Tag Archives: trauma activation

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.

Philosophy

Do I Have To Call My Trauma Team For Incoming Transfers?

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Some trauma centers receive a significant number of transfers  from referring hospitals. Much of the time, a portion of the workup has already been done by the outside hospital. If the patient meets one or more of your trauma activation criteria, do you still need to activate your team when they arrive?

And the answer is: sometimes. But probably not that often.

Think about it. The reason you should be activating your team is that you suspect the patient may have an injury that demands rapid diagnosis and treatment. The purpose of any trauma activation is speed. Rapid evaluation. Fast lab results. Quick access to CT scan or OR. If a significant amount of time has already passed (transported to an outside hospital, worked up for an hour or two, then transported to you), then it is less likely that a trauma activation will benefit the patient.

There are four classes of trauma activation criteria. I’ll touch on each one and the need to activate in a delayed fashion if present, in priority order.

  • Physiologic. If there is a significant disturbance in vital signs while in transit to you (hypotension, tachycardia, respiratory problems, coma), then you must activate. Something else is going on that needs to be corrected as soon as the patient arrives. And remember the two mandatory ACS criteria that fall into this category: respiratory compromise/need for an emergent airway, and patients receiving blood to maintain vital signs. But a patient who needed an airway who is already intubated and no longer compromised does not need to be a trauma activation.
  • Anatomic. Most simple anatomic criteria (e.g. long bone or pelvic fractures) do not need a trauma activation unless the patient is beginning to show signs of physiologic compromise. However, anatomic criteria that require rapid treatment or access to the OR (proximal amputations, mangled or pulseless extremities, spinal cord injury) should be activated.
  • Mechanism. Most of the vague mechanistic criteria (falls, pedestrian struck, vehicle intrusion) do not require trauma activation after transfer to you. But once again, if the mechanism suggests a need for further rapid diagnosis or treatment (penetrating injury to abdomen), then activate.
  • Comorbidities. This includes underlying diseases, extremes of age, and pregnancy. In general, these will not require trauma activation after they arrive.

Bottom line: In many cases, the patient transferred in from another hospital will not need to be a trauma activation, especially if they have been reasonably assessed there. The patient should be rapidly eyeballed by your emergency physicians, and if there is any doubt about their condition, activate then.

However, if little workup was done at the outside hospital (my preference), and the injuries are “fresh” (less than a few hours old), then definitely call your team. 

And finally, if the patient meets any of the ACS hard criteria for activation (this includes hypotension, transfusing blood, and respiratory compromise), don’t hesitate to trigger the activation!

Trauma Center

What GCS Should Trigger Trauma Activation?

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For the most part, trauma centers are free to pick and choose their own trauma team activation trigger criteria. Typically, these are a mix of physiologic, anatomic, and mechanistic items. However, the American College of Surgeons Committee on Trauma mandates that either seven (Orange Book) or eight (Gray Book) specific criteria must present in every center’s highest-level activation list.

One of these mandatory criteria is a Glasgow Coma Scale (GCS) score of eight or less. The reason is that this level denotes a severe brain injury and as patients approach it they are less and less able to protect their own airway. Although this specific GCS is a minimum, centers are free to choose their own specific threshold as long as it is not any lower.

How does a center choose the “right” GCS? It seems straightforward, right? A mild TBI is defined as GCS from 13-15. These patients have only lost one or two points in their eye-opening, verbal, and motor scores and are relatively unlikely to have a significant lesion in their head or an airway issue.

At the other end of the spectrum is the severe TBI, with a GCS of 3-8. These are a chip shot, with the potential for severe injury and a frequently threatened airway. They demand rapid assessment and intervention, hence the required trauma activation.

But what about those patients with moderate TBI with a GCS from 9-12? They obviously have a higher risk for serious intracranial injury. And as the GCS declines, the patient’s ability to protect their airway decreases. At some point between those GCS scores, most clinicians hit their own internal trigger to provide a definitive airway.

So what do actual trauma centers choose as their threshold? I conducted an informal survey of my readers, asking them to provide their specific GCS threshold.

Here are the factoids:

  • A total of 147 trauma centers of all levels responded
  • They were located in the United States, Germany, Saudi Arabia, and Singapore
  • This chart shows the number of centers that selected a threshold less than or equal to the GCS on the horizontal axis:

 

  • Nearly a third of centers (30%) adhere strictly to the ACS criterion of 8
  • Another 22% use a threshold of 9, possibly to avoid any confusion from having a “less than or equal to” criterion
  • There is another bump on the curve at 13, with 20% using this threshold

Bottom line: A little more than half of centers use a GCS threshold of 8 or 9 as their TTA trigger. This meets the ACS criteria, but could potentially leave a few airways unprotected from time to time. Only about 5% of centers use the higher GCS levels with the exception of GCS 13. That seems to be another popular one.

Which one is right for you? GCS 8 will always work because it is the minimum requirement. My own personal threshold trends higher. I would rather be called to an activation and apply my own judgement rather than come running only when the patient needs to be intubated followed by a trip to the OR for craniotomy.

