Trauma & Injury Prevention Section Newsletter - March 2013
Chair’s Corner - Trauma & Injury Prevention Section Newsletter, March 2013
Megan Ranney, MD, MPH
Since the last newsletter, Newtown shook many of us to our core. And ongoing (at the time of this writing) Congressional budget debates continue to threaten our health care system and public health infrastructure. These and other recent events highlight the importance of the work that we’re all doing on a daily basis in our communities and hospitals. They also accentuate the importance of our actively advocating for trauma and injury prevention funding, research, and implementation.
I am quite proud that TIPS is working on many fronts to advance awareness of and funding for critical trauma/injury prevention concepts. As I have mentioned in my previous section-wide emails, we have been particularly active in 3 realms:
- We’ve been leaders in the ACEP-wide discussion about how to best prevent firearm injuries and how to increase funding for gun-related
research (including submitting a Council resolution and authoring an in-press editorial for Annals)
- We’ve developed new collaborations with external groups such as NIDA and the CDC. We are working with both groups to organize a satellite conference on
substance use screening & interventions in the ED setting, to occur on October 13th, just prior to the 2013 Scientific Assembly.
- We’ve had a didactic accepted to the 2013 SA, regarding the incorporation of injury prevention techniques in the ED. Stay tuned for more information.
I thank you all for your dedication to the issues surrounding trauma & injury prevention. And, recognizing that we are among the most motivated members of our specialty, I have a few requests for you:
1. ENCOURAGE SECTION MEMBERSHIP: If you have friends or colleagues who are interested in these issues, please encourage them to join our section.
Only through strong membership can our section have a true “voice” in ACEP.
2. TAKE ACTION ON GUN VIOLENCE: There are a number of specific actions you can take to encourage ACEP to get involved with the national conversation
about gun violence.
a. We would welcome new members of our gun violence working group. Please email me if you are interested in joining.
b. Regardless, please consider emailing the members of the ACEP Board of Directors urging them to put “firearm injury advocacy” in ACEP’s Strategic Plan
for 2013-2014, and to make this topic an active advocacy area (including for NEMPAC and this year’s Leadership & Advocacy Conference).
c. If you make a NEMPAC Contribution this year, please consider writing on the contribution form that you expect ACEP to include reasonable gun violence
prevention policies as criteria for advocacy activities.
3. STAY INVOLVED. We would welcome folks to become more involved in Section Leadership – there are more potential activities than we have time for!
Please email me or Ali Raja if you are interested.
4. PLAN TO ATTEND THE ACEP13 SCIENTIFIC ASSEMBLY IN SEATTLE IN OCTOBER! Again, we are planning a “pre-SA” satellite symposium on substance
abuse, with NIDA, for 10/13; and we will be presenting a lecture during the SA, on 10/14. Your presence and support at both events is important, to signify to the
College that these are important issues for our specialty, and to ensure that ACEP continues to include trauma & injury prevention activities in Scientific
Assembly activities for years to come.
