TRAUMA REVIEW
From the USC Trauma/Critical Care Symposium, sponsored by Keck School of Medicine of the University of
Southern California, Los Angeles, and the Institute of Continuing Education for Nurses
| TRAUMA LABORATORIES: WHAT THEY REALLY MEAN —William K. Mallon, MD, Associate Professor of
Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles
|
| Wasteful use of resources: computed tomography (CT) overused at cost of time and money; “per protocol” greatest offender
(advanced trauma life support [ATLS] assumes “one size fits all”); protocols poor substitutes for observation
and good medical judgment; literature full of evidence that tests should not be performed per protocol
|
| Type and cross: efficient ratio is to type and cross 3 patients for every one transfused; whether patient needs type and
hold vs type and cross easily determined using simple readily available data, saving time, money, and blood; some institutions
performing type and cross in 78 patients for every one transfused; if no risk factors present, patient does not
need blood; one institution asked for patient’s blood pressure (BP) in field and obtained type and cross only if BP low,
saving much money and resulting in no delays in delivering blood products to patients who needed them
|
| Surgical amylase: futility well documented in surgical literature, but some surgeons still ask for it
|
| Lipase: other ways to look for pancreatic injuries; test has low yield; false-positive results more common than true positives,
causing further testing, added expense, and longer hospital stay
|
| Laboratory and bedside tests: electrolytes have indications; one institution obtained only venous blood gas (VBG) and
alcohol level, unless specific indicators present, resulting in reduction in specimens of 27% and savings of $68/patient
(cost, not charges; no adverse outcomes noted)
|
| Utility and costs of admission chemistry panel: done on 91% of patients, even though most were young and had no indications;
only 0.5% had intervention based on this test (intervention was adding potassium to solution; no documentation that it
helped); “let’s stop sending sodiums on a 20-yr-old who crashed his motorcycle”; at one hospital, cost savings of $777,000/
yr realized by eliminating amylase and coagulation tests
|
| Blood-draw anemia: should do better at reducing sample volume
|
| Toxicology screens: false-positives 20% to 30%, false-negatives 20% to 30%; not useful forensically in most states; almost
never result in treatment change; getting alcohol level does not change management (patient in withdrawal has clinical
presentation); study showed no patient had early changes in management based on drug screens (eliminating test saved
$171,000); limited utility supported in many other studies
|
| Preoperative testing: determining which test patient needs from history and physical more effective than routinely testing
everyone; saves $80/patient
|
| GREAT MYTHS AND FALLACIES IN TRAUMA —Kenneth L. Mattox, MD, Professor and Vice Chairman, Michael
E. DeBakey Department of Surgery, Baylor College of Medicine, and Chief of Surgery, Ben Taub General Hospital,
Houston, TX
|
| Introduction: change always with us and often resisted; myths exist and need to be changed; everyone influenced by past
techniques, bias, and legends, and have preconceived notions
|
| Certificate of need to develop hospitals: regulatory mandate invented to limit new hospitals; wrong logic; part of development
of managed care practice
|
| Physicians in ambulance: currently European model, especially in France; poorly studied; political turf involved;
changing in rural France
|
| Needle thoracic decompression: assumes tension pneumothorax; no supportive data for this procedure; high potential
for injury and death (3 deaths this year in Houston alone); should be under direction of receiving trauma surgeon; adverse
effects include systemic air embolism, pulmonary hematoma, and vascular injury
|
| American College of Surgeons optimal resource document: second version recommended firearms be carried on helicopters
to shoot snakes; recommendation removed; however, redundant drugs, gadgets, and recommendations for ambulances,
emergency departments (EDs), and trauma centers still exist
|
| Speeding ambulance with red lights and sirens: has no basis; does not decrease time it takes to get to hospital; long-
standing tradition; contributes to accidents
|
| Helicopter transport: logical for military in war zone; no data to support civilian use; urban use increases death rate, increases
