TRAUMA TO GO
Highlights from the University of Southern California’s 14th Annual Trauma/Critical Care Symposium
| COMPLEX LIVER INJURY DEBATE: PACK AND GO TO THE ICU FOR RESUSCITATION —R. Stephen Smith,
MD, Professor of Surgery, University of Kansas School of Medicine, Wichita
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| Introductory remarks: treatment of complex serious liver injuries challenging for all trauma surgeons and for best
trauma centers; debate not whether postoperative angiography should be used in management of complex liver injuries,
but whether procedure should be used selectively or be required for all patients after surgery
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| Examples of literature supporting use of selective angiography: in 8-yr retrospective review of grades IV
through V liver injuries (23 blunt trauma, 80 penetrating trauma patients; atypical experience), postoperative angiography
required in only 23 patients (of these, 7 died); in study at Baltimore shock trauma facility (80 grades IV and V liver
injuries), authors concluded angiography less useful in blunt trauma than in penetrating trauma, and that postoperative
angiography did not improve survival; in study by Kozar et al, 68% of patients with grades III through V liver injuries
treated nonoperatively (only 12 required angiography for bleeding)
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| Logistic problems associated with angiography in trauma setting: while guidelines published by American
College of Surgeons Committee on Trauma state angiography must be available 30 min after surgery, this rarely occurs
(usually takes much longer to mobilize angiography team); once patient in angiography suite, procedure can take “considerable
amount of time”; pathophysiology of severe liver injury includes hypothermia, coagulopathy, and acidosis from
bleeding, and angiography suite poor location in hospital in which to manage unstable patient; complications of angiography
more common than generally acknowledged (eg, hepatic necrosis, hepatic abscess, hepatic vascular injury, gallbladder
necrosis)
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| New treatment modalities available in operating room (OR) that obviate need for postoperative angiography:
tissue sealants; recombinant activated factor VII; new paradigm of massive resuscitation with earlier and
more frequent use of fresh frozen plasma, platelets, and cryoprecipitate; thrombogenic dressings that can be used to pack
liver; expense of diagnostic angiography and embolization justified when procedures indicated, but not if ordered for every
patient after surgery for liver injuries
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| Conclusion: selective use of postoperative angiography beneficial in small subset of patients with severe liver injury;
however, blanket utilization of procedure difficult, dangerous to many patients, and costly
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| COMPLEX LIVER INJURY DEBATE: PACK AND GO TO ANGIOGRAPHY —Michael J. Sise, MD, Clinical Professor
of Surgery, University of California, San Diego, School of Medicine, and Trauma Director, Scripps Mercy Hospital,
San Diego
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| Introductory remarks: after surgery, question whether patient should be taken to intensive care unit (ICU) or to angiography
suite to manage bleeding; in case of severe liver injury with hemoperitoneum and active blush, remember that
blood flow to liver 80% venous (mainly via portal vein, with some arterial flow; oxygen delivery mainly from vein; can
eliminate artery by embolization if necessary)
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| Literature supporting postoperative angioembolization: in 8-yr retrospective study quoted by Dr. Smith, embolization
of 23 patients resulted in improved survival; University of Pennsylvania study (Johnson et al) found it safe to
go straight to embolization “if you move the ICU with the patient”; University of Michigan study found angiography effective
in limiting hemorrhage; University of Medicine and Dentistry of New Jersey study found early angioembolization
reduced blood use
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| Comments: if patient bleeding, he or she belongs in either OR or angiography suite; if patient already seen in OR, nothing
to be accomplished in ICU (results in further hemodiluting patient); thus, in grades IV and V liver injuries (in which
packing necessary because of excessive bleeding), pack and go to angiography suite and take ICU with you; clear and direct
action required; imperative to interrupt bleeding through angioembolization
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| Immediate goals: create angioembolization capability in trauma OR; treat interventional radiologists as integral members
of trauma team (ie, surgeons to embrace radiologists as surgical specialists, interacting and communicating with them with
immediacy, including them in OR if needed, or moving to their angiography suite and considering it another OR, where
team can stop bleeding); trauma service sits on “4-legged stool” (anesthesia, orthopedics, neurology, and interventional radiology)
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| Dr. Smith’s rebuttal: issues of nursing staff shortages and busy ICUs; logistically, “moving ICU” to angiography suite
unlikely to happen with regularity; cannot achieve same level of care in radiology department as in ICU; agrees that angiographic
skills should be component of surgical training in future; presently, majority of liver injury patients do not require
angioembolization and can be managed successfully in OR and ICU
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| Questions for Drs. Smith and Sise: should every liver-pack injury go to angiography suite? can surgeon pack liver
successfully enough to cause angiographer to miss bleeding vessel?
