Category Archives: General

Gallery August 3, 2011 The Trauma Pro Leave a comment

Is The Glasgow Coma Scale (GCS) Getting Too Old?

Traumatic brain injury (TBI) is one of the leading causes of death from trauma worldwide. The assessment of TBI was revolutionized in 1976 when the GCS scale was first introduced. Shortly after its introduction, it was found to be predictive of outcome after brain injury. But it does have some drawbacks: it is somewhat complicated, and interrater reliability is low.

Interestingly, a number of studies have shown that the motor component of GCS is nearly as accurate as the full score in predicting survival. Thus, the Simplified Motor Score (SMS) was introduced as a possible substitute for the GCS in 2007. It was found to be equivalent for predicting survival when applied in the ED.

SMS scoring:

Obeys commands = 2
Localizes pain = 1
Withdraws (or less) to pain = 0

So can this scale be validated in the field when applied by prehospital providers?

Nearly 10 years of data (almost 20,000 patients) from the Denver Health trauma registry was analyzed to attempt to validate SMS when used by EMS. Although the statistics were not perfect, they found that GCS and SMS were equivalent for predicting the presence of a brain injury, need for emergency intubation, need for neurosurgical intervention, and death. Interestingly, they found that both SMS and GCS were not quite as good at predicting overall outcomes as previously thought.

Bottom line: The simplified motor score is a simple system that has now been shown to be as accurate as GCS in predicting severity and outcome from head injury. To be clear, though, neither is a perfect system. They must still be combined with clinical and radiographic assessments to achieve the best accuracy. But SMS can and should be used both in-hospital and prehospital to get a quick assessment, and may help determine early intervention and need for activating the trauma team.

References:

Assessment of coma and impaired consciousness: a practical scale. Lancet 2:81-84, 1976.
Assessment and prognosis of coma after head injury. Acta Neurochir (Wien) 34:45-55, 1976.
Validation of the simplified motor score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med, in press, Aug 2011.

General

Tranexamic Acid and Trauma

August 2, 2011 The Trauma Pro Leave a comment

I recently received a request to write about tranexamic acid (TXA) and trauma patients. There is a lot of interest in this agent, especially in the military, and there are some good, recent papers to review.

Tranexamic acid works differently than the quick clotting agents out there. It is an antifibrinolytic, so it actually prevents clot breakdown. It has been approved by the FDA for use in hemophiliacs undergoing dental work and for menorrhagia. Thrombotic complications have been described, so it cannot be used with prothrombin complex concentrate or recombinant activated factor VII.

The most recent and best known study on TXA is the CRASH-2 study. It was extremely well designed and included over 20,000 patients in hospitals spanning 40 countries. The study design has survived serious scrutiny. They found that TXA use in trauma patients reduced the relative risk of death by 9% (from 16% to 14.5%). The risk of death specifically from bleeding was reduced by 15%. And use of TXA in the most severely injured patients, those who would die of bleeding on the day of randomization, was reduced by 20%. There were no adverse events or differences in thrombotic events, including deep venous thrombosis.

Bottom line: TXA has been shown to be effective, safe and inexpensive (about $200 for treatment using retail pricing). It is the only drug that has been shown to reduce all-cause mortality from bleeding in a high quality trial. It has already been adopted by some hospitals in both the US and the UK. CRASH-2 suggested that TXA was of most benefit when given within 3 hours of injury and in patients with a systolic pressure less than or equal to 75 torr. Trauma centers should begin incorporating this important drug into their initial treatment protocols now. However, since it’s not FDA approved in the USA, we will need to wait a while and watch everybody else.

Final thought: Will this eventually be started by EMS?

Reference: Tranexamic acid for trauma patients: a critical review of the literature. J Trauma 71(1):S9-S14, 2011.

General

Guidelines for Consultants to the Trauma Service

August 1, 2011 The Trauma Pro Leave a comment

Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps to ensure quality care and provide good communication between caregivers and patients / families.

We have disseminated a set of guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.

