Category Archives: General

What To Do? Small Hospital, Unstable Patient

It’s the situation that physicians in smaller hospitals dread. A major trauma patient gets dropped off at the door. You do your evaluation, quickly determining that they need services that you don’t just have (head injury and positive FAST in the abdomen, let’s say). You call your community EMS service to transport to a Level I trauma center, which is about 30 minutes away by ground. And just as they are rolling out the door to the rig, the blood pressure drops to 60! What to do?!

The ATLS course is very clear, and very correct. Back into the ED for a quick re-evaluation. The most common cause for a significant disturbance in vitals or exam lies within the primary survey. You will almost always find a problem with Airway, Breathing, or Circulation. (A Disability problem can cause a problem on rare occasion (hypotension from impending herniation), but there’s not much that you can do about it, really. Hyperventilate, hyperosmolar therapy, okay but probably a poor outcome for the patient anyway.)

So you didn’t find any airway or breathing issue. But the abdominal stripe(s) you saw on FAST are larger, so it’s circulation. Now what? And does it matter if you have a surgeon available on call? The answer is simpler than you think.

ATLS says that, if you have surgical support available you have to use it in this type of situation. If you don’t have it, package the patient with a lot of blood and plasma and send. If you have a physician or nurse to spare you could consider sending them along to help during transport, but for small community hospitals this is not practical.

But if you do have a surgeon, does it make sense to use them? Not always! You must take into account response times and transport times. Let’s say it’s 2:00 am and you call your surgeon for this hypotensive patient. They may take up to 30 minutes to get in and see the patient. They then agree that the patient needs a laparotomy and she proceeds to call in the OR team. Yet another 30 minutes tick by.  Will the patient still even be alive when they roll into the OR?

Or you could just put the patient back in the ambulance (air preferably, but ground if you have to) and get them to your trauma center quickly. They can then be whisked directly into a waiting OR in less than 30 minutes from your door. This is probably the ideal solution here. Obviously this doesn’t work as well if you are a few hours away from your resource trauma center. 

Bottom line: Deciding what to do with a patient that needs urgent treatment that you can’t immediately deliver is tough! That’s why it’s always a calculus problem when you’re faced with this situation. But take all of the response and transport times into account, and do what’s best for your patient! 

Thanks to EM Res for posing this question!

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EAST Starts Today!

The Eastern Association for the Surgery of Trauma opening session is in progress! I’ll be tweeting and blogging from the meeting through Friday, and I’ll be combing through some of the best papers in the blog next week. I’m on the lookout for groundbreaking work in areas that are practical or interesting to trauma professionals.

I’ll be tweeting live using the hashtag #east2014, so keep an eye out for the good stuff!

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EAST 2014: CT Clearance of the Cervical Spine?

Cervical spine clearance has typically required us to address both bones and ligaments. For a long time, this has involved separate steps: imaging for the bones, and exam (or additional imaging) for the ligaments. But this extra step adds complexity and seems to have a low yield.

The number of studies supporting use of only CT to clear both bones and ligaments continues to increase. A poster being presented this week at EAST details the experience with this at Virginia Commonwealth University. They looked at all their blunt trauma patients over a 5 year period. They detailed all fractures, ligamentous injuries, and how they were discovered.

Here are the factoids:

  • A total of 5676 patients were entered in the study
  • 420 (7%) were diagnosed with cervical fracture
  • 53 (1%) had a ligamentous injury
  • Of the ligamentous injuries, 21 of 53 were suspected based on the CT. The remaining 32 all had fractures in addition to the ligamentous injury.

Bottom line: Yes, it’s small and retrospective, but it continues to paint the same picture as the other papers. The authors conclude that CT alone is sufficient to clear both bones and ligaments. I presume this excludes the group that can be cleared clinically. Adopting this process will streamline the clearance process, and help avoid complications like pressure sores. What about missed injuries? There will always be a few. We are currently at a point of diminishing returns in terms of how much diagnostic radiation, magnetism, and money we throw at this problem. But the key to successfully and safely implementing this is to make sure to have the most experienced clinicians reading the images.

Related posts

Reference: CT scan: it’s not just about the fracture. EAST 2014, poster #35.

 

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EAST 2014: Reducing Trauma Repeat Imaging With A Cloud Service

Radiation exposure from diagnostic imaging remains of high interest to all trauma professionals and the lay public. A number of papers have already been written showing that repeat imaging in transferred patients is high due to issues with transmitting images between sending and receiving trauma centers. 

A variety of solutions exist for reducing this problem. One of the more technically oriented ones is LifeImage, a cloud based service. Images from just about any PACS system can be uploaded to the service by a referring hospital. The receiving center can peruse the images using a sophisticated browser based tool, or they can merge the PACS data for any or all studies into their own PACS system.

ShockTrauma in Baltimore receives severely injured patients for the entire state of Maryland. They reported their experience with this cloud service over a 6 month period, and compared it to 6 months before use during the prior year. Here are the factoids:

  • A total of 1,950 transfers were reviewed (!). Data was collected prospectively.
  • The number of patients undergoing repeat imaging decreased significantly, from 62% to 47%
  • Cost also decreased significantly, from $402K to $327K during the study periods
  • Hospital length of stay decreased from 4.4 to 3.8 days
  • There was no difference in mortality

Bottom line: Cloud solutions for transferring imaging information work! A lot of radiation and money was saved! Frankly, I’m puzzled as to why the decreases were so modest. I suspect that some or many of the potential referring hospitals were not participating at the time of the study. Nevertheless, it looks like the savings should easily pay for the cost of the service. I’ll definitely quiz the authors on this one and return with some answers.

Related posts:

Reference: Reduction in repeat imaging in patients transferred to a Level I urban trauma center decreases cost and radiation exposure. EAST 2014, poster #28.

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EAST 2014: Device Alert! Instant Hgb Monitor

The group at the University of Arizona has been fooling around with an instant-read hemoglobin monitor manufactured by Masimo Corp, the Pronto-7. Interesting little device. It’s a hand-held unit that looks like it uses near-infrared light to calculate the hemoglobin concentration. An optical probe is applied to a finger (like an oximeter probe), and the result is displayed almost immediately. It can also be printed or emailed.

image

Previous iterations of this technology for continuous readings did not correlate well with invasive blood draws. Use of an instant-read system in trauma patients has not been explored to date. The Arizona group looked at the correlation between the results of the Pronto-7 and the usual blood draw in acute trauma patients using a prospective design. Three spot-check results were obtained for every invasive blood draw.

Here are the factoids:

  • 525 patients were spot-checked, with a success rate of 86% (no explanation why!)
  • 173 (38%) of patients had a Hgb <= 8
  • The mean difference between spot-check and blood draw results was only 0.1 g/dL (!)
  • Sensitivity was 96%, accuracy 77%

Bottom line: This is an interesting new tool for acute trauma care. The only downside that I see is that we may lose sight of the fact that hemoglobin values lag behind the true blood volume in rapidly bleeding patients. We mustn’t be fooled into thinking that everything is fine just because a number is normal. There’s still room for common sense!

Related post:

Reference: Transforming hemoglobin measurement in trauma patients: non-invasive spot check hemoglobin. EAST 2014, poster #20.

I have no financial interest in Masimo Corp.

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