All posts by The Trauma Pro

The Tertiary Survey for Trauma: The Basics

July 16, 2021 The Trauma Pro Leave a comment

I’m posting a three part series on the trauma tertiary survey. Today, I’ll cover the basics. In the next two posts I’ll dig into how well it works and who can do it.

Major trauma victims are evaluated by a team to rapidly identify life and limb threatening injuries. This is accomplished during the primary and secondary surveys done in the ED. The ATLS course states that it is more important for the team to identify that the patient has a problem (e.g. significant abdominal pain) than the exact diagnosis (spleen laceration). However, once the patient is ready for admission to the trauma center, it is desirable to know all the diagnoses.

This is harder than it sounds. Physical examination tends to direct diagnostic testing, and some patients may not be feeling pain, or be awake enough to complain of it. Injuries that are painful enough may distract the patient’s attention away from other significant injuries. Overall, somewhere between 7-13% of patients have injuries that are missed during the initial evaluation.

A well-designed tertiary survey helps identify these occult injuries before they are truly “missed.” This survey consists of a structured and comprehensive re-examination that takes place within 48-72 hours, and includes a review of every diagnostic study performed. Ideally, it should be carried out by two people: one familiar with the patient, and the other not. It is desirable that the examiners have some experience with trauma (sorry, medical students).

The patients at highest risk for a missed injury are those with severe injuries (ISS>15) and/or impaired mental status (GCS<15). These patients are more likely to be unable to participate in their exam, so a few injuries may still go undetected despite a good exam.

I recommend that any patient who triggers a trauma team activation should receive a tertiary survey. Those who have an ISS>15 should also undergo the survey. Good documentation is essential, so an easy to use form should be used. Click here to get a copy of our original paper form. We have changed over to an electronic record, and have created a dot phrase template, which you can download here.

In my next post: Does the tertiary survey actually work?

Pharmacy

Is Daily Enoxaparin Dosing As Good As Twice Daily?

July 6, 2021 The Trauma Pro Leave a comment

Venous thromboembolism (VTE) remains a big problem for trauma professionals and the patients they take care of. Every trauma center has some sort of VTE prophylaxis protocol for stratifying risk, prescribing mechanical or pharmacologic prophylaxis, and monitoring effectiveness.

This is all well and good for patients in the hospital. But what happens once they go home? Who needs to continue chemoprophylaxis? For how long? And what product? These are all tough questions, and are not usually part of the protocol. It is an important issue, and I’d like to address the last question in this post.

Typically, patients who need ongoing chemical prophylaxis after trauma are sent home on a low molecular weight heparin product. This is usually enoxaparin. As you know, this drug has two possible dosing regimens for prophylaxis: 30 mg subq twice a day or 40 mg subq once a day.

Now, nobody likes to give themselves a shot, ever. But if one has the choice between once a day vs twice, I think it’s safe to say everyone would pick the single dose. But it just doesn’t seem right that 60 mg spread out over two doses is just as effective as 40 mg once a day. Unless, of course, we are radically overdosing on the twice a day regimen.

So is the one-a-day regimen as good as twice a day? There is older support in the orthopedic surgery literature that it is. However, general trauma patients are probably at higher risk than those old studies would suggest. The trauma group in Gainesville FL looked at this question. They had been using the once a day dose for years, then changed to twice daily administration. They performed a retrospective study of their experience.

Here are the factoids:

The authors excluded the extremes of injury: patients admitted for < 2 days, or death within 2 days
There were 409 patients in the once daily group and 278 patients with twice daily dosing
About 3% of patients with once daily dosing developed VTE vs only 1% in the twice daily group
Bleeding complications occurred in 1.8% of the once daily group vs 2.7% in the twice daily group
Neither of these results was statistically significantly different

Bottom line: Although the authors try to imply that twice daily dosing “may be more effective” than once daily, they do admit that the statistics don’t show that. Unfortunately, the study design makes it nearly impossible to derive any firm results. It is a retrospective study designed long after the actual patient care, and does not take into account anything other than rudimentary risk stratification.

My take on the topic is that it is unlikely that once daily dosing is as good as twice daily. Unfortunately, we just don’t have any literature to support that yet. Until we do, I recommend that you take a close look at your individual patient’s risk for VTE, and err on the side of giving enoxaparin twice daily until we know better.

Reference: Once- Versus Twice-Daily Enoxaparin for Venous Thromboembolism Prophylaxis in High-Risk Trauma Patients. J Intensive Care Med 26(2):111-115, 2011.

Trauma Center

When Should You Activate Your Backup Trauma Surgeon?

July 2, 2021 The Trauma Pro Leave a comment

The American College of Surgeons requires all US Trauma Centers to publish a call schedule that includes a backup trauma surgeon. This is important for several reasons:

It maintains a high level of care when the on-call surgeon is encumbered with multiple critical patients, or has other on-call responsibilities such as acute care surgery
It reduces the need to place the entire trauma center on divert due to surgeon issues

However, the ACS does not provide any guidance regarding the criteria for and logistics of mobilizing the backup surgeon. In my mind, the guiding principle is a simple one:

The backup should be called any time a patient is occupying the on-call surgeon’s time to the extent that they cannot manage the care of a newly arrived (or expected to arrive) patient with critical needs that only the surgeon can provide.

There’s a lot of meat in that sentence, so let’s go over it in detail.

