S1E4: Silver Trauma
Welcome back to TheCase.Report! For our first trauma special, we felt it was important to have a special focus on silver trauma.
Orla and Tom will take us through some contrasting cases, and Dr. Áine Mitchell will look over their work.
For our second segment, Jeff sat down with Prof. Conor Deasy for a chat about the state of trauma services in Ireland and the Major Trauma Audit.
Dr. Shane Broderick joins Jeff for the last segment to give us some invaluable tips when dealing with trauma.
Let's get to it!
Silver Trauma
The Worlds population is getting older and more dependant on healthcare.
1,600 patients a year in Ireland suffer major trauma. It is our job to try to make sure these patients receive the right treatment at the the right time. Being in the right place for this can be challenging and is the basis of the huge piece of work ongoing to develop a trauma network for Ireland.
the typical severely injured patient isn’t the traditional young male injured in a road traffic incident, but now older and injured as a result of falling, with a lower male predominance.
The Major Trauma Audit National Report 2016 shows patients aged over 65 years made up 40% of all trauma. However, this age group accounted for 64% of all mortality. The most common mechanism of injury was falls from less than 2 metres (low falls) and the most common place of injury was in the home. Older patients were more likely to die and suffer higher levels of disability than younger major trauma patients with similar severity of injury score. Two-thirds of trauma deaths in over 65 year olds were due to head injuries.
Trauma approach and triage are traditionally based on mechanism and injury pattern.
We tend to under triage older adults trauma both pre hospital and in hospital. This means less pre alerts, less trauma team calls and less senior reviews in the emergency department.
There is a great paper that is free to access online ‘The Changing Face of Major Trauma in Ireland’ published in age and aging online.
Not all older adults are frail. There have been a number of studies looking at frailty scores being a better predictor of adverse outcomes than age alone.
The frailty index is based on the concept that frailty is a consequence of interacting physical, psychological, and social factors. As deficits accumulate, people become increasingly vulnerable to adverse outcomes. The frailty index is calculated as the number of deficits the patient has, divided by the number of deficits considered.
One study published in JAMA surgery in 2014 used the Frailty index in geriatric trauma patients and defined a score greater than 0.25 as frail. These frail patients had an odds ratio of 2.5 for in hospital complications and 1.6 for adverse discharge disposition. (https://pubmed.ncbi.nlm.nih.gov/24920308/)
Pitfalls
Our older trauma patients may still receive injury based care when they need more holistic patient focused care. For example treating the wrist fracture or hip fracture and not looking into the potentially syncopal cause of the fall and thereby delaying further diagnostic work up or intervention (eg Need for a PPM or ICD).
Older patients may have underlying hypertension, are less able to respond to hypoperfusion and are more likely to have heart rate regulating medications. They have less physiological reserve.
Our older patients have not only a different pattern of injury and more occult injuries but the physiology of ageing may not have the traditional parameters to trigger major trauma pathways.
Approach
Before the patient arrives
Trauma call!
Role as a team leader - effectively designate roles and to provide structured cohesive care.
Prepare your team for the patients arrival. Assign roles, explain what is going to happen next to the more junior members of the team.
Get any equipment you might need ready.
Depending on how much time you might have before the patients arrival it may be beneficial to tie off other loose ends within in the department so it isn’t in chaos when the trauma is finally sorted.
ATLS approach to primary survey with mnemonic ABCDE
Airway maintenance with cervical spine control
Look for signs of airway obstruction
Talk to the patient! This will help you to quickly assess if their airway is ok and not needing intervention at present. Listen for any sounds of an obstructed airway such as stridor or obstructed breath sounds
In complete airway obstruction, there are no breath sounds at the mouth or nose. In partial obstruction, air entry is diminished and often noisy.
Often simple maneovres may help. Jawthrust , airway suctioning. Intubation is required when these fail.
The trauma airway is an inherently difficult airway and should never be taken for granted, these reasons are multifactorial. Video laryngoscopy and Gum elastic bougie can be helpful here to limit neck flexion and extension
Unfasted patient, both the patient and the environment presents multiple challenges. Needs a well thought out management plan and all airway kit available along with a surgical airway kit.
