CT scan is essential in diagnosing injury, although concerns for unnecessary radiation exposure are growing. These concerns are even greater in children, who may be more likely to have long-term effects from it. This makes avoiding duplication of CT scanning extremely important.
Unfortunately, there are only about 50 pediatric trauma centers in the US, so the majority of seriously injured children are seen at another hospital before transfer. Does CT evaluation at the first hospital increase the likelihood that a repeat scan will be needed at the trauma center, increasing radiation exposure and risk?
Rainbow Babies and Children’s Hospital in Cincinnati looked at 3 years of transfers of injured children from community hospitals. They then looked at how many of those children had an initial head and/or abdomen scan at the outside hospital, and whether a repeat scan of those areas was performed within 4 hours or arrival at Rainbow.
Numbers were small, but here are the results:
- 33 had an outside CT scan, 28 (90%) were repeated
- 6 had an outside abdominal scan, 2 (33%) were repeated
- 55 did not have outside scans, none were repeated at Rainbow. (This is a weird thing to look at. I would hope that the trauma center didn’t have to repeat any of their own scans within 4 hours!)
Bottom line: It is critically important for referring hospitals to use radiation wisely! First, if the patient has obvious injuries that require transfer, don’t scan, just send. If you need to scan to decide whether you can keep the patient, use the best ALARA* technique you can. And trauma centers, please send a copy of your CT protocols to your referring hospitals so they can get the best images possible.
*ALARA = As low as reasonably achievable (applied to radiation exposure). Also known as ALARP outside of North America (as low as reasonably practicable). Click here for more info.
Reference: Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated radiation exposure. J Pediatric Surg 43(12): 2268-2272, 2008.
Most trauma systems set certain prehospital criteria that, when met, direct that patient to a trauma center. It is now well-established that care of these patients results in improved survival if they are managed at those centers. Unfortunately, undertriage is still a problem, meaning that those patients may not always be taken to a hospital most appropriate to care for their injuries. What is the penalty that your patient pays if this happens?
The University of Toronto performed a nice, prospective study across a large region with both urban and rural areas. Database information was analyzed for all victims of motor vehicle crashes who had a severe injury (ISS>15) or who died. Over 6,000 crash victims’ data were analyzed.
Just under half of the victims (45%) were triaged to a trauma center. Of those who were taken to other hospitals, slightly more than half (58%) were transferred to one within 24 hours, but nearly 5% died in the non-trauma center ED. The overall mortality for severely injured patients who were taken to a nontrauma center was 8.7%. This was a 30% increase in adjusted mortality compared to those taken to a trauma center directly.
Bottom line: Follow the rules! EMS authorities and trauma systems should make it a priority to adopt the CDC protocol (see below) or create trauma guidelines based on them that ensure patients with significant injuries are taken directly to a trauma center. Going to the nearest hospital (if it is not a trauma center) or bending to the patient’s preference is not in their best interest (and may kill them)!
Click here to download the Centers For Disease Control and Prevention (CDC) National Trauma Triage Protocol. This should be used as a standard!
Reference: The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis. AAST 2011 Annual Meeting, Paper 50.
CPR has increased the survival rate of patients suffering cardiac arrest, and early bystander CPR has been shown to double or triple survival. The sad truth is that CPR is not frequently performed by the general public. The American Heart Association has attempted to simplify CPR to the point that even untrained bystanders can administer chest compressions without a pulse check and without rescue breathing.
But what happens if that well-intentioned bystander starts CPR in someone who has not arrested? How often does this happen? Can the patient be injured?
The Medical College of Wisconsin reviewed the charts of all patients who received bystander CPR in Milwaukee County over a six year period. There were 672 incidents of bystander CPR. Of those cases, 77 (12%) were not in arrest when assessed by EMS personnel, and the researchers focused on those patients.
EMS response time averaged 5 minutes, and was greater than 10 minutes in only 2 cases. Average patient age was 43(!). The male/female ratio was just about 50:50, and the majority of the incidents took place in the home or residence.
