TRAUMA AND VIOLENCE
| PITFALLS IN TRAUMA MANAGEMENT —Robert C. Mackersie, MD, Professor of Surgery, University of California,
San Francisco, School of Medicine, and Director, Trauma Services, San Francisco General Hospital Medical Center
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| Threat and error containment: error types—technical (skill-based); protocol (procedural; rule-based); communication,
eg, during hand-offs between shifts; decision (knowledge-based); intentional noncompliance with protocols;
threats—related to practice environment; external (environment; patient’s condition; staffing; equipment availability;
volume of patients); internal (conflicts within team of providers; proficiency or lack thereof; fatigue); latent (lack of
training programs, policies, and/or protocols; risky equipment; occult injuries)
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| Case examples of importance of early threat recognition and management: patient with severe pelvic
fracture from major motor vehicle accident (MVA)—brought in with systolic blood pressure (BP) of 80 mm Hg; after
fluid resuscitation, BP rose to 120 mm Hg, then fluctuated over next 2 hr; computed tomography (CT) showed major
extravasation from pelvic fracture, but because patient talking, and because BP intermittently rose to >100 mm Hg, assumption
made that patient vasovagal and essentially fine; patient died; (example of mistake in management due to
false attribution and lack of error recognition and containment); MVA patient with altered mental status (Glascow
Coma Score of 13)—CT showed subdural hematoma (SDH) classified by neurosurgeons as “very high risk” for bleeding;
patient returned to emergency department (ED), not intubated, and lined up for transfer to intensive care unit
(ICU); external threats—high-volume chaotic ED; end of shift; many per diem workers due to illnesses and vacancies;
internal threats—only radiology resident on duty (no experienced attending); multiple services caring for patient; latent
threats—inadequate training for per diem workers; no protocol for expediting high-risk unintubated brain injury
patients; trauma rooms designed for 1 patient but used for 2; results—monitors switched; progression of SDH; progressive
obtundation; airway obstruction; respiratory arrest; secondary hypoxia; transient hypotension; death from “otherwise
survivable injury”; errors in case management—inadequate communication about high-risk status; failure to
recognize high-risk nature of patient status; inadequate monitoring of patient upon return to ED; improper use of monitoring
equipment; specific errors—false attribution (abnormal clinical observation linked to erroneous cause and incorrectly
acted on or ignored); false-negative prediction (overestimation of negative predictive power of test); labeling
(giving patient presumptive diagnosis upon presentation and working up for that, rather than pursuing correct diagnosis)
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| Underresuscitation: causes include—reliance on inappropriate end points (eg, BP); no or inadequate preload monitoring,
eg, central venous pressure line (surrogate for right atrial pressure); normovolemia—critical in traumatic
brain injury patients; sudden neurosurgical release of intracranial pressure may lead to sudden death due to decrease in
BP in already hypovolemic patient; extensive repair of orthopedic injuries may also result in hypovolemia; lactic
acidosis—major problem with underresuscitation; in muscle ischemia-reperfusion injuries, reperfusion precursor of
acute respiratory distress syndrome (ARDS) and multiple organ failure; underresuscitation single biggest cause of delayed
or early-onset coagulopathies associated with certain traumatic injuries; transesophageal echocardiography—
proving invaluable tool for assessment of trauma resuscitation; allows visualization of tachycardic underresuscitated
heart; can lead to change in management early in trauma
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| Overresuscitation: false attribution—“all hypotension is hypovolemia,” and “if a little fluid is good, more is better”;
can lead to overresuscitation; studies suggest that “permissive hypotension” effective in managing select group of
patients with major penetrating vascular injuries; massive overresuscitation—can cause edema and acute lung injury
(eg, ARDS) in patient with pulmonary contusion, and secondary abdominal or lower extremity compartment syndromes;
hemodilution can produce more edema and more coagulopathy; overresuscitation with normal saline solution
results in nongap acidosis, worsening strong ion difference, and more acidosis
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| Procedural pitfalls: chest tubes—be cognizant of location when placing chest tubes; do not compromise efficacy of
procedure by making too-small incision; larger incision facilitates correct placement of tube; diagnostic peritoneal lavage
(DPL)—focused abdominal sonography for trauma (FAST) examination has almost completely replaced DPL
for assessment of blunt trauma; however, for detecting intra-abdominal hemorrhage in penetrating abdominal trauma,
