Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Fall With Dementia and No Change from Baseline Mental Status

ResearchBlogging.org
 

This happens many times every day. A patient falls and may have hit her head, but there is no change from her normal mental status. To complicate matter, she takes an anticoagulant.

There are no clear signs of serious trauma. so should we automatically go to the trauma center?

What can help us decide?
 

Patients were not excluded because of dementia, aphasia, or any cognitive or neurologic deficit that was determined by the physician caring for the patient to be the patient’s baseline.[1]

 

The conclusion of the study is useful, but I would reverse the emphasis.
 

Signs of trauma to the head and face or loss of consciousness is predictive of ICI.[1]

 

An absence of Signs of trauma to the head and face or loss of consciousness is predictive of an absence of ICI (IntraCranial Injury).
 

The study is not perfect, for example it is not clear what is included in the signs of trauma to the head, but it does strongly suggest that these patients should not be diverted to a trauma center just for anticoagulants, or for dementia, or for being old.
 

A patient was determined to have no significant acute head injury (1) if he/she had a negative result on head CT performed, (2) if the patient was admitted to the hospital and had no sequelae at discharge, (3) if review of his/her medical record revealed repeat hospital visits unrelated to falls with no sequelae or concerns related to the index visit,or (4) if the patient had no concerns at 30 days postinjury in telephone follow-up.[1]

 

These clearly are not the patients who needed to be trauma alerts.
 


 

Anticoagulants did not matter. While a trend is probably just statistical noise, the trend for anticoagulants other than aspirin was toward less likelihood of ICI.

While Signs of trauma to the head and face increased the likelihood of ICI, History of hitting head had a trend toward less likelihood of ICI.
 

The sensitivity and specificity for signs of trauma to the face/head or loss of consciousness were 92.6% (74.2-98.7) and 40.2% (36.8-43.8), respectively. The positive predictive value in this“low-acuity”cohort was 5.2% (3.4-7.6), and the negative predictive value was 99.4% (97.4-99.9).[1]

 

Should we start to write protocols based on this, or triage patients based on this? We should find out more, but patients with dementia and no change in mental status probably should not be triaged differently from patients with no change in mental status who just happen to not have dementia.

We already knew that, but we did not have evidence to support that bit of common sense.
 

A recent prospective study concluded that 26% of elderly patients presenting to the ED exhibited evidence of cognitive impairment[13].[1]

 

If a quarter of elderly patients have cognitive impairment, this can have a big effect on EMS.
 
 

The following figure that confused me. The percentages in red on the far right are the percentages of each category. That is what I would want to know, when looking at the data. The totals are not explained. Maybe someone will see what I am missing. How did 799 patients become 783, or did they become 783, and what happened to the other 16 patients if the number is now 783?
 


 

Regardless of my confusion with the figure above, this paper is one more reason for me to feel comfortable transporting patients with dementia and no obvious head injury (and no loss of consciousness) to the local hospital.

Footnotes:

[1] Characteristics of elderly fall patients with baseline mental status: high-risk features for intracranial injury.
Hamden K, Agresti D, Jeanmonod R, Woods D, Reiter M, Jeanmonod D.
Am J Emerg Med. 2014 May 12. pii: S0735-6757(14)00318-0. doi: 10.1016/j.ajem.2014.04.051. [Epub ahead of print]
PMID: 24929771 [PubMed – as supplied by publisher]

Hamden K, Agresti D, Jeanmonod R, Woods D, Reiter M, & Jeanmonod D (2014). Characteristics of elderly fall patients with baseline mental status: high-risk features for intracranial injury. The American journal of emergency medicine PMID: 24929771

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Not all mechanisms are created equal

ResearchBlogging.org
 

How do we determine which patients go to a trauma center?

Too often by MOI (Mechanism Of Injury).

Physiologic criteria are not too bad and involve some assessment of the patient.
 


 

Notice that the GCS (Glasgow Coma Score) is not just for a history of a loss of consciousness or for not being fully oriented.

Anatomic criteria are also not too bad and similarly involve some assessment of the patient.
 


 

Mechanism Of Injury is where the most disagreement arises and I have had some entertaining conversations with trauma doctors, but far more disagreement with those doctors who have only anecdotal trauma experience.
 

The MOI that accurately predicts trauma center need remains a controversial debate within the trauma community. One specific example of this controversy is the rollover mechanism. Single-center experience suggests rollover is not predictive of severe injury, while a review of a large government database suggests otherwise.13,14 [1]

 

This study excluded everyone who met physiologic or anatomic criteria in order to assess the ability of MOI alone to identify need for a trauma center.
 

Trauma center need was defined as death, Injury Severity Score (ISS) of more than 15, blood transfusion in the emergency department (ED), intensive care unit (ICU) admission, pelvic fracture, need for laparotomy/thoracotomy/vascular surgery within 24 hours of arrival, two or more proximal long bone fractures, or neurosurgical intervention during admission.[1]

 

Some of those duplicate anatomic criteria, but they appear to refer to pelvic fractures and pairs of long bone fractures that were not identified by EMS and were not documented by EMS as criteria for trauma activation.
 


 

How much risk of death is there for these mechanism-only patients? We do not know, but only 0.3% died in the hospital.

How many of them would have been triaged as trauma alerts by a good assessment?

The biggest problem with this paper is that it is not able to tell us whether these patients would have been triaged as trauma alerts without MOI criteria to point to for documentation.
 

The goal of every trauma center is to treat as many seriously injured patients as possible, while directing care of the less severely injured to community hospitals. To achieve this goal, the ACSCOT suggests that an overtriage rate of 50% is acceptable to maintain an undertriage rate of 5% or less.15[1]

 
 

Our overtriage rate of 77% was higher than that which is considered acceptable by the ACSCOT. The overtriage rate in this study is consistent with that noted in other studies, which used the 1999 guidelines for evaluating MOI in prehospital triage, which ranged from 75% to 91%.21–24 [1]

 
 

In 2006, our system stopped requiring trauma center transport of patients meeting Step 3 criteria.[1]

 

Step 3 is MOI.

