Avoid Falling Objects: Management of Severe Scalp Lacerations
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Avoid Falling Objects: Management of Severe Scalp Lacerations

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  • I think that you can add the detail about the fact that the tree branch was burning, and the context
  • Pertinent positives and negatives here.
  • Opens up radiologic resources, More manpower
  • Not a trauma study
  • Quicker time to scanner, more man power
  • Particularly pertained to Peds ED. Busy night, multiple sick patients
  • Observation studyOBJECTIVES: The purpose of this study was to investigate the nature and causes of human errors in the intensive care unit (ICU), adopting approaches proposed by human factors engineering. The basic assumption was that errors occur and follow a pattern that can be uncovered.DESIGN: Concurrent incident study.SETTING: Medical-surgical ICU of a university hospital.MEASUREMENTS AND MAIN RESULTS: Two types of data were collected: errors reported by physicians and nurses immediately after an error discovery; and activity profiles based on 24-hr records taken by observers with human engineering experience on a sample of patients. During the 4 months of data collection, a total of 554 human errors were reported by the medical staff. Errors were rated for severity and classified according to the body system and type of medical activity involved. There was an average of 178 activities per patient per day and an estimated number of 1.7 errors per patient per day. For the ICU as a whole, a severe or potentially detrimental error occurred on the average twice a day. Physicians and nurses were about equal contributors to the number of errors, although nurses had many more activities per day.CONCLUSIONS: A significant number of dangerous human errors occur in the ICU. Many of these errors could be attributed to problems of communication between the physicians and nurses. Applying human factor engineering concepts to the study of the weak points of a specific ICU may help to reduce the number of errors. Errors should not be considered as an incurable disease, but rather as preventable phenomena.
  • Is this where you are going to talk about how the nurses felt that they were communicating a higher level of urgency than the doctors heard?--Interruptions, closed loop communication--If nurses aren’t being heard, they can go up the COC.
  • 1 neurosurgeon to cover the whole hospital, surgery has more manpower
  • Although not in our patient, nice jumping off point
  • Discuss details of Hwu study- decivf and trend for survival

Avoid Falling Objects: Management of Severe Scalp Lacerations Presentation Transcript

  • 1. Rebecca Starr DO, PEM Fellow November 12, 2013
  • 2. Objectives      Identify goals of trauma activation Review pediatric trauma alert criteria Develop an understanding of medical errors in communication and strategies to minimize Discuss scalp laceration morbidity and implement appropriate initial management Analyze mass transfusion protocol and understand evidence for approach
  • 3. Case 10 year old male with head trauma and scalp laceration
  • 4. HPI 10 y/o M with a scalp laceration sustained from a large tree branch (est 100 lbs) that had fallen onto his head  No loss of consciousness, no vomiting, no confusion  Pt airlifted via LifeNet to MUSC ED  C-collar, backboard, and pressure dressing by LifeNet 
  • 5. HPI continued PMHx: previously healthy  PSHx: none  Allergies: none  Medications: none  ROS: headache 
  • 6. Physical Exam          Vitals: HR 75 BP 124/88 RR 22 SpO2 99% GCS 15 General: Alert and oriented Head: 15cm scalp avulsion/flap with visible galea and active ooze Eyes: PERRLA, EOMI, Pupils ~ 3mm ENT: nares patent, o/p without lesions and 2 small lacerations to tongue, no blood behind TM‟s Neck: in c-collar, No TTP on cervical spine CV/Resp/GI: wnl Skin: left leg with small abrasions and ashes on feet Neuro: CN 2-12 GIT, no focal deficits, good tone, 5/5 UE and LE strength, full ROM, MAEW
