Low Grade Spleen Injury With Contrast Blush

December 10, 2024 The Trauma Pro Leave a comment

It is almost a given that low-grade solid organ injuries are relatively benign and seldom require any intervention. In fact, some trauma centers actually discharge these patients home from the emergency department.

But what about low-grade isolated spleen injuries with a contrast blush? Apparently, a few authors believe that this may be a benign condition that doesn’t require any specific management. This didn’t sit well with some, and a multicenter study was launched to look at this group more closely.

A retrospective cohort study involving 21 trauma centers was organized via the Eastern Association for the Surgery of Trauma. It enrolled adults (>18 years) with a grade I or II injury on CT scan after blunt trauma, which also demonstrated a contrast blush. Hemodynamically unstable patients and those who had clotting disorders or were taking any anticoagulant other than aspirin were excluded.

Here are the factoids:

Although 209 patients were enrolled over a nearly six-year period, 64 were removed due to meeting exclusion criteria or undergoing some intervention or laparotomy for other injuries
The remaining 145 patients were 66% men with an average age of 47
About one-third had a grade I injury, and two-thirds had grade II
20% of these patients failed nonoperative management
These results were unchanged between grade I (18%) and grade II (21%)
Those who failed had a longer hospital stay (8 days vs. 5 days), had a higher likelihood of blood transfusion (55% vs. 26%) and MTP activation (14% vs. 3%)
There was no difference in discharge disposition or mortality

Bottom line: This study was conducted between 2014 and 2019. During that period, the AAST spleen and liver injury grading scales did not consider vascular injury. The 2018 update automatically upgrades injuries with blush or extravasation to Grade IV. This has a significant impact on how we view these injuries.

I have always said that any patient with contrast extravasation is bleeding to death until we stop it. The only exception is pediatric patients, who seem to clot these on their own. The 2018 update bore this out, and this paper confirms that low-grade anatomic injuries become dangerous if extravasation is present. I would also extend this to patients with a CT showing significant pseudoaneurysm formation.

So what should you do? If you have a patient with a spleen or liver injury that has contrast extravasation or a pseudoaneurysm, consider this a patient that needs hemorrhage control by interventional radiology under Standard 4.15 in the 2022 ACS Resources for Optimal Care of the Injured Patient. This means that you must let your IR team know that you have a patient who needs an intervention within 60 minutes, or you will need to transfer to a center with those capabilities as soon as possible.

Reference: Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study. Trauma Surg Acute Care Open. 2024 Mar 7;9(1):e001159. doi: 10.1136/tsaco-2023-001159. PMID: 38464553; PMCID: PMC10921525.

Complications

Incidental Appendectomy During Trauma Laparotomy?

December 6, 2024 The Trauma Pro Leave a comment

The debate over incidental appendectomy has waxed and waned over the years. And for the most part, it has nearly permanently waned in general surgical cases for now. But every once in a while, I am asked about incidental appendectomy during trauma laparotomy. Is it a good idea? What reasons could there possibly be for doing it?

In the old days, we would frequently do an incidental appendectomy because… well, just because we were there. The surgeon was in the midst of a general surgical case, typically an open one, and this normal little appendix was staring us in the face. The justification was usually, “We’ll save him/her another operation in the future in case he develops acute appendicitis.”

Legitimate reason? It took many years for the literature to develop, but it finally did. Here are the reasons we figured out not to do it:

Despite how innocuous a procedure seems, there is a measurable uptick in complication rates. This is true in the usual clean contaminated general surgery cases. Some papers also noted an increased mortality when the appendectomy was added to a cholecystectomy case. In a trauma procedure with bowel injury and contamination, it’s a bit harder to see the correlation. But any time we cut or staple something out, there is always the possibility that it might break down.
Cost increases in laparoscopic cases if additional ports and equipment are needed for the appendectomy. This doesn’t apply to major trauma cases since we better not be doing them laparoscopically!
The appendix is not the useless vestigial structure we initially thought. Evidence shows that it is a repository for the gut microbiome, which can help repopulate the colon with bacteria after a serious insult like prolonged antibiotic administration. Unnecessary removal may ultimately interfere with gut health and disease.

Can acute appendicitis develop after trauma laparotomy? Sure, at any time. Thankfully, it’s not very common. The presenting complaints are the same as we learned in the doctor books. However, the location of the pain and tenderness may not be in the classic location, depending on the post-trauma anatomy and presence of adhesions.

Bottom line: Incidental appendectomy is no longer indicated for just about anything, including trauma laparotomy. If one of your patients presents with abdominal pain at any time, both post-traumatic and other causes must be considered. CT has become the standard for appendicitis workup and is extremely helpful in sorting out causes in the post-op trauma patient. Use it, and if it is one of the rare cases where appendicitis is actually present, then proceed with the usual and appropriate operative on nonoperative management.

References:

Incidental appendicectomy with laparotomy for trauma. Br J Surg 62(6):487-9, 1975
Appendicitis following blunt abdominal trauma. Am J Emerg Med 35(9):1386.e5-1386, 2017.
Systematic review of blunt abdominal trauma as a cause of acute appendicitis. Ann R Coll Surg Engl 92(6):477-82, 2010.

Performance Improvement

The Implications Of A High Pediatric Readiness Score

December 3, 2024 The Trauma Pro Leave a comment

In my last post, I described the Pediatric Readiness Score and its components. Today, I’ll explain why maintaining a high score may benefit your trauma center and what it costs to do so.

