Category Archives: Trauma Center

Mechanism, Trauma Center

Trauma Activation For Strangulation: Yes or No?

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Trauma activation criteria generally fall into four broad categories: physiology, anatomy, mechanism of injury, and co-factors. Of these, the first two are the best predictors of patients who actually need to be assessed by the full trauma team. Many trauma centers include a number of mechanistic criteria, usually much to their chagrin. They typically end up with frequent team activations and the patient usually ends up have trivial injuries.

However, there are some mechanisms that just seem like they demand additional attention. Death of another occupant in the vehicle. Fall from a significant height. But what about a patient who has been strangled?

Unfortunately, the published literature gives us little guidance. This usually means that trauma centers will then just do what seems to “make sense.” And unfortunately, this frequently results in significant overtriage, with many patients going home from the emergency department.

Since there is little to know research to show us the way, I’d like to share my thoughts:

  • As a guiding principle, the trauma  team should be activated when the patient will derive significant benefit from it. And the benefit that the team really provides is speed. The team approach results in quicker diagnosis from physical exam and FAST. It gets patients to diagnostic imaging quicker, if appropriate. And gets them to the OR faster when it’s not appropriate to go to CT.
  • Activating for a strangulation mechanism alone is probably a waste of time.
  • Look at the patient’s physiology first. Are the vital signs normal? What is the GCS? If either are abnormal, activate.
  • Then check out the anatomy. If the patient has any voice changes, or has obvious discoloration from bruising, crepitus, or subcutaneous emphysema, call the team. They may suffer a deteriorating airway at any moment.

If physiologic and anatomic findings don’t trigger an activation, then standard evaluation is in order. Here are some things to think about:

  • A complete physical exam is mandatory. This not only includes the neck, but the rest of the body. Strangulation is a common injury from domestic violence, and other injuries are frequently present.
  • If there are any marks on the neck, CT evaluation is required. This includes soft tissue, CT angiography, and cervical spine evaluation. All three can be done with a single contrast-enhanced scan. The incidence of spine injury is extremely low with strangulation, but the spine images are part of the set anyway.
  • CT of the chest is never indicated. There is no possibility of aortic injury with this mechanism, and all the other stuff will show up on the chest x-ray, if significant enough for treatment.
  • Even if there are no abnormalities, your patient may need admission while social services arranges a safe place for their discharge. Don’t forget the social and forensic aspects of this injury. Law enforcement may need photographic evidence or statements from the patient so this event can’t happen again.

Next post: Trauma Activation for Hanging: Yes or No?

Reference: Strangulation forensic examination: best practice for health care providers. Adv Emerg Nurs J 35(4):314-327, 2013.

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Trauma Center

Nonsurgical Admissions And The Nelson Score

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All trauma centers admit some of their patients to nonsurgical services. This usually occurs when patients have medical comorbidities that overshadow their injuries. Unfortunately, the decision-making that goes into balancing the medical versus trauma issues is not always straightforward. The fear is that if trauma patients are inappropriately placed on a nonsurgical service, mortality and morbidity may be higher because their injuries may not receive adequate attention.

To take some of the variability out of the decision-making process for admitting service, two surgical groups on Long Island created a scoring system that incorporated several parameters described in the ACS Optimal Resource Document (Orange book). Some additional parameters were also included that the authors believed were relevant to the choice of admitting service. Here’s the final list:

The paper’s first author was a nurse, Laura Nelson, and hence this has come to be known as the Nelson Score. Patients with a score of 6 or 7 were considered definitely appropriate for nonsurgical admission. Scores of 4 or 5 were subject to more in-depth review, and those with a score of 3 or less were considered definitely appropriate for trauma service admission. There is no mention of what to do with a score of 6 in the original paper, but I presume it should be almost a slam dunk for considering nonsurgical admission.

The authors evaluated this system’s utility over a two year period. They found that using it placed more patients on the trauma service (nonsurgical admissions decreased from a peak of 28% to somewhere around 10%). They also examined morbidity and mortality statistics between the two types of admissions and found no significant differences.

The concept was further tested by the trauma group at UCHealth in Colorado Springs. They performed a retrospective review of four years of data that included over 2,000 patients. Patients were older (mean 79 years) and nearly all had blunt mechanism. Mean ISS was 9 and the nonsurgical admission rate was 19%. Patients with a Nelson score of 6 or 7 were even older and had more comorbidities.

Regression analysis did not identify admitting service as a predictor of mortality. The authors concluded that using this score is a safe way to objectively identify patients who would benefit from nonsurgical admission.

Bottom line: I have visited a number of hospitals that successfully use the Nelson score to assist with admission service decision-making while the patient is still in the emergency department. The only gray zone is the score of 4 or 5. Each program will need to determine their own cut point so they can make the service decision more objectively.

Trauma programs can also use this tool to expedite PI review of patients who have already been admitted to a nonsurgical service to check appropriateness. If the score is less than 6 further scrutiny is needed to determine if a consult from or transfer to trauma should be recommended.

