UMEM Educational Pearls - By Robert Flint

Category: Trauma

Title: Geriatric Hip fractures: when is a low hgb detrimental.

Keywords: Hip fracture l, hemoglobin l, mortality (PubMed Search)

Posted: 2/25/2024 by Robert Flint, MD (Updated: 2/26/2024)
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In this study, geriatric hip fracture patients with a hemoglobin less than 7.1 had higher mortality, especially in those over age 79, even when controlling for other factors such as ASA Physical status class, anti-platelet use, etc.

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This research letter notes: “The Rural Emergency Hospital is a new Medicare payment model available to hospitals with 50 or fewer beds in rural areas. Rural hospitals converting to this model will have emergency department (ED), observation, and outpatient services.”. Their study concludes that the majority of these hospitals already transfer the vast majority of their admissions to larger hospitals and this designation is a recognition of already established practices.

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Category: Trauma

Title: Do prehospital applied pelvic binders impact mortality?

Keywords: Pelvic binder, trauma, survival, mortality (PubMed Search)

Posted: 2/18/2024 by Robert Flint, MD (Updated: 2/26/2024)
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This retrospective study of 66 trauma patients who had pelvic fractures attempted to determine if prehospital applied pelvic binders had an impact on mortality. There were 3 cohorts: appropriately applied binders (14), inappropriately applied (14 not at the level of the greater trochanter), and none applied (38).  Survival for applied was 92% and those without was 81% which was not statistically significant.  The authors concluded: “In conclusion, our study found that the use of prehospital pelvic binders did not show a significant effect on patient outcomes for those with unstable pelvic fractures. Instead, injury severity score (ISS) emerged as the most significant predictor of survival.”

Previous studies have shown regular education is needed on proper use of binders.  We should continue to educate on appropriate positioning and the use of pelvic binders. For me, this study is not large enough to convince that we should go away from binder use. We need more data before we abandon the pelvic binder.

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Category: Administration

Title: Transfer of emergency general surgery cases

Keywords: Transfer, surgery, scoping review, further research (PubMed Search)

Posted: 1/28/2024 by Robert Flint, MD (Emailed: 2/11/2024) (Updated: 2/11/2024)
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These authors performed a scoping review of English language studies involving United States general surgery patients that required transfer to another facility looking at timing of transfer, triage guidelines, and mode of transport . They concluded: “There were mixed results for the impact of transfer timing on outcomes with heterogeneous definitions of delay and populations. Triage guidelines for EGS transfer were consensus or expert opinion. No studies were identified addressing the mode of interfacility EGS transfer.”  More research is needed in the area concerning timing, triage and mode of transport for these patients.

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Category: Trauma

Title: CT for uncertain head injury in geriatric patients

Keywords: Ct, head injury, geriatric (PubMed Search)

Posted: 1/28/2024 by Robert Flint, MD (Emailed: 2/4/2024) (Updated: 2/4/2024)
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In this prospective study looking at geriatric patients with unknown head injury vs. known head injury, the unknown head injury group had an ICH 1.5%, neurosurgical intervention 0.3% and delayed ICH 0.1% when compared to known head injury (10.5%,  1.2% and 0.7% respectively).  The authors concluded that the risk of ICH was high enough in uncertain head injury patients to warrant scanning.

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Category: Trauma

Title: Can the surprise question predict 1 year mortality in trauma patients?

Keywords: Prediction, surprise question, trauma, mortality (PubMed Search)

Posted: 1/28/2024 by Robert Flint, MD (Updated: 2/26/2024)
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The question “Would I be surprised if the patient died within the next year”  has been validated as a tool to predict patients with a limited life expectancy. This study looked at trauma team members’ ability to use this question to predict one year mortality. Trauma team members over estimated mortality in this study.

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Category: Administration

Title: Conditions associated with diagnostic error

Keywords: Risk, diagnostic error (PubMed Search)

Posted: 1/21/2024 by Robert Flint, MD (Updated: 2/26/2024)
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From the Canadian Medical Protective Association looking at  5 years of closed medical legal cases.  This fits with previous risk management data and should give us pause when treating these conditions.

