Trauma with Dr Sandy Widder

Dr. Widder holds the position of Associate Professor in the Department of Surgery and Critical Care, where she specializes as a trauma/acute care surgeon and Intensivist. Her subspecialty training was successfully completed in Calgary and Miami through a visiting fellowship. Additionally, she holds a Masters in Health Administration from the University of British Columbia’s Sauder School of Business and another in Quality Improvement and Patient Safety from the University of Toronto in 2014. Over the course of her distinguished career, Dr. Widder has assumed various leadership roles, including serving as the former Facility Site Chief for Trauma at the University of Alberta, Canada. She has also held the position of Provincial Medical Co-Chair for Trauma Services and currently serves as the Associate Zone Medical Director in Integrated Quality Management at Alberta Health Services (AHS). Dr. Widder’s professional pursuits are fueled by a deep passion for quality improvement and safety, with a specific dedication to patient-family-centered care. In our conversation, we had the opportunity to explore her insights into the vast realm of trauma.

Introduction:

Trauma is often characterized by a “trimodal” mortality distribution. The initial peak involves patients who succumb instantly, at time zero or upon impact, typically due to severe injuries such as great vessel injury, severe traumatic brain injury, or high spinal cord injury. These cases constitute the first peak in the trimodal distribution. Subsequently, within the first six hours, a second peak emerges, with death predominantly attributed to hemorrhage. The concept of ‘golden hour resuscitation’ originated from this phase, emphasizing the critical window during which bleeding can be identified and effectively managed. The third peak unfolds in the ICU setting, where patients may succumb to multi-organ failure, a complication stemming from their traumatic injuries. This trimodal distribution highlights distinct phases in the trajectory of trauma-related mortality. In this blog, we will explore the topics discussed on our podcast with Dr Widder.

Hemorrhage Control:

Addressing bleeding, a leading cause of mortality in trauma, involves implementing simple yet impactful measures. In a quality improvement initiative in Alberta, Canada, tourniquets were introduced to smaller hospitals, playing a crucial role in hemorrhage control, particularly for extremity bleeding. It is crucial to ensure that tourniquets are applied tightly and avoid placing them over joint areas such as elbows and knees. For bleeding in areas like the neck, armpit, or groin, direct pressure or packing is essential. These techniques are not exclusive to surgeons; even non-surgeons or laypeople can employ them to mitigate bleeding.

Establishing intravenous access is vital in trauma cases. If two large bore IVs are not available within five minutes, intraosseous access should be initiated. Contrary to common perception, inserting central access through triple lumen lines is not as effective as large bore IVs, which facilitate quicker and more efficient infusion of blood and blood products. Additional procedures, including re-warming the patient, replenishing essential electrolytes like calcium, and correcting acidosis, contribute significantly to controlling bleeding. Collectively, these measures buy valuable time until surgical management can be implemented.

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta).

When bleeding is not visibly apparent, the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) emerges as a potential intervention. REBOA functions akin to a closed thoracotomy, enabling the occlusion of the aorta, much like the process of opening a patient’s chest and cross-clamping the aorta. This deliberate occlusion slows down the bleeding, facilitating resuscitation efforts and allowing the surgical team to prepare for definitive management.

While REBOA may seem straightforward, the procedure involves femoral access through the common femoral artery using the Seldinger technique. This entails inserting a sheath and catheter to inflate a balloon in the descending aorta. However, it is crucial to acknowledge the associated risks. Larger medical centers with high volumes regularly perform REBOA, benefiting from skilled individuals whose complication rates are low, and they are equipped to manage any such complications. It is essential to recognize that REBOA is not a definitive solution. If this technology is employed, the patient must be transported to the operating room as expeditiously as possible, typically within 15 to 20 minutes.

While REBOA is currently utilized in some larger trauma centers in Canada, particularly in the face of increasing rates of penetrating trauma, there is hope for more widespread adoption in the near future. In the interim, emphasis should be placed on quality resuscitation measures, including large bore IV access, tourniquets, timely access to the operating room, and familiarity with thoracotomy use. For patients in extremis, the optimal site to continue resuscitation is the operating room. Activation of trauma teams, inclusive of anesthetists and surgeons, should occur promptly within 30 minutes. However, in cities like Edmonton, Alberta, which receive patients from other provinces and northern territories, occluding the aorta for an extended period is likely an unviable option.