First, the on-call surgeon must already be busy. This means that they are actively managing one or more patients. Depending on the structure of the call system, they may be involved with trauma patients, general/acute care surgery patients, ICU patients, or a combination thereof. Busy means tied up to the point that they cannot meaningfully manage another patient.

Note that I did not say “evaluate another patient.” Frequently, it is possible to have a resident (at an appropriate training level) or advanced practice provider (APP) see the new patient while the surgeon is tied up, say in the operating room. They can report back, and the surgeon can then weigh his or her choices regarding the level of management that will be needed. Or if operating with a chief resident, it may be possible for the surgeon to briefly leave the OR to see the second patient or quickly check in on the trauma resuscitation. Remember, our emergency medicine colleagues can easily run a trauma activation and provide initial care for major trauma patients. They just can’t operate on them.

What if the surgeon is in the OR? Should they call the backup every time they are doing a case at night? Or every time a trauma activation is called while they are doing one? In my opinion, no. The chance of having a highest level trauma activation called is not that high, and as above, the surgeon, resident, or APP may be able to assess how much attention the new patient is likely to need. But recognize that the surgeon may not meet the 15 minute trauma activation attendance requirement set forth by the ACS.

However, once such a patient does arrive (or there is notification that one of these patients is on the way), call in the backup surgeon. These would include patients that are known to, or are highly suspected of needing immediate operative management. Good examples are penetrating injuries to the torso with hemodynamic problems, or those with known uncontrolled bleeding (e.g. mangled extremity).

If two or more patients are being managed by the surgeon, and they believe that they would not be able to manage another, it’s a good idea to notify the backup that they may be needed. This lets them plan their evening better to ensure rapid availability.

Finally, what is the expected time for the backup to respond and arrive at the hospital to help? There is no firm guideline, but remember, your partner and the patient are asking for your assistance! In my opinion, total time should be no more than 30 minutes. If it takes longer, then the trauma program should look at its backup structure and come up with a way to meet this time frame.

Complications

Fatigue V: Your Patients

June 28, 2021 The Trauma Pro Leave a comment

I’ve spent the past several posts detailing how interrupted sleep interferes with the health and effectiveness of trauma professionals. But what about our patients? Being in the hospital is nothing like trying to sleep at home. The beds are terrible. There is noise in the hall. Their roommate is confused and calls out at all hours. Nurses keep coming in to check vital signs. The pulse oximeter beeps every 10 minutes.

How bad is it, really? There is no trauma patient-specific literature yet on the topic. But there is a recently published paper detailing the experience of general surgery patients admitted after elective procedures that is very revealing. The group at Dartmouth-Hitchcock Medical Center recruited adults who stayed at least one night at the hospital.

Prior to surgery, each patient completed a questionnaire that measured their baseline home sleep quality. Postop, they completed another questionnaire designed to measure their in-hospital sleep quality. Each patient was fitted with a Fitbit Inspire HR tracker, which they wore during their entire hospitalization. After discharge home, they completed a final outpatient sleep questionnaire.

Here are the factoids:

A total of 74 patients were recruited and 54 completed all phases of the study; 59 finished all of the pre-discharge phases
The average inpatient sleep score was 49/100, where scores less than 50 are considered substandard
The major culprit for in-hospital sleep disturbance was nighttime awakenings
Patients who had better home sleep quality tended to have a higher in-hospital score (65)
Sleep quality was so poor that only 40% of Fitbit devices were able to record sleep time on the first postop night, and that average time asleep was 4.7 hours
As expected, patients with a roommate did not sleep as well as those in private rooms
Average sleep time increased over subsequent nights to about 6 hours, which is still short of the recommended 7 hour minimum
About 88% of patients were poor sleepers preop (!), and this did not change after they returned home (85%)

Bottom line: Sleep quality in the hospital is terrible! I can vouch for this from the standpoint of being a surgeon on call, and also from one experience as a patient. There is very good data on the adverse effects of sleep loss. Fasting glucose and systolic blood pressure rise significantly after a single night of poor sleep. When these occur in a hospital, this sets the clinicians into a frenzy of prescribing sliding scale insulin or antihypertensives and other meds that are probably not needed.

There are numerous other more subtle effects as well. The best way to avoid them is to promote good sleep. But how can you do this in the hospital? Here are some tips:

Be aware that the way you order medications (tid vs q8hrs) has a big impact on when the evening/night doses are given. Talk to your pharmacist so your patient only gets meds when they would normally be awake and not in the middle of the night.
Remove unnecessary monitors that might alarm during sleep. Pulse oximeters are probably the biggest culprit. Does it need to be continuous, or can (very) occasional spot checks be done?
Does your patient really need vital signs taken during the middle of the night? After the first few shifts, most ward patients do not.
Watch out for the phlebotomists! They love to circulate early so lab results are available at the crack of dawn. Can’t it wait?
Some practice guidelines call for repeat scans or other studies after a certain number of hours. If one is due at 3am, can’t it wait until morning? Really?
On a daily basis, review all actual or potential nighttime interruptions with the patient and their nurse. Discontinue or reschedule anything that really can’t wait until morning.

Failing to provide for good sleep quality sets your patient up for complications, abnormal vitals and blood tests, and altered mental status. Do everything you can to optimize their sleep!

Reference: Deep sleep and beeps: sleep quality improvement project in general surgery patients. JACS 232(6):882-888, 2021.

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