DPL better, and sensitivity and specificity can be adjusted by changing cell-count threshold; “central” femoral
lines—pitfalls in placement related to sliding friction; when placing catheter, must be sensitive to resistance to catheter
sliding; if skin incision made for placing line too small, impossible to distinguish resistance caused by artery from
resistance caused by skin; as with chest tubes, making large enough incision eliminates problem; saphenous vein
cutdowns—if necessary, ankle safe place to do it; in many cases, can feel saphenous vein lying against fascia
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| Victim of modern imaging technology (VOMIT) syndrome: history of imaging characterized by dramatic increases
in information; general assumption that more information better; threshold for imaging continues to drop; decreased
thresholds increase application of technology to asymptomatic population; as accuracy of methods increases,
so also does blind faith in diagnostic infallibility; end result errors in diagnosis and management; case examples;
avoiding VOMIT syndrome—more imaging also means more errors; use screening studies carefully; interact directly
with radiologist; look for corroborative evidence when findings do not make sense; when all else fails, do physical examination
(PE)
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| Blunt intestinal injury (BII): mechanism—high-speed MVA; hints to diagnosis include seatbelt sign and pain; patient
may not present with abdominal findings; laboratory studies nonspecific, eg, elevated white blood cell count; CT
mandatory for any patient with abdominal pain and/or tenderness, seatbelt sign, or abdominal ecchymosis; when considering
BII, intraluminal contrast enables distinction between intra- and extraluminal fluid in pelvis; unexplained free
peritoneal fluid one of keys to diagnosis of BII; other findings may include nonspecific thickening of small-bowel
wall and adjacent mesenteric stranding; ask radiologist whether signs present suggesting BII; management—doing
nothing not option; if CT abnormal and BII suspected, consult surgery; in alert and cooperative patient with benign abdominal
examination, seatbelt sign, and CT showing small amount of free peritoneal fluid, observation and repeat CT
reasonable; DPL stratifies patients (eg, clear ascitic fluid, blood-stained fluid, “peas-and-carrots” lumps in fluid); laparoscopy;
laparotomy if patient deteriorates or studies suggest worsening process; timing (unlike penetrating trauma,
BII patients become severely ill within 18-24 hr)
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| Penetrating and blunt extremity injury: ankle brachial index (ABI)—systolic BP measured in corresponding
arm or contralateral leg and compared to BP in at-risk extremity (ABI <0.9 abnormal, <0.7 means serious disease and
indication for early arteriography); lack of hard signs (eg, active bleeding; clear pulse deficits; expanding hematoma)
does not exclude injury; look, listen, and feel (injuries missed with ABI are arteriovenous fistulas and pseudoaneurysms);
watch for signs of developing compartment syndrome, especially in highly resuscitated patients (PE and direct
measurement advised)
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| Penetrating neck injuries: expanding hematoma, active bleeding, bruit, thrill, pulse deficit, and attributable central
nervous system deficit require immediate surgical exploration; vascular clinical signs—hematoma; history of wound
hemorrhage; associated hemo- or peneumothorax; mediastinal hematoma; prevertebral widening; adjacent nerve deficit;
CT indicated; aerodigestive clinical signs—blood or bleeding; air emanating from wound; dysphagia; hoarseness;
altered phonation; air in soft tissue on cervical x-ray or CT; crepitus near wound; respiratory stridor; all these
elements should be on protocolized checklist; if ≥1 present, further evaluation and management required; if all negative,
low likelihood of significant reparable neck injury
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| Penetrating chest injury: air embolism—not seen often; classic example overventilation in intubated patient with
central penetrating wound and major pneumothorax or hemopneumothorax; results in immediate cardiac arrest; avoid
by not using positive-pressure ventilation unless absolutely necessary (if needed, use low tidal volume and low pressure);
indication for immediate thoracotomy (usually cannot be done fast enough); endobronchial hemorrhage—
occurs when air from pulmonary artery goes into bronchus; long-term outcome after surgery in patients with penetrating
chest trauma (given same injury severity) depends more on degree of endobronchial hemorrhage than anything
else; complications include chest infection, ARDS, prolonged sepsis, and late organ failure; emergent management (if
on left side, right mainstem intubation; anesthesiologist can sometimes get bronchial blocker into bronchus and keep
one lung from flooding other); massive hemothorax—rare occurrence after chest tube placement in hypotensive patient;
recommended management clamping chest tube and rushing patient to operating room (OR); autotransfusion no
longer done
