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How Often Should My Multidisciplinary Trauma PI Committee Meet?
and
How Often Should My Trauma Operations Committee Meet?
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In my last post, I reviewed a simple technique utilizing a reminder card and provider feedback loops to reduce deep intubations in pediatric patients. Today, I’ll review three other techniques and discuss a paper that compared their efficacy.
A variety of techniques for determining and/or confirming endotracheal tube position exist. Use of one or more of them is important in children due to their short trachea and increased likelihood of deep intubation. Some, like the confirmatory chest x-ray, are obvious. However, it’s more desirable to apply techniques during the intubation in order to avoid deep intubation in the first place. Hyperinflation of one lung, especially in very small children, can cause a host of impairments and complications that may compound their other injuries.
A paper from the University Hospital Basel in Switzerland evaluated three techniques: bronchoscopic insertion to a specific depth, cuff palpation in the sternal notch, and intentional right mainstem intubation followed by slow withdrawal during auscultation. Each of 68 children ranging in age from 0 to 4 years were studied using all three techniques.
Each endotracheal tube was marked at the ideal insertion point that would ideally be placed just beyond the vocal cords. The distance from this mark to the mouth end of the tube was measured so actual intubation depths could be compared.
Bronchoscopic insertion was always performed first to obtain a baseline depth measurement, essentially the gold standard. The other two techniques were performed in random order. For the cuff palpation technique, the trachea was palpated while the balloon was intermittently partially inflated until it could be felt at the suprasternal notch. For the mainstem intubation technique, the uninflated tube was advanced until breath sounds in the left axilla disappeared. It was then slowly withdrawn until sounds reappeared.
Distances from the tip of the tube to the carina was calculated using the insertion depth at the incisors and the initial ideal intubation depth mark. Here are the factoids:
Bottom line: What to make of all this? Which technique is “best?” First, it’s not practical or advisable to use a bronchoscope for every pediatric intubation. It’s invasive and adds complexity and time to a critical procedure. The cuff palpation technique also takes additional time due to the repeated cuff inflation/deflation that is required. However, the tube position is fairly accurate and safe.
The intentional right mainstem intubation with pull-back seems a bit sketchy. It requires some type of ongoing ventilation while the tube is being inserted, as well as someone who can listen to the left chest. Additionally, it results in a tube position that is so low that neck positioning may move it into the mainstem bronchus again.
In my mind, estimation of the proper depth pre-intubation is probably the best. Strict attention must be paid to the final depth of the tube once it is inserted, as measured by the distance marker at the incisors. This number must match the one decided upon at the start of the procedure. A good exam of the chest should be carried out to quickly identify an inadvertent mainstem intubation. And finally, a quick confirmatory chest x-ray should always be obtained for objective information on tube position.
The fancy techniques described in this paper add too much time and complexity for intubation in a trauma situation. They may very well have a place in the OR where the situation is more controlled and there is more advanced equipment and support. But stick to the basics when intubating children in your trauma bay!
Reference: Assessment of three placement techniques for individualized positioning of the tip of the tracheal tube in children under the age of 4 years. Ped Anesthesia 25:379-285, 2014.
Mainstem intubation in the pediatric patient is a common problem. There are two major issues: the trachea is shorter than in an adult, and the angles are different making intubation of the right mainstem bronchus much easier. Frequently, the intubator watches the balloon slide between the cords, then pushes the tube in “just a little further.”
Unfortunately, that “little bit” can vary significantly. An abstract from my hospital was presented at the Pediatric Trauma Society in 2016. Subjectively, we noticed that mainstem intubation was occurring with some regularity in our pediatric trauma patients. It seemed as though insufficient attention was being paid to the depth of the tube.
A major difference between adult and pediatric intubations is that in adults, optimal tube depth is locked into a relatively narrow range. In children, the depth varies considerably based upon child age and size. And small variances in depth can have major implications for tube position.
We decided to implement a PI project to change our intubation policy. In order to focus the entire team on tube depth, a color coded card was attached to each size of endotracheal tube. This card listed the optimal depth for insertion. Once the provider inserted the tube, the final depth was called out for the team and documentation scribe to hear. This had the added advantage of allowing multiple team members confirm the appropriateness of tube depth. A chest x-ray was immediately obtained to confirm position.
We retrospectively reviewed our seven year experience with pediatric intubations, from 2009-2015. Here are the factoids:
Bottom line: Unfortunately, this series is too small to determine statistical significance. There is a definite trend toward fewer mainstem intubations. It appears that by calling more attention to the proper tube depth, fewer deep placements occur. Our numbers have remained low since this change.
Are there other methods to ensure proper ET tube placement in small patients? In my next post, I’ll review a paper that compares three additional different techniques that can be used.
Reference: Eliminating the Preventable Occurrence of Right Mainstem Intubation in the Pediatric Trauma Patient: A Quality Performance Improvement (PI) Initiative. Pediatric Trauma Society Poster Abstract #1, 2016.
Every trauma center verified by the American College of Surgeons Committee on Trauma (ACS-COT) must have a massive transfusion protocol (MTP). The details and logistics of the protocol are up to the individual center. The difficult question is: how is a trauma professional to know that the MTP should be activated?
