Category Archives: Philosophy

The “Egg Timer” Injury

August 15, 2017 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.

Philosophy, Resuscitation

Don’t Just Read The Abstract: CT Scanning The Unstable Patient

July 28, 2017 The Trauma Pro Leave a comment

I’ve said it many times before: “don’t just read the abstract.” They can be misleading, and doing so makes it impossible to see the shortcomings of the research model and the veracity of the conclusions. Yet good trauma professionals do it all the time.

So I’ve selected a recent poster child to demonstrate this tenet. Let’s go over the study details:

This paper is a retrospective, registry review from Japan. The authors point out that one of the long-held rules is to avoid scanning unstable trauma patients in the “tunnel of death.” The authors cite a prior study that did not show an increase in mortality from this practice. So they decided to repeat/confirm it using 11 years of national registry data.

They included all patients who arrived at the trauma center with blood pressure < 90. Interestingly, they excluded patients in frank or near arrest. And finally, patients with critical data points missing were excluded. They used a regression method to control for covariates such as age, ISS, and vitals upon arrival.

Here are the factoids:

Out of nearly 200,000 patients, about 7,000 were initially eligible. About 1,000 were excluded by the criteria above or because they were treated at a low volume facility. Only 5,809 were included in the study and another 500 were excluded because of missing covariates.
The authors found that there were significantly fewer deaths in the group of unstable patients taken to CT (20 fewer per 100 patients) (!!!?)
However, when corrected for confounders, this significant difference went away completely
But the authors conclusion in the abstract was: “We suggest physicians should consider CT as one of the diagnostic options even when patients are unstable.”

Bottom line: What? The study went from showing that taking an unstable patient to CT was amazing for decreasing mortality, to no different after applying more statistical methods. And since there was no difference, why not just go?

Here’s why. In-hospital and 24 hour mortality are not good indicators of anything because there are so many patient and hospital factors involved. And because it was a registry study, there was no way of knowing if the patient was hypotensive at the time they were taken to CT. They could have had a low blood pressure and responded well to resuscitation. Or they could have been normotensive on arrival and became hypotensive before CT scan. There is no way to cleanly identify the correct study group without a prospective study, or a very painstaking retrospective one.

One of the most important aspects of this study is some background info that is not stated in the paper. Surgeon involvement in initial resuscitation in Japan is not nearly as integrated as it is in the US. So if the resuscitating physicians can’t do anything about the bleeding in the ED, why not just scan them while awaiting arrival of the surgeon? If the patient crashes, was it due to the scan, or a delay in getting to the OR?

So don’t just read the abstract. If it seems to be too good to be true, it is. Or at least self-serving. Read the nitty gritty details and decide for yourself!

Next week: more on unstable patients and the CT scanner

Reference: Computed tomography during initial management and mortality among hemodynamically unstable blunt trauma patients: a nationwide retrospective cohort study. Scand J Trauma 25(1):74, 2017.

Philosophy

When Is It Too Late To Call A Trauma Activation?

July 6, 2017 The Trauma Pro Leave a comment

This is a related, follow-on post from yesterday, where I discussed activating your trauma team after transfer from another hospital. What about patients presenting directly to your hospital, but some time after their injury?

Admit it. It’s happened to you. You get paged to a trauma activation, hustle on down to the ED, and get dressed. The patient is calmly and comfortably lying on a cart, staring at you like you’re from Mars. Then you hear the story. He has a grade V spleen injury. But he just got back from CT scan. And his car crash was yesterday!

Is this appropriate? The answer is no! But, as you will see, the answer is not always as obvious as this example. The top thing to keep in mind in triggering a trauma activation appropriately is the reason behind having them in the first place.

The entire purpose of a trauma activation is speed. The assumption must be that your patient is dying and you have to (quickly) prove that they are not. It’s the null hypothesis of trauma.

Trauma teams are designed with certain common features:

A group of people with a common purpose
The ability to speed through the exam and bedside procedures via division of labor
Rapid access to diagnostic studies, like CT scan
Availability of blood products, if needed
Immediate access to an OR, if needed
Recognition in key departments throughout the hospital that a patient may need resources quickly

Every trauma center has trauma activation triage criteria that try to predict which patients will need this kind of speed. Does the patient in the example above need this? NO! He’s already been selected out to do well. Why, he’s practically finished the nonoperative solid organ management protocol on his own at home.

Here are some general rules:

If the patient meets any of your physiologic and/or anatomic criteria, they are or can be sick. Trigger immediately, regardless of how much time has passed.
If they meet only mechanism criteria and it’s been more than 6 hours since the event, they probably do not need the fast track.
If they only meet the “clinician / EMS judgment” criteria, think about what the suspected injuries are based on a quick history and brief exam. Once again, if more than 6 hours have passed and there are no physiologic disturbances, the time for needing a trauma activation is probably past.

