All posts by TheTraumaPro

General

Trauma In Pregnancy 2: Predicting Outcome

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The data on maternal outcome after trauma is mixed and somewhat confusing. Mortality after major trauma actually appears to be less. However, injury severity score (ISS) still correlates fairly well with overall mortality. But interestingly, other outcomes (complications) appear to be worse, even for relatively minor injuries. The reason behind this is not clear. Could it be a result of all of the physiologic changes noted above, hormonal factors, or something we don’t fully understand?

Fetal outcome is a function of the mechanism of injury (blunt vs penetrating), and extreme injury severity in the mother. Penetrating injury is uniformly devastating to the fetus, with 70% mortality for gunshots and 40% for stabs. Fetal death from blunt injury is primarily a function of placental abruption. About two thirds of blunt fetal deaths are due to abruption, with 50% of them due to car crashes. Maternal ISS does not correlate with fetal death, except in cases of very high scores. These women most likely experience anatomic and physiologic injuries that lead to fetal demise.

Tomorrow: Tips & Tricks

Reference: Trauma during pregnancy. OB Clinics of North America 40:47-57, 2013.

General

Trauma In Pregnancy 1: Introduction

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Trauma in the pregnant patient is scary, but thankfully not very common. About 1 in 15 pregnant women sustain some type of significant injury. About half are from car crashes (most commonly if unrestrained), and 25% each are from assault (frequently domestic) and falls. Unfortunately, trauma is the leading cause of non-obstetric fetal death.

What makes this type of trauma problematic is two-fold, literally. First, you have two patients. And second, neither one has “normal” physiology. The mother has made numerous adaptations to accommodate the pregnancy, and the fetus is essentially a small parasite, totally dependent on her.

Let’s look at the impact of some of the more important maternal adaptations:

  • Total blood volume increases by about one liter. This would seem to be good, but since it is mainly dilutional with no real increase in total RBCs, and this is coupled with a lower mean blood pressure. Trauma professionals can easily underestimate blood loss.
  • Going into the third trimester, the uterus can compress the IVC when the mother is lying supine. but it is quite frequently forgotten. One of the first maneuvers when you suspect an advanced pregnancy is to bump the patient to her left. Do this even if the blood pressure is normal.
  • The pelvic veins are huge. Disruption from pelvic fractures or penetrating injury can lead to massive bleeding.
  • The stomach is probably full, and under pressure from below. This increases aspiration risk in women who have decreased mental status or need intubation.

And don’t forget the fetus:

  • The fetal/placental/uterine complex is one large, non-compressible unit with multiple shear planes within it. Blunt force will stress those planes, and may result in disruption of the uterus from pelvic veins (massive bleeding), or separation of the placenta from the uterus (abruption).
  • The fetus is totally dependent on the mother for survival, but the placenta will protect the mother first, shutting down fetal circulation if she becomes hypotensive or hypoxic.
  • The baby was designed to come into this world at full term. We have developed the technology to sustain life in smaller and more premature babies. The magic number of weeks keeps slowly decreasing, but preemie survival without complications is a challenge.

Tomorrow, we’ll move on and get to the fun stuff, predicting outcome after trauma in pregnancy.

Performance Improvement

Dealing With Trauma Flow Sheet Documentation Problems

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Over the years, I’ve commented a number of times on paper vs electronic trauma flow sheet. For those of you who somehow missed it, let me recap. Don’t use an electronic trauma flow sheet yet if you can possibly avoid it!

I look at the flow sheet as having two phases, input and output. The input phase occurs as data is being recorded on the sheet, hopefully in real time as events occur during the trauma resuscitation and its aftermath. The output phase consists of a human reviewing the completed flow sheet and analyzing the events and timing for performance improvement (PI) purposes.

The electronic trauma flow sheet has major problems in both phases. But the good, old-fashioned paper sheet isn’t perfect either. It is subject to problems during the input phase. The most common issue is incomplete documentation. I’ve seen so many trauma programs with ongoing issues in this area, and they struggle to find ways to improve or eliminate the missing data.

Here are a few tips you should consider:

  • Make sure your paper flow sheet is well-designed. Data items should not be scattered randomly over several pages. Primary survey items should be grouped together. Medications must have their own block. Diagnostic tests performed (not ordered) should be in the same area. Make sure that the narrative block that typically has vital signs and free-form text about what is happening is large enough, with enough room to write comfortably. There are so many good trauma flow sheets out there already. Borrow a few to see if your program can adopt some of the organizational concepts found on them.
  • Identify the commonly incomplete items at your program, then redesign the flow sheet to cluster them together in one prominent spot on it. Common missed items include patient temperature, time of diagnostic tests, and admitting destination  and time the patient leaves the emergency department.
  • If you have only a few problem data points and don’t want to totally redesign your form, manually highlight those blocks with an old-fashioned highlighting pen. This only works if you are highlighting a few items. Any more than two or three, and the scribe will start to ignore all of them. The fancy colored blocks will draw the eye and remind them to ask for the data.
  • Perform an accuracy review of the sheet soon after the resuscitation, ideally before the end of the nursing shift. And since the scribes are typically emergency nurses, it should be their responsibility. Not the trauma program’s. The ED nurses should take responsibility for their own work, and develop their own program to self-correct any deficiencies.

Do you have any suggestions or best practices that have worked for you? Please comment or tweet!

Related posts:

General, Mechanism

Trauma Activation For Hanging: Yes or No?

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In my last post, I discussed a little-reviewed topic, that of strangulation. I recommended activating your trauma team only for patients who met the physiologic criteria for it.

