A set of guidelines for management of blunt solid organ injury in children developed by the American Pediatric Surgical Association was originally published in 1999. One of the elements of the guideline was to place the child on bedrest for a period of time after the injury. Arbitrarily, this period was defined as the injury grade plus one day. So for a grade 3 spleen injury, the child would have to stay in bed for 4 days (!).
A paper published this month looked at the impact of shortening this time interval. Over a 6 year period, all pediatric liver and spleen injuries from blunt trauma were identified and an abbreviated bedrest protocol was implemented. For low grade injuries (grade 1-2), children were kept in bed for 1 day, and for higher grade injuries this was extended to 2 days.
Here are the factoids:
- 249 patients were enrolled (about 40 per year) with an average age of 10. “Bedrest was applicable for 199 patients, 80%.” Huh? Does that mean that 50 patients were excluded due to surgeon preference?
- The organ injured was about 50:50 for spleen vs liver. Twelve children injured both.
- Mean injury grade was 2.7, which is fairly high
- Mean bedrest was 1.6 days, and mean hospital stay was 2.5
- Bedrest was the limiting factor for hospital stay in 62% of cases
- There were no delayed complications of the injury
Bottom line: Come on! Most centers don’t keep adult patients at bedrest this long, and we learned about solid organ injury management from kids! Children almost never fail nonop management, so why treat them more restrictively than adults? And have you ever tried to keep a child at bedrest? Impossible! This study is too underpowered to give real statistically valid results, but it certainly paints a good picture of what works. We’ve been keeping both adults and children at bedrest only overnight, and our average length of stay for isolated solid organs is about 1.5 days. But really, who says that staying in bed for any period of time avoids complications? There are lots of other evil things that can happen!
Reference: Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Ped Surg 48(12):2437-2441, 2013.
Trauma service staffing is important to maintaining trauma center status. Teaching centers in the US have been grappling with resident work hour rules, and non-teaching centers have always had to deal with how to adequately staff their trauma service. What is the impact of staffing a trauma center with midlevel practitioners (MLPs) such as physician assistants and nurse practitioners?
A state designated Level I trauma center in Pennsylvania retrospectively examined the effect of adding MLPs to an existing complement of residents on their trauma service. They examined the usual outcomes, including complications, lengths of stay, ED dwell times and mortality.
Here are the more interesting factoids:
- ED dwell time decreased for trauma activations and transfers in, but it increased for trauma consults. Of note, data on dwell times suffered from inconsistent charting.
- ICU length of stay decreased significantly
- Hospital length of stay decreased somewhat but did not achieve significance
- The incidence of most complications stayed the same, but urinary tract infection decreased significantly
- There was no change in mortality
Bottom line: There is a growing body of literature showing the benefits of employing midlevel providers in trauma programs. Whereas residents may have a variable interest in the trauma service based on their career goals, MLPs are professionally dedicated to this task. This study demonstrates a creative and safe solution for managing daily clinical activity on a busy trauma service.
Reference: Utilization of PAs and NPs at a level I trauma center: effects on outcomes. J Amer Acad Physician Assts, July 2011.
“Bowel sounds are normal”
How often do you see this on an H&P? Probably a lot more often than they are actually listened for, I would wager. But what do they really mean? Are they important to trauma professionals?
(Un)fortunately, there’s not a whole lot of research that’s looked at this mundane item. And pretty much all of it deals with surgical pathology (e.g. SBO) or the state of the postop abdomen. Over the years, papers have been published about the basics, and I will summarize them below:
- Where to listen? Traditionally, auscultation is carried out in all four abdominal quadrants. However, sound transmission is such that listening centrally is usually sufficient.
- Listen before palpation? Some papers suggest that palpation may stimulate peristalsis, so you should listen first.
- How long should you listen? Reports vary from 30 seconds to 7 minutes (!).
- Significance? This is the big question. We’re not expecting to find hyperactive or high pitched sounds suggestive of surgical pathology here. Really, we’re just looking for sounds or no sounds.
But does it make a difference whether we hear anything or not?
Bottom line: In trauma, we don’t care about BS! We’ve all had patients with minimal injury and no bowel sounds, as well as patients with severe abdominal injury and normal ones. We certainly don’t have time to spend several minutes listening for something that has no bearing on our clinical assessment of the patient. Skip this unnecessary part of the physical exam, and continue on with your real evaluation!
Reference: A critical review of auscultating bowel sounds. Br J Nursing 18(18):1125-1129, 2009.
The November newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is Extremities.
In this issue you’ll find articles on:
- Field amputation
- Novel technique for fasciotomy closure
- Use of the arterial pressure index (API)
Subscribers received the newsletter first on Monday. If you want to subscribe (and download back issues), click here.
Download the newsletter here!
The usual thinking is that most unstable trauma patients need a quick trip to the OR to stop the bleeding from something. In the US and Europe, patients with nasty pelvic fractures are no exception, especially those with hemoperitoneum. But many of these patients are bleeding from vessels associated with the pelvic fractures and not so much from associated intra-abdominal injuries. And operative management of pelvic fracture bleeding is far from satisfying, even when using preperitoneal packing.
Well, things are a little different in Japan. In many cases, unstable patients are taken to interventional radiology for angio and possible embolization. Is this prudent, or is it dangerous? A Japanese group decided to critically look at this practice by examining the Japan Trauma Data Bank for answers.
Here are the factoids:
- Patients with pelvic fracture and positive FAST were included, who underwent either laparotomy or angioembolization as their first intervention (n=1153). Those with non-salvageable head injury were excluded, as well as patients who underwent another major procedure first (craniotomy, thoracotomy, ortho procedures, etc.). Only 317 patients remained.
- In-hospital mortality was the primary outcome of interest
- A total of 123 underwent laparotomy first, and 194 went to angio first
- A very small number of patients were hypotensive on arrival (81 laparotomy first, 82 angio first)
- Half of the patients who were hypotensive on arrival went to angio first (!)
- Laparotomy-first patients had a higher crude mortality, but this disappeared when confounders were controlled. This was true in patients who were either normotensive or hypotensive on arrival.
- The authors concluded that the initial intervention should be determined by severity of injury, since in-hospital mortality was no different
Bottom line: Whoa! This is a sweeping statement for a study with so few subjects. Yes, it can be very difficult to determine whether initial bleeding is from the pelvis vs a solid organ or mesenteric injury while in the ED. But it is all too easy to fritter away time (and the patient’s blood/life) in the angiography suite. I recommend trying to stabilize your patient as best you can with fluid and/or blood. If you can maintain a “reasonable” blood pressure, proceed to CT for a quick look at the torso. Then go to the most appropriate location to take care of the problem. And if your patient decompensates in CT or angio, immediately proceed to the operating room!
- Comparison between laparotomy first versus angiographic embolization first in patients with pelvic fracture and hemoperitoneum: a nationwide observational study from the Japan Trauma Data Bank. Scand J Trauma 21:82, 2013.
- Eastern Association for the Surgery of Trauma Practice Management Guidelines for Hemorrhage in Pelvic Fracture-Update and Systematic Review. J Trauma 71:1850-1868, 2011.