Megan L. Ranney MD MPH FACEP
Injury Prevention Center, Department of Emergency Medicine, Brown University/Rhode Island Hospital
Chair, ACEP Trauma & Injury Prevention Section
Post Disaster Violence - Trauma & Injury Prevention Section Newsletter, March 2013
Shawn D’Andrea, MD
International Emergency Medicine Fellow
Brigham and Women’s Hospital
Harvard Medical School
Email Dr. D'Andrea
Disaster medicine and trauma and injury care and prevention plainly fall under the scope of emergency medicine practice. However, what is known about patterns of violence leading to injury and trauma in the wake of disasters is sparse. Disasters of any scale temporarily, if not permanently, disrupt the lives of individuals and groups living in the affected area. There are many intuitive causes for violence to occur following a disaster such as limitation of basic resources such as food and shelter in the short term and poor adaptation to an acute stressful event in the immediate and long term. What is known about patterns of post disaster violence, while limited, is instructive and illuminates areas in need of further investigation. Studies have identified increasing rates of domestic violence following large scale disasters in the US. The National Center for Posttraumatic Stress Disorder (PTSD) summarizes prevalence data on domestic violence following several US disasters including the 1993 Midwest floods and the Mount St. Helens eruption and found increased rates of domestic violence in the wake of disasters. Increase in gender based violence among internally displaced persons following hurricane Katrina has been observed, as was a significant increase in numbers of inflicted traumatic brain injuries among children in eastern North Carolina in the 6 months following Hurricane Floyd in 1999. Such data suggests that post disaster violence extends beyond often sensationalized media reports of looting in the wake of disaster with significant public health consequences and consequences for emergency medicine practitioners. With this in mind the emergency medicine community can become better equipped to care for patients following a disaster. Specifically, the following research agenda would allow for better understanding and management of post disaster violence:
1. It should be acknowledged that existing data albeit limited, does suggest that there is a correlation between disasters and subsequent increase in rates of interpersonal violence.
2. The scope of the problem should be better characterized with emergency department based studies of violent injury patterns in weeks and months following disasters, rather than limiting the focus to hours and days. Emergency medicine researchers and practitioners with expertise and focus on disaster and trauma and injury prevention would likely be able to contribute valuable input to such research efforts.
3. It should be understood that even limited use and dissemination of existing data on post disaster violence trends would allow emergency physicians to better anticipate and screen for increased incidence of interpersonal violence following a disaster. Appropriate screening and referral could prove to be an effective secondary prevention mechanism. However, if providers are unaware of the potential for rates of violence to increase following a disaster, then opportunities for prevention may be missed.
4. The phenomenon of post disaster violence cuts across several subspecialty areas of emergency medicine and further research into and understanding these trends would allow emergency physicians, as well as colleagues in other fields, to better anticipate the needs of our patients.
Keenan HT, Marshall SW, Nocera MA, Runyan DK. Increased incidence of inflicted traumatic brain injury in children after a natural disaster, American Journal of Preventive Medicine. 2004; 26: 189-193
Anastario M, Shehab N, Lawry L. Increased Gender-based Violence Among Women Internally Displaced in Mississippi 2 Years Post-Hurricane Katrina. Disaster Medicine and Public Health Preparedness. 2009; 3:18-26.
Department of Veterans Affairs. Prevalence and impact of domestic violence in the wake of disasters. Available at: http://www.ptsd.va.gov/professional/pages/disasters-domestic-violence.asp. Accessibility verified February 28, 2013.
World Health Organization. Violence and Disasters. Available at http://www.who.int/violence_injury_prevention/publications/violence/violence_disasters.pdf. Accessibility verified February 28, 2013
Greening Vacant Lots to Reduce Violent Crime and Improve Feelings of Safety - Trauma & Injury Prevention Section Newsletter - March 2013
Eugenia C. Garvin, MD
Resident, PGY-1 Dept. of Emergency Medicine
Hospital of the University of Pennsylvania
Email Dr. Garvin
The majority of violence prevention interventions are focused on changing the knowledge, attitude, and behaviors of individuals. While these interventions are important, they can be costly and have a limited population level impact. Urban gun violence is often concentrated in “hot spots,” or small geographical areas where the majority of crimes take place. An alternative public health based approach to violence prevention is to understand how the physical environment in hot spots promotes or prevents crime. Interventions that modify the physical environment are attractive because they can impact large groups of people for long periods of time and few monetary resources. 1 2
Vacant land is a prominent aspect of the physical environment in urban areas. In Philadelphia, for example, there are over 40,000 vacant lots, often filled with overgrown vegetation and trash including condoms and old hypodermic needles. In addition, vacant lots are thought to be places where people hide illegal guns and thus serve as nodes for crime. 3 4 5 They have been associated with violence and fear. To better understand the impact of vacant land on health and safety, as well as study a potential intervention on vacant land, my colleagues at the University of Pennsylvania and I conducted a randomized controlled trial of vacant lot greening 6. We partnered with the Pennsylvania Horticulture Society (PHS), a non-profit organization based in Philadelphia that has been greening vacant lots in Philadelphia for over 10 years. The greening intervention consisted of: (a) removing debris, (b) grading the land and adding topsoil, (c) planting grass and trees, (d) building a low, post-and-rail wooden fence with entry openings around the perimeter, and (e) maintenance every 2 weeks.