Requiring medical command permission to fly patients meeting MOI criteria in Maryland led to an apocalyptic prediction from the top trauma doctor.
 

“Whenever someone says they want to ratchet it back,” says Dr. Thomas M. Scalea, physician in chief at Shock Trauma, “I tell them ‘OK, how many people can die next year to make that worthwhile?’”[2]

 

There have not been any reports of increases in the fatality rate with that change.

How did the MOI criteria do?

Wrong question. Since they eliminated the use of MOI criteria in this system, we have a strong hint.
 

Orthopedic operations were the most common procedures performed on those patients transported from the ED to the operating room (289 patients, 68%). Eighteen patients (4%) did require a laparotomy, thoracotomy, or vascular procedure directly from the ED. Of those requiring laparotomy (11 patients, 3%), 2 were to repair a liver laceration, 2 for splenectomy, and 4 were intestinal repairs/resection. Three nontherapeutic laparotomies were performed.[1]

 

Those numbers are better than what I would expect. I used to work in a trauma center that had less than 5% of trauma alert patients go to surgery in any kind of rush. Surgery is not the only criterion for whether the trauma center is an appropriate destination.
 

Significant MOI predictors of trauma center need include death in the same passenger compartment, ejection from the vehicle, extrication time of more than 20 minutes, fall from more than 20 feet, and pedestrian thrown/runover.[1]

 

Those are the criteria they think have some predictive value.

Here are the ones that are old wives’ tales.
 

Criteria that did not meet our definition of trauma center need were vehicle intrusion, vehicle rollover, speed of more than 40 mph, autopedestrian/autobicycle of more than 5 mph, and both of the motorcycle crash criteria.[1]

 

Separation of the motorcyclist from the motorcycle is not a bad sign, but it shows that the MOI criteria were written by someone who does not understand motorcycles. In a crash, remaining inside a car/truck is protective, but remaining attached to the outside of a motorcycle is almost as bad as being strapped to the outside of a car/truck. This is the reason motorcycles do not have seat belts. Motorcycles do not offer physical protection. The protection is in the increased maneuverability and the ability of the rider to avoid getting in trouble. A motorcycle crash at highway speed is only bad if you are hit, hit something, or if you are not wearing protective gear.

How much better would a good assessment be at correctly identifying patients who have critical injuries?

How much worse would a good assessment be at correctly identifying patients who have critical injuries?

A good assessment would require good education and good oversight.

As with other interventions, this should be studied prospectively.

Footnotes:

[1] Not all mechanisms are created equal: A single-center experience with the national guidelines for field triage of injured patients.
Stuke LE, Duchesne JC, Greiffenstein P, Mooney JL, Marr AB, Meade PC, McSwain NE, Hunt JP.
J Trauma Acute Care Surg. 2013 Jul;75(1):140-5.
PMID: 23940858 [PubMed – indexed for MEDLINE]

[2] Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008
Article

Stuke, Lance E. MD, MPH; Duchesne, Juan C. MD; Greiffenstein, Patrick MD; Mooney, Jennifer L. MD; Marr, Alan B. MD; Meade, Peter C. MD; McSwain, Norman E. MD; Hunt, John P. MD, MPH (2013). Not all mechanisms are created equal: A single-center experience with the national guidelines for field triage of injured patients. Journal of Trauma and Acute Care Surgery, 75 (1), 140-145 DOI: 10.1097/TA.0b013e3182988ae2

.

Is the Difference in Penetrating Trauma Mortality Truly Significant? Part I

ResearchBlogging.org
 

MV observed the following lack of distinction in scene time for penetrating trauma mortality, which I did not give the proper attention in EMS Time and Survival from Blunt and Penetrating Trauma. I will try to correct my mistake here.
 

I find it interesting (good) that they actually published those graphs. I’m not sure what you can really say based on the graphs, as the error bars are way too wide to make good conclusions. For instance, there is no real difference in death rate due to scene time on penetrating injuries that can be determined by this study based on Figure 5.

 

Here is Figure 5.
 

 

On multivariate regression of patients with penetrating trauma, we observed that a scene time greater than or equal to 20 minutes was associated with higher odds of mortality than scene time less than 10 minutes, with an odds ratio (OR) of 2.90 (95% confidence interval [CI] 1.09 to 7.74). Scene time of 10 to 19 minutes was not significantly associated with mortality (OR 1.19; 95% CI 0.66 to 2.16).[1]

 

I should have paid more attention to this, rather than just looking at the brief description of the 0-9 minute vs. the 10-19 minute scene time intervals, which are not graphed vs. mortality.

Clearly, this graph is not a graph of 0-9 minute, 10-19 minute, and 20-29 minute time periods, but there is no explanation of the numbers represented by the graph.

If we eliminate the blunt trauma part of the graph, the wide error bars on the penetrating trauma percent dying show a lot of overlap. The error bars cover as much as a 50% difference in survival in one time period, while the narrowest error bars cover over at least a 15% difference in survival.

Overlap on error bars is usually an indication that the results are not statistically significant, but it depends on the type of error bar. The text describes CIs (Confidence Intervals) when comparing the 0-9 minute vs. 10-19 minute scene time intervals. However, the graphs do not specify which type of error bar is used, so we do not know how the error bars should be interpreted.
 

Error bars are a graphical representation of the variability of data and are used on graphs to indicate the error, or uncertainty in a reported measurement. They give a general idea of how accurate a measurement is, or conversely, how far from the reported value the true (error free) value might be. Error bars often represent one standard deviation of uncertainty, one standard error, or a certain confidence interval (e.g., a 95% interval). These quantities are not the same and so the measure selected should be stated explicitly in the graph or supporting text.[2]

 

There should not be so much overlap if there is any significant difference. It appears that the only way there is a statistically significant difference is by covering a ten minute time period.
 

 
Click on images to make them larger.

