Archive for September, 2009

Austin Trauma Surgeons Say Level I Designation Will Bring Far-Reaching Benefits

Saturday, September 26th, 2009

In the editorial section of today’s Austin American-Statesman, Dr. Carlos Brown, medical director of trauma services at University Medical Center Brackenridge, and Dr. Todd Maxson, trauma medical director of Dell Children’s Medical Center, applaud the state’s recent Level I Trauma Center designation for both facilities. They say that because the designation carries with it a responsibility for conducting research and education, Austinites can expect a higher level of care by all medical personnel, better prevention programs, an easing of the doctor shortage and an invigorated economy.

Maxson and Brown make a great case and connect many advances in household safety — such as seat belts, bicycle helmets, sports mouthpieces and safety goggles — to trauma-based research. “All of these common-sense precautions are the result of trauma research,” they point out. “In fact, most injuries in children are preventable.” Research conducted by Maxson, Brown and others at Austin’s new Level I Trauma Centers will save millions of dollars and many lives.

Congratulations, Austin!

Trauma Comes to NBC Next Monday

Tuesday, September 22nd, 2009

You may be aware by now that the new fall lineup of TV shows on NBC includes a show called Trauma, set in San Francisco, featuring a team of first responder paramedics in a variety of trauma injury situations. NBC’s website features a section on the new series, including a sneak peek trailer of the show on the “Watch Video” section, and a forum for those interested in discussing the show. Peter Berg of “Friday Night Lights” fame is executive producer of the show, and the cast includes a core ensemble of seven.

Though we’re not yet sure how the show will fare when it debuts next Monday night, we’re certainly eager to see how the writers and directors portray the heroic actions of first responders. We’re even more eager to see how the show might help raise awareness of trauma in the United States. As the leading cause of death in Americans ages 1-44, resulting in 37 million ER visits, 2.6 million hospitalizations, and more than 170,000 deaths annually in the U.S., trauma affects us on a magnitude that a number of Americans aren’t yet aware of. As an organization committed to raising awareness of trauma, we’re hopeful that Trauma can help Americans understand the prevalence and magnitude of real-life trauma, and we’re equally hopeful that the show realistically portrays the challenges that first responders routinely face in helping care for patients from the field to the hospital.

Two Austin Hospitals Named Level I Trauma Centers

Monday, September 14th, 2009

There’s some great news from our neighbors to the north, released right before the Symposium started, that we wanted to make sure you didn’t miss. Two Austin hospitals, Dell Children’s Medical Center, and University Medical Center Brackenridge — both part of the Seton Family of Hospitals — have been designated Level I Trauma Centers.

This news story from KUT-FM, the National Public Radio affiliate in Austin, addresses how the Level I Trauma designation helps the health care providers and researchers in the community served by a Level I Trauma Center, as well as the obvious benefits to members of the community who unexpectedly encounter trauma injury.

The story quotes Dr. Todd Maxson and Dr. Carlos Brown, two of Austin’s foremost trauma experts, who both attended the Symposium and shared their expertise on medical vs. surgical treatment for pancreatic injuries in pediatric patients, medical vs. surgical treatment for a retained hemothorax, and evaluating transmediastinal gunshot wounds.

NTI Annual Symposium Report: Identifying and Treating Post-Traumatic Stress Disorder

Thursday, September 3rd, 2009

LCDR Jeffrey Cook, with the National Naval Medical Center in Bethesda, presented on the diagnosis and treatment of Post-Traumatic Stress Disorder (PTSD). Events known to cause PTSD in military and civilian populations include combat zone experiences, rape, natural disasters, child physical and sexual abuse, domestic violence and vehicle accidents. Patients seeking care following a traumatic event, he pointed out, are likely to be in poor mental health as well as physical health.

Cook indicated that there is no consistent laboratory value or imaging result that can confirm the presence of PTSD—hippocampal atrophy was initially believed to be a biomarker, but is now thought to be more of a risk factor than a result of the disorder.

