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Philosophy

The First Law Of Trauma

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Let’s get started with the Laws of Trauma!

After pursuing any discipline for an extended period, one begins to see the common threads and underlying principles of their area of expertise. I’ve been trying to crystallize these for years, and today I’m going to share one of the most basic laws of trauma care.

The First Law of Trauma

Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

Some examples:

  • An elderly patient who crashes his car and presents with arrhythmia and chest pain is not having a heart attack. Nor does he need a cardiologist or a trip to the cath lab. It is far more likely the crash is causing these problems rather than an MI causing a crash.
  • A spot in the liver after blunt trauma is not a cyst or hemangioma; it is a laceration until proven otherwise.
  • A patient found at the bottom of a flight of stairs with blood in their head did not have a stroke and then fall down.
  • A patient who follows up in your trauma clinic with new complaints after a previous gunshot to the abdomen needs further clinical investigation, not just reassurance.

Bottom line: The possibility of trauma always comes first! It is your job to rule it out. Injury can and does kill people more quickly that an MI or a stroke, especially if it was never suspected.

Only consider non-traumatic problems as a last resort. Don’t let your non-trauma colleagues try to steer you down the wrong path, only to have your patient suffer.

Philosophy

The Laws Of Trauma

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It’s been five years since I published my Laws of Trauma, and it’s time to dust them off again. In the meantime, I’ve added a couple of new ones.

But before I start publishing them next week, I’d like to take a moment to share “McSwain’s Rules of Patient Care.”  I met Norm McSwain when I was junior faculty at the University of Pennsylvania. As so many of his era were, he was larger than life. He was friendly, outgoing, animated, and a real champion for quality trauma care.

Norm was a skilled surgeon and teacher, but his achievements were felt far outside his home in Louisiana. He was an early member of the ACS Committee on Trauma, and was very involved in the development of the Advanced Trauma Life Support and Prehospital Trauma Life Support courses. He is credited with developing the original EMS programs in both Kansas, where he took his first faculty position out or residency, and in New Orleans, his home for the remainder of his life. He spent his career at the Charity Hospital there, weathering multiple political storms over the years, as well as the big one, Hurricane Katrina. He was instrumental in achieving Level I Trauma Center status for its replacement, Interim LSU Hospital.

Norm’s accomplishments are, as many of his contemporaries who have left us, too numerous to count. I certainly won’t try to recount them here. But it was his charm, his love for his charges, and his willingness to teach every trauma professional that will always be remembered.

I’ll leave you with his 18 rules of patient care. They are timeless, and will serve you well regardless of your degree and level of medical training.

Download McSwains Rules of Patient Care

Complications

Early Antibiotic Administration In Open Fractures

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Recommendations for open fracture management has evolved over the past 20 years. The old-timey rule used to be: all open fractures need to be treated within 8 hours. This treatment could be washout and ORIF, washout and external fixation, or just washout alone. The washout was the constant across all types of management.

Then the orthopedics literature began to suggest that “lesser” fractures (Gustilo I – II) could go a bit longer. Some centers extended their required time to washout up to 12 or even 16 hours. Subsequently, the value of early IV antibiotics was recognized, and the time to washout started to change again.

Now, we have recommendations for early IV antibiotics competing with the old recommendations for prompt washout. Who is winning?

There are two recent papers that seem to provide conflicting recommendations regarding antibiotics. The first is in process for publication by the ortho group at San Francisco General Hospital. They studied 230 open fracture patients at their Level I Trauma center over a five-year period. They monitored for surgical site infection that occurred during the first 90 days after injury.

Here are the factoids:

  • It took 450 consecutive patients to find the 230 study patients due to these exclusion criteria: missing documentation of antibiotic administration, delayed presentation, and loss to followup
  • There were 169 Gustilo Type I or II fractures and 61 Type III fractures
  • They noted a trend (p = 0.053) toward infection in patients who had antibiotic administration an average of 83 minutes after arrival vs those who received them within one hour
  • Patients who received their antibiotics 2 hours after arrival had a 2.4x increase in likelihood for infection within 90 days

But there was another paper published in the same journal this year that shows the opposite result. This one is from the University of Bristol in the UK. This one reviewed only Gustilo Type III fractures and observed changes in the deep infection rate, before and after the National Health Service guidance on antibiotic administration changed from within three hours to one hour post-injury.

Some more factoids for you:

  • A total of 176 patients were identified at a single center, and only 152 were left after the usual exclusions
  • Average time to antibiotic administration decreased from 180 minutes to 160 minutes after the new guidance was issued (60 minutes(!))
  • Only 12 patients developed deep infections with a median followup of 26 months
  • On regression analysis, no obvious factors  for increased risk were identified

Bottom line: So what gives? Two different answers: antibiotics given after 2 hours is associated with an increased risk of infection, vs no difference?

No, not really. Talk about apples to bananas. The first study looks at all open fractures, not just the most severe. It does not really define “surgical site infection,” so can we assume it was any infection? We don’t know. The second study looked only at deep infections.

The sample sizes are marginal in both studies, although the first was able to show a significant result despite this. And, of course, these are association studies, so other factors could be at play to manifest an infection or not. Both groups showed an 8-11% infection rate of some kind in their Gustilo Grade III fractures. 

But the biggest issue with the second study is that, despite guidance that antibiotics should be given within an hour, the average time decreased from 3 hours to only 2:40. This is still beyond the two hour threshold to higher infection rates suggested in the first paper.