High prevalence of C spine injuries among Poly trauma patients. Take extra care while transferring these patients. Apply a C spine collar and manual in line stabilisation should be carried out for intubation. C spine collars are an emerging area of controversy but we won’t get in to that today….
Breathing and ventilation
Respiratory rate and SpO2
Exposure and inspection essential: external signs of trauma, asymmetrical chest movements
Careful palpation over entire chest wall may reveal unsuspected injury e.g. crepitus / surgical emphysema. Based off a series of recent cases in my department beware of delayed presentations of pneumothorax coming in with extensive facial swelling as their presenting complaint!
Lung ultrasound, now I am no ultrasound guru but this is one of the easiest and most beneficial uses of POCUS - use the Linear or curvi linear probe to assess for lung sliding. Quick, easy to perform and very sensitive for the diagnosis of pneumothorax!
Circulation with haemorrhage control
HR BP Cap refill, cool peripheries. Cognition.
Look systemically for bleeding. Remove any dressings applied pre hospital - I can’t stress this enough, that category 3 that has been waiting 8 hours could have anything underneath that tightly wrapped crep bandage on their head or extremity.
Large bore IV access - 2 by ACF. Sample for crossmatch and VBG then usual bloods.
Ext bleeding - direct pressure, tourniquets, tying off vessels(a skill really worth learning and one I would have struggled with myself. There are some great resources on a website Lacerationrepair.com Avoid big bulky dressings.
Consider Massive transfusion/code red. 1:1:1 in the absence of whole blood( ie everywhere)
Massive transfusion is defined as
replacement of >1 blood volume in 24 hours, or
>50% of blood volume in 4 hours (adult blood volume is approximately 70 mL/kg), or
in children: transfusion of >40 mL/kg (blood volume in children over 1 month old is approximately 80 mL/kg)
EFAST scan
Pelvic binder, splinting long bone fractures. Tourniquet if bleeding cannot be controlled by direct pressure. Document site and time it went on.
TXA 1g stat - give ASAP, has been associated with increased mortality from bleeding if given less than 3 hours or more after injury.
Anticoagulant and antiplatelet reversal. Particularly relevant in our Silver trauma population. Try and find out the anti -coagulant status of the patient. In severely injured patient rapid reversal paramount. Some protocols recommend giving platelets to patient on anti-platelet agents. This will be less of an issue if we are transfuing platelets as part of massive transfusion protocol.
Brief mention Damage control resuscitation. Avoiding crystalloids -as some of favourite EM consultants say - crystalloids are only good for cooking pasta.. Lethal triad - acidosis, hypothermia and coagulopathy- made worse by high volume of crystalloids(worsening acidosis and haemodilution)
Generally try and avoid vasopressors given that haemorrhage is the most common source of shock in trauma patients. The exception to this is spinal shock from traumatic spinal cord injuries. Fluid resuscitation and addition of a vasopressor such as noradrenaline is often required here.
Disability
Assess GCS and document it’s components (e.g. E4, V5, M6 = GCS 15)
Assess pupillary size and responsiveness
Assess gross motor and sensory function in all 4 limbs
look for signs of expanding ICH: palpable skull crepitus/obvious skull fracture, signs of basilar skull fracture, scalp hematoma, and facial bone fractures
If you suspect a spinal injury is present a full neurological assessment is vital at the earliest opportunity — check for priapism, loss of anal sphincter tone and the bulbocavernosus reflex - (Now I have never done this before. It involves squeezing the glans penis or clitoris and monitoring for internal and external anal sphincter contraction. The absence of the reflex in a person with acute paralysis from trauma indicates spinal shock whereas the presence of the reflex would indicate spinal cord severance. Features particularly suggestive in early assessment of spinal cord injury -focal neurologic deficit, priapism, or shock refractory to standard transfusion methods.
Check glucose
Progressively worsening ICH and associated edema can quickly progress, resulting in herniation of intracranial contents. This is often heralded by a combination of vital sign changes and lateralizing physical exam findings. Cushing’s response is the combination of bradycardia and hypertension in the herniating patient.
