Category: Trauma

What Does EAST Say About ED Thoracotomy?

The resuscitative emergency thoracotomy in trauma – rarely used and rarely successful.  However, for appropriately selected patients in extremis, such timely intervention may be literally life-saving.

The downside: resource utilization associated with saving the neurologically unsalvageable and the risks to providers associated with the procedure.

This is an evidence synthesis performed by a group of authors affiliated with the Eastern Association for the Surgery of Trauma, addressing the topic of patient selection for Emergency Department thoracotomy.  Screening 2,152 studies to review, ultimately, 72, these authors review a total of 10,238 patient encounters in which patients underwent ED thoracotomy.  This results in six recommendations for patients presenting pulseless to the Emergency Department after trauma:

  • In patients with signs of life after penetrating thoracic injury: strongly recommend EDT.
  • In patients without signs of life after penetrating thoracic injury: conditionally recommend EDT.
  • In patients with signs of life after penetrating extra-thoracic injury: conditionally recommend EDT.
  • In patients without signs of life after penetrating extra-thoracic injury: conditionally recommend EDT.
  • In patients with signs of life after blunt injury: conditionally recommend EDT.
  • In patients without signs of life after blunt injury: conditionally recommend against EDT.

However, before you start rummaging around in your toolbox for the rib spreaders, it should be recognized the conditional recommendations – except in penetrating thoracic injury – result in absolute intact survival increases only in the range of 20-40 patients per 1000.  Therefore, unless you’re working in a setting of maximal effectiveness and experience, it is unlikely you’ll see even this small absolute benefit.  And, even in the setting with the strong recommendations and excess intact survival benefits of 100 patients per 1000 – your individual hospital system, based on institutional support and experience level of the providers involved, will need to develop specific policies for these situations.  Even though many ED physicians are capable of performing these heroic procedures based on their training, the remaining ED staff and systems in place may not be adequate to support the intervention.

“An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma”
http://www.ncbi.nlm.nih.gov/pubmed/26091330

Where’s the Beef With TXA?

CRASH-2 was a massive, international undertaking, testing the utility of tranexamic acid to improve outcomes in bleeding trauma patients.  When given with 3 hours, there were significant reductions in mortality due to bleeding – and the current push for its widespread use was born.

However, this study, and others like it, is not seeing the same magnitude of success as described in CRASH-2.  This single-center, retrospective evaluation of trauma patients reviewed the mortality benefit associated with implementation of a thromboelastography-based TXA protocol.  In 2011, this institution introduced a TEG-based TXA threshold of estimated percent lysis at 30 minutes of >3.0%, and these authors reviewed all cases of trauma patients between 2009 and 2013 meeting that threshold and eligible for treatment within 3 hours.

These authors identified a cohort of 98 patients who met criteria and received TXA, and compared them with a cohort of 934 patients who met criteria and did not.  In-hospital mortality in the cohort receiving TXA was double those who did not (40% vs. 17%), and this disadvantage persisted despite adjustment for age, gender, mechanism, ISS, hypotension, and base excess.  TXA usage was also not associated with resolution of hyperfibrinolysis, as measured by follow-up TEG, but neither was it associated with an increase in thromboembolic events.

Unfortunately, this retrospective evaluation is biased by confounding and unmeasured selection imbalances.  It is, however, not the only study questioning the value of TXA in the setting of routinely well-resuscitated, modern trauma evaluation.  Nothing in this small review provides compelling evidence regarding cessation or tailoring of TXA therapy in bleeding trauma patients, but it does support its continued evaluation for its role in organized, modern trauma settings.

“The impact of tranexamic acid on mortality in injured patients with hyperfibrinolysis”

Still Not Choosing Wisely in Trauma Imaging

We can all agree the advent of CT has improved our diagnostic capabilities, particularly in multi-system trauma.  Few would challenge an assumption that outcomes are positively impacted by timely, accurate identification of clinically important pathology.

Unfortunately, the pendulum has swung so far in favor of CT in trauma, any intelligent reliance on clinical exam skills has been deprecated to obsolete.  As such, the expected fallout includes increases in costs, radiation, and length-of-stay as the zero-miss culture creeps from multi-system trauma into the lightly injured.  This has become such an issue the American College of Surgeons devoted one of five slots in their first Choosing Wisely Guidelines to reducing the use of the trauma “pan-scan”.

Hopefully, the culture change will happen none-to-soon, as this NHAMCS data review indicates – showing steady increases in CT use for both head and body over the 2007 to 2010 review period.  Head CT increased from 9.6% to 11.6% of all injury-related encounters, while body CT increased from 5.5% to 8.1% – without any corresponding increase in positive findings.  Yield for severe injury dropped from 4.9% to 3.4% on Head CT, along with a drop for body CT from 6.4% to 3.3%.

