Category Archives: General

Wounds: When Are They Too Old To Close?

At some point in their training, every trauma professional is taught that there is a certain period time during which a wound can be safely closed. The exact number varies, but is usually somewhere between 6 and 24 hours. After that, we are told, “bad things happen.”

Always question dogma, I say. Is this true, or is it another one of those “facts” that have been propagated through the ages? Two emergency medicine groups recently performed a meta-analysis to try to answer my question. As usual, they found that much of the published literature is not very good. Out of 418 papers in their original search, only 4 fully met their criteria (laceration repaired primarily, in the ED, with clear early vs delayed criteria.

With the exception of one study with a very limited focus, there was no correlation between wound age and infection or dehiscence after primary closure. None of the studies could reliably provide a specific time beyond which closure was destined to fail. And the use of antibiotics in some of the studies also confounded the results.

Bottom line: It is more likely that infection-prone wounds get infected, not old ones. Although leaving a wound open to heal by secondary intention usually avoids the problem, it’s a big patient dissatisfier, especially with large wounds. Since many patients don’t present to the ED until their wound is “old”, it may be reasonable to try primary closure in all but infection-prone wounds. (The meaning of that phrase is not exactly clear, but most of us know it when we see it.) 

Reference: The impact of wound age on the infection rate of simple lacerations repaired in the emergency department. Injury 43(11):1793-1798, 2012.

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The EMS Second IV In Trauma

One of the critical maneuvers that EMS providers perform is establishing initial vascular access. This IV is important for administering medications and for initiating volume resuscitation in trauma patients. Prehospital Trauma Life Support guidelines state that every trauma patient should receive two large bore IV lines. But is this really necessary?

The upside of having two IVs in the field is that the EMS provider can give lots of volume. However, a growing body of literature tells us that pushing systolic blood pressure up to “normal” levels in people (or animals) with an uncontrolled source of bleeding can increase mortality and hasten coagulopathy.

The downside of placing two lines is that it is challenging in a moving rig, sterility is difficult to maintain, and the chance of a needlestick exposure is doubled. So is it worth it?

A group at UMDNJ New Brunswick did a retrospective review of 320 trauma patients they received over a one year period who had IV lines established in the field. They found that, as expected, patients with two IVs received more fluid (average 348ml) before arriving at the hospital. There was no increase in systolic blood pressure, but there was a significant increase in diastolic pressure with two lines. The reason for this odd finding is not clear. There was no difference in the ultimate ISS calculated, or in mortality or readmission.

Bottom line: This study is limited by its design. However, it implies that the second field IV is not very useful. The amount of extra fluid infused was relatively small, not nearly enough to trigger additional bleeding or coagulopathy. So if another IV does not deliver significant additional fluid and could be harmful even if it did, it’s probably not useful. Prehospital standards organizations should critically look at this old dogma to see if it should be modified.

Reference:

  • Study of placing a second intravenous line in trauma. Prehospital Emerg Care 15:208-213, 2011.
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SCIP: Importance Of Prophylactic Antibiotics In Trauma Laparotomy

Quite a lot of research has been done on the efficacy of prophylactic antibiotics in the prevention of infectious complications after surgical procedures. Antibiotics are now routinely given prior to most elective surgical procedures. In the US, the Centers for Medicare and Medicaid Services has formalized this into part of the Surgical Care Improvement Project (SCIP), which mandates the use of an appropriate antibiotic within 1 hour preop and stopping it within 24 hours postop.

But what about emergent cases, like trauma laparotomy? Ensuring timely antibiotic administration is difficult due to the rapid events leading up to the operation. And sometimes it is not clear whether a hollow viscus injury has occurred until after start of operation, so the antibiotic choice may change in the middle of the case.

Two busy urban trauma centers with high penetrating injury rates looked at one year of experience in patients undergoing trauma laparotomy. They compared surgical site infections (SSI) in patients who received SCIP-compliant antibiotic administration vs those who did not. 