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Category: Trauma

Title: Delirium and Trauma

Keywords: elder, Trauma, delirium, confusion (PubMed Search)

Posted: 1/14/2024 by Robert Flint, MD (Updated: 2/26/2024)
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Imagine lying in a bed staring at the ceiling and these fuzzy faces looking down on you clearly saying something to you but you can't hear them while your hip and pelvis are hurting worse than anything you have ever felt. That's what many of our fall from standing elderly patients experience in emergency departments on a regular basis. Do not remove glasses or hearing aides from your elderly patients. Work with our EMS colleagues to make it a practice to bring glasses and hearing aides along from the scene.  Speak slowly and get close to their ear to help if necessary. That confusion, delirium or dementia you assume this patient has is actually just hearing impairment and poor vision.



Category: Trauma

Title: Age is just a number

Posted: 1/7/2024 by Robert Flint, MD (Updated: 2/26/2024)
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Approaching patients based on their frailty, not their age, leads to better medical decision making. A recent best practice guideline from the American College of Surgeons sums up frailty: 
“It is well recognized that aging is associated with physiological decline, but this decline is not uniform across all individuals or even across one individual’s organ systems. Frailty is a geriatric syndrome, clinically distinct from age, comorbidity, and functional disability, characterized by age- associated depletion of physiological reserves that leads
to a state of augmented vulnerability to physical stressors and a diminished ability to recover from illnesses.” A trauma specific frailty  index exists to identify these high risk patients.

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Since 2014, Medicare has payed for inpatient services for Medicare patients who’s admitting physician noted that hospital stay required at least 48 hours (measured as 2 midnights) or required specialty care that could not be performed as an out patient.  This rule now will apply to Medicare Advantage insurance patients as well. Physicians will need to document their reasoning why a patient’s stay will likely require two midnights.

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Category: Administration

Title: Personal growth, not goal setting

Keywords: Personal growth. (PubMed Search)

Posted: 12/31/2023 by Robert Flint, MD (Updated: 2/26/2024)
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As the calendar flips to a new year, consider not setting goals or resolutions. Studies show unmet goals or having too many half finished projects leads to increased stress, anxiety and depression. Instead, consider approaching the new year looking for growth, introspection, and  striving to achieve excellence.  Understanding the why and what motivates you will lead to the correct what and how. Here are some questions to get you thinking about the why.  May your New Year be filled with growth and excellence!  



For the agitated geriatric patient, if verbal deescalation, distraction, and providing a safe quiet area do not work and you require chemical sedation use oral antipsychotics first.  Follow this with IV or IM antipsychotics. Avoid benzodiazepines due to often worsening delirium or respiratory depression. For dosing, start low and go slow.

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NEXUS criteria for blunt chest trauma patients who are over 14 years old, not intubated:

  • >60 years old

  • rapid deceleration defined as fall > 6 meters or motor vehicle crash >64 km/hour

  • chest pain

  • intoxication

  • abnormal alertness or mental status

  • distracting painful injury

  • tenderness to chest wall palpation

    If abnormal chest X-Ray proceed to chest CT.  Negative predictive value of 99.9% excluding major injury.

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This commentary offers another reminder that there is significant bias in which trauma patients receive alcohol testing when that decision is made on a case by case basis. Age, sex, socioeconomic, race, injury pattern, all have been shown to influence provider ordering. Trauma systems should have pre-defined ordering criteria to eliminate this bias. The importance of gathering this testing information is to provide intervention and treatment to those in need. First we have to identify all patients in need.

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Category: Trauma

Title: Morel-Lavallée Lessions

Keywords: soft tissue injury, trauma, (PubMed Search)

Posted: 12/10/2023 by Robert Flint, MD (Updated: 2/26/2024)
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Here are three good resources to learn about a soft tissue injury seen in high velocity blunt trauma patients called Morel-Lavallee lessions.