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| Penetrating cardiac tamponade: FAST examination best advance in diagnosis of penetrating cardiac injuries (extremely
sensitive and easy to read); however, beware of false-negative results (eg, patient with penetrating cardiac injury
but big enough hole in pericardium that decompression into chest occurs; patients present with large hemothorax;
on FAST examination, might see small amount of blood but no tamponade); trap of easy resuscitation and transient
hemodynamic improvement—cardiac tamponade is compartment syndrome of heart; patient’s BP can rise with just
few hundred milliliters of fluid, giving appearance of easy resuscitation; however, heart becoming progressively ischemic,
and patient must be taken to OR quickly; trap of premature intubation—administering positive-pressure ventilation
too early can “shove” patient down preload curve to point of cardiac arrest; case examples; intubation
sometimes necessary, but avoid prophylactic intubation in patients with cardiac injury
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| VIOLENCE PREVENTION PROGRAMS: ARE THEY DOING THEIR JOB ?—Edward E. Cornwell III, MD, Professor
of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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| Introduction: speaker’s study looked at program at level I trauma center and its impact on patient care and outcome;
compared 3-yr periods before and after changes made at trauma center; concluded that while implementation of dedicated
trauma program associated with significant drop in overall mortality (predominantly in blunt trauma patients),
no progress made in saving lives of patients with gunshot wounds (GSW); in second 3-yr period, 43 patients with
GSW survived to leave ED, then went on to die; significantly greater percentage of all patients with GSW (nearly 1 in
8) dead on arrival (DOA) at trauma center or in extremis; patients 15 to 24 yr of age represent 30% of all trauma patients
who present at speaker’s center, but 70% of those with GSW
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| Efficacy of in-hospital programs: speaker offers example of experience at his trauma center (during 1 wk in June
2006, over 5 consecutive nights, 5 attending physicians each had case with 20-yr-old man; 4 had GSW; 1, stab wound;
3 DOA); at speaker’s center, 99% of patients who leave ED alive survive; yet, in 2005, center had 88 patient deaths
(61 DOA; of remaining 27, 14 had GSW to head and declared dead after brain-death protocols completed in ICU;
even theoretic chance of saving patient in only 13 cases); speaker believes medical centers reaching glass ceiling for
in-hospital efforts to save more patient lives
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| What hospital-based violence-prevention outreach program should look like: citing another study,
speaker suggests that to be effective, program should be located within hospital’s catchment area; true violence prevention
(for center such as speaker’s, where deaths disproportionately young people who arrive DOA) must be centered
outside walls of hospital; by time people arrive at center, in-hospital intervention “just too late”
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| Hopkins Injury Prevention and Community Outreach Collaborative (HIPCOC): utilizes trauma center’s
relationship with nearby police athletic league; includes “rap with doc” sessions (focusing on violence, alcohol,
drugs, and guns) and slide presentations depicting graphic reality of violence and trauma; goal of program to remove
glamour from culture of violence and to illustrate long-term rehabilitation and disability that follow gun violence; program
efficacy—results in first 97 youths to complete program (with mean 28-day follow-up), show short-term
changes in attitudes about conflict and aggression; greater (and more difficult) challenge achieving impact on society
at large
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| What needs to be done: health care professionals must speak out, in symposia and in publications, about youth violence
and related topics (eg, poverty, criminal justice system, gun control, race, drugs and alcohol, access to health
care); new public health challenge images in popular culture that glamorize and romanticize youth violence; to attack
this, speaker’s office has created 3-min video that contrasts romanticized violence of rap music video with reality of
GSW victims from speaker’s trauma center
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| Conclusions: trauma center–based violence prevention program may produce modest changes in attitudes toward violence,
but major societal challenges in producing greater impact against background of culture of violence
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Educational Objectives
| The goal of this program is to review potential pitfalls in trauma management and to provide a brief discussion of the
efficacy of trauma center-based violence prevention programs. After hearing and assimilating this program, the listener
will be better able to:
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 | 1. Identify external, internal, and latent threats in his or her working environment.