If you do decide not to trigger an activation in one of these cases, please let your trauma administrative team (trauma medical director, trauma program manager) know as soon as possible. This may appear to be undertriage as they analyze the admission, and it’s important for them to know the reasoning behind your choice so they can accurately document under- and over-triage.

Philosophy

Do I Have To Call My Trauma Team For Incoming Transfers?

July 5, 2017 The Trauma Pro Leave a comment

I had a great question sent in by a reader last week:

Some trauma centers receive a number of transfers from referring hospitals. Much of the time, a portion of the workup has already been done by that hospital. If the patient meets one or more of your trauma activation criteria, do you still need to activate your team when they arrive?

And the answer is: sometimes. But probably not that often.

Think about it. The reason you should be activating your team is that you suspect the patient may have an injury that demands rapid diagnosis and treatment. The purpose of any trauma activation is speed. Rapid evaluation. Fast lab results. Quick access to CT scan or OR. If a significant amount of time has already passed (transported to an outside hospital, worked up for an hour or two, then transported to you), then it is less likely that a trauma activation will benefit the patient.

There are four classes of trauma activation criteria. I’ll touch on each one and the need to activate in a delayed fashion if present, in priority order.

Physiologic. If there is a significant disturbance in vital signs while in transit to you (hypotension, tachycardia, respiratory problems, coma), then you must activate. Something else is going on that needs to be corrected as soon as the patient arrives. And remember the two mandatory ACS criteria that fall into this category: respiratory compromise/need for an emergent airway, and patients receiving blood to maintain vital signs. But a patient who needed an airway who is already intubated and no longer compromised does not need to be a trauma activation.
Anatomic. Most simple anatomic criteria (e.g. long bone or pelvic fractures) do not need a trauma activation unless the patient is beginning to show signs of physiologic compromise. However, anatomic criteria that require rapid treatment or access to the OR (proximal amputations, mangled or pulseless extremities, spinal cord injury) should be activated.
Mechanism. Most of the vague mechanistic criteria (falls, pedestrian struck, vehicle intrusion) do not require trauma activation after transfer to you. But once again, if the mechanism suggests a need for further rapid diagnosis or treatment (penetrating injury to abdomen), then activate.
Comorbidities. This includes underlying diseases, extremes of age, and pregnancy. In general, these will not require trauma activation after they arrive.

Bottom line: In many cases, the patient transferred in from another hospital will not need to be a trauma activation, especially if they have been reasonably assessed there. The patient should be rapidly eyeballed by your emergency physicians, and if there is any doubt about their condition, activate then.

However, if little workup was done at the outside hospital (my preference), and the injuries are “fresh” (less than a few hours old), then definitely call your team.

Related posts:

Philosophy

Why Did The Trauma Team Cut Off My Clothes?

May 31, 2017 The Trauma Pro Leave a comment

The fifth highest priority taught in the ATLS course is exposure. This generally means getting the patient’s clothes off so any hidden injuries can be identified. Early in my career, I was called to see a patient who had a gunshot to the chest that had been missed because the consulting physician had neglected to cut off her bra. A small caliber wound was found under the elastic strap in her left anterior axillary line after a chest xray showed a bullet in mid-thorax.

The usual trauma activation routine is to cut off the clothes. There are several tips and tricks we use to do this quickly. And a number of commercial products are out there to make it even easier.

But do we really need to cut everyone’s clothes off? I’m not disputing the fact that it’s important to be able to examine every square inch. But do we need to destroy everything our patient is wearing? I once saw a sequined wedding dress cut off (it’s almost as bad as cutting off a down jacket).

The answer is no. The key concept here is patient safety. Can you safely remove the clothing in a less destructive way? For most victims of major blunt trauma, we worry a lot about the spine. Unfortunately, it’s just not possible to allow the patient to wriggle out of their clothes and protect their spine. The same goes for fractures; it may be too uncomfortable to remove clothing because of fracture movement so scissors are required.

Penetrating trauma is a bit different, and in many cases it’s a good idea to try to get the clothing off intact. Once again, if spinal injury is a consideration (gunshots only), the involved clothes should be cut off. A patient with a gunshot to the chest can probably have their pants safely and gently pulled off, but their shirt and coat must be cut.

The police forensic investigators like to have intact clothing, if possible. This is another good reason to try to remove clothing from penetrating injury victims without cutting.

Bottom line: Think before you cut clothes! Major blunt trauma and bad injuries require scissors. Lesser energy blunt injury may allow some pieces of clothing to be removed in the usual method. Most penetrating injury does not require cutting. But if you must (for patient safety), avoid any holes in the fabric so forensics experts can do their job.

Home of the Trauma Professional's Blog