All posts by The Trauma Pro

Complications

Incidental Appendectomy During Trauma Laparotomy?

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The debate over incidental appendectomy has waxed and waned over the years. And for the most part, it has nearly permanently waned in general surgical cases for now. But every once in a while, I am asked about incidental appendectomy during trauma laparotomy. Is it a good idea? What reasons could there possibly be for doing it?

In the old days, we would frequently do an incidental appendectomy because… well, just because we were there. The surgeon was in the midst of a general surgical case, typically an open one, and this normal little appendix was staring us in the face. The justification was usually, “We’ll save him/her another operation in the future in case he develops acute appendicitis.”

Legitimate reason? It took many years for the literature to develop, but it finally did. Here are the reasons we figured out not to do it:

  • Despite how innocuous a procedure seems, there is a measurable uptick in complication rates. This is true in the usual clean contaminated general surgery cases. Some papers also noted an increased mortality when the appendectomy was added to a cholecystectomy case. In a trauma procedure with bowel injury and contamination, it’s a bit harder to see the correlation. But any time we cut or staple something out, there is always the possibility that it might break down.
  • Cost increases in laparoscopic cases if additional ports and equipment are needed for the appendectomy. This doesn’t apply to major trauma cases since we better not be doing them laparoscopically!
  • The appendix is not the useless vestigial structure we initially thought. Evidence shows that it is a repository for the gut microbiome, which can help repopulate the colon with bacteria after a serious insult like prolonged antibiotic administration. Unnecessary removal may ultimately interfere with gut health and disease.

Can acute appendicitis develop after trauma laparotomy? Sure, at any time. Thankfully, it’s not very common. The presenting complaints are the same as we learned in the doctor books. However, the location of the pain and tenderness may not be in the classic location, depending on the post-trauma anatomy and presence of adhesions.

Bottom line: Incidental appendectomy is no longer indicated for just about anything, including trauma laparotomy. If one of your patients presents with abdominal pain at any time, both post-traumatic and other causes must be considered. CT has become the standard for appendicitis workup and is extremely helpful in sorting out causes in the post-op trauma patient. Use it, and if it is one of the rare cases where appendicitis is actually present, then proceed with the usual and appropriate operative on nonoperative management.

References:

  • Incidental appendicectomy with laparotomy for trauma. Br J Surg 62(6):487-9, 1975
  • Appendicitis following blunt abdominal trauma. Am J Emerg Med 35(9):1386.e5-1386, 2017.
  • Systematic review of blunt abdominal trauma as a cause of acute appendicitis. Ann R Coll Surg Engl 92(6):477-82, 2010.
Performance Improvement

The Implications Of A High Pediatric Readiness Score

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In my last post, I described the Pediatric Readiness Score and its components. Today, I’ll explain why maintaining a high score may benefit your trauma center and what it costs to do so.

Research groups at the Oregon Health Sciences University and the University of Utah combined multiple data sources to estimate current levels of ED pediatric readiness, the cost to achieve it, the number of pediatric deaths in emergency departments, and the number of potential lives saved if readiness is maintained.

As you can imagine, this was an extensive data set suffering from the usual glitches. The authors either excluded incomplete data or managed it with sophisticated statistical methods. Data was included from 4,840 emergency departments in all 50 states and the District of Columbia.

Here are the factoids:

  • The authors estimated that nearly 670,000 children receive care in the emergency departments each year
  • Only 15% (842 EDs) had high readiness. The range was 2.9% in Arkansas to 100% in Delaware.
  • The annual cost to achieve high pediatric readiness nationwide was approximately $210 million
  • The annual cost per child to achieve high readiness ranged from $0 in Delaware to $11.84 in North Dakota
  • It was estimated that about 28% of the 7619 childhood deaths each year could be prevented if the treating ED had high pediatric readiness

Bottom line: This paper has a lot of information to digest. Please remember that these are not precisely measured numbers but estimates based on statistical models. So, minor inaccuracies in those models could change these results.

Nonetheless, the data demonstrate the importance of maintaining high pediatric readiness in your emergency department.  Don’t let the total cost of readiness frighten you. Spread evenly across all the EDs studied, this amounts to only about $43,000 annually.

I urge all trauma centers to measure their pediatric readiness score. Then, dedicate the resources your hospital can afford to improve it as much as possible/practical. The number of potential pediatric lives saved is substantial and meaningful.

Reference: State and National Estimates of the Cost of Emergency Department Pediatric Readiness and Lives Saved. JAMA Netw Open. 2024;7(11):e2442154.

Performance Improvement

Why Is Your Hospital’s Pediatric Readiness Score Important?

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The Pediatric Readiness Score (PRS) is a new(er) metric that is now required for all US trauma centers verified by the American College Surgeons. There is no specific threshold that must be met, but the value must be reported for review at the time of the site visit.

What is the PRS? It is a measure introduced by the National Pediatric Readiness Project. This is a quality initiative that was developed by the Emergency Medical Services for Children program (EMS-C), which partnered with the American College of Emergency Physicians, the Emergency Nurses Association, and the American Academy of Pediatrics. The goal was to improve hospitals’ pediatric readiness through a self-administered survey. It was believed that by quantifying readiness, the hospitals would be better able to improve their scores via simple and, hopefully, inexpensive changes.

