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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
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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
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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
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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