SPRING 2019 SPRING | UPMC | TRAUMA ROUNDS UPMC TRAUMA CARE SYSTEM CARE TRAUMA UPMC

Inside This Edition 1 Catheter-Directed Catheter-Directed Thrombolysis Thrombolysis for the Treatment of Frostbite for the Treatment of Frostbite 3 UPMC Hamot Trauma Team

4 Trauma Forensics: Saving Lives by Steven Tamesis, MD, Shantanu Warhadpande, MD, Jenny Ziembicki, MD, and Alain Corcos, MD and Preserving Evidence

6 Trauma Care for Blunt When temperatures plummet in the winter months, the threat of frostbite Cerebrovascular Injuries is very real. Frostbite results from exposure of tissues to the environment, causing freezing at the tissue level. The populations most at risk for

the development of frostbite are those who spend a great deal of time outdoors, such as homeless CME Credit Disclosures: Drs. Tamesis, Warhadpande, people, police officers, firefighters, Ziembicki, Corcos, Alarcon, Nine, and recreational skiers; suffer Reynolds-Hill, and Roach have reported no relevant relationships with entities from psychiatric conditions, producing health care goods or services. neuropathy, or peripheral arterial Instructions: To take the CME disease; are under the influence evaluation and receive credit, please Figure 1. First-degree frostbite. visit https://cme.hs.pitt.edu/ISER of alcohol; or are injured, (case-sensitive) and click on Trauma exhausted, or dehydrated.1 and Emergency. If this is your first visit, you will need to create a free account. Tissue insult from frostbite occurs mainly due to the formation of both intracellular and Accreditation Statement: The University of Pittsburgh School of Medicine is extracellular ice crystals leading to direct cellular accredited by the Accreditation Council damage, as well as vasoconstriction anoxia, for Continuing Medical Education vascular stasis, and thrombosis.1-3 (ACCME) to provide continuing medical education for physicians. The University of There are varying degrees of frostbite. First- Pittsburgh School of Medicine designates degree frostbite is superficial with partial skin this enduring material for a maximum freezing (see Figure 1). The skin is viable, Figure 2. Second-degree frostbite. of .5 AMA PRA Category 1 Credits™. not blistered but with an erythematous and Each physician should only claim credit commensurate with the extent of their edematous appearance. There is no long-term participation in the activity. Other health sequela associated with first-degree frostbite. care professionals are awarded .05 Second-degree frostbite is full thickness skin continuing education units (CEUs), which freezing (see Figure 2). There is erythema, edema, are equivalent to .5 contact hours. and blister formation, containing clear fluid. At this point, there may be some long-term sequela; however, the prognosis is still favorable. Third-degree frostbite is full thickness skin with subcutaneous tissue freezing (see Figure 3). (Continued on Page 2) Figure 3. Third-degree frostbite.

Affiliated with the University of Pittsburgh School of Medicine, UPMC Presbyterian Shadyside is ranked among America’s Best Hospitals by U.S. News & World Report. Catheter-Directed Thrombolysis for the Treatment of Frostbite (Continued from Page 1)