The military now consistently administers a post-deployment health assessment to all returning servicepeople to confirm PTSD and rule out any physical disorder that might cause similar symptoms. Unfortunately, said Cook, of the people who come up positive on these assessments, fewer than one in four will seek follow-up treatment.

Cook distinguished Acute Stress Disorder (ASD) from PTSD primarily by the time horizon—ASD is a syndrome that occurs between two days and one month after exposure to a trauma, while the symptoms of PTSD persist well past one month. PTSD indicators include intrusive thoughts, images, nightmares, flashbacks, intense psychological distress and physiological reactivity upon cue exposure.

Persistent avoidance of activities and people associated with the trauma, unresponsiveness, and diminished interest in pleasurable activities are all signals of PTSD as well. Further, patients with this syndrome exhibit persistent increased arousal, in terms of having difficulty sleeping or concentrating, being irritable and having angry outbursts, being hypervigilant or having an exaggerated startle response.

The more short-lived Acute Stress Disorder manifests in much the same way as PTSD, but with more emphasis on dissociative symptoms such as numbing, derealization (a sense of surrealism), depersonalization and dissociative amnesia.

Among soldiers deployed to Iraq, PTSD increases linearly with the number of firefights they witness. Pre-trauma risk factors for PTSD onset include evidence of previous trauma, psychiatric history, high hostility and family history. Post-trauma risk factors for the onset of PTSD include lack of social support, additional life stress (foreclosure, divorce, etc.) and the severity of injuries.

Cook said that the Psychological First Aid protocol is beginning to replace traditional Critical Incident Stress Debriefing (CISD), as research has revealed that CISD potentially re-traumatizes survivors. Psychological First Aid is a set of interventions that does not emphasize catharsis. The most effective psychotherapies are cognitive and exposure therapies and eye movement desensitization. There is no evidence to recommend mood stabilizers or atypical antipsychotics. Cook indicated that antidepressants may be effective, but not in the initial stage of the disorder.

NTI Annual Symposium Report: Doctors Put an End to Tourniquet Controversy

Wednesday, September 2nd, 2009

Director of Mass Casualty Preparedness and Response at the University of Miami, Mauricio Lynn presented the case for using tourniquets on extremity injuries. They can be used reasonably safely, he said, especially to stop hemorrhage on injuries where it’s difficult to apply direct pressure such as mangled extremities.

Lynn cited a retrospective study conducted in Israel that examined the cases of 550 people injured in combat or terrorist attacks and found that almost 80 percent of tourniquet applications were effective. No limbs were lost due to tourniquet use. Another study of the U.S. experience in Iraq looked at 165 deaths over one year and found that 57 percent of those deaths could have been avoided if tourniquets had been applied.

LtCol Christopher White, Assistant Director of Clinical Research at the U.S. Army Institute of Surgical Research, Fort Sam Houston, reminded the audience that exsanguination is the cause of most deaths after trauma.

He reviewed the long recorded history of tourniquet use in combat and some of the reasons they got a bad name over the years: they can cause gangrene and tissue damage if left on too long, can result in paradoxical bleeding and can slip. Successful use of tourniquets during WWII was spotty because the design at the time was too small for the typical U.S. thigh. Asymmetric or poorly designed tourniquets, or those placed over clothing or pocket items could loosen, and those applied after the onset of shock resulted in 100 percent mortality.

White said that with the increased knowledge that has come from using tourniquets frequently, most of the criticisms have been addressed. We now know that they can be used safely for up to six hours, that the are ineffective if placed below the site of injury, that venous tourniquets should not be used to stop bleeding (this type of tourniquet increases blood flow), and that the optimal width is 38 mm (2 in.).

The Combat Application Tourniquet (CAT), which is now standard issue for U.S. troops, takes into account the most advanced information and has been used successfully thousands of times during the current conflict. White noted, however, that since civilian tourniquet use is relatively light, it’s more likely that mistakes will be made in their application.

He debunked the myth that tourniquets cannot be used successfully below knee or elbow. “They may actually work better on two bone segments,” he said. And he added that they work more effectively in colder climates.

