All posts by The Trauma Pro

Liquid Plasma vs FFP: Definitions

December 15, 2023 The Trauma Pro Leave a comment

I’ll spend the next two posts discussing plasma. This is an important component of any trauma center’s massive transfusion protocol (MTP). Coagulopathy is the enemy of any seriously injured patient, and this product is used to attempt to fix that problem.

And now there are two flavors available: liquid plasma and fresh frozen plasma. But there is often confusion when discussing these products, especially when there are really three flavors! Let’s review what they are exactly, how they are similar, and how they differ.

Fresh frozen plasma (FFP)
This is plasma that is separated from donated whole blood. It is generally frozen within 8 hours, and is called FFP. However, in some cases it may not be frozen for a few more hours (not to exceed 24 hours total) and in that case, is called FP24 or FP. It is functionally identical to FFP. But note that the first “F” is missing. Since it has gone beyond the 8 hour mark, it is no longer considered “fresh.” To be useful in your MTP, it must be thawed, and this takes 20-40 minutes, depending on technique.

Thawed plasma
Take a frozen unit of FFP or FP, thaw, and keep it in the refrigerator. Readily available, right? However, the clock begins ticking until this unit expires after 5 days. Many hospital blood banks keep this product available for the massive transfusion protocol, especially if other hospital services are busy enough to use it if it is getting close to expiration. Waste is bad, and expensive!

Liquid plasma (never frozen)
This is prepared by taking the plasma that was separated from the donated blood and putting it in the refrigerator, not the freezer. It’s shelf life is that of the unit of whole blood it was taken from (21 days), plus another 5, for a total of 26 days. This product used to be a rarity, but is becoming more common because of its longer shelf life compared to thawed plasma.

Finally, a word on plasma compatibility. ABO compatibility is still a concern, but Rh is not. There are no red cells in the plasma to carry any of the antigens. However, plasma is loaded with A and/or B antibodies based on the donor’s blood type. So the compatibility chart is reversed compared to what you are accustomed to when giving red cells.

Remember, you are delivering antibodies with plasma and not antigens. So a Type A donor will have only Type B antibodies floating around in their plasma. This makes it incompatible with people with blood types B or AB.

Type O red cells are the universal donor type because the cells have no antigens on the surface. Since Type AB donors have both antigens on their red cells, they have no antibodies in their plasma. This makes AB plasma is the universal donor type. Weird, huh? Here’s a compatibility chart for plasma.

Next time, I’ll discuss the virtues of the various types of plasma when used for massive transfusion in trauma.

Performance Improvement

Transfers In: Direct Admit vs Send To The ED

December 12, 2023 The Trauma Pro Leave a comment

Level I and II trauma centers are frequently asked to accept patients who need a higher level of care. This necessitates an inter-hospital transfer that is subject to scrutiny by the trauma performance improvement program of both trauma centers. The practice at many centers is to bring all transfer patients in through the emergency department. But is this really necessary?

Bringing Patients To Your Emergency Department

Patients can be reassessed to see if they meet any of your trauma activation criteria.
The work-up from the referring hospital can be re-evaluated. If some testing or imaging has been omitted, it can be obtained after arrival.
Specialist assessment may be more timely or may involve interventions that are more difficult after leaving the ED. Here’s an example. In some hospitals, orthopedics may choose to place a traction pin to provide initial fracture management. They may choose to use sedation, which may not be as readily available on a surgery ward.
Access to certain critical services may be more rapid from the emergency department. A patient may be more rapidly taken to the operating room or interventional radiology if the patient is in the emergency department.
It is easier to determine the correct admitting service in the ED prior to the actual admission. Sometimes patients are suitable for admission to a surgical subspecialist service, or to a medical service if they have complex comorbidities. Initial admission to the correct service from the ED is easier than later transfer.

But there are a few downsides to ED arrival:

The emergency department may be swamped. Taking a patient who could just as easily have been admitted directly increases congestion in the ED and slows throughput even further.
There is a built-in time delay going through any emergency department. You can count on patients spending eight hours, if not much, much more if they come to the ED first.
It’s a big dissatisfier for patients. They’ve already gone through this time-intensive process once and are usually not happy to have to do it again.

