Tag Archives: guidelines

Guidelines

Guidelines for Consultants to the Trauma Service

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Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are among the most frequent consultants, but a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps ensure quality care and improve communication between caregivers and patients/families.

Here are some guidelines you can provide to your consultants to ensure strong relationships and patient satisfaction.

  • Please introduce yourself to our patient and their family, and explain why you are seeing them.
  • Although you may discuss your findings with the patient, please discuss all recommendations with a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
  • Document your consultation results in the medical record in a timely manner.
  • If additional tests, imaging, or medications are recommended, discuss with the trauma service first. We will write the orders or clear you to do so if appropriate, and will discuss the plan with the patient.
  • We round at specific times every day and welcome your attendance and input.
  • Please communicate any post-discharge instructions to us or enter them in the medical record so we can expedite the discharge process and ensure all follow-up visits are scheduled.

Bottom line: A uniform “code of behavior” is important! Ensuring good patient communication is paramount. They need to hear the same plans from all their caregivers; otherwise, they will lose confidence in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature, and they will not be familiar with how their recommendations may impact other injuries outside their specialty.

Click here to download an editable copy of the Trauma Services consultant guidelines for your use.

Guidelines

Guidelines for Consultants to the Trauma Service

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My last two posts were dedicated to the use of consultants for your trauma patients. Here are my thoughts on best practices in using their services.

Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but various other surgical and medical specialists may be needed. I have found that providing guidelines to consultants helps ensure quality care and good communication between caregivers and patients/families.

We have disseminated guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.

To deliver the highest quality and most cost-effective care, we request that the services we consult do the following:

  • Please introduce yourself to our patient and their family, and explain why you are seeing them.
  • Although you may discuss your findings with the patient, please discuss all recommendations with a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
  • Document your consultation results in writing (paper or EMR) promptly.
  • If additional tests, imaging, or medications are recommended, discuss with the trauma service first. If appropriate, we will write the orders or clear you to do so and discuss the plan with the patient.
  • We round at specific daily times and welcome your attendance and input.
  • Please communicate any post-discharge instructions to us or enter into the medical record so we can expedite the discharge process and ensure all follow-up visits are scheduled.

Bottom line: A uniform “code of behavior” is essential! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers, or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature and will not be familiar with how their recommendations may impact other injuries.

Click here to download a sample Trauma Services consultant guidelines document.

Abdomen

Guidelines For Diagnosis Of Diaphragmatic Injury

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In today’s post, I will review the diaphragmatic injury practice guidelines published by the Eastern Association for the Surgery of Trauma (EAST).  I will follow this up on Friday with an interesting delayed diaphragm injury case.

Diaphragm injury is a troublesome one to diagnose. It is essentially an elliptical sheet of muscle that is doubly curved, so it does not lend itself well to diagnosis by axial imaging. The addition of sagittal and coronal reconstructions to a thoracoabdominal CT has been helpful but still has a far from perfect diagnostic record.

From an evaluation standpoint, there are several possibilities:

  • Observation – not generally recommended. It is usually combined with imaging such as a chest x-ray to see if interval changes occur that would indicate the injury.
  • Chest x-ray – this is not often diagnostic, but when herniation of abdominal contents is obvious, the patient most assuredly has an operative problem.
  • Thoracoabdominal CT scan – this technology keeps improving, especially with thinner cuts and different planes of reconstruction. Sometimes even subtle injuries can be detected. But this exam is still imperfect.
  • Laparoscopy or thoracoscopy – this technique yields excellent accuracy when the injury is in an area that can be viewed from the operative entry point chosen.
  • Laparotomy or thoracotomy – this is the ultimate choice and should be nearly 100% accurate. It is almost the most invasive and has more potential associated complications.

EAST reviewed a large body of literature and selected 56 pertinent papers for their quality and design. Then, they critically reviewed them and applied a standard methodology to answer several questions.

