Tag Archives: trauma activation

The Trauma Activation Pat-Down?

Yes, this is another one of my pet peeves. During a trauma activation, we all strive to adhere to the Advanced Trauma Life Support protocols. Primary survey, secondary survey, etc. Usually, the primary survey is done well.

But then we get to the secondary survey, and things get sloppy.

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The secondary survey is supposed to be a quick yet thorough physical exam, both front and back. But all too often it’s quick, and not so thorough. There is the usual laying on of the hands, but barely. Abdominal palpation is usually done well. But little effort is put into checking stability of the pelvis. The extremities are gently patted down with the hope of finding fractures. Joints are slightly flexed, but not stressed at all.

Is it just a slow degradation of physical exam skills? Is it increasing (and misguided) faith in the utility of the CT scanner? I don’t really know. But it’s real!

Bottom line: Watch yourself and your team as they perform the secondary survey! Your goal is to find all the injuries you can before you go to imaging. This means deep palpation, twisting and trying to bend extremities looking for fractures, stressing joints looking for laxity. And doing a good neuro exam! Don’t let your physical exam skills atrophy! Your patients will thank you.

Best Practice: Laundry Basket In The Resus Room?

How do you get patients out of their clothes during a trauma resuscitation? Most of the time, I bet your answer is “with a pair of scissors.” And once they are off, what do you do with them? Admit it. You just throw them on the floor. And sometime later, someone’s job is to find it all, put it in a bag, and store it or hand it over to the police.

There are more problems than you might think with this approach. First, and most importantly to the patient, their stuff can get lost. Swept up with all the other detritus from a trauma activation. And second, their belongings may become evidence and it’s just been contaminated.

So here’s an easy solution. Create a specific place to put the clothes. Make it small, with a tiny footprint in your trauma room. Make it movable so it can be kept out of the way. And make sure it is shaped so it can contain a large paper bag to preserve evidence without contamination.

And here’s the answer:

Yes, it’s a plain old laundry basket. The perfect solution. And best of all, these are dirt cheap when you are used to seeing what hospitals charge for stuff. So your ED can buy several ($14.29 ea on Amazon.com) in case they can’t be cleaned anymore or just disappear.

The ACS “Gang Of 6” Trauma Activation Criteria

For more than 10 years, all trauma centers verified by the American College of Surgeons (ACS) have been required to have a group of mandatory criteria for their highest level of trauma activation. I call these the gang of 6 (ACS-6). They are:

  1. Hypotension (systolic < 90 torr for adults, age specific for children)
  2. Gunshot to neck, chest, abdomen or extremities proximal to elbow or knee
  3. GCS < 9 from trauma
  4. Transfer patients receiving blood to maintain vital signs
  5. Intubated patients from scene or patients with respiratory compromise transferred in (may already be intubated but still having compromise)
  6. Emergency physician discretion

For the most part, it seems obvious that any one of these criteria would indicate a seriously injured patient needing rapid trauma team evaluation. But do all centers use these criteria?

The answer, detailed in a recently published paper, would seem to be no! Researchers at the Universities of Minnesota and Michigan looked at the Trauma Quality Improvement Program database for all Level I and II centers in Michigan over a three year period. They specifically analyzed the data to determine how many centers used all 6 criteria, and any differences in mortality between those that did and those that didn’t. They reviewed records for adults with blunt and penetrating trauma with an ISS > 5.

Here are the factoids:

  • More than 50,000 patient records were reviewed, and 12% met at least one of the ACS-6
  • Only 66% of patients with at least one ACS-6 criterion were full trauma activations (!!)
  • Compliance was poorest with hypotension (only half activated), compared to intubation (75%), central gunshot (75%), and coma (82%)
  • 79% of patients meeting any ACS-6 criterion needed an intervention, with a third going emergently to the OR
  • Undertriaged patients (ACS-6 with no high level activation) were significantly more likely to die (30% vs 21%), and this was most pronounced in the coma group (47% vs 40%)

Bottom line: Physiologic trauma activation criteria are important, as is the central gunshot one! Although this is a database review subject to the usual flaws (retrospective, data accuracy), the numbers are large and the statistics are sound. And remember, this is an association study, so we don’t really know why the mortality numbers were different, just that they were.

Nevertheless, there is a lot to learn from it. Why don’t all centers use the ACS-6? They certainly have them in their criteria list, or they would have failed their verification visit. It’s because of undertriage! How does this happen? Two ways: either the information in the field is incorrect (GCS may be incorrectly estimated, hypotension may be transient), or personnel in the ED failed to activate properly.

This study shows the importance of rigidly adhering to the criteria. It found a 20% mortality reduction if all of the ACS-6 were applied properly. So make sure that your own trauma program regularly monitors for undertriage, especially with respect to the “gang of 6”!

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Reference: Noncompliance with American College of Surgeons Committee on Trauma recommended criteria for full trauma team activation is associated with undertriage deaths. J Trauma 84(2):287-294, 2018.

