How Fast Do Trauma Patients Die?

May 9, 2023 The Trauma Pro Leave a comment

For years, I’ve taught my residents participating in trauma activations, “Your patient is bleeding to death until proven otherwise.” This concept served as the basis of the [poorly documented] “Golden Hour” and for decades has directed our efforts at getting patients to a center with an immediately available OR as quickly as possible.

Donald Trunkey published the first paper illustrating the trimodal distribution of death in 1983 in Scientific American. A crude graph showed the large spike in early deaths that occurred within this first hour. But the paper was mainly observational and was not based on quantitative data.

Wouldn’t it be nice to know how quickly these injured patients were dying, and of what? The trauma group at the University of Pennsylvania massaged data in the state trauma database, focusing on patients who died of their injuries during the first four hours. They created two variables to more objectively compare times, the TD5 and the TD50. These are the time at which 5% and the time at which 50% (median) had died, respectively.

The Pennsylvania Trauma Outcomes Study database contains a huge amount of data. During the 11 years of the study, a total of 6,547 met the mortality criteria for analysis.

Here are the factoids:

The mechanism of injury was about 60% blunt / 40% penetrating, with an average ISS of 33
The majority of these patients (85%) were hypotensive before their death, meaning that they were likely bleeding to death on arrival
The overall TD5 was 23 minutes, and the TD50 was 59 minutes
These numbers were shorter for penetrating injuries, TD5=19 minutes and TD50=43 minutes
Patients who were not hypotensive lived a little longer: TD5=44 minutes and TD50 = 2 hours 18 minutes
77% of patients died in the ED and 19% in the OR. The remainder died in the ICU.

This chart shows the TD5 by mechanism and type of surgery. This represents when after arrival, patients start dying due to their injuries. Penetrating injury plus hypotension kills the fastest at 19 minutes and head injuries the slowest at 1:20.

Bottom line: The authors clearly show how soon seriously injured patients start to die. It’s less than 20 minutes in victims of penetrating injury with early hypotension. And the time between the “just start do die” point (TD5) and the “half are dead” point (TD50) is frighteningly short, just an additional twenty minutes!

There appears to be a bit of a grace period in patients who arrive with a normal blood pressure. Their TD50 is extended out to about two hours. All this means is that they are bleeding more slowly, but it is still killing them.

A good rule of thumb is that ANY hypotensive patient should make you justify why you are NOT ALREADY IN THE OPERATING ROOM! Dawdling in the trauma bay or performing unnecessary scans will push your patient much closer to the point of no return. Look at the huger percentage of patients in this study who died in the ED.

Remember, your patient is bleeding to death in front of your eyes, and the only place you can stop it is the OR!

Reference: Defining the optimal time to the operating room may
salvage early trauma deaths, J Trauma 76(5):1251-1258, 2014.

Philosophy

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

May 5, 2023 The Trauma Pro Leave a comment

Some trauma centers receive a significant number of transfers from referring hospitals. Much of the time, a portion of the workup has already been done by the outside hospital. 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. The reason you should be activating your team is that 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. If there is a significant disturbance in vital signs while in transit to you (hypotension, tachycardia, respiratory problems, coma), then you must activate. 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!

Resuscitation

Jehovah’s Witnesses And Blood Transfusion Demystified

May 2, 2023 The Trauma Pro Leave a comment

Injury can be a bloody business, and trauma professionals take replacement of blood products for granted. Some patients object to this practice on religious grounds, and their health care providers often have a hard time understanding this. So why would someone refuse blood when the trauma team is convinced that it is the only thing that may save their life?

Jehovah’s Witnesses are the most common group encountered in the US that refuse transfusion. There are more than 20 million Witnesses worldwide, with over 7 million actively preaching. It is a Christian denomination that originated in Pennsylvania during the 1870s.

