In follow-up to last week’s pearl regarding the inequitable distribution of trauma care, there were a few more thoughts:
1. A huge shout out to those ED physicians working in critical access facilities without surgical back up, access to specialists, and who are regularly struggling to get their patients transferred to trauma centers to receive the care they need.
2. All centers, big and small, are struggling with crowding, staffing, and patient flow. It is critical to the entire system that these issues get addressed. They need to be addressed at a system level by all stake holders. Smaller EDs, critical access EDs, or Level 2 and 3 centers holding patients that need to be transferred has a deleterious effect not only on that individual patient, but the patients that can’t be seen while the most critically ill are being attended to.
3. Hospital administrators, medical directors, national organizations, department leaders, and each of us in the trenches owe it to our communities and patients to get involved in fixing the problems. These issues are best addressed by a meeting of stake holders than by an overwhelmed ED provider at 2 am desperately trying to do the right thing for their patient.
4. The best systems have:
a. ongoing education for EMS providers, hospital providers, nurses and the general public,
b. pre-hospital protocols regarding trauma patients,
c. a timely means to get patients to the correct facility,
d. injury prevention programs,
e. post-acute care rehabilitation services, and
f. family support services in place.
5. Those with well-functioning systems, please publish your results and the steps you have taken to become well-functioning. We need leadership. We do not need to reinvent the wheel. Please take an active role in lifting the less functional systems to your level.
6. Those that are struggling, ask for help! Also publish your efforts, your struggles, and your needs.
For those interested in a deeper dive into where we have come from and the concept of trauma systems, please read the attached reference. This is a call to all that care for the critically ill to work to improve our stressed system, publish your work so we ca all learn and to advocate and lobby for your patients.
This pearl's author is open to comments, criticism, concerns and questions.
Back to clinical pearls next week.
The impact of trauma systems on patient outcomes
Curr Probl Surg. 2021 Jan; 58(1): 100849.
Keywords: level I, Level II, Level III, Trauma Center, Accessibility (PubMed Search)
This study found that 22% of Americans do not have access to a trauma center within 60 minutes. Eight percent of the population relied on Level III centers. Not unexpectantly, Black and Native Americans were overly represented in the group receiveing care at Level III centers. White and Native Americans were over represented in the group without access to trauma care within 60 minutes. Most disappointing of all, none of this has changed since 2010. Some states have a robust trauma network, while others need to evaluate their needs and potentially add Level III centers to cut down the time to trauma care. What is your area's trauma coverage and what level?
Jarman, Molly P. PhD, MPH; Dalton, Michael K. MD, MPH; Askari, Reza MD; Sonderman, Kristin MD, MPH; Salim, Ali MD; Inaba, Kenji MD
Accessibility of Level III trauma centers for underserved populations: A cross-sectional study
Journal of Trauma and Acute Care Surgery: November 2022 - Volume 93 - Issue 5 - p 664-671
This small study looked at patients with penetrating neck injuries and tried to determine in those with "hard signs" of injury (hemorrhage, expanding hematoma, or ischemia) if they required immediate operative managment. The authors concluded:
"Although hard signs in PCVIs are associated with the need for operative intervention, initial CT imaging can facilitate endovascular options or nonoperative management in a significant subgroup. Hard signs should not be considered an absolute indication for immediate surgical exploration."
This is a small study and it is unclear why some patients went to CT vs directly to the operating room. This may not be a practice changing study, but it may validate provider gestalt of CT vs direct to operating room. We can add this to the growing body of evidence that CT scanning in penetrating trauma can be used to diffrentiate who needs emergent operative intervention vs. endovascular therapy vs close observation. This study certainly opens the door for further reaserch in the area of management of penetratign neck injuries.
Reading the signs in penetrating cervical vascular injuries: Analysis of hard/soft signs and initial management from a nationwide vascular trauma database
Marrotte, Alexander MD; Calvo, Richard Y. PhD; Badiee, Jayraan MPH; Rooney, Alexandra S. MPH; Krzyzaniak, Andrea MA; Sise, Michael MD; Bansal, Vishal MD; DuBose, Joseph MD; Martin, Matthew J. MD; the AAST PROOVIT Study Group; Morrison, Jonny MD, PhD
Journal of Trauma and Acute Care Surgery: November 2022 - Volume 93 - Issue 5 - p 632-638
Keywords: trauma, elderly, pelvic fracture, plain radiographs (PubMed Search)
This retrospective study compared plain radiographs to CT scan for the detection of pelvic fractures in patients over 65 years of age. The authors concluded “Pelvic radiographs have low sensitivity in detecting traumatic pelvic fractures. These radiographically occult fractures may be clinically significant as a cause of long-term pain and may require orthopedic consultation and possible surgical management.”
