Category Archives: Complications

Syncope Workup in Trauma Patients – Updated With CPG

Syncope accounts for 1-2% of all ED visits, and is a factor in some patients with blunt trauma, especially the elderly. If syncope is suspected, a “syncope workup” is frequently ordered. Just what this consists of is poorly defined. Even less understood is how useful the syncope workup really is.

Researchers at Yale retrospectively looked at their experience doing syncope workups in trauma patients. They were interested in seeing what was typically ordered, if it was clinically useful, and if it impacted length of stay.

A total of 14% of trauma patients had syncope as a possible contributor to their injury. The investigators found that the following tests were typically ordered in these patients:

  • Carotid ultrasound (96%)
  • 2D Echo (96%)
  • Cardiac enzymes (81%)
  • Cardiology consult (23%)
  • Neurology consult (11%)
  • EEG (7%)
  • MRI (6%)

Most of this testing was normal. About 3% of cardiac enzymes were abnormal, as were 5% of carotid imaging and 4% of echocardiograms.

Important! Of the patients who underwent an intervention after workup, 69% could have been identified based on history, physical exam, or EKG and did not depend on any of the other diagnostic tests.

Is it possible to determine a subset of this population that may show a higher yield for this screening? Surgeons at Temple University in Philadelphia found that there was little utility in using carotid duplex studies. They did note that patients with a history of heart disease were more likely to have an abnormal EKG, and that an abnormal EKG predicted an abnormal echo. Overall, only patients with a history of significant cardiac comorbidity, older age, and higher ISS had findings requiring intervention.

Bottom line: Don’t just reflexively order a syncope workup when there is a question of this problem. Think about it first, because the majority of these studies are nonproductive. They are not needed routinely in trauma patients with “syncope” as a contributing factor.  Obtain a good cardiac history, and if indicated, order an EKG and go from there. See the practice guideline proposed by the Temple group below. And be sure to include the patients primary doctor in the loop!

References:

  1. Routine or protocol evaluation of trauma patients with suspected syncope is unnecessary. J Trauma 70(2):428-432, 2011.
  2. Syncope workup: Greater yield in select trauma population. Intl J Surg, accepted for publication June 27, 2017.

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The ICU Bounce Back

We’ve all experienced it. A seriously injured trauma patient is admitted to the ICU and begins the process of recovery. Everything looks well, and after a few days they’re transferred to a ward bed. But then they languish, never really doing what we expect. Finally (and usually in the middle of the night), they begin to look bad enough where we have to transfer them back to the ICU. Before or after the call to the Rapid Response Team. Yes, it’s the feared “unexpected readmission to ICU.”

What’s the problem here? A failure of the ICU team? Did they send the patient out too soon? Did we all miss something about the patient? And is there any way we can avoid this problem? The major issue is that these “bounce backs” tend to do poorly compared to patients who successfully stay in their ward bed. Estimates are that mortality for patients successfully and finally discharged from the ICU range from 4-8%, whereas the mortality in bounce back patients is 20-40%!

Researchers at the Medical University of South Carolina in Charleston looked at the characteristics that defined the bounce back patient. They reviewed nearly 2000 patients discharged from their trauma ICU and analyzed the variables that predicted an unplanned bounce back. They noted the following interesting factoids:

  • More than two thirds of bounce backs occurred within 3 days
  • Males, patients with an initial GCS < 9, transfer during the day shift  were the major risk factors
  • More comorbidities was associated with a higher chance of bounce back
  • Mortality in the bounce back group was 20%
  • The most common immediate factors causing bounce back were respiratory failure or bleeding

Bottom line: This is an intriguing single-institution study that supports my own personal observations. Fewer bounce backs occur at night because staffing tends to be lower and there is more resistance to transfers out of the ICU then. Both the ICU team and the ward team need to scrutinize every transfer carefully. Significant head injury or the presence of medical comorbidities should trigger a careful assessment to make sure that the transfer is appropriate. Otherwise, your patient may be placed in unnecessary jeopardy.

Next, I’ll discuss when an unexpected return to ICU is not an unexpected return!

Reference: Intensive care unit bounce back in trauma patients: An analysis of unplanned returns to the intensive care unit. J Trauma 74(6):1528-1533, 2013.

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Top 10 Worst Complications: #1 Nasocerebral Tube

Minor complications from nasogastric tube insertion occur relatively frequently. Emesis is fairly common when the gag reflex is stimulated by the tube in the back of the oropharynx. An infrequent but possibly fatal one is insertion through the cribriform plate. 

The cribriform plate is located directly posterior to the nares and is part of the ethmoid bone. It is very porous in nature and weaker than the surrounding portions of the ethmoid. It is easily fractured, and can be seen is association with basilar skull fractures. This is one source for rhinorrhea in patients with these fractures.

Cribriform fracture is a contraindication to unprotected insertion of a nasogastric tube. If you look at the sagittal section below, the plate lies directly behind the nares. When inserting the NG tube, we are usually taught to aim the tube straight back. Unfortunately, this aims it directly at the cribriform. If a fracture is present, it is possible that you may be inserting a nasocerebral tube!

Cribriform plate - sagittal section

The usual symptoms when this occurs consist of immediate neurologic deterioration to coma, and a unilateral or bilateral blown pupil. The tube must not be withdrawn, because it will cause significant injury to the base of the brain. A stat neurosurgical consultation must be obtained, and if the patient is salvageable, the tube must be withdrawn through a craniectomy.

