All posts by The Trauma Pro

General

Again? Trauma Surgeon In-House vs At Home

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Here we go again. Yet another paper debating whether we really need to have a trauma surgeon in-house at high level trauma centers. A paper published in December 2013 looks at this topic, and is a perfect illustration of why you need to read the whole article, not just the abstract!

This retrospective study primarily examined patient mortality, as well as a few other LOS indicators. They compared their results as they changed from having trauma surgeons who took call from home to taking in-house call. It involves only one trauma center in Lexington, Kentucky and covers two 21 month periods. 

Here are the factoids:

  • There were roughly 5000 patients each in the at-home and in-house groups
  • Overall demographics looked identical, even though the authors thought they detected differences in age and ISS
  • Time in ED, ICU LOS, hospital LOS decreased significantly, and percent taken to OR increased in the in-house group. There was no change in mortality.
  • These patterns were the same in trauma activation patients, who were obviously more seriously injured.
  • The authors conclude that having an in-house surgeon does not impact survival, but can speed things up for patients throughout their hospital stay.

I have many problems with this study:

  • The statistical results are weird. Many of the allegedly significant differences appear to be identical (e.g. mean age 44+/-19 vs 45+/-19, hospital LOS 3 days vs 3 days). And even if the authors found a test that makes them look statistically significant, they are clinically insignificant. ICU LOS differences were measured in hours, and 25 hours was significant? 
  • Attending presence “improved” from 51% to 88%. This means that they were not present in 1 of 5 trauma activations. This can easily overshadow any positive effect their presence may have had.
  • Mortality is too crude an indicator to judge the value of surgeon presence.
  • Lengths of stay can be due to so many other factors, it is not a valid measure either.
  • A retrospective, registry study has too few of the really critical data points

Bottom line: This paper is the poster child for why you MUST read the full paper, not just the abstract. If you had done the latter, you may believe that having an in-house surgeon is not necessary. Many papers (of variable quality) have looked at this (poorly) and there is no consensus yet. But it is a requirement for ACS verification if the surgeon can’t make it to the bedside of a seriously injured patients within 15 minutes. 

After observing trauma activations for 32 years, I know there is value in having an experienced surgeon present at the bedside during them. However, this value is very hard to quantify and every paper that has tried has not looked at the right variables. And these variables cannot be assessed in a retrospective, registry type study. 

Yes, there is no good, hard evidence of the value of the in-house surgeon. But it is there. Let’s stop publishing (and not critically reading) this kind of junk and confusing the issue!

Reference: Influence of In-House Attending Presence on Trauma Outcomes and Hospital Efficiency. J Am College Surg 281(4):734-738, 2013.

General, protocols

The Value of Protocols in Trauma

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Most trauma centers have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question arose: why do we need another protocol? Can we show some benefit to using a protocol?

I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols.

In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues.

  • They allow us to build in adherence to any known practice guidelines or literature.
  • They help conserve resources by standardizing care orders and resource use.
  • They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
  • They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
  • They promote team building, particularly when the protocol components involve several different services within the hospital.
  • They teach a consistent, workable approach to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.

A number of years ago, we implemented a solid organ injury protocol here at Regions Hospital. I noted that there were large variations in simple things like time at bedrest, frequency of blood draws, how long the patient was kept without food and whether angiography should be considered. Once we implemented the protocol, patients were treated much more consistently and we found that costs were reduced by over $1000 per patient. Since we treat about 200 of these patients per year, the hospital saved quite a bit of money! And our blunt trauma radiographic imaging protocol has significantly reduced patient exposure to radiation.

Bottom line: Although the proof is not necessarily apparent in the literature, protocol development is important for trauma programs for the reasons outlined above. But don’t develop them for their own sake. Identify common problems that can benefit from consistency. It will turn out to be a very positive exercise and reap the benefits listed above.

General

Lab Values From Intraosseous Blood

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The intraosseous access device (IO) has been a lifesaver by providing vascular access in patients who are difficult IV sticks. In some cases, it is even difficult to draw blood in these patients by a direct venipuncture. So is it okay to send IO blood to the lab for analysis during a trauma resuscitation?

A study using 10 volunteers was published last year (imagine volunteering to have an IO needle placed)! All IO devices were inserted in the proximal humerus. Here is a summary of the results comparing IO and IV blood:

  • Hemoglobin / hematocrit – good correlation
  • White blood cell count – no correlation
  • Platelet count – no correlation
  • Sodium – no correlation but within 5% of IV value
  • Potassium – no correlation
  • Choloride – good correlation
  • Serum CO2 – no correlation
  • Calcium – no correlation but within 10% of IV value
  • Glucose – good correlation
  • BUN / Creatinine – good correlation

Bottom line: Intraosseous blood can be used if blood from arterial or venous puncture is not available. Discarding the first 2cc of marrow aspirated improves the accuracy of the lab results obtained. The important tests (hemoglobin/hematocrit, glucose) are reasonably accurate, as are Na, Cl, BUN, and creatinine. The use of IO blood for type and cross is not yet widely accepted by blood banks, but can be used until other blood is available.

