Surgeons and trauma teams

There can be issues associated with calling surgeons to trauma team activations in the ED, including interruption to the surgeon’s other duties, and the absence of anything useful for the surgeon to do, when most blunt trauma patients are managed by emergency physicians, intensivists, and orthopaedic surgeons, with a growing input from interventional radiologists. At one American major trauma centre for example, emergency operation by a trauma surgeon for blunt trauma averages once every 7 weeks for adults and less than once every 3 years for children1.

While there are many surgeons who are passionate about trauma care and excellent in the non-operative aspects of trauma management, there are probably more who would welcome measures to reduce the need to attend ED for all trauma team activations. Of course no triage tool is perfect: they will always have to trade sensitivity against specificity. One such tool from the Loma Linda University Medical Center uses the simple criteria of penetrating trauma, systolic blood pressure, and heart rate. These pertain to pre-hospital measurement and therefore the surgeon can be activated prior to patient arrival.

This triage tool performed better than the American College of Surgeons’ “major resuscitation” trauma triage criteria2:

STUDY OBJECTIVE: Trauma centers use “secondary triage” to determine the necessity of trauma surgeon involvement. A clinical decision rule, which includes penetrating injury, an initial systolic blood pressure less than 100 mm Hg, or an initial pulse rate greater than 100 beats/min, was developed to predict which trauma patients require emergency operative intervention or emergency procedural intervention (cricothyroidotomy or thoracotomy) in the emergency department. Our goal was to validate this rule in an adult trauma population and to compare it with the American College of Surgeons’ major resuscitation criteria.

METHODS: We used Level I trauma center registry data from September 1, 1995, through November 30, 2008. Outcomes were confirmed with blinded abstractors. Sensitivity, specificity, and 95% confidence intervals (CIs) were calculated.

RESULTS: Our patient sample included 20,872 individuals. The median Injury Severity Score was 9 (interquartile range 4 to 16), 15.3% of patients had penetrating injuries, 13.5% had a systolic blood pressure less than 100 mm Hg, and 32.5% had a pulse rate greater than 100 beats/min. Emergency operative intervention or procedural intervention was required in 1,099 patients (5.3%; 95% CI 5.0% to 5.6%). The sensitivities and specificities of the rule and the major resuscitation criteria for predicting emergency operative intervention or emergency procedural intervention were 95.6% (95% CI 94.3% to 96.8%) and 56.1% (95% CI 55.4% to 56.8%) and 85.5% (95% CI 83.3% to 87.5%) and 80.9% (95% CI 80.3% to 81.4%), respectively.

CONCLUSION: This new rule was more sensitive for predicting the need for emergency operative intervention or emergency procedural intervention directly compared with the American College of Surgeons’ major resuscitation criteria, which may improve the effectiveness and efficiency of trauma triage.

Although not mentioned in the abstract, the study also included assessment of refinements of the Loma Linda Rule based on different cutoffs of heart rate and blood pressure. Once such refinement that included penetrating injury to the torso and less conservative physiological criteria (systolic blood pressure <90 mm Hg and pulse rate >110 beats/min) resulted in a slightly lower sensitivity, with a dramatic improvement in specificity compared with the original Loma Linda Rule.

A good point is made by Steve Green in his accompanying editoral3:

A possibility is that emergency physicians supervising out-of-hospital radio calls can predict the need for surgeon presence just as accurately (or perhaps more accurately) as any of these rules. After all, judgment is the time-tested mechanism by which emergency physicians summon all other consultants for all other conditions.

Unfortunately for many UK and Australasian centres, the challenge that remains is not deciding when to call the surgeon, but getting one when you do call, preferable one who is not committed to an elective operating list and one who has some training and experience in trauma surgery.

1. Clinical decision rules for secondary trauma triage: predictors of emergency operative management.
Ann Emerg Med. 2006 Feb;47(2):135

2. Validation and refinement of a rule to predict emergency intervention in adult trauma patients
Ann Emerg Med. 2011 Aug;58(2):164-71

3. Trauma is occasionally a surgical disease: how can we best predict when?
Ann Emerg Med. 2011 Aug;58(2):172-177