Here are the questions with the recommendations from EAST, along with my comments:

  • Should laparoscopy or CT be used to evaluate left-sided thoracoabdominal stab wounds? First, these patients must be hemodynamically stable and not have peritonitis. If either is present, there is no further need for diagnosis; a therapeutic procedure must be performed.
    Left-sided diaphragm injuries from stabs are evil. The hole is small, and since the pressure within the abdomen is greater than the chest, things always try to wiggle their way through this small hole. It can remain asymptomatic if the wiggler is just a piece of fat, but it can be catastrophic if a bit of the stomach or colon pushes through and becomes strangulated. Furthermore, these holes enlarge over time, so more and more stuff can push up into the chest.
    EAST recommends using laparoscopy for evaluation to decrease the incidence of missed injury. However, if the injury is in a less accessible location (posterior), the patient has body habitus issues or adhesions from previous surgery may lead to incomplete evaluation, laparotomy should be strongly considered.
  • Should operative or nonoperative management be used to evaluate right-sided thoracoabdominal penetrating wounds? Note that this is different than the last question. All penetrating injuries (stabs and gunshots) are included, and this one is for management, not evaluation. And the same caveats regarding hemodynamic stability and peritonitis apply. Again, it applies to both stabs and gunshots.
    Unlike left-sided injuries, right-sided ones are much more benign. This is because the liver keeps anything from pushing up through small holes, and they do not tend to enlarge over time due to this protection. For that reason, EAST recommends nonoperative management to reduce operation-related mortality and morbidity.
  • Should stable patients with acute diaphragm injury undergo repair via an abdominal or thoracic approach? This question applies to any diaphragm injury that requires an operation, such as a right-sided penetrating injury or any blunt injury. EAST recommends an approach from the abdomen to reduce morbidity and mortality. However, since abdominal injury frequently occurs in these cases, an approach from the chest limits the ability to identify and repair abdominal injuries. Otherwise, you may find yourself doing a laparotomy in addition to the thoracotomy.
  • Should patients with delayed visceral herniation through a diaphragm injury undergo repair via an abdominal or thoracic approach?  For years, the preferred approach for delayed presentations has been through the chest because the injury is easier to appreciate and repair.  However, if ischemic or gangrenous viscera are present, it will be more challenging to manage and repair from the chest. EAST does not make a specific recommendation for this question and suggests the surgical approach be determined on a case-by-case basis.
  • Should patients with an acute diaphragm injury from penetrating injury without concern for other intra-abdominal injuries undergo open or laparoscopic repair? The quality and quantity of data addressing this question were very low, but EAST recommends laparoscopy to repair these injuries to reduce morbidity and mortality. This includes blunt injuries, which tend to be larger. There were some conversions to an open procedure, especially in the blunt cases. The usual caveats on exposure, injury location, body habitus, and previous surgery apply.

Reference: Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma 85(1):198-207.

Guidelines

5 Guidelines For Diaphragmatic Injury

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Today’s post is another review of some of the practice guidelines published by the Eastern Association for the Surgery of Trauma (EAST).  This one covers the evaluation and management of diaphragmatic injury.

Diaphragm injury is a troublesome one to diagnose. It is essentially an elliptical sheet of muscle that is doubly-curved, so it does not lend itself well to diagnosis by axial imaging. Addition of sagittal and coronal reconstructions to a thoraco-abdominal CT has been helpful, but still has a far from perfect diagnostic record.

From an evaluation standpoint, there are several possibilities:

  • Observation – not generally recommended. It is usually combined with imaging such as chest x-ray to see if interval changes occur that would indicate the injury.
  • Chest x-ray – this is not often diagnostic, but when herniation of abdominal contents is obvious the patient most assuredly has an operative problem.
  • Thoraco-abdominal CT scan – this technology keeps getting better, especially with thinner cuts and different planes of reconstruction. Sometimes even subtle injuries can be detected. But this exam is still imperfect.
  • Laparoscopy or thoracoscopy – this technique yields excellent accuracy when the injury is in an area that can be viewed from the operative entry point chosen.
  • Laparotomy or thoracotomy – this is the ultimate choice and should be nearly 100% accurate. It is almost the most invasive and has more potential associated complications.