In close, White said the tourniquet is a double-edged sword. “It can save your life; it can defend you, but it must be used appropriately.” His recommended protocol for treatment of hemorrhage is:

-Apply direct pressure and elevate
-Apply hemostatic dressing and/or elastic bandages
-Have a tourniquet at the ready if the first steps do not stop the bleeding

Lynn noted that tourniquet use was just added in the new edition of ATLS. “The curse is gone,” he said.

NTI Annual Symposium Report: Do Topical Hemostatic Agents Save Lives?

Tuesday, September 1st, 2009

Presenters in this session agreed that the literature on hemostatic agents is conflicting. Dr. Dror Soffer, Director of the Yitzhak Rabin Trauma Division at Tel-Aviv Sourasky Medical Center in Israel, said that the more studies he explored, the more conflicted he became. “The articles on this subject were all over the map.” The ideal hemostatic agent, Soffer said, would be FDA approved, safe, effective, easy to use, and cost-effective.

While Soffer cited a 2008 BJS review article concluding that there is a significant body of evidence in support of topical hemostatic agents in a wide variety of situations, his co-presenter, MAJ John Bini, Trauma Critical Care General Surgeon at Wilford Hall Medical Center, said that anecdotal reports from the field indicate it is not easy to apply and is not effective.

Attempting to present the “pro” argument, Soffer reviewed a variety of hemostatic agents available today–including gelatin, microfibrillar collagen, oxidized regenerated cellulose, Hemcon, Quickclot and fibrin sealants—and concluded that there is enough evidence to show they are effective. The use of local/topical hemostats lowers transfusion requirements, which means less bleeding, which equals higher survival, he reasoned.

Bini mentioned that hemostatic agents have been known to generate significant heat in wounds and cause burning. Some studies show overall good results, including one conducted with Quickclot. But Bini noted that the wounds where Quickclot failed—clavicular, groin, sternum and chest wounds—are all places where it’s also difficult to apply direct pressure. Thus, he questioned its efficacy.

Bini concluded that in light of the conflicting studies, and an especial lack of human studies–direct pressure, tourniquets and a surgeon are better options than hemostatic agents. Soffer added, “The fact that there are so many products on the market means that they are not good.”

NTI Annual Symposium Report: Treating Cardiac Arrest with Hypothermia

Tuesday, September 1st, 2009

Maj Julio Lairet, Medical Director of the CCATT Pilot Unit at Wilford Hall Medical Center, discussed the use of hypothermia in treating cardiac arrest patients.

Cardiac arrest frequently leads to severe neurological impairment; thus, preservation of brain function is the end goal of any treatment. Mild hypothermia reduces the basic metabolic rate, decreases heart rate and results in better ventilation—all of which have positive repercussions for brain functioning.

Lairet mentioned a 2002-2003 New England Journal of Medicine report on a big multicenter study that was one of the first to look at more long-term outcomes and whether patients were leaving the hospital neurologically intact after being treated with hypothermia. The study’s findings were positive overall, giving indications of both total recovery (CPC 1) and moderate disability (CPC 2).

Capt. Andrew Muck, an emergency medicine physician at Wilford Hall Medical Center, who was responsible for setting up the first hypothermia protocol there, led the “con” side of the debate lightheartedly. Clearly, the evidence is on the side of using hypothermia, he said, including two landmark studies and a wealth of anecdotal evidence.

However, there are downsides related to cardiac function, coagulation, compromised immune system, medication clearance, hyperglycemia and more. “These patients are the sickest of the sick, and we’re messing with their basic physiology,” said Muck. “It’s not good for everyone.” His other major observation was that, while it seems clear that hypothermia works, no one knows exactly why it works.

In addition, the intravascular devices that are the preferred method of cold delivery are very expensive and may not be within the reach of medical centers in small or rural communities.

Moderator Col Linda Lawrence, Chief Emergency Medicine Consultant to the Air Force Surgeon General and immediate past president of the American College of Emergency Physicians (ACEP), answered a question from the audience about getting research on hypothermia into practice outside of metropolitan, academic settings. She said it’s true that there is wide variation in the capabilities of hospitals across the country. “We are looking at ways to drive resources around the country to raise everyone’s level of care up instead of just academic centers,” she said. “We don’t want severe variability–We want to raise the level of emergency care for everyone, not have a tiered quality of care.”