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| SPLENECTOMY IN PEDIATRIC PATIENTS: A PREVENTABLE COMPLICATION ?—Jeffrey S. Upperman, MD, Associate
Professor of Surgery, Department of Pediatric Surgery, Keck School of Medicine of the University of Southern California,
Los Angeles, and Director, Trauma Program, Childrens Hospital Los Angeles
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| Splenic trauma in children: spleen abdominal organ most commonly injured due to blunt trauma (associated injuries
include long bone fracture and head injury); majority treated in community hospitals and adult trauma centers
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| Overwhelming postsplenectomy infection (OPSI): OPSI originally reported in small group of children in 1952;
since then, risk for OPSI reason for reluctance to perform splenectomy in cases of pediatric splenic trauma; risk for OPSI
decreases with age (adults at much lower risk than children; in patients <5 yr of age, risk increased 10-fold); risk greatest
in children who have other medical problems, eg, hematologic disorders
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| Benefit of splenic preservation: reduced risk for OPSI; fewer postoperative complications; longer quality-adjusted
life expectancy
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| Difference in pediatric splenic injuries: splenic capsule in children relatively thicker; parenchyma of spleen in children
contains more smooth muscle; adult splenic injuries usually require greater force; associated lower rib fracture occurs
in 20% of adults, but uncommon in children due to rib cage flexibility
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| Pediatric trauma outcome study (PTOS) database (Pennsylvania): compared care at 2 pediatric trauma centers
(PTCs) to care at adult trauma centers (ATCs) with added qualifications to treat children (AQ), and at level I and
level II ATCs; majority of pediatric population received nonoperative management, but percentage had splenectomy;
analysis of data shows that although age and injury severity score (ISS) not significant factors in determining mode of
treatment, PTCs had higher proportion of nonoperative management than ATCs (in turn, ATCs that managed pediatric
patients had higher proportion than adults-only trauma centers); PTCs also associated with lower incidence of patient
mortality than ATCs (reasons unclear)
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| Greater rate of splenectomy in non-PTCs: analysis of Pennsylvania discharge database concluded that PTCs performed
splenectomies less frequently than other types of medical centers (ATCs with AQ, levels I and II ATCs, nontrauma
centers); Vermont study showed similar findings; study by Mooney et al found children treated at adult hospitals
had almost 3-fold greater risk of undergoing splenectomy than those treated at pediatric medical centers
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| Risk factors for pediatric splenectomy: in reexamination of PTOS data, risk factors for pediatric splenectomy included
low Glasgow Coma Score (GCS), high injury grade (eg, abbreviated injury score [AIS] ≥4), other intraabdominal
injuries, older age/appearance; study of factors associated with failure of nonoperative management (based on data from
7 PTCs) showed similar findings
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| Reasons for greater incidence of nonoperative management at PTCs: 8 yr ago, Stylianos et al created evidence-based
management guideline for PTCs, which many institutions and pediatric surgeons have adopted; data since that
time suggest that patient less likely to have spleen removed if treated at PTC and by physician following these guidelines
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| PLAIN FILMS FOR TRAUMA: WHAT’S NEEDED, WHAT’S NOT —Marc Eckstein, MD, Associate Professor of Emergency
Medicine, and Director, Prehospital Care, Keck School of Medicine of the University of Southern California, Los Angeles
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| Cervical spine (C-spine) radiography: difficult to obtain adequate view of C-spine on plain films; “bottom line,”
many or most patients with blunt trauma who arrive at hospital on backboard can be cleared clinically without plain
films, computed tomography (CT), or magnetic resonance imaging (MRI), eg, patients categorized as low risk who meet
National Emergency X-Radiography Utilization Study (NEXUS) criteria or Canadian C-spine rule (sensitivity superior
to NEXUS) may not require cervical imaging studies; high-risk patients whose plain films technically inadequate or who
have abnormality suggesting possible secondary C-spine injury (eg, subluxation, soft-tissue swelling, bony abnormality)
require CT or MRI