1 Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health 2010;100:590-5.
2 Mair JS, Mair M. Violence prevention and control through environmental modifications. Annu Rev Publ Health 2003;24:209-25.
3 Brownlow A. An archaeology of fear and environmental change in Philadelphia. Geoforum 2006;37:227-45.
4 Branas CC, Cheney RA, Macdonald JM, Tam VW, Jackson TD, Ten Have TR. A Difference-in-Differences Analysis of Health, Safety, and Greening Vacant Urban Space. Am J Epidemiol 2011;174:1-11
5 Furr-Holden CDM, Lee MH, Milam AJ, Johnson RM, Lee KS, Ialongo NS. The Growth of Neighborhood Disorder and Marijuana Use Among Urban Adolescents: A Case for Policy and Environmental Interventions. J Stud Alcohol Drugs 2011;72:371-9.
6 Garvin EC, Cannuscio CC, Branas CC. Greening vacant lots to reduce violent crime: a randomised controlled trial. Injury Prevention. online publication August 7, 2012.
For the trial, we randomly selected two groups of vacant lots in one section of Philadelphia, one receiving the greening intervention and the other serving as a control group. We interviewed people living around the two sites before and after the greening, and also analyzed crime data from the police department. We found that people living at the greening site felt safer after greening compared to participants at the control site. Results from the qualitative portion of the interview showed that participants felt a significant impact of vacant land on community health, including crime and safety 7. A downward trend for overall crime around the intervention site was found, but these results were not significant due to our small sample size, so must be interpreted with caution. We also walked with people around the neighborhood, including past the vacant lots, and measured their heart rates as a marker for stress. Data from this portion of the study is under analysis.
Our study adds to the growing body of literature surrounding the impact of the physical environment on crime and safety. Gun violence has received renewed and well deserved attention by policy makers and the media in the last several months. As gun control legislation is debated around the nation, it is important for public health researchers and practitioners to continue to emphasize gun violence as a disease that requires education and intervention, targeted both at individuals and the physical environment.
7 Garvin EC, Branas CC, Kedem S, Sellman J, Cannuscio CC. More than just an eyesore: Local insights and solutions on vacant land and health. Journal of Urban Health. Online publication November 28, 2012
Trauma Center Spotlight: Brigham and Women’s Hospital - Trauma & Injury Prevention Section Newsletter, March 2013
Jonathan Gates, MD, MBA
Director, Trauma Services, Brigham and Women’s Hospital
Division of Trauma, Burn, and Surgical Critical Care and
Division of Vascular Surgery
Assistant Professor, Harvard Medical School
Email Dr. Gates
The knowledge gleaned from the recent military conflicts in Iraq and Afghanistan has contributed greatly to the collective improvement in the care of the civilian trauma patient. It has been established that hemorrhage is the second leading cause of death in trauma patients and is responsible for up to 30% of the overall mortality. Improvements geared toward control of that hemorrhage will definitely lead to improved mortality rates. In addition, overwhelming evidence supports the assertion that pre-hospital permissive hypotension until surgical control, judicious use of the tourniquet in extremity wounds and application of hemostatic bandages will improve the status of the injured patient upon presentation to the trauma center.
