Category Archives: General

Unstable Patient & Pelvic Fracture + Hemoperitoneum

December 5, 2013 The Trauma Pro Leave a comment

The usual thinking is that most unstable trauma patients need a quick trip to the OR to stop the bleeding from something. In the US and Europe, patients with nasty pelvic fractures are no exception, especially those with hemoperitoneum. But many of these patients are bleeding from vessels associated with the pelvic fractures and not so much from associated intra-abdominal injuries. And operative management of pelvic fracture bleeding is far from satisfying, even when using preperitoneal packing.

Well, things are a little different in Japan. In many cases, unstable patients are taken to interventional radiology for angio and possible embolization. Is this prudent, or is it dangerous? A Japanese group decided to critically look at this practice by examining the Japan Trauma Data Bank for answers.

Here are the factoids:

Patients with pelvic fracture and positive FAST were included, who underwent either laparotomy or angioembolization as their first intervention (n=1153). Those with non-salvageable head injury were excluded, as well as patients who underwent another major procedure first (craniotomy, thoracotomy, ortho procedures, etc.). Only 317 patients remained.
In-hospital mortality was the primary outcome of interest
A total of 123 underwent laparotomy first, and 194 went to angio first
A very small number of patients were hypotensive on arrival (81 laparotomy first, 82 angio first)
Half of the patients who were hypotensive on arrival went to angio first (!)
Laparotomy-first patients had a higher crude mortality, but this disappeared when confounders were controlled. This was true in patients who were either normotensive or hypotensive on arrival.
The authors concluded that the initial intervention should be determined by severity of injury, since in-hospital mortality was no different

Bottom line: Whoa! This is a sweeping statement for a study with so few subjects. Yes, it can be very difficult to determine whether initial bleeding is from the pelvis vs a solid organ or mesenteric injury while in the ED. But it is all too easy to fritter away time (and the patient’s blood/life) in the angiography suite. I recommend trying to stabilize your patient as best you can with fluid and/or blood. If you can maintain a “reasonable” blood pressure, proceed to CT for a quick look at the torso. Then go to the most appropriate location to take care of the problem. And if your patient decompensates in CT or angio, immediately proceed to the operating room!

Related posts:

References:

Comparison between laparotomy first versus angiographic embolization first in patients with pelvic fracture and hemoperitoneum: a nationwide observational study from the Japan Trauma Data Bank. Scand J Trauma 21:82, 2013.
Eastern Association for the Surgery of Trauma Practice Management Guidelines for Hemorrhage in Pelvic Fracture-Update and Systematic Review. J Trauma 71:1850-1868, 2011.

General

Practice Guidelines: Reinventing The Wheel

December 3, 2013 The Trauma Pro Leave a comment

Most will agree that practice guidelines can be a good thing. Here are some of the benefits:

They provide a consistent way of approaching a clinical issue. Everybody working with the patient knows how things will be done, so they don’t have to remember the nuances that particular doctors or providers like.
They (hopefully) use the best and most valid scientific data to address the care issue, thus giving trauma professionals the opportunity to provide the best care we know of.
They decrease errors and complications by narrowing the number of choices available to providers.
They decrease waste for the same reason. For example, drawing blood every 6 hours vs daily for solid organ injuries can add up to three unneeded tests every day.
They provide our trainees with one good way to deal with the clinical issue. This is important when they move on to independent practice, and sometimes when taking standardized tests (boards).

To top it off, trauma verification agencies like the American College of Surgeons require trauma centers to implement ones that apply to them.

But here’s another of my pet peeves. Why does every trauma program decide to reinvent the wheel when it comes to developing them? Many organizations, particularly the Eastern Association for the Surgery of Trauma (www.east.org) have done a lot of work in preparing well-researched guidelines. And I’ve published a bunch that my program has developed. Why does a hospital have to convene a work group and design guidelines from scratch?

Bottom line: If you want to use some guidelines, look at what is already out there and use that as a basis for your protocols. Yes, you will need to modify them a bit to suit your local needs. But don’t waste a lot of your time and energy when someone has already done a lot of the leg work! Don’t reinvent the wheel!

