UMEM Educational Pearls - By Robert Flint

Category: Trauma

Title: Paramedic clearance of cervical spine injuries

Keywords: EMS, C-Spine, Canadian C-Spine Rule, spinal injury, trauma (PubMed Search)

Posted: 3/5/2023 by Robert Flint, MD
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Applying a cervical collar to all patients involved in motor vehicle collisions and mechanical falls has been shown to add to patient discomfort, unwarranted imaging studies and prolonged on scene time for emergency medical services. This study adds further evidence that paramedics can use validated algorithms to clinically clear cervical spine injuries without any bad outcomes including spinal cord injuries. EMS medical directors and all of us who interact with EMS providers should be proactive in developing protocols to use cervical immobilization in appropriately selected patients only.  This study used the Modified Canadian C-Spine Rule. 

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Category: Trauma

Title: Fentanyl use is common in violently injured patients

Keywords: substance abuse, trauma, fentanyl, injury (PubMed Search)

Posted: 2/26/2023 by Robert Flint, MD (Updated: 5/25/2024)
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In a small study at a single level one trauma center, ? of patients screened positive for illicit fentanyl use prior to violent or intentional injury. Those who screened positive were more likely to require ICU admission and had a higher rate of previous trauma center admission. The authors concluded: 



“Exposure to illicit fentanyl was common among victims of violence in this single-center study. These patients are at increased risk of being admitted to intensive care units and repeated trauma center visits, suggesting fentanyl testing may help identify those who could benefit from violence prevention and substance abuse treatment.”

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Category: Trauma

Title: Are anti-coagulated elderly head injured patients at risk for delayed intracranial hemorrhage?

Keywords: head injury, anticoagulation, delayed, intracranial, warfarin, DOAC, risk (PubMed Search)

Posted: 2/18/2023 by Robert Flint, MD (Emailed: 2/19/2023) (Updated: 5/25/2024)
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This study looked at 69,321 head injured patients over age 65 in a health care database for delayed intracranial hemorrhage (within 90 days of visit). 58,233 patients were not on oral anticoagulants, 3081 (4.4%) were on warfarin and 8007 (11.6%) were on direct oral anticoagulants. One percent of patients not on anticoagulation and those on oral direct anticoagulation had a delayed hemorrhage while those on warfarin had a 1.8% delayed hemorrhage rate.

 

Bottom Line: Direct oral anticoagulants do not increase the risk of delayed intracranial hemorrhage in patients over age 65 from baseline but warfarin does. 

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Category: Trauma

Title: Trauma Patients and Substance Use Disorders

Keywords: substance abuse, alcohol abuse, SBIRT, intervention, FACS (PubMed Search)

Posted: 2/10/2023 by Robert Flint, MD (Emailed: 2/12/2023)
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In December 2022, The American College of Surgeons released a practice guidine discussing screening trauma patients for mental health disorders and substance use disorders. There is a very high likelihood that your acute trauma patient has a pre-existing disorder.

"Over 50% of hospitalized trauma patients report an alcohol and/or drug use diagnosis during their lifetime. At the time of admission, one in four trauma victims meet diagnostic criteria for an active alcohol use problem and 18% meet diagnostic criteria for a drug use problem".

Screening, Brief Intervention and Referal to Treatment (SBIRT) programs have a major impact on injury recidivism and future mortality. Trauma patients should be screened for mental health disorders and substance use disorders. 

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Category: Trauma

Title: Zone Out! Penetrating neck trauma

Keywords: penetrating neck trauma, zones, hard signs, operative management (PubMed Search)

Posted: 2/5/2023 by Robert Flint, MD
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Question

The classic teaching regarding penetrating neck trauma is violation of the platysma muscle in zones 1 and 3 requires angiography, endoscopy and bronchoscopy.  Injury to zone 2 is an automatic operative evaluation. Now, more anatomic and physiologic signs dictate operative management and those not meeting these hard signs get evaluated with Ct angiography. 

 

Neck zones and hard vs soft signs available by clicking link

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Category: Trauma

Title: How to identify blunt cervical vascular injuries

Keywords: Blunt neck trauma, Denver criteria, expanded Denver Criteria, cervical trauma (PubMed Search)

Posted: 1/29/2023 by Robert Flint, MD (Updated: 5/25/2024)
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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

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Category: Trauma

Title: Where and when should we intubate unstable trauma patients?

