Wichita, Kansas looked at their 10 year experience with ICP monitor placement, where it can be done by neurosurgeons, trauma surgeons or general surgical residents (under trauma surgeon supervision). A total of 63 were placed by neurosurgeons, 30 by trauma surgeons, and 464 by residents under supervision. The usual demographics, including hospital stay, were the same across groups. There were essentially no significant differences based on who placed the monitor. Curiously, the article does not state whether the monitors were extradural or intraventricular, or both. The discussion section alludes to the fact that they were “parencyhmal.”
There were only three iatrogenic bleeds, and all occurred with resident placed monitors. None were clinically significant. Malfunction rate was about 5% across all groups. Monitors had to be replaced at some point in about 11% of all three groups. One CNS infection occurred in a patient with a resident-placed monitor.
Bottom line: With proper training and supervision, ICP monitors can be placed by just about anyone. This is particularly important in more rural locations where there are few if any neurosurgeons. But as always, this process needs to be monitored carefully by the hospital’s Trauma Performance Improvement / Patient Safety program (PIPS).
Reference: Placement of intracranial pressure monitors by non-neurosurgeons: excellent outcomes can be achieved. J Trauma 73(3):558-563, 2012.
The May issue of Trauma MedEd is ready to go! Subscribers will receive it overnight tonight. This issue is devoted to Traumatic Brain Injury.
Included are articles on:
- Brain injury and DVT prophylaxis
- Controlling fever in brain injury
- An alternative to the GCS?
- Pneumocephalus and air transport
- and more!
As mentioned above, subscribers will get the issue delivered tonight 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!
We’ve all experienced it. A seriously injured trauma patient is admitted to the ICU and begins the process of recovery. Everything looks well, and after a few days they are transferred to a ward bed. But then they languish, never really doing what we expect. Finally (and usually in the middle of the night), they begin to look bad enough where we have to transfer them back to the ICU.
What’s the problem here? A failure of the ICU team? Did we all miss something? Is there any way we can avoid this problem? The major issue is that these “bounce backs” tend to do poorly compared to patients who successfully stay in their ward bed. Estimates are that mortality for patients successfully and finally discharged from the ICU range from 4-8%, whereas the mortality in bounce back patients is 20-40%!
Researchers at the Medical University of South Carolina in Charleston looked at the characteristics that defined the bounce back patient. They looked at nearly 2000 patients discharged from the trauma ICU and analyzed the variables that predicted an unplanned bounce back. They noted the following interesting findings:
- More than two thirds of bounce backs occurred within 3 days
- Males, patients with an initial GCS < 9, transfer during the day shift were the major risk factors
- More comorbidities was associated with a higher chance of bounce back
- Mortality in the bounce back group was 20%
- The most common factors causing bounce back were respiratory failure or bleeding
Bottom line: This is an intriguing single-institution study that supports my own personal observations. Fewer bounce backs occur at night because staffing tends to be lower and there is more resistance to transfers out. Both the ICU team and the ward team need to scrutinize every transfer carefully. Significant head injury or the presence of medical comorbidities should trigger a careful assessment to make sure that the transfer is appropriate. Otherwise, your patient may be placed in unnecessary jeopardy.
Reference: Intensive care unit bounce back in trauma patients: An analysis of unplanned returns to the intensive care unit. J Trauma 74(6):1528-1533, 2013.
An anonymous reader posted this question. Let me first start by saying that I’m happy to answer any and all questions. However, it helps if you register with Tumblr or Disqus so I can reply directly to you as well. Sometimes I’ve answered a question in a previous post but am unable to explain why I’m not answering again. So please, register or email me directly so I can reply to your query!
Trauma PI is the most important part of any trauma program or center. Not only does the program have to provide high quality care, but it has to prove that it does this on paper. A performance improvement plan is important, as this outlines the specific methods used to self-assess clinical care. An important component of the plan is the PI dictionary.
A PI dictionary is simply the list of the clinical issues that are tracked by your PI program. This includes specific audit filters used to trigger PI review, as well as the list of issues and events that are routinely scrutinized. There is a core set of items that are found at every trauma center, like deaths and significant complications. However, no two centers’ dictionaries are identical because they must include local issues and problems as well.
Your trauma center should have a well-defined dictionary of PI review issues. And this dictionary must contain a “reasonable” number of items. Too many, and you will never be able to reasonably track everything down; too few and you will miss important problems that demand investigation.
Bucket Handle Injury
A bucket handle injury is a type of mesenteric injury of the intestine. The intestine itself separates from the mesentery, leaving a devascularized segment of bowel that looks like the handle on a bucket (get it?).
These injuries can occur after blunt trauma to the abdomen. The force required is rather extreme, so the usual mechanism is motor vehicle crash. In theory, it could occur after a fall from a significant height, and I have seen once case where a wood fragment was hurled at the abdomen by a malfunctioning lathe.
The mechanics of this injury are related to fixed vs mobile structures in the abdomen. Injuries tend to occur adjacent to areas of the intestine that are fixed, such as the cecum, ligament of Treitz, colonic flexures and rectum. During sudden deceleration, portions of the intestine adjacent to these areas continue to move, pulling on the nearby attachments. This causes the intestine itself to pull off of its mesentery.
The terminal ileum is the most common site for bucket handle tears. Proximal jejunum, transverse colon, and sigmoid colon are other possible areas. The picture above shows multiple bucket handle injuries in one patient. There are 3 injuries in the small bowel, and one involving the entire transverse colon. Note the obviously devascularized segment at the bottom center of the photo.
Always think about the possibility of this injury in patients with very high speed decelerations. Seat belt marks have a particularly high association with this injury. If your patient has an abnormal exam in the right lower quadrant, or if the CT shows unusual changes there (“dirty” mesenteric fat, thickened bowel wall, extravasation), I recommend a trip to the OR. In these cases, an injury will nearly always be present.
Source: personal archive. Not treated at Regions Hospital