Direct Admissions

Direct admissions essentially reverse the pros and cons listed for emergency department evaluation.

There is a mistaken belief that the ACS Verification Review Committee looks askance direct admissions. This is not the case, and there are no criterion deficiencies that refer to them. Direct admits may be reported on the site visit pre-review questionnaire, and the reviewers may have questions about your numbers and how you identify them. Otherwise, each center is free to choose how they handle them.

Here are some guidelines for directing incoming patients to the most appropriate place.

Are you familiar with the referring physician or APP? If you have worked with them before and are confident of their evaluation skills, then a direct admission could be appropriate.
Is the referring hospital a trauma center, and are you familiar with how they work up patients? What has your previous experience with them been? Again, if they are part of your hospital system and/or you have had successful direct admissions from them in the past, consider it again.
Will the patient need rapid access to specialized services after arrival? Do they need to go to the operating room quickly? Or might they need advanced imaging that can be arranged more expeditiously from the ED?
Will they need any procedures after arrival that are more easily done in your ED? Do they need a complicated laceration repair best done with equipment in the ED? Will they require conscious sedation for a procedure?
Are you unsure of the most appropriate admitting service? Does the patient have significant comorbidities? Do you have two or more potential admitting services but just need to lay eyes on the patient to help you decide?
How busy is your ED? The longer the wait time, the more desirable it is to just skip it altogether, especially if none of the items above apply.

But make sure that you are able to accurately identify and track each and every direct admission coming into the hospital. Although high numbers of direct admission patients is not a violation of ACS standards, allowing trauma patients to get into the hospital on non-trauma services without being identified by the PIPS program is. I recommend that you review each and every one of them shortly after they arrive. Then make sure the decision-making was correct and the patient is on the service that best meets their needs.

Thorax

What You Need To Know About Blunt Cardiac Injury

December 5, 2023 The Trauma Pro Leave a comment

Blunt cardiac injury can be an enigma. Significant injuries are uncommon, and the literature on it consists of case reports and small series. The group at Scripps La Jolla has an excellent review article on the topic that is currently in press. This post will relate some of the key points in this nicely prepared article.

Use the correct nomenclature. For years, many have called this condition “cardiac contusion” or “myocardial contusion.” Unfortunately, these descriptors are too specific. The proper term is “blunt cardiac injury (BCI),” which encompasses the entire gamut of injury from asymptomatic contusion to pericardial injury to cardiac rupture.
BCI occurs more commonly than you think. If one defines BCI as any arrhythmia or cardiac enzyme elevation, it is fairly common. However, if the definition is limited to clinically significant sequelae such as potentially malignant arrhythmia or cardiac failure, the incidence is easily less than 1% in blunt trauma patients.
Be aware of the usual mechanisms of injury. This is a condition caused by blunt trauma, with motor vehicle crashes causing half and pedestrians struck by them another one-third. Motorcycle crashes and falls caused the remaining 12%.
Diagnosis can be challenging.
- Physical examination is usually of little help. New onset of a heart murmur may indicate a serious cardiac injury but is exceedingly rare.
- EKG evidence of a new onset arrhythmia is important, particularly bundle branch blocks, PVCs, and ST segment / T wave changes, which require further investigation.
- CPK-MB enzyme measurements are useless. Please don’t get them.
- Troponin T and Troponin I are frequently used but do not reliably predict BCI. Testing in asymptomatic patients is not helpful and may result in additional asymptomatic testing.
- Echocardiography is not indicated in asymptomatic patients with isolated enzyme elevations.
- Cardiac CT may be used to differentiate acute MI from BCI. Frequently, patients at risk are having a chest CT with contrast performed anyway.