To avoid this dreaded complication, identify patients at risk for cribriform injury. They are:

  • patients with signs of trauma from eyebrows to zygoma
  • comatose patients
  • patients with signs of basilar skull fracture (Battle’s sign, raccoon eyes, oto- or rhinorrhea)

If your patient is at risk, follow these guidelines:

  • first, does the patient really need a gastric tube?
  • if comatose, insert an orogastric tube
  • if awake, don’t put the tube in their mouth, as they will gag continuously. Instead, place a lubricated, curved nasal airway. Then lube up a slightly smaller Salem sump tube and pass it through the airway.
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Nausea In The Trauma Bay: Gastric Tube vs Anti-Emetic Drugs?

Nausea and vomiting are common problems in trauma patients, particularly those in a trauma activation. Inciting factors include pain, full stomach from food eaten before the event or blood swallowed after, or reaction to pain medications. For years, trauma professionals reached for the lowly gastric tube to evacuate stomach contents to “solve” the problem.

But how many of you have seen a patient forcefully empty their stomach as soon as the tube touches the oropharynx? And of course, your patient is lying supine, so the vomitus goes straight up, then back down into their airway. And if their mental status is not quite right, they may aspirate, causing even bigger problems.

We’ve had anti-emetic medications for a long time, some more effective than others. Only recently have we begun to rely on these as a first line defense in the trauma resuscitation room. But do they work? Are they safer?

The University Medical Center Utrecht in the Netherlands looked at this problem. They changed their policy from inserting a gastric tube to administering anti-emetics at the beginning of 2014. They studied their experience for the 6 months before and 6 months after the policy change. They inserted an orogastric (OG) tube preferentially before the switch, and used ondansetron and/or metoclopramide after.

Here are the factoids:

  • A total of 1446 trauma patients were admitted during this period. After excluding patients who were intubated or did not complain of nausea, 453 were analyzed (30%)
  • 20% of patients who had an OG tube placed vomited vs only 3% receiving medication (significant)
  • After therapy, 14% of patients receiving an OG were still nauseated vs only 2% getting meds (also significant)
  • 3 patients vomited and aspirated after OG placement, and 1 developed a pneumonia. 2 patients became bradycardic and med administration, and one developed QT-prolongation

Bottom line: This is a relatively small, retrospective study. Furthermore, the choice of gastric tube route (oral) is a setup for gagging and vomiting. Nasogastric tubes are a bit less noxious, but can’t be inserted in all patients (see tomorrow’s post). Even so, the use of anti-emetics in trauma patients complaining of nausea seems like the kinder, gentler way to go. 

Which drug to use? Previous studies have shown that ondansetron 4mg is as effective as 8mg, and that this drug is about equally as effective as metoclopramide. There is also some evidence that giving both is more effective than just giving one.

Gastric tubes are still important, particularly in the comatose patient. But since these patients are at risk for cribriform plate injury, only the oral route should be used.

Reference: Analysis of two treatment modalities for the prevention of vomiting after trauma: orogastric tube or anti-emetics. Injury (accepted manuscript, in press) online 8 July 2017.

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Aspirin For DVT Prophylaxis In Trauma

The use of mechanical and pharmacologic prophylaxis for prevention of deep venous thrombosis (DVT) and venous thromboembolism (VTE) in trauma patients is nearly universal. However, no matter how closely we adhere to existing guidelines, some patients will develop these conditions. Indeed, about 80% of patient who suffer some type of VTE event were receiving prophylaxis at the time.

Trauma is a major factor in causing hypercoagulability. Although current chemoprophylaxis focuses on clotting factors, platelets play a big part in the clot formation process. Our usual drugs, though (various flavors of heparin), have no effect on them.

What about adding aspirin to the regimen? My orthopedic colleagues have been requesting this for years. There is a reasonable amount of data in their literature that it is effect in patients with knee arthroplasty only. As usual, it is misguided to try to generalize management based on experience from one specific body region or operation.

A single Level I trauma center reviewed its data on aspirin prophylaxis for trauma patients. They reviewed their registry data from 2006 to 2011. They identified 172 trauma patients with duplex ultrasound proven DVT. These patients were matched with 1,901 control patients who underwent at least one duplex and never developed DVT. Matching was performed carefully to ensure that age, probability of death, number of DVT risk factors, and presence of TBI were similar. The total number of matched patients studied was 110.

And here are the factoids:

  • About 7% of patients with DVT were on aspirin at the time of their injury, vs 14% of the matched controls
  • 7% were taking warfarin, and 4% were taking clopidogrel
  • Analysis showed that patients taking aspirin had a significantly decreased chance of DVT after injury
  • On further analysis, it was found that this effect was only significant if some form of heparin was given for prophylaxis as well.

Bottom line: So before you run off and start giving your patients aspirin, think about what this study really said. Patients taking aspirin before their injury and coupled with heparin after their injury have a lower rate of DVT. It gives us no guidance as to whether adding aspirin after the fact, or using aspirin alone, are useful.  And we still don’t know if any of this decreases pulmonary embolism or mortality rates.

Related posts:

Reference: Aspirin as added prophylaxis for deep vein thrombosis in trauma: a retrospective case-control study. J Trauma 80(4):625-30, 2016.

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