References:

  1. Nonsurgical Admissions With Traumatic Injury: Medical Patients Are Trauma Patients Too. Journal of Trauma Nursing, 25 (3), 192-195, 2018.
  2. Evaluation of the Nelson criteria as an indicator for nonsurgical admission in trauma patients. Am Surg, 88(7), 1537-1540, 2022.
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Trauma Center

When Should You Activate Your Backup Trauma Surgeon?

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The American College of Surgeons requires all US Trauma Centers to publish a call schedule that includes a backup trauma surgeon. This is important for several reasons:

  • It maintains a high level of care when the on-call surgeon is encumbered with multiple critical patients, or has other on-call responsibilities such as acute care surgery
  • It reduces the need to place the entire trauma center on divert due to surgeon issues

However, the ACS does not provide any guidance regarding the criteria for and logistics of mobilizing the backup surgeon. In my mind, the guiding principle is a simple one:

The backup should be called any time a patient is occupying the on-call surgeon’s time to the extent that they cannot manage the care of a newly arrived (or expected to arrive) patient with critical needs that only the surgeon can provide.

There’s a lot of meat in that sentence, so let’s go over it in detail. 

First, the on-call surgeon must already be busy. This means that they are actively managing one or more patients. Depending on the structure of the call system, they may be involved with trauma patients, general/acute care surgery patients, ICU patients, or a combination thereof. Busy means tied up to the point that they cannot meaningfully manage another patient.

Note that I did not say “evaluate another patient.” Frequently, it is possible to have a resident (at an appropriate training level) or advanced practice provider (APP) see the new patient while the surgeon is tied up, say in the operating room. They can report back, and the surgeon can then weigh his or her choices regarding the level of management that will be needed. Or if operating with a chief resident, it may be possible for the surgeon to briefly leave the OR to see the second patient or quickly check in on the trauma resuscitation. Remember, our emergency medicine colleagues can easily run a trauma activation and provide initial care for major trauma patients. They just can’t operate on them.

What if the surgeon is in the OR? Should they call the backup every time they are doing a case at night? Or every time a trauma activation is called while they are doing one? In my opinion, no. The chance of having a highest level trauma activation called is not that high, and as above, the surgeon, resident, or APP may be able to assess how much attention the new patient is likely to need. But recognize that the surgeon may not meet the 15 minute trauma activation attendance requirement set forth by the ACS.

However, once such a patient does arrive (or there is notification that one of these patients is on the way), call in the backup surgeon. These would include patients that are known to, or are highly suspected of needing immediate operative management. Good examples are penetrating injuries to the torso with hemodynamic problems, or those with known uncontrolled bleeding (e.g. mangled extremity).

If two or more patients are being managed by the surgeon, and they believe that they would not be able to manage another, it’s a good idea to notify the backup that they may be needed. This lets them plan their evening better to ensure rapid availability.

Finally, what is the expected time for the backup to respond and arrive at the hospital to help? There is no firm guideline, but remember, your partner and the patient are asking for your assistance! In my opinion, total time should be no more than 30 minutes. If it takes longer, then the trauma program should look at its backup structure and come up with a way to meet this time frame.

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Trauma Center

Trauma Activation Vs. Stroke Code

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Let’s look at an uncommon scenario that crops up from time to time. Most seasoned trauma professionals have seen this one a time or two:

An elderly male is driving on a sunny afternoon, and crashes his car into a highway divider at  25 miles per hour. EMS responds and notes that he has a few facial lacerations, is awake but confused. They note some possible facial asymmetry  and perhaps a bit of upper extremity weakness. No medical history is available. Witnesses state that he was driving erratically before he crashed. Medics call the receiving trauma center in advance to advise them that they have a stroke code.

Is this a reasonable request? Stroke centers pride themselves on the speed of their stroke teams in assessing, scanning, and when appropriate, administering thrombolytics to resolve the problem. But if there are suspicions of stroke in a trauma patient, which diagnosis wins? Trauma team or stroke team?

Lets analyze this a bit further, starting with diagnosis. Remember the first law of trauma:

Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

Could the symptoms that the paramedics are observing be due to the car crash? Absolutely! The patient could have a subdural or epidural hematoma that is compressing a cranial nerve. There might be a central cord injury causing the arm weakness. His TBI might be the source of his confusion. The facial asymmetry could be due to a pre-existing Bell’s palsy, or he could have had a stroke years ago from which he has only partially recovered.

If the stroke team is called for the patient, they will focus on the neuro exam and the brain. They will not think about trauma. They will follow the patient to CT scan looking for the thing that they do best with. If they don’t see it, the patient will return to the ED for (hopefully) a full trauma workup. If there are occult injuries in the abdomen, then the patient may have been bleeding for an hour by then. This elderly patient will then be way behind the eight ball.

