Category Archives: General

More On Time To Surgery After Open Fractures

October 27, 2014 The Trauma Pro Leave a comment

Open fracture dogma has mandated management of these injuries within an 8 hour window. Over the past several years, there has been a growing number of good papers that dispute this fact. As is the norm, many are retrospective in nature, or meta-analyses of retrospective papers.

Recently, a paper was published that detailed a (small) prospective and multi-center study (3 hospitals in Canada) looking at deep infection, Gustillo grade, antibiotics, and time to treatment. My hopes were raised!

Here are the factoids:

939 patients were screened, but only 736 were actually enrolled
Only 482 completed the entire study (>90 days clinical followup and an interview after 1 year). Others with less clinical followup were still included and analyzed.
Information on fracture grade, time to antibiotic administration, time to OR, and development of deep infections were recorded. Cellulitis and pin site infections were not considered.
Time to antibiotic administration ranged from 1 hour to 10 hours (!!?)
Time to OR ranged from 6 to 13 hours
46 patients developed deep infections, and 56 had cellulitis or pin site infections
Of those who developed infections, there was no clear association with time to OR
Also in those with infections, antibiotics were given after about 3 hours, vs 2.5 hours in those without.

The authors concluded that neither time to antibiotic administration nor time to surgery made any difference on deep tissue infections. But should I believe them?

Bottom line: SLOPPY! If you just read the abstract you might believe the wrong thing. This paper cobbled together surgeons at 3 different centers and let them do their own thing. The researchers just observed the management that these fellowship trained surgeons chose. No guidelines. No protocols. The variability of practice in this study leaves me flabberghasted. The median time to antibiotic administration was 3 hours, with some waiting up to 10 hours! The median time to OR was 9 hours, not so far off the 8 hour mark the everyone seems to look at. No wonder they couldn’t find any differences.

Give antibiotics early. Get to the OR in a reasonable amount of time, preferably using the Gustillo grade to take high grades there sooner. And keep your eye on the literature for papers that are much, much better than this one!

Related posts:

Reference: Time to Initial Operative Treatment Following Open Fracture Does Not Impact Development of Deep Infection: A Prospective Cohort Study of 736 Subjects. J Orthop Trauma 28(11):613-619, 2014.

General

Lack of EMS Documentation is Associated With Increased Mortality

October 24, 2014 The Trauma Pro Leave a comment

EMS policy and the trauma center verification process requires that all trauma patients delivered to a trauma center must have a copy of the EMS run sheet. Two parameters that are commonly used to monitor performance improvement (PI) in EMS are:

accurate record of scene physiology (SBP, HR, RR, GCS)
request by on-scene BLS for ALS assistance

A study looked at the impact of those criteria on patient survival. A total of 4744 patients from the National Trauma Data Bank were analyzed.

Physiologic data: About 28% had at least one missing physiologic data point, with respiratory rate being most commonly missed. They found that the mortality in the group with missing data was over twice as high (10.3%) as it was in the group with complete date (4.5%).

BLS call for ALS assistance: This assist was called for in 17% of cases. These cases were less likely to involve penetrating injuries and more likely to involve car or motorcycle crashes. Injury Severity Score was the same. Eventual patient mortality was the same for BLS calling ALS and ALS response alone.

So why does failure to record physiologic data translate into higher mortality? The initial response may be that the patient was sicker, and so they needed more intense care during transport with less time to record vitals. However, the researchers controlled for this and found it was not a factor. Other issues that may be a factor are EMS training and proficiency, leadership at the scene and enroute, and available staff and resources, among other things.

The researchers speculate that documentation might be a good global measure of appropriate or inappropriate prehospital care that rolls all of these possible factors into one easily identifiable audit filter. They recommend that this be used to focus performance improvement efforts and hopefully improve survival.

Bottom line: I have visited a number of states where EMS often does not leave their run sheet at all! I recommend that the results of this study be taken to heart and used to help persuade EMS programs to get religious about recording complete vital signs and leaving the run sheet at the trauma center every time a patient is delivered. Documentation should be evaluated regularly, and all cases with any missing vital signs should be reviewed closely. Trauma Center PI programs should work with EMS to analyze this data and look for the patterns that increase mortality.

Reference: Lack of Emergency Medical Services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. Journal of the American College of Surgeons, 210(2):220-227, 2010.

General

Update: Can TBI Be Managed Without Neurosurgical Consultation?

October 22, 2014 The Trauma Pro Leave a comment

This paper was presented at EAST in 2013, and this is an update of that work using the entire manuscript which has now been published.

The standard of care in most high level trauma centers is to involve neurosurgeons in the care of patients with significant traumatic brain injury (TBI). However, not all hospitals that take care of trauma patients have immediate availability of this resource. The University of Arizona at Tucson looked at management of these patients by their acute care surgeons.

The authors did a retrospective cohort study of patients at their center who had a mild TBI and positive head CT, managed with or without neurosurgery consultation, over a two year period. They matched the patients with and without neurosurgical consultation for age, GCS, AIS-Head and presence of skull fracture and intracranial hemorrhage.

