Category Archives: General

AAST 2011: Placement of ICP Monitors By Non-Neurosurgeons

September 15, 2011 The Trauma Pro Leave a comment

Traumatic brain injury (TBI) is a common injury world-wide, but neurosurgeons are scarce. Traditionally, neurosurgeons are the ones to place invasive monitors to watch intracranial pressure (ICP). But what about injured people who are taken to a hospital where there is no available neurosurgeon?

A group at Wichita, Kansas looked at their 10 year experience with ICP monitor placement, where it can be done by neurosurgeons, trauma surgeons or general surgical residents (under trauma surgeon supervision). A total of 63 were placed by neurosurgeons, 30 by trauma surgeons, and 464 by residents under supervision. The usual demographics, including hospital stay, were the same across groups. There were essentially no significant differences based on who placed the monitor. The abstract did not state whether the monitors were extradural or intraventricular, or both.

There were only three iatrogenic bleeds, and all occurred with resident placed monitors. None were clinically significant. Malfunction rate was about 5% across all groups. Monitors had to be replaced at some point in about 11% of all three groups. One CNS infection occurred in a patient with a resident-placed monitor.

Bottom line: With proper training and supervision, ICP monitors can be placed by just about anyone. This is particularly important in more rural locations where there are few if any neurosurgeons. But as always, this process needs to be monitored carefully by the hospital’s Trauma Performance Improvement / Patient Safety program (PIPS).

ICP monitoring: less is more?

Reference: Placement of intracranial pressure monitors by non-neurosurgeons: good outcomes are achieved. AAST 2011 Annual Meeting, Paper 72.

General

Gallery September 14, 2011 The Trauma Pro Leave a comment

Novel Hip Reduction Technique: The Captain Morgan

I wrote about posterior hip dislocation and how to reduce it using the “standard” technique about 9 months ago. Emergency physicians and orthopedic surgeons at UCSF-Fresno just published their experience with a reduction technique called the Captain Morgan.

Named after the pose of the trademark pirate for Captain Morgan rum, this technique simplifies the task of pulling the hip back into position. One of the disadvantages of the standard technique is that it takes a fair amount of strength (and patient sedation) to reduce the hip. If the physician is small or the patient is big, the technique may fail.

In the Captain Morgan technique, the patient is left in their usual supine position and the pelvis is fixed to the table using a strap (call your OR to find one). The dislocated hip and the knee are both flexed to 90 degrees. The physician places their foot on the table with their knee behind the patient’s knee. Gentle downward force is placed on the patient’s ankle to keep the knee in flexion, and the physician then pushes down with their own foot, raising their calf. Gentle rotation of the patient’s hip while applying this upward traction behind the patient’s knee usually results in reduction.

Some orthopedic surgeons use a similar technique, but apply downward force on the patient’s ankle, using the leverage across their own knee to develop the reduction force needed. The Captain Morgan technique use the upward lift from their own leg to develop the reduction force. This may be gentler on the patient’s knee.

The authors report a series of 13 reductions, and all but one were successful. The failure occurred due to an intra-articular fragment, and that hip had to be reduced in the operating room.

I’m interested in hearing comments from anyone who has used this technique (or the leverage one). And does anyone have any other techniques that have worked for them?

Posterior hip dislocation

Reference: The Captain Morgan technique for the reduction of the dislocated hip. Ann Emerg Med (in press) dol:1016/j.annemergmed.2011.07.010, 2011.

Thanks to Sam Stellpflug MD at Regions Hospital for bringing this article to my attention.

General

Pediatric CT Scans Before Transfer to a Pediatric Trauma Center

September 13, 2011 The Trauma Pro Leave a comment

CT scan is essential in diagnosing injury, although concerns for unnecessary radiation exposure are growing. These concerns are even greater in children, who may be more likely to have long-term effects from it. This makes avoiding duplication of CT scanning extremely important.

Unfortunately, there are only about 50 pediatric trauma centers in the US, so the majority of seriously injured children are seen at another hospital before transfer. Does CT evaluation at the first hospital increase the likelihood that a repeat scan will be needed at the trauma center, increasing radiation exposure and risk?

Rainbow Babies and Children’s Hospital in Cincinnati looked at 3 years of transfers of injured children from community hospitals. They then looked at how many of those children had an initial head and/or abdomen scan at the outside hospital, and whether a repeat scan of those areas was performed within 4 hours or arrival at Rainbow.

