Today is the last day of the annual AAST meeting, so I’ll wind up with one last abstract presented at this meeting.
PTSD can cause significant morbidity after trauma. Most centers manage this problem reactively, when the patient exhibits obvious symptoms in the hospital or after discharge. Wouldn’t it make more sense to screen for it routinely? Is there a way to figure out which patients are at higher risk?
The University of Pittsburgh prospectively screened 1,386 injured patients presenting to their followup clinic using the PTSD Checklist – Civilian (PCL-C) instrument. A score of>=35 has a sensitivity of 85% and was considered a positive result.
The authors found that more than 25% of their outpatient clinic patients met the threshold. The most common mechanism was assault, both blunt and penetrating. Younger age (<55), female gender and motor vehicle crash were also found to be predictors.
Bottom line: Consider routine PTSD screening in patients with the listed risk factors, just like we perform routine TBI screening in patients with head injuries. The PCL-C is self-administered and takes only about 5 minutes to complete. The most reliable way is to send it home with your patient, with instructions to complete it before they see you or their primary physician in the outpatient clinic.
Reference: Predictors of post-traumatic stress disorder (PTSD) following civilian trauma: highest incidence and severity of symptoms after assault. AAST 2011 Annual Meeting, Paper 33.
Most trauma systems set certain prehospital criteria that, when met, direct that patient to a trauma center. It is now well-established that care of these patients results in improved survival if they are managed at those centers. Unfortunately, undertriage is still a problem, meaning that those patients may not always be taken to a hospital most appropriate to care for their injuries. What is the penalty that your patient pays if this happens?
The University of Toronto performed a nice, prospective study across a large region with both urban and rural areas. Database information was analyzed for all victims of motor vehicle crashes who had a severe injury (ISS>15) or who died. Over 6,000 crash victims’ data were analyzed.
Just under half of the victims (45%) were triaged to a trauma center. Of those who were taken to other hospitals, slightly more than half (58%) were transferred to one within 24 hours, but nearly 5% died in the non-trauma center ED. The overall mortality for severely injured patients who were taken to a nontrauma center was 8.7%. This was a 30% increase in adjusted mortality compared to those taken to a trauma center directly.
Bottom line: Follow the rules! EMS authorities and trauma systems should make it a priority to adopt the CDC protocol (see below) or create trauma guidelines based on them that ensure patients with significant injuries are taken directly to a trauma center. Going to the nearest hospital (if it is not a trauma center) or bending to the patient’s preference is not in their best interest (and may kill them)!
Click here to download the Centers For Disease Control and Prevention (CDC) National Trauma Triage Protocol. This should be used as a standard!
Reference: The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis. AAST 2011 Annual Meeting, Paper 50.
For decades, the standard of care for irrigation and debridement (I&D) of open fractures has been within 8 hours of injury. There is a growing body of orthopedic literature that says this isn’t necessarily so.
A paper being presented at the AAST meeting in Chicago next week retrospectively looked at their experience with early (<8hrs) vs late I&D in a series of 248 patients. They looked at infection rates stratified by time and upper vs lower extremity.
They found that the infection rates overall were not significantly different. However, when subgrouped by extremity and higher Gustilo type >= III, they noted that both delayed I&D and Gustilo type correlated with infection risk. For the upper extremity, only Gustilo type >= III correlated with a higher infection rate.
The authors concluded that all lower extremity open fractures should be dealt with in the 8 hour time frame, whereas upper extremity fractures can be delayed for lower Gustilo classes.
Bottom line: I don’t necessarily buy into all the results from this small study. The orthopedic literature has already refined this concept. At Regions Hospital, we allow up to 16 hours to I&D for open fractures up to and including Gustilo class IIIA. Above that, the 8 hour rule is followed. We periodically review our registry data on all open fracture patients to make sure that the extended time frame patients are not experiencing an increase in wound complications. And they haven’t in our 8 year experience in handling them this way.
Refresher on the Gustilo classification system:
- Class I – open fracture, clean wound, <1cm laceration
- Class II – clean wound, laceration >1cm with minimal soft tissue damage
- Class IIIA – clean wound, more extensive soft tissue damage or laceration, periosteum intact, minimal contamination
- Class IIIB – extensive soft tissue damage with periosteal stripping or bone damage, significant contamination
- Class IIIC – arterial injury without regard for degree soft tissue injury
Reference: Open extremity fractures: does delay in operative debridement and irrigation impact infection rates? AAST 2011 Annual Meeting, Paper 22.
Traditional teaching is that we bleed whole blood, and it takes time to pull volume out of the interstitial space to replace it. Therefore, the initial hematocrit should be normal when a fresh, bleeding trauma patient rolls through the doors.
An observation I have made over the years is that this is not necessarily so. A few patients have low initial hemoglobin or hematocrit readings, and they tend to be bleeding briskly from somewhere. A paper to be presented at next week’s AAST meeting in Chicago shows just that.
The authors retrospectively reviewed 198 trauma patients requiring emergency surgery at a Level I trauma center. Patients with lower initial hematocrits tended to have lower systolic blood pressure, lower GCS, lose more blood, and require infusion of more blood products during surgery. They also had a higher ISS and mortality. The biggest jump in these indicators occurred when the Hct dropped below 37.
Bottom line: A low hematocrit on the first blood drawn during trauma resuscitation is more helpful that previously thought. Be sure to check those lab values early, and if the hematocrit value is in the mid-30s or lower, start looking for significant sources of bleeding.
Reference: The initial hematocrit matters in trauma: a paradigm shift? AAST 2011 Annual Meeting, Paper 38.
Injured patients transported to the ED are just the tip of the iceberg. There are some patients who are evaluated by EMS, either at the scene or in their home, but never transported. These patients do not appear in any trauma registry and little information is known about how they do after their evaluation.
Stanford University reviewed county data and found 5,865 patients out of 69,000 who were evaluated by EMS but not transported (3 counties, 3 years of data). Over a quarter (29%) presented to an ED later and 92 were admitted (2% of the total). By linking available vital statistics data, at least 7 were found to have died.
Bottom line: Patients who are evaluated by EMS but ultimately not transported to a hospital may have unsuspected problems. The mortality is very low (0.14%) but these may represent preventable deaths. It is not practical to force everyone to go to the ED. However, it should be cost-effective to at least make a followup call the next day on these select patients to see if they should be urged to get further evaluation in the ED.
Reference: The forgotten trauma patient: outcomes for injured patients evaluated by EMS but not transported. AAST 2011 Annual Meeting, Oral Paper 46.