NTI Annual Symposium Report: Medical vs. Surgical Therapy for Pancreatic Injuries

Tuesday, September 1st, 2009

Dr. Todd Maxson, Trauma Medical Director at Dell Children’s Medical Center in Austin, talked about pancreatic injuries in pediatric patients, such as resulting from lap belts in car accidents – something that he hoped we’ll all be seeing less of in Texas with new rules around booster seats going into effect today. He began by discussing CT results, noting that CTs done 12-18 hours after an injury are better indicators than CTs done immediately after the injury. He also noted that ERCP is the gold standard in ductal interrogation, especially when compared to MRCP, but acknowledges the test is difficult to conduct with children.

He laid out what he termed a rational approach on opting for surgery, having to do with hemodynamic stability of the patient. If hemodynamic stability is initially unclear, he recommends monitoring the patient and holding off on surgery for at least the first 18-24 hours, in order to get more reliable lab results.

LTC Matthew Martin, MD, Trauma Medical Director and Chief of Surgical Critical Care with the Madigan Army Medical Center in Tacoma, noted that while it’s possible to nonoperatively manage anything, there are cases that we should be managing operatively. He illustrated a typical case of a “successful” non-operative management of a pancreatic injury with a 45-day hospital stay, 30 pounds of weight loss, five CT scans through the course of the hospital stay, and the patient being discharged with a drain still inserted. He also warned of significantly increased morbidity if there is a delay in surgical management of a pancreatic injury. Because Martin sees it as an uncommon injury, unfamiliar territory, and an unforgiving organ, where the first shot is the best shot in resolving a trauma injury, he advocates surgery in most cases.

NTI Annual Symposium Report: Medical vs. Surgical Therapy for Retained Hemothorax

Tuesday, September 1st, 2009

Dr. Carlos Brown, Chief of Trauma and Surgical Critical Care at University Medical Center Brackenridge in Austin, presented on medical therapy for a retained hemothorax. Brown started by noting in the case of a retained hemothorax, a CT rather than a chest X-ray is needed to do a proper diagnosis. Three possible outcomes included absorption, fibrothorax formation, or infection. Brown discussed some surgical options, including a thoracotomy or a VATS procedure – both of which take up OR time and can lead to complications, including, in the case of a thoracotomy, increased morbidity.

Brown then discussed medical options, including intrapleural thrombolytics – a therapy first discussed in the Annals of Surgery back in 1951. Brown cited several studies with 92 percent resolution, taking between three and 12 days.

CDR Dan Gramins, MD, Head of the Department of Cardiothoracic Surgery Staff at the Navy Medical Center of San Diego, provided the rebuttal advocating for surgical treatment of the retained hemothorax. He looked at both VATS and thoracotomy statistics, and pointed out that two years out, 92 percent of VATS patients are pain-free two years after the procedure, compared to 50 percent who received thoracotomy.

NTI Annual Symposium Report: Physical Rehab with TBI: Vestibular and Balance Retraining

Tuesday, September 1st, 2009

CPT Yadira Del Toro, DPT, VRT, CBIST, with the National Naval Medical Center in Bethesda, Md., spoke on vestibular and balance retraining for patients with traumatic brain injury.

Del Toro reviewed the various levels of TBI, and noted that about 90 percent of TBI are mild, with 70 percent of all TBIs being blast-related – which tend to cause balance and dizziness issues. While over 50 percent of balance disorders in civilian population will resolve over time, less than 20 percent of war injured balance disorders resolve without treatment. However, over 70-80 percent of vestibular deficits improve with only five to eight weeks of treatment, and 73 percent of blast-related cases improve with eight weeks of treatment.

She recommended simple diagnostic techniques for patient caregivers, and then detailed various diagnoses and treatment techniques for blast-related disorders. Del Toro emphasized that the standards for military personnel are higher than those for civilian populations, because military personnel generally require more physical exertion in their daily on-the-job activity.