You will need to work with your emergency physicians, trauma surgeons, and neurosurgeons to determine their collective comfort levels. It comes down to a balance between safety and unnecessary intubation. Look at your own center’s experience and pick a threshold that achieves a proper balance of overall patient safety.

Guidelines

Best Practice: Use of CT Scan In Trauma Activations – Part 2

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In my last post, I described how the unscheduled and random use of CT scan in trauma activations can interfere with normal radiology department workflow, creating access problems for other emergency and elective patients. Today, I’ll detail a project implemented at my hospital to analyze the magnitude of this problem and try to resolve it.

We started with a detailed analysis of how the scanner was being used for trauma activation patients. Regions Hospital has a single-tier trauma activation system, with no mechanism of injury criteria other than penetrating injury to the head, neck, and torso. There were usually about 850highest-level activations per year at the time, and traditionally the CT scanner had been “locked down” when the activation is announced. The CT techs would complete the current study on the table, then hold the scanner open until called or released by the trauma team.

Since we are a predominantly blunt trauma institution, we scan most stable patients. Our average time in the trauma bay is a bit less than 20 minutes. Add this time to the trauma activation prenotification time of up to 10 minutes, and the scanner has the potential to sit idle for up to half an hour. And in some cases when scan is not needed (minor injuries, rapid transport to OR) the techs were not notified and were not aware they could continue scanning their scheduled cases.

A multidisciplinary group was created and started with direct observation of the trauma activation process and a review of chart documentation and radiology logs. On average it was calculated that the scanner was held idle for an average of 17.9 minutes too long. This is more than enough time to complete one, or even two studies!

A new process was implemented that required the trauma team leader to call out to the ED clerk placing orders for the resuscitation 5 minutes before the patient would be ready for scan. I still remember the first time this happened to me. I was so used to just packing up and heading to scan, I got a little irritated when told that I hadn’t made the 5-minute call. But it’s a good feedback loop, and I never forgot again!

We studied our workflow and results over a 9-week period. And here are the factoids:

  • The average CT idle time for trauma activations before the project was 17.9 minutes
  • This decreased to an average idle time of 6.4 minutes during the pilot project
  • Total idle time for all activations was 8.3 hours, but would have been 36 hours under the old system
  • A total of 28.6 hours were freed up, which allowed an additional 114 patients to be scanned while waiting for the trauma activation patients

This was deemed a success, and the 5-minute rule is now part of the routine flow of our trauma activations. We rarely ever have to wait for CT, and if we do it’s usually due to the team leader not thinking ahead.

Bottom line: This illustrates the processes that should be used when a quality problem surfaces in your program:

  • Recognize that there is a problem
  • Convene a small group of experts to consider the nuances
  • Generate objective data that describes the problem in detail
  • Put on your thinking caps to come up with creative solutions
  • Test the solutions until you find one that shows the desired improvement
  • Be prepared to modify your new systems over time to ensure they continue to meet your needs
Guidelines

Best Practice: Use of CT Scan In Trauma Activations – Part 1

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Computed tomography is an essential part of the diagnostic workup for many trauma patients. However, it’s a limited resource in most hospitals. Only so many scanners are affordable and available.  Typically, trauma centers have a scanner located in or very near the trauma bay, which makes physical access easy. Others may be located farther away, which can pose logistical and safety issues for critically injured patients.

Even if the CT is close to the ED, availability can be an issue. This availability applies not only to trauma scans, but to others as well. There is an expectation that CT be immediately available when needed for trauma activation patients. However, chances are that the same scanner is also used for high priority scans for services other than trauma, such as stroke evaluation.

Who gets the scanner first? Obviously, many trauma patients need rapid diagnosis for treatment of their serious injuries. But a fresh stroke patient also has a neurologic recovery countdown clock running if they might be eligible for lytic administration.

And don’t forget that trauma and stroke aren’t the only services vying for that scanner. The hospital undoubtedly has a stream of elective scans queued up for other in-house patients. Every urgent or emergent scan needed for trauma sets the elective schedule back another 30 minutes or more.

How does your trauma center manage CT scan usage for trauma? The vast majority essentially lock it down at some fixed point. This is typically either upon trauma activation, or at patient arrival. The former is very common, but also very wasteful because there can be a significant wait for the patient to actually arrive. Then add on the time it takes to complete the trauma bay evaluation. Up to an hour may pass, with no throughput in the CT scanner. This can be a major work flow headache for your radiology department.

Is there another way? My center was one of those that stopped the scanner after the current patient was finished at the time the trauma activation was called. We have two scanners just 30 feet from the trauma bays, so one could continue working while the other was held. However, this cut their throughput by 50% for roughly half an hour. We recognized that this was a creating a problem for the whole hospital, so we worked with the radiology department to come up with a better way.

In my next post I’ll detail the new system we implemented, and provide data showing the real impact of this new system on CT scan productivity.