This is the NHAMCS probabilistic sample, of course, and it’s simply a coarse observational cohort without detailed clinical factors.  However, I think the likelihood these observations accurately reflect reality is rather high.

Choose more wisely, please.

“Trends in Advanced Computed Tomography Use for Injured Patients in United States Emergency Departments: 2007–2010”
http://www.ncbi.nlm.nih.gov/pubmed/25996245

The Very Young Pediatric C-Spine Rarely Needs Radiologic Clearance

It is usually reasonable to exercise an abundance of caution with trauma patients suspected of having cervical spine injuries.  However, an abundance of caution sometimes means an abundance of radiation – and the costs and harms associated with such testing can be immense, regardless of technical difficulty in a young pediatric population.

This is a retrospective evaluation of 2,972 trauma patients aged less than 5 years, reviewing specifically the overall incidence of diagnosed cervical spine injury.  In this 12 year cohort, a grand total of 22 had confirmed CSI.  Most importantly, however, nearly all cases of CSI were associated with other serious injuries – a cohort with a median ISS of 33.  Twelve of 22 arrived intubated, 13 were in extremis, and overall mortality was 50%.  All evaluable patients had either neurologic deficits, severe neck pain, or were unable to range their neck.

These authors do not further describe their cohort for evaluation with regard to developing a predictive instrument for cervical spine injury, but these data do support a very reasonable conclusion regarding the rarity of pediatric injuries – and the near impossibility of isolated cervical spine injuries.  I tend to agree with the authors’ stated management strategy for such patients:

“Pediatric patients with abnormal neurologic examination result, decreased mental status, neck pain, or torticollis are evaluated with cervical spine CT; however if the child is asymptomatic defined by a normal neurologic examination result, appropriate mental status, with absence of neck pain or torticollis, our first step is to remove the cervical collar. We examine the patient for cervical tenderness if they are able to communicate and observe the child for normal range of motion of the neck. In preverbal patients, we simply observe neck range of motion with the collar removed. If the child seems to move his or her neck without discomfort and full range of motion, then we do not pursue any further radiologic evaluation.”

“Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger”
http://www.ncbi.nlm.nih.gov/pubmed/25909413

Where Should You Admit the Elderly with Rib Fractures?

In general, trauma results in disproportionately severe injuries in elderly patients despite similar mechanisms.  A frequent concern, specifically, is the risk of pneumonia or intubation associated with rib fractures – previously demonstrated to increase linear for each fracture in patients aged greater than 65.

However, a dichotomous age cut-off paired with a single variable is an obviously simplistic model.  These authors retrospectively reviewed 400 patients aged greater than 55 years of age hospitalized with injuries including rib fractures.  A regression model was developed to determine predictors of respiratory failure or pulmonary complications.

Six variables shook out of their analysis as significant predictors of subsequent complications:  COPD, low serum albumin, use of an ambulatory assist device, a tube thoracostomy in place, injury severity score, and total number of rib fractures.  Transforming these variables into a scoring system resulted in a predictive instrument with and AUC of 0.82 (0.77 – 0.88), with sensitivities and specificities in the 70%s based on their chosen threshold.

While this performance is suboptimal, the model has obvious face validity – the frail, severely injured, with underlying pulmonary disease are the most likely to deteriorate.  Their model also requires external validation.  However, given that most patients do develop pulmonary complications, such a tool could be reasonably used to reduce the costs and resource utilization associated with prophylactic ICU admissions – as long as you were willing to accept the risk of approximately 1 in 20 patients requiring unexpected escalation in care from the floor.

“A pilot single-institution predictive model to guide rib fracture management in elderly patients”
http://www.ncbi.nlm.nih.gov/pubmed/25909417

Blunt Trauma Thoracotomy: Probably Still Not Time for Heroics

A guest post by Matthew DeLaney, Assistant Program Director of the University of Alabama at Birmingham Emergency Medicine residency. 

For most providers, there is a limited but well delineated role for emergency department thoracotomy (EDT) in patients with penetrating trauma. The potential role for EDT in blunt trauma patients is much less clear. In a recent meta-analysis, Slessor et al. included 13 studies consisting of 1369 patients who underwent EDT after blunt trauma.

Overall most of the patients who underwent a thoracotomy did poorly, with only 21(1.5%) patients having a good neurologic outcome. The highest rate of survival was found in patients who had vital signs either in the field or in the emergency department. All patients who experienced good neurologic outcomes had vital signs in the emergency department. Patients who have vital signs in the field but he did not have vital signs in the emergency department had lower rates of survival and worse neurologic outcomes compared to the patients who had signs of life in the ED.

