All posts by The Trauma Pro

Resuscitation

How To Remember Those “Classes of Hemorrhage”

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The Advanced Trauma Life Support course lists “classes of hemorrhage”, and various other sources list a similar classification for shock. I’ve not been able to pinpoint where these concepts came from, exactly. But I am sure of one thing: you will be tested on it at some point in your lifetime.

Here’s the table used by the ATLS course:

classes_of_shock

The question you will always be asked is:

What class of hemorrhage (or what % of blood volume loss) is the first to demonstrate systolic hypotension?

This is important because prehospital providers and those in the ED typically rely on systolic blood pressure to figure out if their patient is in trouble.

The answer is Class III, or 30-40%. But how do you remember the damn percentages?

multiscore-maxi1

It’s easy! The numbers are all tennis scores. Here’s how to remember them:

Class I up to 15% Love – 15
Class II 15-30% 15 – 30
Class III 30-40 30 – 40
Class IV >40% Game (almost) over!

Bottom line: Never miss that question again!

Equipment, Prehospital

The Rise And Fall Of MAST Trousers

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Remember MAST Trousers (Military Anti-Shock Trousers)? They were a staple of prehospital care starting in the 1970s and lasting through the turn of the century. But what happened after that? They seem to have disappeared. I recently received a question on the topic recently and wanted to share the real story with you readers.

The basic MAST trouser consists of three inflatable compartments: two legs and one covering the abdomen and pelvis. Each can be inflated or deflated separately. The basic concept was first described by a surgeon who wanted to increase blood pressure during neurosurgical procedures in the early 1900s. The US military embraced the concept during the Vietnam war, using it to augment systolic pressure in servicemen in shock.

Military surgeons migrated this device into civilian prehospital care during the mid-1970s, and the American College of Surgeons Committee on Trauma listed this device as essential on all ambulances in 1977. MAST trousers then came into widespread use throughout the 1980s and 1990s.

Early research in the 1970s suggested that this device could provide up to a 20% boost in volume to the upper part of the body when applied. But as occurs with so many new toys, additional research demonstrated that this auto-transfusion effect was actually only about 5% of blood volume. Some significant complications also came to light as lower extremity ischemia and compartment syndromes were described. Ben Taub Hospital published a study in 1987 which showed no improvement in mortality in patients with penetrating injury.

At the end of the century, support for MAST started to dry up. The NAEMSP published a position paper limiting use to ruptured abdominal aortic aneurysms and pelvic fractures with hypotension. The final straw was a review by the Cochrane Collaboration in 2000 that confirmed no reduction in mortality with MAST use.

Although a few older textbooks may still mention MAST trousers, they are no longer the standard of care. There are no longer any accepted indications for their use, and the few trousers that remain are gathering cobwebs in some corner of the trauma basement.

Reference: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.

How to

How To: The Serial Abdominal Exam

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How often have you seen this in an admitting history and physical exam note? “Admit for observation; serial abdominal exams.” We say it so often it almost doesn’t mean anything. And during your training, did anyone really teach you how to do it? For most trauma professionals, I believe the answer is no.

Yet the serial abdominal exam is a key part of the management of many clinical issues, for both trauma patients as well as those with acute care surgical problems.

Here are the key points:

  • Establish a baseline. As an examiner, you need to be able to determine if your patient is getting worse. So you need to do an initial exam as a basis for comparisons.
  • Pay attention to analgesics. Make sure you know what was given last, and when. You do not need to withhold pain medications. They will reduce pain, but not eliminate it. You just need enough information to determine if the exam is getting worse with the same amount of medication on board.
  • Perform regular exams. It’s one thing to write down that serial exams will be done, but someone actually has to do them. How often? Consider how quickly your patient’s status could change, given the clinical possibilities you have in mind. In general, every 4 hours should be sufficient. Every shift is not. And be thorough!
  • Document, document, document. A new progress note should be written, dated and timed, every time you see your patient. Leave a detailed description of how the patient looks, vital signs, pertinent labs, and of course, exact details of the physical exam.
  • Practice good handoffs. Yes, we understand that you won’t be able to see the patient shift after shift. So when it’s time to handoff, bring the person relieving you and do the exam with them. You can describe the pertinent history, the exam to date, the analgesic history, and allow them to establish a baseline that matches yours. And of course, make sure they can contact you if there are any questions.
Equipment, Prehospital

Cool EMS Stuff: The Backboard Washer!

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Backboards are made to get messy. And every time your friendly EMS provider brings you a patient, they invariably have to swab it down to give the next patient a reasonably sanitary surface to lie on. But sometimes the boards get downright nasty and the cleanup job is a major production.

Enter… the backboard washer. I recently saw one of these for the first time at a Level III hospital in Ohio. Fascinating! Pop the board inside and seven minutes later it’s clean. And I mean really squeaky clean. You may think it looks clean and a good hand wash, but just take a look at the effluent water coming out of this washer!

These units use standard 100V 20A power and only require a hot water hookup and a drain. They can wash two boards at once.

Hospitals in the know need to locate one of these next to a work area for completing paperwork and some free food. What could be better?

Reference: Aqua Phase A-8000 spec sheet. Click to download.

Complications

Complications After Single-Look Laparotomy

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Damage control laparotomy (DCL) has been around now for over 25 years. Many, many papers have been written on its benefits, and the decreased mortality for abdominal trauma specifically. In fact, its use has been generalized to trauma for all other body cavities as well.

However, with this improved mortality came an increase in complications. Incisional hernias remain common, as do episodes of delayed small bowel obstruction. Much of the emphasis in traumatic damage control surgery has now shifted to finding ways to close wounds more quickly and reduce the overall complication rate.

In contrast to damage control laparotomy, much less is known about the potential complications associated with the single-look trauma laparotomy.

This procedure is carried out more frequently than DCL, but we have spent less time studying outcomes and risk factors for complications in this group of patients.

The surgery group at Scripps Mercy Hospital in San Diego conducted a statewide retrospective review of a hospital discharge database of adult trauma patients over an eight-year period. Patients with multiple laparotomies were excluded, as it was assumed that these were damage control patients.

The primary outcomes studied were surgical complications, including bowel obstruction, hernia, fistula, wound infection or dehiscence, and evisceration. Complications were recorded during the initial admission, and during any readmissions in the study period.

Here are the factoids:

  • Over 3700 patients were identified as undergoing trauma laparotomy during the study period
  • About 2100 were left for review after excluding those with multiple laparotomies (DCL) or an unclear trauma mechanism
  • 80% of patients were male and 60% had a penetrating mechanism
  • One third of patients were readmitted for a surgery-related complication: SBO 18%, hernia 12%, infection 9%
  • Median time to readmission was about 4 months (range 1 week to 1.5 years)
  • Patients with blunt injury tended to present with complications earlier (6 days) than penetrating injuries (6 weeks)

Bottom line: This paper is unique in that it is one of the few that was able to follow a large patient population for complications occurring both during and after the initial admission. The overall complication rate was surprisingly high (33%), which is similar to that seen after emergency surgery.

Knowing all of this, what should we do? To date, we have not come close to solving the problems of postop adhesive small bowel obstruction, wound infection, and incisional hernia in any surgical population. However, this work points out the importance of counseling our patients about the potential for complications, how to recognize them, and when to present for evaluation and treatment.

Reference: Outcomes after single-look trauma laparotomy: A large population-based study. J Trauma 86(4):565-572, 2019.