The Brigham and Women’s Hospital and many other institutions have been beneficiaries of this new information and have since developed a number of new initiatives designed to improve the care of the injured patients. These include improvements in blood transfusion, hemostatic drugs, access to the Operating Room (OR), and the type of operative environment. These improvements are naturally now available to all the trauma patients but needed by most those who are most gravely injured. Gravely injured trauma patients amount to 1-3% of the civilian trauma patient population and 7% of the military injuries. However, it is that 1-3% of the injured where most improvements need to and have been made in trauma care.
Numerous trauma centers across the United States have developed a massive transfusion protocol (MTP) for the adjuvant management of the actively bleeding trauma patient starting in 2006. Brigham and Women’s Hospital has created this protocol for use in the Emergency Department, the Operating Room, and the Intensive Care unit and continues to fine tune it. The definition of massive blood loss is debatable, but a need for at least 10 units of packed red blood cells within 24 hours is a good place to start. The survival of combat casualties requiring the MTP has increased from 62% (pre-2006) to greater than 80% (post-2006). In many studies, 30% of the severely injured trauma patients present with severe coagulopathy from consumption and loss of clotting factors, metabolic acidosis, anemia, hyperfibrinolysis and hypothermia.
Trauma care is undergoing a huge change from the confines of the “old” practice of 3 liters of crystalloid for each unit of blood lost. The old practice consisted of 6-8 units of red cells before initiating the administration of fresh frozen plasma. Further, fresh frozen plasma was given as directed by the PT/PTT and platelets were administered as directed by the platelet count. The current standard practice resuscitation formula in the massively bleeding trauma patient is focused more on hemostasis. The use of crystalloid is relegated to 2-5 liters within the first 24 hours and no more. Borgman et al. (Journal of Trauma, 2007) looked at the proper ratio of fresh frozen plasma to packed red cells and defined three groups as low (1:8), medium (1:2.5) and high ratio (1:1.4). There was a significant reduction in mortality from 65% in the low group to 19% in the high group ensuring that a close approximation of plasma to red cells is highly successful. This translated into a 55% reduction in mortality in comparably injured trauma patients! The current standard of care in hemostatic resuscitation includes a 1:1:1 ratio of plasma to red cells to platelets. Even this approach approximates about one half of the normal platelet count, fibrinogen level and coagulation activity of whole blood. The Massive Transfusion Protocol is now part of everyday life in the OR for use with any bleeding situation whether it is in the OB/GYN, general surgery, vascular surgery or trauma patient.
Recombinant factor VIIa enjoyed a brief but very appropriate popularity as a specific hemostatic agent around the 2006-2009 time periods. It was hampered by cost, questionable effectiveness and the concern about intravascular thrombosis. It has since been replaced by the improved safety profile of the anti-fibrinolytic agent, tranexamic acid (TXA). The CRASH II study was a large randomized multi-center study of 20,211 trauma patients in 40 countries across the globe. These patients were thought to be at risk of hemorrhage or had demonstrated that they were actively hemorrhaging. Those patients treated with tranexamic acid within 8 hours of injury demonstrated all-cause mortality at 30 days of 14.5% in the TXA group compared to 16% in the control group. It was clear from the data that the early administration of the drug within an hour of injury reduced the death rate from bleeding to 5.3% compared to 7.7% in the placebo group. There appears to be no increase in the incidence of adverse intravascular thromboses with the use of tranexamic acid in trauma. The use of TXA is now incorporated into the MTP at the Brigham.
The hybrid Operating Room represents the confluence of the traditional Operating Room for open procedures and the endovascular suite. It represents a patient-centric approach to trauma care whereby the patient is brought into the room in extremis in the most controlled environment; the Operating Room. Open surgical intervention is performed in the usual fashion and should the patient require further endovascular embolization of bleeding pelvic injuries or solid organ injuries then the patient is not moved from the room as the interventional team comes to the patient and provides the angiogram, embolization, and/or endograft placement for definitive control. This option allows trauma teams to visit new approaches in trauma care and deliver a wide variety of interventions to the patient that minimizes transport, hand-offs and subjecting the sickest patients to less controlled situations. These technological improvements allow the caregivers to challenge old dogma and establish new opportunities for improved care (Havens JM, Gravereaux E, Gates JD, et al. A case of combined aortic and pancreatic transection. Presented at the American College of Surgeons, San Francisco, CA October 26, 2011).