Hospital records were available for further analysis in 72 of the patients. A quarter were sent home, a quarter admitted to a ward bed, and half were admitted to an ICU. Only 12 (17%) had a cardiac-related discharge diagnosis. The next most common discharge diagnoses were near-drowning, respiratory failure and drug overdose. Younger patients (<19) were usually near-drowning victims, and older patients (>54) were most commonly diagnosed with syncope. Five patients did not survive. Only one CPR injury was identified, which was charted as rhabdomyolysis “secondary to having received CPR” (a weak injury diagnosis, in my opinion).
Bottom line: The potential benefit of bystander CPR outweighs the risk of injury or performing it on a victim who is not in arrest. This study shows that, although these patients may not need CPR, they are generally very ill. Given the rapid EMS response times and the younger average age of the victims, no real injuries occurred. The new American Heart Association recommendations are beneficial and should be distributed widely.
Reference: The frequency and consequences of cardiopulmonary resuscitation performed by bystanders on patients who are not in cardiac arrest. Prehosp Emerg Care 15:282-287, 2011.
For decades, the standard of care for irrigation and debridement (I&D) of open fractures has been within 8 hours of injury. There is a growing body of orthopedic literature that says this isn’t necessarily so.
A paper being presented at the AAST meeting in Chicago next week retrospectively looked at their experience with early (<8hrs) vs late I&D in a series of 248 patients. They looked at infection rates stratified by time and upper vs lower extremity.
They found that the infection rates overall were not significantly different. However, when subgrouped by extremity and higher Gustilo type >= III, they noted that both delayed I&D and Gustilo type correlated with infection risk. For the upper extremity, only Gustilo type >= III correlated with a higher infection rate.
The authors concluded that all lower extremity open fractures should be dealt with in the 8 hour time frame, whereas upper extremity fractures can be delayed for lower Gustilo classes.
Bottom line: I don’t necessarily buy into all the results from this small study. The orthopedic literature has already refined this concept. At Regions Hospital, we allow up to 16 hours to I&D for open fractures up to and including Gustilo class IIIA. Above that, the 8 hour rule is followed. We periodically review our registry data on all open fracture patients to make sure that the extended time frame patients are not experiencing an increase in wound complications. And they haven’t in our 8 year experience in handling them this way.
Refresher on the Gustilo classification system:
- Class I – open fracture, clean wound, <1cm laceration
- Class II – clean wound, laceration >1cm with minimal soft tissue damage
- Class IIIA – clean wound, more extensive soft tissue damage or laceration, periosteum intact, minimal contamination
- Class IIIB – extensive soft tissue damage with periosteal stripping or bone damage, significant contamination
- Class IIIC – arterial injury without regard for degree soft tissue injury
Reference: Open extremity fractures: does delay in operative debridement and irrigation impact infection rates? AAST 2011 Annual Meeting, Paper 22.
Intubation is the one procedure that provokes the most anxiety for trauma professionals. What about those facial fractures? What if you can’t get it? Video-assisted intubation is now readily available and at a reasonable cost. And it seems like a great idea, but does it make intubation easier?
A paper to be presented at the AAST next week looked at intubation success among relatively inexperienced users, junior residents. They compared success rates of video assisted (VA) intubation in an ICU (74 patients) with direct laryngoscopic (DL) intubation performed in an ED (54 patients).
All patients were successfully intubated by the junior resident, or by a more senior backup if they were unsuccessful (fellow or attending). The junior residents were successful in 96% of the VA intubations, but in only 76% of DL intubations. Less experienced residents (<20 intubations) were successful in all 96% of the VA intubations but in only 40% of the DL. And the least experienced, those who had done less than 5 intubations, obtained an airway with VA 37% of the time vs 7% for DL. The number of desaturations to less than 80% and hospital mortality was the same for the two groups.
Bottom line: Video assisted intubation is superior to the old-fashioned direct laryngoscopic technique. Even inexperienced providers have a better success rate with the video assisted technique. Over the next few years, it will become the standard for intubating patients, both in the field by medics and in the hospital.
Reference: The emergent airway: video-assisted intubation is superior to direct laryngoscopy for teaching junior residents. AAST 2011 Paper #65.