Blood Products and Massive Hemorrhage Protocols:

Timely access to blood and blood products is a critical aspect of trauma resuscitation that cannot be overstated. In Edmonton, quality reviews of massive hemorrhage protocols revealed significant delays attributed to waiting for Fresh Frozen Plasma to thaw. Consequently, the massive hemorrhage protocol was revamped into two distinct ‘packages.’ The initial package includes four units of packed red blood cells upfront, coupled with 2g of fibrinogen. Subsequently, the second package comprises Fresh Frozen Plasma, additional packed red cells, and platelets.

Fibrinogen has been integral to resuscitation in the Edmonton zone for the past eight years. Demonstrated through both trials and local data, its use correlates with decreased blood product consumption and earlier cessation of hemorrhaging. Incorporating fibrinogen into the resuscitation process is strongly recommended. While cryoglobulin serves specific indications like Von Willebrand’s disease or hemophilia, additional advice from transfusion medicine specialists may be sought in such cases. Fibrinogen concentrate, preferred by most surgeons, contains more fibrinogen than cryoglobulin and can be administered directly through an intravenous or intraosseous line, with the added benefit of room temperature storage for prolonged periods.

Despite the advantages of a massive hemorrhage protocol, a notable drawback is the potential wastage of blood and blood products, particularly if Fresh Frozen Plasma remains unused. This consideration is essential, especially in resource-limited settings. Nevertheless, the significance of having blood readily available at the bedside and initiating resuscitation early cannot be underestimated.

The ABC score and decision making around massive hemorrhage protocol activation:

The ABC score proves invaluable in guiding the application of massive hemorrhage transfusion protocols, widely adopted by numerous Canadian and US trauma centers, including pre-hospital providers. This score hinges on four parameters, each carrying a one-point score:

1. Presence of penetrating trauma.

2. Positive eFAST.

3. Hypotension, defined as a systolic blood pressure of < 90mmHg.

4. Heart rate exceeding 120.

An ABC score of two or more signals a high likelihood that the patient will require a massive hemorrhage transfusion protocol. Conversely, if the patient scores less than two, the negative predictive value stands at an impressive 95%, indicating a mere 5% chance of wastage.

Utilizing a scoring system and fostering enhanced communication with pre-hospital colleagues play pivotal roles in deciding when to activate massive hemorrhage transfusion protocols. Activating these protocols sooner rather than later is consistently recommended to mitigate delays. While uncrossmatched blood may be requested at the patient’s bedside, it’s important to note that this is restricted to packed red cells, lacking the benefits of fibrinogen, FFP, and platelets.

Noteworthy adjuncts like Desmopressin (DDAVP) and Tranexamic acid (TXA) come into play at this juncture. Although DDAVP is typically not utilized in trauma, TXA assumes a crucial role in the trauma armamentarium. Numerous studies have affirmed the efficacy of TXA, showcasing reduced mortality and diminished blood product usage when incorporated into trauma management strategies.

Use of the eFAST scan:

The extended focused abdominal sonography for trauma (eFAST) ideally should be completed within five minutes or less. In cases where the patient is deemed unstable, they are likely to be promptly moved to the operating room without waiting for the results of any specialized investigation. However, for stable patients, additional imaging, including the eFAST scan, is likely to be conducted. Conducting serial eFAST scans can provide substantial benefits in monitoring stable patients over time.

The use of special imaging like CT Angiography:

Specialized imaging, such as CT Angiography of the head and neck, is recommended for almost anyone with severe injuries, especially when considering the expanded Denver criteria. Individuals with specific conditions like stroke or other neurological symptoms, spinal injuries, upper rib injuries, or any type of thoracic vascular injury or craniofacial injury should be given particular consideration for such diagnostic procedures.

Use of Seizure Prophylaxis in Head Injured Patients:

Seizure prophylaxis is not universally warranted for every trauma patient. The Glasgow Coma Scale (GCS) serves as a guide for clinicians to assess the severity of Traumatic Brain Injury (TBI) and determine the necessity for seizure prophylaxis. Patients with moderate to severe traumatic brain injury, typically with a GCS less than 13, should be administered seizure prophylaxis.

Levetiracetam is currently recommended for seizure prophylaxis due to its favorable side effect profile compared to Phenytoin. Monitoring levels is unnecessary, and a standard regimen typically involves a 1g loading dose followed by 500mg twice daily, usually administered for seven days in most trauma patients.

