Trauma Activation For Hanging: Yes or No?

May 2, 2025 The Trauma Pro Leave a comment

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?

April 29, 2025 The Trauma Pro Leave a comment

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.

Performance Improvement

Blame The Trauma Surgeon?

April 22, 2025 The Trauma Pro Leave a comment

I found an interesting paper published a couple of years ago that purports to examine individual surgeon outcomes after trauma laparotomy. This was presented at the annual AAST meeting in 2021 and then published in the Journal the following year.

Everyone seems to be giving this paper a pass. I won’t be so easy on it. Let me provide some details.

The authors observe that the mortality in patients presenting in shock who require emergent laparotomy averages more than 40%, and hasn’t changed significantly in at least 20 years. They also note that this mortality varies widely from 11-46%, and therefore, “significant differences must exist at the level of the individual surgeon.” They go on to point out that damage control usage varies between individuals and trauma centers, which could lead to the same conclusion.

So the authors designed a retrospective cohort study of results from their hospital to try to look at the impact of individual surgeon performance on survival.

Here are the factoids:

Over the 15-month study period, there were over 7,000 trauma activations and 252 emergent laparotomies for hemorrhage control
There were 13 different trauma surgeons, and the number of laparotomies for each ranged from 7 to 31, with a median of 15
There were no differences in [crude, in my opinion] patient demographics, hemodynamics, or lab values preop
“Significant” differences in management and outcomes between surgeons were noted:
- Median total OR time was significantly different, ranging from 120-197 minutes
- Median operation time was also different, from 75-151 minutes across the cohort of surgeons
- Some of the surgeons had a higher proportion of patients with ED LOS < 60 minutes and OR time < 120 minutes
- Resuscitation with red cells and plasma varied “significantly” across the surgeons
Mortality rates “varied significantly” across surgeons at all time points (24-hour, and hospital stay)
There were no mortality differences based on surgeons’ volume of cases, age, or experience level

The authors acknowledged several limitations, included the study’s retrospective and single-center nature, the limited number of patients, and its limited scope. Yet despite this, they concluded that the study “suggests that differences between individual surgeons appear to affect patient care.” They urge surgeons to openly and honestly evaluated ourselves. And of course, they recommend a large, prospective, multicenter study to further develop this idea.

Bottom line: This study is an example of a good idea gone astray. Although the authors tried to find a way to stratify patient injury (using ISS and individual AIS scores and presence of specific injuries) and intervention times (time in ED, time to OR, time in OR, op time), these variables just don’t cut it. They are just too crude. The ability to meaningfully compare these number across surgeons is also severely limited by low patient numbers.

The authors found some fancy statistical ways to demonstrate a significant difference. But upon closer inspection, many of these differences are not meaningful clinically. Here are some examples:

Intraoperative FFP ranged from 0-7 units between surgeons, with a p value of 0.03
Postoperative FFP ranged from 0-7 units, with a p value of 0.01
Intraoperative RBC usage was 0-6 units with the exception of one surgeon who used 15 in a case, resulting in a p value of 0.04

The claim that mortality rates varied significantly is difficult to understand. Overall p values were > 0.05, but they singled out one surgeon who had a significant difference from the rest in 22 of 25 mortality parameters listed. This surgeon also had the second highest patient volume, at 25.

The authors are claiming that they are able to detect significant variations in surgeon performance which impacts timing, resuscitation, and mortality. I don’t buy it! They believe that they are able to accurately standardize these patients using simple demographic and performance variables. Unfortunately, the variables selected are far too crude to accurately describe what is wrong inside the patient and what the surgeon will have to do to fix it.

Think about your last 10 trauma laparotomies where your patient was truly bleeding to death. How similar were they? Is there no difference between a patient with a mesenteric laceration with bleeding, an injury near the confluence of the superior mesenteric vessels, and a right hepatic vein injury? Of course there is. And this will definitely affect the parameters measured here and crude outcomes. Then add some unfavorable patient variables like obesity or previous laparotomy.

In my estimation, this paper completely misses the point because it’s not possible to retrospectively categorize all the possible variables impacting “surgeon performance.” This is particularly true of the patient variables that could not possibly be captured. The only way to do this right is to analyze each case as prospectively as possible, as close to the time of the procedure and as honestly as possible. And this is exactly what a good trauma M&M process does!

So forget the strained attempts at achieving statistical significance. Individual surgeon performance and variability will come to light at a proper morbidity and mortality conference, and should be evened out using the peer review and mentoring process. It’s not time to start blaming the surgeon!

Reference: It is time to look in the mirror: Individual surgeon outcomes after emergent trauma laparotomy. J Trauma 92(5):769-780, 2022.

Thorax

Can I Keep Patients With More Than Three Rib Fractures At My Level IV Trauma Center?

April 18, 2025 The Trauma Pro Leave a comment

Rib fractures are one of the most common thoracic injuries presenting to trauma centers. Traditionally, many state designation standards set limits on the number of rib fractures in patients to be admitted to Level IV trauma centers. The assumption was that these centers had limited surgical capabilities and might not have the expertise to manage them to achieve optimal patient outcomes. They were then forced to transfer these patients upstream to a higher-level trauma center.

