Missing blunt cervical vascular injuries can lead to delayed catastrophic sequela such as stroke. Usie the epanded Denver criteria to help you identify these injuries.
Expanded Denver criteria for BCVI
-Signs/symptoms of BCVI
Potential arterial hemorrhage from neck/nose/mouth
Cervical bruit in patient less than 50 years old
Expanding cervical hematoma
Focal neurologic defect: TIA, hemiparesis, vertebrobasilar symptoms, Horner's syndrome
Neurologic deficit inconsistent with head CT
Stroke on CT or MRI
-Risk factors for BCVI
High-energy transfer mechanism
Displaced midface fracture (LeFort II or III)
Mandible fracture
Complex skull fracture/basilar skull fracture/occipital condyle fracture
Severe TBI with GCS less than 6
Cervical spine fracture, subluxation, or ligamentous injury at any level
Near hanging with anoxic brain injury
Clothesline type injury or seat belt abrasion with significant swelling, pain, or altered mental status
TBI with thoracic injuries
Scalp degloving
Thoracic vascular injuries
Blunt cardiac rupture
Upper rib fractures
At this month’s Eastern Association for the Surgery of Trauma annual meeting there was a presentation asserting that hemodynamically unstable trauma patients have worse outcomes when intubated in the emergency department vs the operating room. This was not a study diminishing the intubating skills of EM providers but a look at the fact that hemorrhaging patients will crash after intubation and if they are not in a position for immediate surgical intervention they will die. The loss of sympathetic tone, positive inter-thoracic pressure, loss of muscle tone as well as the agents used all contribute to peri-intubation arrest. This month’s EmCrit episode tackled this topic as well.
Synthesizing all of the opinion and literature regarding hemodynamically unstable trauma patients requiring operative intervention the take home points are:
Much of this is counter to historical teaching of early airway management on ED arrival. It certainly fits with recent literature supporting resuscitation prior to airway management whenever feasible.
A systemic review and meta-analysis revealed that the literature and science surrounding timing and effectiveness of prophlactic antibiotic use in tube thoracotomy for trauma is not robust. The heterogeneity of the antibiotics used, the duration of antibiotics and the nature of the trauma (majority penetrating) make it very difficult to give an iron clad recommendation. The authors conclusion, which is the practice management guideline from the Eastern Association for the Surgery of Trauma, ultimately was:
“We conditionally recommend that antibiotic prophylaxis be given at the time of insertion to reduce empyema in adult patients who require TT for traumatic hemothorax or pneumothorax.”
Pelvic fractures caused by large force compression (open book) and vertical sheer injuries can lead to life threatening massive hemorrhage from arterial injury, venous injury (most common), bone bleeding or muscle hemorrhage. Advanced Trauma Life Support and many other trauma organizations recommend pelvic binding be applied after the secondary survey is complete. This should preferentially happen in the pre-hospital envirnonment. The literature has not shown a mortality benefit to pelvic binding. One reason that external compression has not been shown to be of benefit is the high percentage of incorrectly applied compression devices. Commercial pelvic compression devices are superior to the old sheet method. If the device is not applied with maxim compression over the greater trochanters the benefit of pelvic compression is lost.
Beser et al. demonstrated in their recent study in the Journal of Trauma Nursing that it takes about 8 attempts to learn to properly place the binder over the greater trochanters. This adds to the literature that appropriate education and continuing education is needed to assure that these devices are appropriately applied.
It is this pearl author’s recommendation that new EMS, nursing and ED and trauma provider staff receive training on these devices with repetitive application until proficient and that yearly competency be performed to maintain our skills in this low frequency potentially high yield procedure.
Open to thoughts and comments.
Happy New Year!
In this retrospective chart review, 3720 admitted trauma patients with rib fractures were looked at for 30 day readmission. 206 patients in the group were readmitted within 30 days.
The authors concluded:
In patients with traumatic rib fractures, those with anticoagulant use, those who actively smoke, those with a psychiatric diagnosis, or those with associated abdominal injuries are at the highest risk of re-hospitalization following discharge.
While this study is retrospective and looks at patients that were sick enough to be admitted, it is a good reminder that patients with rib fractures can have high morbidity and mortality and it gives us certain patient populations in which to show extra concern.
The use of a serratus anterior plane nerve block has previously been described as effective for anterior and lateral rib fracture pain control. A new, small study by Singh et al. shows efficacy in using this block for posterior rib fractures as well.
The reference link to the ACEPNow website shows how to perform this block using ultrasound guidance.
TACTICS
Transfusion
1:1:1
Whole Blood O+
Activate mass transfusion
TXA
TEG
Adjuncts
Arterial Line
Antibiotics( 2 grams cefazolin with first blood product, redoes 1 gram every 4th product)
Calcium
Treat hypocalcemia with CaCl2 (1 gram after every fourth product)
Check ionized calcium after second dose of calcium
Temperature
Increase room tem to 80 F
Warm blankets
Warm blood products
IV Access
Peripheral x2
I/O
Central Line
Consider
Hemostatic gauze
Tourniquet
Pelvic Binder
Reboa
IR
Cryopercipitate (10 units if fibrinogen low)
Scrub
Call OR
Hybrid Room
Call anesthesia
Call for Back up
This paper outlines a training course by Hartford Hospital for general surgery and emergency medicine residents. Their goal was to assess pre-and post-training effectiveness of hemorrhagic shock management in a simulation environment. The training was on using a novel aid (TACTICS) to prompt the participants in appropriate care decisions involving patients with massive hemorrhage.
The bottom line is having a poster in the resuscitation bay helped the health care providers manage hemorrhagic shock patients. Visual prompts work, especially for new and learning physicians.
Please click below to see their fantastic poster.
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.
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?
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.
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.
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.
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.
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."
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.
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.
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.
PEARLS:
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.
(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?