Each hospital completes a comprehensive assessment online (the paper version is 19 pages long). It solicits information on the following topics

  • presence of a physician pediatric care coordinator
  • presence of an ED nurse pediatric emergency care coordinator
  • pediatric training and education of any health professionals taking care of children
  • existence of an ED performance improvement plan for pediatric patients
  • details of monitoring and care of children in the ED
  • presence of social services and transfer guidelines for children
  • existence of policies for family-centered care in the ED
  • disaster planning polices including children
  • presence of pediatric equipment, supplies, and resuscitation equipment in the ED

The scores provided by this assessment provide a standardized measure of pediatric readiness, ranging from 0 to 100. Scores can be improved relatively easily by ensuring that appropriate pediatric equipment is available in the ED, and ensuring that social services and transfer agreements include children and are up to date. Tasking a physician and nurse to oversee pediatric readiness is not necessarily as easy, but many are more than willing to step in to improve pediatric care at their hospital.

The biggest question I have when any major assessment / intervention is rolled out is, does it do what it is intended to do? In my next post, I’ll review a paper published last week that looks at the real-world implications of pediatric readiness vs. the lack thereof. This is of significance to both trauma and non-trauma hospitals.

References:

  1. The National Pediatric Readiness Project website (pedsready.org)
  2. Download a copy of the assessment
Head

Everything You Wanted To Know About: Cranial Bone Flaps

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Patients with severe TBI frequently undergo surgical procedures to remove clot or decompress the brain. Most of the time, they undergo a craniotomy, in which a bone flap is raised temporarily and then replaced at the end of the procedure.

But in decompressive surgery, the bone flap cannot be replaced because doing so may increase intracranial pressure. What to do with it?

There are four options:

  1. The piece of bone can buried in the subcutaneous tissue of the abdominal wall. The advantage is that it can’t get lost. Cosmetically, it looks odd, but so does having a bone flap missing from the side of your head. And this technique can’t be used as easily if the patient has had prior abdominal surgery.

2. Some centers have buried the flap in the subgaleal tissues of the scalp on the opposite side of the skull. The few papers on this technique demonstrated a low infection rate. The advantage is that only one surgical field is necessary at the time the flap is replaced. However, the cosmetic disadvantage before the flap is replaced is much more pronounced.

3. Most commonly, the flap is frozen and “banked” for later replacement. There are reports of some mineral loss from the flap after replacement, and occasional infection. And occasionally the entire piece is misplaced. Another disadvantage is that if the patient moves away or presents to another hospital for flap replacement, the logistics of transferring a frozen piece of bone are very challenging.

4. Some centers just throw the bone flap away. This necessitates replacing it with some other material like metal or plastic. This tends to be more complicated and expensive, since the replacement needs to be sculpted to fit the existing gap.

So which flap management technique is best? Unfortunately, we don’t know yet, and probably never will. Your neurosurgeons will have their favorite technique, and that will ultimately be the option of choice.

Reference: Bone flap management in neurosurgery. Rev Neuroscience 17(2):133-137, 2009.

Guidelines

Best Practice: The MTP Coordinator

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Every trauma center has a massive transfusion protocol (MTP). But every trauma center also does it entirely differently. Ideally, an MTP is designed with the resources available at the hospital in mind. These may include whole blood, the use of O- vs. O+ blood, the number of units of each product per cooler, the different products in different coolers, and personnel available to move those coolers to the correct locations.

In my experience, one of the areas with the greatest variability is the person or persons who are actually directing the blood resuscitation, hanging the units, and doing the paperwork. Frequently, this is split across several people. In the ED, the surgeon is usually directing it. However, nurses typically hang the products and do the paperwork.

Often, though, the surgeon may be up to their elbows in a resuscitative thoracotomy and may be unable to direct their full attention to figuring out if more products are needed. In the OR, the anesthesiologist can frequently take over this task while the surgeon is busy in a body cavity. But sometimes, the resuscitation needs may overwhelm even their ability to concentrate on the MTP.

The Solution

The solution to this problem borrows from the team leader concept in trauma resuscitation. It is best if the team leader has minimal clinical responsibilities during the resuscitation. Once they move in and touch the patient, their area of attention collapses to that one spot, and they cannot fully concentrate on all of the big-picture issues going on in the room.

This is where the MTP coordinator comes in. This is a dedicated person who only has one job: to deal with the MTP.  They have no other responsibilities in the room.

Here is a list of tasks that they can offload from the other nurses and physicians in the ED/OR:

  • Call for the next cooler to be sent from the blood bank, taking into account the transit time
  • Ensure required labs are being sent for crossmatch and TEG/ROTEM, if used
  • Order and hang TXA on appropriate patients
  • Transfuse products in the appropriate order
  • Fill out all required transfusion records
  • Ensure 1:1:1 transfusion ratios
  • Regularly inform the surgeon of the current product counts
  • Order calcium and cryoprecipitate when appropriate, according to your protocol
  • Inform the blood bank when the patient moves to a new area (e.g. ED to OR) and follow along with the patient
  • As the resuscitation winds down, interpret TEG/ROTEM and modify transfused products as indicated
  • Notify the blood bank when the MTP is terminated
  • Ensure all final paperwork is complete

This seems like a lot! But we are normally asking numerous people in the trauma bay to do it. Assigning it to one person and one person only creates a much more reliable and efficient system.

Who should it be assigned to? Generally, not one of the usual ED nurses. This is a specialized position that requires additional training and practice. Some trauma programs have dedicated trauma nurses for trauma resuscitation, and they may be a good choice. However, they are frequently the only nurses assigned to resuscitations, and making them the MTP coordinator takes them off all other duties. This may not be practical.

In my opinion, the best candidate is an ICU nurse who has received training for this duty. Ideally, it would be the ICU nurse who would be receiving and taking care of that patient in the ICU if they survive. They will be very familiar with their patient once they arrive there.

If you have an MTP coordinator at your center, please take a moment to leave comments or suggestions below! Let us know how you do it.