The Brigham and Women’s Hospital has also had a direct-to-OR policy in place for many years. It first started with the vascular surgical patients with known contained ruptured aneurysms and has evolved into the trauma patients with known or suspected ongoing bleeding from traumatic injuries. There is little mystery that minimizing the time from onset of bleeding to surgical control of that surgical bleeding, if required, will benefit the patient and ultimately to the healthcare system.
The ultimate goal of all of these changes to the care of the bleeding trauma patient is early recognition of the injury, temporary control of bleeding through use of a tourniquet, relative control of the inaccessible bleeding through permissive hypotension, early surgical control, and hemostatic resuscitation at all times. This combination of damage control resuscitation and early damage control innovative surgery will produce improved outcomes compared to the historically dismal results seen in the exsanguinating trauma patient.
Violent Injury Prevention Programs in the ED - Trauma & Injury Prevention Section Newsletter, March 2013
Jennifer Avegno, MD
Director of Undergraduate Medical Education
Associate Residency Director
LSU Health Sciences Center Emergency Medicine
Emergency practitioners regularly witness the human and health care system toll that violence takes on our patients and communities. In 2007 alone, over 650,000 youths aged 10-24 were treated in U.S. EDs for violent injury (1); and nearly 10% of patients will require hospitalization (2). The cost of victims of interpersonal violence who are treated and released in EDs is estimated to be nearly $6 billion dollars annually (3). As physicians on the “front line” of the epidemic, EPs are uniquely positioned to assess, interact, and intervene with these patients, and ACEP – through policy statements and advocacy – encourages its members to engage in advocacy, education, and research initiatives designed at violence prevention (4).
ED and hospital-based violence intervention programs are generally reflective of a public health approach to violence, and focus on reduction of recidivism (either injury or legal) and cost savings. Although there are many programs in EDs all over the country, few have been studied in the literature to help inform best practices for others wishing to start their own. Many have shown trends towards positive outcomes, but the complexity of violence and the general resource limitations faced by EDs may hamper rigorous evaluations and significance of results. Still, some insight can be gained into “what works” by reviewing a few published studies.
The concept of the “teachable moment” – catching injured patients and/or their families at the instant of a violent event – is the hallmark of many programs, and has been shown to favorably impact chances for long-term success. In Oakland, the Youth Alive! Program provided peer violence intervention specialists with injured youth admitted to the trauma center, assessed their needs and provided case management and other services for them and their family after discharge. Although there was no significant difference between the treatment and control group in rates of reinjury, rehospitalization, or death, there was a trend towards reduction in violent criminal behavior and cost savings associated with the intervention group. (5) Zun et al provided trained social worker interventions to youths in an inner-city ED who presented for violent injury, and then 6 months of outpatient social service assistance. Target group participants had significantly fewer self-reported injuries, but no significant difference with a control group was found in terms of ED utilization or arrest. (6) In Baltimore, adult patients who had previously been violently injured and were admitted to the trauma center with a subsequent, separate injury were given in-hospital social work evaluation and linkage to services with outpatient meetings and group sessions. These patients had a far lower ED recidivism rate (5% compared to 36% in a control group) and significant legal and medical cost savings. (7)
Other injury prevention programs, such as Cure Violence (formerly Ceasefire) in Chicago and Ceasefire – New Orleans, use an infectious disease model and incorporate EDs as a critical piece of a larger, community-wide, multipronged approach to violence eradication. These programs have seen success in reducing penetrating trauma in target areas, but the effects on the health care system have not yet been evaluated. (8) As such, there is a wealth of opportunity for new and innovative research on “what works” in terms of ED-based injury prevention, and as EPs, we are uniquely positioned to lead the charge for better, safer communities.
