All posts by TheTraumaPro

What Would You Do? The Elderly Patient With Subdural Hematoma – Part 2

I described several variations on the theme of elderly patients and subdural hematoma in my last post. All were situations in which an operation was not immediately indicated. Practice guidelines were in place to smooth the evaluation process for such patients. But do those guidelines really apply in some or all of these cases?

The real question that needs to be answered is “what is the real purpose of the guideline?”

Is it designed to standardize and streamline care? Certainly. But what is it’s real purpose? It is supposed to separate those who need additional treatment from those who do not. So in this case, it seeks to identify patients who are likely to need surgical intervention for their lesion.

In scenario 2, where the patient presents 8 hours after the fall, the “evaluation timer” started at the time of the event. If your practice guideline dictates that you obtain a repeat head CT 6 hours after arrival in the ED, isn’t your first scan at 8 hours really the same as the repeat scan? Shouldn’t you just need the one image, then send them home if they have a normal neurologic exam?

And isn’t there a point at which surgical intervention is no longer an option? That’s what makes scenarios 3-5 more difficult. Can we identify a subset of patients for whom surgery is not an option? For those who have a written “do not resuscitate” status (scenario 4) and don’t change their mind, is any followup evaluation needed at all?

For the other scenarios, we really need to know if there are subsets of patients for whom surgical intervention is inadvisable or contraindicated. Those patients should not need followup studies or even additional monitoring. One could even argue that they don’t need to be seen in an ED at all!

Lots of questions! In my next post, I’ll review some of the data on outcomes after brain surgery for traumatic injuries in elderly patients. Hopefully, we can come to some conclusions and/or recommendations for my scenarios based on this data!

 

What Would You Do? The Elderly Patient With Subdural Hematoma

All trauma centers are seeing a steady increase in the number of elderly patients, particularly victims of falls. Frequently, these patients strike their head, and some develop various flavors of intracranial hemorrhage. Several are taking drugs that interfere with clotting or platelet function.

Many centers, like my own, have developed practice guidelines to help trauma professionals deal with these issues in a consistent fashion. But are the guidelines suitable for all elderly head-injured patients?

Let’s consider a case.

Scenario 1. An elderly female falls at her senior living facility, striking her head on a side table.  She is brought to your center’s emergency department for evaluation. An exam and head CT are performed, which demonstrate an asymptomatic 6mm subdural hematoma with no midline shift. The patient is not taking any drugs that would interfere with clotting. You have a clinical practice guideline that requires neurologic monitoring for 6 hours, followed by a repeat CT scan. If the neurologic exam remains stable and the repeat CT shows no progression of the lesion, the patient may be discharged.

Seems pretty straightforward, right? Now let’s add some interesting tidbits.

Scenario 2. Same as above, but the patient is brought to your center the next morning, 8 hours after the fall.

Scenario 3. Same as scenario 1, but the patient is very demented.

Scenario 4. Same as scenario 1, but the patient has a well-documented “do not actively resuscitate” order in place.

Scenario 5. Same as scenario 1, but the patient is 95 years old.

Think about these carefully. Would the extra findings in scenarios 2-5 cause you to change your practice and diverge from the practice guideline? In what ways? What else do you need to know to make good decisions?

Over my next few posts, I’ll consider each of these cases. I’ll cite some of the pertinent literature that I think we need to know. Then I’ll finish up with my take on each of the scenarios.

As always, feel free to share your thoughts about them. You can email, leave comments at the end of this post, or shout it out on Twitter. I’ll respond to each and every one.

Retained Hemothorax: The Practice Guideline

Over the last few days, I’ve reviewed some data on managing hemothorax, as well as the use of lytics. Then I looked at a paper describing one institution’s experience dealing with retained hemothorax, including the use of VATS. But there really isn’t much out there on how to roll all this together.

Until now. The trauma group at Vanderbilt published a paper describing their experience with a home-grown practice guideline for managing retained hemothorax.  Here’s what it looks like:

I know it’s small, so just click it to download a pdf copy. I’ve simplified the flow a little as well.

All stable patients with hemothorax admitted to the trauma service were included over a 2.5 year period. The practice guideline was implemented midway through this study period. Before implementation, patients were treated at the discretion of the surgeon. Afterwards, the practice guideline was followed.

Here are the factoids:

  • There were an equal number of patients pre- and post-guideline implementation (326 vs 316)
  • An equal proportion of each group required an initial intervention, generally a chest tube (69% vs 65%)
  • The number of patients requiring an additional intervention (chest tube, VATS, lytics, etc) decreased significantly from 15% to 9%
  • Empyema rate was unchanged at 2.5%
  • Use of VATS decreased significantly from 8% to 3%
  • Use of catheter guided drainage increased significantly from 0.6% to 3%
  • Hospital length of stay was the same, ranging from 4 to 11 days (much shorter than the lytics studies!)

Bottom line: This is how design of practice guidelines is supposed to work. Identify a problem, typically a clinical issue with a large amount of provider care variability. Look at the literature. In general, find it of little help. Design a practical guideline that covers the major issues. Implement, monitor, and analyze. Tweak as necessary based on lessons learned. If you wait for the definitive study to guide you, you’ll be waiting for a long time.

