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Prehospital tourniquets in civilian settings significantly decreased mortality
BALTIMORE – Prehospital tourniquet use on injured civilians in trauma situations was associated with a nearly sixfold decrease in mortality, according to a study presented at the annual meeting of the American Association for Surgery of Trauma.
While tourniquets have been an effective tool in military settings, data on successful applications in civilian settings have been scarce.
Dr. Teixeira and his coinvestigators conducted a multicenter, retrospective study of 1,026 peripheral–vascular injury patients admitted to level I trauma centers between January 2011 and December 2016. Among the patients studied, 181 (17.6%) received a tourniquet prior to hospital admission.
A majority of tourniquets were applied to the limbs, with the most common application sites on the arm (49%) and the thigh (29%).Tourniquets were held in place for an average 77 minutes.
Of the patients in the study, 98 (9.6%) underwent an amputation; 35 of these patients had received a tourniquet.
After adjusting for confounding factors, such as age and mechanism of injury, investigators found patients who received tourniquets were nearly six times more likely to survive than were their nontourniquet counterparts (odds ratio, 5.86; 95% confidence interval, 1.41-24.47; P = .015).
While the overall mortality rate among those with a tourniquet – compared with those without a tourniquet – was significantly lower, the comparative mortality rate among amputee patients was not significant, which investigators hypothesized could be because of the smaller number of patients in this subgroup.
Additionally, patients who did not receive a tourniquet had lower injury severity scores, had better vital signs, and needed less blood, according to investigators.
The findings of this study mirror what many military medical professionals have historically, and adamantly, supported, according to discussant Jay J. Doucet, MD, FACS, medical director for the surgical intensive care unit at the University of California San Diego Medical Center and a former combat surgeon.
“The medical lessons on our battlefields that hold such great promise have to be carefully relearned, brought home, and fearlessly applied here,” said Dr. Doucet. “I have yet to meet an employed military surgeon who does not believe the tourniquet is an indispensable tool.” While Dr. Doucet did acknowledge the benefit of tourniquets outside military use and addressed the need for increased implementation among civilian hospitals, he did pose a query about the mortality rate that investigators had found.
“The no-tourniquet group has an adjusted odds of death at a rate that is 5.86 times higher, yet they had better vitals, needed less blood, had lower [injury severity scores], had less head injury, fewer traumatic amputations, and fewer complications,” said Dr. Doucet. “So why do they die?”
Investigators were not able to pinpoint the cause of death among patients because of the limitations of their study; however, Dr. Teixeira and his colleagues were able to determine the presence of cardiac complications, pulmonary complications, and acute kidney injury, none of which had a significantly different presence between the two study groups.
The data gathered from this study are strong enough to support the use of tourniquets in civilian situations, asserted Dr. Teixeira, which means the next hurdle is to integrate it into the health system.
“What’s important from our perspective as leaders of this issue is what we are doing to increase the rate [of tourniquet use],” said Dr. Teixeira. “I think one of the important things is the Stop the Bleed program, [in which] we are actually teaching the Austin police department, and we are trying to increase the use of the tourniquet and demonstrate its importance.”
Investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
On Twitter @eaztweets
BALTIMORE – Prehospital tourniquet use on injured civilians in trauma situations was associated with a nearly sixfold decrease in mortality, according to a study presented at the annual meeting of the American Association for Surgery of Trauma.
While tourniquets have been an effective tool in military settings, data on successful applications in civilian settings have been scarce.
Dr. Teixeira and his coinvestigators conducted a multicenter, retrospective study of 1,026 peripheral–vascular injury patients admitted to level I trauma centers between January 2011 and December 2016. Among the patients studied, 181 (17.6%) received a tourniquet prior to hospital admission.
A majority of tourniquets were applied to the limbs, with the most common application sites on the arm (49%) and the thigh (29%).Tourniquets were held in place for an average 77 minutes.
Of the patients in the study, 98 (9.6%) underwent an amputation; 35 of these patients had received a tourniquet.
After adjusting for confounding factors, such as age and mechanism of injury, investigators found patients who received tourniquets were nearly six times more likely to survive than were their nontourniquet counterparts (odds ratio, 5.86; 95% confidence interval, 1.41-24.47; P = .015).
