All US trauma centers verified by the American College of Surgeons are required to have clinical practice guidelines (CPG). Trauma centers around the world generally have them, but may not be required to by their designating authority. But don’t confuse a policy about clinical management, say for head injury, with a real CPG. Policies are generally broad statements about how you (are supposed to) do things, whereas a CPG is a specific set of rules you use when managing a specific patient problem.
- Look around; don’t reinvent the wheel! This is the first mistake nearly every center makes. It seems like most want to spend hours and hours combing through the literature, trying to synthesize it and come up with a CPG from scratch. Guess what? Hundreds of other centers have already done this! And many have posted theirs online for all to see and learn from. Take advantage of their generosity. Look at several. Find the one that comes closest to meeting your needs. Then “borrow” it.
- Review the newest literature. Any existing CPG should have been created using the most up to date literature at the time. But that could have been several years ago. Look for anything new (and significant) that may require a few tweaks to the existing CPG.
- Create your draft, customizing it to your hospital. Doing things exactly the same as another center doesn’t always make sense, and it may not be possible. Tweak the protocols to match your resources and local standards of care. But don’t stray too far off of what the literature tells you is right.
- Make sure it is actionable. It should not be a literature summary, or a bunch of wishy-washy statements saying you could do this or consider doing that. Your CPG should spell out exactly what to do and when. (see examples below)
- Get buy-in from all services involved. Don’t try to implement your CPG by fiat. Use your draft as a launching pad. Let everyone who will be involved with it have their say, and be prepared to make some minor modifications to get buy-in from as many people as possible.
- Educate everybody! Start a campaign to explain the rationale and details of your CPG to everyone: physicians, nurses, techs, etc. Give educational presentations. You don’t want the eventual implementation to surprise anyone. Your colleagues don’t like surprises and will be less likely to follow along.
- Roll it out. Create processes and a timeline to roll it out. Give everyone several months to get used to it.
- Now monitor it! It makes no sense to implement something that no one follows. Create a monitoring system using your PI program. Include it in your reports or dashboards so providers can see how they are doing. And if you really want participation, let providers see how they are doing compared to their colleagues. Everyone wants to be the top dog.
Some sample CPGs:
I still encounter a quite a bit of confusion about ED thoracotomy: when to do it, when to stop. A nice set of guidelines was developed by the Subcommittee on Outcomes of the American College of Surgeons Committee on Trauma about 10 years ago. And really, things haven’t changed very much since then.
In general, the literature on this topic has been all over the place. Most studies are retrospective with very little statistical validation. But there’s a lot of it out there. The subcommittee used fairly standard methods to evaluate the literature and come up with some recommendations.
The overall survival rate for all comers was 8% (11% for penetrating, 1.6% for blunt). About 15% of survivors (no breakdown of blunt vs penetrating) suffered from neurologic impairment. Penetrating cardiac injury had the best survival (31%). In the 4 studies on children, the survival numbers paralleled the adults.
Because of the relatively weak quality of the data, only level II recommendations were given. They were:
- Don’t consider ED thoracotomy in blunt trauma patients unless the patient arrests in front of you. Otherwise, meaningful survival is almost nonexistent.
- Consider ED thoracotomy for penetrating chest injury if there were witnessed signs of life and a short transport time (5-10 minutes max, in my opinion). Look for pupillary response, spontaneous respirations, palpable pulse, or a narrow complex cardiac rhythm.
- ED thoracotomy for penetrating abdominal injuries has a low survival rate, but can be considered if the injury may involve the chest.
- Consider thoracotomy for suspected abdominal vascular injury, but survival is also very low.
- The guidelines above apply equally to children.
Practical tips: ED thoracotomy is a seldom used and dangerous procedure. There are many opportunities for injury to trauma professionals, so be selective and take precautions. Assign someone to run the chemical code while the surgeons open the chest. Watch out for broken ribs and scalpels gone wild!
I’ll post pictures and specific pointers over the next three days.
Reference: Practice management guidelines for emergency department thoracotomy. JACS 193(3):303-309, 2001.
The Eastern Association for the Surgery of Trauma is in the process of updating their trauma practice guidelines for spleen injury. The first set of guidelines was introduced in 2003, and several advances in management have occurred since. here is a summary of the current status of the guidelines:
Level I recommendations (best quality data):
Level II recommendations (good data):
- Initial management of hemodynamically stable patients should be nonoperative
- Unstable patients should undergo immediate operation or angiographic embolization (my interpretation: unstable patients belong in the OR, not the angio suite!)
- Patients with peritonitis should go to the operating room
- Age, grade of injury, amount of hemoperitoneum and age are not contraindications to nonoperative management. Only hemodynamic stability matters.
- CT of the abdomen with IV contrast is the most reliable method to assess severity of spleen injury (my interpretation: in the hemodynamically stable patient)
- Angiography with embolization should be considered if a contrast blush is seen on CT, AAST grade > 3, moderate hemoperitoneum is present, or there is evidence of ongoing bleeding
- Nonoperative management should only be considered if continuous monitoring and serial exams can be carried out at your hospital, and if an operating room is immediately available if needed
Level III recommendations (weak data):
- Clinical status should dictate need and frequency of followup imaging (my interpretation: only do it if the patient condition changes for the worse)
- Contrast blush is not an absolute indication for operation or angio-embolization. Age, grade of injury and presence of hypotension need to be considered. (My interpretation: don’t operate or do angio on kids without a really good reason)
- Angio is an adjunct to nonop management in patients who are at high risk for delayed bleeding or to look for vascular injuries (pseudoaneurysms) that may lead to rupture or delayed hemorrhage
Reference: Trauma Practice Guideline Update, 24th Annual Scientic Assembly, Eastern Association for the Surgery of Trauma, January 2011.