Keywords: trauma, unstable, intubation, arrest, resuscitate (PubMed Search)

Posted: 1/22/2023 by Robert Flint, MD (Updated: 5/25/2024)
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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:

 

  1. Resuscitate with mass transfusion and TXA
  2. If the OR is ready, do nothing else but facilitate rapid transfer to the OR
  3. If there is a delay in going to the OR, carefully monitor the patent's work of breathing and CO2. If they are tiring or have normal or rising CO2 then intubate.
    1. Weingart suggests that Ketamine dissociative intubation is the safest and most physiologic neutral way to accomplish airway control in these patients. (A skill that must be practiced!)
    2. Consider push dose pressors at the time of intubation

 

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. 

 

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Category: Trauma

Title: Should we be giving antibiotics prior to or after chest tube insertion

Keywords: chest tube, antibiotics, tube thoracotomy, prophylaxis, meta-analysis, EAST (PubMed Search)

Posted: 1/15/2023 by Robert Flint, MD (Updated: 5/25/2024)
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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.”

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Category: Misc

Title: Stabilizing the healthcare system

Keywords: Health policy, healthcare (PubMed Search)

Posted: 1/7/2023 by Robert Flint, MD (Updated: 5/25/2024)
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These two pieces from Becker’s Hospital Review demonstrate significant areas of weakness within the American healthcare system. Hospitals that care for underserved as well as medically and socially complicated patients should be afforded protection and financial security. Not only do they care for the most complex patients, they often educate the next generation of health care providers. 

 

The loss of small community or rural hospitals also has a major negative impact on the US health care system. For time sensitive conditions such as trauma, myocardial infarction or stroke these facilities are often the first, closest facility to initiate care or stabilization. The loss of these critical smaller hospitals also adds to the burden at already overwhelmed larger facilities. 

 

As medical providers, we are in a unique position to advocate for our patients, our co-workers and our communities. Join your professional societies (ACEP, AAEM, SAEM etc.), write your local and national representatives, find like minded colleagues, please get involved with the process any way you can.  As a nation we can not afford to lose large essential hospitals or small critical access, rural hospitals.

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Category: Trauma

Title: Pelvic fractures, compression and the need for education

Keywords: Pelvic Trauma, education, pelvic binder, hemorrhage control, pelvic compression (PubMed Search)

Posted: 1/1/2023 by Robert Flint, MD (Updated: 5/25/2024)
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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!

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Category: Trauma

Title: Predicting 30 day readmission in rib fracture patients

Keywords: Rib Fractures, re-admission, 30 day (PubMed Search)

Posted: 12/9/2022 by Robert Flint, MD (Emailed: 12/25/2022) (Updated: 5/25/2024)
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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.

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Category: Trauma

Title: Use of Serratus Anterior plane block for posterior rib fractures

Keywords: rib fracture, pain control, trauma, nerve block (PubMed Search)

Posted: 12/9/2022 by Robert Flint, MD (Emailed: 12/18/2022) (Updated: 5/25/2024)
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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.

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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

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Category: Trauma

Title: Novel prompt for hemmoragic shock resuscitation

Keywords: simulation, trauma, exsanguination, TACTICS, mass transfusion (PubMed Search)

Posted: 12/9/2022 by Robert Flint, MD (Emailed: 12/11/2022) (Updated: 12/11/2022)
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Question

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.

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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.

 

 

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Category: Trauma

Title: Trauma Center Accessibility

Keywords: level I, Level II, Level III, Trauma Center, Accessibility (PubMed Search)

Posted: 11/5/2022 by Robert Flint, MD (Emailed: 11/27/2022) (Updated: 11/26/2022)
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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?

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Category: Trauma

Title: A new approach to penetrating neck injuries?

Posted: 11/18/2022 by Robert Flint, MD (Emailed: 11/20/2022) (Updated: 5/25/2024)
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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. 

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Category: Trauma

Title: Pelvic Radiographs Utility in Elderly Fall Patients

Keywords: trauma, elderly, pelvic fracture, plain radiographs (PubMed Search)

Posted: 10/28/2022 by Robert Flint, MD (Emailed: 11/6/2022)
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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. 

 

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Category: Trauma

Title: Can you discharge a patient with seat belt sign?

Keywords: abdominal trauma, seat belt sign, Ct scan, discharge, hollow vicsus injury (PubMed Search)

Posted: 10/28/2022 by Robert Flint, MD (Emailed: 10/30/2022) (Updated: 10/30/2022)
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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.

 

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Category: Trauma

Title: Is obesity a protection in penetrating trauma?

Keywords: penetrating trauma, trauma, obesity, armour phenomenon (PubMed Search)

Posted: 10/12/2022 by Robert Flint, MD (Emailed: 10/23/2022) (Updated: 5/25/2024)
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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. 

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