All posts by TheTraumaPro

Laboratory, Resuscitation

MTP Week Part I: How To Build Your Massive Transfusion Protocol

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It’s Massive Transfusion Protocol (MTP) week! I’m releasing the next Trauma MedEd newsletter to subscribers at the end of the week, which deals with advanced MTP topics. So leading up to that, I’ll be reviewing the basics for the next several days. I’ll start today with tips on how to build a solid MTP at your center.

Your massive transfusion protocol is a complex set of processes that touch many, many areas within your hospital. There are five basic components (and a few sub-components) to any MTP, so let’s dig into them one by one. They are:

  • Universality
  • Activation
  • Logistics
    • Components
    • Runners
    • Documentation
    • Coolers
  • Deactivation
  • Analysis

Let’s scrutinize each one, starting with the first two today.

Universality. This means that there should be one, and only one MTP in your hospital. I’ve seen some hospitals that have one MTP for trauma, one for cardiothoracic surgery, one for OB, one for GI, and on and on. Yes, each of those services deals with patients who are suffering from blood loss. But it’s the same blood that your trauma patients lose! There’s no need to create a protocol for each, with different ratios, extra drugs, etc. This can and will create confusion in the blood bank which may lead to serious errors.

Activation. This consists of two parts: how do we decide to activate, and then how does everyone involved find out that the MTP is actually being activated? I’ll discuss activation criteria on Thursday. But what about the notification process? Phone call? Order in the electronic medical record (EMR)? Smoke signals?

The most reliable method is a good, old-fashioned phone call. Do not use your EMR except for documentation purposes. Unless there is a very reliable system in the blood bank that translates an EMR order into an annoying alarm or flashing lights, don’t rely on this at all.

Then decide upon the minimum amount of information that the blood bank needs to begin preparing blood products. This usually consists of a name or temporary patient identifier, sex, and location of activation. Ensure that an ID or transfusion band is affixed to the patient so that wrong blood products are not given in multiple patient events.

Tomorrow, I’ll continue with the logistics of the MTP.

And don’t forget to subscribe to TraumaMed if you want to get a full newsletter discussing advanced MTP topics this Friday. Otherwise, you’ll be reading a post on CT scans and rib fractures in the elderly! Subscribe and download back issues by clicking here.

Links: (note – future links will not be live until 9am the day they are published)

Newsletter

FINALLY! The Next Trauma MedEd Newsletter Is Ready For Release!

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I’m finally back on track! After a multi-month hiatus, the next Trauma MedEd newsletter will be released at the end of next week. In this issue, I will finish my coverage of the Massive Transfusion Protocol (MTP).

Topics will include:

  • What’s the big deal about product ratios?
  • Use of tranexamic acid (TXA) in MTP
  • Is TEG a useful adjunct to the MTP?
  • The newest greatest thing: good old whole blood
  • and more!

As always, this issue will go to all of my subscribers first. If you are not yet one of them, click this link to sign up now and/or download back issues.

Unfortunately, non-subscribers will have to wait even a little longer until I release the issue on this blog, about a week later. So sign up now!

CNS

Glasgow Coma Scale For Trauma Activation: What’s The Optimal Score?

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Last month, I posted a survey to  find out the Glasgow Coma Scale (GCS) values trauma centers were using to trigger their highest level trauma activation. Nearly 150 people responded, providing a nice snapshot of practices worldwide. Today, I’ll summarize the responses and provide a bit of commentary about them.

There were a total of 147 respondents from around the world. I tried to eliminate duplicates from the same center using a self-reported postal code. However, this was an optional field, so there is the possibility that a few crept in. Readers from at least six countries outside the US also responded.

The question  was: “What is the highest GCS score that triggers a top-level trauma activation at your trauma center?”

Here is a chart that shows the results. The proper way to read it is “a trauma activation is called if GCS < xx” where xx is the score under the bar in the chart.

The whole point to calling a trauma activation is to have the full trauma team and infrastructure (labs, imaging, blood, etc.) in place to rapidly assess a patient with life-threatening injuries. In theory this should afford them the best probability of survival.

So what is the optimal GCS score to activate your trauma team? Unfortunately, this remains difficult to answer exactly. From the chart, you can see that the most common scores were 8, 9, and 13. Why such a spread?

The GCS 8 and 9 levels are a no-brainer (ha!). These patients are comatose or nearly so, and obviously need prompt attention such as airway control, head CT, and neurosurgical consultation. But what about the patients with GCS 13? They have lost two points, typically for eye-opening and verbal response. This may indeed indicate  a significant head injury. But all too often we see this same score in patients who are intoxicated. Do we really need (or want) to activate the full team for each and every intoxicated patient? Can we screen them out in some way?

The answer to both questions is yes. The most important tip is to know your patient population. There is an association between GCS and need for operative intervention that was oft-quoted in the ATLS course. However, I have not been able to find a definitive paper on this topic.

I recommend that you tap into your trauma registry and create a chart that shows presenting GCS vs early neuro-intervention (ICP monitor or craniectomy within 24 hours). Find the GCS score where you see a “significant” bump in the number needing a procedure, and use this as your trauma activation threshold. This report will automatically take into account the number of intoxicated patients you treat.

I would also recommend you do a separate report on age vs need for neuro-intervention with GCS<15. The older population tends to require craniectomy for TBI more often and at higher GCS levels than younger people. You may factor this into your single GCS criterion, or add a separate one at a different level for patients over 55, or 60, or whatever reflects your patient age mix.

Bottom line: Make sure your GCS trauma activation criteria adequately identify your patients who truly have a need for speed in their trauma evaluation. A GCS of 8 or 9 may be too low, and a score in the teens is probably more appropriate for most centers. Use your trauma registry to determine the best score for you so you can capture the patients who have critical needs while trying to keep overtriage under control.

