All posts by TheTraumaPro

EAST 24th Annual Scientific Assembly

I’m currently attending the EAST annual meeting. I’ll be tweeting about all the interesting papers and events that are presented. In order to make them easy to find, I’ll be using the hashtag #east2011

In addition I’ll also be doing a more in-depth analysis of some of the more interesting abstracts. You can find the abstracts for all the oral presentations here. Feel free to send me requests to talk about the ones you find fascinating!

Does Interrupting DVT Prophylaxis Increase Risk for DVT/PE?

Deep venous thrombosis is a common concern in trauma care. Most trauma centers have well defined protocols for prophylaxis and surveillance. Ongoing use of pharmacologic thromboprophylaxis (PTP) in patients with traumatic brain injury (TBI), or in patients who need surgical procedures is controversial.  We have all experienced some form of “prophylaxis interruptus”, where our orthopedic or neurosurgical colleagues want us to forego or interrupt ongoing administration of heparin products. Does this create new problems?

A trial was conducted at two Denver trauma centers, trying to clarify the optimal administration of PTP in patients with stable TBI. One cohort received PTP, the other did not (either not indicated, short stay, or already on blood thinners). The group receiving PTP was also stratified into those who received it continuously and those who had interruptions in treatment.

They found that the incidence of DVT and PE was similar for patients receiving PTP vs those not receiving it. The two groups were very different, though, because the ones who did not receive it had less severe injuries and were more likely to be ambulating by discharge.  The most interesting finding was that being started on PTP and then interrupting it increased the incidence of DVT fourfold.

What is it about prophylaxis interruptus that is so risky? First, there were only 480 patients in this study, so statistical anomalies could be present. Could it be that the conditions (TBI) and operations that cause it to be interrupted greatly increase the risk? Unfortunately this study can’t answer those questions.

The bottom line: DVT and its prophylaxis is still a muddy concept. What we really need to do is to find out if PTP is really necessary in all the patients in whom we are using it. It would also be helpful if we knew how harmful it really is in patients with significant bleeding in their head, or in patients who need to undergo surgery. One alternative, if this paper pans out, is to begin with mechanical prophylaxis until cleared by neurosurgery and all operations are completed. For now, it’s not yet appropriate to change your existing practice and procedures.

Reference: Interrupted pharmocologic prophylaxis increases venous thromboembolism in traumatic brain injury. J Trauma 70(1):19-26, 2011.The term “prophylaxis interruptus” was coined by Tom Esposito in his discussion of this paper.

AAST Revises Renal Injury Grading

Organ injury scaling was developed to give clinicians and researchers a common language for describing and studying the effects of trauma. The Organ Injury Scaling classification for kidney injuries was developed by the AAST in 1989. Over time, it was recognized that grades IV and V were somewhat confusing, and some injuries were not originally included. An updated grading system was published this month to correct these shortcomings.

Grades I, II, and III remain unchanged. Grades IV and V are updated as follows:

  • Grade IV – originally encompassed contained injuries to the main renal artery and vein, and collecting system injuries. Revision: adds segmental arterial and venous injury, and laceration to the renal pelvis or ureteropelvic junction. Multiple lacerations into the collecting system used to be considered a shattered kidney (Grade V), but now remains Grade IV.
  • Grade V – orignally included main renal artery or vein laceration or avulsion, and multiple collecting system lacerations (shattered kidney). The revised classification includes only vascular injury (arterial or venous) and includes laceration, avulsion or thrombosis.

Reference: Revision of current American Association for the Surgery of Trauma renal injury grading system. J Trauma 70(1):35-37, 2011.

How To Identify Sick Pediatric Trauma Patients Before They Get Too Sick

We all have a pretty good idea of when an inpatient adult trauma patient is getting into trouble. Most rapid response teams have a set of criteria that are used by nursing personnel to initiate an RRT response. However, children who are beginning to decompensate can show it in more subtle ways. Fortunately, there is a tool that can be used to identify children who are showing early signs of developing problems.

The Pediatric Early Warning Signs tool (PEWS) is an objective system for assessing the potential for deterioration in a child. It can be customized based on institutional needs, and typically has behavioral, cardiovascular, and respiratory components. At our pediatric trauma center, we added a urinary output component as well. Scoring for each component ranges from 0 (best) to 3 (worst).

The total score is calculated, and is used to classify the child as green (benign) to red (immediate action needed). Again, these thresholds can be adjusted by each hospital. At our center, nursing calculates the PEWS score every 4 hours on non-ventilated patients.

Score category and actions are as follows:

  • Green (0-3 points) – no action, reassess as ordered
  • Yellow (4-6 points) – notify charge nurse, resident and attending physician
  • Red (7 or more points) – call rapid response team, resident and attending physician
  • A score of 3 in any category – call resident and attending physician

We implemented this system earlier this month and will be validating it during the coming year. Our hope is that it will reduce the number of RRT and code calls by identify deterioration at a much earlier stage.

You can download a copy of our PEWS instrument here. Thanks to Tracy Larsen RN, our pediatric Trauma Program Manager, for providing information on this system.


Trauma Care on the Largest Cruise Ship in the World

During my recent cruise on Royal Caribbean’s Allure of the Seas, I had the opportunity to visit the medical center and check out the ship’s trauma care capabilities.

The major cruise lines, including Royal Caribbean, abide by the “Health Care Guidelines for Cruise Ship Medical Facilities” published by the American College of Emergency Physicians (ACEP). This document outlines the staffing, space, equipment and administrative capabilities needed to provide the highest quality of care at sea. 

The ship is staffed by three emergency physicians and five nurses. Each physician is on call for a 24 hour period and has the following day off. The doctors and nurses provide comprehensive medical coverage to passengers and crew for both emergent and non-emergent problems. All of the physicians are ATLS certified, and some are ATLS instructors.

The medical staff responds to medical emergencies around the ship (code alpha) and have regular clinics in the medical facility for patients with less urgent problems. There is a specific treatment room for surgical / trauma problems that is well stocked with equipment for all procedures that might be required. This includes chest tubes, airway equipment, fracture care and more. A separate treatment room for medical patients can also be used as an ICU, with ventilators, invasive monitoring, and vasoactive medication drips. There are a number of other exam and treatment rooms that are used for patients with less urgent problems.

Digital xray equipment is available for conventional imaging, and the laboratory can do most routine tests as well as a few more exotic ones. Many of the tests are performed using iStat type equipment. The pharmacy carries a wide variety of medications. Due to space constraints, only one drug of each particular class is carried, which is sufficient for the majority of medical issues.

If patients sustain significant injuries that require services not available in the medical facility, they can be airlifted off the ship if it is within 150 miles of a port. If not, the medical treatment room is converted to an ICU and the patient remains there until they can be moved off the ship.

I was quite impressed with the facility and how much can be done in the available space. The staff is quite skilled and personable, and very aware of their capabilities. They are also in tune with the capabilities of the hospitals in the various ports of call, and have well thought out procedures regarding who can be taken care of on the ship and who needs to be transferred ashore.

Being a paranoid trauma surgeon, I always think about which trauma centers are nearby when I travel. After seeing the medical facility on the Allure, I am quite comfortable that they can handle the vast majority of traumatic injuries that might arise on the ship.