Related post:

Reference: A new study of intraosseous blood for laboratory analysis. Arch Path Lab Med 134(9):1253-1260, 2010.

General

Tips For Trauma Pros: Seat Belt Sign

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We see seat belt signs at our trauma center with some regularity. There are plenty of papers out there that detail the injuries that occur and the need for a low threshold for surgically exploring these patients. I have not been able to find specific management guidelines, and want to share some tidbits I have learned over the years. Yes, this is based on anecdotal experience, but it’s the best we have right now.

Tips for trauma professionals:

  • Common injuries involve the terminal ileum, proximal jejunum, and sigmoid colon. My observation is that location in the car is associated with the injury location, probably because of the location of the seat belt buckle. In the US, drivers buckle on the right, and I’ve seen more terminal ileum and buckethandle injuries in this group. Front seat passengers buckle on the left, and I tend to see proximal jejunum and sigmoid injuries more often in them.
  • Seat belt sign on physical exam requires abdominal CT for evaluation, regardless of age. The high incidence of significant injury mandates this test.
  • Seat belt sign plus any anomaly on CT requires evaluation in the OR. The only exception would be a patient with minimal fluid only in the pelvis with an unremarkable abdominal exam. But I would watch them like a hawk.
  • In patients who cannot be examined clinically (e.g. severe TBI), a rising WBC count or lactate beginning on day 2 after adequate resuscitation should prompt a trip to the OR. This is an indirect method for detecting injured bowel or mesentery.
  • Laparoscopy may be used in patients with equivocal findings. Excessive blood, bile tinged fluid, succus, or lots of fibrin deposits on the bowel should prompt conversion to laparotomy. Tip: place all ports distant to the seat belt mark. The soft tissues are frequently disrupted, and gas may leak into this pocket prohibiting good insufflation of the peritoneal cavity.
  • If in doubt, open the abdomen. It’s bad form to put in the scope, see something odd, and walk away. Remember, any abnormal finding after trauma is related to trauma until proven otherwise. It’s almost never pre-existing disease.

Related posts:

General

Fasciotomy Closure: VAC vs Shoestrings

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Fasciotomy is the definitive management for compartment syndrome. But by definition, once you make the incision things are going to gape apart. If they don’t, hmmm, there probably wasn’t a compartment syndrome in the first place. 

That’s the easy part. Now, how do you make the wound edges come together and achieve some kind of cosmetic result? Historically, a variety of techniques have been used. They include leaving it open to granulate, brute force sutures, progressive closures, and more recently, the VAC suction dressing. 

This latter technique has really caught on, and there are a number of benefits. First, the suction can reduce tissue edema, which may facilitate quicker closure. Another big advantage is that this dressing can be changed every 3 days, as opposed to daily (or more) for conventional dressings. 

The downsides: cost, and the fact that some people in the US don’t have insurance that covers home use of this device. This may drive up costs by increasing hospital length of stay.

But is it better than the other closure methods? A recently published paper from an orthopaedic and plastic surgical group in Greece details a randomized, prospective study comparing VAC assisted closure versus the shoelace technique.

Here are the factoids:

  • 50 patients with 82 leg fasciotomy wounds were randomized over 5 years
  • The VAC group had the device applied 3-6 days postop with a pressure of -125 torr. They were changed every 3 days.
  • The shoelace group had the bands applied at the end of the operation. Tightening began 4-6 days postop and was then performed daily.
  • Time to closure with the VAC was 19 days vs 15 days for shoelaces. This was a significant difference.
  • Skin grafts were required to complete the closure in 6 VAC cases, but in none of the shoelace patients
  • There were 6 wound infections in the VAC group vs 4 in the shoelace group (NS)
  • Average daily cost in the VAC group was 135 euro, but only 14 euro for shoelaces
  • The cost to add a skin graft in the VAC group added substantial additional expense

Bottom line: This is a nice comparison of two techniques that try to solve the wound closure problem using two different methods. The VAC reduces edema but does not shrink the wound, while shoelaces stretch the skin to close the wound but do nothing about edema. The VAC is slower and more expensive, and frequently requires an additional (and expensive) skin graft. Shoelaces are quicker and cheap. What to do? It would appear that wound shrinking methods are preferred. However, if edema is significant, apply a VAC first. Then switch to shoelaces once the edema has subsided for faster (and graft-less) closure.

Related post:

Reference: Wound closure of leg fasciotomy: Comparison of vacuum-assisted closure versus shoelace technique. A randomised study. Injury 45(5):890-893, 2014.