 

General, Mechanism

Trauma Activation For Hanging: Yes or No?

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In my last post, I discussed a little-reviewed topic, that of strangulation. I recommended activating your trauma team only for patients who met the physiologic criteria for it.

But now, what about hangings? There are basically two types. The judicial hanging is something most of you will never see. This is a precisely carried out technique for execution and involves falling a certain height while a professionally fashioned noose arrests the fall. This results in a fairly predictable set of cervical spine/cord, airway, and vascular injuries. Death is rapid.

Suicidal hangings are far different. They involve some type of ligature around the neck, but rarely and fall. This causes slow asphyxiation and death, sometimes. The literature dealing with near hangings is a potpourri of case reports, speculation, and very few actual studies. So once again, we are left with little guidance.

What type of workup should occur? Does the trauma team need to be called? A very busy Level I trauma center reviewed their registry for adult near-hangings over a 19 year period. Hanging was strictly defined as a ligature around the neck with only the body weight for suspension. A total of 125 patients were analyzed, and were grouped into patients presenting with a normal GCS (15), and those who were abnormal (<15).

Here are the factoids:

  • Two thirds of patients presented with normal GCS, and one third were impaired
  • Most occurred at home (64%), and jail hangings occurred in 6%
  • Only 13% actually fell some distance before the ligature tightened
  • If there was no fall, 32% had full weight on the ligature, 28% had no weight on it,  and 40% had partial weight
  • Patients with decreased GCS tended to have full weight on suspension (76%), were much more likely to be intubated prior to arrival (83% vs 0% for GCS 15), had loss of consciousness (77% vs 35%) and had dysphonia and/or dysphagia (30% vs 8%)
  • Other than a ligature mark, physical findings were rare, especially in the normal GCS group. Subq air was found in only 12% and stridor in 18%.
  • No patients had physical findings associated with vascular injury (thrill, bruit)
  • Injuries were only found in 4 patients: 1 cervical spine fracture, 2 vascular injuries, and 1 pneumothorax
  • 10 patients died and 8 suffered permanent disability, all in the low GCS group

Bottom line: It is obvious that patients with normal GCS after attempted hanging are very different from those who are impaired. The authors developed an algorithm based on the initial GCS, which I agree with. Here is what I recommend:

  • Do not activate the trauma team, even for low GCS. This mechanism seldom produces injuries that require any surgical specialist. This is an exception to the usual GCS criterion.
  • The emergency physician should direct the initial diagnosis and management. This includes airway, selection of imaging, and directing disposition. A good physical exam, including auscultation (remember that?) is essential.
  • Patients with normal GCS and minimal neck tenderness or other symptoms do not need imaging of any kind.
  • Patients with abnormal GCS should undergo CT scanning, consisting of a CT angiogram of the neck and brain with soft tissue images of the neck and cervical spine recons.
  • Based on final diagnoses, the patient can be admitted to an appropriate medical service or mental health. In the very rare case of a spine, airway, or vascular injury, the appropriate service can be consulted.

Reference: A case for less workup in near hanging. J Trauma 81(5):925-930, 2016.

Mechanism, Trauma Center

Trauma Activation For Strangulation: Yes or No?

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Trauma activation criteria generally fall into four broad categories: physiology, anatomy, mechanism of injury, and co-factors. Of these, the first two are the best predictors of patients who actually need to be assessed by the full trauma team. Many trauma centers include a number of mechanistic criteria, usually much to their chagrin. They typically end up with frequent team activations and the patient usually ends up have trivial injuries.

However, there are some mechanisms that just seem like they demand additional attention. Death of another occupant in the vehicle. Fall from a significant height. But what about a patient who has been strangled?

Unfortunately, the published literature gives us little guidance. This usually means that trauma centers will then just do what seems to “make sense.” And unfortunately, this frequently results in significant overtriage, with many patients going home from the emergency department.

Since there is little to know research to show us the way, I’d like to share my thoughts:

  • As a guiding principle, the trauma  team should be activated when the patient will derive significant benefit from it. And the benefit that the team really provides is speed. The team approach results in quicker diagnosis from physical exam and FAST. It gets patients to diagnostic imaging quicker, if appropriate. And gets them to the OR faster when it’s not appropriate to go to CT.
  • Activating for a strangulation mechanism alone is probably a waste of time.
  • Look at the patient’s physiology first. Are the vital signs normal? What is the GCS? If either are abnormal, activate.
  • Then check out the anatomy. If the patient has any voice changes, or has obvious discoloration from bruising, crepitus, or subcutaneous emphysema, call the team. They may suffer a deteriorating airway at any moment.

If physiologic and anatomic findings don’t trigger an activation, then standard evaluation is in order. Here are some things to think about:

  • A complete physical exam is mandatory. This not only includes the neck, but the rest of the body. Strangulation is a common injury from domestic violence, and other injuries are frequently present.
  • If there are any marks on the neck, CT evaluation is required. This includes soft tissue, CT angiography, and cervical spine evaluation. All three can be done with a single contrast-enhanced scan. The incidence of spine injury is extremely low with strangulation, but the spine images are part of the set anyway.
  • CT of the chest is never indicated. There is no possibility of aortic injury with this mechanism, and all the other stuff will show up on the chest x-ray, if significant enough for treatment.
  • Even if there are no abnormalities, your patient may need admission while social services arranges a safe place for their discharge. Don’t forget the social and forensic aspects of this injury. Law enforcement may need photographic evidence or statements from the patient so this event can’t happen again.

Next post: Trauma Activation for Hanging: Yes or No?

Reference: Strangulation forensic examination: best practice for health care providers. Adv Emerg Nurs J 35(4):314-327, 2013.