Category Archives: General

The Three Strikes And You’re Out Airway Rule

July 22, 2014 The Trauma Pro Leave a comment

Rapid airway control is key in critically injured trauma patients. But too many times, I’ve seen trauma professionals take far too much time to establish one. Here’s a good rule of thumb to use in these situations.

After pre-oxygenating the patient, your first pro gets a crack at it. They generally have the most time available, often 3-5 minutes before sats begin to drop.

In the unlikely situation that they are not successful, strike 1. Stop trying and resume bagging the patient. At this point, someone (trauma surgeon, lead medic) must get the crich set out. Then the next most experienced intubator gets a shot.

If they are not successful, strike 2. Resume bagging and open the crich set.

The most experienced intubator now gets their chance, using any advanced technology available. No success even now? Strike 3, use the crich set!

Bottom line: We should never allow more than 3 airway attempts, and sometimes clinical conditions will dictate fewer tries. Examples that come to mind are severe brain injury patients (hypoxia is bad) and patients who do not recover from oxygen desaturation when they are bagged. Don’t lose track of time and the number of attempts!

General

Trauma Surgeons And PTSD??

July 21, 2014 The Trauma Pro Leave a comment

A number of studies have documented post-traumatic stress disorder in our trauma patients, pre-hospital providers, and combat veterans. A new study now suggests that PTSD symptoms are present in 41% of trauma surgeons(!). Can it be true??

The study was carried out using an email questionnaire that was sent to all EAST and AAST members. Respondents were directed to an online questionnaire that polled them for basic demographics, as well as a series of questions using a well-established PTSD checklist scale, the PCL-C.

Here are the factoids:

1104 questionnaires were distributed, and 453 were complete enough for analysis (41%)
Respondents tended to be younger (68% < 50 years old), male (76%) and white (80%)
The majority worked in Level I (71%) urban (90%) academic centers (81%) with resident coverage (83%)
85% took at least 4 in-house calls each month, 27% had 2 weeks or less of vacation each year (!), and 81% believed that trauma surgery was more stressful than other surgical subspecialties
40% of respondents had PCL scores consistent with PTSD (!)
The only independent predictor of having PTSD symptoms was managing 5 or more critical cases while on call

Bottom line: Hmm, be skeptical of this one. Yes, it does seem to show some possible issues with PTSD in a select group of trauma surgeons. However, I don’t believe this is easily generalized, and my personal contact with surgeons around the country does not really bear this out. The survey methodology, response rate, and the skewed demographics raise some serious questions about the quality of this data. And can self-reporting of PTSD symptoms from a group of trauma surgeons really be reliable?? It does appear that a subset of surgeons who work at very busy urban centers may be at risk, and this certainly deserves further scrutiny. But this study does not really apply to the majority of surgeons practicing trauma care in this country, who don’t work in that kind of environment.

Related posts:

Reference: Unveiling posttraumatic stress disorder in trauma surgeons: A national survey. J Trauma 77(1):148-154, 2014.

General

The Flat Vena Cava Sign? Published and Revisited

July 17, 2014 The Trauma Pro Leave a comment

I’ve previously blogged about the flat vena cava sign as an indicator of low volume status in trauma patients. And I commented on this paper when it was presented at EAST, which had a surprisingly negative result. It’s now been vetted by peer reviewers and published, and I’ve had the opportunity to read through the entire manuscript (always important). So let’s take a second look now.

A retrospective study at George Washington University was carried out over a one year period. They looked at all of their highest level trauma activation patients who also underwent CT scan of the abdomen. Images were read by three radiologists and inter-rater reliability was reviewed. The transverse to anteroposterior diameter ratios were calculated to determine flatness.

Here are the factoids:

276 patients met enrollment criteria, and were mostly male and blunt trauma
The IVC was nearly round in 21% of patients and collapsed in 26%
There was no association between IVC shape and shock index, blood pressure, Hbg, lactate, urgent operation, angiography or length of stay
There was also no association between IVC shape and blood transfusion or death
Correlation of the reads between radiologists was good

So what gives? A paper I reviewed three years ago in the Journal of Trauma came to a different conclusion. They found that a flat IVC on CT scan (defined as a transverse to AP ratio of 4:1 or greater) was associated with a significantly higher chance of receiving more crystalloid or blood, as well as requiring an operation within 24 hours.

This newer paper was able to look at a larger group of patients, and they were able to tease out why it initially looked like the flat cava looked like a good predictor for bad things to come. The problem was statistical skewing from a few extreme outliers. When properly corrected, it completely changed things. And looking at the older study, it appears that outliers may have also been the reason for the positive result. This is why I encourage everyone to always read the entire paper! The older paper involved a smaller series (114 patients), but it was prospective and seemed to have reasonable statistical analyses.

