UMEM Educational Pearls - Trauma

Category: Trauma

Title: Chest X-Ray is not a reliable screening tool for blunt aortic injury

Keywords: CXR, blunt aortic injury (PubMed Search)

Posted: 4/30/2023 by Robert Flint, MD (Updated: 3/3/2024)
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Category: Trauma

Title: Cervical Spine Injuries in Patients Over Age 65

Keywords: elderly, cervical spine, trauma, systematic review (PubMed Search)

Posted: 3/28/2023 by Robert Flint, MD (Emailed: 4/16/2023) (Updated: 3/3/2024)
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In a systematic review looking at patients over age 65 who sustained a cervical spine injury from a low-level fall, there was a 3.8% prevalence of injury identified. The paper could not correlate injury with GCS level or altered level of consciousness due to the quality of the data available.

Bottom line again is patients over age 65 with low-level falls should be considered to have significant injury until proven otherwise.

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Category: Trauma

Title: IM TXA?

Keywords: TXA, intramuscular, pre-hospital (PubMed Search)

Posted: 3/28/2023 by Robert Flint, MD (Emailed: 4/9/2023) (Updated: 3/3/2024)
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This paper looks at the possibility of intramuscular tranexamic acid (TXA) administration. Pharmacologic studies support this route as giving correct drug bioavailability to control hemorrhage. Several London, England pre-hospital services have begun using intramuscular TXA for trauma patients when intravenous access cannot be quickly obtained. This paper suggests 500 mg intramuscular injection dosing. 

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Category: Trauma

Title: Traumatic injuries associated with sexual assault

Keywords: sexual assault, injury, trauma, intimate partner violence (PubMed Search)

Posted: 3/28/2023 by Robert Flint, MD (Emailed: 4/2/2023) (Updated: 3/3/2024)
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A retrospective review of patients over age 13 presenting to one urban level one trauma center and one urban community hospital looked at traumatic injuries in patients presenting for sexual assault. They looked at 157 patients and found 61% of assailants were acquaintances, 22% strangers, and 15% intimate partners. One third of all patients had some traumatic injury however only 12 patients has serious injuries such as non-fatal strangulation or a fracture. Assault by an intimate partner was more likely to lead to injury/trauma including non-fatal strangulation. Drug and alcohol use was not associated with presence of injury.

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Category: Trauma

Title: Hypoxia is bad for traumatically brain injured patients

Keywords: Head injury, TBI, oxygenation, hypoxia, outcome, (PubMed Search)

Posted: 3/26/2023 by Robert Flint, MD (Updated: 3/3/2024)
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This study is a secondary analysis of another studying looking at hypertonic saline in traumatic brain injury (TBI) making it not the most robust study however it found that TBI patients who’s PaO2 dropped below 100 had a worse outcome than those whose PaO2 did not fall below 100.

 

Bottom line: This is a reminder that traumatic brain injury patients do not do well with hypoxia or hypotension even if transient (during intubation, etc.). Pre-oxygenate and resuscitate prior to intubation and maintain oxygen saturations in the mid-90s for your traumatic brain injured patients.  This applies to prehospital, emergency department, and ICU settings

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Category: Trauma

Title: Predicting mass transfusion with RABT

Keywords: trauma, whole blood, reduction, blood products, MHP, Shock index, RABT, hemorrhage (PubMed Search)

Posted: 3/19/2023 by Robert Flint, MD (Updated: 3/3/2024)
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Predicting the need for a mass hemorrhage protocol (MHP) activation is important both for individual patient outcome as well as for proper utilization of critical resources such as blood products and healthcare workers time and effort. These two studies look at using the RABT score to predict the need for mass transfusion. The RABT score is:

A 4-point score

blunt (0)/penetrating trauma (1),

shock index (hr/SBP)≥ 1 (1),

pelvic fracture (1)

FAST positive (1)

With a score >2 predictive of needing MHP.

 

These studies (one in Canadian trauma centers, the other in US trauma centers) validate the use of this score to predict the need for activation of a mass hemorrhage protocol.

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Category: Trauma

Title: Thoracic trauma as a predictor of 30 day mortality

Keywords: thoracic trauma, rib fractures, Sweden, trauma, 30 day mortality (PubMed Search)

Posted: 3/12/2023 by Robert Flint, MD (Updated: 3/3/2024)
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This study from Sweden looked at 2397 trauma patients and identified 768 with thoracic injury. Those with thoracic injury had a 30-day mortality of 11% whereas those without thoracic injury had a 4% 30-day mortality. Patients over age 60 had higher mortality and were more likely to have rib fractures. Those under 60 with thoracic injury were more likely to have thoracic organ injury than rib fracture.

 

Bottom line: Rib fractures were more common over age 60 and there was a higher mortality for those with thoracic vs non-thoracic trauma.

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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: 3/3/2024)
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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: 3/3/2024)
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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: 3/3/2024)
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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: 3/3/2024)
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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: 3/3/2024)
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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: 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: 3/3/2024)
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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: 3/3/2024)
Click here to contact Robert Flint, MD

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: 3/3/2024)
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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)
Click here to contact Robert Flint, MD

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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