Trauma Committee Solid Organ Injury Protocol - APSA Practice Gaps 2019

All right, so we're going to now move on to uh Dr. Lee who's going to talk to us about trauma. Great. Thank you. So, uh at APSA this year what was presented was the new APSA guidelines for management of um uh blunt liver and spleen injuries. And boy did I learn a lot from that. So what we have here is a 12-year-old uh male who was a restrained passenger in a motor vehicle collision. Uh he presents to the emergency department with the vital signs as shown, a heart rate of 125, blood pressure of 110 over 55, and a respiratory rate of 16. His uh initial lab shows a hemoglobin of 11 milligrams per deciliter and on examination is otherwise normal except that he has a seat belt sign across his uh chest and abdomen, uh and abdominal exam shows no evidence of peritonitis. Um he does get a CT scan and the CT scan shows a grade four splenic injury with moderate free fluid and a contrast blush. Uh in the emergency department he was given a 20 ml per kilogram of normal saline bolus uh and his repeat uh vital signs show a heart rate of 110, blood pressure of 120 over 60 and same respiratory rate of 16. So the question we have is the best next step in management for this patient is emission and uh A observation, B bolus with additional 20 ml per kilo of normal saline, C transfuse 10 ml per kilo of packed red blood cells, D selective angioembolization or E exploratory laparotomy. And while people are waiting just to repeat the case, any comments about this before. Now this is an example of the same with the opioids, those of you who who uh are loyalists to this event and have been coming every year, you know that we've we did this with uh Dr. Notrica. Uh this is one that's important enough to keep to to hit on again. So I'm glad that we're presenting this again. Hopefully uh we learn some things from Dr. Notrica. And the correct answer here would be observation. So here are the uh updated APSA blunt liver spleen injury guidelines. This was um presented at the uh APSA annual meeting. Lots of work went into this by the Trauma Committee of APSA and as you know as you David Notrica as well as the rest of the Atomic Group uh was uh instrumental in developing these guidelines. Um so as as as shown for admission, um basically the bottom line for this which is what I learned uh at this meeting was we really want to treat on patients uh on patient's hemodynamic status. And as they stated before, is the patient bleeding or have recently bled or is the patient stable? And there are different ways to determine that uh and and they use a shock index, which was modified for pediatrics uh as one way and that's basically the heart rate over the systolic blood pressure. And based on age, you can determine whether that patient is uh you think may be still bleeding. Uh and in those instances then we would recommend an ICU admission. Otherwise if patients have uh responded to the normal saline bolus uh and remain uh hemodynamically stable then those patients uh just need to be observed. Okay. Uh that's probably the biggest key. Uh uh it's not really based on grade book. I know that that's been or the grade of the uh injury. I think that's been uh shown multiple times in prospective studies. Um so uh that's one key point. Um as you can see under the admission uh uh parameters, if the patient's admitted to the ward, then they would need uh really just another hemoglobin check uh in six hours. Uh they're able to have a regular diet and there's really no activity restrictions for them. Um you don't want them jumping up and down on the bed but they really don't need any additional activity restrictions. Uh interesting that angioembolization was one of the things uh people have shown or have chosen for the uh for the uh uh as one of the answers. And what's shown for the procedures uh portion is again, uh only uh transfuse if patients are unstable or again that critical threshold of a hemoglobin less than seven. Um uh if there are signs of ongoing bleeding then again you would want to transfuse. Uh angioembolization in stable patients does not need to be done even with the contrast blush. Uh particularly in patients with splenic injuries. Those have shown that uh they do not uh continue to bleed, uh but if there's evidence of of ongoing bleeding then that's when the angioembolization should be performed. And obviously we know for any uh any patients who have continued bleeding then we would like to then you need to proceed to the operating room. Questions. Yeah, we got a lot. I mean, I do. So uh I want to make sure I review this because the big thing that I learned last year or two years ago um was that I was always giving two boluses of fluid. I would give fluid, if it didn't work, I'd give another bolus of fluid. Now it's give blood early. Give blood after your first bolus. Correct. Is that right? Correct. So after your first 20 ml per