Evidence based guidelines continue to be part of the practice of medicine. They seek to standardize what we trauma professionals do to manage common clinical problems. A new orthopedic guideline was evaluated at the University of Michigan and the results are being reported at the upcoming AAST meeting in San Francisco.
There is considerable variation in the management of open fractures, ranging from timing of washout/repair, grading, and antibiotic management. The U of M group standardized the way they administered antibiotics in these patients. They implemented a protocol as follows:
- Gustilo Grade I or II – cefazolin for 48 hours (clindamycin if allergic)
- Gustilo Grade III – ceftriaxone for 48 hours (clinda or aztreonam if allergic)
- No aminogyclosides, penicillin or vancomycin
They studied their results in 174 patients with open femur or tib/fib fractures (101 pre-protocol and 73 post; one apparently had both areas fractured). Risk adjusted surgical infection rates were calculated using the National Health Safety Index risk index, which is calculated using the ASA score, the wound classification, and the duration of the operative procedure.
Here are the factoids:
- The use of aminoglycosides and vancomycin decreased from 54% to 16%
- Skin and soft tissue infection rates were not different (21% pre and 25% post)
- People did not change their fracture grading to “game” the system
- Infections with antibiotic resistant organisms or MRSA were similar in the two groups
- The authors did not report time to operation in these open fractures
Bottom line: This is a good first shot at standardizing antibiotic use in patients with open fractures. The numbers are very small, and time to OR was not taken into account. Whereas the 8 hour rule for open fractures was dogma and has pretty much been discounted, antibiotic use is a case of “every man for himself.” It is important to continue this work, because I’m sure there will be cost and education benefits from following a protocol like this. More numbers need to be generated, and anyone who adopts this protocol now needs to closely watch their soft tissue and bone infection results in their PI process.
Reference: Evidence-based protocol for prophylactic antibiotics in open fractures: improved antibiotic stewardship with no increase in infection rates. AAST 2013 Paper 62.
The August newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is trauma centers.
In this issue you’ll find articles on:
- The value of trauma center care
- Benefit of transport to a trauma center
- Going from Level II to Level I
- Financial triage – the wallet biopsy
- Is there a shortage of on-call specialists
- Why do trauma patients get readmitted?
Subscribers had the newsletter emailed to them last weekend. If you want to subscribe (and download back issues), click here.
Download the newsletter here!
Thursday, September 5 – 8am to noon Central time (1-5pm GMT)
Conference details here!
Link to the live web stream here!
This conference is less than 24 hours away! It is designed to provide high quality trauma education for physicians, nurses, and paramedics in a fast paced and innovative format.
- You think you know… – why we still believe trauma myths and how to bust them
- Dislocated hip reduction techniques
- Field amputation: indications, challenges, techniques
- Finger thoracostomy – from Scott Weingart!
- Burn size estimation
- Nursing considerations in burn patients
- Keeping rare but critical knowledge fresh
- Intraosseous tips
- Disruptive innovation in education
- Curbside consults – we ask specialists the questions you always with you had
All of this, delivered in short, easy to digest presentations and videos!
For those of you unable to attend the live event at the Minnesota History Center in St. Paul, join our live web stream. Submit questions or comments to the presenters in real time via #TETNG13 on Twitter. See you there!
Link to the live web stream here!
Practice guidelines from the Brain Trauma Foundation recommend placement of an ICP monitor in trauma patients with GCS<8 and any type of intracranial hemorrhage. Some rural trauma centers may not have immediate access to a neurosurgeon for this procedure, and geography and/or weather may preclude transferring the patient. What to do?
Well, one person is guaranteed to be available at any trauma center. The trauma surgeon. Six years of data regarding placement of bolt type ICP monitors by appropriately trained and credentialed trauma surgeons or neurosurgeons was reviewed. The study was actually carried out at a Level I center, where both specialties were available. A total of 407 cases were studied.
Here are the interesting factoids:
- Patients tended to be young (average 41 years), and male (of course)
- About one third were falls and one third were motor vehicle crashes
- Trauma surgeons placed 71% of the ICP bolts, neurosurgeons 29%
- Complication rates were low and not significantly different (2.5% for surgeons, 0.8% for neurosurgeons)
Bottom line: This study is intriguing, and I know a few centers in the US and many abroad already allow surgeons to place ICP monitors. However, this study is too small and underpowered to reach a definitive conclusion. A much larger, multicenter trial is warranted, although it will be difficult to carry out. In the meantime, if your hospital needs this resouirce, consider training your trauma surgeons for the procedure. But be sure to monitor complications and outcomes very carefully via your trauma PI process!
Reference: Placement of intracranial bolt monitors by trauma surgeons – a 6 year review. AAST 2013 Paper 20.