4.22.2010

Dr. Mullins Trauma Top Ten (part one)

Day two of the 21st Annual Northwest States Trauma Conference here in Sunriver and we get an early start counting down some of the latest research in trauma care. OHSU Trauma Surgery Eminence Dr. Richard Mullins held forth on the following hot topics.

#10
CT versus Laparotomy with penetrating wounds to the abdomen - The question: how do we best find injuries in the abdomen with patients presenting with penetrating abdominal wounds? Do we CT them? Open them up and look around or do serial, noninvasive physical exams.

The OAKLAND group found that CT was a great way find to triage abdominal injuries if "mandatory laparotomy signs" weren't present. Out of 306 patients, half of which got CT exams and only two false negatives were found. "That's pretty good," said Mullins, "but I think those guys probably missed a few more holes in the diaphragm." In any case, the Oakland group was dealing mostly with gunshot wounds and a lot of them.

The WESTERN just focused on stab wounds and defined the abdomen as below the costal margin. This group did wound exploration. Positive findings bought the patient 23 hours of serial physical exams. If they weren't showing signs of peritonitis, bleeding and were still hemodynamically stable, they got to go home.

The EASTERN trauma surgeons agree that serial physical exam is reliable IF there is a system to follow for the exams and a systematic way to record any changes. In otherwords, observation only works if you pay attention.

Mullins said he likes a delayed CT with oral contrast after six hours if there is still the possibility of damage to the bowel.

#9
 Using CT to determine which kidney injuries require intervention - One 5th of cardiac output is going to the renal system, so trauma can cause rapid exsanguination.  So who needs surgical intervention or angioembolization to control bleeding? Who will get better if you just observe them? Researchers found that injury scales are valid, correlating highly with outcomes. We also know now that there are three features of grade 3 and 4 renal injuries that require intervention to control bleeding. Most can be managed -- and managed earlier with angioembolization rather than later surgery and need for blood transfusions.

#8
 Surrogate and Doctor Expectations regarding ICU patient's long term Outcomes - This study was fascinating and sad. Surgeons managing a ICU patient on long term ventilation go to family members to ask for permission to put in a tracheostomy. Twenty percent of the patients died after the trach and of those that lived, only one out of 10 patients was doing well one year after discharge from the hospital to long term care. When asked of expected outcomes, neither the doctors, nor the surrogate decisionmakers were anywhere close to the reality of the outcomes. Worse, when the surrogates and family members were asked what had happened in the past year, 49 percent reported more stress in their lives and 84 percent had to quit their jobs to take care of the patient.

"We are looking at an enormous burden of families, and we need to communicate that accurately when we ask for persmission."

#7
Using procrit and other Erythropoiesis stimulating agents (ESAs) in patients with traumatic brain injuries - Usually ESAs are given to cancer patients to stimulate the growth of new red blood cells. However, this research looked at ten years of the drug's use in patient's with traumatic brain injuries. The death rate for those getting ESA was 8 percent compared to 24 percent in the other group. Strangely those getting the ESA had a lower hemoglobin on average than the control group.

#6
 Using Warm Fresh Whole Blood for trauma - Recent studies have shown that "old blood is bad blood" Mullins says. "Older than 29 days and you have two times the risk of infection. Yet the FDA says that blood can be kept for 42 days."

This study looked at the use of warm fresh whole blood in trauma patients in Iraq. While fresh whole blood in almost never given in the US these days due to screening restriction, in Iraq, pre-screening of military donors allowed 6,000 units of fresh whole blood to be given right after donation.  The results seem to be better trauma survival outcomes.

Why?

Even though the total red blood cells is the same, fresh blood has the plasma included.
"I think maybe the frozen plasma and platelets we give are not as good a coagulation cocktail as fresh warm blood," Mullin said. Studies in Japan have shown that trauma activates a coagulation cascade which consumes coagulation factors. Of the non-surviving trauma patients studied 87 percent had evidence of DIC. Fresh Warm Blood may stave off DIC in major trauma. "Some day blood donors will be part of the level one trauma team activation," Mullins concludes.

Read the Rest of the Top Ten HERE

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