Category Archives: General

Using Mechanism of Injury In Your Trauma Activation Criteria

The Centers for Disease Control and Prevention (CDC) published a set of Guidelines for Field Triage two years ago. Click here to download them. They list 4 tiers of activation criteria to help prehospital providers triage patients appropriately to trauma centers. 

Tier 1, which are physiologic criteria, and Tier 2 (anatomic criteria) are very accurate in predicting injury serious enough to require trauma team activation. Tier 3 contains mechanism criteria, and many centers who use these verbatim in their activation criteria end up with a fair amount of overtriage. Some centers even see a significant number of patients who meet Tier 3 criteria go home from the ED!

The Yale department of Emergency Medicine looked at intrusion into vehicle criteria (more than 12" near an occupant, more than 18" anywhere on the vehicle) to see if they are a valid predictor for admission or trauma center transport. It was a retrospective review of EMS transports to the Yale ED or to one satellite site. 

Unfortunately, the number of vehicles that met intrusion criteria (48) was small compared to the number without significant intrusion (560). This makes the data a little less convincing than it may have been. The likelihood that intrusion would require trauma center admission (Positive Predictive Value) was only 26%. The likelihood that trauma center resources would be utilized (for issues like death, ICU stay, operation, spinal injury or intracranial hemorrhage) was only 13%. The authors recommend that the CDC guidelines be tweaked based on this data.

Bottom line: I think the numbers are far too small to convince the CDC to change their guidelines. But I would urge each trauma center that uses the intrusion criteria for activation to carefully study how many of those patients have minor injuries or go home from the emergency department. They may find that they can rely on other more accurate criteria and decrease their overtriage rate at the same time.

Reference: Motor vehicle intrusion alone does not predict trauma center admission or use of trauma center resources. Prehospital Emerg Care 15:203-207, 2011.

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EAST Guidelines Update: Spleen Injury

The Eastern Association for the Surgery of Trauma is in the process of updating their trauma practice guidelines for spleen injury. The first set of guidelines was introduced in 2003, and several advances in management have occurred since. here is a summary of the current status of the guidelines:

Level I recommendations (best quality data): 

  • none

Level II recommendations (good data):

  • Initial management of hemodynamically stable patients should be nonoperative
  • Unstable patients should undergo immediate operation or angiographic embolization (my interpretation: unstable patients belong in the OR, not the angio suite!)
  • Patients with peritonitis should go to the operating room
  • Age, grade of injury, amount of hemoperitoneum and age are not contraindications to nonoperative management. Only hemodynamic stability matters.
  • CT of the abdomen with IV contrast is the most reliable method to assess severity of spleen injury (my interpretation: in the hemodynamically stable patient)
  • Angiography with embolization should be considered if a contrast blush is seen on CT, AAST grade > 3, moderate hemoperitoneum is present, or there is evidence of ongoing bleeding
  • Nonoperative management should only be considered if continuous monitoring and serial exams can be carried out at your hospital, and if an operating room is immediately available if needed

Level III recommendations (weak data):

  • Clinical status should dictate need and frequency of followup imaging (my interpretation: only do it if the patient condition changes for the worse)
  • Contrast blush is not an absolute indication for operation or angio-embolization. Age, grade of injury and presence of hypotension need to be considered. (My interpretation: don’t operate or do angio on kids without a really good reason)
  • Angio is an adjunct to nonop management in patients who are at high risk for delayed bleeding or to look for vascular injuries (pseudoaneurysms) that may lead to rupture or delayed hemorrhage

Reference: Trauma Practice Guideline Update, 24th Annual Scientic Assembly, Eastern Association for the Surgery of Trauma, January 2011.

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EAST Guidelines Update: Liver Injury

The Eastern Association for the Surgery of Trauma is in the process of updating their trauma practice guidelines for liver injury. The first set of guidelines was introduced in 2003, and several advances in management have occurred since. here is a summary of the current status of the guidelines:

Level I recommendations (best quality data): 

  • none

Level II recommendations (good data):