EAST reviewed a large body of literature and selected 56 pertinent papers for their quality and design. They critically reviewed them and applied a standard methodology to answer several questions.

Here are the questions with the recommendations from EAST, along with my comments:

  • Should laparoscopy or CT be used to evaluate left-sided thoraco-abdominal stab wounds? First, these patients must be hemodynamically stable and not have peritonitis. If either is present, there is no further need for diagnosis; a therapeutic procedure must be performed.
    Left sided diaphragm injuries from stabs are evil. The hole is small, and since the pressure within the abdomen is greater that the chest, things always try to wiggle their way through this small hole. It can remain asymptomatic if the wiggler is just a piece of fat, but can be catastrophic if a bit of the stomach or colon pushes through and becomes strangulated. Furthermore, these holes enlarge over time, so more and more stuff can push up into the chest.
    EAST recommends the use of laparoscopy for evaluation to decrease the incidence of missed injury. However, if the injury is in a less accessible location (posterior), the patient has body habitus issues, or adhesions from previous surgery may lead to incomplete evaluation, laparotomy should be strongly considered.
  • Should operative or nonoperative management be used to evaluate right-sided thoraco-abdominal penetrating wounds? Note that this is different than the last question. All penetrating injuries are included (stabs and gunshots), and this one is for management, not evaluation. And the same caveats regarding hemodynamic stability and peritonitis apply. It applies to both stabs and gunshots.
    Unlike left-sided injuries, right-sided ones are much more benign. The liver keeps anything from pushing up through small holes, and they do not tend to enlarge over time due to this protection. For that reason, EAST recommends nonoperative management to reduce mortality and morbidity related to operation.
  • Should stable patients with acute diaphragm injury undergo repair via an abdominal or thoracic approach? This question applies to any diaphragm injury that requires operation, such as right-sided penetrating injury or any blunt injury. EAST recommends an approach from the abdomen to reduce morbidity and mortality. Since abdominal injury frequently occurs in these cases, an approach from the chest limits the ability to identify and repair abdominal injuries. Otherwise, you may find yourself doing a laparotomy in addition to the thoracotomy.
  • Should patients with delayed visceral herniation through a diaphragm injury undergo repair via an abdominal or thoracic approach?  For years, the preferred approach for delayed presentations has been through the chest because the injury is easier to appreciate and repair.  However, if ischemic or gangrenous viscera are present, it will be more difficult to manage and repair from the chest. EAST does not make a specific recommendation for this question and suggests the surgical approach be determined on a case by case basis.
  • Should patients with an acute diaphragm injury from penetrating injury without concern for other intra-abdominal injuries undergo open or laparoscopic repair? The quality and quantity of data addressing this question were very low, but EAST recommends laparoscopy for repair of these injuries to reduce morbidity and mortality. This includes blunt injuries, which tend to be larger. There were some conversions to an open procedure, especially in the blunt cases. The usual caveats on exposure, injury location, body habitus and previous surgery apply.

Reference: Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma 85(1):198-207.

Guidelines

Guidelines for Consultants to the Trauma Service

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This post is a favorite, and I’m publishing it again since I just finished my “When To Call” series.

Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps to ensure quality care and provide good communication between caregivers and patients / families.

We have disseminated a set of guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.

In order to deliver the highest quality and most cost-effective care, we request that services we consult do the following:

  • Please introduce yourself to our patient and their family, and explain why you are seeing them.
  • Although you may discuss your findings with the patient, please discuss all recommendations with a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
  • Document your consultation results in writing (paper or EMR) in a timely manner.
  • If additional tests, imaging or medications are recommended, discuss with the trauma service first. We will write the orders or clear you to do so if appropriate, and will discuss the plan with the patient.
  • We round at specific times every day and welcome your attendance and input.
  • Please communicate any post-discharge instructions to us or enter in the medical record so we can expedite the discharge process and ensure all followup visits are scheduled.

Bottom line: A uniform “code of behavior” is important! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature, and they will not be familiar with how their recommendations may impact other injuries.

Click here to download the full copy of the Regions Hospital Trauma Services consultant guidelines.