Category Archives: General

Trauma Overtriage: Why Is It Bad?

February 25, 2011 The Trauma Pro Leave a comment

Back in December I talked about the dangers of undertriaging trauma patients (click here to review). What about the opposite problem, overtriage?

First, how do you calculate your overtriage rate? It’s pretty simple. Use your trauma registry to count how many patients arriving in the ED were trauma activations but didn’t meet any criteria:

(Number of ED trauma patients who were trauma activations
but did not meet activation criteria)

——————————————————– x 100
(Total number of trauma activations)

This can only be accurately determined if the activation criteria are recorded on each patient. If not, use the following equation:

(Number of ED trauma patients who were trauma activations
   with ISS <= 15)
   ——————————————————— x 100
   (Total number of trauma activations)

Values can range from 0% to 100%. The usually acceptable overtriage rate is 50-80%. What happens when the overtriage rate is too high? You wear out your trauma team. They are being called for patients with injuries that don’t warrant it.

The solution for overtriage? Change your activation criteria, or add a second level trauma response that doesn’t require as many people to respond. This requires a thoughtful analysis of your existing criteria so you can decide what needs to be changed or discarded.

The danger? More undertriage. Over- and undertriage go hand in hand. As overtriage decreases, undertriage increases. You need to strike a balance so that the undertriage rate stays below 5%. This makes an excellent performance improvement (PI) program project!

General

Treating Bile Leaks After Liver Trauma

February 24, 2011 The Trauma Pro Leave a comment

Nonoperative management is the standard of care for most solid organ injuries, including the liver. More serious injury may require operative intervention. Unlike the spleen, however, the liver has a higher complication rate when managed nonoperatively or operatively. One of the more troubling problems is the persistent bile leak. Our radiology colleagues do a great job a draining collections, but what should we do if the bile keeps pouring out?

ERCP seems like a reasonable choice. But does it work? The Shock Trauma Center looked at their experience over a 6 year period. They included both blunt and penetrating injuries to the liver, and found a total of 26 patients in their database. All but 2 underwent an initial attempt at operative control of the bile leak. All but one had ERCP performed within 3 weeks of admission.

They found that ERCP resulted in decreased drain output within 2 days. All bile leaks stopped within 7 months, with an average closure time of 47 days. There were no complications from ERCP itself.

Bottom line: consider ERCP part of your armamentarium when dealing with major liver injuries. Depending on patient condition, it might even be used as the initial approach to controlling a bile leak. If the leak does not decrease significantly or close in a reasonable period of time (not yet defined), operative intervention will still be required.

Reference: Endoscopic retrograde cholangiopancreatography is an effective treatment for bile leak after severe liver trauma. J Trauma, in press, 2011.

General

Gallery February 23, 2011 The Trauma Pro Leave a comment

What Next? An Inkjet Printer for Skin?

Everyone is familiar with inkjet printer technology. You’ve probably got one in your house for printing 2D page images from your computer. Engineers have already taken this one step further and created 3D printers that print objects from computer aided design (CAD) files. Instead of shooting tiny dots of ink from a cartridge, they squirt out tiny dots of molten plastic.

This same technology is poised to change the way we do things in medicine. James Yoo and colleagues from Wake Forest have designed a printer that can print skin. This unit has been redesigned from earlier versions and now uses a laser to scan the contours of the area to be grafted. It then prints a skin graft over the area using different layers of cells.

The Department of Defense is funding this work, which has amazing implications for the battlefield and for disaster areas. Imagine being able to print a skin graft onto a wounded soldier or civilian to reduce fluid loss and decrease infections. In these applications, cartridges of skin cells are more easily transported than freezers of cadaver skin. However, these grafts would be temporary, just like cadaver or pig skin, because the cells would be from unmatched donors. But ultimately, we should be able to prepare cartridges from our own cells for long lasting grafts.

The Wake Forest group is successfully printing 10x10cm grafts onto pigs right now. But think of the broader implications of this technology. Other groups are looking at using 3D printer technology to squirt a variety of cell types to create complete organs. This could eventually revolutionize transplant technology as we know it!

References

In Situ Bioprinting of the Skin for Burns. Binder, Yoo et al. Presented at the American College of Surgeons Clinical Congress, October 5,2010, Washington DC.
Presentation at the American Association for the Advancement of Science, February 16-20 2011, Vancouver BC, Canada.

General

Gallery February 18, 2011 The Trauma Pro Leave a comment

Pneumomediastinum After Falling Down

Finding pneumomediastinum on a chest xray or CT scan always gets one’s attention. However, seeing this condition after a simple fall from standing is very simple to evaluate and manage.

There are 3 potential sources of gas in the mediastinum after trauma:

Esophagus
Trachea
Smaller airways / lung parenchyma

Blunt injury to the esophagus is extremely rare, and probably nonexistent after just falling down. Likewise, a tracheal injury from falling over is unheard of. Both of these injuries are far more common with penetrating trauma.

This leaves the lung and smaller airways within it to consider. They are, by far, the most common sources of pneumomediastinum. The most common pattern is that this injury causes a small pneumothorax, which dissects into the mediastinum over time. On occasion, the leak tracks along the visceral pleura and moves directly to the mediastinum.

Management is simple: a repeat chest xray after 6 hours is needed to show non-progression of any pneumothorax, occult or obvious. This image will usually show that the mediastinal air is diminishing as well. There is no need for the patient to be kept NPO or in bed. Monitor any subjective complaints and if all progresses as expected, they can be discharged after a very brief stay.

General

Gallery February 17, 2011 The Trauma Pro Leave a comment

Extraperitoneal Bladder Rupture

This injury is likely to occur in patients who have a full bladder and sustain anterior pelvic trauma that typically leads to fractures. They generally present with gross hematuria upon placement of the bladder catheter. This should prompt an abdominal CT scan with cystogram technique.

CT cystogram involves pressurizing the bladder with contrast prior to the study. This differs from the usual method of clamping the catheter and allowing the bladder to passively fill. The literature here is clear: failure to use cysto technique will miss 50% of these injuries.

The majority of extraperitoneal bladder injuries can be treated nonoperatively, and probably do not need Urology involvement. The bladder catheter is left in place 10-14 days (we do 10 days), and a repeat cystogram is obtained. If there is no leak, the catheter can be removed. If there is still some leakage, Urology consultation should then be obtained.

There are a few cases where operative management is required:

There is some intraperitoneal component of bladder injury
Fixation of the pubic rami is required (bathing the orthopedic hardware with urine is frowned upon)
Failure of conservative management

Arrows in the photo show extraperitoneal extravasation of cystogram contrast.

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