Bottom line: It looks like the flat vena cava sign, as measured by a static CT, should be discarded as an indicator of impending shock. Whether or not a more dynamic look (using ultrasound) is valuable remains to be determined.

Related post:

The flat vena cava in blunt trauma

Reference: Inferior vena cava size is not associated with shock following injury. J Trauma 77(1):34-39, 2014.

General

Phlebotomy And Pediatric Solid Organ Injury

July 16, 2014 The Trauma Pro Leave a comment

I recently wrote about this journal article from a couple of pediatric trauma programs in New York. The article tried to focus on reducing the rate of phlebotomy in children who are being observed for solid organ injury. I was more excited about the overall protocol being used to manage liver and spleen injury, as it was a great advance over the original APSA guideline. But let’s look at the phlebotomy part as well.

This is an interestingly weird study, and you’ll see what I mean shortly. Two New York trauma hospitals that take care of pediatric patients pooled 4 years of registry records on children with isolated blunt liver and/or spleen injuries. Then they did a tabletop excercise, looking at “what if” they had applied the APSA guideline, and “what if” they had applied their new, proposed guideline.

Interestingly, this implies that they were using neither! I presume they are trying to justify (and push all their partners) to move to the new protocol from (probably) random, individual choice.

Here are the factoids:

120 records were identified across the 2 hospitals that met criteria
Late presentation to the hospital, contrast extravasation, comorbidities, lack of imaging, operative intervention at an outside hospital excluded 59 patients, leaving 61 for analysis. Three of those patients became unstable and were also excluded.
None of the remaining patients required operation or angioembolization
Use of the “new” (proposed) protocol would reduce ICU admissions by 65%, reduce blood draws by 70%, and reduce hospital stay by 37%
Conclusion: use of the protocol would eliminate the need for serial phlebotomy (huh?)

Bottom line: Huh? All this to justify decreasing blood draws? I know, kids hate needles, but the data on decreased length of stay in the hospital and ICU is much more important! We’ve been using a protocol similar to their “new” one at Regions Hospital, which I’ve shared below. We’ve been enjoying decreased resource utilization, blood draws, and very short lengths of stay for over a decade. And our analysis showed that we save $1000 for every patient entering the protocol, compared to the old-fashioned and inefficient way we used to manage them.

Related posts:

Reference: Reducing scheduled phlebotomy in stable pediatric patients with liver or spleen injury. J Ped Surg 49(5):759-762, 2014.

General

Pediatric Solid Organ Injury Management: It’s About Time!

July 14, 2014 The Trauma Pro Leave a comment

There was an interesting article released in the Journal of Pediatric Surgery in May about spleen and liver injury management in children. It’s interesting because if you just look at the title, you might just skip over it. The title suggests that it describes reducing scheduled phlebotomy in kids who are undergoing solid organ injury management. But the real meat of this article has to do with the protocol they are using to treat the children.

Nonoperative management of these injuries in children started becoming popular 40 years ago (!). But for decades, everyone put their own spin on how to do it. Bed rest for a week (or more). NPO for days! Limited physical activity for extended periods. Then the American Pediatric Surgery Association (APSA) published a set of guidelines about 15 years ago that took some of the guesswork out of it.

Although nonoperative management of these injuries in kids preceded its adoption in adults by a nearly two decades, it has languished in the APSA format for quite some time. Many pediatric surgeons still use these guidelines, even though adult spleen and liver injury management have advanced to shorter and more streamlined care.

We adopted a solid organ management guideline at Regions Hospital over ten years ago, and have made a few minor tweaks over the years. Nowadays, our grade I-III injuries can be home as early as 36 hours after admission, and frequently are. Grades IV and V are eligible to be discharged after just 24 more hours if they have no other injuries to keep them in the hospital.There are very rare failures.

I’ll detail the factoids about the phlebotomy part of this paper in tomorrow’s post. But I do want to show you the more aggressive protocol the authors are using (one of whom authored the original APSA guideline).

Here it is:

Bottom line: Note how quickly children are allowed to get up, eat, and get out of the hospital using the “new” protocol. Many adult centers have been using similar ones for years. It’s nice to see that adult and pediatric protocols are finally beginning to converge. After all, we figured out our current adult management based on our experience with kids 30 years ago!

Related posts:

Reference: Reducing scheduled phlebotomy in stable pediatric patients with liver or spleen injury. J Ped Surg 49(5):759-762, 2014.

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