aztracc-making matters worse

7/30/2019 AZTrACC-Making Matters Worse

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Making Matters Worse:Iatrogenic Injuries / ComplicationsDuring Resuscitation

Scott R. Petersen, MD, FACS

St. Josephs Hospital and Medical Center

Phoenix, Arizona


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DOCTORS ARE THE THIRD LEADING CAUSE OFDEATH IN THE U.S., CAUSING 250,000 DEATHSEVERY YEAR

Deaths per year

12,000 - Unnecessary surgery

7,000- Medication errors

20,000- Other errors

80,000- Nosocomial infections

106,000- Negative ADEs

After heart/cardiovascular disease,cancer; Higher than trauma!!

Starfield B: JAMA 2000; 284: 483-5


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Principle of Medicine:

PRIMUM NON NOCERE

First do no harm

Hippocrates


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Hippocrates Injunction:

First do no harm

Neither Hippocrates or Galen

Middle Agestransmitted orally

Thomas Sydenham (1624-1689),

English Physician

Common use in U.S. since 1880

Potent reminder that every medicaldecision can harm the patient


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Iatrogenesis:

Unfavorable response to medical

treatment that is induced by thetherapeutic effort itself.

4-9% of hospitalized patients

Dubois RW, Brooks RH: Preventable deaths: Who, how often and why?

Ann Int Med 1988; 109: 582-589.


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Pandoras Box Errors in Medicine

20% iatrogenic injury- 1964 Schimmel

4% iatrogenic injury- 1991 Brennan

Harvard medical practice study14%fatality rate

Estimates180,000 deaths/year

~ 3 jumbo jet crashes q 2 days

Leape LL, JAMA 1994


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ICU Errors

Each patient experiences 178

events/day (staff, procedure,medical interactions

1.7 errors / day (1% failure rate)

Perspective:

2 unsafe landings at OHare/day

US mail16,000 lost pieces / hour

Banking32,000 checks deductedfrom wrong account/hour


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Iatrogenesis

We need to fundamentallychange the way we think

about errors and why theyoccur

Leape LL, JAMA 1994


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Preventable Deaths1991-2004

0

2

4

6

8

10

12

14

NumberofDeath

s

St. Josephs Hospital and Medical Center, Phoenix, AZ

Causes of Preventable Deathsn = 73 / 2,216 (3.3%)


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Iatrogenic Complications inTrauma

8.2% overallFailure to intubate

Esophageal intubation

Technical errors/cricothyroidotomy

Inability to intubate RSI

Aspiration with LMA, oral airways

Preventable deaths

Prehospital Errors:

Universally due to failure to appropriately manage theairway!


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Preventable Deaths1991-2004

0

2

4

6

8

10

12

14

NumberofDeath

s

St. Josephs Hospital and Medical Center, Phoenix, AZ

Causes of Preventable Deathsn = 73 / 2,216 (3.3%)


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Preventable DeathsSan Diego Trauma System

n=76/1295 deaths (5.9%)

14%

50%

36%

Resuscitation Phase

Critical Care PhaseOperative Phase

Davis JW, et al: J Trauma 1992; 32: 660-666.


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Errors in Trauma SystemSan Diego Trauma System

n=1032 errors / 22,577 patients4.5% overall

25.5%

21.1%

53.4%

Resuscitation Phase

Critical Care PhaseOperative Phase

Davis JW, et al: J Trauma 1992; 32: 660-666.


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Iatrogenic Injuries and Resuscitation

Phases of Care

Primary Survey Resuscitation

Secondary survey

Diagnostic imaging /tests Medications/drugs Interventions

Errors

Airway, C-spine Inadequate volume /fluid

overloadHypothermia

Failure to splint; controlhemorrhage; delays;missed injuries

Delays / errors ininterpretation ADEs Lines, tubes, drains

(LTDs)


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Iatrogenic Injuries and ResuscitationPrimary Survey

Failure to recognize:

Upper airway obstruction

Tension pneumothorax

Massive hemothorax

Open pneumothorax

Cardiac tamponade

Flail Chest

All can lead to cardiopulmonaryarrest in the trauma room


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Value of Intubating Patients withSuspected Head Injury

AVOID HYPOXIA!

RSISuccinylcholine (1 mg/kg)

Obtunded

Head injury (GCS < 10) Shock

Drugs, ETOH,

Pitfalls:

Perform a rapid neurologicexamination prior to paralysis

Redan JA, et al J Trauma 1991; 31: 371.


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The Agitated, Combative Patient .