“Morel Lavallee lesions are soft tissue injuries seen in high-velocity trauma and are usually associated with underlying fractures of the pelvis, acetabulum, or proximal femur. Often these injuries are not immediately diagnosed due to the distracting concomitant bony injuries. However, identification of such injuries is important as they may pose as an independent risk factor for surgical site infection. The clinical findings include soft tissue swelling, bruise/ ecchymosis, fluctuance, and compressibility in the swelling. The diagnosis is usually established on physical examination, however, radiological investigations including ultrasonography and CT might help. The management options include nonoperative treatment, percutaneous aspiration, and open debridement.” 1

“Morel-Lavallée lesions are often the result of skin and subcutaneous tissue quickly tearing away from the underlying fascia. This allows a range of fluids to fill the space in the form of hemolymphatic masses. The two most common sites are the prepatellar plate of the knee and the lateral fascia of the hip.” 2

“ML lesion is often undiagnosed during initial presentation of a trauma patient, and emergency physicians and trauma surgeons should be aware of the possibility of occurrence of this injury. MRI is the imaging modality of choice, and the presence or absence of a capsule is an important imaging finding that guides appropriate therapy. Early diagnosis and management will help prevent long-term morbidity and complications in these patients.”3

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A retrospective study of 2 years of data from 24 trauma centers looking at end tidal CO2 as a predictor of mortality in trauma patients found:

"A total of 1,324 patients were enrolled. ETCO2 was better in predicting mortality than shock index (SI) and systolic blood pressure (SBP).  Prehospital lowest ETCO2 , SBP , and SI  were all predictive of Mass Transfusion."

 

Another data point to consider when setting up trauma triage protocols and looking for patients who will require intensive interventions early. 

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Category: Trauma

Title: Geriatric trauma mortality predictors

Keywords: Geriatric, trauma, mortality, risk factors (PubMed Search)

Posted: 11/26/2023 by Robert Flint, MD (Updated: 2/26/2024)
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A chart review of 1300 patients over age 65 admitted to the trauma service, arrived as a trauma activation, or had an injury severity score over 12 over a 6 year period looking at 30 day mortality found: 

"five factors associated with increased 30-day mortality in older trauma patients: GCS < 15, ISS > 15, age ≥ 85 years, anticoagulation, and multimorbidity."

Fall from standing was the leading cause of trauma  

Again, fragility is the index we should be using, not age alone. This study is limited in its retrospective chart review nature. Prospective research in the area of geriatric trauma is needed. Until then, assess those over age 65 for risk factors associated with fragility and treat accordingly. 

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Category: Trauma

Title: Geriatric vs. Super-geriatric Trauma

Keywords: Geriatric, older person, trauma, super-geriatric (PubMed Search)

Posted: 11/23/2023 by Robert Flint, MD (Updated: 2/26/2024)
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This retrospective study looked at trauma patients over age 65 and divided them into age ranges 65-80 (geriatric) and 80 plus (super-geriatric). They then looked at mechanusm of injury, mortality, interventions,etc. What they found was ages 65-80 were more likely to be injured in motor vehicle crashes vs. falls for those over 80. Those over 80 received less interventions including hemmorhage control surgery and had much higher levels of withdrawal of care. 

This study highlights that the geriatric population is not as a monolithic group over age 65, but more nuanced by various age ranges over 65. Research going forward should be adjusted to these nuanced age ranges. Out treatment approaches should be adjusted in geriatric vs. super-geriatric patients as well. 

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Category: Trauma

Title: Use of reverse shock index times GCS to predict Peds trauma needs

Keywords: Reverse shock index, Peds trauma, prediction (PubMed Search)

Posted: 11/18/2023 by Robert Flint, MD (Emailed: 11/19/2023)
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This small study suggests using reverse shock index times the Glasgow Comma Scake score may give a prognostication on pediatric trauma severity and resource utilization. 
 

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Category: Trauma

Title: Ketamine, ICP and pediatric brain injury

Keywords: Brain injury, ketamine ICP (PubMed Search)

Posted: 11/12/2023 by Robert Flint, MD
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This pediatric ICU study measured ICP during and after ketamine infusion.  There was no increase in ICP associated with the ketamine infusion. This small study adds to the data that ketamine is safe in pediatric brain injured patients. 

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