Here is the recommended treatment algorithm:

If BCI is possible based on mechanism of injury, follow the ATLS protocols and perform a physical exam, E-FAST, and place on EKG monitoring.
If the patient is hemodynamically unstable, quickly identify and treat tamponade or tension pneumothorax if present. If significant arrhythmias are present, treat with appropriate medications. If heart failure is present, treat medically and evaluate for surgical problems such as valve, septum, or coronary artery injury.
If the patient is hemodynamically stable, obtain a 12 lead EKG. If significant arrythmias are present, treat with appropriate medications. If there is organ hypoperfusion, obtain an echocardiogram. If this study reveals an effusion, a pericardial window is indicated. If the echo shows hypokinesis or structural injury, appropriate medical or surgical management should be carried out.
Patients who have only significant arrhythmias should be admitted to a monitored bed for 24 hours. Once arrhythmias have resolved, the patent can be discharged.
Patients with nonspecific EKG changes should have troponin levels drawn after 8 hours of observation in the ED. If elevated, admit to a monitored bed for 24 hours. Once EKG and troponin have normalized, the patent can be discharged.
If EKG and labs are normal, may discharge home from the ED if there are no other indications for admission.

Reference: Diagnosis and Management of Blunt Cardiac Injury: What You Need to Know. J Trauma, accepted for publication. DOI: 10.1097/TA.0000000000004216

Pet Peeve, Research

The Power Of Trauma Research?

November 21, 2023 The Trauma Pro Leave a comment

The veracity of medical research conclusions, specifically trauma research, has always fascinated me. I see so many people who are content to jump to conclusions based on a paper’s title or the conclusions listed in its abstract. However, having read thousands of research papers over the years, I am no longer surprised when these easy-to-digest blurbs don’t entirely match up with the actual details embedded within the manuscript.

The authors of these publications genuinely intend to provide new and valuable information, either for clinical use or to allow future studies to build upon. Unfortunately, mistakes can be made that degrade their value. Problems with research design are among the top culprits that affect the significance of these papers.

I will focus on what are considered “gold standard” studies in this post. The randomized, controlled trial (RCT) is usually considered the big kahuna among research designs. They can provide solid answers to our clinical questions if designed and carried out properly.

In 2010, a checklist of 25 guidelines was created (CONSORT 2010, see reference 1) to guide researchers on the essential items that should be included in all RCTs to ensure high-quality results. A group of investigators from Jackson Memorial in Miami and Denver Health published a paper earlier this month that critically reviewed 187 trauma surgery RCTs published from 2000 to 2021. They analyzed power calculations, adherence to the CONSORT guidelines, and an interesting metric called the fragility index.

Here is a summary of their findings:

Only 46% of studies calculated the sample size needed to prove their thesis before beginning data collection. With no pre-defined stop point, the researchers might never be able to demonstrate significant results or may be wasting money on subjects in excess of the number actually needed.
Of the 54% that did calculate the needed sample size, two-thirds did not achieve it and were not powered to identify even very large effects. Once again, they are spending research money and will almost certainly be unable to show statistical differences between the groups, even if one actually existed.
The CONSORT checklist was applied to studies published after they were developed in 2010; the average number of criteria met was 20/25, and only 11% met all 25 criteria. The most common issue was failure to publish the randomization scheme to ensure no bias was possible due to it.
Among 30 studies that had a statistically significant binary outcome, the mean fragility index was 2. In half of these studies, having a different outcome in as few as two patients could swing the final results and conclusion of the study.
The majority of the studies (76%) were single-center trials. Frequently, such trial results cannot be generalized to larger and more disparate populations. Larger, confirmatory studies often have results that are at odds with the single-center ones.

Bottom line: What does it all mean? Basically, a lot of well-intentioned but poorly designed research gets published. The sheer volume of it and the work needed to interpret it correctly make it very difficult for the average trauma professional to understand and apply. And unfortunately, there is a lot of pressure to pump out publication volume and not necessarily quality.

My advice for researchers is to ensure you have access to good research infrastructure, including experts in study design and statistical analysis. Resist the temptation to write up that limited registry review from only your center. Go for bigger numbers and better analysis so your contribution to the research literature is a meaningful one!

References:

CONSORT 2010 Guidelines Checklist for randomized, controlled trials
Statistical Power of Randomized Controlled Trials in Trauma Surgery. JACS 237(5):731-736, 2023.

Bringing Patients To Your Emergency Department

Direct Admissions

Home of the Trauma Professional's Blog