Category Archives: General

CNS, General

GCS At 40: Pediatric Glasgow Coma Scale

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I’ve been discussing the Glasgow Coma Scale (GCS), but only the adult version so far. The pediatric GCS was created about 10 years after the classic adult scale after it was recognized that several of the scores were not appropriate for younger non-verbal children, typically less than one year of age. It has been validated several times over the ensuing years and has been integrated into our trauma practices.

So what is different about the pediatric GCS scale? It has the same three main components, eye opening, best verbal response, and best motor response. The number of scores under each remains the same as well. The major changes occurred in the verbal response scores. Here’s the breakdown; I’ve highlighted the differences.

Eye Opening

  • All components are the same as for adults

Best Verbal Response

  1. No response to stimuli
  2. Inconsolable, agitated
  3. Inconsistently inconsolable, moaning
  4. Cries but consolable. Has appropriate interactions.
  5. The child smiles, orients to sounds, follows objects, and interacts with adults

Best Motor Response

  1. No response to stimuli
  2. Decerebrate posturing (extension to stimulation, see the adult post for details)
  3. Decorticate posturing (flexion to stimulation, see the adult post for details)
  4. Withdraws from pain
  5. Withdraws from touch
  6. Spontaneous, purposeful movement

In my next post in the series, I’ll review what’s new with the GCS-40 score.

Reference: Neurologic evaluation and support in the child with an acute brain insult. Pediatric Annals 15(1):16-22, 1986.

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General

Can Lead Poisoning Occur After A Gunshot?

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This is a fairly common question from victims of gunshots and their families. As you know, bullets are routinely left in place unless they are superficial. It may cause more damage to try to extract one, especially if it has come to rest in a deep location. But is there danger in leaving the bullet alone?

One of the classic papers on this topic was published in 1982 by Erwin Thal at Parkland Hospital in Dallas. The paper recounted a series of 16 patients who had developed signs and symptoms of lead poisoning (plumbism) after a gunshot or shotgun injury. The common thread in these cases was that the injury involved a joint or bursa near a joint. In some cases the missile passed through the joint/bursa but came to rest nearby, and a synovial pseudocyst formed which included the piece of lead. The joint fluid bathing the projectile caused lead to leach into the circulation.

The patients in the Parkland paper developed symptoms anywhere from 3 days to 40 years after injury. As is the case with plumbism, symptoms were variable and nonspecific. Patients presented with abdominal pain, anemia, cognitive problems, renal dysfunction and seizures to name a few.

Bottom line: Any patient with a bullet or lead shot that is located in or near a joint or bursa should have the missile(s) promptly and surgically removed. Any lead that has come to rest within the GI tract (particularly the stomach) must be removed as well. If a patient presents with odd symptoms and has a history of a retained bullet, obtain a toxicology consult and begin a workup for lead poisoning. If levels are elevated, the missile must be extracted. Chelation therapy should be started preop because manipulation of the site may further increase lead levels. The missile and any stained tissues or pseudocyst must be removed in their entirety.

Reference: Lead poisoning from retained bullets. Ann Surg 195(3):305-313, 1982.

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General

Help Your PI Meetings Run Smoothly

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Multidisciplinary Trauma PI Committee is an essential part of all trauma centers verified by the American College of Surgeons. A lot happens in that one hour (or so) meeting. But efficiency hinges on being prepared, and we’ve all experienced meetings where the case presentations just weren’t crisp.  Unfortunately, some of the committee members may not have even glanced at the record in advance, and try to catch up during the actual meeting!

What to do? Here’s a set of guidelines to help your presenters do the best job possible. They rely on advance preparation and good communication with your trauma program.

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Download a pdf copy of the guidelines here

And please comment with your own twists and turns on making trauma PI an efficient and meaningful process!

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General

Trauma Coverage By Locum Tenens Surgeons

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Trauma call coverage is not always easy to come by, especially at Level III and IV trauma centers and in rural areas. Many centers come to rely on locum tenens surgeons to fill gaps in their call schedules. Unfortunately, this can create quite a few headaches.

There is currently no trauma literature on this topic. Other disciplines, most recently pediatric surgery, have some published suggestions (I hesitate to call them guidelines) for requirements and expectations based on the ACGME core competencies.

Here are some of the nuances that any trauma program needs to recognize if the use of locum tenens surgeons is being considered:

  • Board certification – This is a basic tenet of trauma center verification and is absolutely required
  • Trauma CME – Recent changes in CME requirements by the American College of Surgeons have nearly eliminated this need. However, do you want a surgeon who does not keep up with trauma education on your call panel? If you allow this, prepare yourself for some interesting performance improvement issues. Make sure that all locums meet some basic requirement for CME or internal education program (IEP) before they start
  • Dissemination of committee proceedings – Make sure that this is well-documented. These surgeons must attend at least 50% of your required committee meetings. If they can’t make it, they must be aware of all items discussed, particularly if it involves their care. Use teleconferencing, or at least send them a (confidential) copy of the minutes. However, this does not absolve them of the attendance requirement.
  • Responsibility for quality issues – This is the most troubling aspect of using locums. It’s tough to hold one of these surgeons responsible for issues arising from their care if they have left and are never coming back. Make sure there is a mechanism to send feedback about their care even after they are gone for good. And document it well!

Bottom line: In my opinion, the use of locum tenens to cover trauma call gaps is a necessary evil for some centers. They should only be used until a more stable coverage pool is available. The management of quality issues in particular is much more difficult when using roving surgeons. And with the adoption of the new Resource Document (Orange Book), it’s even harder to use them. If you must, use them wisely and only briefly.

Reference: Proposed standards for use of locum tenens coverage in pediatric surgery practices. J Pediatric Surg 48:700-703, 2013 (letter).

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