All posts by TheTraumaPro

Scoop And Run VS Stay And Play: Evolution

I previously published a series on the concept of scoop and run vs stay and play. For those new to the concept, it involves decision-making by prehospital providers to throw the patient into the ambulance and book it to the trauma center, or perform potentially life-saving interventions on scene first.

I’m going to repost the series first to give you a historical perspective on this idea. Then I’ll finish up with the results of a recent multi-center trial conducted by EAST to provide the finishing touch.

For trauma patients time is the enemy and there are two different flavors of scoop and run vs stay and play. The more commonly understood one has to do with treating on scene (or not) before going to a high level (I or II) trauma center. The other flavor that rural prehospital providers face is, do I take the patient to a nearby hospital that is not a high level trauma center (III or IV) to stay and play, or do I scoop and run to the nearest Level I or II center which may be farther away?

Here are the factoids:

  • Admissions to a group of 8 trauma centers were analyzed over a 3 year period, and included a total of 1112 patients
  • A total of 76% were taken directly to a Level I trauma center (scoop and run, 76%); 24% were transferred to the trauma center from another hospital (stay and play?).
  • Patients who were taken to a non-trauma center first received 3 times more IV crystalloid, 12 times more blood, and were nearly 4 times more likely to die!

Obviously, the cause of this increased mortality cannot be determined from the data. The authors speculated that patients may undergo more aggressive resuscitation with crystalloid and blood at the outside hospital making them look better than they really are, and then they die. Alternatively, they may have been under-resuscitated at the outside hospital, making it more difficult to ensure survival at the trauma center.

Bottom line: This is an interesting paper, but it’s kind of a mutant. When I think about the true stay and play concent, I’m really thinking about delays going to a high-level trauma center, not a lower level trauma hospital first! And the authors never really define a “nontrauma hospital.” Does a Level III or IV center count? How did patients who stayed at the outside hospital do?

Obviously, a lot of work needs to be done to add detail to this particular paper. In my next post, I’ll look at this concept as it applies to patients with penetrating injury.

Reference: Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer’s effect on mortality. J Trauma 69(3):595-601, 2010.

TXA Hesitancy: Part II

In my last post, I reviewed a huge systematic review and meta-analysis of the use of tranexamic acid (TXA)  by all medical disciplines using it. There were more than 125,000 cases included and showed the incidence of thrombotic complications in TXA vs non-TXA patients was exactly the same at about 2%.

Our orthopedic surgery colleagues have been using TXA to reduce bleeding in their cases for decades. There is nothing close to the degree of “TXA hesitancy” in orthopedic surgeons than I see in surgical practices across trauma centers. What do the orthopods know that we don’t?

Trauma orthopedic groups in Malta and the UK published a paper just this month in which they performed a systematic review and meta-analysis of the use of TXA in hip fracture surgery. They focused on randomized, controlled trials published after 2010. A standard approach was used in the analysis, which looked specifically at the impact of IV TXA on transfusion requirements in surgery. Only adults were studied, and eligible studies compared TXA with a placebo, or TXA with no TXA.

Here are the factoids:

  • Out of 85 studies initially identified, only 13 met all criteria
  • Across these trials, a total of 1194 patients were enrolled
  • The need for blood transfusion was reduced by more than 50% when the transfusion threshold was Hgb 8g/dl, which was highly statistically significant
  • When a higher transfusion threshold was used (between 8-10 g/dl Hbg) the risk reduction was only 23% which was not significant
  • The incidence of thrombotic events was identical for TXA and no-TXA groups

Bottom line: This paper presents more high-quality evidence that the use of TXA in surgically induced injury (hip fracture repair) significantly reduces the need for transfusion in the group with the most blood loss. 

However, as with any meta-analysis the results are only as good as the quality of the individual papers. There were differences in how the TXA was given. It was also not possible to separate out results from the various types of hip surgery performed. And obviously, these are not major, multi-trauma patients.

Most TXA hesitant surgeons are either concerned with the efficacy of TXA, or the potential risks. This paper shows that, overall, TXA is effect in these patients despite the mix of doses and timing of delivery. And it clearly shows that the risk for thrombotic complications was identical to that of not giving it.

We have a cheap, effective tool to reduce the need for blood transfusion (read “blood loss”) in trauma patients that has a totally neutral risk profile for thrombosis. We all need to ask ourselves, “why are we not using it?”

Reference: The Use of Tranexamic Acid in Hip Fracture Surgery — A
Systematic Review and Meta-analysis . J Orthop Trauma, 36(2):e442-3448, 2022.

TXA Hesitancy: Part I

I’ve visited several hundred trauma centers over the past 25 years, and recently I’ve begun to appreciate that there are two tribes when it comes to the use of tranexamic acid: the TXA believers and the TXA hesitant.

There have been a number of large studies that seem to suggest a benefit with respect to survival from major hemorrhage, particularly if given soon after injury (CRASH-2, MATTERs). This drug is dirt cheap and has been around a long time, so it has a clearly defined risk profile.

However, many of those hesitant to use it point to the possibility of thromboembolic events that have been sporadically reported. Several years ago, I did my own literature review and found that the number of thrombotic events from TXA was nearly identical to that of transfusing plasma.

JAMA Surgery published a large systematic review, meta-analysis, and meta-regression last year that sought to examine the association between thromboembolic events (TE) in patients of any age and involving all medical disciplines, not just trauma.

The anesthesia group at the University Hospital Frankfurt in German did a systematic search of the Cochrane Central Register of Controlled Trials, as well as MEDLINE, for randomized controlled trials involving TXA. They covered all published studies through December 2020.