1) Corbin TJ et al. Developing a trauma-informed, emergency department-based intervention for victims of urban violence. J Trauma Dissoc 2011; 12(5), 510-25.
2) Cunningham R et al. Before and after the trauma bay: the prevention of violent injury among youth. Ann Emerg Med 2009; 53: 490-500.
3) CDC, NCHS Vital Statistics and NEISS, 2005.
4) ACEP policy statement on a Violence-Free Society. Accessed at https://www.acep.org/Clinical---Practice-Management/Violence-Free-Society/ on February 20, 2013.
5) Shibru et al. Benefits of a hospital-based peer intervention program for violently injured youth. J Am Coll Surg 2007;205:684–689
6) Zun LS, Downey L, Rosen J. The effectiveness of an ED-based violence prevention program. Am J Emerg Med 2006;24:8-13.
7) Cooper C, Eslinger DM, Stolley PD. Hospital-based violence intervention programs work. J Trauma 2006;61:534-40.
8) Skogan WG et al. Executive summary evaluation of CeaseFire Chicago. Department of Justice 2008.
Eastern Association for the Surgery of Trauma (EAST) Update - Trauma & Injury Prevention Section Newsletter, March 2013
Julie Mayglothling, MD
Trauma, Critical Care, and Emergency Surgery and
Department of Emergency Medicine
VCU Medical Center
The Eastern Association for the Surgery of Trauma (EAST) held its 26th annual Scientific Assembly in Scottsdale Arizona January 15-19th 2013. EAST is a fantastic organization that was initially started to help develop young trauma surgeons, but has expanded to embrace all trauma providers, including emergency physicians, anesthesiologists, mid-level providers and nurses. In addition to trauma, there is a focus on violence and injury prevention, critical care and emergency surgery topics.
The meeting format and content is unique- it’s not a series of lectures on basic trauma topics. It is a combination of oral abstract presentations of original research, morning Sunrise Sessions on emerging or controversial topics, and didactic sessions with differing formats, such as “Papers that should change your practice” and point counter-point debates between “Old Dogs versus Young Bucks”. And in keeping with EAST’s commitment to career development, there is also an ongoing Leadership Development Workshop and a Masters Course where experienced trauma surgeons talk about difficult cases and techniques.
We have made a concerted effort to increase membership and participation by emergency physicians in EAST, increasing our membership by 50% this year and with representatives on the Careers in Trauma Committee and the Membership committee. The 27th Annual Assembly is January 14-18th, 2014 in Naples, Florida at the Waldorf Astoria. We hope to see you there!
Needless Abdominal CT Scans Can be Avoided in Children - Trauma & Injury Prevention Section Newsletter, March 2013
From the UC Davis Health System Public Affairs Department
Courtesy of Daniel Nishijima, MD, MAS
Department of Emergency Medicine
UC Davis Medical Center
Email Dr. Nishijima
A study of more than 12,000 children from emergency departments throughout the country in the Pediatric Emergency Care Applied Research Network (PECARN) has identified seven factors that can help physicians determine the need for a computed tomography (CT) scan following blunt trauma to the abdomen. Because CT scans pose radiation hazards for youngsters, the findings may enable doctors to determine which children do not need to be exposed to such tests after a traumatic injury.
UC Davis researchers have identified factors to lessen radiation exposure in youngsters who suffer abdominal injuries
The study, titled “Identifying children at very low risk of clinically important blunt abdominal injuries,” is online first in advance of an upcoming issue of the Annals of Emergency Medicine.
“CT scans involve significant radiation risk, especially for children, who are more vulnerable than adults to radiation’s effects,” said principal investigator and lead author of the study James Holmes, a professor of emergency medicine at the UC Davis School of Medicine. “We have now identified a population of pediatric patients that does not typically benefit from a CT scan, which is an important step in reducing radiation exposure.”
