Most trauma centers have a book of practice protocols or guidelines. Actually, it is required by the American College of Surgeons verification standards. All centers must have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question sometimes arises: why do we need another protocol? Why can’t I do it my own way?
I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols/guidelines.
In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues.
They allow us to build in adherence to any known literature support (evidence based).
They help conserve resources by standardizing care orders and resource use. This means they save money!
They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
They promote team building, particularly when the protocol components involve several different services within the hospital.
They teach a consistent, workable approach. This is especially important to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.
Tomorrow, I’ll write about imaging guidelines, and how they can help avoid VOMIT (victims of medical imaging technology).
Bottom line: It’s interesting that there are so many articles about practice guidelines, but very few explaining why they are important. Although the proof is not necessarily apparent in the literature, protocol and guideline development is important for trauma programs for the reasons outlined above. But don’t develop them just so you can have an encyclopedia of fifty! Identify common problems that can benefit from the consistency they provide. It will turn out to be a very positive exercise and reap the benefits listed above.
A set of guidelines for management of blunt solid organ injury in children developed by the American Pediatric Surgical Association was originally published in 1999. One of the elements of the guideline was to place the child on bedrest for a period of time after the injury. Arbitrarily, this period was defined as the injury grade plus one day. So for a grade 3 spleen injury, the child would have to stay in bed for 4 days (!).
A paper published in 2013 looked at the impact of shortening this time interval. Over a 6 year period, all pediatric liver and spleen injuries from blunt trauma were identified and an abbreviated bedrest protocol was implemented. For low grade injuries (grade 1-2), children were kept in bed for 1 day, and for higher grade injuries this was extended to 2 days.
Here are the factoids:
249 patients were enrolled (about 40 per year) with an average age of 10. “Bedrest was applicable for 199 patients, 80%.” Huh? Does that mean that 50 patients were excluded due to surgeon preference?
The organ injured was about 50:50 for spleen vs liver. Twelve children injured both.
Mean injury grade was 2.7, which is fairly high
Mean bedrest was 1.6 days, and mean hospital stay was 2.5
Bedrest was the limiting factor for hospital stay in 62% of cases
There were no delayed complications of the injury
Bottom line: Come on! Most centers don’t keep adult patients at bedrest this long, and we learned about solid organ injury management from kids! Children almost never fail nonop management, so why treat them more restrictively than adults? And have you ever tried to keep a child at bedrest? Impossible! This study is too underpowered to give real statistically valid results, but it certainly paints a good picture of what works. We recently updated our adult and pediatric protocols to eliminate bedrest and npo status. Let’s get rid of these anachronisms once and for all!
Reference: Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Ped Surg 48(12):2437-2441, 2013.
Here is another one of those papers that have this nicely done abstract that arrives at what seems to be a reasonable conclusion. But then you sit back and think about it. And it’s no longer so reasonable.
This study seems like it should be a good one! It’s a multi-center trial involving data from ten level I trauma centers. The research infrastructure used to collect the data and the statistical analyses for this retrospective review were sound.
Here are the factoids:
Of nearly 15,000 patients with blunt chest trauma, about 6,000 (40%) underwent both chest x-ray and CT
25% (1,454) of these patient had new injuries discovered by the CT
954 were truly occult, only being found on the CT; the remaining 500 scans found more injuries than seen on chest x-ray
202 patients had major interventions (chest tube, ventilator, surgery)
343 had minor interventions (admission, extended observation)
Chest x-ray was not very good at detecting aortic or diaphragm injury (surprise)
76% of the major interventions were chest tube insertions
32% of of patients with new fractures seen were hospitalized for pain control
None of the odds ratios reported were statistically significant
Bottom line: What could possibly go wrong? Ten trauma centers. Six thousand patients. Lots of data points. There are two major issues. First, the primary outcome was a major intervention based on the chest CT. The problem with having so many participating centers is that it is hard to figure out why they performed the interventions. Are they saying that a pneumothorax or hemothorax that was invisible on chest x-ray required a chest tube? Based on whose judgment? Unfortunately, that is a big variable. The authors admit that they did not know whether “interventions based on chest CT were truly necessary or beneficial because we did not study patient outcomes” and that the decisions for intervention “were largely made by residents (usually) or fellows.”
And the secondary outcome was admission or extended observation based on the chest CT. Yet these admissions were primarily for pain management in patients with fractures. Did the patients develop additional pain due to irradiation, or was it there all along?
So adding a chest CT greatly increases the likelihood of doing additional procedures. And it is difficult to tell (from this study) if those procedures were truly necessary. But we know that they can certainly be dangerous. If you back out all of the potentially unnecessary chest tubes and the admissions for pain that should have been admitted anyway, this study demonstrates very little additional value from CT.
A well-crafted imaging guideline will help determine which patients really need CT to identify patients with those occult injuries that are dangerous enough that they can’t be missed. The authors even conclude that “a validated decision instrument to support clinical judgment is needed.”
Reference: Prevalence and clinical import of thoracic injury identified by chest computed tomography but not chesty radiography in blunt trauma: multicenter prospective cohort study. Annals Emerg Med 66(6):589-600, 2015.
Over the past several days, I’ve been writing about updates to our solid organ injury protocol. It eliminates orders for bed rest and NPO diet status afterwards. After looking at our experience over the years, the number of early failures is practically zero. So how many days do you need to keep a patient in bed to make sure they have an empty stomach when they need to be whisked away to the OR. And does walking around really make your injured spleen fall apart?
The answers are none and no. So we’ve updated our protocol at Regions Hospital to reflect this. Feel free to download and modify to your heart’s content. If you want a copy of the Microsoft Publisher file, just email me!
It’s one of those time honored treatments that most hospital-based providers are familiar with. The banana bag, reserved for intoxicated patients presenting to the ED or admitted to the hospital. They’ve been around so long, we just take them for granted. But like most things that have become dogmatic, they are due to be questioned from time to time.
A banana bag is a proprietary mix of “good” stuff, including electrolytes and vitamins, especially thiamine and magnesium. The exact content varies from hospital to hospital. Thiamine and other B vitamins give the resulting solution the characteristic color, hence the term “banana.”
Does it actually do good things like ward off Wernicke’s encephalopathy and megaloblastic anemia? A paper from Jacobi Medical Center in the Bronx prospectively evaluated a series of intoxicated people entering their ED. They drew vitamin B12, folate, and thiamine levels to see if they were deficient enough to even need vitamin supplementation.
These folks (only 77 patients) were very drunk! Average BAC was 280mg/dL.
Vitamin B12 and folate levels were not critically low in any patient
Thiamine was low in 15% of patients, but none had clinical evidence of a deficiency
Later review of prior visits revealed that some patients with low levels had received a previous banana bag within 1 month. Did it do any good?
Bottom line: Most of our intoxicated patients are not vitamin deficient, and don’t need supplementation. The real kicker is that we almost never really try to find out if the patient might be a chronic abuser and potentially at risk. We just hang the bag. Remember, everything we do in medicine has a potential downside. And if the patient really doesn’t need a banana bag in the first place, there is no benefit to balance that risk. The next time you ask for that little yellow bag, think again!
Reference: Vitamin deficiencies in acutely intoxicated patients in the ED. Am J Emerg Med 26(7):729-795, 2008.
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