Category Archives: General

State Laws And Pediatric Firearms Injuries

January 18, 2013 The Trauma Pro Leave a comment

The US federal government records some basic statistics regarding firearm injuries, mostly related to deaths. However, the Agency for Healthcare Research and Quality maintains a database that contains detailed information on pediatric hospitalizations, including injury information. A group at Tufts University used this database to compare injury trends in pediatric firearm injury (age 0-20) in states with and without a Stand Your Ground law (SYG). Stand Your Ground laws, which many first became aware of after the death of Trayvon Martin in Florida, allow an individual to defend themelves from an unlawful threat without having to retreat first.

The database used was fairly robust. Data were submitted from 44 states, and 4 years were reviewed for the study. Over 19,000 pediatric firearm injury records were analyzed. The following interesting reslts were uncovered:

Nearly two thirds were assualts, and 27% were accidental injury.
Average length of stay for both mechanisms was about 3 days
Hospital cost for assault was $61,000 and for accidental injury was $46,000, per child
Children were about 10% more likely to suffer a firearm assault in SYG states
Kids in SYG states were also more likely to suffer accidental firearm injury and commit suicide with a firearm(?!)
Statistical association of firearm injury with the usual culprits (race, age > 16, male sex, socioeconomic status) was also noted

Bottom line: At best, this is a weak observational study. And of course, it is impossible to say that Stand Your Ground laws are the cause of a greater number of pediatric firearm injuries. The fact that (even greater) increases in accidental injury and suicide were noted points out this weakness even better. Although it is tempting to blame SYG laws on this perceived increase in injuries, it’s not correct. Much better analyses need to occur before we can really draw any actionable conclusions on the effects of these laws..

States with Stand Your Ground laws: AL, AK, AZ, CA, FL, GA, IA, IL, IN, KS, KY, LA, ME, MI, MS, MO, MT, NH, NC, ND, OH, OK,, PA, RI, SC, SD, TN, X, UT, WV, WI, WY

General

Pigtail Cathers Instead Of Chest Tubes?

January 17, 2013 The Trauma Pro Leave a comment

I reviewed this abstract a few months ago, and now I’ve had the opportunity to hear it and see the data. Here’s an update on whether this is worthwhile..

This was a relatively small, prospective study, and only 40 of 74 eligible patients were actually enrolled over 20 months at a Level I trauma center in the US. Pain was measured using a standard Visual Analog Scale, as was complication and failure rate, tube duration and hospital stay.

The following interesting findings were noted:

Chest wall pain was similar. This is expected because the underlying cause of the pneumothorax, most likely rib fractures, is unchanged.
Tube site pain was significantly less with the pigtail
The failure rate was the same (5-10%)
Complication rate was also the same (10%)
Time that the tube was in, and hospital stay was the same

There were a few questions regarding blinding of the pain scale raters, but other than the small sample size, the study was nicely done.

Bottom line: There may be some benefit in terms of tube site pain when using a smaller catheter instead of a chest tube. But remember, this is a very small study, so be prepared for different results if you try it for your own trauma program. If you do choose to use a smaller tube or catheter, remember to do so only in patients with a pure pneumothorax. Clotted blood from a hemothorax will not be completely evacuated.

Related posts:

Reference: A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, Jan 17, 2013.

General

Angiography And Splenic Salvage

January 16, 2013 The Trauma Pro Leave a comment

Variations in the way we deal with trauma can have a significant impact on patient outcome. This has been documented most recently in the use of angioembolization when dealing with patients with spleen injuries. The first paper presented at EAST 2013 looked at outcomes at hospitals that use angio more heavily vs those who don’t.

They analyzed 1275 patients presenting to 4 Level I trauma centers. Two centers were high-use (11% and 19% usage) and the other 2 were low-use (1% and 4%). The outcomes studied were the splenic salvage rate and success in nonoperative management. And although patients at the low angio use centers had a higher ISS, the splenic injury grade was the same.

Interesting findings included:

Admission splenectomy rate was the same, meaning that both types of centers used the same criteria when the patient rolled through the door
High angio use centers had higher overall salvage rates (82% vs 77%) and greater success with nonoperative managment (96% vs 92%)
In high grade injury (grade 3 and 4) the salvage rate was still better (67% vs 56%) and nonop success rates were much better (92% vs 80%)
In patients who were initially managed nonoperatively, use of angio was associated with salvage
Patients in high angio centers were more likely to leave the hospital with their spleen where it should be
There was no analysis of complications from angiography
There was no comment on how these patients were managed on a day to day basis

Bottom line: There is a considerable amount of variation in how trauma centers use angiography for spleen injury. Unfortunately, this variability is allowing people to lose their spleens at centers who don’t use it as much. The overall success rate in managing spleen injury (all comers) has historically been about 93%. More aggressive use of angiography is now shown to improve that to 97%. Given this new data, angio needs to be considered in patients with grade 3+ injury and in any with contrast extravasation. And the overall management should be standardized as well.

Reference: Variation in splenic artery embolization and spleen salvage: a multicenter analysis. Paper 1, EAST annual scientific assembly, Jan 15, 2013.

General

EAST Starts Tomorrow!

January 15, 2013 The Trauma Pro Leave a comment

I’m off to Phoenix for the Eastern Association for the Surgery of Trauma (EAST) annual scientific assembly. I’ll be tweeting continuously during the various scientific sessions using the hashtag #east2013. And I’ll select the most interesting presentations daily and post more in-depth discussions of them here. I’ll review the new and revised trauma practice guidelines next week, and I’ll probably have a few more papers to discuss over the coming weeks.

For any fans attending the meeting, please stop me and say hi!

General

The Referral Hospital Trauma Rule

January 14, 2013 The Trauma Pro Leave a comment

The majority of trauma patients are seen initially at non-trauma centers. And the majority of those patients can be treated just fine at that local hospital. However, a few (some say about 15%) do need to be transferred. The question frequently arises, “what studies do I need to do before transferring?”

The danger is that doing things that slow down the transfer can result in bad outcomes. For example, a patient may have a spleen injury that is actively bleeding. Every minute that this patient is not receiving “definitive treatment”, she loses more blood. And every cc of blood lost causes her to inch closer to shock, other complications, or death.

The key is to get people who need a higher level of trauma care on their way to a higher level trauma center as soon as the need is recognized. There is a natural tendency to do diagnostic studies, such as CT scan, in these patients. Sometimes they are needed to actually figure out what is going on. But more often they are obtained to “do a complete workup” or because “the trauma center expects me to.”

Unfortunately, these are incorrect assumptions. The complete workup cannot be used by the referral center if they are shipping the patient, and for a variety of reasons they may not be useful to the trauma center. This is one of the major reasons that referral patients receive extra radiation exposure. About half of the studies performed at the referral hospitals need to be repeated!

The Referral Hospital Trauma Rule: Do any simple study needed to ensure the patient will stay alive until the helicopter/ambulance arrives (typically chest or pelvic xray). If at any point, you see something obviously not treatable at your hospital (i.e. open fracture, GCS 8, partial amputation), DO NO FURTHER STUDIES AND PREPARE TO TRANSFER. If the patient does not have such an obvious problem, do only the tests you need to determine if you can keep the patient. But as soon as you find anything that you cannot treat, stop further studies and prepare to send the patient onward. And don’t forget to send working copies of the few studies that you did get.

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