Traumagram spring 2016
- 1. Greetings, Welcome to the internal educational program (IEP) of the Vanderbilt University Division of Trauma, Emergency Surgery and Surgical Critical Care. Our goal is to provide an opportunity to pursue topics germane to trauma from all aspects of the team. My hope is to explore all areas of interest throughout the course of the year including pre-hospital care, acute care issues, post-discharge requirements, as well as injury prevention. We will attempt to outline the care provided to our trauma patient population from point of injury until the patients care is completed. As you know, the trauma team consists of the Chief of the Division, Dr. Rick Miller, our Trauma Program Manager, Melissa Smith, RN, the Performance Improvement Director, Dr. Tim Nunez, the Outreach and Prevention coordinator, Cathy Wilson, RN, the Trauma Resuscitation Manager, Kevin High, RN, as well as the entire trauma faculty and Acute Care Surgery Fellows. Our multidisciplinary liaison team includes Tyler Barrett (EM), Robert Boyce (Ortho), Reid Thompson (Neurosurgery), Shannon Kilkelly (Anesthesia), Peter Bream (Radiology) and the LifeFlight team. Our goal is to improve the care of the trauma patient in a caring and consistent manner and to help minimize injury in the Middle Tennessee region through outreach and prevention efforts determined by the needs of the community. Please take a few minutes to review this material and complete the survey. Yours Truly, Oscar Guillamondegui The ACS trauma education requirement (for faculty who are not liaisons) may be met by documenting acquisition of 16 hours of trauma-related CME per year on average or by demonstrating participation in an internal educational process (IEP) conducted by the trauma program based on the principles of practice-based learning and the PIPs program. A Message from the Trauma Medical Director, Oscar Guillamondegui, MD Spring 2016
- 2. 2 1. The predominant immunoglobin associated with life threatening hemolytic transfusion reaction is: a. IgA b. IgG c. IgM d. IVIG 2. True or False: IVIG can induce hemolytic transfusion reactions or TRALI. 3. According to the Vanderbilt Blood Product Administration policy, a. The unused blood and IV set including IV solution must be sent to the lab b. The transfusion should not be restarted under any circumstance c. The first step is to obtain the patient’s vital signs d. The post-transfusion patient blood sample should be sent in a blue top. 4. The most common transfusion reaction is: a. Hemolytic transfusion reaction leading to hematuria, respiratory distress or death b. Transfusion related acute lung injury c. Mild temperature elevation and flushing d. Red urine with urticarial 5. If you suspect a blood transfusion reaction what should be what should be turned into the blood bank: a. Remainder of the blood product, including the IV solution and IV set (needle removed); b. Scan or copy of the TAR; c. Completed Report of Suspected Transfusion Reaction form; and d. Post-transfusion patient blood product sample, purple top (EDTA), properly labeled for Blood Bank. e. All the above Answer Key for Winter 2016 Trauma IEP Newsletter (answers are in bold and Italics below)
- 3. 3 Rich Lesperance, MD Case Study: A 49 year-old female was brought to Vanderbilt by EMS after a high-speed motor-vehicle collision. She has a past medical history of morbid obesity (BMI 40), asthma and Type 2 Diabetes. Her injuries included multiple long-bone, spine and pelvic fractures, and a ruptured diaphragm. She was admitted to the trauma ICU and made multiple trips to the operating room over the next few days for repair of her orthopedic, spine and visceral injuries. Subcutaneous low-molecular weight heparin (LMWH) was initiated as Deep Vein Thrombosis (DVT) prophylaxis. The 19th century pathologist, Rudolph Virchow, was the first to scientifically describe venous thrombosis. The “triad” of venous stasis, hypercoagulability and endothelial injury was named in his honor (but not actually described by him1) and is still used today to understand the pathophysiology of venous thrombosis2. Deep vein thrombosis remains a serious, widespread problem amongst trauma patients. Estimates of its frequency vary from 12% to 65% in hospitalized trauma patients not receiving prophylaxis3, this variance may be due to variable screening regimens for DVT (see below). This included an associated