time to hospital, and cost 10 times higher than ground ambulance; significantly overused
|
| Rapid sequence intubation in field: “an ego trip”; ties hands of emergency center (EC) surgeons and emergency physician;
rarely quality assessed and should be eliminated
|
| Golden hour of trauma: not proven, despite multiple studies; “time as an independent variable does not influence outcome
if this is true, maybe our entire concept of ambulance, emergency medicine, and trauma surgeons and system
need to be changed”
|
| Cardiopulmonary resuscitation (CPR): “biggest hoax ever perpetrated on mankind”; no cases of trauma patients surviving
unless intubated within 10 min; if not intubated, speaker has not seen any survivors who received CPR >4 min
|
| Antecubital fossa as intravenous (IV) site: causes infiltrates and eliminates more peripheral sites; ties hands of anesthesiologist;
“is an ego trip for the people that work in the emergency room”; causes forearm compartment syndrome
|
| Military antishock trousers (MAST): designed to raise BP; do not autotransfuse; increase compartment syndromes; increase
afterload; creates additional problems in patient with pelvic fracture; increases cardiac workload; increases rate
of bleeding; increases chances of dying
|
| BP as end point: low BP protective in trauma; BP extremely variable; creates false objectives; presence of pulse better
end point
|
| Aggressive IV fluid administration: activates cytokines; increases death rate; worst of all myths
|
| Intraosseous fluid infusion: no data to support this tactic in anyone at any time in trauma; based on logic that fluid increases
BP and elevation of BP increases survival; however, these concepts wrong
|
| Plasma and albumin: plasma used during second world war when blood banking not yet developed; albumin use outgrowth
of plasma use; albumin given IV gets into interstitial space and increases pulmonary insufficiency, among
other adverse effects, and should not be used
|
| Pericardiocentesis: included in ATLS and advanced cardiac life support (ACLS) courses; speaker has never seen
trauma patient benefit from it
|
| Single-shot intravenous pyelography (IVP): nephrotoxic in hypotensive patients; many other options available to evaluate
kidney function
|
| Skull x-rays in head trauma: replaced by CT; absence or presence of fracture does not rule out intracranial injury
|
| Abdominal focused assessment with sonography for trauma (FAST) examination: overrated; helpful with hemopericardium,
but can be confusing in patients with abdominal fluid; no use in prehospital phase; often followed by other
tests; not helpful in penetrating wounds; confusing in blunt trauma
|
| Trauma laboratory panel: results rarely affect therapy; often delays response; not consistently applied from one center
to another; do not order test if unable to write progress note indicating how management will change if test positive
|
| Practice guidelines, best practices, clinical pathways: helpful as educational tools but when applied to individual patient,
remove judgment and assume all biologic responses identical
|
| Family in shock room during procedures: “dumb idea”; 3 wives of one patient appeared, did not know about each others’
existence; one wife shot another wife
|
| Acute CT evaluation of acute chest injury: no indication except for mediastinal traverse; does not provide any useful
information not present on initial chest x-ray; always leads to additional tests; overread by radiologists; newer CT images
produce more confusion; high cost and radiation; shows hematomas; does not show aortic injuries; leads to vomiting;
high risk for lawsuits
|
| No operation for splenic injuries: overrated; now seeing late complications of splenic injuries; longer and more complex
follow-up in patients with splenic salvage; if spleen injured and patient needs 1 unit of blood, spleen needs to be removed
|
| Anesthesia’s use of pressor agents: makes record look good; bursts clots, impairs heart and blood vessel repair, increases
cardiac workload, does not improve outcome
|
| Use of pledgets in cardiac wounds: does not distribute suture forces; covers large holes; increases bleeding from new
tears; makes suturing more difficult
|
| Clamping chest tubes: only indication is anticipatory autotransfusion
|
| Keyhole incision subxiphoid pericardiotomy: no indication with suspected heart wound; no prospective randomized
trials to support it; creates new problems
|