kilo of normal saline bolus, then if patient still requires any additional fluids, then give blood. Okay. And that's a great point. Some people define boluses different. Some are 10 ccs per kilo, 20 ccs per kilo. We're saying a 20 cc per kilo bolus of fluid, if they if they're still hemodynamically unstable, uh so, you know, whatever that might be, whether that's 125 or whatever number we choose, if it's still seeming like they are symptomatic, you would give blood at that point. That's correct. Okay. And you would give 10 ccs per kilo of blood. Correct. Okay. Um other big things to sort of repeat here if you look again I want to highlight things you talked about. Um again, this should be available for people in the to download if you want these I think. Um right, Jay? Uh but because this is a good thing a good slide. So the diet the activity. You'll notice that the there's there's says no activity restrictions. Big change uh from from when we were using the grade book before. Uh yes and no the I think the original uh guidelines actually did did not address activity. Um restriction well I guess for in-house bed rest that was not. Okay. Originally addressed. Some people interpreted it to be but it really wasn't. Uh I'll take that. Yeah. So so but basically that's correct so now I think the the the the recommendations is if they're admitted to the floor uh or the ward, then they do not need any activity restrictions. They can go to the bathroom, they can walk around and all those other things. That's right. I see. Anyone um doing angioembolization ever their institution. No. Okay. So that that was a change at um because we practice at multiple institutions and one of our institutions is uh with a predominantly adult trauma base and uh that was one of the things that they would do in 15 16 year old kids was angioembolization for contrast. But now we're really putting the brakes on that. Okay. Um also you don't have to the blush on CT you don't have to do anything about that. Again not unless they have evidence of bleeding. Uh if they do have evidence of bleeding that's when angioembolization would be indicated. Okay. And this is a little bit tangentially related but um there's a paper released a couple months ago that was looking at non-invasive monitoring of hemoglobin where essentially wear like a pulse ox like device that is able to give a pretty um decent estimation of hemoglobin um at least in terms of trends. Uh have you had any experience with that yourself or um um we have not had any experience with that but that would be very interesting because uh some would advocate that you probably don't even need to monitor the hemoglobin and your physical exam is probably a better indicator as far as capillary refill uh and other indications heart rate uh particularly for hemodynamic status. Question is curious how many in the audience in a hemodynamically stable patient with a grade four splenic laceration with active blush and hemoperitoneum uh who goes to the floor on admission based on this protocol would order a regular diet immediately. Well I think based on the guidelines that's what um that's what is recommended. Uh obviously guidelines are meant for um assisting uh and every patient will be treated based on, you know, the clinician's experience and and um expertise but I would personally, you know, especially in splenic injuries, uh if they've stopped bleeding, meaning they responded to the normal saline bolus, then I would advocate to advance to a regular diet. I think I mean I think that whoever uh I don't know who you are, p b h i i i but uh uh we're I'm curious where you're from. So let us know. Um I think I think I love the way you actually phrase that question uh because you put it into real life situation and it made me think because I'm thinking I follow these guidelines but you're right. I'd feel a little uneasy even though I probably I might delay the diet just a little bit. Um uh but I I think grade four yes. Um blush. Is there anyone here that would be afraid to admit to the floor with a blush? You guys would all admit to the floor with the blush. You would not. In my in my program we wouldn't have but Okay. I'm learning too. Yeah, okay. So um the way I interpreted the question was that uh the patient had a significant injury uh has a blush so that takes some time during that time your patient's being resuscitated, getting to the floor. And so in my mind that could be a four to six hour process. So by that time you have a chance to evaluate whether the patient's stable or not. And four to six hours later if the patient's stable then starting a regular diet is not unreasonable. It's also not unreasonable to either keep him in him or her NPO for a few hours or start some clear liquids. Yeah. The point is that a regular diet can be started if you feel the patient's comfortable. Okay. Great point. Dan. I guess from my perspective the question is what is the