This study did not significantly change outcomes like hospital stay or complications. But it did decrease the number of more invasive procedures and decreased variability of care, with the attendant benefits from both of these. It also dictates more selective (and intelligent) use of additional tubes, catheters, and lytics. 

I like this so much that I’ve incorporated parts of it into the chest tube guideline at my center!

Download the practice guideline here.

Related posts:

Reference: Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions. J Trauma 82(4):728-732, 2017.

Surgical Management Of Retained Hemothorax – VATS

I’ve written about the use of lytics to treat retained hemothorax over the past few days. Although it sounds like a good idea, we just don’t know that it works very well. And they certainly don’t work fast. Lengths of stay were on the order of two weeks in both studies reviewed.

The alternative is video assisted thoracoscopic surgery (VATS). So let’s take a look at what we know about it. This procedure is basically laparoscopy of the chest. A camera is inserted, and other ports are added to allow insertion of instruments to suck, peel, and scrape out the hemothorax.

A prospective, multi-center study was performed over a 2 year period starting in 2009. Twenty centers participated, contributing data on 328 patients with retained hemothorax. This was defined as CT confirmation of retained blood and clot after chest tube placement, with evidence of pleural thickening.

Here are the factoids:

  • 41% of patients had antibiotics given for chest tube placement (this is interesting given the lack of consensus regarding their effectiveness!)
  • A third of patients were initially managed with observation, and most of them (82%) did not need any further procedures (83 of 101 patients)
  • Observation was more successful in patients who were older, had smaller hemothoraces (<300cc), smaller chest tubes (!!, <34 Fr), blunt trauma, and peri-procedure antibiotics (?)
  • An additional chest tube was inserted in 19% of patients, image guided drain placement in 5%, and lytics in 5%. Half to two-thirds of these patients required additional management.
  • VATS was used in 34% of patients. One third of them required additional management including another chest tube, another VATS, or even thoracotomy.
  • Thoracotomy was most likely required if there was a diaphragm injury or large hemothorax (<900cc)
  • Empyema and pneumonia were common (27% and 20%, respectively)

Bottom line: There’s a lot of data in this paper. Most notably, many patients resolve their hemothorax without any additional management. But if they don’t, additional tubes, guided drain placement, and lytics work only a third of the time and contribute to additional time in the hospital. Even VATS and thoracotomy require additional maneuvers 20-30% of the time. And infectious complications are common. This is a tough problem!

Tomorrow, I’ll try to roll it all together and suggest an algorithm to try to optimize both outcomes and cost.

Reference: Management of post-traumatic retained hemothorax: A prospective, observational, multicenter AAST study. 72(1):11-24, 2012.

Retained Hemothorax Part 2: Lytics (again)

Yesterday, I reviewed a small case report that was published a couple of years ago on lytics for treatment of retained hemothorax. But surely, there must be something better, right?

After digging around, I did find a paper from 2007 that prospectively looked at protocolized management of retained hemothorax, and its aftermath. It was carried out at a busy Level I trauma center over a 16 month period.

All patients with a hemothorax treated with chest tube received daily chest x-rays. Those with significant opacification on day 3 underwent CT scan of the chest. If more than 300 cc of retained blood was present, the patient received streptokinase or urokinase (surgeon preference and drug availability) daily, and rolled around in bed for 4 hours to attempt to distribute it. The chest tube was then unclamped and allowed to drain. This was repeated for 3 days, and if there was still opacification, a repeat CT was obtained. If the volume was still greater than 300 cc, the cycle was repeated for the next 3 days. If the opacification cleared at any point, or the repeat CT showed less than 300 cc, the protocol was stopped and the chest tube removed. If the chest was still opacified after 6 days, VATS was offered.

Here are the factoids:

  • A total of 203 patients with hemothorax were admitted during the study period and 25 (12%) developed a retained hemothorax
  • While a few had treatment start within 4 days, the majority did not receive lytics until day 9 (range 3  –30 days!)
  • The average length of time in hospital after start of lytics was 7 days, leading to a total length of stay of 18 days
  • 92% of patients had “effective” evacuation of their retained hemothorax, although 1 had VATS anyway which found only 100 cc of fluid
  • 16 patients had “complete” evacuation, and 5 had “partial” evacuation
  • There were no hemorrhagic complications, but one third of patients reported significant pain with drug administration

Bottom line: Sounds good, right? The drug seems reasonably effective, although lengths of stay are relatively long. However, streptokinase and urokinase are no longer available in the US, having been replaced with tissue plasminogen activator (tPA). This paper does a cost analysis of lytics vs VATS and found that the former treatment cost about $15000 (drug + hospital stay) vs $34000 for VATS. However, a big part of this was that the drug only cost about $75 per dose. tPA is much more expensive.

So once again, small series, longer lengths of stay, but at least nicely done. Unfortunately, the drug choice is no longer available so use of tPA tilts the balance away from lytics. 

Reference: Intrapleural Thrombolysis for the Management of Undrained Traumatic Hemothorax: A Prospective Observational Study. J Trauma 62(5):1175-1179, 2007.