The prospective study involved children who arrived at emergency departments in the PECARN network after blunt trauma to their torsos, such as sustained from a car or bicycle crash, a fall or an assault. A variety of factors related to the children’s histories and clinical presentations were evaluated. Among these, seven were identified by statistical analysis to correlate with risk for involving a clinically important injury. The factors included evidence of trauma on the abdomen or chest (such as seat-belt marks), neurological changes, abdominal pain or tenderness, abnormal breath sounds and vomiting.
Children who had none of the factors when evaluated in the emergency department had only a 0.1 percent chance of having an abdominal injury that required acute intervention. For the great majority of these cases, a CT scan would not likely provide additional useful information. According to the authors, the risk of developing a future cancer from radiation exposure from a CT scan in this situation (i.e., when lacking all seven factors) outweighs the risk of having a significant medical problem from the abdominal injury.
The authors stated that the prediction rule is intended only to help “rule out” the need for CT for children when none of the seven factors is present. However, the rule does not mandate a CT solely based on any one of the factors being present. If the prediction rule were used in that way, CT usage would actually increase over current levels. The authors emphasized that clinical judgment must play an important role in determining whether a CT is needed in each case. Extending the period of observation in the emergency department, and using findings from laboratory tests and ultrasonography, can also contribute to decision-making in cases of abdominal trauma.
According to Holmes, the prediction rule must be tested in another clinical trial designed specifically to evaluate its validity before being generally adopted. He expects that this will be carried out in the near future.
Another related ongoing study at UC Davis Medical Center is investigating the role of ultrasonography in the evaluation of abdominal trauma in children, and whether increasing its use can lead to further reduction of the need for CT scans.
This study also was conducted through PECARN, a network of pediatric emergency departments throughout the United States that enables researchers to gather enough data to perform significant studies on critical issues in pediatric emergency medicine. PECARN studies have previously led to new standards of care for infants or children presenting with head trauma, diabetic crisis and infections.
“Because of PECARN, we are uniquely positioned to perform large studies that can provide important information,” said Nathan Kuppermann, senior investigator of the study, who is professor of pediatrics and emergency medicine and chair of the Department of Emergency Medicine at the UC Davis School of Medicine. “The results of such studies are making emergency medicine decision-making more of a science and leading to better and safer outcomes for children.”
Kuppermann is founding chair of PECARN and leads one of the network’s research nodes, which is centered at UC Davis Medical Center and includes the children’s hospitals of the University of Utah and University of Pennsylvania.
Other UC Davis Medical Center investigators involved in the study are Peter Sokolove, professor of emergency medicine, David Wisner, professor of surgery, and Sandra Wootton-Gorges, professor and medical director of radiology at the Shriners Hospital for Children Northern California. Other authors were from emergency departments in Maryland, Massachusetts, Michigan, Missouri, New York, Ohio, Utah, Wisconsin and Washington, D.C. A complete listing of the authors and their affiliations can be found in the article.
Resident Perspective: New Recipes in Trauma Management - Trauma & Injury Prevention Section Newsletter, March 2013
George Lim, MD
Resident, PGY-2 Dept. of Emergency Medicine
Mount Sinai Emergency Medicine Residency
Email Dr. Lim
Trauma management in the ED is often quoted to be as straightforward as your ABC (DE)s. In fact, trauma algorithms in major EM textbooks haven’t changed significantly over the last few decades. For this reason, many physicians consider trauma management as “cookbook”. However, new evidence and technological advances have improved trauma care and provided subtleties in management of the trauma patient that can dramatically affect patient outcome.