While the overall mortality rate among those with a tourniquet – compared with those without a tourniquet – was significantly lower, the comparative mortality rate among amputee patients was not significant, which investigators hypothesized could be because of the smaller number of patients in this subgroup.
Additionally, patients who did not receive a tourniquet had lower injury severity scores, had better vital signs, and needed less blood, according to investigators.
The findings of this study mirror what many military medical professionals have historically, and adamantly, supported, according to discussant Jay J. Doucet, MD, FACS, medical director for the surgical intensive care unit at the University of California San Diego Medical Center and a former combat surgeon.
“The medical lessons on our battlefields that hold such great promise have to be carefully relearned, brought home, and fearlessly applied here,” said Dr. Doucet. “I have yet to meet an employed military surgeon who does not believe the tourniquet is an indispensable tool.” While Dr. Doucet did acknowledge the benefit of tourniquets outside military use and addressed the need for increased implementation among civilian hospitals, he did pose a query about the mortality rate that investigators had found.
“The no-tourniquet group has an adjusted odds of death at a rate that is 5.86 times higher, yet they had better vitals, needed less blood, had lower [injury severity scores], had less head injury, fewer traumatic amputations, and fewer complications,” said Dr. Doucet. “So why do they die?”
Investigators were not able to pinpoint the cause of death among patients because of the limitations of their study; however, Dr. Teixeira and his colleagues were able to determine the presence of cardiac complications, pulmonary complications, and acute kidney injury, none of which had a significantly different presence between the two study groups.
The data gathered from this study are strong enough to support the use of tourniquets in civilian situations, asserted Dr. Teixeira, which means the next hurdle is to integrate it into the health system.
“What’s important from our perspective as leaders of this issue is what we are doing to increase the rate [of tourniquet use],” said Dr. Teixeira. “I think one of the important things is the Stop the Bleed program, [in which] we are actually teaching the Austin police department, and we are trying to increase the use of the tourniquet and demonstrate its importance.”
Investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
On Twitter @eaztweets
BALTIMORE – Prehospital tourniquet use on injured civilians in trauma situations was associated with a nearly sixfold decrease in mortality, according to a study presented at the annual meeting of the American Association for Surgery of Trauma.
While tourniquets have been an effective tool in military settings, data on successful applications in civilian settings have been scarce.
Dr. Teixeira and his coinvestigators conducted a multicenter, retrospective study of 1,026 peripheral–vascular injury patients admitted to level I trauma centers between January 2011 and December 2016. Among the patients studied, 181 (17.6%) received a tourniquet prior to hospital admission.
A majority of tourniquets were applied to the limbs, with the most common application sites on the arm (49%) and the thigh (29%).Tourniquets were held in place for an average 77 minutes.
Of the patients in the study, 98 (9.6%) underwent an amputation; 35 of these patients had received a tourniquet.
After adjusting for confounding factors, such as age and mechanism of injury, investigators found patients who received tourniquets were nearly six times more likely to survive than were their nontourniquet counterparts (odds ratio, 5.86; 95% confidence interval, 1.41-24.47; P = .015).
While the overall mortality rate among those with a tourniquet – compared with those without a tourniquet – was significantly lower, the comparative mortality rate among amputee patients was not significant, which investigators hypothesized could be because of the smaller number of patients in this subgroup.
Additionally, patients who did not receive a tourniquet had lower injury severity scores, had better vital signs, and needed less blood, according to investigators.
The findings of this study mirror what many military medical professionals have historically, and adamantly, supported, according to discussant Jay J. Doucet, MD, FACS, medical director for the surgical intensive care unit at the University of California San Diego Medical Center and a former combat surgeon.
“The medical lessons on our battlefields that hold such great promise have to be carefully relearned, brought home, and fearlessly applied here,” said Dr. Doucet. “I have yet to meet an employed military surgeon who does not believe the tourniquet is an indispensable tool.” While Dr. Doucet did acknowledge the benefit of tourniquets outside military use and addressed the need for increased implementation among civilian hospitals, he did pose a query about the mortality rate that investigators had found.
“The no-tourniquet group has an adjusted odds of death at a rate that is 5.86 times higher, yet they had better vitals, needed less blood, had lower [injury severity scores], had less head injury, fewer traumatic amputations, and fewer complications,” said Dr. Doucet. “So why do they die?”