And let me pose the worst case scenario. The patient is taken to CT by the stroke team, and lo and behold he has a thrombotic stroke!  This patient had a stroke, which caused him to lose control of his car and explains most of his findings. Again, the stroke team will do what they are trained to do and give a thrombolytic. They are still not thinking about trauma. Within minutes the patient becomes hypotensive and his abdomen appears a bit more distended. He is rushed back to the ED (remember, no CT in hypotensive patients even if you are in the scanner) and a FAST exam is very positive for free fluid throughout the abdomen. Imagine the look you will get from the surgeon as they run to the OR to perform a splenectomy on this fully anticoagulated patient!

Bottom line: Starting a patient encounter with the wrong type of activation can cause major problems. The most common problem is anchoring bias. When a stroke code is called, everyone focuses on the neurologic change that triggered the call. And they stop looking for other things that might call it into question. For example, they might be so intent in calling neurology and getting the patient to CT that they miss the bloody laceration on the back of the scalp.

If you have a patient who is trauma vs stroke, trauma always wins! Remember the first law and try to find traumatic reasons for all signs and symptoms. Perform your standard trauma workup and incorporate the appropriate head scans into your evaluation. Then and only then should the stroke team be called.

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Trauma Center

Adolescent Experience At Pediatric vs Adult Trauma Centers

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A number of papers have addressed the clinical differences between adult trauma centers that provide care for children and pediatric trauma centers. For example, differences in TBI outcomes and solid organ injury management have been noted, to name a few. But I’ve seen very little written on the patient (and parent) experiences at these centers.

Adolescents exist between the adult and pediatric worlds. They frequently suffer injury from adult mechanisms like car crashes, interpersonal violence, and drugs/alcohol. But they are still developing from anatomic, physiologic, and psychosocial standpoints. So which trauma center is better for them? An adult center with more experience managing their injuries, or a pediatric center more attuned to their distinct psychosocial needs?

The surgery group at the University of Calgary in Alberta, Canada, performed a prospective, 1.5 year study of adolescents (aged 15-17) and their caregivers when admitted to the local adult or pediatric trauma center. Enrollees received a survey eight weeks after discharge to glean details of their experience. This survey was a validated tool called the QTTAC-PREM ( Quality of Teen Trauma Care Patient Reported Experience Measure).

This survey was very comprehensive and clocked in at 31 pages in length! It included questions on visits by friends, interactions with hospital staff, schoolwork, pain control, mental health, privacy, and follow-up visits.

Here are the factoids:

  •  A total of 90 patients were enrolled; 51 were admitted to pediatric trauma centers and 39 to adult centers
  • Survey completion rates were reasonable, with 77 returned in the pediatric center group and 41 in the adult center group (surveys could be completed by the patient, their caregiver, or both)
  • Patients taken to the adult center were more seriously injured (56% with ISS>9 vs. 10%)
  • Overall, there were few differences in experience, but parents gave lower ratings for communication, follow-up care, and the overall hospital score
  • The adult trauma centers had poorer family accommodations, as noted by both the patients and their parents

Bottom line: This is a (somewhat) interesting study looking beyond the purely clinical differences in adult vs. pediatric trauma centers. It has some significant problems, although it is still possible to derive some valuable information. 

First, it was a survey. And a 31-page survey at that! I throw most one-page surveys I receive away without a thought. So the enrollment and return rates are guaranteed to be low. Next, it was performed during the height of COVID, which changed everything. Fewer patients presented to the hospitals, and measures were in place, making them less friendly and accessible for patients and their caregivers. This could significantly alter any opinions of patient/parent experiences.

And finally, there are only two trauma centers in Calgary, one adult and one pediatric. So this study cannot be generalized easily to other centers in Canada or anywhere else in the world. In many ways, they are unique. So the actionable information contained in it is very limited. 

However, we can learn something. Communication is always an issue in hospitals. Pediatric centers are very familiar with dealing with parents, and adult centers would benefit by taking this page from their playbooks. Similarly, pediatric centers routinely provide housing for the parents, while adult centers have never had to prioritize this. 

A related question needs to be addressed: what about dual centers? That is, a combined Level I adult and Level I pediatric center. These hybrids are largely ignored, although they are more common in larger metropolitan areas. 

Regardless, ALL trauma centers can benefit from improved communication with their patients and accommodations for parents of pediatric patients.

Reference: Between Paradigms: Comparing experiences for adolescents treated at pediatric and adult trauma centres. Injury, published ahead of print, April 12, 2023.

If you are interested in the QTTAC-PREM questionnaire used in this study, you can find it in the supplemental data for this study:

Yeung M, Hagel BE, Bobrovitz N, Stelfox TH, Yanchar NL. Development of the quality of teen trauma acute care patient and parent-reported experience measure. BMC Res Notes. 2022 Sep 23;15(1):304. doi: 10.1186/s13104-022-06194-x. PMID: 36138467; PMCID: PMC9503226.

If you need help obtaining a copy, please feel free to email me.

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