I imagine yourself working a typical Saturday night ED shift. Your department is beyond capacity and your waiting room is brimming with patients and their loved ones. Just as you sit down to place some orders, your Saturday night special comes bursting through the ambulance bay entrance. As the medics wheel in the patient to the trauma bay, they give you a quick report. “36 year-old female in high speed MVC with extreme abdominal tenderness and bilateral upper extremity obvious deformities; vital signs notable for hypotension and tachycardia”. Trauma team has already been activated and as team leader you adeptly coordinate the simultaneous actions of ATLS. Due to the extent of this patient’s injuries, quickly placed peripheral large bore IVs are but a fantasy and unstable vitals demand immediate access. What do you do?
You reach for the intraosseous drill. IO access in pediatric emergency medicine has been well established and is gaining a more and more significant foothold in adult emergency medicine. Placement takes only a few seconds and placement sites (i.e. manubrium, proximal humerus, distal femur, proximal tibia, and distal tibia or fibula) can be tailored to individual patients. Medication and fluid administration through an IO line is comparable to administration through an IV line.1 Furthermore, IO access can be achieved even through full thickness burns.2
Your FAST exam and the patient’s hypotension indicate significant abdominal hemorrhage and you activate your hospital’s massive transfusion protocol. You set up the Level 1™ transfuser with O negative pRBCs and attach the line to the introducer placed in anticipation of blood transfusion. It’s still within 1 hour of the patient’s MVA and you reflexively request tranexamic acid and PCC.
The CRASH-2 study (and the subsequent studies validating initial findings from CRASH-2) found significant reduction in all cause mortality with the use tranexamic acid in bleeding trauma patients within 3 hours of injury without adverse effects.3 In addition to TXA, prothrombin complex concentrate and other factor concentrates are increasingly being utilized to achieve rapid hemostasis not just in patients taking warfarin but also in those with life threatening traumatic injury. These medications help to reduce the use of blood products and their associated risks.4 Furthermore, thromboelastometry (TEM) and thromboelastography (TEG) help to assess coagulopathy and guide therapy in trauma patients. Increased survival rates have been observed when trauma patients have been treated with TEM-guided administration of hemostatic agents.5
Your patient has been given appropriate medication and is receiving her first unit of blood. What is your goal blood pressure?
With literature suggesting the benefit of damage control resuscitation (DCR) in trauma patients, even ideal blood pressures/MAP’s have come into question. DCR encompasses the principles of hemostatic resuscitation, permissive hypotension, and damage control surgery and is associated with a decrease in mortality in polytrauma patients.6 Even the 9th edition of ATLS emphasizes a “balanced resuscitation” eliminating the term “aggressive resuscitation”. Although an ideal blood pressure or MAP range has not been definitively established, the principles of DCR should guide management in trauma care.
The initial management of a trauma patient is a time when minutes and even seconds matter. A time during which decisive and appropriate interventions are crucial to patient well being. Therefore, we owe it to our patients to remain vigilant and up-to-date with the evolving field of evidence based trauma medicine. We owe it to our patients to advocate for the incorporation of evidence-based interventions such as TXA and IOs into our EDs.
1Von Hoff DD et al. Does Intraosseous equal intravenous? A Pharmocokinetic Study. Am J Emerg Med. 2008 Jan;26(1):31-8.
2Frascone R et al. Successful Placement of an Adult Sternal Intraosseous Line Through Burned Skin. J Burn Care Rehabil. 2003 Sep-Oct;24(5):306-8.
3Roberts I et al. Antifibrinolytic Drugs for Acute Traumatic Injury. Cochrane Database Syst Rev. 2012;12:CD004896.
4Joseph B et al. Factor IX Complex for the Correction of Traumatic Coagulopathy. J Trauma Acute Care Surg. 2012 Apr;72(4):828-34.
5Schochl H et al. Goal-Directed Coagulation Management of Major Trauma Patients using Thromboelastometry (ROTEM)-guided Administration of Fibrinogen Concentrate and Prothrombin Complex Concentrate. Crit Care. 2010;14(2):R55.
6Carlino W. Damage Control Resuscitation from Major Haemorrhage in Polytrauma. Euro J Orthop Surg Traumatol. 2013 Jan 31.