Investigators were not able to pinpoint the cause of death among patients because of the limitations of their study; however, Dr. Teixeira and his colleagues were able to determine the presence of cardiac complications, pulmonary complications, and acute kidney injury, none of which had a significantly different presence between the two study groups.
The data gathered from this study are strong enough to support the use of tourniquets in civilian situations, asserted Dr. Teixeira, which means the next hurdle is to integrate it into the health system.
“What’s important from our perspective as leaders of this issue is what we are doing to increase the rate [of tourniquet use],” said Dr. Teixeira. “I think one of the important things is the Stop the Bleed program, [in which] we are actually teaching the Austin police department, and we are trying to increase the use of the tourniquet and demonstrate its importance.”
Investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
On Twitter @eaztweets
At the AAST Annual Meeting
Key clinical point:
Major finding: Patients who were given a prehospital tourniquet were associated with a survival odds ratio nearly sixfold higher than those without (odds ratio, 5.86; 95% confidence interval, 1.41-24.47; P = .015).
Data source: Multicenter retrospective study of 1,026 patients with peripheral vascular injuries admitted to a level I trauma facility between January 2011 and December 2016.
Disclosures: Investigators reported no relevant financial disclosures.
Opioid management protocol lowered trauma patient pain medication use
BALTIMORE – A pain management protocol implemented in a trauma service reduced opioid intake in trauma patients while improving patient satisfaction, according to a retrospective study.
The opioid epidemic continues to grow every day, partly as a result of irresponsible overprescribing of opioid medication, according to Jessica Gross, MB BAO BCh, FACS, a trauma surgeon from Wake Forest (N.C.) Baptist Health at the American Association for the Surgery of Trauma annual meeting. Dr. Gross and her colleagues developed a pain management protocol (PMP) to provide adequate pain control while using fewer opioids in the postdischarge setting. They tested their PMP through a retrospective chart review of 498 patients admitted to the trauma service between January 2015 and December 2016, half of which were admitted before the PMP was initiated and half of which were admitted afterward.
The PMP involved a stepped approach to treating pain, with acetaminophen or ibuprofen as needed for mild pain, one 5-mg tablet of oxycodone/acetaminophen every 6 hours for moderate pain, two tablets for severe pain, and 50-100 mg of tramadol every 6 hours for breakthrough pain.
Counseling services for patients who were found to be in danger of substance use were provided in the hospital, and at discharge, patients received a weaning plan for their medication, according to Dr. Gross.
If the short-acting medications were found to be inadequate to control pain, patients were given slow-release pain medication as needed.
Average total medication, including at discharge and for refills, prescribed after PMP initiation was 1,242 morphine milligram equivalents (MME), compared with 2,421 MME prior to the protocol (P less than .0001).
After the protocol was implemented, Dr. Gross and her colleagues found the number of patients prescribed a refill dropped from 39.7% to 28.1%, with the size of those refills dropping from 1,032 MME to 213 MME on average.
“By having a comprehensive pain management protocol, we can reduce the amount of pain medications we prescribe for outpatient use, from discharge from the trauma service,” said Dr. Gross. “Additionally, we have shown that by having a protocol in place, we not only decreased the number of refills we were providing, but also the amount of pain medications that was prescribed within these refills.”
Through a Press Ganey survey analysis of patients during the month before and the month after the PMP implementation, investigators found a significant increase in patient satisfaction and overall pain management, according to Dr. Gross,
In addition, the main trauma floor where the PMP was implemented was recognized for the most improvement in overall hospital rating and pain management, compared with the previous year.
Discussant Oscar Guillamondegui MD,FACS, medical director of the trauma ICU at Vanderbilt University, Nashville, Tenn., acknowledged the importance of PMPs and the work investigators presented.
“I would consider this the next generation of ERAS [enhanced recovery after surgery], or ERAT [enhanced recovery after trauma] in pain perception modification,” said Dr. Guillamondegui. “Dr. Gross and the multidisciplinary group at Wake Forest have provided compelling evidence to help alleviate [the opioid epidemic].”
In a question-and-answer session following the presentation, attendees voiced concern over how a PMP would be used among patients who are more familiar with hospital systems, in particular concerning self-reported pain levels.