Sometimes it’s extremely obvious. The patient is very hypotensive. Blood is spurting all over the room. But sometimes it’s more subtle and the need just seems to creep up on you. And frequently, this delays activation and the actual arrival of the blood that is so desperately needed.
I’ve previously written about common triggers for the MTP, including psychic powers, shock index, and ABC index. See the links below to read my MTP week posts. But is one better than the other? The group at Vancouver General Hospital in British Columbia, Canada performed a systematic review of the literature to try to answer this question.
A total of 45 pertinent articles were identified in the literature up to 2017. Fifteen different scoring systems were evaluated involving combinations of clinical assessment, laboratory tests, and ultrasound evaluation.
Here are the factoids:
Bottom line: There are many, many systems out there for predicting need for activation of the MTP (at least 15 to date)! This review concludes that the system used should be tailored to the center implementing it.
Simpler is better. I still recommend either Shock Index (SI) or ABC. Shock index is quickly calculated based on physical exam as heart rate divided by systolic blood pressure. The normal range is 0.5 to 0.7. The likelihood of MTP escalates 2x with SI > 0.9, 4x if SI > 1.1, and 7x with SI > 1.3. The ratio can easily be calculated based on numbers available from EMS providers prior to arrival. Basically, pick your threshold.
The Assessment of Blood Consumption (ABC) uses four parameters, three of which could be reported prior to patient arrival:
If two or more criteria are met, the patient has a 41% likelihood of needing MTP.
So basically, use a system that works for you. From my experience, centers that use a system tend to use ABC. But definitely pick a system, don’t leave it up to chance with the trauma surgeon. And use your trauma PI program to assess utilization to see if it’s the best tool for your center.
Related posts:
Reference: Systematic Reviews of Scores and Predictors to Trigger Activation of Massive Transfusion Protocols. Accepted ahead of print, J Trauma, 2019.
Earlier this week, I wrote about a new tool for monitoring over- and under-triage for trauma programs. In place of using ISS as the metric for triggering review, the Need For Trauma Intervention (NFTI) is based on resource utilization during the initial portion of the hospital stay.
The original study was performed at a single Level I trauma center in Dallas. The authors then rolled it out as a multicenter study to test its overall reliability. However, the authors changed the focus in this work. The original paper focused on the development of a new tool to improve upon the evaluation of proper decisions to activate the trauma team. The authors have now extrapolated that their system predicts when a patient’s physiologic reserve is depleted. In turn, this should be the indicator that a trauma activation is needed.
The authors performed a convenience sample of 38 trauma centers around the US. Of these, 25 were adult only, 3, pediatric only, and 10 were combined adult/peds centers. Two years of data were collected from each. Injury severity score (ISS) and revised trauma score (RTS) were calculated for all patients. Outcomes analyzed were discharge location (home vs ongoing care), complications, and length of stay.
A complicated statistical model was adopted that evaluated the associations between higher ISS (> 15), lower RTS (< 7.84) and any positive NFTI factor. To refresh your memory, here’s the list of NFTI factors:
Here are the factoids regarding the new study:
The authors conclude that NFTI was a better indicator of major trauma when compared to ISS and RTS. They claim that it is the best single definition because the model fit is better and that it has stronger associations with complications, discharge location, and length of stay.
Bottom line: Hmm, I’m not so sure. It’s a great idea and does allow us to drill down on those patients most in need of high-level trauma center resources. The authors admit that each tool (ISS, RTS, and NFTI) identifies some important patients that the others do not. It just seems that more of them tend to be identified by NFTI.
I always worry when complicated statistical models are needed to show these differences. This is a complex concept, so more sophisticated models may indeed be needed by virtue of the data that needs to be analyzed. Overtriage can be easily identified in many cases when NFTI- patients trigger a full trauma activation. Obvious undertriage occurs in NFTI+ patients with no activation.
But NFTI still does not obviate the need to search harder for undertriage. What about the case of a stab to the chest in the “box” region, who does not end up with a cardiac injury or hemo/pneumothorax? They would be NFTI- but mechanism positive.
How do we learn from NFTI+ patients who did not have a trauma activation. Just like using the Cribari grid, we must look at each individual chart and ask two questions:
So NFTI is a somewhat improved version of the Cribari grid. Sure, it can predict complications better, as well as length of stay (which may be related). But not discharge location, as claimed. As for being an indicator of depleted patient reserve, I think that’s just speculation at this point. Both tools can be used to automatically generate data for review from the trauma registry. And both will have some false negatives and positives.
My recommendation: This paper provides an academic argument that NFTI is somewhat better than the Cribari method. Now it’s time to get practical. Some enterprising trauma centers need to do a study where they use both systems side by side. How many charts for review are generated by each? How many false negatives and positives are there? How much work (abstractor / registrar time) is needed to analyze and act on the results? This is the only way we can answer the question of which one is better in the real world.
Reference: Rethinking the definition of major trauma: The Need For Trauma Intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers. J Trauma publish ahead of print, 2019.