All posts by TheTraumaPro

Trauma Activation For Hanging: Yes or No?

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.

Trauma Activation For Strangulation: Yes or No?

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.

EAST 2019 #13: Geomapping Helicopter transports

Helicopter EMS (HEMS) transports are a valuable yet very expensive resource. Unfortunately, many state trauma systems or local EMS agencies do not provide specific guidance for best use. A group at the University of Alabama in Birmingham performed a geospatial analysis of helicopter transports in their area to determine the efficiency of HEMS operations.

This group created a sort of “heat map” that showed the number of transports overlaid on a geographical map of their catchment area. It included HEMS transports over a 6-year period directly from the scene. Drive and flight times were calculated, and the latter also included flight time to reach the scene.


Here’s the heat map showing the entire state of Alabama. The approximate location of Birmingham is indicated in yellow.

Here are the factoids:

  • Nearly 3000 patients were identified, and 1911 had scene locations recorded so analysis could be performed
  • 35% of patients had minor injuries with ISS 1-8 (!!)
  • Median flight time was 58 minutes, and median drive time was only 65 minutes
  • In 28% of cases, drive time would have been shorter than flight time when considering time for the helicopter to reach the scene
  • Conclusion: over one fourth of patients might have arrived at the hospital more quickly by ground ambulance

Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:

  • Why include time for the helicopter to reach the scene but not a ground ambulance? Doesn’t this stack the deck in favor of ground transport?
  • Was there any correlation between scene proximity and high ISS? This might have been a reason for calling the helicopter.
  • Did you see any patterns in the low ISS group? This could provide insight into the EMS thought processes. These patients are potentially the low hanging fruit to direct educational activities to reduce HEMS use.

This is thought-provoking work and I look forward to hearing all the details!

Reference: Use of helicopters for retrieval of trauma patients: a geospatial analysis. EAST 2019, Quick Shot Paper #26.

EAST 2019 #12: Unplanned Readmissions After Trauma

Trauma programs and their registries are very good at abstracting and compiling a wide variety of data points on admitted trauma patients. They are not so great at recognizing readmissions after the original event. And they completely fail to capture (or at least link) readmissions to another hospital after the initial injury.

The US federal government implemented a Nationwide Readmissions Database (NRD), which provides information on patient readmissions nationally across all payors and the uninsured. This is extremely important data which provides interesting data about a population that is normally very difficult to identify.

A multidisciplinary group at Johns Hopkins analyzed the NRD for trauma patients age 15 or greater over a six year period. Patients were excluded if they were transferred, died during the initial hospitalization, or were admitted to a low trauma volume hospital (<100 patients per year). Readmissions within 1, 3, and 6 months were analyzed and statistical tools were applied to help identify predictors of readmission.

Here are the factoids:

  • A total of 3 million trauma patients were identified, with 93% blunt, 6% penetrating, and 1% burns
  • Readmissions were 10% within 1 month, 20% in 3 months, and 26% within 6 months (!)
  • These numbers remained relatively constant across all three mechanisms
  • Predictors of readmission, with odds ratios, included:
    • male gender (1.15)
    • lowest income quartile (1.04)
    • number of comorbidities (1.17)
    • leaving the hospital AMA (2.32)
    • initial admission to a private hospital (1.17)

The authors concluded that understanding these factors provides an opportunity for quality improvement and offers implications for hospital benchmarking.

Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:

  • Is there any indication in the data about why patients were readmitted? This would offer even more specific information to help focus quality improvement efforts.
  • Can you make any specific recommendations at this point as to how to begin to identify patients who have a higher potential to be readmitted? The odds ratio for income was not very high. Gender and AMA were more predictive, but apply to quite a few of our patients.
  • Can you speculate about why readmission risk increases for private hospitals? This is not intuitive to me.

This is another excellent and provocative paper from this group. I’m looking forward to hearing the nitty gritty during the presentation.

Reference: Unplanned readmission after traumatic injury: a long-term nationwide analysis. EAST 2019, Quick Shot Paper #27.

EAST 2019 #11: Thawed Plasma And Rural Trauma Centers

A massive transfusion protocol must be available at all trauma centers, large and small, urban and rural. In an ideal setting, attempts are made to keep the ratios of red blood cells to plasma transfused somewhere between a 1:1 and 2:1 ratio. Unfortunately, many hospitals do not keep any thawed plasma because of its 5-day shelf life, so they must resort to thawing it on demand. This process is slow and may take 20-40 minutes, so it is often difficult for these centers to keep within the optimal ratios.

The group at the Guthrie Clinic, a Level II trauma center in northern Pennsylvania, tried a novel approach to thawed plasma availability: keeping two units continuously available in the ED for trauma use only. After three days, these units were returned to the blood bank for general use and were replaced with new ones. They reviewed their one year experience with wasted plasma and compared it with the two years prior to implementation.

Here are the factoids:

  • The blood bank thawed 1127 units during the study period; 274 units were placed in the trauma bay
  • There was a significant increase in waste and cost of wasted products
  • Yet the authors did not find an increase in the relative cost of plasma waste
  • The average cost to maintain access to plasma in the trauma bay was $117 per month
  • The authors concluded that the increased waste and cost were insignificant compared to the cost of total blood bank waste (?)

Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:

  • What do all the terms mean, like relative cost? I’m confused that the cost of waste is significantly higher, but not the relative cost. Please explain in your presentation.
  • Is the $117/month to maintain access just for the refrigerator itself and any other support hardware or software? It’s not clear if this includes any part of the blood product cost.
  • Why not keep the plasma in the blood bank? Even though it might still be wasted, couldn’t you save the $117 monthly and avoid the hassle of trying to find a cubby to put the ED blood refrigerator in?
  • Why is 3 days your magic number? Did you consider doing a simulation after you completed the study to see what would have happened if you picked 2 or 4 days in the ED instead?

This is a very creative approach to stocking perishable goods that are infrequently used. I look forward to hearing the presentation.

Reference: A novel protocol to maintain continuous access to thawed plasma at a rural trauma center. EAST 2019, Quick Shot Paper #14.