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| 2. Recognize and contain errors (eg, technical, communication, decision-making) that occur during the management
of trauma patients.
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| 3. Avoid potential pitfalls in the management of patients with blunt intestinal injuries, extremity injuries, and
penetrating neck, chest, and cardiac injuries.
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| 4. Describe supporting evidence for the efficacy of violence-prevention programs.
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| 5. Discuss the challenges in attempting to reduce traumatic deaths through in-hospital or outpatient violence-prevention
programs.
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Discussed on This Program
0.9% Sodium Chloride Irrigation
Dextrose-electrolyte solutions [many trade names and formulations]
Lactated Ringer’s Irrigation
Mannitol [Osmitrol, Resectisol]
Suggested Reading
Asensio JA et al: Penetrating cardiac injuries: a complex challenge. Surg Today 31:1041, 2001; Brody JM et al:
CT of blunt trauma bowel and mesenteric injury: typical findings and pitfalls in diagnosis. Radiographics 20:1525,
2000; Burns JM et al: The role of transesophageal echocardiography in optimizing resuscitation in acutely injured
patients. J Trauma 59:36, 2005; Chang DC, Cornwell EE 3rd et al: A multidisciplinary youth violence-prevention
initiative: impact on attitudes. J Am Coll Surg 201:721, 2005; Chang D, Cornwell EE 3rd et al: Community
characteristics and demographic information as determinants for a hospital-based injury prevention outreach program.
Arch Surg 138:1344, 2003; Collins D: Aetiology and management of acute cardiac tamponade. Crit Care Resusc
6:54, 2004; Cornwell EE 3rd et al: Enhanced trauma program commitment at a level I trauma center: effect
on the process and outcome of care. Arch Surg 138:838, 2003; Cornwell EE 3rd : Violence, guns, and race: health-
care professionals must speak out. J Natl Med Assoc 86:333, 1994; Demetriades D et al: Evaluation of penetrating
injuries of the neck: prospective study of 223 patients. World J Surg 21:41, 1997; Efron DT et al: Alarming surge
in nonsurvivable urban trauma and the case for violence prevention. Arch Surg 141:800, 2006; Enriquez SG et al:
Delayed pericardial tamponade after penetrating chest trauma. Eur J Emerg Med 12:86, 2005; Goudy SL et al:
Neck crepitance: evaluation and management of suspected upper aerodigestive tract injury. Laryngoscope 112:791,
2002; Heng K et al: Complications of intercostal catheter insertion using EMST techniques for chest trauma. ANZ J
Surg 74:420, 2004; Maxwell RA et al: Secondary abdominal compartment syndrome: an underappreciated manifestation
of severe hemorrhagic shock. J Trauma 47:995, 1999; Miller MT et al: Not so FAST. J Trauma 54:52,
2003; Singh H et al: Understanding diagnostic errors in medicine: a lesson from aviation. Qual Saf Health Care
15:159, 2006; Tellez ML, Mackersie RC: Violence prevention involvement among trauma surgeons: description
and preliminary evaluation. J Trauma 40:602, 1996; Ullman EA et al: Pulmonary trauma emergency department
evaluation and management. Emerg Med Clin North Am 21:291, 2003; van Vugt AB: Pitfalls in penetrating trauma.
Acta Chir Belg 103:358, 2003; Wall MJ Jr et al: Pitfalls in the care of the injured patient. Curr Probl Surg
35:1019, 1998; Yonas M et al: Readiness to change and the role of inpatient counseling for alcohol/substance abusing
youth with major trauma. J Trauma 59:466, 2005.
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 faculty report nothing to disclose.
Dr. Mackersie lectured at High-Risk Emergency Medicine, held May 24-26, 2006, in San Francisco and sponsored by
the University of California, San Francisco, School of Medicine. Dr. Cornwell spoke at the 13th Annual USC
Trauma/Critical Care Symposium, held May 22-23, 2006, in Pasadena, CA, and sponsored by the Division of
Trauma/Critical Care and the Office of Continuing Medical Education at the Keck School of Medicine, University of
Southern California, and the Institute of Continuing Education for Nurses, Department of Nursing, Los Angeles-USC
Medical Center. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production
of this program.
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