risk of starting a regular diet and the how many times do you if if it's because you're worried that the patient's then going to go have anesthesia and they should have an empty stomach. First of all, they probably don't have an empty stomach to start with and second of all, in my career, I think I've taken out two spleens for trauma and I probably shouldn't have taken out one of them. So the risk that you're actually going to go to the operating room is really very low. So if that's the rationale for not starting a diet then I think you you can probably breathe pretty confident in starting a diet. If the patient doesn't tolerate you're not going to force them to eat but putting them on a diet is probably not unreasonable. Okay. Yeah, to what Dan said, I I think all of us know that what we order and what actually happens are completely not they're not connected, right? You can order the kid a regular diet but if they don't feel well and if they have a bad hemoperitoneum and an ileus, they're probably not going to eat it. Yeah. So that's a great point actually. Um I I I hate disagreeing with my boss but I but uh you know, I I'm fired. I I I say what's the hurry. I I totally hear you. And even if there was an issue, it's not that you would go to the operating room, you might give more blood or something you would not have to rush them right then to the operating room. However, I don't see the hurry in just waiting a few more hours. But um Yeah, but I agree they're probably not going to be starving after I mean if they're that sick, they're not going to have a big Mac and an order of fries. Right, right. Yeah. You hope. Okay. Go ahead. I have I have a couple questions from the audience. So I know when they're talking about operative intervention, um an indication is unstable vitals despite packed red blood cell uh transfusions, but their question is how many are you giving? So the the based on the Atomic protocol, uh 40 mls per kilogram of packed red blood cells. So once you reach that threshold, you really should be going to the operating. That's a great That's a great question. Great question, great point. Uh just to say that again, 40 ccs per kilo uh now, is it when you hit 40 ccs per kilo or is it if you need more than 40 ccs per kilo? When you need more than 40 ccs. Okay. So it's greater than not equal to. Right. So once you if you need more than 40, it's time to go to the operating or some places would do angioembolization. Correct. Okay. And then I know we talked about grade plus two for um for uh restriction of activity. Would this apply even for like contact sports? So if somebody plays football, you let them go play football in a few weeks after injury? Correct. Okay. Yeah, so um Steve uh Whit had a question. Can you tell us so give us a background on atomic. What hospitals the atomic stands for? I know it's not all of them because I know we don't have a letter in that but So what what is atomic in general? You might not know all but what is the gist? Yes. So uh atomic is uh was started in 2010 and it was a group of level one pediatric trauma centers coming together to really study the the vital questions for trauma in a prospective fashion. Uh Atomic I believe is Arkansas, Texas, Oklahoma, Memphis and I is Oh A is another A. so uh Arizona. So. And Akron was part of it too. And so and now it's expanded even to more I believe Akron I think Kansas City is part of it. Uh and so they really came up with a initially a a set of guidelines for uh management of blunt uh and spleen injuries. Uh isolated injuries uh and then they then they went ahead and prospectively studied it. Uh they've come out with a number of publications based on that and that really kind of redefined the guidelines that were adopted by apps of this past year. Yeah, and and just to make a comment about that in general. We need to do more of these. Yes. Uh congratulations to that team for finally putting a bunch of hospitals together to collect real data. Uh we need to do more of that. The Midwest pediatric surgical consortium does something very similar. This needs to be the trend over the next 10 years that we need uh more consortiums popping up because I know that some of them can only have a certain number uh but this is the way we're going to get answers to our questions. Any other questions? So um the transfusion uh the 40 ccs per kilo low target. At what point also are you going to be doing the massive transfusion protocol? So like the 1 to 1 to one uh ratio. That's a that's a great question. Um I think um if that goes back to the original question if you think the patient is still bleeding, uh then there is there's not great evidence in the pediatric literature for the 1 to 1 to 1. Um uh there's mixed results with that. Uh but if the patient is certainly still bleeding and uh unstable that's when you would want to think about activating the massive transfusion protocol. Great great question.