The EAST Practice Management Guideline on management of geriatric trauma was updated early this year. This post gives the details of the proposed changes. Click here to open a copy of the existing PMG for comparison.
- Level II – Injured patients with advanced age (>=65) and pre-existing medical conditions (PECs) should lower the threshold for field triage directly to a designated/verified trauma center.
- Level II – With the exception of patients who are moribund on arrival, an initial aggressive approach should be pursued with the elderly patient.
- Level III – Patients 70 years of age or greater should receive care under the structure of the highest level of trauma activation and receive liberal application of invasive monitoring.
- Level III – Elderly patients with at least one body system with an AIS >= 3 should be treated in designated trauma centers, preferably in ICUs staffed by surgeon-intensivists.
- Level III – In patients 65 years of age or older with a GCS < 8, if substantial improvement in GCS is not realized within 72 hours of injury, consideration should be given to limiting further aggressive therapeutic interventions.
Head injury and anticoagulation
- Level III – All patients who receive daily therapeutic anticoagulation should have appropriate assessment of their coagulation profile as soon as possible after admission. Those with suspected head injury should be evaluated with head CT as soon as possible after admission. Patient receiving warfarin with post-traumatic intracranial hemorrhage should receive initiation of therapy to correct their INR to normal range within 2 hours of admission.
Base deficit for triage
- Level III – Base deficit measurements may provide useful information in determining status of initial resuscitation and risk of mortality for geriatric patients. ICU admission should be considered for patients >=65 with an initial base deficit >= -6.
Deleted guidelines – the following have been recommended for deletion from the PMG.
- Attempts should be made to optimize cardiac index > 4L/min/M2 and/or oxygen consumption index of 170 cc/min/M2.
- Complications negatively impact survival. Specific therapies to reduce complications should lead to optimal outcomes.
- Admission trauma score < 7 is associated with 100% mortality and aggressive therapeutic interventions should be limited.
- Admission respiratory rate < 10 is associated with 100% mortality and aggressive therapeutic interventions should be limited.
This preliminary EAST Practice Management Guideline was presented and discussed at the 23rd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma.
The EAST practice guideline regarding evaluation of blunt abdominal trauma was first published in 2001. It was updated by performing a new literature search spanning 1998 to 2009. A total of 33 new articles were reviewed to provide material for the revised guideline. As usual, the number of high quality references (3 Class I and 11 Class II) were outnumbered by lower quality Class III references (19).
For information on classes of data and levels of recommendations, please refer to the Primer on Evidenced Based Medicine on the EAST website.
Important: These guidelines are preliminary and may undergo further minor revision, so the final version may be slightly different than described here!
The Level I recommendations remained basically the same, with one modification (bolded below):
- FAST may be considered as the initial diagnostic modality to exclude hemoperitoneum.
- Exploratory laparotomy is indicated in hemodynamically unstable patients with a positive FAST. In hemodynamically stable patients with a positive FAST, follow-up CT scan permits nonoperative management of select injuries.
- Exploratory laparotomy is indicated for patients with a positive DPL and hemodynamic instability.
There was some interesting discussion about the continued utility of DPL. Some audience members felt that this was an outdated technique. Others pointed out that not all surgeons work in a Level I or II trauma center, and that FAST may not be available to them, so the technique remains relevant. Additionally, these guidelines may be used abroad where more advanced diagnostic testing is not as readily available, so it was recommended that the DPL language be retained.
The Level II recommendations are:
- When DPL is used, clinical decisions should be made on the basis of the presence of gross blood on initial aspiration (i.e. 10ml) or microscopic analysis of lavage effluent.
- Surveillance studies (i.e. DPL, CT scan, repeat FAST) should be considered in hemodynamically stable patients with indeterminate FAST results.
- CT scanning is recommended for the evaluation of hemodynamically stable patients with equivocal findings on physical examination, associated with neurologic injury, or multiple extra-abdominal injuries. Under these circumstances, patients with a negative CT should be admitted for observation.
- CT scanning is the diagnostic modality of choice for nonoperative management of solid visceral injuries.
- In hemodynamically stable patients, DPL and CT scanning are complementary diagnostic modalities.
- Contrast enhanced ultrasound (CEUS) is more sensitive than non-contrast ultrasound in the detection of solid organ injury. Many members of the audience were not familiar with this technique. I will comment on it in a later blog entry.
- In the patient at high risk for intra-abdominal injury (e.g. multiple orthopedic injuries, severe chest wall trauma, neurologic impairment) a CT scan should be considered in hemodynamically stable patients, even after a negative FAST.
Finally, the Level III recommendations are:
- Objective testing (i.e. FAST, DPL, CT scanning) is indicated for patients with abnormal mentation, equivocal findings on physical examination, multiple injuries, concomitant chest injury, or hematuria.
- Patients with seat belt sign should be admitted for observation and serial physical examination. The presence of intraperitoneal fluid on FAST or CT scan in a patient with seat belt sign suggests the presence of an intra-abdominal injury that may require surgery.
- CT scanning is indicated for suspected renal injuries.
- In hemodynamically stable patients with a positive DPL, a CT scan should be considered, especially in the presence of pelvic fracture or suspected injuries to the genitourinary tract, diaphragm or pancreas.
- Patients with free fluid and no solid organ injury on CT should be considered for laparotomy. Alternatively, laparoscopy or DPL may aid in diagnosis of bowel injury. Patients with no head injury and clear mentation may be followed by serial exams.