  • Initial management of hemodynamically stable patients should be nonoperative
  • CT of the abdomen with IV contrast is the most reliable method to assess severity of liver injury in the hemodynamically stable patient
  • Unstable patients should undergo operative or endovascular management of their injury, not imaging
  • Patients with peritonitis should go to the operating room
  • Age, grade of injury, amount of hemoperitoneum and age are not contraindications to nonoperative management. Only hemodynamic stability matters.
  • Angiography with embolization should be considered if a contrast blush is seen on CT
  • Angiography with embolization may also be considered if there is evidence of ongoing blood loss without blush on CT
  • Nonoperative management should only be considered if continuous monitoring and serial exams can be carried out at your hospital, and if an operating room is immediately available if needed

Level III recommendations (weak data):

  • Clinical status should dictate need and frequency of followup imaging (my interpretation: only do it if the patient condition changes for the worse)
  • Interventional modalities may be used to treat complications (ERCP, percutaneous drainage, laparoscopy, etc)
  • If a patient transiently responds to fluid initially, try angiography with embolization while they are still stable

On Monday, I’ll present the updated guidelines for management of spleen injury.

Reference: Trauma Practice Guideline Update, 24th Annual Scientic Assembly, Eastern Association for the Surgery of Trauma, January 2011.

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Violating Resuscitation Guidelines for Prehospital Traumatic Arrest

Eight years ago, the National Association of Emergency Medical Services Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACS-COT) released guidelines regarding withholding or terminating resuscitation in traumatic cardiopulmonary arrest (TCPA). Survival rates were extremely low (<2%) and were thought to have poor outcomes. But validation of the guidelines has been challenging, and some even doubted that EMS personnel could accurately assess these patients in the field!!

Researchers at Mt. Sinai Hospital in Chicago performed a large retrospective study of all patients in TCPA brought to their hospital by the Chicago Fire Department over at 7.5 year period. These patients met exclusion criteria but had been resuscitated anyway. Their series was relatively large (294 patients), and looked not only at the ultimate outcome, but also at EMS performance and cost.

They found that field assessments by EMS were very accurate and consistent. Violation of the guidelines resulted in only 6 survivors, and they all were resuscitated to a neurologically devastated state (4 brain dead, 1 family withdrew support, 1 sent to TCU with long-term GCS 6). No loss of neurologically intact survivors would have occurred if the guidelines were followed. Finally, the cost of trying to resuscitate these patients was $385,000 per year.

Bottom line: EMS can and should apply the NAEMSP/ACS-COT criteria for traumatic cardiopulmonary arrest and withhold resuscitation for these patients. Tragically, it is an expensive waste of time to try to bring them back. 

To review the NAEMSP guidelines, click here.

Reference: The consequences of violating current guidelines regarding resuscitation of patients in prehospital traumatic arrest. Presented at the 34th annual Residents Trauma Paper Competition at the 89th Annual Meeting of the ACS Committee on Trauma, March 10, 2011.

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Nursing: When Is Drain Output Too Bloody?

Trauma surgeons frequently place some type of drain in their patients, whether it be a chest tube, a damage control system, or a bulb suction drain near the pancreas. On occasion, nursing may become concerned with the character of the output, wondering if the patient is bleeding significantly. How can you tell if the output is too bloody?

First, most drains are in place to drain serous fluid which may have a little blood in it. Drainage that is mostly bloody is very uncommon from these drains, which are typically placed after orthopedic, spine or abdominal surgery. However, some drains are placed in areas where unexpected bleeding may occur, such as:

  • Damage control drain systems – as patients warm up, arterial sources that were not surgically controlled may open up
  • Pericardial drains – more common in cardiac surgery, not trauma
  • Chest tubes in patients with penetrating trauma

What should you do if you have concerns about your patient’s drain output?

  • Familiarize yourself with what kind of drain it is and what it should be draining
  • Look at the volume of output – it takes 500cc of pure blood to drop the patient’s hemoglobin by about 1 gram. Low outputs are not dangerous, even if it is pure blood.
  • Look at the change in output– if it is increasing significantly or changes color, call the physician to evaluate.
  • Look at the color of the output – most drainage ranges from clear to something like cranberry juice and appears to be partially transparent. Look carefully if it appears to be darker or more opaque, and compare it to the blood that you would see in a blood collection tube. Even the darkest drain output usually looks a little watery compared to whole blood. Bright red output needs to be evaluated by a physician.
  • If in doubt, check the fluid’s hematocrit. Whole blood has a hematocrit of 30% or more. Most bloody-looking drain output maxes out at about 5%. If the value is closer to whole blood, have a physician evaluate the patient.
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