Sounds like an easy question, right? In the trauma resuscitation room! But how long can (should) they stay there? Can they leave for testing and come back? As you may expect, there are a lot of variables to consider.
All major trauma patients should start in the resuscitation room. In a few institutions around the world this may be an OR, but this is uncommon. I’m talking about major injuries, multiple fractures, significant potential for blood loss, not the minor stuff. Once the necessary stabilization and evaluation is complete, the patient may need further diagnostics like CT or plain xrays. But once those are done, where does the patient with ongoing resuscitation needs go?
In many cases, they end up back in the ED. Some surgical specialists may want to evaluate them there. They may need minor procedures like suturing or traction pin placement. An ICU bed might not be immediately available. But is this really the right place?
Unfortunately, it isn’t. This class of patient needs ICU care, which includes very close monitoring and ongoing attention to resuscitation. This level of care is just not available in a busy emergency ward. The physicians are seeing other patients, and the nurses may be less familiar with continuously providing this level of care. Arterial line and ICP placement / monitoring is difficult. It’s really not the right place to be.
Bottom line: There are only two places for a complex patient with ongoing resuscitation needs: a surgical ICU or an operating room. The choice depends on whether the patient really needs an operation now. If not, they should be resuscitated in an ICU prior to general anesthesia. The trauma physician must triage all requests for tests or minor procedures from consultants, keeping the overall patient condition in mind. If a particular test will not significantly alter near-term management, it must be postponed. If an ICU bed is not available, the ED resuscitation room may be the only alternative. In this case, a nurse (preferably with ICU experience) must stay with the patient at all times. And an experienced trauma physician should ideally be there as well, if not in person, at least by phone (and quickly). Finally, get the patient to an ICU as soon as humanly possible!
All designating/verifying agencies differentiate between highest level trauma centers (regional resource, or Level I in the US) and an intermediate level center (Level II in the US). For most, the differences are not huge on paper. Level I’s usually require a significant education and research component, as well as continuously available specialists in all disciplines. There are usually minimum volume and/or injury severity requirements as well.
Several previously published reports using NTDB data have shown that mortality is decreased in trauma patients taken to Level I centers compared to Level II. A report out this month confirms this using data from the Pennsylvania Trauma System Foundation database. The authors noted the following:
- Patients admitted to Level I centers were younger and more often male than those admitted to Level II
- Level I’s admitted more patients with gunshots and fewer with same level falls
- Overall, mortality of patients admitted to Level I centers was 15% lower than in those admitted to a Level II
- This survival advantage was principally in the most severely injured patients (20% in patients with ISS >= 25). In lower ISS patients, there was no apparent survival advantage.
- Complication rates were 37% higher in Level I centers!
Bottom line: What does all this actually mean? First, this applies in the US only. Next, this study shows an association, but can’t assign a cause for the better survival. But it is consistent now across a number of studies. The US criteria for Level I centers are fairly stringent. Level II criteria are less so. Some Level II’s function like a Level I, but others are barely better than a Level III. It’s time to figure out what those less tangible differences are and implement them as best practices for all centers, if possible. And, oh yes, we better figure out why the major complication rate in Level I’s is so ridiculously high. It does no good to survive if the patient sustains significant functional limitations due to complications!
Reference: Impact of Trauma Center Designation on Outcomes: Is There a Difference Between Level I and Level II Trauma Centers? Journal Amer Coll Surgeons 215(3):372-378, 2012.
Most emergency departments do not see much penetrating trauma. But it is helpful to be able to learn as much as possible from the appearance of these piercing injuries when you do see them. This post will describe the basics of reading stab wounds.
Important: This information will allow some basic interpretation of wounds. It will not qualify you as a forensics expert by any means. I do not recommend that you document any of this information in the medical record unless you have specific forensic training. You should only write things like “a wound was noted in the midepigastrium that is 2 cm in length.” Your note can and will be used in a court of law, and if you are wrong there can be significant consequences for the plaintiff or the defendant. This information is for your edification only.
1. What is the length of the wound? This does not necessarily correspond to the width of the blade. Skin stretches as it is cut, so the wound will usually retract to a length that is shorter than the full width of the blade.