  • 7. Timeline of Events   1925- Arrival to ED awake and alert, GCS 15 1930- Primary and secondary survey by PED MD‟s, wound examined and pressure dressing reapplied  Decision to not call trauma activation  Neurosurgery paged       1938- Fentanyl 25mcg and 1L NS bolus given 1940- CXR and pelvis 1950- CT Head and Neck 2010- Back from CT, “active bleeding continues” 2015- Neurosurgery at bedside to address lac 2025- Dressing reapplied after neurosurgery removed, plan to sedate for laceration repair
  • 8. Timeline of Events 2045- Neurosurgery called away to adult trauma  2115- Pt complains of feeling “hot and sweaty”  BP 96/29 and HR 157  MD to bedside  1L NS bolus by pressure bag and placed in trendelenburg  2130- BP 80/39 and HR 146  1L NS bolus repeated  I stat and repeat CBC  Pediatric Surgery consulted  ○ Considered closing at bedside 2225- Attending to attending conversation (ED and Surg)  2300- To OR  Total time in PED (1925-2300) 
  • 9. Imaging CT neck- normal  CT head  No intracranial injury or fracture  Large right posterior-superior parietal subgaleal hematoma with evidence of scalp laceration and subcutaneous emphysema CXR- normal  Pelvis xray- normal 
  • 10. Pertinent Labs Initial CBC (1940)     WBC 10.9 Hgb 12.5 Hct 35.2 Plts 214 Repeat CBC (2211)     WBC 10.2 Hgb 8.2 Hct 24 Plts 156
  • 11. Hospital course         Taken to OR 15cm right parietal scalp laceration/avulsion repaired TLS drain placed Transferred to PACU at 0130 Admitted to floor/trauma surgery TLS drain removed Hgb: 8.2 9.4, HCT: 24  27 Discharged home the next day
  • 12. Areas for Discussion Considerations for calling a trauma activation  Delay in subspecialty care/transfer  Communication/chain of command concerns   Between RN and MD  Between subspecialty physicians  Between training levels Scalp laceration morbidity  Role of Mass Transfusion Protocol 
  • 13. Effect of Trauma Service in Peds ED  Goals of Trauma Service  Mobilization of resources  Quicker definitive care  Vernon et al -patients treated by a trauma team vs. ED staff without a peds trauma team  Shorter times from arrival to CT scan (27 vs 41min)  Shorter times from arrival to OR (62 vs 123min)  Shorter total time in the ED (85 vs 121min)  Perno et al- implementation of a trauma service showed significant reduction in delayed diagnosis of injury  Pre trauma team 4% DDI and post trauma team 0.5% DDI Vernon et al. Pediatrics.1999 Perno et al. Pediatric Emergency Care. 2005
  • 14. Delay in Transfer Affects Outcomes Mortality is significantly reduced when early goal-directed therapy is instituted  Chalfin et al “Delay in critically ill patients > 6 hours from ED to transfer to ICU/OR increased hospital length of stay and increased mortality”   Not just trauma patients, all comers  Results can be extrapolated Chalfin et al. Critical Care Medicine. 2007
  • 15. MUSC Pediatric Trauma Alert Criteria Level A  Physiologic Criteria  GCS <9 at time of EMS transport  Hypotension  Suspicion of respiratory compromise  Attending concern for serious injury
  • 16. MUSC Pediatric Trauma Alert Criteria Level A  Anatomic Criteria  Penetrating injury to head, neck, torso  Penetrating injury to extremity proximal to elbow        or knee with ongoing bleeding Flail chest Two or more long bone fractures Crushed/degloving injury Amputation proximal to wrist or ankle Open or depressed skull fracture Suspected Pelvic fracture 2nd or 3rd degree burns >40% BSA
  • 17. MUSC Pediatric Trauma Alert Criteria Level A Trauma Transfer from OSH  Hemodynamically unstable  Intubated  Urgent need for surgical intervention  Blood transfusion prior to transfer
  • 18. MUSC Pediatric Trauma Alert Criteria Level B  Physiologic Criteria  GCS >9 and <14 at EMS transport  Anatomic Criteria  Penetrating injury to extremity proximal to elbow or knee without ongoing bleeding  2nd or 3rd degree burns > 20% BSA and < 40% BSA  Attending concern for serious injury
