Category Archives: General

What Is: An “Egg Timer Injury”?

July 16, 2015 The Trauma Pro Leave a comment

Most patients with major traumatic injuries are handled in a very systematic way by both EMS and trauma centers. We have routines and protocols designed to provide rapid, quality care to these individuals. But over the years, I’ve begun to appreciate the fact that there is a very small subset of these patients who are different.

I term these patients as having an “egg timer injury”. These are patients who have only a certain number of minutes to live. This fact requires us to change the usual way we do things in order to save their lives or limbs. The usual routine may be too slow.

And unfortunately, no one can tell us exactly how many minutes are left on the timer. We only know that it’s ticking. Here are some examples of such injuries:

Pericardial tamponade

Penetrating injury to the torso with profound hypotension

Orbital compartment syndrome

In each case, speed is of the essence. What can we do to decrease the time to definitive intervention? For prehospital providers, you may need to bypass a closer hospital that might not have the necessary resources at a particular time of day. Once at the hospital, the patient may need to bypass the emergency department and proceed straight to the OR. Or you may need to do a lateral canthotomy yourself, rather than waiting for an ophthalmologist to drive in only to have the patient lose their vision because of the delay.

Bottom line: Remember that protocols are not necessarily etched in stone. They will cover 99.9% of cases you see. But that remaining 0.1%, the patients with the “egg timer injury”, will require you to think through what you know about the patient at the time, and make decisions about their care that may have a huge outcome on their life or livelihood. And as always, if you find that you must do things differently in the best interest of your patient, be sure to document what you knew and your thought processes thoroughly so you explain and/or justify your decision-making when you are invariably asked.

General

How To Craft A Practice Guideline

July 15, 2015 The Trauma Pro Leave a comment

All US trauma centers verified by the American College of Surgeons are required to have clinical practice guidelines (CPG). Trauma centers around the world generally have them, but may not be required to by their designating authority. But don’t confuse a policy about clinical management, say for head injury, with a real CPG. Policies are generally broad statements about how you (are supposed to) do things, whereas a CPG is a specific set of rules you use when managing a specific patient problem.

Look around; don’t reinvent the wheel! This is the first mistake nearly every center makes. It seems like most want to spend hours and hours combing through the literature, trying to synthesize it and come up with a CPG from scratch. Guess what? Hundreds of other centers have already done this! And many have posted theirs online for all to see and learn from. Take advantage of their generosity. Look at several. Find the one that comes closest to meeting your needs. Then “borrow” it.
Review the newest literature. Any existing CPG should have been created using the most up to date literature at the time. But that could have been several years ago. Look for anything new (and significant) that may require a few tweaks to the existing CPG.
Create your draft, customizing it to your hospital. Doing things exactly the same as another center doesn’t always make sense, and it may not be possible. Tweak the protocols to match your resources and local standards of care. But don’t stray too far off of what the literature tells you is right.
Make sure it is actionable. It should not be a literature summary, or a bunch of wishy-washy statements saying you could do this or consider doing that. Your CPG should spell out exactly what to do and when. (see examples below)
Get buy-in from all services involved. Don’t try to implement your CPG by fiat. Use your draft as a launching pad. Let everyone who will be involved with it have their say, and be prepared to make some minor modifications to get buy-in from as many people as possible.
Educate everybody! Start a campaign to explain the rationale and details of your CPG to everyone: physicians, nurses, techs, etc. Give educational presentations. You don’t want the eventual implementation to surprise anyone. Your colleagues don’t like surprises and will be less likely to follow along.
Roll it out. Create processes and a timeline to roll it out. Give everyone several months to get used to it.
Now monitor it! It makes no sense to implement something that no one follows. Create a monitoring system using your PI program. Include it in your reports or dashboards so providers can see how they are doing. And if you really want participation, let providers see how they are doing compared to their colleagues. Everyone wants to be the top dog.

Some sample CPGs:

General

Jehovah’s Witnesses And Blood Transfusion Demystified

July 14, 2015 The Trauma Pro Leave a comment

Injury can be a bloody business, and trauma professionals take replacement of blood products for granted. Some patients object to this practice on religious grounds, and their health care providers often have a hard time understanding this. So why would someone refuse blood when the trauma team is convinced that it is the only thing that may save their life?

Jehovah’s Witnesses are the most common group encountered in the US that refuse transfusion. There are more than 20 million Witnesses worldwide, with over 7 million actively preaching. It is a Christian denomination that originated in Pennsylvania during the 1870s.