The last time period (≈ 26 minute scene time) has error bars that overlap with all of the other time periods, including the ≈2 minute scene time. The ≈2 minute scene time is the only time period where the median is not within the error bars for the ≈ 26 minute scene time.

 

 

Even the shortest scene time (≈2 minute scene time) has wide enough error bars to include the medians from two other time periods (≈6 minute scene time and ≈10 minute scene time). These would all fall within the 0-9 minute scene time group and the larger group can have enough patients to narrow the error bars. Wide error bars are often an indication of small numbers. For an example of this, look at the graph that contains the blunt trauma patients – those error bars are much narrower than the error bars for the penetrating trauma patients. The study had 16,170 blunt trauma patients and only 2,997 penetrating trauma patients. That means 5.4 times as many blunt trauma patients.

Paradoxically, the much larger group of blunt trauma patients did not produce any statistically significant difference in outcomes based on scene times or transport times. with more penetrating trauma patients, would the statistical significance disappear?

We do not know.

The authors state that the choice of time periods was made before analysis of the data, so this does not appear to be an example of trying to find the right groups to make the data fit the hypothesis.
 

We categorized out-of-hospital times into 10-minute intervals a priori with the intent of choosing an interval that is operationally practical, clinically feasible, and politically acceptable.[1]

 

I would like to see what the graph of 0-9 minute, 10-19 minute, and 20-29 minutes would look like.

None of this suggests that the concept of the Golden Hour should survive.
 

It is crucial for medical researchers to critically examine concepts such as the golden hour that are widely accepted but are in fact not scientifically supported. We frequently strive to push ever higher the ceiling of medical knowledge, but we must also ensure that the knowledge base upon which we stand is solid.[3]

 

Ignorance may be bliss for some people, but we will not improve outcomes for our patients by promoting ignorance.

Footnotes:

[1] Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center.
McCoy CE, Menchine M, Sampson S, Anderson C, Kahn C.
Ann Emerg Med. 2013 Feb;61(2):167-74. doi: 10.1016/j.annemergmed.2012.08.026. Epub 2012 Nov 9.
PMID: 23142007 [PubMed – in process]

[2] Error bar
Wikipedia
Article

[3] The golden hour: scientific fact or medical “urban legend”?
Lerner EB, Moscati RM.
Acad Emerg Med. 2001 Jul;8(7):758-60. Review.
PMID: 11435197 [PubMed – indexed for MEDLINE]

Link to Free Full Text Download in PDF format from Academic Emergency Medicine

Lerner EB, & Moscati RM (2001). The golden hour: scientific fact or medical “urban legend”? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 8 (7), 758-60 PMID: 11435197

McCoy CE, Menchine M, Sampson S, Anderson C, & Kahn C (2013). Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center. Annals of emergency medicine, 61 (2), 167-74 PMID: 23142007

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EMS Time and Survival from Blunt and Penetrating Trauma

ResearchBlogging.org
 

People will tell you that they just know that we need to load and go. Some even claim that the mythological Golden Hour is real. Maybe there will be an episode of Ancient Aliens about R Adams Cowley identifying the meaning of trauma and writing it on a cocktail napkin in a bar.
 

Debate continues over the “load and go” versus “stay and stabilize” approach to patient care in the out-of-hospital setting because there is a paucity of supportive data for either argument.[1]

 

All trauma alerts and patients who were not trauma alerts, but were later admitted to the trauma service of a level 1 trauma center from 1996 to 2009 were included.
 

Exclusion criteria were extrication, missing or erroneous out-of-hospital times, intervals exceeding 5 hours, missing data, and nonblunt or penetrating injury (ie, burns, drowning, hangings).[1]

 

One odd aspect of the data is that they do not record the response times, so the out-of-hospital times do not include response times.
 

we contacted the county EMS agency to obtain general descriptive information on county response times. For basic life support response, the median 90th percentile for system standard response times is 6 minutes 15 seconds (range 4 to 8 minutes). For advanced life support response, the median 90th percentile for system standard response times is 6 minutes 5 seconds (range 4 minutes 28 seconds to 7 minutes 45 seconds).[1]

 

The response times seem to have pretty good consistency, so maybe that does not affect outcomes. Still, the out of hospital time period does need to have response time added.
 

We categorized out-of-hospital times into 10-minute intervals a priori with the intent of choosing an interval that is operationally practical, clinically feasible, and politically acceptable.[1]

 

 

It is interesting that the mortality rate increases until about 22 minutes of scene time, then mortality improves. This could just be a factor of the small numbers with scene times that long.

For blunt trauma, almost the opposite pattern exists. Fans of immobilization might see this as some kind of evidence that back boards save lives. Maybe immobilization kills any benefit to short scene times, but shorter scene times do seem to increase mortality.

There may be a Diamond Scene Time of 5 minutes for penetrating trauma. Between the ≈2 minute scene time and the ≈7 minute scene time the mortality rate jumps dramatically, but this may also just be a function of small numbers.

How much time is appropriate/necessary for penetrating trauma?

Even PHTLS (PreHospital Trauma Life Support) guidelines tell us that there is no reason to worry about “spinal immobilization” for penetrating trauma, unless there is some noticeable neurological deficit.[2] No worries about distracting injuries with penetrating trauma. There probably still is not any benefit to immobilizing these patients.

Therefore, for trauma patients with serious injuries, the most important parts of scene time are the time taking the stretcher (without the spinal implements of destruction) to the patient, a rapid assessment, plugging the holes and managing airway while moving the patient to the stretcher, then moving the stretcher to the ambulance.

Not much time needed.
 

 

There is a very clear connection between severity of injury and survival.
 

The odds of mortality with patients having an Injury Severity Score greater than 15 was 91.06 compared with those with less than 15 (95% CI 70.07 to 118.34) (Figure 6).[1]

 

An OR (Odds Ratio) of 90 is huge.
 

