All posts by TheTraumaPro

The 30:60 Rule For Interventional Radiology

Interventional radiology (IR) can be a very helpful adjunct to the evaluation and management of trauma patients. I’m going to talk specifically about using it for blunt trauma today because the use in penetrating trauma can be a little more nuanced.

For blunt trauma, IR is used primarily to stop bleeding. In a smaller subset of patients, this tool is used to evaluate pulse deficits. There are two basic principles that apply in either case, and I’ve wrapped them up into a single concept: the 30:60 rule for interventional radiology. 

Of course, the second law of trauma still applies: hypotensive patients cannot leave the ED to go anywhere but the OR. Once you make sure you are not violating that one, you can start the process of going to IR.

The two portions of the rule are times: the time for the IR team to arrive to start the evaluation, and the maximum time allowed for them to succeed, hence the 30:60 numbers.

The maximum acceptable time for the patient to wait until the IR team is ready for them is typically 30 minutes. US trauma center verification requires a reasonable arrival time frame, and the vast majority of hospitals have a 30 minute expectation if the team is not already in place. This response time needs to be monitored by the trauma performance improvement program (PI) and addressed if it ever exceeds the limit.

The second number is the maximum time the radiologist is given to be successful. Like other physicians, radiologists like to do a good job and finish the work they start. If they find a particularly tortuous splenic artery to navigate, they will persist at trying to get through it in order to do a selective embolization and kill the smallest piece of spleen possible. Unfortunately, this takes time and radiation (lots). And a bleeding patient is running out of time.

The good thing is that there are surgical alternatives to most of the tasks the radiologist is working on. True, some are much more difficult surgically, like managing a shattered liver or dealing with a bleeding pelvis. In those cases, I may let the interventionalist work a little longer while I keep up with blood transfusions and monitor patient status.

Bottom line:

  • Expect a 30 minute response time from the IR team
  • Let the radiologist know they have about 60 minutes to succeed. If it looks like they can’t make that, have them go to plan B (e.g. main splenic artery embolization instead of selective)
  • Make sure an experienced trauma physician is watching the patient for decompensation and is managing fluids and blood products (no pressors!)
  • If the patient decompensates at any point, they are done in IR and must proceed to OR

Operative Management Of TBI By Non-Neurosurgeons?

In the US, Level I and II trauma centers are required to have around the clock neurosurgical coverage. This becomes problematic, especially in more rural areas, because they are a scarce resource. This problem is not limited to the States, and other countries have learned how to deal with it in their own ways.

A recent paper from Austria and the Slovak Republic looked at how this issue is dealt with at some centers in central Europe, and the impact of having neurosurgical procedures performed by trauma surgeons. The researchers looked at various databases maintained by 10 tertiary care hospitals in a retrospective fashion. Patients were included if they had a GCS of 8 or less and they survived to ICU admission. Some centers had neurosurgeons available, while others had only trauma surgeons. Procedures were performed by the appropriate type of surgeon in each center.

A total of 743 patients were evaluated, and about 68% underwent a neurosurgical procedure while 6% had an ICP monitor inserted. About a quarter of these patients had other significant associated injuries and were excluded, since the authors were interested in measuring effects in TBI patients. This left 311 patients, of whom 61% were treated by neurosurgeons and the remainder by trauma surgeons.

Here are some of the interesting findings:

  • Prehospital airway was provided more frequently in the neurosurgical treatment group, which should potentially improve outcome
  • ED management time and time to OR was shorter in the neurosurgical treatment group, which should also potentially improve outcome
  • However, there was no difference in ICU survival, hospital survival, or long-term outcome!

Bottom line: This is an interesting but poorly constructed study. Don’t believe the results! Other researchers’ leftover databases were used, and some databases were excluded because “quality of care was not comparable” to other centers. This is the worst kind of selection bias! If you believe the results, then you would also have to believe that airway control and prompt operative management don’t really matter much. The paucity of neurosurgeons who are interested in trauma care is pervasive. However, we still need to look for solutions to this problem and they remain a very valuable member of the trauma team.

Reference: Outcome of patients with severe brain trauma who were treated either by neurosurgeons or by trauma surgeons. J Trauma 72(5):1263-1270, 2012.

Predicting Escalation Of Domestic Violence

Most trauma professionals will have the opportunity to provide care for victims of domestic violence some time during their career. We are on the front lines and can unfortunately see the damage first hand. From time to time, the abuse escalates to a point where the woman (typically) is murdered. Is there a way to predict this fatal progression so it can be avoided?

The answer is yes! The Danger Assessment Tool (DAT) was developed 25 years ago and has been validated. Even though the instrument is old, it remains extremely helpful. The unfortunate thing is that at least half of the women involved do not recognize the grave peril they are in.