So what do I make of all of this? The UK paper is lacking the power and enough of a treatment change to be taken seriously. The San Francisco paper shows borderline results with a 2.4x increase in all infections if antibiotics are given after 2 hours. 

So until we have better data and larger series, 1 hour antibiotic administration seems like a painless way to decrease the likelihood of an infection. But whether that can safely delay the time to washout remains to be seen.

References:

  • Delay of Antibiotic Administration Greater than 2 Hours Predicts Surgical Site Infection in Open Fractures. Injury, in press, May 29, 2020.
  • Time to intravenous antibiotic administration (TIbiA) in severe open tibial fractures: Impact of change to national guidance. Injury 51:1086-1090, 2020.
General

Announcing My New Trauma PI Website!

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For my audience members who have an interest in trauma performance improvement (PI), I have a special announcement. I’ve officially unveiled by new website dedicated exclusively to that topic.

You can find it at TraumaMedEd.com. There, you will find a growing collection of instructional videos, courses, PI blog posts, and downloadable materials. I am migrating the entire library of my trauma newsletters to the site as well.

My intent is to provide performance improvement information that you want to know about. To that end, I encourage you to sign up on the site and let me know what topics really interest you.

And if performance improvement is just not your thing, keep reading this blog!

I just released an 8-minute video detailing “When The Trauma PI Clock Starts Ticking.” Click the link or picture below to head over to the site and view it.

And please follow the new site on Facebook and Twitter, and use those platforms to send me topics to include in future content.

Enjoy!
Michael

 

CNS

Epidural Hematoma Treated With Middle Meningeal Artery Embolization

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Epidural hematoma is a life-threatening condition that is typically associated with arterial bleeding outside of the dura. Most frequently, this is due to a skull fracture that extends across and lacerates the middle meningeal artery (MMA).

The standard treatment regimen is neurologic monitoring in patients who have a (nearly) normal GCS and do not change neurologically. That escalates to rapid craniectomy and evacuation in those with neurologic compromise.  Interestingly, there have been a few case reports over the last 10 years describing attempted management by embolization of the MMA.

Let’s look at this idea more critically. This seems like it should be a good idea. But remember, in medicine you’ve actually got to study it. There are too many examples of things that make sense that are worthless or actually cause harm.

The first report I found was a series of one in which the patient was found to have a large subdural hematoma. He was taken to surgery and the lesion was evacuated. However, there was persistent epidural bleeding intraop which was thought to be controlled. Repeat scan the next day showed a large epidural, so he was returned to the OR. Once again, there was persistent epidural oozing and the collection was removed. Followup CT showed yet another epidural. The patient was finally taken to interventional radiology for embolization of the MMA. This was successful, and the patient had no further recurrences.

This case provided proof of concept, although the bleeding was not due to known traumatic injury to the MMA. Last year, another case report was published that described an experience (of one again) with a young male who was found down. He awakened and then became obtunded again. CT showed bilateral epidural hematomas. He was taken to the OR for operative evacuation of the larger one. Postop CT showed expansion of the smaller one.

The patient was then taken to the endovascular suite and MMA embolization was carried out. The hematoma stabilized and the patient was later discharged without sequelae.

This case was trauma-related, but not for an acute bleed. Now, let’s look at a bigger case series to see how well this works. This one detailed the experience of a neurosurgery group in Sao Paulo, Brazil. All patients who underwent conservative management based on “standard criteria” were studied. Patients with large hematomas, midline shift, depressed skull fracture, coagulopathy, or incomplete data were excluded. One third of the injuries were due to falls, and the rest were due to other blunt mechanisms.

Here are the factoids:

  • 85% had an attendant skull fracture
  • About 82% had active extravasation from the MMA
  • All patients had followup CT scan 1-7 days after the procedure, and no increase in epidural size was noted
  • None of the patients had a change in GCS or needed operative intervention
  • The authors compared these results to historical controls from other published literature

Bottom line: Sounds impressive, right? But not so fast, there are a lot of loose ends here. First, these are supposedly all patients with epidural hematoma who were treated without operation. Decision to operate was based on criteria set out in a paper published 15 years ago. This strains the imagination a bit. There is usually no uniformity in the way individual neurosurgeons decide to operate, so it is likely there may be some significant selection bias here. It is very easy to believe that patients who were predicted to do well were the only ones enrolled in the study. This also explains why the authors had to use controls from other authors’ research for outcome comparison.

The results are too clean as well. No adverse events. No patients who ended up needing surgery. Followup scans were performed any time between postop day 1 and 7, but there is no frequency breakdown. If most of the repeat scans were performed near the beginning of the postop period, little change would be expected. MMA embolization is either a miracle cure or …

You know what they say, “if it seems to good to be true…” A single case series like this should never change one’s practice. Middle meningeal artery embolization sounds like common sense, but the devil is always in the details. This concept needs a lot more study before you should ever consider it in your patients. Or, you could start a real, IRB-approved study and make an excellent contribution to the neurosurgery literature.

References:

  1. Embolization of the Middle Meningeal Artery for the Treatment of Epidural Hematoma. J Neurosurg 110(6):1247-1249, 2009.
  2. Middle Meningeal Artery Embolization for the Treatment of an Expanding Epidural Hematoma. World Neurosurg 128:284-286,2019
  3. Endovascular Management of Acute Epidural Hematomas: Clinical Experience With 80 Cases. J Neurosurg 128(4):1044-1050, 2018.