pulmonary embolism rate of 17%4. The risk drops precipitously to approximately 10-12% overall with the introduction of chemoprophylaxis and mechanical devices to stave off the effects of venous stasis/immobility. There are many risk factors for DVT identified in trauma patients. Severe head injury, pelvic injury, long bone fractures, increased age, greater than one operative procedure and greater than 3 days on a ventilator have all been associated with an increased risk of a DVT.5,6 It should be noted that many of these could be considered surrogates of “immobility”. Comorbidities such as diabetes, obesity, renal failure and malignancies have all been shown to increase the risk of a DVT formation.7 The incidence of DVT increases as screening measures increase. Universal screening of all trauma patients has been proposed to help identify and start treatment, but this is not a straightforward proposition. Many of the studies suggesting a benefit to screening were performed prior to widespread use of pharmacologic DVT prophylaxis. More recent studies showed that universal screening is not cost- effective, requiring between $20,000 and $65,000 per positive diagnosis.8,9 There is a wide range of opinion among trauma surgeons on whether universal screening is beneficial, with only about half of surgeons surveyed stating they routinely screen all trauma patients.10 The most current edition of practice guidelines from the American College of Chest Physicians recommends against universal screening of trauma patients.11 Classic physical exam findings for a DVT include swelling, pain or erythema of the affected limb. The “Homans’ Sign” (calf discomfort on forced dorsiflexion of the foot) has also been taught to generations of medical providers as a physical exam finding suggestive of a DVT. Unfortunately, DVTs are quite difficult to diagnose based on physical findings alone -even the surgeon that the Homans’ sign was named after refuted
- 4. 4 it later in his career.12 Multiple studies on the accuracy of physical exam findings revealed Homans’ sign was positive less than 50% of the time in all patients (including medical) later confirmed to have a DVT12. In trauma patients the accuracy is even lower: one of the largest studies to use ultrasound to define the incidence found that only 2% of the DVTs had physical exam findings suggestive of the diagnosis.4 Because they are notoriously difficult to diagnose, clinical suspicion and non-invasive imaging are of critical importance in diagnosing a DVT. The most common imaging study to screen for and diagnose a DVT is duplex ultrasonography. Duplex ultrasonography, is highly (>95%) sensitive and specific for DVT in the proximal leg veins, when compared to contrast venography studies13. Another non-invasive diagnostic modality is impedance plethysmography, which uses electrical sensors to measure the change in blood volume in the leg when a venous occlusion tourniquet is released. Impedance plethysmography can also be highly sensitive and specific14, but requires special equipment and training. Contrast venography has for many years been the gold standard for diagnosis, but is an invasive angiogram requiring venous cannulation and administration of contrast material. It is rarely performed. Other modalities of venography including CT or MRI are also able to determine the presence of a DVT with a high degree of accuracy. However, these studies are expensive, and require movement of the patient to the scanner and administration of contrast material, which can be problematic in the trauma population. The patient underwent several operative procedures during her first few days in the Trauma ICU, and several doses of LMWH were held as a result. On her fifth hospital day an occlusive thrombus in her common femoral vein was identified on ultrasound, and a continuous infusion of unfractionated heparin (UH) was started for therapeutic anticoagulation. Missed doses of chemoprophylaxis, or delayed initiation, have been found to increase the risk for DVT 6,15. Common reasons include: not ordering DVT prophylaxis promptly, or holding doses for surgical procedures due to hemorrhage fears. The Vanderbilt Trauma and Orthopedic services have recently formalized an understanding that the risk of DVT outweighs the risk of perioperative bleeding in most trauma patients, and prophylaxis will not be held prior to most abdominal and orthopedic