2. Is the item sharp on one side or both? This can usually be determined by the appearance of the wound. A linear wound with two sharp ends is generally a two sided knife. A wound with one flat end and one sharp end is usually from a one-sided weapon. The picture below shows a knife wound with one sharp side.
3. Is there a hilt mark? This can usually be detected by looking for bruising around the wound. The picture below shows a knife wound with a hilt mark.
4. What is the angle? If both edges are symmetric, the knife went straight in. If one surface has a tangential appearance, then the knife was angled toward that side. You can approximate the direction of entry by looking at the tangential surface of the wound edge. In this example, the blade is angling upward toward the right.
5. How deep did it go? You have no way of knowing unless you have the blood stained blade in your possession. And yes, it is possible for the wound to go deeper than the length of the knife, since the abdominal wall or other soft tissues can be pushed inwards during the stab.
One of the tenets of trauma surgery, handed down for generations, is that we should pack the abdomen to help manage major abdominal hemorrhage. “All four quadrants were packed” reads the typical operative note. But how exactly do you do that? Sounds easy, right?
Well, there are nuances not found in the surgery textbooks. Here are some practical tips for the trauma surgeon:
- Prepare. Have your scrub nurse fluff up about 20 laparotomy pads in advance. The point of packing is two-fold: soak up blood and stop bleeding. Fluffed up pads work better than the flat, rolled up pads shown above. And you will need them fast, so have a supply ready.
- Do you really need to pack? Your patient is hypotensive, and you are convinced the abdomen is the source. You run to the OR, open it and… no blood. So don’t pack. It won’t slow down the (lack of) bleeding, but it is possible to cause serosal tears or worse. Just figure out where the bleeding is really coming from.
- Be careful. Don’t just jam them in there. Carefully place pads over and under the liver. Carefully place a hand on the spleen and push toward the hilum so you can place pads between spleen and body wall. Try not to cause more damage than is already there.
- Penetrating trauma: Pack where you know (or think) the penetrations are first. Basically, if it’s not bleeding there, don’t pack there.
- Blunt trauma: Pack the upper quadrants first. This is where the money is, because the liver and spleen are the top culprits. Then pack the lower quadrants to soak up shed blood.
- Once packed, check for successful control. If bleeding has stopped (or at least decreased significantly) stop and wait for anesthesia to catch up and continue your massive transfusion protocol. If bleeding continues, remove packs from the offending area and try to obtain definitive control. This is now the patient’s only chance, since you can’t stop the bleeding with packing.
- Remove packs in the proper order. In blunt trauma, remove the lower quadrant packs first. They’re not doing anything and just take up valuable space. In penetrating trauma remove the packs in the area of the injury first.
- Get an xray to confirm that all packs are out at the end of the case. Self explanatory. It’s easy to lose a few in the heat of the moment. I’ve seen two bundles (10 pads) left over the liver in one case decades ago!
Pregnant women get seriously injured, too. And pregnancy is an independent risk factor for deep venous thrombosis. We reflexively start at-risk patients on prophylactic agents for DVT, the most common being enoxaparin. But is it safe to give enoxaparin during pregnancy?
Studies have looked at drug levels in cord blood when the mother is receiving enoxaparin, and none has been found. No specific bleeding complications have been identified, either. So from the baby’s standpoint, administration is probably safe.
However, there are two other issues to consider. In a study looking at the use of enoxaparin for prophylaxis in women with a mechanical heart valve, 2 of 8 women (and their babies) died. Both suffered from clots that developed and blocked the valves. Most likely, the standard dose of enoxaparin was insufficient, so monitoring of anti-Factor Xa levels must be done.
The other problem lies in the multi-dose vial of Lovenox (Sanofi-Aventis). Each 100mg vial contains 45mg of benzyl alcohol, which has been associated with a fatal “gasping syndrome” in premature infants. The individual dose syringes do not have this preservative.
Bottom line: It is probably safe to give enoxaparin to pregnant women after trauma. However, it is unclear if the dose needs to be increased to achieve adequate prophylaxis. Only consider using this medication after consultation with the patient’s obstetrician, and use only the individual dose syringes. Otherwise fall back to standard subcutaneous non-fractionated heparin (even though it is a Category C drug by FDA; it is still considered the anticoagulant of choice during pregnancy).