“Most of us employed at acute care centers are not working in utopia. Many of our patients are heroin addicts, are very bright, and know how to identify 10 on those silly smiley faces so that they get more medicine,” said Charles Lucas, MD, FACS, professor of surgeon at Wayne State University, Detroit. Dr. Lucas also pointed out that even when patients report false levels of pain, doctors still are required to put it into the electronic medical record for fear of repercussions,
In response, Dr. Gross said doctors on the floor reviewed patients to make sure they were receiving all doses of pain medications. If doctors felt the patient’s pain regimen was adequate, despite the patient reporting otherwise, no changes were made.
Certain limitations include not being able to confirm whether patients received prescription medication elsewhere, nor any concrete data on patient satisfaction after discharge other than an inference based on fewer refills and lower refill MME.
Investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
On Twitter @eaztweets
BALTIMORE – A pain management protocol implemented in a trauma service reduced opioid intake in trauma patients while improving patient satisfaction, according to a retrospective study.
The opioid epidemic continues to grow every day, partly as a result of irresponsible overprescribing of opioid medication, according to Jessica Gross, MB BAO BCh, FACS, a trauma surgeon from Wake Forest (N.C.) Baptist Health at the American Association for the Surgery of Trauma annual meeting. Dr. Gross and her colleagues developed a pain management protocol (PMP) to provide adequate pain control while using fewer opioids in the postdischarge setting. They tested their PMP through a retrospective chart review of 498 patients admitted to the trauma service between January 2015 and December 2016, half of which were admitted before the PMP was initiated and half of which were admitted afterward.
The PMP involved a stepped approach to treating pain, with acetaminophen or ibuprofen as needed for mild pain, one 5-mg tablet of oxycodone/acetaminophen every 6 hours for moderate pain, two tablets for severe pain, and 50-100 mg of tramadol every 6 hours for breakthrough pain.
Counseling services for patients who were found to be in danger of substance use were provided in the hospital, and at discharge, patients received a weaning plan for their medication, according to Dr. Gross.
If the short-acting medications were found to be inadequate to control pain, patients were given slow-release pain medication as needed.
Average total medication, including at discharge and for refills, prescribed after PMP initiation was 1,242 morphine milligram equivalents (MME), compared with 2,421 MME prior to the protocol (P less than .0001).
After the protocol was implemented, Dr. Gross and her colleagues found the number of patients prescribed a refill dropped from 39.7% to 28.1%, with the size of those refills dropping from 1,032 MME to 213 MME on average.
“By having a comprehensive pain management protocol, we can reduce the amount of pain medications we prescribe for outpatient use, from discharge from the trauma service,” said Dr. Gross. “Additionally, we have shown that by having a protocol in place, we not only decreased the number of refills we were providing, but also the amount of pain medications that was prescribed within these refills.”
Through a Press Ganey survey analysis of patients during the month before and the month after the PMP implementation, investigators found a significant increase in patient satisfaction and overall pain management, according to Dr. Gross,
In addition, the main trauma floor where the PMP was implemented was recognized for the most improvement in overall hospital rating and pain management, compared with the previous year.
Discussant Oscar Guillamondegui MD,FACS, medical director of the trauma ICU at Vanderbilt University, Nashville, Tenn., acknowledged the importance of PMPs and the work investigators presented.
“I would consider this the next generation of ERAS [enhanced recovery after surgery], or ERAT [enhanced recovery after trauma] in pain perception modification,” said Dr. Guillamondegui. “Dr. Gross and the multidisciplinary group at Wake Forest have provided compelling evidence to help alleviate [the opioid epidemic].”
In a question-and-answer session following the presentation, attendees voiced concern over how a PMP would be used among patients who are more familiar with hospital systems, in particular concerning self-reported pain levels.
“Most of us employed at acute care centers are not working in utopia. Many of our patients are heroin addicts, are very bright, and know how to identify 10 on those silly smiley faces so that they get more medicine,” said Charles Lucas, MD, FACS, professor of surgeon at Wayne State University, Detroit. Dr. Lucas also pointed out that even when patients report false levels of pain, doctors still are required to put it into the electronic medical record for fear of repercussions,
In response, Dr. Gross said doctors on the floor reviewed patients to make sure they were receiving all doses of pain medications. If doctors felt the patient’s pain regimen was adequate, despite the patient reporting otherwise, no changes were made.