| Cardiac contusion: misnomer; does not fully describe range of cardiac injury; better description blunt cardiac injury
with electrocardiographic (ECG) abnormality
|
| Steroids: wonderful for patients with adrenal insufficiency; no study shows any functional benefit from steroids; complications
of steroids well known; use should be stopped in spinal cord injury and taken out of ATLS course
|
| Conclusion: new trauma myths and fallacies emerging daily; medical advances of future will be determined by what clinicians
have courage to change
|
| HELPING THE ORGAN SHORTAGE WITH NONBEATING ORGAN DONORS —Bradley J. Roth, MD, Assistant
Professor of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles
|
| Incidence: nonheart-beating donation (donation after cardiac death) gets little press because of low incidence
|
| Potential organ donors: if death occurs, try to eliminate deceleration of care by continuing resuscitation, so transplant
recipient benefits maximally; case of 15-yr-old boy with self-inflicted gunshot wound to head
|
| Steps to salvaging organs: identify terminal patient in intensive care unit (ICU); family requests stopping care; notify
organ procurement organization (OPO); OPO approaches family; Wisconsin Criteria used to assess if patient qualifies
as organ donor; transplant team and operating room (OR) notified; patient taken to OR; must have physician champion
to support physician through process and reassure other clinicians and staff about process; many health care providers
have problems allowing patients to die in OR; speaker, therefore, asks for volunteers; some hospitals require
protocols; if so, speaker suggests protocol allow flexibility
|
| Conclusion: nationwide protocol being developed for this type of organ donation
|
| COMPLICATIONS FROM STREET DRUGS —Edward J. Newton, MD, Professor of Clinical Emergency Medicine,
and Chair, Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los
Angeles
|
| Alcohol: causes most complications with trauma; produces more trauma than any other drug; involved in ≈50% of all
trauma deaths, 70% of all fatal motor vehicle accidents; intoxication worsens outcomes and complicates evaluation;
intoxicated patients more likely to have drop in BP or to stop breathing during anesthesia or procedural sedation; alcohol
withdrawal complicates recovery
|
| Drug-related ED visits: peak incidence from adolescence to age 20 yr (overlaps with peak trauma years); patients
mostly male
|
| Cocaine: responsible for 44 ED visits/100,000 population (most not traumatic); cocaine trade very violent; gives state of
euphoria followed by resumption of craving; users adjust to autonomic effects, but psychiatric effects cumulative;
causes seizures, dysrhythmias, paranoia, psychosis, multiorgan failure (generally induced by hyperthermia), high BP,
fast heart rate; do not use β-blockers (will increase BP); benzodiazepines best antidote (decrease brain epinephrine and
norepinephrine)
|
| Methamphetamine: rural epidemic gradually spreading to cities; almost all high-speed car chases involve methamphetamine
use; induces intense paranoid psychosis; highly volatile while being synthesized; very addictive; less expensive
and longer lasting than cocaine (half-life 7 to 34 hr vs 30 min for cocaine); has same effect as cocaine but induces
more paranoid psychosis; patients very violent and have more strength than usual; cannot calm them down by talking
to them; has strong autonomic effect
|
| 3,4-methylenedioxymethamphetamine (MDMA): derivative of methamphetamine; street name Ecstasy; has strong
hallucinogenic effect; most users 15 to 17 yr of age; expensive; used more by middle class kids; has empathogenic
effect (ie, going to party with 1000 very best friends); urban myth that it dries out spinal fluid; users commonly
drink copious amounts of water and develop hyponatremia; produces syndrome of inappropriate secretion of antidiuretic
hormone (SIADH) and hyperthermia; check creatine phosphokinase (CPK) and urinalysis; patients can have
renal failure, stroke, myocardial infarction (MI), congestive heart failure (CHF), and liver failure; can develop extreme
hyperthermia (temperatures up to 108° F) and must be cooled quickly (icepacks in groin and axillae, irrigation
of stomach or bladder with iced saline)
|
Educational Objectives
| The goal of this program is to educate the listener about trauma. After hearing and assimilating this program, the clinician
will be better able to:
|
 | 1. Discuss laboratory tests per protocol as a waste of resources.