  • 19. MUSC Pediatric Trauma Alert Criteria Level B  Mechanism of Injury Criteria  Fall >20 ft (1 story equals 10ft)  Ejection from vehicle  Death in same passenger compartment  Auto/pedestrian or auto/bike with impact >20 MPH  Motorcycle or ATV crash >20 MPG  MVC > 25 MPH
  • 20. MUSC Pediatric Trauma Alert Criteria Level B Trauma Transfer from OSH  Accepted for transfer by trauma service  Request for trauma alert by accepting service  Hemodynamically stable but possible surgical intervention needed
  • 21. Learning Point A trauma activation for this patient may have helped mobilize more resources and facilitated quicker definitive care
  • 22. Frequent Sources of Medical Error  Medication errors (weight-based dosing)  Level of training  Staffing  Overcrowding  Stress  Fatigue (Most ED errors between 4am-8am)  Communication Selbst et al. Pediatric Emergency Care. 2004
  • 23. Communication  High volume and velocity of information exchanges  Multiple check outs and handoffs  Frequent interruptions  Multitasking  Significant source of medical errors Coiera et al. MJA. 2002
  • 24. Interdisciplinary Communication Donchin study found ICU doctor to nurse verbal communication was only 2% of total daily communication but accounted for 37% of error reports  Hierarchy of exchange  Donchin et al. Critical Care Medicine. 1995
  • 25. Communication Pitfalls for this Case Communication of urgency  Chain of command 
  • 26. Communication Learning Point Closed loop / confirmatory feedback  Minimize hierarchy  Be receptive/ approachable  Remember/utilize chain of command 
  • 27. Scalp lacerations  May be grossly underestimated  Often ignored until patient‟s work up complete Potential for large blood loss  Beware large laceration or several minor lacerations  Delay in wound management alone can lead to hemorrhagic shock  Lemos et.al., J. Emerg. Med. 1988
  • 28. The Scalp Richest subcutaneous vascular supply in the entire body Lemos et.al., J. Emerg. Med. 1988
  • 29. Scalp lacerations  When lacerated, small arteries retract between the septa  7-10 cm laceration can cause loss of 30% blood volume Lemos et.al., J. Emerg. Med. 1988 Turnage and Maull, Southern Medical Journal. 2000
  • 30. Case Reports in the Literature  45 y/o M with large scalp lac and epidural hematoma after bike vs. car  Transfer from community hospital to tertiary     care center for neurosurgery involvement Scalp laceration not closed before transfer Arrival to hospital in shock (systolic BP 65 and HR 156) requiring aggressive resuscitation Hgb 6.3 on arrival to hospital Multiple transfusions of PRBCs and clotting factors given Fitzpatrick et al, J Accid Emerg Med.1996
  • 31. Case Reports in the Literature  27 y/o F with multiple scalp lacerations and depressed skull fracture with a small subdural hematoma due to knife stabbing  Scalp wounds stapled before transfer to tertiary      care center En route had a seizure and required intubation Several staples dislodged during event and profuse bleeding from scalp wound occurred Arrival to hospital in shock (BP 70/40 and HR 130) requiring aggressive resuscitation Hgb 7.1 on arrival to hospital 4 units PRBCs given Fitzpatrick et al, J Accid Emerg Med.1996
  • 32. Bleeding Control Direct constant pressure  Dressing application  Elevation  Direct clamping  Suture  Staples  Lemos et.al., J. Emerg. Med. 1988
  • 33. Initial Management   Direct applied pressure Pressure dressing as a temporizing method  Frequently fails  Temporary single layer closure with running stitch  Interferes with wound evaluation  Surgical staples  Temporary  Hemostats applied to edge of scalp  Tedious and interferes with radiographic studies  Scalp clips  Requires special equipment Lemos et.al., J. Emerg. Med. 1988 Fitzpatrick et al, J Accid Emerg Med.1996
  • 34. Raney Clips Quick, effective, and inexpensive  Compresses the wound edge and occludes the blood vessels  Maintain good exposure of the wound  Do not interfere with radiographic studies  Sykes, Annals of Emergency Medicine, 1989
  • 35. Raney Clips
  • 36. Multiple Techniques
  • 37. Definitive Closure  Likely with subspecialty service for larger lacerations  Surgery  Neurosurgery  Plastics Sykes, Annals of Emergency Medicine, 1989
