All posts by TheTraumaPro

Giving TXA Via An Intraosseous Line?

Seriously injured patients frequently develop coagulopathy, which makes resuscitation (and survival) more challenging. A few years ago, the CRASH-2 study lent support for using tranexamic acid (TXA) in select trauma patients to improve survival. This drug is cheap and has antifibrinolytic properties that may be beneficial if given for life-threatening bleeding within 3 hours of initial injury. It’s typically given as a rapid IV infusion, followed by a slower followup infusion. The US military has adopted its routine use at forward combat hospitals.

But what if you don’t have IV access? This can and does occur with military type injuries. Surgeons at Madigan Army Medical Center in Washington state tried using a common alternative access device, the intraosseous needle, to see if the results were equivalent. This study used an adult swine model with hemorrhage and aortic crossclamping to simulate military injury and resuscitation. Half of the animals then received IV TXA, the other half had it administered via IO. Only the bolus dose was given. Serum TXA levels were monitored, and serial ROTEM determinations were performed to evaluate coagulopathy.

Here are the factoids:

  • The serum TXA peak and taper curves were similar. The IV peak was higher than IO and approached statistical significance (0.053)
  • ROTEM showed that the animals were significantly hyperfibrinolytic after injury, but rapidly corrected after administration of TXA. Results were the same for both IV and IO groups.

Bottom line: This was a very simple and elegant study. The usual animal study issues come into play (small numbers, pigs are not people). But it would be nearly impossible to have such a study approved in humans. Even though the peak TXA concentration via IO is (nearly significantly) lower, this doesn’t appear to matter. The anti-fibrinolytic effect was very similar according to ROTEM analysis.

From a practical standpoint, I’m not recommending that we start giving TXA via IO in civilian practice. We don’t typically see military style injuries, and are usually able to establish some type of IV access within a reasonably short period of time. But for our military colleagues, this could be a very valuable tool!

Related posts:

Reference: No intravenous access, no problem: Intraosseous administration of tranexamic acid is as effective as intravenous in a porcine hemorrhage model. J Trauma 84(2):379-385, 2018.

Uber / Lyft For Medical Transport???

In this day and age of ride sharing apps like Uber and Lyft, it is possible to get a cheap ride virtually anywhere there is car service and a smart phone. And of course, some people have used these services for transportation to the hospital in lieu of an ambulance ride. What might the impact be of ride services on patient transport, for both patient and EMS?

A paper in preparation suggests that ambulance service calls decreased by 7% after the introduction of UberX rides. Now, there are a lot of questions here, because the full paper has not yet been peer reviewed, and the results write-up is pretty sketchy. But it does beg the question.

Ambulance rides are expensive. Depending on region, they may range from $500-$5000. And although insurance may reduce the out of pocket cost, it can still be expensive. So what are the pros vs the cons of using Uber or Lyft for medical transport?

Pros:

  • Ride shares are inexpensive compared to an ambulance ride
  • They may arrive more quickly because they tend to circulate around an area, as opposed to using a fixed base
  • Riders may select their preferred hospital without being overridden by EMS (although it may be an incorrect choice)
  • May reduce EMS usage for low acuity patients

Cons:

  • No professional medical care available during the ride
  • May end up being slower due to lack of lights and siren
  • Damage fees of $250+ for messing up the car

Bottom line: Uber and Lyft are just another version of the “arrival by private vehicle” paradigm. Use of these services relies on the customer/patient having very good judgment and insight into their medical conditions and care needs. And from personal experience, this is not always the case. I would not encourage the general public to use these services for medical transport, and neither do the companies themselves!

Reference: Did UberX Reduce Ambulance Volume? Unpublished paper, October 24, 2017.

A Quick and Dirty Test for Traumatic Brain Injury

Traumatic brain injury (TBI) is an extremely common diagnosis in trauma patients. The majority are minor concussions that show no evidence of injury on head CT. Despite normal findings, however, a short conversation with the patient frequently demonstrates that they really do have a TBI.

Scoring systems can help quantify how significant the head injury is. The Glasgow Coma Scale (GCS) score is frequently used. This scoring system is not sensitive enough for minor head injuries, since a patient may be perseverating even with a GCS of 15.

The Short Blessed Test (SBT) is a 25 year old scoring system for minor TBI that has been well-validated. It takes only a few minutes to administer, and is very easy to score.