The authors adhered to standard guidelines for conducting reviews and meta-analysis (PRISMA). They specifically searched for outcomes involving TEs, such as venous thromboembolism, myocardial infarction or ischemia, limb ischemia, mesenteric thrombosis, and hepatic artery thrombosis. They also tallied the overall mortality, bleeding mortality, and non-bleeding mortality.

Here are the factoids:

  • A total of 216 eligible trials were identified that included over 125,000 patients (!)
  • Total TEs in the TXA group were 1,020 (2.1%) vs 900 (2.0%) in the control group
  • Studies at lowest risk for selection bias showed similar results

Bottom line: The authors concluded that IV TXA, irrespective of the dose, does not increase the risk of thromboembolic events. Period.

In my next post I’ll describe an even more recent systematic review and meta-analysis in orthopedic patients. Our orthopedic colleagues have been using this drug successfully for hip surgery for decades. Let’s see what they think.

Reference: Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality A Systematic Review, Meta-analysis, and Meta-regression. JAMA Surgery 156(6):3210884, 2021.

How To Avoid Missed Injuries

I’ve just spent two days here looking at the phenomenon of “delayed diagnosis” or missed injury. I believe that there are only two fundamental reason why this occurs:

  • Insufficient diagnostic technique – A good physical exam and/or specific diagnostic techniques were not performed. Or rarely, the injury cannot be readily detected by existing techniques and technology. The former is usually the real problem, and may be an issue with either the physical exam completeness and/or technique, or judgment used to obtain the appropriate diagnostic test. Example 1: a penetrating injury to the back is missed because the patient is not logrolled to examine this area. Example 2: a spine fracture is missed in an elderly patient with a fall from standing because the back pain found on physical exam is evaluated only with conventional imaging of the spine, not CT.
  • Failure to recognize the injury – The injury was actually identified on a test, but was not appreciated by the clinician. Example 1: the radiologist may not have appreciated and reported out a subtle anomaly in the cervical spine imaging. Example 2: you fail to check you patient’s lab tests and miss a sudden spike in serum amylase or lipase the day after your patient was kicked in the epigastrium by a horse.

So what can you do to avoid this potential problem? Here are some tips:

  • Admit that it can really happen to you. If the missed injury rate at your center is off the low end of the bell curve (< 5%) then you are either really good or really blind. You’d better take a close look at your performance improvement process, because you may be fooling yourself.
  • Adopt a firm definition of “delayed diagnosis.” Basically, you need a time frame after which a new diagnosis is considered “delayed.” It should be a reasonable time interval after the patient has left the ED. If it’s too short an interval (e.g. once they leave the ED), your number will be unnecessarily high. If it’s too long (days and days later), then significant morbidity may occur that you don’t account for. Most centers have adopted 24, 36, or 48 hours after patient arrival.
  • Implement a tertiary survey process. This is a complete physical re-examination followed by a review of all diagnostic studies (lab and radiology) that have been performed. This exam needs to be dated and timed to ensure that it is performed within the time frame noted above. If a new finding is discovered on the tertiary survey, it is not considered a delayed diagnosis. If found after the survey (or after the pre-determined time interval), it is and must be entered into your performance improvement process.
  • Be paranoid. I hate the phrase, “maintain a high index of suspicion” because it’s meaningless. It’s like those stupid “start seeing motorcycles” bumper stickers. You can’t see what you can’t see. But you can be suspicious all the time, constantly looking for the inevitable clinical surprises of trauma care. 

Does The Tertiary Survey Really Work?

Delayed diagnoses / missed injuries are with us to stay. The typical trauma activation is a fast-paced process, with lots of things going on at once. Trauma professionals are very good about doing a thorough exam and selecting pertinent diagnostic tests to seek out the obvious and not so obvious injuries.

But we will always miss a few. The incidence varies from 1% to about 40%, depending on who your read. Most of the time, they are subtle and have little clinical impact. But some are not so subtle, and some of the rare ones can be life-threatening.

The trauma tertiary survey has been around for at least 30 years, and is executed a little differently everywhere you go. But the concept is the same. Do another exam and check all the diagnostic tests after 24 to 48 hours to make sure you are not missing the obvious.

Does it actually work? There have been a few studies over the years that have tried to find the answer. A paper was published that used meta-analysis to figure this out. The authors defined two types of missed injury:

  • Type I – an injury that was missed during the initial evaluation but was detected by the tertiary survey.
  • Type II – an injury missed by both the initial exam and the tertiary survey

Here are the factoids:

  • Only 10 observational studies were identified, and only 3 were suitable for meta-analysis
  • The average Type I missed injury rate was 4.3%. The number tended to be lower in large studies and higher in small studies.
  • Only 1 study looked at the Type II missed injury rate – 1.5%
  • Three studies looked at the change in missed injury rates before and after implementation of a tertiary survey process. Type I increased from 3% to 7%, and Type II decreased from 2.4% to 1.5%, both highly significant.
  • 10% to 30% of missed injuries were significant enough to require operative management

Bottom line: In the complex dance of a trauma activation, injuries will be missed. The good news is that the tertiary survey does work at picking up many, but not all, of the “occult” injuries. And with proper attention to your patient, nearly all will be found by the time of discharge. Develop your process, adopt a form, and crush missed injuries!

Reference: The effect of tertiary surveys on missed injuries in trauma: a systematic review. Scand J Trauma Resusc Emerg Med 20:77, 2012.