  • 38. Learning Point Quick and effective initial management is imperative in scalp lacerations  Potential for scalp lacerations to cause hemorrhagic shock 
  • 39. Traumatic Blood Loss Fluid resuscitation remains the cornerstone of treatment  A specific level of blood loss or anemia that triggers transfusion has not been officially defined in pediatrics   Based on clinical condition and expected further blood loss  Institution specific  Rapid exsanguination may not be reflected in Hgb or Hct levels until fluid resuscitation catches up Dehmer and Adamson, Seminars in Pediatric Surgery, 2010
  • 40. It‟s Just a Flesh Wound
  • 41. Coagulopathy in the “Lethal Triad” Well documented part of trauma  Cycle of worsening coagulopathy, hypothermia, and acidosis   Hypothermia decreases platelet activation and adhesion  Hemodilution decreases clotting factors and increases hypothermia  Acidosis worsens clotting factor function Nosanov et al., American Journal of Surgery, 2013
  • 42. Pediatric Blood Volumes Age     Premature Infant Term infant to 3 months Children older than 3 months Obese children Estimated Blood Volume (mL/kg) 90-100 80-90 70 65 Dehmer and Adamson, Seminars in Pediatric Surgery, 2010
  • 43. Pediatric Blood Volume in Units Weight    10 kg 25 kg 50 kg (adult standard) Blood Volume    2 units 5 units 10 units
  • 44. Fresh Whole Blood  Fresh whole blood has been used in adults in combat setting  Fresh whole blood transfusions have been noted to improve 30 day survival rates  FWB not widely available in civilian setting  Only 15% of children‟s hospitals stocked FWB Dehmer and Adamson, Seminars in Pediatric Surgery, 2010
  • 45. Pediatric Mass Transfusion  Defined by the volume of blood products given to maintain hemodynamic stability  Transfusion of blood components equaling one or more blood volume within a 24 hour period  Definition differs per institution  Pediatric MTP‟s are less widely available than adult MTP‟s Chidester et al., J Trauma Acute Care Surg.,2012
  • 46. Goals of Pediatric MTP Maintaining platelets above 50,000  Hemoglobin higher than 10mg/dL  Normalization of coagulation assays  Chidester et al., J Trauma Acute Care Surg.,2012
  • 47. Pediatric Mass Transfusion Activated when 1 circulating blood volume has been lost Or Evidence of massive hemorrhage, hemodynamically unstable and already received 40ml/kg crystalloid Chidester et al., J Trauma Acute Care Surg.,2012
  • 48. Pediatric Mass Transfusion  Ratio of FFP/PRBCs/Platelets 1:1:1  Most resembles whole blood  Ratios of 1:1:1 has shown to have survival benefits in adult literature  Adult data may not be generalized to pediatrics  Controversy exists between proper blood products ratio  Further pediatric research is needed Chidester et al., J Trauma Acute Care Surg.,2012
  • 49. Pediatric Mass Transfusion  Higher FFP/PRBCs ratio has not been statistically shown to have increased survival in children  Hwu study at Washington University in St. Louis  “Adoption of pediatric MTP in one study led to a fourfold decrease in length of time to FFP transfusion”  15 min unthaw time for FFP Hendrickson et al, Transfusion, 2012 Nosanov et al., American Journal of Surgery, 2013
  • 50. Labs to Monitor           Hgb/Hct Plts PT PTT Fibrinogen Fibrin degradation products Ca+ K+ pH Lactate Chidester et al., J Trauma Acute Care Surg.,2012
  • 51. Complications of MTP FFP transfusion associated with increased risk of respiratory distress and ARDS  Increased susceptibility to hyperkalemia secondary to blood product transfusion   K+ slowly leaks out of RBC‟s during storage and can increase K+ concentrations  9 case reports of pediatric hyperkalemic cardiac arrest due to MTP in literature  Cardiac patients and neonates increased risk  Mean K+ 9.2 mmol/L (6.3-12mmol/L) Lee et al, Transfusion, 2013
  • 52. Lee et al, Transfusion, 2013