The association between increased out-of-hospital times and decreased mortality may be in part explained by EMS providers moving with haste for patients thought to have serious injury and taking more time for patients recognized as having minor injuries.[1]

 

With penetrating trauma, there may be less of an effect, but it should not produce opposite outcomes.
 

Our study did not find an association between transport times and mortality.[1]

 

Even further suggestion that we fly far too many patients for no apparent benefit.

The authors suggest that this might reflect the benefit of driving past a non-trauma hospital to arrive at a trauma center.

Almost all of the patients had scene times in the 0-9 minute and 10-19 minute groups and transport times in the same groups. The scene times produced statistically significant differences with distributions similar to the distributions of the transport times.

Is the transport time less important?

Does more time on scene really improve survival for blunt trauma patients?

 

Also see –

Is the Golden Hour Full of Crap?

And my correction of my too simple look at the data and graphs from this study –

Is the Difference in Penetrating Trauma Mortality Truly Significant? Part I

Footnotes:

[1] Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center.
McCoy CE, Menchine M, Sampson S, Anderson C, Kahn C.
Ann Emerg Med. 2013 Feb;61(2):167-74. doi: 10.1016/j.annemergmed.2012.08.026. Epub 2012 Nov 9.
PMID: 23142007 [PubMed – in process]

[2] Spine Immobilization Following Penetrating Trauma
PHTLS podcast
PHTLS (Prehospital Trauma Life Support)
http://www.phtls.org
1/18/2010 12:00 PM
Podcast page

McCoy CE, Menchine M, Sampson S, Anderson C, & Kahn C (2013). Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center. Annals of emergency medicine, 61 (2), 167-74 PMID: 23142007

.

On FaceBook Medics Let Imaginary Lawyers Tell Them What To Do

I was having a good day, during a bad week. Then Kelly Grayson – everybody’s favorite Ambulance Driver – directed me to a discussion of tourniquets.

We believe all sorts of scare stories about lawyers.

Why?

Ignorance and repetition. Too often, these are our teachers in EMS.

The discussion was based on a good question and does include some good comments, but too many are suggesting that use of tourniquets carries some sort of greater legal liability than other EMS care.

That is nonsense.
 

it’s called Civil Liability… not an issue in the Armed Forces ( thankfully ) and thank you for your service !!!!!!!

As in – Thank you for your service, but don’t get an extremity injury with severe bleeding when I am on duty?

A tourniquet, when indicated, is good patient care.

Withholding a tourniquet, when a tourniquet is indicated, is bad patient care.

Not knowing how and when to use our equipment is bad patient care.

Bad patient care IS a liability.

We can be sued for anything. Most nonsense will probably not be accepted by a plaintiff’s lawyer, or will probably be thrown out by the judge. For the rest, the best defense should be that we provided the best care we could.

Gene Gandy has stated this many times. He is both a lawyer and a paramedic. Skip Kirkwood has expressed similar sentiments. He is also both a lawyer and a paramedic.

Should we learn from wannabe lawyers on FaceBook, or should we learn from real lawyers?

Some more of the FaceBook advice –

you can’t get sued in the military. civilians love to earn a buck on our behalf, even if it was life threatening.

 

One word…lawyers. aside from civi medic I’m a Red Cross pro rescue 1 aid n cpr instructor. Lawyers and arm chair docs dictate civilian EMS. Military has no such hinderance. Lots more operational liberty in the military where civi ambulance chasers have no power

 

I have to agree with the above poster. Military medic is totally different then city ems. Totally different protocols. Seems to me city ems has to constantly walk on egg shells with their patient’s because people are lying and saying thing’s that never happened to try and make a quick buck. I think tourniquets are better then applying pressure but sad to say civilians won’t see it that way. Civilian world will never be like military world and that’s that.

 

Using a TQ may result in the loss of an arm or leg.

 

Image credit.

According to the people commenting, this patient’s amputations are the result of the tourniquets (TQs).

They are not pretty prepackaged tourniquets, but what matters is whether they work.

The tourniquets are the problem?

No.

Incorrectly Using a TQ may result in the loss of an arm or leg.

Tourniquets do not sneak up and steal our patients’ limbs. We generally have to screw up in a big way.
 

I treated a patient with a BTK amputation and did not use a TQ. As a result, the team at the University of Cincinnati Trauma Center Hospital was able to reattach the patients leg.

Would the outcome have been worse if a tourniquet had been used?

Based on what?

It seems as if this person does not understand that tourniquets are not amputations. They aren’t even spelled the same way.

Competent tourniquet use does NOT cause amputations.
 

Civilians aren’t trained for war zone injuries, military are……….

Civilians are not trained to treat for shootings, stabbings, or explosions?

What about farming accidents? Farming equipment can be just as nasty as any military weapon.
 

Risk management. The military doesn’t have as much risk of being sued if used improperly. So, in this case, the safest bet is to not use it.

What?

I am not competent, so I will let my patient die. That will prevent me from being sued!

No.

That might even encourage an aggressive attorney to try to bring manslaughter charges against you.

Is that negligence any more responsible than driving while extremely drunk and on bath salts and texting about it at the same time?
 

because tactical medicine is different than civilian medicine. Tactical focuses mote on saving lives in a fast environment and there’s no time to try to save the limb. civilian world = save life, and hopefully limb also. if there’s time to stop bleeding with an alternate method then why TQ and cause loss of a limb? makes sense huh? thanks. – civilian paramedic!

For all those tunnel visioned by “MAJOR INJURIES/BLEEDS” and say TQ first…i have personally seen an amputated leg, above knee, and even with femoral being severed…direct pressure and pressure point stopped bleeding. no TQ needed. theres a reason for the difference in medicine tactical vs civilian ….learn them, and use common sense to understand why, before criticizing!

Another one mistakenly claiming that tourniquet equals amputation and that because he once saw bad bleeding controlled without a tourniquet, that tourniquets are unnecessary and very bad. The back to back comments are by the same person.

This guy needs to provide evidence to support his criticism of tourniquets.

Making irrelevant comments is not evidence.