ACS Trauma Abstracts #3: Using Mechanism Criteria To Activate The Trauma Team

Most US trauma centers have two tiers of trauma activation. The higher tier is typically called for physiologic derangements like hypotension, tachypnea, or decreased mental status. This triggers arrival of the full trauma team for rapid assessment and management.

The second tier is reserved for patients who may be less seriously injured and usually results in a reduced team. And depending on how good the activation criteria for this tier are, many patients eventually turn out to have no serious injuries and are discharged from the emergency department. This is the purest form of overtriage, and if it occurs frequently, can wear down your trauma team and waste resources.

Criteria for the second tier trauma activation may include mechanism of injury criteria such as ejection, pedestrian struck, intrusion into the passenger compartment, death at the scene, and other similar criteria. They sound like good criteria, but how helpful are they, really? The group at Baylor University Medical Center in Dallas performed a retrospective review of their trauma activations over a one and a half year period to test the efficacy of some of these criteria. They had recently added some mechanism-based criteria to their second tier activations.

Here are the factoids:

  • During the study period, they had 1325 second tier activations, and 603 were based on mechanism criteria
  • The mean injury severity score of mechanism-based criteria was only 5, versus 10 for anatomic criteria (significant)
  • A whopping 37% of mechanistic criteria patients were discharged home from the ED, versus only 10% for other criteria (also significant)
  • Second tier activations for physician discretion were just as good as non-mechanism criteria, with an ISS of 10 and 13% discharged home
  • Looking at specific criteria, compartment intrusion, ejection, and death in the compartment appeared to be the major overtriage offenders, with an ISS of 5 and 40% discharge rate
  • Incidentally, penetrating injury proximal to knee or elbow had very high overtriage rates, with an ISS of 1 and discharge rate of 48%

Bottom line: Trauma centers are encouraged to review their trauma triage criteria periodically, especially when overtriage rates are high. This center is presenting a nice paper that shows the benefit of doing this. They identified four mechanistic criteria that do not appear to be any better than just relying on physician discretion. What they are not saying is that it is probably better to rely on physiologic and anatomic criteria, as well as physician discretion, to determine which level of trauma activation to trigger.

And incidentally, the new ACS highest-level criterion of gunshot proximal to knee or elbow may not be everything its cracked up to be. It’s difficult to say for sure because stabs and gunshots were not separated out in this abstract, and the number they encountered was not specified. But it certainly suggests this criterion needs some fine-tuning as well.

Reference: Intrusion, ejection, and death in the compartment: mechanism-based trauma activation criteria fail to identify seriously injured patients. JACS 225(4S1):S56, 2017.

When Is It Too Late To Call A Trauma Activation?

This is a related, follow-on post from yesterday, where I discussed activating your trauma team after transfer from another hospital. What about patients presenting directly to your hospital, but some time after their injury?

Admit it. It’s happened to you. You get paged to a trauma activation, hustle on down to the ED, and get dressed. The patient is calmly and comfortably lying on a cart, staring at you like you’re from Mars. Then you hear the story. He has a grade V spleen injury. But he just got back from CT scan. And his car crash was yesterday!

Is this appropriate? The answer is no! But, as you will see, the answer is not always as obvious as this example. The top thing to keep in mind in triggering a trauma activation appropriately is the reason behind having them in the first place.

The entire purpose of a trauma activation is speed. The assumption must be that your patient is dying and you have to (quickly) prove that they are not. It’s the null hypothesis of trauma.

Trauma teams are designed with certain common features:

  • A group of people with a common purpose
  • The ability to speed through the exam and bedside procedures via division of labor
  • Rapid access to diagnostic studies, like CT scan
  • Availability of blood products, if needed
  • Immediate access to an OR, if needed
  • Recognition in key departments throughout the hospital that a patient may need resources quickly

Every trauma center has trauma activation triage criteria that try to predict which patients will need this kind of speed. Does the patient in the example above need this? NO! He’s already been selected out to do well. Why, he’s practically finished the nonoperative solid organ management protocol on his own at home.

Here are some general rules:

  • If the patient meets any of your physiologic and/or anatomic criteria, they are or can be sick. Trigger immediately, regardless of how much time has passed.
  • If they meet only mechanism criteria and it’s been more than 6 hours since the event, they probably do not need the fast track.
  • If they only meet the “clinician / EMS judgment” criteria, think about what the suspected injuries are based on a quick history and brief exam. Once again, if more than 6 hours have passed and there are no physiologic disturbances, the time for needing a trauma activation is probably past.

If you do decide not to trigger an activation in one of these cases, please let your trauma administrative team (trauma medical director, trauma program manager) know as soon as possible. This may appear to be undertriage as they analyze the admission, and it’s important for them to know the reasoning behind your choice so they can accurately document under- and over-triage.

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