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| Reliability of negative chest x-ray in ruling out serious injury: many studies comparing sensitivity of chest x-
ray to chest CT (gold standard for ruling out significant intrathoracic injuries); x-ray found to miss up to 50% of occult
pneumothoraces; in addition, studies show x-ray has 40% false-negative rate and ≤30% false-positive rate in detecting
traumatic injury, compared to CT (some authors recommend eliminating chest x-ray in favor of chest CT); bedside ultrasonography
also shown more sensitive than plain chest x-ray in detecting pneumothorax; studies also show chest x-ray
has low sensitivity for detecting traumatic aortic rupture
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| Pelvic x-ray: literature “overwhelmingly” shows awake alert blunt trauma patient who exhibits no tenderness in pelvis on
clinical examination does not require pelvic radiography; CT more sensitive and specific; if any suggestion that surgical fixation
necessary, orthopedic colleagues will require CT of pelvis
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| Conclusions: many evaluable stable trauma patients may have C-spines cleared clinically by using decision rule; in high-
risk patient, reasonable to skip plain films and get CT; in major trauma patient undergoing panoramic CT, reasonable to
obtain initial portable chest x-ray; if any suspicion of pelvic fracture, plain pelvic films helpful
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| PREVENTABLE DEATHS: LESSONS LEARNED AT A MATURE TRAUMA CENTER —Kenji Inaba, MD, Assistant
Professor of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles
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| “End results idea”: proposed by E. Codman, MD (1869�); “common sense notion” that every hospital and every
practitioner within hospital should follow patients to assess whether treatment successful (and if not successful, to learn
from results and prevent similar failures in future); Dr. Codman spent decades trying to convince physicians of importance
of tracking results and learning from patients’ deaths and complications; Dr. Codman ridiculed and ostracized by
colleagues, driven to poverty, and forgotten
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| Comments: contemporary generations more receptive and have come to understand importance of learning from mistakes;
trauma surgeons now recognize preventable deaths important easy-to-track quality improvement outcome measure;
not only used as marker to assess global quality of trauma care, but also as tool to evaluate protocols, systems, and
treatments performed on daily basis; question, what is rate of preventable mortality in mature trauma center, and can it
be reduced to zero?
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| 8-yr prospective review (1998�): goal of study to analyze preventable and potentially preventable deaths at mature
level I trauma center; all deaths at institution reviewed by division at weekly morbidity and mortality conference,
and by multidisciplinary Combined Trauma Death Review Committee (CTDRC; included representatives from all
phases of patient care; reviewed all clinical and autopsy data; determined whether there was element of preventability
in death); in all cases in which deaths ruled preventable or potentially preventable, study author looked at cause, timing,
location, contributing errors, and personnel or system involved
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 | Results: over study period, center admitted >35,000 patients, 2000 of whom died; after CTDRC review, 40 deaths judged
potentially preventable, and 11 deaths judged frankly preventable; mean age of patients 40 yr; 66% men; 75% blunt-
trauma patients, with mean ISS of 27; yearly rate of preventable deaths constant throughout study period; cause—
bleeding most common cause of preventable deaths, followed by factors such as multiorgan failure and cardiorespiratory
arrest; timing—whereas nonpreventable deaths most frequently peak at 1 hr and at 1 to 6 hr, similar spike not observed
in occurrence of preventable deaths; instead, outlined across first week of treatment; also, while nonpreventable
deaths tend to diminish after 7 days, preventable deaths continued to occur past that time; location—>50% of preventable
deaths occurred in ICU, 25% in OR; remainder occurred in ED or while patients undergoing imaging; contributing
errors—treatment delay accounted for >50%; next most common judgment error, missed diagnoses, and
technical errors in OR or in ICU; personnel or system involved—20% of deaths due to system errors, 80% due to human
error
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| Conclusions: preventable mortalities continue to occur at mature trauma centers; rate constant over last 8 yr; majority