If you have a high clinical suspicion due to pain or inability to ambulate, CT may be warranted if the X-Ray is negative.
Ma, Y., Mandell, J.C., Rocha, T. et al. Diagnostic accuracy of pelvic radiographs for the detection of traumatic pelvic fractures in the elderly. Emerg Radiol (2022). https://doi.org/10.1007/s10140-022-02090-w
Keywords: abdominal trauma, seat belt sign, Ct scan, discharge, hollow vicsus injury (PubMed Search)
Traditional trauma teaching is to admit trauma patients with abdominal wall ecchymosis caused by seat belts (seat belt sign) for fear of missing a hollow viscus injury leading to peritonitis and sepsis.
Over the past few years there have been studies pointing toward the safety of discharging blunt abdominal trauma patients with a negative CT even if they do have a seat belt sign.
In this most recent study, a negative CT was defined as
1. No free fluid (free fluid was the leading indicator of occult hollow viscus injury)
2. No solid organ injury
3. No bowel wall irregular contours, thickening, hematoma or air
4. No abdominal wall soft tissue contusion
5. No mesenteric stranding or hematoma
6. No bowel dilatation
If the patient’s CT did not include any of these findings, there was a 0.01% chance of finding a delayed hollow viscus injury. The authors conclude it is safe to discharge patients meeting these criteria.
If we include no rebound or guarding on physical exam along with a negative CT scan, it appears to be safe to discharge trauma patient’s with seat belt sign.
Keywords: penetrating trauma, trauma, obesity, armour phenomenon (PubMed Search)
This meta-analyisis looked at whether obesity was a protective factor for penetrating trauma (the armour phenomenon). The authors concluded that insteaed of being protective, obesity added to morbidity and mortality.
"Obese patients that sustained stab injuries underwent more nontherapeutic operations. Obese patients that sustained gunshot injuries had longer intensive care and total hospital length of stay. Obese patients suffered more respiratory complications and were at an increased risk of death during their admission."
Further evidence that obesity is a major health concern in both medical and trauma pateints.
Keywords: trauma, transport, police, ALS, penetrating trauma, rapid transport, prehospital, EMS (PubMed Search)
In this prospective, observational study performed at 25 urban trauma centers, police transport (18%) was compared to Advanced Life Support (ALS) transport (81%) for mortality in penetrating trauma patients with an injury severity score over 16. There was no difference in outcome for those transported by ALS.
The authors conclude "Police transport of penetrating trauma patients in urban locations results in similar outcomes compared with ALS. Immediate transport to definitive trauma care should be emphasized in this patient population."
Keywords: Shock, Shock index, trauma, mass transfusion, mortality, geriatric trauma (PubMed Search)
The use of the shock index (systolic blood pressure/heart rate) value under 0.9 has been shown to be effective in predicting the need for mass blood transfusion as well as mortality for trauma patients age 16-64. Using age times shock index has been shown to be an effective marker of mortality and the need for transfer/transport to a trauma center in those over age 65. The change in shock index over time is also useful for pre-hospital providers deciding the appropriate destination for traumatically injured individuals.
Pandit, Viraj MD et al. Shock index predicts mortality in geriatric trauma patients An analysis of the National Trauma Data Bank Journal of Trauma and Acute Care Surgery: April 2014 - Volume 76 - Issue 4 - p 1111-1115
Keywords: trauma, whole blood, blood products, resucitation (PubMed Search)
A fourteen center study enrolling 1623 trauma patients (53% penetrating) comparing cold-stored whole blood vs. blood component products found no difference in AKI, thromboembolism, or pulmonary complications. And more interestingly, patients receiving whole blood were 48% less likely to die than those receiving standard blood component products. Add this data point to a growing trend toward cold-stored whole blood for trauma patients.
Hazelton, J., et al. “Use of Cold-Stored Whole Blood is Associated with Improved Mortality in Hemostatic Resuscitation of Major Bleeding A Multicenter Study” Annals of Surgery October 2022, Volume 276, Issue 4, p. 579-88.
Keywords: Trauma, Airway Management, Resuscitation (PubMed Search)
Manageing the airway of a trauma patient presents difficulties because of both anatomic and physiologic derangement.
The Bottom Line: Trauma patients requiring intubation are a challenge and should be managed by the most expereinced person in the room. No study shows superiority of direct vs.video laryngoscopy. Use the technique you are most facile with and develop more techniques through courses, mentoring, and expanding your repertoire in less ill patients first. Use induction agents with lower liklelihood of causing hypotension like Etomidate and ketamine (avoid propofol and benzodiazepenes). Avoid hypoxia, hypotension and hypocarbia by resucitating as much as possible prior to intubation (use blood products and pressors where appropriate). Have a plan, a back up plan, and know when to switch to a surgical airway approach. This ia a low frequency, high risk proceedure. Mentally visualize yourself doing this proceedure regualrly to create a comfort level when it is actually needed.