His confused attempt at logic does not demonstrate that tourniquets are a bad idea.
 

Litigation is the way “I” rationalised between being a PAARNG Medic and an EMT.

Wow!

He won’t become a medic, because he is afraid of being sued?

Don’t worry. Basic EMTs get sued, too.
 

when theyre used people tend to loose limbs. In the civilian world that can mean ones lively hood.

No evidence, just another uninformed opinion.
 

We see these comments enough and some of us may start to believe that these people actually know what they are writing about.

They do not know what they are writing about.

Skip Kirkwood writes –

This is old news. The civilian world has been teaching and using tourniquets for years. Litigation has nothing to do with it – try to find any case law involving the use of the big T – you won’t find any.

And there is this excellent comment –

As a former Army medic, I can’t help but agree. I always said it’s easier to replace air than blood…priorities…and ensured everyone had three CAT’s on them at once.

 

The alphabet has A before B and B before C, but our patients will die (and stay dead) if we let them bleed out while we are messing with A or B.

We can deal with Airway and Breathing after we control major bleeding. Using a tourniquet makes it more likely that we will be able to deal with the bleeding and the airway/breathing problems and save a life that would not be saved without a tourniquet.

Practical use of emergency tourniquets to stop bleeding in major limb trauma.
Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB.
J Trauma. 2008 Feb;64(2 Suppl):S38-49; discussion S49-50.
PMID: 18376170 [PubMed – indexed for MEDLINE]

CONCLUSIONS:
Morbidity risk was low, and there was a positive risk benefit ratio in light of the survival benefit. No limbs were lost because of tourniquet use, and tourniquet duration was not associated with increased morbidity. Education for early military tourniquet use should continue.

Minor morbidity with emergency tourniquet use to stop bleeding in severe limb trauma: research, history, and reconciling advocates and abolitionists.
Kragh JF Jr, O’Neill ML, Walters TJ, Jones JA, Baer DG, Gershman LK, Wade CE, Holcomb JB.
Mil Med. 2011 Jul;176(7):817-23.
PMID: 22128725 [PubMed – indexed for MEDLINE]

RESULTS:
After comparable methods were verified for both the first and current studies, we report the results of 499 patients who had 862 tourniquets applied on 651 limbs. The clinical results were consistent. No limbs were lost from tourniquet use.

CONCLUSION:
We found that morbidity was minor in light of major survival benefits consistent with prior reports.

Complications associated with prolonged tourniquet application on the battlefield.
Dayan L, Zinmann C, Stahl S, Norman D.
Mil Med. 2008 Jan;173(1):63-6.
PMID: 18251333 [PubMed – indexed for MEDLINE]

The use of a tourniquet to control bleeding is a necessity in both surgical and prehospital settings. Tourniquet application, if performed properly, can be a lifesaving procedure, particularly in a traumatic setting such as the battlefield. A tourniquet is easily applied and requires the use of a relatively uncomplicated piece of equipment. However, improper or prolonged placement of a tourniquet because of poor medical training can lead to serious injuries, such as nerve paralysis and limb ischemia. Here we present five case reports of improper tourniquet applications on the battlefield that resulted in nerve damage. We conclude that there is a need for improved training among medical personnel in the use of tourniquets,

Tourniquets are not that complicated, but they do require that we know how to use them and that we know how to reassess our patients.

If we don’t know how to use our equipment and we do not know how to reassess our patients, we are not safe with anything.

.

What is the effect of clopidogrel on head injuries? Part IV

ResearchBlogging.org

Continuing from Part I, Part II, and Part III about the comparative effects of warfarin (Coumadin) and clopidogrel (Plavix) on tICH (traumatic IntraCranial Hemorrhage).

What about the patients with delayed tICH (traumatic IntraCranial Hemorrhage)? There were four cases of delayed tICH.[1] Should this information encourage adoption of the European approach of admitting people for 24 hour observation and repeat CT (Computerized Tomography) scanning?

What would have been the result of a 24 hour observation period with a thousand patients, rather than the paltry 87 (or 97, depending on your ability at math) in the study recommending a 24 hour observation period?[2],[3],[4]

All of these patients were ground-level falls, so from standing, or sitting, or lying on bed. All of these patients had a GCS (Glasgow Coma Scale/Glasgow Coma Score[5]) of 15, which is normal. There does not appear to have been anything alarming about any of these patients, but two of them died – and the information does not provide any clues to identify them while they might have been treated successfully.
 


Click on images to make them larger.[1]

Delayed tICH patient #2 was admitted without any requirement for 24 hour observation. The delayed tICH was identified on the first day of hospitalization, so this would probably have been picked up by the European protocol.

This patient was probably admitted because the doctor was concerned about something and wanted to observe the patient. The reason for admission and observation is not given.

The patient’s INR (International Normalizated Ratio[6]) was 1.50, which is sub-therapeutic for a patient taking warfarin. Using the INR for guidance would suggest that this patient is not one of the patients at high risk for delayed bleeding due to taking an anti-coagulant. Maybe he has skipped some doses of his medication. Maybe his medication dosing needs to be adjusted.

Delayed tICH patient #2 was discharged home on day 4 with no apparent treatment or complications.

Delayed tICH patient #3 was admitted without any requirement for 24 hour observation. The delayed tICH was identified on the seventh day of hospitalization, because of a change in mental status. It is not known if the delayed tICH would have been picked up by the European protocol.

This patient was also probably admitted because the doctor was concerned about something and wanted to observe the patient. The reason for admission and observation is not given.

The patient’s INR was 4.95, which is high, even for a patient taking warfarin. Using the INR for guidance would suggest that this patient is one of the patients at high risk for delayed bleeding due to taking an anti-coagulant. Maybe his medication dosing needs to be adjusted.

Delayed tICH patient #3 improved and was discharged home on day 8 with no apparent treatment or complications.

Delayed tICH patient #4 was admitted without any requirement for 24 hour observation. The delayed tICH was identified on the third day of hospitalization, because of a change in mental status. It is not known if the delayed tICH would have been picked up by the European protocol. He was made DNR (Do Not Resuscitate) and died on hospital day without treatment.