Witnesses believe that the bible prohibits taking any blood products, including red cells, white cells, platelets or plasma. It also includes the use of any dialysis or pump equipment that must be primed with blood. This is based on the belief that life is a gift from God and that it should not be sustained by receiving blood products. The status of certain prepared fractions such as albumin, factor concentrates, blood substitutes derived from hemoglobin, and albumin is not clear, and the majority of Witnesses will accept these products. Cell saver techniques may be acceptable if the shed blood is not stored but is immediately reinfused.

Why are Witnesses so adamant about refusing blood products? If a transfusion is accepted, that person has abandoned the basic doctrines of the religion, and essentially separates themselves from it. They may then be shunned by other believers.

So what can trauma professionals do to provide best care while abiding by our patient’s religious belief? In trauma care it gets tricky, because time is not on our side and non-blood products are not necessarily effective or available. Here are some tips:

Your first duty is to your patient. Provide the best, state of the art care you can until it is absolutely confirmed that they do not wish to receive blood products. In they are comatose, you must use blood if indicated until the patient has been definitively identified by a relative who can confirm their wishes with regard to blood. Mistaken identity does occur on occasion when there are multiple casualties, and withholding blood by mistake is a catastrophe.
Talk with the patient or their family. Find out exactly what they believe and what they will allow. And stick to it.
Aggressively reduce blood loss in the ED. We are not always as fastidious as we should be because of the universal availability of blood products. Use direct pressure or direct suture ligation for external bleeding. Splint to reduce fracture bleeding.
Aggressively use damage control surgery. Don’t go for a definitive laparotomy which may take hours. Pack well, close and re-establish normal physiology before doing all the final repairs.
Always watch the temperature. Pull out all the stops in terms of warming equipment. Keep the OR hot. Cover every bit of the patient possible with warming blankets. All fluids should be hot. Even the ventilator gases can be heated.
Think about inorganic and recombinant products such as Factor VIIa, tranexamic acid and Vitamin K. These are generally acceptable.
Consider angiography if appropriate, and call them early so their are no delays between ED and angio suite or OR and angio suite.

Bottom line: Do what is right for your patient. Once you are aware of their beliefs, avoid the use of any prohibited products. Speak with them and their family to clarify exactly what you can and cannot do. This is essentially an informed consent discussion, so make sure they understand the consequences. Follow their wishes to the letter, and don’t let your own beliefs interfere with what they want.

Trauma Center

Adolescent Experience At Pediatric vs Adult Trauma Centers

April 27, 2023 The Trauma Pro Leave a comment

A number of papers have addressed the clinical differences between adult trauma centers that provide care for children and pediatric trauma centers. For example, differences in TBI outcomes and solid organ injury management have been noted, to name a few. But I’ve seen very little written on the patient (and parent) experiences at these centers.

Adolescents exist between the adult and pediatric worlds. They frequently suffer injury from adult mechanisms like car crashes, interpersonal violence, and drugs/alcohol. But they are still developing from anatomic, physiologic, and psychosocial standpoints. So which trauma center is better for them? An adult center with more experience managing their injuries, or a pediatric center more attuned to their distinct psychosocial needs?

The surgery group at the University of Calgary in Alberta, Canada, performed a prospective, 1.5 year study of adolescents (aged 15-17) and their caregivers when admitted to the local adult or pediatric trauma center. Enrollees received a survey eight weeks after discharge to glean details of their experience. This survey was a validated tool called the QTTAC-PREM ( Quality of Teen Trauma Care Patient Reported Experience Measure).

This survey was very comprehensive and clocked in at 31 pages in length! It included questions on visits by friends, interactions with hospital staff, schoolwork, pain control, mental health, privacy, and follow-up visits.

Here are the factoids:

A total of 90 patients were enrolled; 51 were admitted to pediatric trauma centers and 39 to adult centers
Survey completion rates were reasonable, with 77 returned in the pediatric center group and 41 in the adult center group (surveys could be completed by the patient, their caregiver, or both)
Patients taken to the adult center were more seriously injured (56% with ISS>9 vs. 10%)
Overall, there were few differences in experience, but parents gave lower ratings for communication, follow-up care, and the overall hospital score
The adult trauma centers had poorer family accommodations, as noted by both the patients and their parents

Bottom line: This is a (somewhat) interesting study looking beyond the purely clinical differences in adult vs. pediatric trauma centers. It has some significant problems, although it is still possible to derive some valuable information.