Some key points that were uncovered in the development of the DAT:

  • If a gun or other weapon is used to threaten, the risk of being murdered increases 20-fold
  • If there is merely a gun in the house, the risk of murder increases 6 times
  • If the abuser threatens murder, the risk of being killed increases 15-fold
  • Other indications of increased risk of death include heavy substance abuse, extreme jealousy, stepchild in the household, attempts to choke and forced sex

Bottom line: Domestic violence is criminal. We must go beyond the physical treatment and make sure these individuals are safe. Use the Danger Assessment Tool routinely to help identify women most at risk of losing their lives and bring all your social services resources to bear to keep them safe!

Download: Danger Assessment Tool

References:

  • Campbell, Jacquelyn C., Assessing Dangerousness: Violence by Sexual Offenders, Batterers, and Child Abusers, Newbury Park, CA: Sage Publications, 1995.
  • Campbell, Jacquelyn C. , Phyllis W. Sharps, and Nancy Glass, “Risk Assessment for Intimate Partner Violence,” in Clinical Assessment of Dangerousness: Empirical Contributions, ed. Georges-Franck Pinard and Linda Pagani, New York: Cambridge University Press, 2000: 136–157.

CT Contrast Administration Via Intraosseous Cathether

The standard of care in vascular access in trauma patients is the intravenous route. Unfortunately, not all patients have veins that can be quickly accessed by prehospital providers. Introduction of the intraosseous device (IO) has made vascular access in the field much more achievable. And it appears that most fluids and medications can be administered via this route. But what about iodinated contrast agents via IO for CT scanning?

Physicians at Henry Ford Hospital in Detroit published a case report on the use of this route for contrast administration. They treated a pedestrian struck by a car with a lack of IV access sites by IO insertion in the proximal humerus, which took about 30 seconds. They then intubated using rapid sequence induction, with drugs injected through the IO device. They performed full CT scanning using contrast injected through the site using a power injector. Images were excellent, and ultimately the patient received an internal jugular catheter using ultrasound. The IO line was then discontinued.

This paper suggests that the IO line can be used as access for injection of CT contrast if no IV sites are available. Although it is a single human case, a fair amount of studies have been done on animals (goats?). The animal studies show that power injection works adequately with excellent flow rates.

The authors prefer using an IO placement site in the proximal humerus. This does seem to cause a bit more pain, and takes a little practice see the video above). A small xylocaine flush can be administered to reduce injection discomfort in awake patients. Additionally, the arm cannot be raised over the head for the torso portion of the scan.

Bottom line: CT contrast can be injected into an intraosseous line (IO) with excellent imaging results. Insert the IO in a site that you are comfortable with. I do not recommend power injection at this time. Although the marrow cavity can support it, the connecting tubing may not. Have your radiologist hand-inject and time the scan accordingly.

Note: long term effects of iodinated contrast in the bone marrow are not known. For this reason, and because of smaller marrow cavities, this technique is not suitable for pediatric patients.

Related post: Air embolism from an intraosseous line

Reference: Intraosseous injection of iodinated computed tomography contrast agent in an adult blunt trauma patient. Annals Emerg Med 57(4):382-386, 2011.

Helicopter Transport of Trauma Patients Saves Lives

Helicopter EMS (HEMS) transport of trauma patients is used primarily to decrease the amount of time between injury and arrival at the trauma center. Unfortunately, efficacy studies have provided conflicting answers as to whether this is actually true. Last year, the CDC completed a large sample study of this issue using the National Trauma Data Bank (NTDB) in an attempt to determine if HEMS flights are effective.

Using almost 150,000 entries in the NTDB for 2007, they were able to isolate over 56,000 adult records with complete data points. They looked for mortality patterns based on age, injury severity, and revised trauma score, comparing patients who were transported by air vs ground.

They found the following:

  • Odds of dying in-hospital were 39% lower overall when transported by helicopter
  • This survival advantaged disappeared for patients age 55 and older, possibly because of decreased reserve, comorbidities, more complications, or medications that interfere with successful resuscitation
  • Regardless of type of transport, males always fared worse than females

Bottom line: This is a large and intriguing study. About 85% of the US population has access to a Level I or II trauma center within an hour. However, a third of those can only get there in that period of time if transported by air. This mode of transport has a significantly lower mortality rate. However, there are cost and safety considerations as well. The key now is to figure out which patients will have the best outcomes after air transport. This will require more work, looking at more than just mortality (e.g. disability, complications). And what’s the deal with men having poorer outcomes???

Reference: Reduced mortality in injured adults transported by helicopter emergency medical services. Prehospital Emerg Care 15(3):295-302, 2011.