Time to EDT seemed to play a role in terms of improving patient outcomes. The authors note one instance where an EDT was performed after 136 minutes of CPR, not surprisingly this patient did not have a good outcome. When looking at patient’s who underwent CPR, all patients who experienced good outcomes received less than 15 minutes of CPR before undergoing an EDT. Patients with no signs of life at any point did poorly with a reported survival rate of 0.4% with a 100% rate of bad neurologic outcomes.

While authors of the study concluded that the chances of survival with a good outcome were approximate 1.5%, this may not be applicable to most emergency medicine trained providers. Most of the included studies involved procedures performed by surgeons at large trauma centers, in fact only 1 study included EDT performed by emergency medicine providers. Unfortunately this study included a small number of cases with no reported survivors. Even under ideal circumstances if we look at cases where we as emergency department providers could be expected to make a critical intervention, (cardiac tamponade / penetrating cardiac injury) the rate of survival with good outcomes is closer to 0.07% (4/1369).

When performed by surgeons in large trauma centers, the EDT may be a reasonable “hail-mary” for a blunt trauma patient who is actively dying. Despite being the largest study to date on this subject, this study provides essentially no evidence to support the use of EDT by emergency trained providers.  Given the invasive nature of the EDT, there is a very real risk of harm to the providers and staff from needle/scalpel injuries and exposure to broken ribs and blood. As with other seldom performed heroic procedures, there may be a clinical scenario where EDT by an emergency medicine provider is effective.When treating a patient in cardiac arrest from a blunt trauma, providers need to balance the potential risk of harm to provider and staff before performing an invasive procedure with a very low chance of success.

“To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis.”
http://www.ncbi.nlm.nih.gov/pubmed/25443990

The Golden Hour, Revisited

Medicine is full of “golden” times.  tPA, door-to-balloon time, sepsis bundles, and more – as the various time-dependent mandates pile up and resources remain static, it is important to revisit each and prioritize.

These authors are making an observational comment on the “golden hour” as it applies to seriously injured trauma patients.  Modern trauma systems have evolved to rapidly funnel patients through the system to the best-equipped facility.  This has involved significant investment and resource utilization by aeromedical transport.  While glamorous and heroic, unfortunately many patients transported by this inefficient and dangerous method are either too lightly or badly damaged to demonstrate any benefit from alacrity.

These authors, looking at data from a clinical trial concerning early resuscitation fluids, analyze 778 patients with hemorrhagic shock and 1,239 patients with traumatic brain injury.  Patients whose pre-hospital time exceeded 60 minutes – the “golden hour” – were no more likely to be dead or neurologically devastated than those who reached the hospital within 60 minutes.  Thus, questioning the “golden hour” of trauma.

However, at least, within the hemorrhagic shock group, the subset of 484 patients in which a “critical intervention” was performed within 24 hours of arrival did show a survival advantage – OR 2.37 (95% CI 1.05 to 5.37).  It is probably still reasonable to continue transporting those in hypovolemic shock until validated criteria for non-survivability or lack of intervention exist.  Traumatic brain injury patients, however, may urgently need to be revisited for the necessity of resource-intensive transport.

This is, additionally, a lovely example of secondary use of clinical trial data.  Even though the original trial was stopped early due to futility regarding the primary efficacy endpoint, the re-use of the rigorously collected data redeems the invested resources.  High-quality clinical trial data is accumulating rapidly – and perhaps the greatest tragedy in medicine is how much it is locked away as proprietary intellectual property.  Share!  Share!

“Revisiting the ‘Golden Hour’: An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury”
http://www.ncbi.nlm.nih.gov/pubmed/25596960

Flights of the Minimally Injured

Helicopter transport of trauma patients is a controversial topic.  Most agree there is a cohort of severely and specifically injured patients who receive important benefits from HEMS versus ground transportation.  However, it is reasonably suggested from registry studies those patients are rather few.  And, if only a subset of seriously injured patients benefit from HEMS, then, certainly the minimally injured patient does not.

But, unfortunately, flights of the minimally injured are hardly infrequent.

This is a retrospective review of all trauma transports at a single academic center in Arizona.  “Minimally injured” was defined as an ISS of 5 or lower, and who did not require intensive care or operative intervention.  Over the six years of the study period, this center received 3,992 ground transports, 39% of which were minimally injured.  They also received 981 HEMS arrivals – 27% of which were minimally injured.

Or, approximately $4.8 million burned for no benefit on just pre-hospital transportation by helicopter.