There is bluish-gray discoloration of the Unroofing blisters is thought to remove local intervention; they are admitted to the ICU skin with violaceous/hemorrhagic blister chemokines, which compromises local for close hemodynamic monitoring and formation, and eventual skin necrosis. wound healing and may even extend soft intra-arterial catheter care. The infusion is Fourth-degree frostbite is full thickness skin, tissue damage. On the other hand, unroofing continued until angiographic evidence of subcutaneous tissue, muscle, tendon, and blisters may allow better visualization and reperfusion or for a total of 48 hours. bone freezing. Skin appears mottled, deep characterization of the wound. The current red, or cyanotic. This ultimately progresses recommendation and practice at UPMC Outcomes to a dry, black, and mummified­ appearance, Mercy is that if blisters cause any form of Our initial experience with catheter-directed and eventual auto-amputation.4,7 functional impairment, they should be deflated using the sterile needle technique. thrombolysis for severe frostbite has been very encouraging. A review conducted by Current Therapy and Outcomes Otherwise, blisters should be left intact. All blistered areas should be dressed with Warhadpande et al. looked at six patients Prior to the initiation of frostbite treatment, aloe vera gel and covered with a loosely who presented with severe frostbite and it is highly important to address the patient’s fitted dry bulky dressing to allow for edema were evaluated with angiography. Of these hypo­thermia if present. Passive and active formation. Wounds should be reevaluated six patients, five (49 digits) were shown rewarming techniques should be employed to have evidence of vascular compromise and redressed daily.6,7 as indicated. The patient’s core temperature and were treated with catheter-directed should be at or above 35 degrees centigrade Analgesics and anxiolytics should be thrombolysis. In total, 29 digits were shown before frostbite rewarming. Once hypo­ administered as needed. Tetanus prophylaxis to have angiographic evidence of revascular­ thermia is addressed, attention should turn should also be given. Other important ization on the first post-lytic angiogram. to treating any tissue with evidence of adjuncts to the treatment of frostbite are All of these digits were eventually salvaged. frostbite. The treatment of frostbite consists smoking cessation and withholding of any The remaining 20 digits continued to | 2 | TRAUMA ROUNDS | ROUNDS | 2 TRAUMA mainly of rewarming the affected tissue. products that contain nicotine, and bedrest show evidence of vascular compromise on Initial therapy consists of removing all until resolution of edema and ambulation angiogram and were ultimately unsalvageable. jewelry and any wet and constricting with special protective footwear for frostbite This study suggests that patients who clothing. Any affected area should be that involves the feet. Systemic antibiotics respond early to catheter-directed therapy submersed in water warmed to 37 to 39 are reserved for those with evidence of can expect a high digit salvage rate.8 degrees centigrade for 15 to 60 minutes. surrounding cellulitis.6,7 The primary endpoint of rewarming is the Conclusion return of perfusion as indicated by a pliable Catheter-Directed Thrombolysis Frostbite results from exposure of tissues appearance of tissue, red to purple color, and for the Treatment of Frostbite to the environment, causing freezing at the return of sensation or pain.5 The affected In 2017, UPMC Mercy initiated a catheter- tissue level. Tissue insult from frostbite tissue must then be allowed to air dry.6 directed thrombolysis protocol for the occurs mainly due to the formation of both Rubbing the affected tissue before or after treatment of patients with severe frostbite intracellular and extracellular ice crystals rewarming is not recommended as this may (third- and fourth-degree). After appropriate leading to direct cellular damage, as well as cause additional trauma. Once rewarming is thawing and rewarming, we evaluate the vasoconstriction anoxia, vascular stasis, and complete, the vascular status of the affected affected extremities for ongoing vascular thrombosis. There are varying degrees of area should be assessed. Exam findings such compromise using a dye study called frostbite with first- and second-degree as dusky, blue, gray, or pallorous skin color; angiography, which is similar to cardiac injuries being mild and recoverable, and capillary refill greater than two seconds; and catheterization. Indications for catheter- third- and fourth-degree injuries being decreased blood flow on a Doppler ultrasound directed angiography are pallor or dusky severe, often leading to tissue necrosis and indicate ongoing vascular compromise.7 skin appearance, decreased distal pulses, amputation. The mainstay of treatment for After rewarming is complete, local wound prolonged capillary refill, decreased Doppler frostbite continues to be rewarming and care should be applied. Wounds are signal, cool skin after rewarming, and local wound care. For patients with severe classified by their post-thaw appearance. hemorrhagic blister formation. frostbite, assessment for evidence of Frost nip and first-degree frostbite should be vascular compromise after rewarming using treated with aloe vera gel four times daily If any of these findings are present, the angiography can identify some patients and should be left open to air. Second- to angiogram is performed urgently by our who will benefit from catheter-directed fourth-degree frostbite should be assessed interventional radiologists. Patients with thrombolysis, a new and exciting therapeutic for blister formation. There is considerable evidence of vascular compromise are then option. Our institutional experience shows controversy with unroofing blisters. treated with regional delivery of tissue that for digits with angiographic evidence of plasminogen activator (tPA), heparin, and response to catheter-directed thrombolysis papaverine by continuous infusion. Patients on the first day after lytic therapy, the digit must present within 24 hours from the time salvage rate is 100%. of injury to be considered candidates for SPRING 2019 | 3 | UPMC TRAUMA CARE SYSTEM |