General

Gunshots And CT Scan Of The Abdomen

December 2, 2013 The Trauma Pro Leave a comment

Abdominal gunshots and CT scanning are usually thought to be mutually exclusive. The usual algorithm generally means a prompt trip to the operating room. But as with many things in the management of trauma, there are always exceptions. The key is to understand when exactly one of those exceptions is warranted.

Exception 1: Did it really enter the abdomen? Gunshots have enough energy that they usually do get inside. However, freaky combinations of trajectory and body habitus do occur. There are three tests that must be passed in order to entertain the possibility that the bullet may not have made it inside your patient: physiology, anatomy, and physical exam. For physiology, the patient must be completely hemodynamically stable. Anatomically, the trajectory must make sense. If the known wounds and angles allow a tangential course make sense, then fine. But if there is a hole in the epigastrium and another next to the spine, you have to assume the bullet went straight through. Finally, the physical exam must be normal. No peritonitis. No generalized guarding. Focal tenderness only in the immediate area of any wounds. If all three of these criteria are passed, then a CT can be obtained to demonstrate the trajectory.

Exception 2: Did it enter an unimportant area of the abdomen? Well, there’s really only one of these, and that’s the area involving the right lobe of the liver and extending posteriorly and lateral to it. If the bullet hole(s) involve only this area, and the three tests above are passed, CT may confirm an injury that can be observed. However, there should only be a minimal amount of free fluid, and no soft tissue changes of any kind adjacent to bowel.

Exception 3: A prompt trauma lap was performed, but you think you need more information afterwards. This is rare. The usual belief is that the eyes of the surgeon provide the gold standard evaluation during a trauma lap. For most low velocity injuries with an easily understood trajectory, this is probably true. However, high velocity injuries, those involving multiple projectiles, or complicated trajectories (side to side) can be challenging for even the most experienced surgeon. Some areas (think retroperitoneum or deep in the pelvis) are tough to visualize completely, especially when there’s blood everywhere. These are also the cases most likely to require damage control surgery, so once the patient has been temporarily closed, warmed and resuscitated, a quick trip to CT may be helful in revealing unexpected shrapnel, unsuspected injuries, or other issues that may change your management. Even a completely unsurprising scan can provide a higher sense of security.

Bottom line: CT of the abdomen and gunshots to that area may actually coexist in some special cases. Make sure the physiology, anatomy and physical exam criteria are passed first. I also make a point of announcing to all trainees that taking these patients to CT is not the norm, and carefully explain the rationale. Finally, apply the concept of the null hypothesis to this situation. Your null hypothesis should state that your patient does not need a CT after gunshot to the abdomen, and you have to work to prove otherwise!

General

More On DVT In Children

November 27, 2013 The Trauma Pro Leave a comment

Deep venous thrombosis has been a problem in adult trauma patients for some time. Turns out, it’s a problem in injured children as well although much less common (<1%). However, the subset of kids admitted to the ICU for trauma have a much higher rate if not given prophylaxis (approx. 6%). Most trauma centers have protocols for chemical prophylaxis of adult patients, but not many have similar protocols for children.

The Medical College of Wisconsin looked at trends prior to and after implementation of a DVT protocol for patients < 19 years old. They used the following protocol to assess risk in patients admitted to the PICU and to determine what type of prophylaxis was warranted:

The need for and type of prophylaxis was balanced against the risk for significant bleeding, and this was accounted for in the protocol. The following significant findings were noted:

The overall incidence of DVT decreased significantly (65%) after the protocol was introduced, from 5.2% to 1.8%
The 1.8% incidence after protocol use is still higher than most other non-trauma pediatric populations
After the protocol was used, all DVT was detected via screening. Suspicion based on clinical findings (edema, pain) only occurred pre-implementation.
Use of the protocol did not increase use of anticoagulation, it standardized management in pediatric patients

Bottom line: DVT does occur in injured children, particularly in severely injured ones who require admission to the ICU. Implementation of a regimented system of monitoring and prophylaxis decreases the overall DVT rate and standardizes care in this group of patients. This is another example of how the use of a well thought out protocol can benefit our patients and provide a more uniform way of managing them.

Related posts:

Reference: Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma 72(5):1292-1297, 2012.

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