In order to deliver the highest quality and most cost-effective care, we request that services we consult do the following:

Please introduce yourself to our patient and their family, and explain why you are seeing them.
Although you may discuss your findings with the patient, please discuss all recommendations with a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
Document your consultation results in writing (paper or EMR) in a timely manner.
If additional tests, imaging or medications are recommended, discuss with the trauma service first. We will write the orders or clear you to do so if appropriate, and will discuss the plan with the patient.
We round at specific times every day and welcome your attendance and input.
Please communicate any post-discharge instructions to us or enter in the medical record so we can expedite the discharge process and ensure all followup visits are scheduled.

Bottom line: A uniform “code of behavior” is important! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature, and they will not be familiar with how their recommendations may impact other injuries.

Click here to download the full copy of the Regions Hospital Trauma Services consultant guidelines.

General

Financial Triage (Wallet Biopsy) and Transfer to Trauma Centers

July 28, 2011 The Trauma Pro Leave a comment

A significant amount of volume coming in to Level I and Level II trauma centers is transferred from other hospitals. Occasionally, concerns are raised that some hospitals “cherry pick” the patients, retaining those who are insured and transferring those who are not. If this is true, it has the potential to undermine the entire trauma transfer system by delaying and impeding patient care and by financially damaging the higher level trauma centers. A few single state or single health care system studies have been performed, and some of them have suggested that the uninsured were more likely to be transferred to high level trauma centers.

The group at Parkland looked at a national sample using the National Trauma Databank, and compared the insurance status of patients transferred to Level I and II centers to those retained at Level III and IV centers. Overall, most patients (83%) were insured. At first glance, transferred patients were significantly more likely to be uninsured (18% vs 14%). However, they were also more seriously injured and more likely to have multiple injuries. When adjusted for these differences, the transferred patients were no more likely to be uninsured than the others.

Bottom line: There does not appear to be any concerted effort nationally to inappropriately transfer uninsured injured patients to high level trauma centers. The perception arises because the uninsured have a tendency toward higher risk behaviors that may result in serious injury.

However, it is possible that cherry picking may occur on occasion at the local level. If you are a trauma director experiencing this phenomenon, the best course of action is to speak directly to the director at the referring hospital. Politely discuss your perceptions and offer to see if there is anything you can do to help with their triage process. Frequently, letting them know you are aware of the pattern causes them to improve their transfer decision making.

Reference: Financial triage in transfer of trauma patients: a myth or a reality. Am J Surg 198(3):e35-e38, 2009.

General

Brain Injury and Chemical Prophylaxis for DVT

July 27, 2011 The Trauma Pro Leave a comment

Deep venous thrombosis (DVT) and its complications are recognized and common problems in trauma patients, particularly those with traumatic brain injury (TBI). We know that giving chemical prophylaxis like heparin and low molecular weight heparin (LMWH) reduces the risk. Unfortunately, trauma professionals (and neurosurgeons in particular) are reluctant to give it after acute TBI for fear of making intracranial hemorrhage worse.

Froedtert Hospital in Milwaukee modified their protocol for TBI patients to allow chemical prophylaxis to start 24 to 48 hours after a 24 hour followup CT that showed no progression of any bleeding. Therefore, prophylaxis could be started 48 to 72 hours after injury. They used subq heparin three times daily, or LMWH twice daily. All others received mechanical prophylaxis and were screened twice weekly by duplex ultrasound. The chemical prophylaxis group was not screened routinely.

A total of 812 patients were studied, half of whom received early prophylaxis per protocol. The average Abbreviated Injury Score for the head in these patients was 3.4, which represents fairly serious injury. There was a significant decrease in the incidence of DVT in the chemical prophylaxis group (1% vs 3%). More intriguing, there was a lower rate of injury progression in this group as well (3% vs 6%), although not quite statistically significant.

Bottom line: Although this is a small and retrospective study, it was well designed and relatively large compared to most other similar work. It shows that use of chemical prophylaxis works in patients with serious TBI, and appears to be safe. Similar protocols should be considered by trauma program multidisciplinary operations committees to further systematize this process.

Reference: Safety and efficacy of prophylactic anticoagulation in patients with traumatic brain injury. J Am Coll Surg 213:148-154, 2011.

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