  • 53. Recombinant Factor VIIa  Useful adjunct for control of bleeding  Enhances production of thrombin on the surface of activated platelets  Adult studies have documented decreased blood product requirements  No sufficient pediatric studies No change in mortality in MTP  Lower incidence of thromboembolic events  Chidester et al., J Trauma Acute Care Surg.,2012
  • 54. MTP and Organ Donation  MTP activation in one study showed 2 incidences where viability of organ donation was made possible  1 patient with nonsurvivable injuries which was a non MTP patient was rejected as an organ donor due to severe hemodilution Chidester et al., J Trauma Acute Care Surg.,2012
  • 55. MTP Learning Points Activate when one circulating blood volume was lost or evidence of massive hemorrhage, hemodynamically unstable and already received 40ml/kg crystalloid  Monitor K+ and consider transfusion associated hyperkalemic cardiac arrest  Consider recombinant Factor VIIa 
  • 56. Summary   Trauma activation helps mobilize more resources and facilitates quicker definitive care Keys for successful communication in the ED        Closed loop / confirmatory feedback Minimize hierarchy Be receptive/ approachable Remember/utilize chain of command Quick and effective initial management is imperative in scalp lacerations Potential for scalp lacerations to cause hemorrhagic shock Utilize Mass Transfusion Protocol when dealing with an actively hemorrhaging patient
  • 57. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Dehmer, J.J., M.D, et al. Massive transfusion and blood product use in the pediatric trauma patient. Seminars in Pediatric Surgery. 2010;19:286-291. doi:10.1053/j.sempedsurg.2010.07.002. Lee, A.C. et al. Transfusion-associated hyperkalemic cardiac arrest in pediatric patients receiving massive transfusion. Transfusion. 2013 doi:10.1111/trf.12192. Hendrickson, J.E., et al. Implementation of pediatric trauma massive transfusion protocol: one institution's experience. Transfusion.2012;52:1228-1236. doi:10.1111/j.1537-2995.2011.03458.x. Nosanov, L., et al. The impact of blood product ratios in massively transfused pediatric trauma patients. The American Journal of Surgery. 2013. Chidester, S.J. A pediatric massive transfusion protocol. The Journal of Trauma, Acute Care, and Surgery. 12012;73 :1273-1277. doi:10.1097/TA.0b013e318265d267. Turnage, B. & Maull, K. Scalp laceration: an obvious 'occult„ cause of shock. Southern Medical Journal. 2000;93:265-266. Lemos, M.J., & Clark, D.E. Scalp lacerations resulting in hemorrhagic shock: case reports and recommended management. The Journal of Emergency Medicine.1988;6:377-379. Sykes, L.N. Management of hemorrhage from severe scalp lacerations with Raney clips. Annals of Emergency Medicine. 1989;18:995996. Fitzpatrick, M.O., & Seex, K. Scalp lacerations demand careful attention before interhospital transfer of head injured patients. Journal of Accidental Emergency Medicine. 1996;13:207-208. doi:10.1136/emj.13.3.207 Chalfin, D.B., et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Critical Care Medicine. 2007;35:1477-1483. Selbst, S.M., et al. Preventing Medical Errors in Pediatric Emergency Medicine. Pediatric Emergency Care. 2004; 20:702-709. Alvarez, G. & Enrico Coiera. Interdisciplinary communication: an uncharted source of medical error?. Journal of Critical Care 21. 2006:236-242. Coiera, E.W., et al. Communication loads on clinical staff in the emergency department. Medical Journal of Austrailia. 2002;176:415418. Sutcliffe, K.M. et al. Communication Failures: an insidious contributor to medical mishaps. Academic Medicine. 2004; 79:186-194. Vernon, D.D. et al. Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims. Pediatrics. 1999;103:20-24. Perno, J.F., et al. Significant reduction in delayed diagnosis of injury with implementation of a pediatric trauma service. Pediatric Emergency Care. 2005;21:367-371. Donchin Y. et al., A look into the nature and causes of human errors in the intensive care unit. Critical Care Medicine. 1995;23:294-300
  • 58. Special Thanks Thank you to Dr. Rachel Tuuri, Dr. Olivia Titus, Dr. Scott Russell, Dr. Fred Tecklenburg, and Madeline Gehrig for their help.