Key findings:

  • Patient mix was 30% blunt, 44% gunshot, 27% stab wounds
  • There were 151 SCIP-compliant patients and 155 noncompliant ones
  • Half of the noncompliant group did not receive the appropriate antibiotic (usually Cefazolin in hollow viscus injury), and half had antibiotics given for more than 24 hours
  • SCIP-compliant patients had significantly fewer wound infections and shorter length of stay. Mortality was the same.

Bottom line: I recommend adhering to SCIP prophylactic antibiotic guidelines for trauma laparotomy. There is no reason why this subset of patients should be treated any differently, and this study presents evidence that it is beneficial. Using the SCIP guidelines in emergent surgery reinforces the usual preop routine in hospitals that have already embraced them. In general, blunt trauma patients undergoing laparotomy should receive prophylaxis that covers skin organisms. Since penetrating trauma has a much higher chance of involving the intestinal tract, broader spectrum antibiotics should be selected. In either case, use the antibiotic that has been selected for this purpose by your hospital. And be sure they are stopped during the first 24 hours.

Reference: “SCIP"ping antibiotic prophylaxis guidelines in trauma: the consequences of noncompliance. J Trauma 73(2):452-456, 2012.

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Using The Slide Board In The ED

I’ve written several times on the importance of getting patients off the backboard promptly in the ED, but the topic keeps coming up! Many hospitals use slide boards to facilitate patient movement on and off the ED cart when undergoing imaging studies. How should we manage the use of this device?

There is no difference between a backboard and a slide board to the patient. It’s hard and uncomfortable to lie on for any period of time, and can cause soft tissue injury. To trauma professionals in the ED it is thinner, less bulky, easier to manipulate, and does not interfere with xrays as much. We tend to pay less attention to it than a backboard. Although it does not immobilize the spine as well as a backboard does, the difference is not clinically significant (in a cooperative patient). Remember, if your patient actually has a spine fracture, they will be placed on logroll precautions on a soft mattress only somewhere in your hospital! No stiff boards of any kind!

Slide board management tips:

  • Slide boards are for blunt trauma only! Patients with penetrating injury may need an upright chest xray in the ED and the board won’t flex enough.
  • Insert the slide board in any patient who will be getting several diagnostic studies. For trauma activation patients, this can occur as you roll them off the backboard.
  • As soon as diagnostic studies are done, remove the slide board
  • If there are unforeseen delays, remove the slide board and reinsert when ready to move
  • Remember that the soft tissue timer is counting down as soon as the patient is placed on a backboard or slide board
  • Plan an efficient road trip through diagnostic studies for your patient. This allows you to minimize time on the board. 
  • Repeated logrolls onto and off of the slide board are discouraged. Every roll is an opportunity for mishap.
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The Chest Tube Autotransfuser

Autotransfusing blood that has been shed from the chest tube is an easy way to resuscitate trauma patients with significant hemorrhage from the chest. Plus, it’s usually not contaminated from bowel injury and it doesn’t need any fancy equipment to prepare it for infusion. 

It looks like fresh whole blood in the collection system. But is it? A prospective study of 22 patients was carried out to answer this question. A blood sample from the collection system of trauma patients with more than 50 cc of blood loss in 4 hours was analyzed for hematology, electrolyte and coagulation profiles.

The authors found that:

  • The hemoglobin and hematocrit from the chest tube were lower than venous blood (Hgb by about 2 grams, Hct by 7.5%)
  • Platelet count was very low in chest tube blood
  • Potassium was higher (4.9 mmol/L), but not dangerously so
  • INR, PTT, TT, Factor V and fibrinogen were unmeasurable

Bottom line: Although shed blood from the chest looks like whole blood, it’s missing key coagulation factors and will not clot. Reinfusing it will boost oxygen carrying capacity, but it won’t help with clotting. You may use it as part of your massive transfusion protocol, but don’t forget to give plasma and platelets according to protocol. This also explains why you don’t need to add an anticoagulant to the autotransfusion unit prior to collecting or giving the shed blood!

Related post: Chest tubes and autotransfusion

Reference: Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood? Am J Surg 202(6):817-822, 2011.

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