All posts by TheTraumaPro

Timed PI Audit Filters: When Does The Clock Start?

Several of the performance improvement (PI) audit filters typically used at trauma centers include a time parameter. These include:

  • Craniotomy > 4 hrs
  • Laparotomy > 4 hrs
  • OR for open fracture > 8 hrs
  • Compartment syndrome > 2 hrs

The question that needs to be asked is: 2 or 4 or 8 hours after what?

There are several possible points at which to start the clock:

  • Arrival in the ED
  • When the diagnosis is made
  • When the decision to operate occurs

The answer is certainly open to interpretation. Here is my opinion on it:

The purpose of a PI filter is to measure system performance. There are a myriad of system problems that can delay taking a patient to the OR. These include care delays in the ED, delays in getting or interpreting diagnostic tests, delays in contact or response for consultants, delays in diagnosis, delays in OR scheduling or availability, and more. Does it make sense to limit the evaluation of your system by setting one of the later decision points as your start time?

Bottom line: I recommend starting the audit filter clock at the time of patient arrival in the ED. This enables the PI program to evaluate every system that can possibly enable or impede your patient’s progress to the OR.

Followup Cystogram After Bladder Injury

I’ve previously written about management of extraperitoneal bladder injuries. One of the tenets is that every injury needs to have a routine followup cystogram to ensure healing and allow removal of any bladder catheter. I routinely like to question dogma, so I asked myself, is this really necessary? A retrospective registry review from the Ryder trauma center in Miami helped to answer this question.

Over 20,000 records were screened for bladder injury and 87 were found in living patients. Fifty were intraperitoneal injuries, and half of them were caused by pelvic fractures (interesting). All were operated on, and 47 were classified as simple (dome disruption or through and through penetrating) and 3 were “complex” (involving trigone). All trackable patients (42 of the 50) had followup cystograms 9-16 days later. All of the simple injuries had a normal followup exam, but a leak was detected on one of the complex injuries.

There were 42 patients with extraperitoneal bladder injuries. All were due to blunt trauma, and 92% were associated with pelvic fractures. Most were found with CT cystogram. Two patients had operative repair, probably due to the need to fix the pubic bones with hardware. 37 of the 42 were available for followup, and 22% of repeat cystograms were positive (average study done on day 9). In the studies that showed a leak, repeat cystograms were done, and they took an average of 47 days to fully heal.

Bottom line: Patients with extraperitoneal or complex intraperitoneal bladder injuries (trigone) really do need a followup cystogram before removing the bladder catheter. Those who underwent a simple repair of their intraperitoneal injury do not.

Related posts:

Reference: Cystogram follow-up in the management of traumatic bladder disruption. J Trauma 60(1):23-28, 2006.

CIWA Protocol Precautions

The post entitled “CIWA Demystified” is one of the most popular on this blog. This type of symptom triggered therapy for alcohol withdrawal applies some degree of objectivity to a somewhat subjective problem. However, it is possible to take it too far.

A retrospective review of registry patients who received CIWA guided therapy was performed. A total of 124 records were reviewed for appropriateness of CIWA useand adverse events. They found that only about half of patients (48%) met both usage criteria (able to communicate verbally, recent alcohol use). And 31% did not meet either criterion! There were 55 nondrinkers in this study, and even though 64% of them could communicate that fact, they were placed on the protocol anyway! Eleven patients suffered adverse events (delirium tremens, seizures, death). Four of them did not meet criteria for use of the protocol.

Bottom line: In order to be placed on the CIWA protocol, a patient must have a recent history of alcohol use, and must be able to communicate verbally. Some physicians assume that patients with autonomic hyperactivity or psychological distress are withdrawing and order the CIWA protocol. This can  cover up other causes of delirium, or may make it worse by administering benzodiazepines. This represents inappropriate use of the protocol!

Reference: Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc 83(3):274-279, 2008.

Trauma 20 Years Ago: CAVR For Hypothermia

Hypothermia is the bane of major trauma resuscitation, causing mortality to skyrocket. A number of rewarming techniques have been developed over the years. These are classified as passive (the patient generates their own heat) or active (we deliver calories to them), and noninvasive vs invasive. Rewarming speed increases as we move from passive to active and from noninvasive to invasive.

Continuous arteriovenous rewarming (CAVR) is one of the invasive techniques used today. Its use in humans was first reported 20 years ago this month. Larry Gentilello at Harborview in Seattle had experimented with this technique in animals, and reported one case of use in a human who had crashed his car into icy water. After a 20 minute extrication, the patient was pulseless with fixed and dilated pupils, but he regained pulse and blood pressure at the hospital.

The initial core temperature was 31.5C. Peritoneal, bladder and gastric lavage were carried out for warming, as was delivery of warm inspired gas via the ventilator. However, after an hour the temperature had dropped to 29.5C. CAVR was initiated as a last-ditch effort using a jerry-rigged Rapid Fluid Warmer from Level 1 Technologies. The core temperature was raised to 35C after 85 minutes.

The patient did have typical complications (ARDS, acute renal failure), but survived with recovery of his renal and pulmonary function, and a normal neurologic exam. At the time, the authors were unsure whether the complications were due to the near-drowning or the rapid rewarming.

Reference: Continuous arteriovenous rewarming: report of a new technique fo9r treating hypothermia. J Trauma 31(8):1151-1154, 1991.

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Procedural Sedation and Analgesia

The Regions Hospital Multidisciplinary Trauma Conference on August 4 dealt with the use of procedural sedation in the emergency department. The presentation was delivered by Ben Watters MD.

This presentation is 56 minutes long. 

Important disclosure information: off-label use of ketamine is discussed.