This patient was also probably admitted because the doctor was concerned about something and wanted to observe the patient. The reason for admission and observation is not given.

The patient’s INR was 1.90, which is slightly sub-therapeutic for a patient taking warfarin. Using the INR for guidance would suggest that this patient is not one of the patients at high risk for delayed bleeding due to taking an anti-coagulant.

What would it take to prevent his death?

Could anything have prevented his death?

He was already in the hospital when he began to show symptoms.

How many CT scans might have been needed to catch this early?

One every other day?

One every day?

One with each meal?

If this bleed were caught early, would it have made any difference in the outcome?

There is a lot we do not know.

Making rules, based on ignorance, will probably not improve outcomes.

This is the really interesting patient. This is also a very sad case. She was discharged home without admission. The bleed was identified 3 days after the original injury. She was found at home with a level of consciousness described as obtunded, which describes most of the very broad gray area between not fully unresponsive and not fully responsive.

She was taken to the hospital and treated with mannitol (an osmotic diuretic that is used to try to decrease the swelling in the brain) without success. She died that day due to an uncal herniation.
 

Transtentorial (Uncal) Herniation: (3) Due to the cerebral edema, the uncus of the temporal lobe (medial temporal lobe) herniates downward into the posterior fossa. Central herniation (2) occurs when there is downward pressure centrally and can result in bilateral uncal herniation.[7]

 

Would a 24 hour observation period have identified this patient?

Was she alone at home?

Did she live alone?

When did she start to have symptoms?

What symptoms did she have?

Could she have recognized these symptoms and called for help?

Was this a sudden onset?

We do not know the answers to any of these questions.

Her INR was 1.15, which is the least likely to raise concerns about any kind of bleeding on warfarin. This level is also sub-therapeutic. Did she start taking extra warfarin because her INR was too low? We don’t know.

Since she was discharged home, we would expect that she leads a somewhat normal life – able to care for herself, or able to be cared for by family, but we do not know any of those circumstances.

What would it take to prevent her death?

Could anything have prevented her death?

If we hospitalize every patient taking an anticoagulant who has a possible head injury, how many patients will have bad outcomes just because of being hospitalized. Unnecessary hospitalization is not benign.

Several doctors have suggested that the standard of care needs to be to miss the diagnosis on the first time for several conditions, such as low risk of pulmonary embolus, low risk chest pain. Maybe this should also fall into that category.

The problem is convincing a jury that expects a perfect outcome, no matter how unreasonable that expectation is.

Is it time to initiate medical courts to decide medical issues, rather than have the most medically naive people available make decisions about what is good patient care?

Why did the editors decide to make the tiny Menditto study,[2] free for all visitors to their site, but keep this this much larger, very well designed, study behind a paywall? The Menditto study draws broad conclusions from inadequate data. The Menditto study probably should not have been approved for publication, yet it is the featured paper in a prestigious journal.

I expect much better from Annals of Emergency Medicine.

Am I asking too much?

Footnotes:

[1] Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use.
Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, Reed ME, Holmes JF; Clinical Research in Emergency Services and Treatment (CREST) Network.
Ann Emerg Med. 2012 Jun;59(6):460-468.e7.
PMID: 22626015 [PubMed – in process]

Mp3 of this section of the June 2012 Annals of Emergency Medicine podcast.

[2] Management of Minor Head Injury in Patients Receiving Oral Anticoagulant Therapy: A Prospective Study of a 24-Hour Observation Protocol.
Menditto VG, Lucci M, Polonara S, Pomponio G, Gabrielli A.
Ann Emerg Med. 2012 Jan 13. [Epub ahead of print]
PMID: 22244878 [PubMed – as supplied by publisher]

Free Full Text from Annals of Emergency Medicine

[3] Observation For Anticoagulated Head Trauma
EM Literature of Note
Radecki
Article

[4] This is the Way to Bad Medicine
Rogue Medic
Tue, 24 Jan 2012
Article

[5] Glasgow Coma Scale
Wikipedia
Article

[6] International Normalizated Ratio
Wikipedia
Article

[7] Brain Herniation
CNS Response to Injury
UCSF.edu
Article

Nishijima, D., Offerman, S., Ballard, D., Vinson, D., Chettipally, U., Rauchwerger, A., Reed, M., & Holmes, J. (2012). Immediate and Delayed Traumatic Intracranial Hemorrhage in Patients With Head Trauma and Preinjury Warfarin or Clopidogrel Use Annals of Emergency Medicine, 59 (6), 460-2147483647 DOI: 10.1016/j.annemergmed.2012.04.007

Menditto, V., Lucci, M., Polonara, S., Pomponio, G., & Gabrielli, A. (2012). Management of Minor Head Injury in Patients Receiving Oral Anticoagulant Therapy: A Prospective Study of a 24-Hour Observation Protocol Annals of Emergency Medicine DOI: 10.1016/j.annemergmed.2011.12.003

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What is the effect of clopidogrel on head injuries? Part III

ResearchBlogging.org

Continuing from Part I and Part II about the comparative effects of warfarin (Coumadin) and clopidogrel (Plavix) on tICH (traumatic IntraCranial Hemorrhage).

Total patients – 1,064.

Total seen at a trauma center – 364 (34.2%).

Total seen at a community hospital – 700 (65.8%).

What was the outcome of tICH patients who were seen at the community hospitals? I could not find that. That might be useful for examining how well community hospitals are managing these minor head injury patients and for determining how well we are doing at triaging patients away from hospitals that are not expected to manage them well (when they need a neurosurgeon). Neurosurgery is not all that is available at a trauma center, but it is the most significant intervention for tICH.

Should we calculate the immediate tICH patients based on the 1,000 who had CT scans right away? Do we include the 64 patients who did not have CT scans based on the lack of other evidence of immediate tICH, even though we do not know if any bleeding showed up on the CT scan it would never have caused symptoms?