First, it was a survey. And a 31-page survey at that! I throw most one-page surveys I receive away without a thought. So the enrollment and return rates are guaranteed to be low. Next, it was performed during the height of COVID, which changed everything. Fewer patients presented to the hospitals, and measures were in place, making them less friendly and accessible for patients and their caregivers. This could significantly alter any opinions of patient/parent experiences.

And finally, there are only two trauma centers in Calgary, one adult and one pediatric. So this study cannot be generalized easily to other centers in Canada or anywhere else in the world. In many ways, they are unique. So the actionable information contained in it is very limited.

However, we can learn something. Communication is always an issue in hospitals. Pediatric centers are very familiar with dealing with parents, and adult centers would benefit by taking this page from their playbooks. Similarly, pediatric centers routinely provide housing for the parents, while adult centers have never had to prioritize this.

A related question needs to be addressed: what about dual centers? That is, a combined Level I adult and Level I pediatric center. These hybrids are largely ignored, although they are more common in larger metropolitan areas.

Regardless, ALL trauma centers can benefit from improved communication with their patients and accommodations for parents of pediatric patients.

Reference: Between Paradigms: Comparing experiences for adolescents treated at pediatric and adult trauma centres. Injury, published ahead of print, April 12, 2023.

If you are interested in the QTTAC-PREM questionnaire used in this study, you can find it in the supplemental data for this study:

Yeung M, Hagel BE, Bobrovitz N, Stelfox TH, Yanchar NL. Development of the quality of teen trauma acute care patient and parent-reported experience measure. BMC Res Notes. 2022 Sep 23;15(1):304. doi: 10.1186/s13104-022-06194-x. PMID: 36138467; PMCID: PMC9503226.

If you need help obtaining a copy, please feel free to email me.

Complications

Predicting VTE Risk In Children

April 21, 2023 The Trauma Pro Leave a comment

There’s a lot of debate about if and at what age injured children develop significant risk for venous thromboembolism (VTE). In the adult world, it’s a little more clear cut, and nearly every patient gets some type of prophylactic device or drug. Kids, we’re not so certain about at all.

The Children’s Hospital of Wisconsin tried to tease out these factors to develop and implement a practice guideline for pediatric VTE prophylaxis. They prospectively reviewed over 4000 pediatric patients admitted over a 6 year period.

It looks like the guideline was developed using some or all of this data, then tested using regression models to determine which factors were significant. The guideline was then tweaked and a final model was implemented.

Here are the factoids:

588 of the patients (14%) were admitted to the ICU, and 199 of these were identified as high-risk by the guidelines
Median age was 10 (this is always important in these studies)
VTE occurred in 4% of the ICU patients, and 10% of the high-risk ones
Significant risk factors included presence of central venous catheter, use of inotropes, immobilization, and GCS < 9

Bottom line: This abstract confuses me. How were the guidelines developed? What were they, exactly? And the results seem to pertain to the ICU patients only. What about the non-ICU kids? The abstract just can’t convey enough information to do the study justice. Hopefully, the oral presentation will explain all.

I prefer a very nice analysis done at the Oregon Health Science University in Portland. I wrote about this study earlier this year. The authors developed a very useful calculator that includes most of the risk factors in this model, and a few more. Input the specific risks, and out comes a nice score. The only issue is, what is the score threshold to begin prophylaxis and monitoring? Much more practical (and understandable) than this abstract. Check it out at the link below.

References:

Evaluation of guidelines for injured children at high risk for venous thromboembolism: A prospective observational study. J Trauma Acute Care Surg. 2017 May;82(5):836-844.
A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients. JAMA Surg 151(1):50-57, 2016.

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