Certain limitations include not being able to confirm whether patients received prescription medication elsewhere, nor any concrete data on patient satisfaction after discharge other than an inference based on fewer refills and lower refill MME.
Investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
On Twitter @eaztweets
BALTIMORE – A pain management protocol implemented in a trauma service reduced opioid intake in trauma patients while improving patient satisfaction, according to a retrospective study.
The opioid epidemic continues to grow every day, partly as a result of irresponsible overprescribing of opioid medication, according to Jessica Gross, MB BAO BCh, FACS, a trauma surgeon from Wake Forest (N.C.) Baptist Health at the American Association for the Surgery of Trauma annual meeting. Dr. Gross and her colleagues developed a pain management protocol (PMP) to provide adequate pain control while using fewer opioids in the postdischarge setting. They tested their PMP through a retrospective chart review of 498 patients admitted to the trauma service between January 2015 and December 2016, half of which were admitted before the PMP was initiated and half of which were admitted afterward.
The PMP involved a stepped approach to treating pain, with acetaminophen or ibuprofen as needed for mild pain, one 5-mg tablet of oxycodone/acetaminophen every 6 hours for moderate pain, two tablets for severe pain, and 50-100 mg of tramadol every 6 hours for breakthrough pain.
Counseling services for patients who were found to be in danger of substance use were provided in the hospital, and at discharge, patients received a weaning plan for their medication, according to Dr. Gross.
If the short-acting medications were found to be inadequate to control pain, patients were given slow-release pain medication as needed.
Average total medication, including at discharge and for refills, prescribed after PMP initiation was 1,242 morphine milligram equivalents (MME), compared with 2,421 MME prior to the protocol (P less than .0001).
After the protocol was implemented, Dr. Gross and her colleagues found the number of patients prescribed a refill dropped from 39.7% to 28.1%, with the size of those refills dropping from 1,032 MME to 213 MME on average.
“By having a comprehensive pain management protocol, we can reduce the amount of pain medications we prescribe for outpatient use, from discharge from the trauma service,” said Dr. Gross. “Additionally, we have shown that by having a protocol in place, we not only decreased the number of refills we were providing, but also the amount of pain medications that was prescribed within these refills.”
Through a Press Ganey survey analysis of patients during the month before and the month after the PMP implementation, investigators found a significant increase in patient satisfaction and overall pain management, according to Dr. Gross,
In addition, the main trauma floor where the PMP was implemented was recognized for the most improvement in overall hospital rating and pain management, compared with the previous year.
Discussant Oscar Guillamondegui MD,FACS, medical director of the trauma ICU at Vanderbilt University, Nashville, Tenn., acknowledged the importance of PMPs and the work investigators presented.
“I would consider this the next generation of ERAS [enhanced recovery after surgery], or ERAT [enhanced recovery after trauma] in pain perception modification,” said Dr. Guillamondegui. “Dr. Gross and the multidisciplinary group at Wake Forest have provided compelling evidence to help alleviate [the opioid epidemic].”
In a question-and-answer session following the presentation, attendees voiced concern over how a PMP would be used among patients who are more familiar with hospital systems, in particular concerning self-reported pain levels.
“Most of us employed at acute care centers are not working in utopia. Many of our patients are heroin addicts, are very bright, and know how to identify 10 on those silly smiley faces so that they get more medicine,” said Charles Lucas, MD, FACS, professor of surgeon at Wayne State University, Detroit. Dr. Lucas also pointed out that even when patients report false levels of pain, doctors still are required to put it into the electronic medical record for fear of repercussions,
In response, Dr. Gross said doctors on the floor reviewed patients to make sure they were receiving all doses of pain medications. If doctors felt the patient’s pain regimen was adequate, despite the patient reporting otherwise, no changes were made.
Certain limitations include not being able to confirm whether patients received prescription medication elsewhere, nor any concrete data on patient satisfaction after discharge other than an inference based on fewer refills and lower refill MME.
Investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
On Twitter @eaztweets
AT THE AAST ANNUAL MEETING
Key clinical point:
Major finding: Average prescription fell to 1,242 morphine milligram equivalents (MME) per prescription, compared with 2,421 MME per prescription prior to the protocol.
Data Source: Retrospective chart review of 498 trauma patients from Jan. 1, 2015, and Dec. 31, 2016.
Disclosures: Investigators reported no relevant financial disclosures.