1. Blood/Emesis A. Use a double suction set up with one suction placed into the airway near the esophagus and then moved to the left of the mouth with the second used by the intubator to clear their view.
B. If you can't visualize becaue of vomit/emesis it is very likely BVM and super glotic airways are not going to be possible and you will need to move to a surgical (front of neck) airway.
2. Limited Jaw Opening Cervical collars can impede jaw opening. Loosen/open the collar to allow more jaw opening. Studies show that there is limited movement of C-Spine when the intubator uses caution not to flex the neck during intubation meaning the collar does not have to be in place. No study shows diret or video laryngoscopy to be superior.
3. Blunt or penetrating neck injury Highest level of difficulty. Should be most expereienced intubator. Can use an awake intubation technique if you are adept at this method. Go with the airway approach that gives YOU the best first pass success chance. Another situation where BVM or suprglotic airway device may not work and requires surgical airway. May require low tracheostomy approach.
4. Hypoxia Avoiding hypoxia is a must especially in traumatic brain injured patients. Pre-oxygenate and use the airway technique that is going to give you the best first past chance of success.
5. Hypotension: A. Resuscitate with blood products as much as possible before intubation. B. Use induction agents that are the most hemodynamically neutral such as Etomidate or Ketamine (safe in head injury patients!)
6.. Hypocarbia: Congrats on getting the tube! Now slow down your bagging. Hypocarbia leads to increased injury in traumatic brain injured patients.
George Kovacs MD, Nicolas Sowers, MD
Airway Management in Trauma
Emerg Med Clin N Am 36 (2018) 61-84
Keywords: C-Spine Clearance, altered mental status (PubMed Search)
Keywords: blunt trauma, pneumothorax, CXR supine, ultrasound, seashore, stratasphere (PubMed Search)
(Please note the prior version of this pearl was incorrect with respect to the images referenced. This version is corrected.)
Patient s/p blunt chest trauma. CXR (image 1) vs. lung ultrasound (image 2), do you see any inconsistencies?
Lung ultrasound in traumatic pneumothorax: The "Stratosphere Sign"
Written by Dr. Michael Allison.
For advanced sonographers:
1. Blaivas, M. et al. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Academic Emergency Med. 2005 Sep;12(9):844-9.
2. Lichtenstein D et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005 June;33(6): 1231-8.
Keywords: Apical cap, dissection, blunt aortic injury, chest xray, radiology (PubMed Search)
44 y/o female restrained driver s/p motor vehicle crash complaining of chest pain and shortness of breath.
Answer: Left pleural apical cap.
The Apical Cap
An apical cap is a unilateral or bilateral irregular density over the apex of the lung, generally less than 5mm. The lower border is often sharp but undulating.
Fabian TC, Richardson JD, Smith JS Jr, et al. Prospective study of blunt aortic injury: multi-center trial of the American Association for the Surgery of Trauma. J Trauma 1997;42:374-383.
McLoud TC, Isler RJ, Novelline RA, et al. The apical cap. Amer J Rad 1981; 137:299-306.
Rivas LA, Fishman JE, Munera F, et al. Multislice CT in thoracic trauma. Radiol Clin North Am2003; 41:599-616.
Keywords: Epinephrine, Lidocaine, Fingers, (PubMed Search)
Lidocaine with Epinephrine and it use on Fingers and Toes
It has been taught for a long time that Lidocaine with Epinephrine should not be used on fingers, toes, ears and nose [There has to be a kid's song in there somewhere] due to the risk of vasoconstricition/vasospasm and possible digitial infarcation.
The short story is that this practice is not supported by the literature, and there are now numerous publications that have shown that lidocaine with epinephrine is safe for use on the finger tips. It turns out the the original case reports were submitted with procaine and epinephrine and not lidocaine with epinephrine. Most of the cases of digital infarction where with straight procaine that is now thought to have been contaiminated or too acidic pH close to 1 when injected.
The effects of epinephrine last approximately 6 hours. This time is well within the accepted limit of ischemia for fingers that has been established in digitial replanation.
So why use Lidocaine with Epinephrine:
Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg. Jan 2007;119(1):260-266.
Keywords: Seatbelt Sign, Abdominal, Trauma (PubMed Search)
Keywords: Ankle, Maisonneuve, Jones, Fracture (PubMed Search)