Hazard to themselves

Prevent injuries to personnel

Two F-word Rule

Pitfalls: Allow these patients to

struggle, injure themselves orothers, interfere with diagnosticimaging (movement)

Occasionally intubate a drunk,but ..

At least not a hypoxic drunk !!


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AGITATION = HYPOXIA

Intubation NOT Medication


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CirculationControlling Hemorrhage

Best method: Direct pressure

Avoid inappropriate clamps/tourniquets

Five areas for occult bleeding Chest - CXR

Abdomen - FAST, DPL Pelvis - Pelvic x-rays

Thighs - Femur Fxs

Street

DO NOT overlook scalping laceration

Hemorrhage under bulky dressingsPitfalls:

Delay in getting a bleeding patientto the operating room for definitivecontrol


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Iatrogenic Complications DuringResuscitation

Fluid / volume overload ACS, Secondary ACS Secondary extremity compartment

syndrome

Avoid excessive crystalloid infusion Hypothermia

Cold environment, fluids, blood

Coagulopathy Prevention is paramount

Damage control Metabolic acidosis

Excessive use of saline forresuscitation can contribute toacidosisJ Trauma 53: 833-837, 2002

J Trauma 51: 173-177, 2001


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Secondary Survey

Head-to-Toe Examination

Tube and Fingers in every

orifice (ATLS)

Usually risk free EXCEPT:

Probing neck wounds that

penetrate the platysma Examination of cervical spine
http://www-cdu.dc.med.unipi.it/Archives/photogallery/PenetratingNeckInjury/pages/Diapositiva06_JPG.htm


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Penetrating neck injuries

Iatrogenic errors Probing wound may dislodge

clots and disrupt hematomas

Result in exsanguinating

hemorrhage Compromise the airway.

Urgent situation NOW becomesand EMERGENCY!!

Prevent: Explore these wounds in the

operating room / Zone II

Alternatively: CT angiography, endoscopy

in stable patients


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Evaluation of the Cervical Spine

Principles: Rarely clear C-spine in the trauma

room (Leave in C-collar)

C-spine radiographs must be

perfect (thru C7-T1) with NO midlinespine tenderness

LIBERAL use of CT (entire cervicalspine)

Clinical clearance only with Trivial

Mechanisms

~15% incidence of additional Fxs ineither cervical, thoracic or lumbarspine.


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Clinical Clearance - Cervical Spine

Blunt Trauma

1. Patient alert and oriented

2. NO distracting injuries

3. NO ETOH, drugs, medications4. NO spinal / neurological deficits

5. NO neck pain

6. NO midline neck tenderness

7. Trivial Mechanism

*Modified after: Hoffman, et al: N Engl J Med 2000; 343: 94-

97.


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Bypassing C-Spine Radiographs

in Acutely Injured Patients1. CSR will miss ~ 15% of C-spine Fx

2. CT much more sensitive (1-0.4%)

3. CSR must be perfect if obtained

4. May miss obvious injury if skipped

Sanchez, et al J Trauma 2005; 59: 197-183.


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Cervical Spine Clearance Protocol

Cervical Spine Clearance

99.9%98.9%97.6%

89.1%

95.0%

0%

25%

50%

75%

100%

Goal

Baseline

20042005

2006Qtr1

FY

Compliance

(%)


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Iatrogenic Complications:

DiagnosisAbdominal Trauma

DPL - 0.5% injuries; 6-8% negativelaparotomies

US (FAST)8% false negative

CT La promenade de mort

Charles Wolferth, MD, FACS

1994


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IatrogenesisDiagnostic Imaging

Inadequate films

Inordinate delays

Oral Contrast

Gastrograffinrisk of aspiration; poor detail Bariumadjuvant to abscess formation

Iodinated Intravenous Contrast Nephrotoxicitydose related,

hypovolemia, sepsis, diabetes, antibiotics;Prevent with IV hydration, NaHCO3,

acetylcysteine; Visipaque; Gadolinium (NSF) Allergyrash, shellfish allergy; serious reaction0.22% (hypotension, dyspnea, cardiac arrest

Local Extravasationcompartment syndrome

Air Embolismpower injectors, CTA


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Filmless Radiology

Potential Problems /Misinterpretations

Inadequate, inexpensive monitors

High ambient light in trauma room Image misinterpretation / subtle

findings

Communication betweenradiologists and surgeons
http://www.spinadental.com/imgs/logos/logo_kodak.gif


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Adverse Drug Events (ADE)Resuscitation

Drug

Tetanus toxoid

Antibiotics

Corticosteroids Vasopressors

Osmotic agents(mannitol)