surgeries. LMWH or low-dose unfractionated heparin (LDUH) are the typical agents used for pharmacologic DVT prophylaxis. In addition to drugs, mechanical adjuncts to prevent stasis in the lower extremities (ie, SCDs, compression stockings) have been used as well. Pharmacologic DVT prophylaxis is considered more effective than mechanical, but the effects are additive so patients should benefit from both.16 LMWH is thought to be superior to LDUH for DVT prophylaxis17, and enoxaparin is the preferred agent at Vanderbilt. Twice daily enoxaparin dosing is thought to be the optimal starting dose in the trauma population. Exceptions include renal failure or high risk bleeding situations such as spinal epidural catheter placement and intracranial pressure monitor placement, in which case LDUH is used. The Vanderbilt Department of Trauma and Surgical Critical Care Practice Management Guideline for DVT prophylaxis can be accessed (by clicking on “Protocols”) via any clinical workstation by clicking the MDSCC icon, or accessed anywhere at the following URL: https://medschool.vanderbilt.edu/trauma-and- scc/trauma-and-surgical-critical-care-practice-management-guidelines
- 5. 5 VUMC Clinical Management Guideline Group (see protocol for risk details) Risk Interventions Low / Moderate Risk 2-4% DVT 1-2% PE LMWH + SCDs for all patients without contraindications Renal Failure: lower LMWH dose or use LDUH. Indwelling CNS catheter: use LDUH Obesity: increase LMWH or LDUH dose (see protocol for details) High Risk 4-6% DVT 1-2% PE Consider surveillance duplex Very High Risk 10-20% DVT 5-10% PE (0.2-5% fatal) Consider surveillance duplex and/or IVC filter
- 6. 6 References: Bagot CN, Arya R. Virchow and his triad: a question of attribution. Br J Haematol. Oct 2008;143(2):180-190. 2. Wolberg AS, Aleman MM, Leiderman K, Machlus KR. Procoagulant activity in hemostasis and thrombosis: Virchow's triad revisited. Anesth Analg. Feb 2012;114(2):275-285. 3. Lozano LM, Perel P, Ker K, Cirocchi R, Farinella E, Morales CH. Thromboprophylaxis for trauma patients. Cochrane Database Syst Rev. 2010;2010(1). 4. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med. Dec 15 1994;331(24):1601-1606. 5. Haut ER, Chang DC, Pierce CA, et al. Predictors of posttraumatic deep vein thrombosis (DVT): hospital practice versus patient factors-an analysis of the National Trauma Data Bank (NTDB). J Trauma. Apr 2009;66(4):994-999; discussion 999-1001. 6. Michetti CP, Franco E, Coleman J, Bradford A, Trickey AW. Deep vein thrombosis screening and risk factors in a high-risk trauma population. J Surg Res. Dec 2015;199(2):545-551. 7. Paffrath T, Wafaisade A, Lefering R, et al. Venous thromboembolism after severe trauma: incidence, risk factors and outcome. Injury. Jan 2010;41(1):97-101. 8. Brasel KJ, Borgstrom DC, Weigelt JA. Cost-effective prevention of pulmonary embolus in high-risk trauma patients. J Trauma. Mar 1997;42(3):456-460; discussion 460-452. 9. Satiani B, Falcone R, Shook L, Price J. Screening for major deep vein thrombosis in seriously injured patients: a prospective study. Ann Vasc Surg. Nov 1997;11(6):626-629. 10. Haut ER, Schneider EB, Patel A, et al. Duplex ultrasound screening for deep vein thrombosis in asymptomatic trauma patients: a survey of individual trauma surgeon opinions and current trauma center practices. J Trauma. Jan 2011;70(1):27-33; discussion 33-24. 11. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. Feb 2012;141(2 Suppl):e227S-277S. 12. McGee SR. Evidence-based physical diagnosis. 3rd ed. Philadelphia: Elsevier/Saunders; 2012. 13. Gaitini D. Current approaches and controversial issues in the diagnosis of deep vein thrombosis via duplex Doppler ultrasound. J Clin Ultrasound. Jul-Aug 2006;34(6):289-297. 14. Locker T, Goodacre S, Sampson F, Webster A, Sutton AJ. Meta-analysis of plethysmography and rheography in the diagnosis of deep vein thrombosis. Emerg Med J. Aug 2006;23(8):630-635. 15. Louis SG, Sato M, Geraci T, et al. Correlation of missed doses of enoxaparin with increased incidence of deep vein thrombosis in trauma and general surgery patients. JAMA Surg. Apr 2014;149(4):365- 370. 16. Barrera LM, Perel P, Ker K, Cirocchi R, Farinella E, Morales Uribe CH. Thromboprophylaxis for trauma patients. Cochrane Database Syst Rev. 2013;3:CD008303. 17. Geerts WH, Jay RM, Code KI, et al. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med. Sep 5 1996;335(10):701-707.