The authors’ title says it all:

“Overuse of helicopter transport in the minimally injured: A health care system problem that should be corrected”
http://www.ncbi.nlm.nih.gov/pubmed/25710420

The Fixed-Ratio Massive Transfusion Answer

After years of wondering and wandering, we finally have the definitive answer for how best to resuscitate the severely-injured trauma patient – transfusion ratios best mimicking whole blood.  You know, just as we all expected, just as these authors hoped, and just what’s been reported from prior observational series and military combat experience.

More or less.

Regardless, this study – the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) trial – was a remarkable undertaking in logistics.  Each participating Level 1 trauma center incorporated sealed coolers into their ready blood supply, providing a random allocation of product ratio when the massive transfusion protocol was activated.  As transfusion continued, more coolers with the same ratio arrived.  As best as can be implemented, this reduces the immortality bias seen in other observational series – where survivors were survivors in part, basically, because they survived.

This trial randomized patients to 1:1:1 vs. 1:1:2 – that is, equal numbers of FFP, platelets and RBCs, or half as much FFP and platelets as RBCs.  Ultimately, it didn’t precisely test those same ratios, except as the initial resuscitation strategy.  Following the intervention period, the 1:1:2 arm caught up a bit with plasma and FFP – but the quantities transfused were not substantial.

Technically, this is a negative trial – the mortality advantage favoring the 1:1:1 cohort did not reach statistical significance at 24 hours or 30 days.  However, the authors powered the study expecting a 10% mortality advantage – and instead it was only 4.2% (95% CI -1.1 to 9.6) and 3.7% (95% CI -2.7 to 10.2) at each time point, respectively.  We are then left with the question whether this small difference reflects the underlying truth or chance.

Do the secondary aspects of these data validate the difference?  The expected advantage of 1:1:1 resuscitation is the warding off of evil spirits associated with transfusion-related coagulopathy – and we see in this study the primary driver of differences in mortality was related to deaths secondary to exsanguination.  Likewise, a greater number in the 1:1:1 group achieved satisfactory hemostasis.  So, using a Bayesian approach to interpreting the statistical tests for mortality, it is reasonable to adopt approaches based initial 1:1:1 resuscitation when massive transfusion is necessary, despite the limitations of the evidence.

One oddity worth noting in these data were the relatively small differences in sepsis and ARDS in the 1:1:1 group.  Increased use of FFP and, in particular, platelets are associated with these transfusion-related complications – and it has always been of particular interest whether a 1:1:1 ratio is safe, for precisely these reasons.  The inclusion of platelets in the 1:1:1 randomization may also be a matter for debate; few patients had any indication for platelets following the intervention, and further work could consider the relative utility of aggressive use of platelets.

Overall, however, this is best evidence to date the 1:1:1 ratio is a worthy initial target.

“Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma”
http://www.ncbi.nlm.nih.gov/pubmed/25647203

Overstated Benefit of “Compliance” with Massive Transfusion

A couple days ago, @karimbrohi drew a bit of attention to this article on Twitter:

Compliance with Massive Transfusion Protocol improves outcome: http://t.co/Z2yf3EOQeM [Protocol followed- 10% mortality. Not followed – 60%]
— Karim Brohi (@karimbrohi) January 3, 2015

Massive transfusion protocols are, essentially, the standard of care in advanced trauma care.  Coordinated systems to produce timely quantities of appropriate blood products are nothing new.  However, the contemporary usage of MTP has been to describe a protocol with fixed ratio of product – usually approximating a 1:1 ratio of PRBCs and FFP, and some programs include platelets.

This small study retrospectively evaluated the survival of 72 consecutive MTP activations at their trauma facility.  Compliance with 13 quality measures associated with resuscitation and transfusion was 66% overall.  Mortality rates in the cohorts with <60% compliance, 60-80% compliance, and >80% compliance with quality measures were 62%, 50%, and 10%, respectively.  Thus – compliance saves lives!

Maybe?

Tables 4 and 5 compare the baseline characteristics between survivors and non-survivors – and, frankly, it’s hard to decisively say “compliance” made the difference.  Worse initial GCS, median ISS, and AIS head/spine were all significantly associated with poorer outcomes.  Then, as far as differences in “compliance”, there was actually little difference between survivors and non-survivors regarding actual issuing and receipt of blood products.  Rather, the differences were in the quality measures associated with specific lab work – and hypothermia correction, which suffered greatly in non-survivors, almost certainly because they were in the OR for heroic measures rather than in the ICU.  So, it’s rather difficult to reliably state the quality of care was lower for those who did not survive.

And certainly not to account for the entire magnitude of this 60% to 10% mortality advantage!

“Compliance with a massive transfusion protocol (MTP) impacts patient outcome”
http://www.ncbi.nlm.nih.gov/pubmed/25452004