UMEM Educational Pearls - Trauma

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: 2/22/2024)
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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: 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: 2/22/2024)
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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: Trauma

Title: Delirium and Trauma

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

Posted: 1/14/2024 by Robert Flint, MD (Updated: 2/22/2024)
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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: 2/22/2024)
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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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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: 2/22/2024)
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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: 2/22/2024)
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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: 2/22/2024)
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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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Category: Trauma

Title: ECMO in Trauma

Keywords: ECMO, Trauma, Survivial (PubMed Search)

Posted: 10/14/2023 by Robert Flint, MD (Emailed: 11/4/2023) (Updated: 2/22/2024)
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This systematic review and analysis found in 1822 trauma patients treated with ECMO:

-Overall 66% survival to discharge

-VV ECMO was significantly superior to VA ECMO

-Mean age was 35 years. Typical of ECMO use in trauma is younger healthier patients are chosen to receive ECMO

 

“ECMO is not a routine life-saving intervention following trauma, but rather a salvage therapy that effectively replaces conventional treatment for young, healthy patients when conventional methods fail. Its complexity requires a multidisciplinary healthcare team and sufficient resources for optimal implementation.”

 

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Category: Trauma

Title: Does empiric high dose cryoprecipitate added to MHP improve survival?

Keywords: transfusion, mass hemorrhage protocol, cryoprecipitate (PubMed Search)

Posted: 10/14/2023 by Robert Flint, MD (Emailed: 10/29/2023) (Updated: 2/22/2024)
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This large UK and US study looked at the addition of high dose cryoprecipitate to mass transfusion protocols and found:  “Among patients with trauma and bleeding who required activation of a major hemorrhage protocol, the addition of early and empirical high-dose cryoprecipitate to standard care did not improve all cause 28-day mortality.”

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Category: Trauma

Title: Challenges of resuscitation in pediatric trauma

Keywords: trauma, pediatrics, resuscitation, MTP, MHP (PubMed Search)

Posted: 10/14/2023 by Robert Flint, MD (Emailed: 10/22/2023) (Updated: 2/22/2024)
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This excellent review article discussing damage control resuscitation in traumatically injured children highlights several points including:

 

-”Damage-control resuscitation (DCR) consists of rapid control of bleeding, avoidance of hemodilution, acidosis, and hypothermia; early empiric balanced transfusions with red blood cells, plasma and platelets, or whole blood when available, and the use of intravenous or mechanical hemostatic adjuncts when indicated.”

 

-”he 30-day mortality in children with traumatic hemorrhagic shock is estimated to be 36% to 50% compared with the 25% reported mortality in similar adults. The early stages of hemorrhagic shock after injury in children can be more challenging to recognize because of their remarkable compensatory mechanisms. In children unlike adults, blood pressure alone is an insensitive indicator of hemorrhagic shock as hypotension is a late sign often not occurring until blood volume is reduced by >40%.”

 

-”Based on the current literature, the challenges health care providers must focus on are the early recognition of shock in the pediatric patient, moving the hemostatic resuscitation forward to the prehospital phase when feasible, improvement in times to first blood product, balanced resuscitation and efficiency of massive transfusion protocols (MTPs).”

 

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Category: Trauma

Title: Does REBOA improve survival in trauma patients?

Keywords: REBOA, trauma, survival (PubMed Search)

Posted: 10/14/2023 by Robert Flint, MD (Emailed: 10/15/2023) (Updated: 2/22/2024)
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This UK study randomized 90 trauma patients suspected of having major life threatening torso hemorrhage to receive standard resuscitative care vs. standard care plus resuscitative endovascular occlusion of the aorta (REBOA). Mortality was 54% in the REBOA group and 42% in the standard care group. This calls into question the routine use of REBOA in trauma resuscitations.

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Category: Trauma

Title: Large bore vs small bore chest tube for traumatic hemothorax

Keywords: Chest tube henothorax (PubMed Search)

Posted: 10/8/2023 by Robert Flint, MD (Updated: 2/22/2024)
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This article reminds us that using a small bore chest tube to drain traumatic hemothorax is supported by small studies and the Easterm Society for the Surgery in Trauma. 

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Category: Trauma

Title: Hypertonic Saline or Mannitol for Head Injury?

Keywords: Head injury mannitol saline ICP (PubMed Search)

Posted: 10/1/2023 by Robert Flint, MD (Updated: 2/22/2024)
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"The main findings were the following: (1) there was no evidence of an effect of HTS compared with other agents (mainly mannitol) on long-term neurological outcome in patients with raised ICP; (2) similarly, there was no evidence of a beneficial effect of HTS on all-cause mortality, uncontrolled ICP, length of hospital or ICU stay, and ICP reduction; and (3) HTS may be associated with increased risk of adverse hypernatremia.”

 

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Category: Trauma

Title: Rural damage control laparotomy can be life saving

Keywords: rural, trauma, laparotomy, damage control (PubMed Search)

Posted: 8/19/2023 by Robert Flint, MD (Emailed: 9/10/2023) (Updated: 2/22/2024)
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For rural emergency departments, the decision to transfer a trauma patient to a level one center involves multiple factors including the patient’s hemodynamic stability. Harwell et al. looked at 47 trauma patients transferred from a rural hospital to a level one center. They found: “Overall mortality was significantly different between patients who had damage control laparotomy at a rural hospital (14.3%), were unstable transfer patients (75.0%), and stable transfer patients (3.3%; P < 0.001).”  They concluded: “Rural damage control laparotomy may be used as a means of stabilization prior to transfer to a Level 1 center, and in appropriate patients may be life-saving.”

Preplanning with emergency medicine, surgery, radiology, anesthesia, nursing, and the receiving trauma center on how to manage these patients is critical.  

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