70/1,000 = 7% with immediate tICH.

70(+?)/1,064 =

Of the 6% who did not have a CT scan, there were no cases of tICH identified. Does that mean that we can definitely screen out some patients?

Since the decision to order a CT was based on physician preference, there does not appear to be anything consistent about these patients, except that they did not raise the suspicions of the treating physician as much as the other 94% did.

Was the choice not to get a CT scan more common among physicians in trauma centers, more common in community hospitals, or roughly the same in both settings?

54 of the 64 patients who did not have CT scans were seen at community hospitals. 54/700 (7.7%) at community hospitals, while only 10/364 (2.7%) at trauma centers did not have a CT scan.

Were the patients seen at the trauma centers more seriously injured than those seen at the community hospitals? I hope so, otherwise triage to trauma centers would not appear to be effective.

What percentage of tICH patients were seen at the community hospitals?

The prevalence of traumatic intracranial hemorrhage was highest at the Level I trauma center (12.6%; 95% CI 8.1% to 18.3%) compared with the Level II trauma center (5.0%; 95% CI 2.3% to 9.2%) and the 4 community centers (5.4%; 95% CI 3.9% to 7.4%).[1]

Except for hospitals that only handle trauma, the trauma centers are always going to have some minor injuries come to them because they also serve the community as EDs (Emergency Departments). Some patients will be transported to the trauma center as a precaution because it does not take much longer to get to the trauma center than to the closest hospital. Some patients will be transported to the trauma center because of the anticoagulants on board. Some patients will be transported to a trauma center because of a serious injury.

We do not know what the reason was for the destination decisions.
 


 

11 (1%) patients had severe head injuries (GCS 3-8). How many of them went to the level I trauma center? How many went to the level II trauma center. How many went to the 4 community hospitals? What were their outcomes?

We don’t know.

18 (1.7%) patients had moderate head injuries (GCS 9-12). How many of them went to the level I trauma center? How many went to the level II trauma center. How many went to the 4 community hospitals? What were their outcomes?

We don’t know.

Should we be taking all anticoagulated patients to trauma centers?

Probably not, but this study was not designed to answer that question.

Should we be taking all patients on clopidogrel to trauma centers?

12.0% of clopidogrel patients had tICH, but only 5.1% of warfarin patients had tICH.

I am going to be more likely to take them to a trauma center, but we need to have a much larger study to have good answers to these questions.

The combination of clopidogrel and a head injury, even with no obvious injury, does seem to more than double the likelihood of a serious injury. That is probably better than almost all of the MOI (Mechanism Of Injury) criteria, not that we should be using MOI to triage patients.


Click on images to make them larger.

There are only 37 patients in the warfarin group and 33 patients in the clopidogrel group, so trying to compare subgroups is not useful. The numbers are too small for anyone to draw valid conclusions based on differences among the subgroups.

The difference in the number of bleeds between clopidogrel and warfarin is based on the much larger numbers of patients and the CI (Confidence Interval) is narrow, so these are the numbers that should be consistently reproducible.

70 patients out of 1,000 (7%) had immediate tICH –

But only 27 (2.5% of 1,064) died or had neurosurgical intervention.

Should we include the 64 patients who did not die or have any indications for neurosurgery?

Yes.

Does that change things much? No.

27/1,064 is 2.5%, rather than 27/1,000 (2.7%). The difference is not big.

While 70 anticoagulated patients had an immediate traumatic bleed, only 27 appear to have needed a trauma center.

How many of the 27 patients were transported to a trauma center?

How many of the asymptomatic tICH patients died or required neurosurgery?

We don’t know.

How many of the patients with only minor symptoms died or required neurosurgery?

We don’t know.

How many of the patients were taken to the closest hospital because there was nothing that the trauma center would be able to do to improve outcomes? Head injury + DNR? Head injury + advanced age and significant comorbidities that would make surviving surgery improbable?

How many of the patients were taken to a facility that could realistically change the outcome?

Would any of the 15 patients who died after immediate tICH have survived if taken to a level I trauma center? Were any of these 15 patients taken to any of the community hospitals, or to the level II trauma center?

A lot more questions than answers, but the study was not designed to answer these questions and the authors do not suggest otherwise.

To be continued in Part IV.

Footnotes:

[1] Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use.
Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, Reed ME, Holmes JF; Clinical Research in Emergency Services and Treatment (CREST) Network.
Ann Emerg Med. 2012 Jun;59(6):460-468.e7.
PMID: 22626015 [PubMed – in process]

Mp3 of this section of the June 2012 Annals of Emergency Medicine podcast.

Nishijima, D., Offerman, S., Ballard, D., Vinson, D., Chettipally, U., Rauchwerger, A., Reed, M., & Holmes, J. (2012). Immediate and Delayed Traumatic Intracranial Hemorrhage in Patients With Head Trauma and Preinjury Warfarin or Clopidogrel Use Annals of Emergency Medicine, 59 (6), 460-2147483647 DOI: 10.1016/j.annemergmed.2012.04.007

.

What is the effect of clopidogrel on head injuries? Part II

ResearchBlogging.org

Continuing from Part I.

A part of this study that should received more attention is the rate of immediate tICH (traumatic IntraCranial Hemorrhage) among patients taking clopidogrel or warfarin.

5.1% of warfarin (Coumadin) patients had immediate traumatic intracranial hemorrhage.

12.0% of clopidogrel (Plavix) patients had immediate traumatic intracranial hemorrhage.

The sample was from all patients with any kind of head trauma who presented to the participating trauma centers or to the participating community hospitals. From major head trauma transported to a trauma center through to minor head trauma, such as the patient transported to a community hospital because of a nursing home slid out of bed in the dementia unit and might have hit head protocol. This should increase the relevance of this study to emergency physicians in community hospitals and could affect the decisions about where to transport these patients.