Colloid expanders

Local anesthetics

Etomidate

Adverse event

Inexcusable disease

Reactions, superinfections

< 8 hrs SCI, adrenal insufficiency Contraindicated in hypo. shock

Hypovolemia

CHF, coagulopathy

Allergy, seizures, resp.arrest

Adrenal insufficiency


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Vasopressors During Resuscitation

Contraindicated in thetreatment of hypovolemia

Maybe? w/ neurogenic

shock Neurogenic shock Rx

Initial Rxvolume expansion

BradycardiaRx atropine

MonitoringCVP, PA catheter Vasopressorsdopamine, neo

Keep MAP > 80


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Lines, Tubes, Drains (LTD)

Common source of iatrogeniccomplications

60% are preventable

Related factors: Multiple injuries (high ISS)

Body size (small children, obesity)

Provider knowledge, skill, experience

CVP lines - most common Technical, infections, thrombosis

Laceration/injury to any structure invicinitylung, vessels, brachial plexus,thoracic duct, etc.


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Complications related to centralvenous catheters Technical

Pneumothorax / hemothorax

Mal-position

Laceration structures in vicinity

Infectious

Length of time in place Violations of sterile technique

Single vs. multi-lumen

Biopatches; biocatheter

Location: Subclavian < IJ < Femoral

AVOID problems:

Use Trendelenbergs position Follow placement with CXR

Pull lines placed in resuscitation area @24 hours

Use side of chest tube /injury


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High Risk LTDS during resuscitation(other)

PrehospitalAll!! RSI, cricothyroidotomy, needle

thoracostomy, CVP lines, tube

thoracostomy, Sternal I/O Cricothyroidotomy

ED physicians36%complication rate

Tube thoracostomy Extrathoracic placement Hemorrhage

Diaphragm injury, lung,

liver, spleen, stomach


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Chest Trocars

Blind placement has beenassociated with injury toevery intrathoracic organand many intraabdominal

ones Hazard even greater if

traumatic diaphragmatichernia is present

Avoid by performing digitalexploration of pleuralspace


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High Risk LTDS during resuscitation(other)

Urethral catheter Blood at urethral

meatus

Severe pelvic Fx High-riding prostate

Large perinealhematoma

Nasogastric tube
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/9931072urethral_injury_1.jpg&template=izoom2


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Complications with Transfusions

Massive transfusions

Hypothermia

Coagulopathy

Metabolic acidosis

Transfusion reactions Hemolytic, nonhemolytic

Transfusion-transmitted diseases (TTD)

Hep B, C, HIV, HTLV, CMV, prion

Transfusion-related acute lung injury(TRALI)

Transfusion-mediatedimmunomodulation


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Missed Injuries

The Trauma Surgeons Nemesis Incidence - 9-12%

Contributing Factors:

Clinical Radiologic

Admission to inappropriate service

Transfers

Tertiary Trauma Survey Reduces the risk of patients leaving

the hospital with missed injuries

Enderson BL, Maull KI; Surg Clin N Am 1991; 71: 399-418.


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Missed Injuries - Trauma

Legal Implications MOST lawsuits directed toward

perpetrator

MOST are related to blunt injury

MOST malpractice is related tomissed injuries

Study in Arizona Trauma and malpractice claims

Nontrauma hospitals / outpatientfacilities - 78%

Level I trauma centers22%

Weiland DE, et al: Am J Surgery 1989; 158: 553.


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Summary:

Analyze outcomes and errors

Often, our own worst critics

Educate, trend and discuss

errors

Avoid blame

Learn from our mistakes

Dont make the same mistake twice

It happens!! Even in the best of hands


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Petersens Rules Avoiding Iatrogenic Injuries

Do not delay life-saving therapy to clearthe spine

CT can be a dangerous place!

Treatment of obvious arterial injuries shouldnot be delayed for unnecessaryarteriography

Repeat the physical exam at intervals

The Tertiary Survey

DO NOT use vasopressors in hemorrhagicshock

The treatment of hemorrhage ishemostasis

Sometimes, the treatment of hemorrhagemust precede the Rx of shock


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Remember ..

W. Rohlfing MD, FACS,

San Francisco, 1975


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Why doctors are 9,000 times more likely toaccidentally kill you than gun owners?

Number physicians in U.S.700,000

Accidental deaths caused by physicians/year120,000

Accidental deaths/physcian/year = 0.071

Number of gun owners80,000,000

Number of accidental gun deaths1,500

Accidental deaths/gun owner0.000018

Therefore: Doctors are 9000 X moredangerous than gun owners

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