due to human error; despite advances in all aspects of trauma care, evidence-based protocols, and technology (eg, imaging),
effective treatment still requires human interface with element of judgment; human element prone to error; thus,
continuous review of all deaths and “near misses” extremely important
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Suggested Reading
Asensio JA et al: Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries:
trauma surgeons still need to operate, but angioembolization helps. J Trauma 54:647, 2003; Barrett TW et al: Injuries
missed by limited computed tomographic imaging of patients with cervical spine injuries. Ann Emerg Med 47:129, 2006;
Demetriades D et al: Routine helical computed tomographic evaluation of the mediastinum in high-risk blunt trauma
patients. Arch Surg 133:1084, 1998; Duane TM et al: Blunt trauma and the role of routine pelvic radiographs: a prospective
analysis. J Trauma 53:463, 2002; Duane TM et al: Reevaluating the management and outcomes of severe blunt
liver trauma. J Trauma 57:494, 2004; Gruen RL et al: Patterns of errors contributing to trauma mortality: lessons
learned from 2,594 deaths. Ann Surg 244:371, 2006; Kulkarni R et al: Successful use of activated recombinant Factor
VII in traumatic liver injuries in children. J Trauma 56:1348, 2004; Kushimoto S et al: Immediate postoperative angiographic
embolization after damage control surgery for liver injury: report of a case. Surg Today 36:566, 2006; Lee SK,
Carillo EH: Advances and changes in the management of liver injuries. Am J Surg 73:201, 2007; Lopes JA et al: The
trauma bay chest radiograph in stable blunt-trauma patients: do we really need it? Am Surg 72:31, 2006; Mohr JW et al:
Angiographic embolization for liver injuries; low mortality, high mortality. J Trauma 55:1077, 2003; Mooney DP et al:
Variation in the management of pediatric splenic injuries in New Hampshire. J Pediatr Surg 33:1076, 1998; Mooney DP
et al: Variation in the management of pediatric splenic injuries in the United States. J Trauma 61:330, 2006; Mower
WR et al: Use of plain radiography to screen for cervical spine injuries. Ann Emerg Med 38:1, 2001; Obaid AK et al:
Utility of plain film pelvic radiographs in blunt trauma patients in the emergency department. Am Surg 72:951, 2006;
Peitzman AB et al: Injury to the spleen. Curr Probl Surg 38:932, 2001; Potoka DA et al: Impact of pediatric trauma
centers on mortality in a statewide system. J Trauma 49:237, 2000; Potoka DA et al: Risk factors for splenectomy in
children with blunt splenic trauma. J Pediatr Surg 37:294, 2002; Stiell IG et al: The Canadian C-spine rule for radiography
in alert and stable trauma patients. JAMA 286:1841, 2001; Stylianos S: Evidence-based guidelines for resource utilization
in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg 35:164, 2000;
Stylianos S et al: Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for
dissemination of American Pediatric Surgical Association benchmarks and guidelines. J Am Coll Surg 202:247, 2006;
Trunkey DD: Hepatic trauma: contemporary management. Surg Clin N Am 84:437, 2004; Wisbach GG, Sise MJ et
al: What is the role of chest X-ray in the initial assessment of stable trauma patients? J Trauma 62:74, 2007.
Educational Objectives
| The goal of this program is to improve trauma management, particularly as it pertains to severe liver injury, pediatric
splenectomy, blunt trauma, and preventable deaths. After hearing and assimilating this program, the clinician will be
better able to:
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| 1. Cite the arguments for selective vs routine use of postoperative angioembolization in the management of complex
liver injuries.
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| 2. Explain issues in pediatric splenectomy and nonoperative management of blunt splenic trauma.
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| 3. Recognize the indications for pediatric splenectomy.
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| 4. Discern when plain cervical radiographs and pelvic films are indicated in blunt trauma patients, and when
computed tomography of the cervical spine is appropriate.
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| 5. Explain the importance of reviewing and learning from patient deaths and treatment complications that continue
to occur at mature trauma centers.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgments
Drs. Smith, Sise, Upperman, Eckstein, and Inaba spoke at the University of Southern California’s 14th Annual Trauma/
Critical Care Symposium, held May 16-17, 2007, 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 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.
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