Doing trauma right... in the right order... at the right time..

The folks at St Emlyn's blog in the UK just released a nice discussion of how to handle trauma patients. Apparently, there is a new quality marker on trauma care in UK major trauma centres: 30 minutes from ED presentation to Pan-Scan CT image acquisition on trauma patients with an ISS >15. 

http://stemlynsblog.org/ttl-podcast-1-getting-ct-30-minutes/

This new trauma quality indicator is different from the older pan-scan quality indicator of getting at pan scan report 1 hour after presentation. 

While the idea of getting this done in less than 30 minutes might seem crazy to many ED providers in New Zealand, it can certainly be done. Whether it is a beneficial, safe, and reasonable goal is a different question. However, I think it is a reasonable aspirational goal that could really focus people's thinking.

I'm not aware of any evidence that explicitly supports a 30 minute door-to-CT time, but I certainly believe that trauma systems that can get patients from ED to theatre in around 20 minutes are better than those that take longer. A 30-45min ED to CT timeframe is probably reasonable as well. I look forward to them publishing about their experience.   

Anyway, taking patients to CT in less time requires an enormous multidisciplinary effort. Sure, the scanner needs to be cleared, radiologists need to be ready to read, and the patient needs to be packaged, but what else needs to happen? What needs to NOT happen? 

Traditionally, before transporting a trauma patient, all sorts of crazy stuff got done to them: log-rolls, exposure, auscultations, 2 liters of saline, fingers and tubes shoved every-which-way. X-rays, ultrasounds, plasters, binders, and bandages. Once you start thinking about a 30min time-crunch, you start to think about which parts of that initial 30 minutes give you the best bang-for-the buck and which parts are just done because of tradition, ignorance, and PROVIDER comfort. 

These guys (Simon Carley and Iain Beardsell) do a great job is discussing the stuff that most everyone agrees could be removed from the urgent trauma resus before urgent pan-scan: c-spine x-rays, "springing" the pelvis, plaster splinting, and combing that patient's hair. They also question the utility of some other "historical" portions of the primary and secondary exam that may have limited value: auscultation the chest, tracheal palpation, the log roll, routine rectal exams, and the chest and pelvic x-ray. 

I totally support questioning the value these protocolized, insensitive, nonspecific, and time-wasting tests and procedures on sick blunt trauma patients who will be through the CT scanner in less than 30 minutes. Of course there are times when your want to use your clinical judgment and a focused exam to ADD a chest x-ray on hypoxic or dyspneic patients. However, these patients can almost always identified in seconds from the end of the bed.

This post reminds me of my favourite axiom in medicine:

"Don't do stuff that doesn’t impact patient outcome."

Especially: don't do bad tests (tests that take essential time and have poor sensitivity and specificity) if you're about to do a good test in the next 30 minutes. 

Anyway it is worth listening to, and, even through I mostly disagree with him, Andy Buck's comments are definitely worth a read as well. 

Andy

PS: They also briefly discussed some controversies surrounding common debates: CXR vs Lung US,  pelvic x-rays vs pelvic binders, crystalloid vs blood vs nothing, chest tube vs needle vs finger thoracostomies, but I suspect we'll cover those in future posts.