Exposure and environmental control
While maintaining thermostasis, completely expose the patient
If not yet done, consider log-rolling the patient now
Areas where potentially life threating injuries can be missed are:— Back of head— Back— Buttocks— Perineum— Axillae— Skin folds
TXA:
The Evidence in Trauma
Tranexamic acid is a synthetic derivative of lysine that reversibly attaches to lysine binding sites on plasminogen, preventing its activation to plasmin. Since plasmin breaks down fibrin clots, TXA prevents clot breakdown, which can maintain (not create) clots and reduce bleeding. Also, the coagulation and inflammatory cascades overlap (eg, plasmin activates complement), so TXA may have an anti-inflammatory mechanism as well.
Originally studied in elective surgery patients. A systematic review of 53 RCT’s noted a decrease in need for peri-operative transfusion of one third (RR 0.62) although no difference in mortality.
CRASH -2 Trial
Large multi centre randomised placebo controlled trial in 2011.
Over 20,000 adult trauma patients with or at risk of significant bleeding in 274 hospitals in 40 countries were randomly assigned to TXA (loading dose 1 g IV plus another 1 g IV over the next eight hours) or placebo within eight hours of injury. The primary outcome was all-cause mortality at four weeks. Secondary outcomes included vascular occlusive events, surgical interventions, need for blood transfusion, and amount of blood products transfused.
1.3% decrease in all cause mortality.RR 0.91. NNT 67. Timing is vital!!
1st hour - 2.3% decrease in mort. RR 0.68
1-3hrs - 1.3% decrease in mort RR 0.79
3hrs or greater- 1.3% increase in mort RR 1.44
No apparent increase in fatal or non fatal vascular occlusive events and no significant differences in any of the secondary outcome measures.
CRASH-3
Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. The Lancet October 2019
Population: Adult patients 16 years and older with traumatic brain injuries with GCS score of 12 or lower or any intracranial bleed on CT scan and no extracranial bleeding treated within 3 hours of injury
Excluded: Age less than 16 years of age, extracranial bleeding, or greater than 8 hours since injury (limited to greater than 3 hours from September, 2016)
Intervention: TXA 1g infused over 10 minutes followed by an infusion of another 1g over 8 hours
Comparison: Saline placebo
Outcome:
Primary Outcome: Head injury-related deaths within 28 days
Secondary Outcomes: Early head injury deaths (<24hrs), all-cause and cause specific mortality, disability, vascular occlusive events (myocardial infarctions, stroke, venous thromboembolism), seizures, complications, neurosurgery, days in the intensive care unit (ICU), adverse events within 28 days and subgroup analyses.
Primary Outcome: Death due to head injury
18.5% TXA vs. 19.8% placebo, RR 0.94 (95% CI 0.86 to 1.02) Confidence intervals cross 1 so no statistically significant results.
Secondary Outcomes: The two statistically significant results were less head injuries deaths within the first 24 hours and in the subgroup of patients with milder injuries (GCS 9-15). Disability was similar between both groups. There was no evidence of increased vascular events, seizures, complications or adverse events.
Interpretation of this trial’s results vary greatly. There was also no significant difference in all cause mortality with TXA RR 0.98 (95% CI 0.89 -1.04).
Áine’s Resources
Many thanks to our Adult in the Room this month Dr. Áine Mitchell, who not only gave us some great feedback and tips, but also recommended the great resources below!
Adapted by Airedale EM from work by HECTOR
Rib fractures in the elderly, Bulger et al., J Trauma, 2000
”Elderly patients who sustain blunt chest trauma with rib fxs have twice the mortality and thoracic morbidity of younger patients with similar injuries...”
https://pubmed.ncbi.nlm.nih.gov/10866248/
HECTOR (The Heartlands’ Elderly Care Trauma & Ongoing Recovery Programme)
Course manual:
https://nebula.wsimg.com/e27a5f71599c4008097061a64d486286?AccessKeyId=71C7B1EA5618F4C499E1&disposition=0&alloworigin=1
or through link at https://www.mcctn.org.uk/silver-trauma.html
London Major Trauma System: Management of elderly major trauma patients
Pan-London Clinical Guidance:
https://www.c4ts.qmul.ac.uk/downloads/pan-london-major-trauma-system-elderly-trauma-guidancesecond-editiondecember-2018.pdf