Pitfalls in C-Spine Clearance:

Accurate documentation of cervical spine clearance is crucial, particularly for ICU trauma patients facing challenges in clinical examination. Timely clearance, preferably within 24 hours, is imperative. Delays in clearance can impede patient mobility, elevate intracranial pressure, intensify discomfort and pain, complicate nursing care, contribute to skin breakdown, and increase the risk of secondary infections.

Typically, C-spine clearance in trauma patients relies on a normal CT C-spine. Although the risk of missing an isolated ligamentous injury is rare, studies demonstrating radiological clearance predominantly focused on typical young male patients with healthy bone structures and minimal arthropathy. Geriatric patients, more prone to traumatic injuries, warrant a meticulous evaluation of their spinal column, considering potential degenerative changes. Clearance should involve appropriate specialties, and if evidence of degeneration or incomplete imaging exists, radiological clearance cannot be performed.

DVT Prophylaxis:

DVT prophylaxis is generally recommended for most patients upon admission, but certain considerations should be taken into account:

1. Head Injury Patients with Traumatic Hemorrhage:

 Re-imaging is advised 24 hours after admission. If there is no expansion of intracranial pathology, DVT prophylaxis may be initiated.

2. Severe Thoraco-Abdominal Injuries:

Anticoagulation should be withheld for the first 24 hours, prioritizing coagulopathy correction during resuscitation. After 24 hours, DVT prophylaxis can be initiated.

3. Patients with Spinal Cord Injuries:

These patients are at a high risk of DVT. If stabilization surgery occurs early, DVT chemoprophylaxis may begin within the first 24 hours. In cases of anticipated delays in surgical management, discussions with surgeons are crucial. At a minimum, these patients should have mechanical prophylaxis for DVT.

Geriatric Trauma:

Over the next decade, approximately 30% of our population will be 65 years or older. With people surviving longer, there is an unfortunate increase in their involvement in traumatic incidents. What often goes unrecognized is that this demographic represents a sub-specialized population, undergoing not only physiological but also anatomical changes with age. More and more surgeons are acknowledging that these patients carry additional risk factors, leading to the emergence of Geriatric Trauma as a distinct sub-specialty in its own right.

Rib Fixation for Rib Fractures:

Compelling evidence supports the consideration of rib fixation for individuals with multiple rib fractures, particularly in the presence of a flail segment. Studies indicate that fixation can lead to a reduction in ICU length of stay and fewer ventilator days.

Most trauma surgeons who have completed trauma fellowship training should possess the necessary skills for rib fixation. Additionally, some orthopaedists and thoracic surgeons are capable of facilitating this procedure.

Conclusion:

As the trajectory of trauma care advances, this exploration into trauma care offers valuable insights for healthcare professionals and enthusiasts alike. Stay informed, stay prepared, and join us on the frontlines of trauma care evolution.

Further Reading:

1. ABC assessment: Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption) Nunez TC, Voskresensky IV, Dossett LA, Dutton WD, Cotton BA.  J. Trauma.  2009.  Feb 66 (2): 346-52.
2. TXA: Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage (CRASH-2): a randomized, placebo-controlled trial.  Lancet.  2010.  376: 23-32.
3. Fibrinogen: Reversal of trauma-induced coagulopathy using first-line coagulation factor concentrates or fresh frozen plasma (RETIC): a single-centre, parallel-group, open label, randomized trial.  Innerhofer P, Fries D, Mittermayer M, Innerhofer N, von Langen D, Hell T et al.  Lancet Haematology.  2017.  4 (6): 258-271.
4. Stop the bleed:  ⁠www.stopthebleed.org⁠
5. VTE Prophylaxis: Updated guidelines to reduce venous thromboembolism in trauma patients: a Western Trauma Association critical decisions algorithm.  Let EJ, Brown C, Moore E, et al.  The Journal of Trauma and Acute Care Surgery.  2020.  89 (5): 971-981.
6. Geriatric trauma: ACS TQIP Geriatric Trauma Management Guidelines.  HTTPS:\\⁠www.facs.org/media/314or1oq/geriatric_guidelines.pdf⁠
7. Rib fractures: Western Trauma Association Critical Decisions in Trauma: Management of rib fractures.  Brasel KJ, Moore E, Albrecht RA et al.  2017.   Journal of Trauma and Acute Care Surgery.  82 (1): 200 – 203.