More than 60% of patients with immediate traumatic intracranial hemorrhage in both warfarin and clopidogrel cohorts had a normal mental status (GCS score = 15).[1]

Does that mean that tICH is more common with a normal GCS (Glasgow Coma Scale/Score) than with a lower GCS?

No.

Definitely not.

From Table 4, there are 45 tICH patients with a GCS of 15. There are a total of 70 tICH patients. 45/70 = 64.3%.

Only 64.3% of patients with a tICH had a GCS of 15, while the patients with a GCS of 15 made up 87.6% of the patients evaluated for head injury. 3.6% of the warfarin patients with a GCS of 15 had immediate tICH, while 9.2% of the clopidogrel patients with a GCS of 15 had immediate tICH.

Only 12.4% of the patients had a GCS <15, but they made up 35.7% of the cases of tICH.

Suppose we don't require a GCS of 15, but only ≥13. Those with a GCS of 12 or less made up 2.7% of patients, but 15.7% of the cases of tICH. It appears that the lower the GCS, the greater the likelihood of tICH, but a GCS of 15 is not a reason to assume that there is no head injury, especially if the patient is taking clopidogrel.

1/11 clopidogrel patients (GCS of 15 and hit head) will have a bleed vs. 1/28 warfarin (GCS of 15 and hit head) patients. Are the newer drugs better? Will the claimed better than clopidogrel drugs be better at avoiding side effects or will they be better at causing intracranial bleeding from minor injuries? The newer drugs include prasugrel (Effient), ticagrelor (Brilinta), dabigatran (Pradaxa), rivaroxaban (Xarelto), and others.

We don’t know yet, but it would not be reasonable to assume that these drugs will be safer.

Should all anticoagulated patients receive a CT scan, regardless of how unremarkable their physical exam?

According to the authors, yes. However, they did not scan every patient. There were 64 patients who did not receive CT scans. This is about 2/3 of the size of the study that claims that these patients should be observed in the hospital for 24 hours, then receive another CT scan.[2]

How reckless was skipping the CT on these apparently uninjured patients?


Click on image to make it larger.

Zero patients with tICH.

This is from a very small number (64 patients), so it is not good evidence (and the authors do not claim that this is good evidence), but this is almost on a par with numbers in the Menditto study (97 patients).[2] With small numbers, we can come up with answers that satisfy almost any hypothesis.

Is there good evidence for admission and a 24 hour observation period followed by a second CT scan for every anticoagulated patient with any head trauma?

No.

Is there good evidence for a CT scan for every anticoagulated patient with any head trauma?

Yes. Until there is a good way to decide which patients do not need to be scanned. The problem is that there does not appear to be a good substitute for a CT scan – and even the CT scan misses tICH (delayed tICH).

27/70 (38.7%) tICH patients had neurosurgery or died.

How many of them had a GCS of 15?

How many of them had a GCS of ≥13?

What was it about these patients that encouraged the doctors to not use a CT scan on the 64 patients who did not receive a CT scan?

We do not know.

When we look at the delayed tICH patients, we will see that there is not an easy way to pick out the slow bleeds from the GCS, INR, mechanism, or anything else.

Table 4 shows that those 45 tICH patients are out of 45/870 patients with a GCS of 15. 45/870 is 5.2%. This is from Table 4, out of the total of 1,064 patients, so why do they state elsewhere that there are 932 patients (87.6%) with a GCS of 15? Where are the 62 patients who make up the difference? The footnote states that this is *Based on patients who received a cranial CT scan on initial evaluation after head injury. The conclusion appears to be that 62/64 (96.9%) patients, who did not have a CT scan, did have an initial GCS of 15. That makes sense. 45/870 patients who had a GCS of 15, had a CT scan, and had an immediate tICH.

Normal mental status (GCS = 15) – 932 (87.6%).

752 (70.7%) patients had physical examination findings of head trauma above the clavicles, but only 707 of those patients had CT scans and 50/707 (7.1%) had immediate tICH. 45 patients with physical examination findings of head trauma above the clavicles do not appear to have had a CT scan. 45 (70.3%) of the 64 patients who did not have a CT scan, do appear to have had physical examination findings of head trauma above the clavicles. When reading the results in Table 4, this appears to be the explanation for the differences in the numbers. It would be nice if this were clearer on the first reading of the paper.

To be continued in Part III and Part IV.

Footnotes:

[1] Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use.
Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, Reed ME, Holmes JF; Clinical Research in Emergency Services and Treatment (CREST) Network.
Ann Emerg Med. 2012 Jun;59(6):460-468.e7.
PMID: 22626015 [PubMed – in process]

There is a podcast covering this at Annals of Emergency Medicine. Podcast on this article in Mp3 format.

[2] Management of Minor Head Injury in Patients Receiving Oral Anticoagulant Therapy: A Prospective Study of a 24-Hour Observation Protocol.
Menditto VG, Lucci M, Polonara S, Pomponio G, Gabrielli A.
Ann Emerg Med. 2012 Jan 13. [Epub ahead of print]
PMID: 22244878 [PubMed – as supplied by publisher]

Free Full Text from Annals of Emergency Medicine

There is a separate podcast covering this article at Annals of Emergency Medicine. Podcast on this article in Mp3 format.

I covered this in January in This is the Way to Bad Medicine.

Menditto, V., Lucci, M., Polonara, S., Pomponio, G., & Gabrielli, A. (2012). Management of Minor Head Injury in Patients Receiving Oral Anticoagulant Therapy: A Prospective Study of a 24-Hour Observation Protocol Annals of Emergency Medicine DOI: 10.1016/j.annemergmed.2011.12.003

Nishijima, D., Offerman, S., Ballard, D., Vinson, D., Chettipally, U., Rauchwerger, A., Reed, M., & Holmes, J. (2012). Immediate and Delayed Traumatic Intracranial Hemorrhage in Patients With Head Trauma and Preinjury Warfarin or Clopidogrel Use Annals of Emergency Medicine, 59 (6), 460-2147483647 DOI: 10.1016/j.annemergmed.2012.04.007

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