Numbers were small, but here are the results:

33 had an outside CT scan, 28 (90%) were repeated
6 had an outside abdominal scan, 2 (33%) were repeated
55 did not have outside scans, none were repeated at Rainbow. (This is a weird thing to look at. I would hope that the trauma center didn’t have to repeat any of their own scans within 4 hours!)

Bottom line: It is critically important for referring hospitals to use radiation wisely! First, if the patient has obvious injuries that require transfer, don’t scan, just send. If you need to scan to decide whether you can keep the patient, use the best ALARA* technique you can. And trauma centers, please send a copy of your CT protocols to your referring hospitals so they can get the best images possible.

*ALARA = As low as reasonably achievable (applied to radiation exposure). Also known as ALARP outside of North America (as low as reasonably practicable). Click here for more info.

Reference: Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated radiation exposure. J Pediatric Surg 43(12): 2268-2272, 2008.

General

AAST 2011: Benefit of Transport to a Trauma Center

September 12, 2011 The Trauma Pro Leave a comment

Most trauma systems set certain prehospital criteria that, when met, direct that patient to a trauma center. It is now well-established that care of these patients results in improved survival if they are managed at those centers. Unfortunately, undertriage is still a problem, meaning that those patients may not always be taken to a hospital most appropriate to care for their injuries. What is the penalty that your patient pays if this happens?

The University of Toronto performed a nice, prospective study across a large region with both urban and rural areas. Database information was analyzed for all victims of motor vehicle crashes who had a severe injury (ISS>15) or who died. Over 6,000 crash victims’ data were analyzed.

Just under half of the victims (45%) were triaged to a trauma center. Of those who were taken to other hospitals, slightly more than half (58%) were transferred to one within 24 hours, but nearly 5% died in the non-trauma center ED. The overall mortality for severely injured patients who were taken to a nontrauma center was 8.7%. This was a 30% increase in adjusted mortality compared to those taken to a trauma center directly.

Bottom line: Follow the rules! EMS authorities and trauma systems should make it a priority to adopt the CDC protocol (see below) or create trauma guidelines based on them that ensure patients with significant injuries are taken directly to a trauma center. Going to the nearest hospital (if it is not a trauma center) or bending to the patient’s preference is not in their best interest (and may kill them)!

Click here to download the Centers For Disease Control and Prevention (CDC) National Trauma Triage Protocol. This should be used as a standard!

Reference: The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis. AAST 2011 Annual Meeting, Paper 50.

General

Bystander CPR For People Not In Cardiac Arrest

September 9, 2011 The Trauma Pro Leave a comment

CPR has increased the survival rate of patients suffering cardiac arrest, and early bystander CPR has been shown to double or triple survival. The sad truth is that CPR is not frequently performed by the general public. The American Heart Association has attempted to simplify CPR to the point that even untrained bystanders can administer chest compressions without a pulse check and without rescue breathing.

Bystander CPR

But what happens if that well-intentioned bystander starts CPR in someone who has not arrested? How often does this happen? Can the patient be injured?

The Medical College of Wisconsin reviewed the charts of all patients who received bystander CPR in Milwaukee County over a six year period. There were 672 incidents of bystander CPR. Of those cases, 77 (12%) were not in arrest when assessed by EMS personnel, and the researchers focused on those patients.

EMS response time averaged 5 minutes, and was greater than 10 minutes in only 2 cases. Average patient age was 43(!). The male/female ratio was just about 50:50, and the majority of the incidents took place in the home or residence.

Hospital records were available for further analysis in 72 of the patients. A quarter were sent home, a quarter admitted to a ward bed, and half were admitted to an ICU. Only 12 (17%) had a cardiac-related discharge diagnosis. The next most common discharge diagnoses were near-drowning, respiratory failure and drug overdose. Younger patients (<19) were usually near-drowning victims, and older patients (>54) were most commonly diagnosed with syncope. Five patients did not survive. Only one CPR injury was identified, which was charted as rhabdomyolysis “secondary to having received CPR” (a weak injury diagnosis, in my opinion).

Bottom line: The potential benefit of bystander CPR outweighs the risk of injury or performing it on a victim who is not in arrest. This study shows that, although these patients may not need CPR, they are generally very ill. Given the rapid EMS response times and the younger average age of the victims, no real injuries occurred. The new American Heart Association recommendations are beneficial and should be distributed widely.

Reference: The frequency and consequences of cardiopulmonary resuscitation performed by bystanders on patients who are not in cardiac arrest. Prehosp Emerg Care 15:282-287, 2011.

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