Research groups at the Oregon Health Sciences University and the University of Utah combined multiple data sources to estimate current levels of ED pediatric readiness, the cost to achieve it, the number of pediatric deaths in emergency departments, and the number of potential lives saved if readiness is maintained.

As you can imagine, this was an extensive data set suffering from the usual glitches. The authors either excluded incomplete data or managed it with sophisticated statistical methods. Data was included from 4,840 emergency departments in all 50 states and the District of Columbia.

Here are the factoids:

The authors estimated that nearly 670,000 children receive care in the emergency departments each year
Only 15% (842 EDs) had high readiness. The range was 2.9% in Arkansas to 100% in Delaware.
The annual cost to achieve high pediatric readiness nationwide was approximately $210 million
The annual cost per child to achieve high readiness ranged from $0 in Delaware to $11.84 in North Dakota
It was estimated that about 28% of the 7619 childhood deaths each year could be prevented if the treating ED had high pediatric readiness

Bottom line: This paper has a lot of information to digest. Please remember that these are not precisely measured numbers but estimates based on statistical models. So, minor inaccuracies in those models could change these results.

Nonetheless, the data demonstrate the importance of maintaining high pediatric readiness in your emergency department. Don’t let the total cost of readiness frighten you. Spread evenly across all the EDs studied, this amounts to only about $43,000 annually.

I urge all trauma centers to measure their pediatric readiness score. Then, dedicate the resources your hospital can afford to improve it as much as possible/practical. The number of potential pediatric lives saved is substantial and meaningful.

Reference: State and National Estimates of the Cost of Emergency Department Pediatric Readiness and Lives Saved. JAMA Netw Open. 2024;7(11):e2442154.

Performance Improvement

Why Is Your Hospital’s Pediatric Readiness Score Important?

November 12, 2024 The Trauma Pro Leave a comment

The Pediatric Readiness Score (PRS) is a new(er) metric that is now required for all US trauma centers verified by the American College Surgeons. There is no specific threshold that must be met, but the value must be reported for review at the time of the site visit.

What is the PRS? It is a measure introduced by the National Pediatric Readiness Project. This is a quality initiative that was developed by the Emergency Medical Services for Children program (EMS-C), which partnered with the American College of Emergency Physicians, the Emergency Nurses Association, and the American Academy of Pediatrics. The goal was to improve hospitals’ pediatric readiness through a self-administered survey. It was believed that by quantifying readiness, the hospitals would be better able to improve their scores via simple and, hopefully, inexpensive changes.

Each hospital completes a comprehensive assessment online (the paper version is 19 pages long). It solicits information on the following topics

presence of a physician pediatric care coordinator
presence of an ED nurse pediatric emergency care coordinator
pediatric training and education of any health professionals taking care of children
existence of an ED performance improvement plan for pediatric patients
details of monitoring and care of children in the ED
presence of social services and transfer guidelines for children
existence of policies for family-centered care in the ED
disaster planning polices including children
presence of pediatric equipment, supplies, and resuscitation equipment in the ED

The scores provided by this assessment provide a standardized measure of pediatric readiness, ranging from 0 to 100. Scores can be improved relatively easily by ensuring that appropriate pediatric equipment is available in the ED, and ensuring that social services and transfer agreements include children and are up to date. Tasking a physician and nurse to oversee pediatric readiness is not necessarily as easy, but many are more than willing to step in to improve pediatric care at their hospital.

The biggest question I have when any major assessment / intervention is rolled out is, does it do what it is intended to do? In my next post, I’ll review a paper published last week that looks at the real-world implications of pediatric readiness vs. the lack thereof. This is of significance to both trauma and non-trauma hospitals.

References:

Head

Everything You Wanted To Know About: Cranial Bone Flaps

November 8, 2024 The Trauma Pro Leave a comment

Patients with severe TBI frequently undergo surgical procedures to remove clot or decompress the brain. Most of the time, they undergo a craniotomy, in which a bone flap is raised temporarily and then replaced at the end of the procedure.

But in decompressive surgery, the bone flap cannot be replaced because doing so may increase intracranial pressure. What to do with it?

There are four options:

The piece of bone can buried in the subcutaneous tissue of the abdominal wall. The advantage is that it can’t get lost. Cosmetically, it looks odd, but so does having a bone flap missing from the side of your head. And this technique can’t be used as easily if the patient has had prior abdominal surgery.

2. Some centers have buried the flap in the subgaleal tissues of the scalp on the opposite side of the skull. The few papers on this technique demonstrated a low infection rate. The advantage is that only one surgical field is necessary at the time the flap is replaced. However, the cosmetic disadvantage before the flap is replaced is much more pronounced.

3. Most commonly, the flap is frozen and “banked” for later replacement. There are reports of some mineral loss from the flap after replacement, and occasional infection. And occasionally the entire piece is misplaced. Another disadvantage is that if the patient moves away or presents to another hospital for flap replacement, the logistics of transferring a frozen piece of bone are very challenging.

4. Some centers just throw the bone flap away. This necessitates replacing it with some other material like metal or plastic. This tends to be more complicated and expensive, since the replacement needs to be sculpted to fit the existing gap.

So which flap management technique is best? Unfortunately, we don’t know yet, and probably never will. Your neurosurgeons will have their favorite technique, and that will ultimately be the option of choice.

Reference: Bone flap management in neurosurgery. Rev Neuroscience 17(2):133-137, 2009.

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