Category Archives: General

General

Personal Decisions are the Leading Cause of Death

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A relatively obscure research paper published in late 2008 by Ralph Keeney at Duke University makes this startling claim: over half of the people who died in this country in the year 2000 did so because of their own personal decisions! If you look at current mortality statistics, the top four causes of death from year to year are heart disease, cancer, stroke and injury. We naturally look at this and think that these people had a heart attack or discovered a cancer or crashed their car. What these statistics fail to show is how the people really ended up with these conditions.

Keeney’s paper looked beyond what was written on the death certificate and looked at how frequently personal choices caused these conditions. For example, smoking leads to heart disease, cancer, stroke, and high blood pressure, to name a few. Being overweight leads to heart disease, diabetes, high blood pressure, and many others. Inappropriate use of alcohol can lead to cancer, liver disease and a tendency to get into accidents.

The top causes of death were analyzed, looking at the percentage that could be caused by personal decisions such as smoking, diet, exercise, and use of alcohol or other drugs. A personal decision was defined as a situation where the individual could make a choice between two or more readily available alternatives (for example, smoking and not smoking) and that they had control over this choice. These choices are not necessarily easy to make because habits, social pressure, or genetic predisposition can make some alternatives hard to select.

Keeney found that about 55% of deaths in 2000 were caused by personal decisions. This compares to about 5% in the year 1900. This is due to the fact that the majority of the causes of death in 1900 were due to infectious diseases, and there were no antibiotics at the time to treat them.

What this paper shows us is that the need for high quality prevention activities is even greater that we thought, and that we may not be focusing on the right areas.Trauma centers habitually direct their prevention programs toward car seats, diving injuries, red light running, falls prevention and others. What we really need to focus on is personal choice, and teaching people how to make the right decisions. For trauma prevention, alcohol-related programs will probably give the greatest result since it is involved in so many of the top causes of death, even causes not related to trauma.

Trauma centers need to scrutinize their own prevention programs, and look critically at ways they can teach wise choices. It may be necessary to chage the focus of existing programs, or move to new programs that find ways to influence personal decision making. That way, trauma centers can have a hand not only in preventing certain types of injuries, but in directly decreasing the overall death rate as well.

Reference: Keeney RL. Operations Research 56:6, 1335-1347, 2008.

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General

Syncope Workup in Trauma Patients

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Syncope accounts for 1-2% of all ED visits, and is a factor in some patients with blunt trauma, especially the elderly. If syncope is suspected, a “syncope workup” is frequently ordered. Just what this consists of is poorly defined. Even less understood is how useful the syncope workup really is.

Researchers at Yale retrospectively looked at their experience doing syncope workups in trauma patients. They were interested in seeing what was typically ordered, if it was clinically useful, and if it impacted length of stay. 

A total of 14% of trauma patients had syncope as a possible contributor to their injury. The investigators found that the following tests were typically ordered in these patients:

  • Carotid ultrasound (96%)
  • 2D Echo (96%)
  • Cardiac enzymes (81%)
  • Cardiology consult (23%)
  • Neurology consult (11%)
  • EEG (7%)
  • MRI (6%)

Most of this testing was normal. About 3% of cardiac enzymes were abnormal, as were 5% of carotid imaging and 4% of echocardiograms. 

Important! Of the patients who underwent an intervention after workup, 69% could have been identified based on history, physical exam, or EKG and did not depend on any of the other diagnostic tests.

Conclusion: Syncope workup is not needed routinely in trauma patients with syncope as a contributing factor. Need for intervention can usually be determined by history, exam and EKG performed in the ED. In this study, $216,000 in excess costs would have been saved!

Reference: Routine / protocol evaluation of trauma patients with suspected syncope is unnecessary. Davis, et al, Yale University. Presented at the 23rd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 2010.

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General

EMS: Which Field Airways Work The Best?

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Oral endotracheal intubation is the gold standard when a field airway is needed. However, they are not always possible due to protocol, training, patient anatomy or specific injuries. To allow airway support in these situations, a number of techniques and devices have been developed. The problem is, do we really know which one(s) are best?

To try to answer this question, a huge meta-analysis of all the English literature with information on success rates for these techniques was carried out. Over 2000 papers were identified, and they were narrowed down to 35 studies involving over 10,000 patients. 

The success rates that they identified were as follows:

  • King LT airway – 96.5%
  • Esophageal Obturator / Esophageal Gastric Tube Airway – 92.6%
  • Surgical cricothyroidotomy – 90.5%
  • Laryngeal mask airway (LMA) 87.4%
  • Combitube – 85.4%
  • Pharyngeotrachael laryngeal airway (PTLA) – 82.1%
  • Needle cricothyroidotomy – 65.8%

The Bottom Line: The King airway has the highest success rate of the alternative airway devices, although there was less data available and the effectiveness of ventilation has not been worked out yet. The best percutaneous rescue airway was the surgical crich.

Reference: A Meta-Analysis of Prehospital Airway Control Techniques Part II: Alternative Airway Devices and Cricothyrotomy Success Rates. Prehospital Emergency Care 14(4):515-530, Oct-Dec 2010.

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General

Trauma Factoid: What Cars Were Doing When Involved In A Fatal Crash?

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What were cars doing when they got involved in a fatal crash?

  • 69% – going straight ahead
  • 15% – negotiating a curve
  • 6% – turning left
  • 4% – not known
  • 2% – passing
  • 2% – merging or changing lanes
  • 1.5% – stopping, slowing or starting in a traffic lane
  • 0.8% – turning right

Bottom line – most fatal crashes occur when moving straight ahead, but look out when turning left!!

Reference: NHTSA

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General

Trauma 20 Years Ago: Blunt Aortic Injury in Children

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We always worry about the aorta after high-energy blunt trauma in adults. Should we be doing the same in kids? After all, they are very elastic and for the most part they are tough to break.

A 13 year review was undertaken by the CV surgeons at Harborview twenty years ago which tried to answer this question. They looked at medical examiner records of all pediatric deaths (16 or younger) and identified the ones with traumatic aortic injury. They found only 12 deaths (2.1%), and somehow they also tracked one survivor (from ME data???). The age range was 3-15, with a mean of 12 (which means that the majority were in the older age group).

Six children were pedestrian struck, 5 were involved in car crashes, and two were on motorized bikes or ATVs. None of the children in car crashes were restrained and two were ejected. Four of the five were traveling > 55mph. All had other serious injuries, including abdominal and orthopedic.

It’s tough to draw any meaningful conclusions from this paper due to the small numbers, the retrospective design, and the lack of a denominator. The only thing it does tell us is that aortic injury is bad, and that kids should not get hit by cars and should wear their seat belts. The mean age suggests that it involves primarily older children. But we kind of knew all that already.

What it does not help with is figuring out at what age we need to start thinking about imaging the aorta with CT scan. I’ll be digging into that a little more this week.

Reference: Eddy et al. The epidemiology of traumatic rupture of the aorta in children: a 13 year review. J Trauma 30(8): 989-992, 1990.

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