All posts by TheTraumaPro

Trauma Mortality Nomenclature: Part 1

This is the first in a series of four posts on mortality in trauma performance improvement.

The American College of Surgeons has a very specific naming convention for trauma deaths. This is an update of the system used prior to the current Optimal Resource Document (Orange Book), and has actually been revised since it was published. Of course, anytime you change something up, there will be some confusion. I’m going to compare old and new and give some of my thoughts on the nuances of the changes.

Old nomenclature: Nonpreventable death
Newest nomenclature: Mortality without opportunity for improvement (mortality w/o OFI)

They seem similar, right? But the new name takes into account a growing phenomenon: elderly patients (or younger ones for that matter) who sustain injuries that might be survivable, but are devastating enough to cause the family to withdraw support. Technically, the deaths could be preventable to some degree, but the family did not wish to attempt it. The new system recognizes that it is an expected outcome due to patient or family choice.

There are several key points to handling mortality w/o OFI. First, if your center is providing great care, the majority of your deaths  (about 90%) should be classified this way. Every one of them needs some degree of review, whether from just the trauma medical director and/or program manager or via the full trauma PI committee. However, your full PI committee needs to at least see a summary of the death if it’s not discussed in full.

How to decide on abbreviated review and report vs discussion by full committee? It depends on your trauma volume, and program preference. Higher volume centers do not usually have the luxury of discussing every case due to time constraints. Low volume centers may find value in reviewing these cases just to keep up on the detailed analysis and discussion required.

And how do you decide that there is no opportunity for improvement? The key is to look at the true clinical patient impact of the issue identified. If the issue is a minor clerical issue that has little impact on patient outcome or care, it can be classified as being without OFI. But it still needs to be reviewed, closed, and documented. If, however, future patients would benefit from having it closed, you must bump it up to the next category, mortality with opportunity for improvement.

In my next post, I’ll discuss the next type of trauma mortality, mortality with opportunity for improvement. I’ll follow up with the dreaded unanticipated mortality, and end with a bonus post on some nuances to that classification.

Glasgow Coma Scale And Trauma Activation

The American College of Surgeons has a list of seven required criteria that must trigger a top-level trauma activation at trauma centers verified by it. One of the seven involves the Glasgow Coma Scale (GCS) score, and the threshold is defined as GCS < 9.  However, the range of actual scores used by trauma programs varies widely from about 13 down to the minimum of 8.

So I’m curious: what does your trauma center use? Please help me out and answer the survey I’ve posted below. Remember, I am asking for the threshold you use for only your top-level trauma activation. I’ll post the range of answers next week. Thanks!

Sorry, the survey is closed

Gluteal Compartment Syndrome

Compartment syndromes can occur virtually anywhere a muscle group is surrounded by relatively unforgiving soft tissue. In trauma, these classically involve the calf, forearm, and occasionally the thigh compartments. But they are occur unsuspected in the less common areas they can easily be missed, leading to significant morbidity, disability, and even death.

The gluteal compartment syndrome is one of those uncommon occurrences. Actually, it’s extremely rare, with less than 50 cases documented in the English literature. It is typically seen in patients who are impaired in some manner (drugs, alcohol, stroke) and are unable to move. If they lie in such a way that significant pressure is exerted on the buttock, the full syndrome can develop.

Typical symptoms include swelling, firmness, and pain in the buttock. Neurologic findings are fairly common. Paresthesias can develop late, and pressure on the sciatic nerve can ultimately begin to cause a sciatic palsy.

As with most compartment syndromes, the diagnosis is usually made solely on physical exam. However, in patients with more body fat it may not be as apparent. A pressure monitor can be inserted directly into the fleshiest part of the buttock, and elevated pressures (approaching or exceeding 30 torr) clinches the diagnosis.

The mainstays of treatment are surgical release and physiologic support, primarily for rhabdomyolysis and secondary renal injury. There are two types of incision that may be used. The classic straight line, shown on the right below, is simple but significantly disfiguring. The question mark incision on the left is kinder and gentler, but more challenging to perform properly.

Bottom line: Compartment syndromes can occur in any enclosed muscle group, which is just about all of them. Always be suspicious if your patient has unexplained elevations of CK, especially if they have tight muscle groups or deep pain in hard to access muscles. Err on the side of checking pressures and releasing those compartments in order to minimize morbidity and ultimate disability.

Reference: Gluteal compartment syndrome: a case report. Cases J. 2:190, 2009.

Finding Tough-To-See Veins – Revisited

I’m always interested in technology that makes what we do easier, and this item seems to be in the news again. It’s not new technology any more; I first wrote about this way back in 2011. Here’s an objective look at an interesting machine that’s been around for a while. It uses near-infrared light to detect skin temperature changes to allow it to map out veins. It then projects an image of the map in real time onto the skin. In theory, this should make IV starts easier (as long as you can keep your head out of the way of the projector).

One of the first published papers was from Providence, Rhode Island.  It evaluated this device to see if it could simplify IV starts in a tertiary pediatric ED. It was a prospective, randomized sample of 323 children from age 0 to 17 looking at time to IV placement, number of attempts, and pain scores.

Unfortunately, the authors did not find any differences. They found that nearly 80% of IVs were started on the first attempt with or without the VeinViewer, which is less than the literature reported 2-3 attempts. This is most likely due to the level of experience of the nurses in this pediatric ED.

The authors did a planned subgroup analysis of the youngest patients (age 0-2) and found a modest decrease in IV start time (46 seconds) and the nurse’s perception of the child’s pain. Interestingly, the parents did not appreciate a difference in pain between the two groups. This may be due to the VeinViewer’s pretty green display acting as distraction therapy for the child.

The Children’s Hospital of Colorado repeated this study and reported their results earlier this year. And unfortunately they had similar findings. There were no significant differences in success rates using the VeinViewer. Also, nurses did not note any difference in their perceived insertion skills or confidence.

Bottom line: Once again, it seemed like a good idea. But that doesn’t necessarily mean that it is. And we always automatically reach for the new shiny toy. This paper points out the importance of carefully reviewing all new (read: expensive at about $20,000 each) technology before blindly implementing it. In this case, an expensive peice of equipment can’t improve upon what an experienced ED or pediatric nurse can already accomplish.

 

References: 

  1. VeinViewer-assisted intravenous catheter placement in a pediatric emergency department. Acad Emerg Med, 18(9):966-971, 2011.
  2. Utilization of a biomedical device (VeinViewer® ) to assist with peripheral intravenous catheter (PIV) insertion for pediatric nurses. J Spec Pediatr Nurs. 23(2):e12208, 2018.

I have no financial interest in Christie Digital Systems, distributor of the VeinViewer Vision®.

Air Embolism From an Intraosseous (IO) Line

IO lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.

But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.

This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC).

During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line is not closed properly, there could be.

Bottom line: Treat an IO line as carefully as you would a regular IV. You can give anything through it that can be given via a regular IV: crystalloid, blood, drugs. And even air, so be careful!