|
| 2. Debate the utility of toxicology screens.
|
| 3. Name at least 5 myths and fallacies in trauma care.
|
| 4. Illustrate an example of a nonheart-beating donor.
|
| 5. List the most common drugs of abuse associated with trauma and describe the management of each type of intoxication.
|
Discussed on This Program
Cocaine [Cocaine HCl, Cocaine Viscous]
Dobutamine [Dobutrex]
Dopamine HCl [Intropin, Dopamine HCl in 5% Dextrose]
Epinephrine (many trade names)
Heroin HCl (diacetylmorphine HCl)
Lorazepam [Ativan, Lorazepam Intensol]
Methamphetamine HCl (desoxyephedrine HCl) [Desoxyn]
Norepinephrine bitartrate (levarterenol) [Levophed]
Programs of Related Interest
Jackimczyk KC, Avner JR: Spine and head trauma. Audio-Digest Emergency Medicine 23:07(Apr 7), 2006; McSwain
NE Jr et al: Trauma: the surgeon’s perspective. Audio-Digest Emergency Medicine 22:09(May 7), 2005; McGonigal
MD et al: Issues in trauma and critical care surgery. Audio-Digest General Surgery 52:11(Jun 7), 2005; Plumley DA,
Scalea TM: Trauma from beginning to end. Audio-Digest Emergency Medicine 21:20(Oct) 21, 2004.
To Order, Contact Subscriber Service (1-800-423-2308)
Suggested Reading
Baker JB et al: Type and crossmatch of the trauma patient. Trauma 50:878, 2001; Bell MD: Non-heartbeating organ
donation: clinical process and fundamental issues. Br J Anaesth 94:474, 2005; Blaisdell FW: Trauma myths and magic:
1984 Fitts lecture. J Trauma 25:856, 1985; Demetriades D et al: Alcohol and illicit drugs in traumatic deaths: prevalence
and association with type and severity of injuries. J Am Coll Surg 199:687, 2004; Grupp-Phelan J et al: How rational
is the crossmatching of blood in a pediatric emergency department? Arch Pediatr Adolesc Med 150:1140, 1996;
Himmelseher S et al: Revising a dogma: ketamine for patients with neurological injury? Anesth Analg 101:524, 2005;
Jacobs IA et al: Cost savings associated with changes in routine laboratory tests ordered for victims of trauma. Am Surg
66:579, 2000; Lucas CE: The impact of street drugs on trauma care. J Trauma 59:S57, 2005; Miller MS et al: Negative
pressure wound therapy: "a rose by any other name". Ostomy Wound Manage 51:44, 2005; Myers C: Fluid resuscitation.
Eur J Emerg Med 4:224, 1997; Namias N et al: Utility of admission chemistry and coagulation profiles in trauma
patients: a reappraisal of traditional practice. J Trauma 41:21, 1996; Paauw DS: Did we learn evidence-based medicine
in medical school? Some common medical mythology. J Am Board Fam Pract 12:143, 1999; Tzovaras G et al: New
trends in the management of colonic trauma. Injury 36:1011, 2005; Vincent JL et al: Anemia and blood transfusion in
critically ill patients. JAMA 288:1499, 2002; Wiedeman JE et al: Civilian versus military trauma dogma: who do you
trust? Mil Med 164:256, 1999.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the speakers
reported no conflict.
The speakers on this program were recorded at the USC Trauma/Critical Care Symposium, held May 23-24, 2005, in
Pasadena, CA, and sponsored by the Division of Trauma/Critical Care and the Office of Continuing Medical Education,
Keck School of Medicine of the University of Southern California, Los Angeles, and the Institute of Continuing Education
for Nurses, Department of Nursing, Los Angeles County/USC Medical Center. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
|