And then, unfortunately, COVID came along, and things changed. Mainly for the worse. Due to reduced professional staffing throughout the entire continuum of health care, the upstream centers are saturated and have limited availability to absorb patients who don’t take advantage of their increased resources.

Both staffing and reimbursement issues strain rural EMS agencies. It is difficult to justify transferring a patient to a center that takes the only ambulance in the community out of service for a good portion of the day. Also, most current state trauma system standards do not fully appreciate non-surgeon clinicians’ interest and skill levels at those Level IV centers.

The Pennsylvania Trauma Systems Foundation recognized these issues at the centers in its state. In 2020, it opted to liberalize the number of rib fractures that could be treated at Level IV centers. It required hospitalists to be current in ATLS in order to admit these patients. The centers were also required to adhere to a chest injury guideline created for them.

To gauge the safety and effectiveness of this change, a retrospective state registry study was performed comparing patients admitted during the 2.5 years before the standards change to the 2.5 years after. Demographics, injury characteristics, length of stay, and mortality were compared between the groups. Patients were excluded if they had significant injuries in other body regions, were age < 18 years of age, or had complicated fractures (requiring supplemental oxygen on admission, concomitant pneumothorax or hemothorax, pulmonary contusion or laceration, or who did not require admission

Here are the factoids:

Over 4,000 patients were recorded in the registry during the 5 years, but 3350 were excluded due to the definition of complex rib fractures
A final total of 1,070 patients were included, with 710 admitted to Level III centers and 360 to Level IV centers
This left 132 Level III patients and 228 Level IV patients in the pre- and post-standard groups, respectively
The number of transfers out of the Level IV centers dropped significantly, from 56% to 21%
Patients with <3 rib fractures had the same length of stay as those with more than three (3 vs 2, respectively)
Mortality was extremely low and not significantly different based on the number of rib fractures

Bottom line: This study showed that the change in admission standards for rib fractures in Pennsylvania did not impact outcomes and resulted in significantly fewer transfers.

The key to a successful change like this involves education and protocols. The requirement that hospitalists be current in ATLS is beneficial because it gives them a better understanding of the physiologic effects and priorities in managing trauma patients. A well-designed practice guideline is critical so that all clinicians apply best practices in caring for these patients.

This is an important paper, and should be considered in any state where local resources are being challenged, and hospital reimbursements are declining. This type of standards change may breathe new life into many of our Level IV centers.

Philosophy

Do I Have To Call My Trauma Team For Incoming Transfers?

April 15, 2025 The Trauma Pro Leave a comment

Some trauma centers receive a significant number of transfers from referring hospitals. Much of the time, the outside hospital has already done a portion of the workup. If the patient meets one or more of your trauma activation criteria, do you still need to activate your team when they arrive?

And the answer is: sometimes. But probably not that often.

Think about it. You should be activating your team because you suspect the patient may have an injury that demands rapid diagnosis and treatment. The purpose of any trauma activation is speed. Rapid evaluation. Fast lab results. Quick access to CT scan or OR. If a significant amount of time has already passed (transported to an outside hospital, worked up for an hour or two, then transported to you), then it is less likely that a trauma activation will benefit the patient.

There are four classes of trauma activation criteria. I’ll touch on each one and the need to activate in a delayed fashion if present, in priority order.

Physiologic. You must activate if there is a significant disturbance in vital signs while in transit to you (hypotension, tachycardia, respiratory problems, coma). Something else is going on that needs to be corrected as soon as the patient arrives. And remember the two mandatory ACS criteria that fall into this category: respiratory compromise/need for an emergent airway, and patients receiving blood to maintain vital signs. But a patient who needed an airway who is already intubated and no longer compromised does not need to be a trauma activation.
Anatomic. Most simple anatomic criteria (e.g., long bone or pelvic fractures) do not need a trauma activation unless the patient is beginning to show signs of physiologic compromise. However, anatomic criteria that require rapid treatment or access to the OR (proximal amputations, mangled or pulseless extremities, spinal cord injury) should be activated.
Mechanism. Most of the vague mechanistic criteria (falls, pedestrian struck, vehicle intrusion) do not require trauma activation after transfer to you. But once again, if the mechanism suggests a need for further rapid diagnosis or treatment (penetrating injury to abdomen), then activate.
Comorbidities. This includes underlying diseases, extremes of age, and pregnancy. In general, these will not require trauma activation after they arrive.

Bottom line: In many cases, the patient transferred in from another hospital will not need to be a trauma activation, especially if they have been reasonably assessed there. The patient should be rapidly eyeballed by your emergency physicians, and if there is any doubt about their condition, activate then.

However, if little workup was done at the outside hospital (my preference), and the injuries are “fresh” (less than a few hours old), then definitely call your team.

And finally, if the patient meets any of the ACS hard criteria for activation (this includes hypotension, transfusing blood, and respiratory compromise), don’t hesitate to trigger the activation!

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