Witnesses believe that the bible prohibits taking any blood products, including red cells, white cells, platelets or plasma. It also includes the use of any dialysis or pump equipment that must be primed with blood. This is based on the belief that life is a gift from God and that it should not be sustained by receiving blood products. The status of certain prepared fractions such as albumin, factor concentrates, blood substitutes derived from hemoglobin, and albumin is not clear, and the majority of Witnesses will accept these products. Cell saver techniques may be acceptable if the shed blood is not stored but is immediately reinfused.

Why are Witnesses so adamant about refusing blood products? If a transfusion is accepted, that person has abandoned the basic doctrines of the religion, and essentially separates themselves from it. They may then be shunned by other believers.

So what can trauma professionals do to provide best care while abiding by our patient’s religious belief? In trauma care it gets tricky, because time is not on our side and non-blood products are not necessarily effective or available. Here are some tips:

Your first duty is to your patient. Provide the best, state of the art care you can until it is absolutely confirmed that they do not wish to receive blood products. In they are comatose, you must use blood if indicated until the patient has been definitively identified by a relative who can confirm their wishes with regard to blood. Mistaken identity does occur on occasion when there are multiple casualties, and withholding blood by mistake is a catastrophe.
Talk with the patient or their family. Find out exactly what they believe and what they will allow. And stick to it.
Aggressively reduce blood loss in the ED. We are not always as fastidious as we should be because of the universal availability of blood products. Use direct pressure or direct suture ligation for external bleeding. Splint to reduce fracture bleeding.
Aggressively use damage control surgery. Don’t go for a definitive laparotomy which may take hours. Pack well, close and re-establish normal physiology before doing all the final repairs.
Always watch the temperature. Pull out all the stops in terms of warming equipment. Keep the OR hot. Cover every bit of the patient possible with warming blankets. All fluids should be hot. Even the ventilator gases can be heated.
Think about inorganic and recombinant products such as Factor VIIa, tranexamic acid and Vitamin K. These are generally acceptable.
Consider angiography if appropriate, and call them early so their are no delays between ED and angio suite or OR and angio suite.

Bottom line: Do what is right for your patient. Once you are aware of their beliefs, avoid the use of any prohibited products. Speak with them and their family to clarify exactly what you can and cannot do. This is essentially an informed consent discussion, so make sure they understand the consequences. Follow their wishes to the letter, and don’t let your own beliefs interfere with what they want.

General

“Found Down”: Do We Need To Worry About The Abdomen?

July 8, 2015 The Trauma Pro Leave a comment

It’s that dreaded mechanism of injury: “found down.” What really happened? Did they fall, or get assaulted? Or did the patient suffer a medical problem that led to them falling down? Trauma professionals rely heavily on what I call “context.” Is the patient elderly and frail? Are they intoxicated? What was their location when found? Are there pre-existing medical conditions?

All of these factors allow us to begin building a story in our mind that tells us what might have happened, and what the injuries might be. But with little or no context, we are flying by the seat of our pants. We end up suspecting everything, which means we image everything. With CT scans. And IV contrast. There is always a chance that we can add to the harm already suffered by this patient, or waste time and money.

The abdomen is a black box in a patient with an unreliable or absent physical exam. The emergency medicine group at Cedars-Sinai in Los Angeles looked at the utlity of CT scanning the abdomen in this group of patients. They retrospectively reviewed 10 years of their data. They found 342 patients, of which 154 underwent some type of abdominal imaging (CT, FAST).

Here are the factoids:

About 60% had alcohol present, and 98% of those had a level greater than 0.08 g/dL
Overall mortality was 10%. 24 were trauma related (severe TBI, traumatic arrest in ED), and 9 were medical (CVA, sepsis)
55% did not undergo any abdominal imaging, and their mortality was 6% (TBI, stroke, MI). None manifested a late abdominal injury.
Of the 45% who did have abdominal imaging, 57% had CT, 24% FAST, and 19% both
14 patients in the imaged group had a positive abdominal CT, but all were minor (Abbreviated Injury Score (AIS) <3)
5 patients had a positive FAST, and all had an abdominal AIS<3

Bottom line: Patients who are “found down” seldom have significant intra-abdominal injuries. Keep in mind that this is a small study group, but it does seem to correlate with personal experience and reviews of many charts. Although you can’t completely ignore the abdomen in this group of patients, you should place a higher priority on head and neck trauma, or CVA/sepsis in patient without other obvious injury.

Related posts:

Reference: Abdominal injuries in the “found down”: is imaging indicated? J Am Col Surg 221(1):17-25, 2015.

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