But now, what about hangings? There are basically two types. The judicial hanging is something most of you will never see. This is a precisely carried out technique for execution and involves falling a certain height while a professionally fashioned noose arrests the fall. This results in a fairly predictable set of cervical spine/cord, airway, and vascular injuries. Death is rapid.

Suicidal hangings are far different. They involve some type of ligature around the neck, but rarely and fall. This causes slow asphyxiation and death, sometimes. The literature dealing with near hangings is a potpourri of case reports, speculation, and very few actual studies. So once again, we are left with little guidance.

What type of workup should occur? Does the trauma team need to be called? A very busy Level I trauma center reviewed their registry for adult near-hangings over a 19 year period. Hanging was strictly defined as a ligature around the neck with only the body weight for suspension. A total of 125 patients were analyzed, and were grouped into patients presenting with a normal GCS (15), and those who were abnormal (<15).

Here are the factoids:

  • Two thirds of patients presented with normal GCS, and one third were impaired
  • Most occurred at home (64%), and jail hangings occurred in 6%
  • Only 13% actually fell some distance before the ligature tightened
  • If there was no fall, 32% had full weight on the ligature, 28% had no weight on it,  and 40% had partial weight
  • Patients with decreased GCS tended to have full weight on suspension (76%), were much more likely to be intubated prior to arrival (83% vs 0% for GCS 15), had loss of consciousness (77% vs 35%) and had dysphonia and/or dysphagia (30% vs 8%)
  • Other than a ligature mark, physical findings were rare, especially in the normal GCS group. Subq air was found in only 12% and stridor in 18%.
  • No patients had physical findings associated with vascular injury (thrill, bruit)
  • Injuries were only found in 4 patients: 1 cervical spine fracture, 2 vascular injuries, and 1 pneumothorax
  • 10 patients died and 8 suffered permanent disability, all in the low GCS group

Bottom line: It is obvious that patients with normal GCS after attempted hanging are very different from those who are impaired. The authors developed an algorithm based on the initial GCS, which I agree with. Here is what I recommend:

  • Do not activate the trauma team, even for low GCS. This mechanism seldom produces injuries that require any surgical specialist. This is an exception to the usual GCS criterion.
  • The emergency physician should direct the initial diagnosis and management. This includes airway, selection of imaging, and directing disposition. A good physical exam, including auscultation (remember that?) is essential.
  • Patients with normal GCS and minimal neck tenderness or other symptoms do not need imaging of any kind.
  • Patients with abnormal GCS should undergo CT scanning, consisting of a CT angiogram of the neck and brain with soft tissue images of the neck and cervical spine recons.
  • Based on final diagnoses, the patient can be admitted to an appropriate medical service or mental health. In the very rare case of a spine, airway, or vascular injury, the appropriate service can be consulted.

Reference: A case for less workup in near hanging. J Trauma 81(5):925-930, 2016.

Mechanism, Trauma Center

Trauma Activation For Strangulation: Yes or No?

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I received a request to discuss this topic from a reader in Salina, KS. Thanks!

Trauma activation criteria generally fall into four broad categories: physiology, anatomy, mechanism of injury, and co-factors. Of these, the first two are the best predictors of patients who actually need to be assessed by the full trauma team. Many trauma centers include a number of mechanistic criteria, usually much to their chagrin. They typically end up with frequent team activations and the patient usually ends up have trivial injuries.

However, there are some mechanisms that just seem like they demand additional attention. Death of another occupant in the vehicle. Fall from a significant height. But what about a patient who has been strangled?

Unfortunately, the published literature gives us little guidance. This usually means that trauma centers will then just do what seems to “make sense.” And unfortunately, this frequently results in significant overtriage, with many patients going home from the emergency department.

Since there is little to know research to show us the way, I’d like to share my thoughts:

  • As a guiding principle, the trauma  team should be activated when the patient will derive significant benefit from it. And the benefit that the team really provides is speed. The team approach results in quicker diagnosis from physical exam and FAST. It gets patients to diagnostic imaging quicker, if appropriate. And gets them to the OR faster when it’s not appropriate to go to CT.
  • Activating for a strangulation mechanism alone is probably a waste of time.
  • Look at the patient’s physiology first. Are the vital signs normal? What is the GCS? If either are abnormal, activate.
  • Then check out the anatomy. If the patient has any voice changes, or has obvious discoloration from bruising, crepitus, or subcutaneous emphysema, call the team. They may suffer a deteriorating airway at any moment.

If physiologic and anatomic findings don’t trigger an activation, then standard evaluation is in order. Here are some things to think about:

  • A complete physical exam is mandatory. This not only includes the neck, but the rest of the body. Strangulation is a common injury from domestic violence, and other injuries are frequently present.
  • If there are any marks on the neck, CT evaluation is required. This includes soft tissue, CT angiography, and cervical spine evaluation. All three can be done with a single contrast-enhanced scan. The incidence of spine injury is extremely low with strangulation, but the spine images are part of the set anyway.
  • CT of the chest is never indicated. There is no possibility of aortic injury with this mechanism, and all the other stuff will show up on the chest x-ray, if significant enough for treatment.
  • Even if there are no abnormalities, your patient may need admission while social services arranges a safe place for their discharge. Don’t forget the social and forensic aspects of this injury. Law enforcement may need photographic evidence or statements from the patient so this event can’t happen again.

Next post: Trauma Activation for Hanging: Yes or No?

Reference: Strangulation forensic examination: best practice for health care providers. Adv Emerg Nurs J 35(4):314-327, 2013.