A total of 90 patients with and 180 patients without neurosurgical involvement were reviewed. Here are the factoids:

Hospital admission rate was identical for both groups (87-89%)
ICU admission was significantly higher if neurosurgeons were involved (20% vs 44%)
Repeat head CT was ordered more than 3 times as often by neurosurgeons (20% vs 86%)
Post-discharge head CT was ordered more often by neurosurgeons, but was not significantly different (5% vs 12%)
There were no surgical interventions, in-hospital mortality, or readmissions within 30 days in either group.
Cost of the hospital stay was significantly increased if neurosurgery was consulted.

Bottom line: Can surgeons safely manage select patients with intracranial injury? Granted, this is a small, retrospective study, but the answer is probably yes. The majority of patients with mild to moderate TBI with small intracranial bleeds or skull fractures do well despite everything we throw at them. And it appears that surgeons use fewer resources managing them than neurosurgeons do. The keys to being able to use this type of system are to identify at-risk patients who really do need a neurosurgeon early, and having a quick way to get the neurosurgeon involved (by consultation or hospital transfer). Having a specific practice guideline for management is essential as well. As neurosurgery involvement in acute trauma declines, this concept will become more and more pertinent.

Related posts:

Reference: The acute care surgery model: managing traumatic brain injury without an inpatient neurosurgical consultation. J Trauma 75(1):102-105, 2013.

General

Tech: Bandage Indicates Wound Tissue Oxygen Concentration

October 21, 2014 The Trauma Pro Leave a comment

Tissue oxygenation is critical to wound healing. But unfortunately, there is no easy way to “see” how healthy the wound is just by looking at it. A research team at the Massachusetts General Hospital is developing a spray-on “smart” bandage that determine, at a glance, shows a map of tissue oxygen levels.

Now, of course, the researchers had to get clever and come up with a lame acronym. So here it is: sensing, monitoring and release of therapeutics (SMART). Get it? SMART bandage.

Here’s what it looks like:

Okay, so how does it work? There are three components: a sensor molecule that glows over a useful range of oxygenation values, a bandage material to bind it to, and an imaging device for capturing useful images.

The sensor molecule is a phospor derivative that glows longer and brighter as tissue oxygen decreases. The bandage is a viscous liquid that is painted on the skin and dries as a solid film within a minute (think NewSkin). It contains the sensor molecule. In order to keep room air from seeping into the bandage and interfering with the readings, a transparent barrier is placed over it (think Tegaderm).

Finally, the detector is … a smartphone or camera! No need for other expensive equipment. The flash stimulates the phosphors as the image is recorded. The image can then be analyzed for brightness and color of the phosphors.

What is this good for? Trauma professionals deal with soft tissue wounds on a regular basis. Some of the more complicated ones require skin grafts or flaps, and maintaining their health is very important. Imagine begin able to identify oxygenation problems early in the edges of a flap or from a small seroma under a skin graft. This could lead to earlier correction of any problems and an increase in graft salvage. And it may allow us to better predict which burns are getting worse or may need grafting. Here are images of burn vs normal skin:

Bottom line: Yet another cool (and probably inexpensive) tool in expanding our senses to appreciate factors that help wound healing. Once the kinks are worked out, expect this to move into clinical care fairly quickly.

Related posts:

Reference: Non-invasive transdermal two-dimensional mapping of cutaneous oxygenation with a rapid-drying liquid bandage. Biomedical Optics Express 5(11):3748-3764, 2014.

General

What Is: The LisFranc Injury?

October 17, 2014 The Trauma Pro Leave a comment

Medicine is full of conditions with eponyms. Trauma is no exception. There’s the Mattox maneuver and the Cushing response, to name two. Many times, the name is just a kind of vanity plate for the discoverer of the condition. But in the case of the LisFranc injury (or fracture), it makes some sense. This injury is tough to describe in a sentence or two, let alone a few words.

Jacques LisFranc de St. Martin was a French surgeon and gynecologist (!) who described this condition in about 1815. It entails the fracture of the heads of the metatarsal bones and possible dislocation from the tarsals (the cuboid, navicular, and three cuneiform bones). This area is known as the LisFranc joint complex.

The injury can involve any or all of the metatarsals. The typical mechanism applies high energy across the midfoot, which can often be seen in head-on motor vehicle crashes. Crush injury to the proximal foot can also do this, such as running the foot over with a car. Occasionally, this injury pattern is produced with lower energy during sports play. In this case, the top of the foot is typically contacting the ground, plantar flexing it. At the same time, another player steps on the heel, grinding the foot into the ground (ouch). Interestingly, LisFranc did not describe the injury pattern or mechanism. His name is associated with the joint complex, and it is an injury to his joint complex.

Most of the time, the injury is obvious. There is usually notable pain and swelling of the foot. X-ray findings are generally not subtle. However, lower energy mechanisms may not cause much displacement, and initial imaging may not show the injury. If your patient starts to complain of pain in the midfoot when they begin to ambulate, think of LisFranc.

Treatment depends on the degree of displacement and the amount of disruption of the tarso-metatarsal joints. If minimal, a trial of nonoperative, non-weight bearing may be sufficient. But frequently, surgical reconstruction is required.

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