The most important part of the administration process is choosing a threshold for further evaluation and testing. We administer this test to all trauma patients with a suspected TBI (defined as known or suspected loss of consciousness, or amnesia for the traumatic event). If the final score is >7, we refer the patient for more extensive evaluation by physical and occupational therapy. If the score is 7 or less but not zero, consideration should be given to offering routine followup in a minor neurotrauma clinic as an outpatient. In all cases, patients should be advised to avoid situations that would lead to a repeat concussion in the next month.

Reference: Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry. 1983 Jun;140(6):734-9.

The Electronic Trauma Flow Sheet – Final Answer

After more than 10 years of experience, moving to an electronic trauma flow sheet is still not ready for prime time. I’ve seen many, many hospitals struggling to make it work. And all but a very few have failed.

There are two major problems. First, existing computer input technology is underdeveloped. Trying to rapidly put information into small windows on a computer, and having to switch between mouse and keyboard and back is just too slow. And second, output reports are terrible. Humans cannot scan 26 pages of chronological data and reconstruct a trauma activation in their head. There is so much extra data in the typical computer-generated reports, the signal (potential PI issues) gets lost in the noise.

The technology exists to remedy both of the problems. However, the EHR vendors keep tight control over data exchange in and out of their products. Sure, there is CareAnywhere and it’s ilk, but the user is still forced to use the vendor’s flawed input and output systems.

Bottom line: You can’t make a complex system (trauma care) easier or safer by adding complexity (the EHR). Yet.

The electronic trauma flow sheet will never work as well as it could until all the vendors settle on a strong data interchange standard to put data into and get reports out of the EHR. Once that happens, scores of startup companies will start to design easy input systems and report outputs or displays that are actually meaningful. There’s not enough interest in this niche market to make it worthwhile for a company the size of Epic or McKesson, but there is definitely enough for a lot of young companies just chomping at the bit in Silicon Valley.

The Electronic Trauma Flow Sheet – Part 1

I started voicing my concerns about trying to use an electronic trauma flow sheet (eTFS) way back in 2008. There are very few reports in the literature that specifically detail using the EHR as a trauma flow sheet. The first (see reference 1 below) described an early experience with the conversion process. It outlines lessons learned during one center’s experience, and I’ve not seen any published followup from that center.

Now, on to a report of a “positive” experience. A Level I pediatric trauma center made the same change to the eTFS. They designed a custom menu-driven electronic documentation system, once again using Epic. Specific nurses were trained to act as the

electronic scribe, and had to be present at every trauma resuscitation. The goal of the study was to compare completion rates between paper and electronic documentation. One year of experience with each was collected.

Here are the factoids:

  • There were about 200 trauma activations each year that were admitted, and only 50 or so were highest level activations (in a year!)
  • 11 data elements were compared, including treatments prior to arrival, vitals, fluids, primary survey, level and time of activation, patient and surgeon arrival, and disposition
  • The eTFS was better at capturing time of activation, primary survey components, attending arrival time, and fluid administration

Yes. That’s it. They looked at 11 data points. It says nothing about the wealth of other information that has to be recorded and needs to be abstracted or analyzed. And nothing about the reports generated and their utility. Or how much additional time must be spent by the trauma PI program to figure out what really happened. Or how good their paper documentation was in the first place (not so good, apparently). Or the bias of knowing that your documentation under Epic is being scrutinized for the study.

And to get to that level, this hospital had to maintain a complement of highly trained nurses who were facile with their customized Epic trauma narrator. And they had to maintain their skills despite seeing only one highest level trauma activation patient per week, or one activation at any level only every other day.

I’ve had a few discussions with the trauma program manager from this hospital, and I am convinced that they have managed to make it work well at their center. However, I’m not certain that their system can be generalized to hospitals with higher volumes and and degree of staffing restraints.

In my final post of this series, I’ll tell you what I really think about using the electronic trauma flow sheet in your trauma resuscitations, and why.

References:

  1. Using the electronic medical record for trauma resuscitations: is it possible? J Emerg Nursing 36(4):381-384, 2010.
  2. A comparison of paper documentation to electronic documentation for trauma resuscitations at a Level I pediatric trauma center. J Emerg Nursing 41(1):52-56, 2015.