- 7. 7 The Society of Trauma Nurses is a professional nonprofit organization whose mission is to ensure optimal trauma care to all people through initiatives focused on trauma nurses related to prevention, education and collaboration. At this year’s Society of Trauma Nurses’ conference held in Anaheim, California a few nurses from the Division of Trauma presented topics on palliative care and research on the Rural Trauma Team Development Course. Melissa Smith – Trauma Program Mgr [email protected] Oscar Guillamondegui – Trauma Medical Director [email protected] Tim Nunez – Trauma PI Director [email protected] Cathy Wilson – Trauma Outreach & Injury Prevention Coordinator [email protected] Rich Lesperance– ACS Fellow/IEP editor [email protected] Spring 2016 Contributors Trauma IEP Newsletter Melissa Smith & Cathy Wilson won the Research Poster Award for their work on the Rural Trauma Team Development course along with Dr. Brad Dennis. Teresa Hobt-Bingham presented 2 sessions entitled, “Improving Palliative Care Consultation in a Trauma ICU and Step-Down Unit. This is work that is currently going on in the Trauma ICU.
- 8. "Safe Steps for Seniors" The American Trauma Society, in collaboration with the Society of Trauma Nurses, is once again pleased to present National Trauma Awareness Month. This May, National Trauma Awareness Month celebrates its 28th anniversary with the campaign slogan, “Safe Steps for Seniors” and focuses on senior safety and falls. Falls are the leading cause of fatal and non-fatal injuries for older Americans. Falls result in more than 2.5 million injuries treated in emergency departments annually, including over 734,000 hospitalizations and more than 21,700 deaths. Falls threaten seniors’ safety and independence and generate enormous economic and personal costs. However, falling is not an inevitable result of aging. Through practical lifestyle adjustments, evidence-based falls prevention programs, and clinical-community partnerships, the number of falls among seniors can be substantially reduced. One-third of Americans aged 65+ falls each year. One out of five falls causes a serious injury such as broken bones or a head injury. Each year, 2.5 million older people are treated in emergency departments for fall injuries. That equates to 1 older adult every 13 seconds. Over 734,000 patients a year are hospitalized because of a fall injury, more than 21,700 suffer fatalities. Each year at least 250,000 older people are hospitalized for hip fractures. More than 95% of hip fractures are caused by falling, usually by falling sideways. Falls are the most common cause of traumatic brain injuries (TBI). Adjusted for inflation, the direct medical costs for fall injuries are $34 billion annually. Hospital costs account for two-thirds of the total. The financial toll for older adult falls is expected to increase as the population ages and may reach $67.7 billion by 2020.
- 9. 9 Trauma Admissions are Increasing!! Melissa Smith in the Division of Trauma has created a diagram to show the increase in Trauma Admissions that have been steadily going up over the past 5+ years. As Nashville is one of the largest growing cities, we believe the same will be happening to us! According to CNN Money Nashville is one of the fastest growing cities: In 2015, 30,000 new residents moved here, population is now at 1.8 million: http://money.cnn.com/gallery/real_estate/2014/03/27/fastest-growing-cities/7.html The Tennessean and others have named Nashville the new “IT CITY” bringing in 82 residents a day http://www.tennessean.com/story/insider/extras/2016/03/26/nashville-has-exciting-growth-uncertainty-city/81109814/
- 10. 10 Division of Trauma and Surgical Critical Care For any questions in regards to the IEP or Trauma cases please contact: Melissa Smith: 322.6745 or Oscar Guillamondegui: 936.0180