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Kristen Pichler, PA-C, Jenny Ziembicki, MD Ziembicki, Jenny of director is medical Burn Mercy the UPMC her She earned Center. at Temple degree medical and completed University surgery her general at the University residency MD Tamesis, Steven resident is a PGY-3 Mercy in the UPMC Surgery General Tamesis Dr. program. earned his medical Eastern Far from degree – Nicanor University Back left row, right: to Hospitals of Cleveland/Case Western Reserve Reserve Western of Cleveland/Case Hospitals and a trauma/burn by followed University, at Metro fellowship care critical surgical Ohio. in Cleveland, Center Health Medical of Medicine, Philippines. Institute Reyes

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, is a PGY-3 resident , is a PGY-3 in the UPMC Diagnosticin the UPMC Radiology program. earned Warhadpande Dr. at the degree his medical University Ohio State of Medicine. College Alain Corcos, MD, FACS MD, Corcos, Alain Division ofis chief of the in Trauma Multisystem the Department of Surgery he where Mercy, at UPMC medical as trauma serves chief academic director, and residency, of surgical Warhadpande, Shantanu MD Additionally, he completed a fellowship in a fellowship he completed Additionally, at the trauma and care University critical surgical Center. San Diego Medical of California head of the section of surgical critical care. He is He care. critical head of the section of surgical at of surgery professor assistant also a clinical earned Corcos Dr. of Pittsburgh. the University Health Services Oregon from degree his medical general in residency his completed He University. in the Division of and a fellowship Cardiosurgery at St. Luke’s- Surgery and Thoracic vascular City. York in New Center Hospital Roosevelt Sarah PA-C, Melissa Troup, Loveranes, DO, Suzanne Iacobucci, Sean CRNP, Cain, MD, Crystal Goss, PA-C, Front left row, right: to

2014;3:7. 2014;3:7. . Current Surgical Therapy. Therapy. Surgical Current Total Burn Care. 4th Ed. Ed. 4th Burn Care. Total Baylor University Medical Medical University Baylor (2010): 23(3): 261-262. (2010): 23(3): Postgraduate Medical Journal. Journal. Medical Postgraduate Wilderness & Environmental Medicine. & Environmental Wilderness amot Team Trauma Philadelphia: Saunders Elsevier. (2017): Elsevier. Philadelphia: Saunders

frostbite with angiographic response as a predictive as a predictive response with angiographic frostbite with six experience amputation rates: for factor SIR Annual Scientific patients.” consecutive 2018. 17-22, March CA. Angeles, Meeting: Los Burn Services Practice Guidelines. (2018): 1-6. Practice Burn Services for protocol structured S, et al. “A Warhadpande digital severe for thrombolysis catheter-directed for the prevention and treatment of frostbite: 2014 of frostbite: and treatment the prevention for update.” 4: 543-554. 25, Issue Volume 2014-12-01, and Trauma Mercy UPMC Barry J. Ziembicki J, GG, McDevitt M, Imray CH, Johnson EL, Dow J, J, CH, Johnson EL, Dow M, Imray GG, McDevitt Medical Society. PH, Wilderness Hackett guidelines practice Medical Society “Wilderness Extreme Physiology & Medicine. & Medicine. Physiology Extreme Doi:10.1186/2046-7648-3-7. CK, L, Grissom SE, Opacic M, Freer McIntosh A, Giesbrecht Cochran GW, PS, Rodway Auerbach 85(1007):481-8. Sept. 2009. 85(1007):481-8. K, et al. “Frostbite: Russell P, C, Buxton Handford hospital management.” to approach a practical Imray C, Grieve A, Dhillon S, Caudwell Xtreme Xtreme S, Caudwell A, Dhillon C, Grieve Imray the to damage “Cold Group. Research Everest cold and non-freezing frostbite extremities: injuries.” Cameron JL, Cameron A. JL, Cameron Cameron 12th Ed. 1298-1303. Center Proceedings. Proceedings. Center Jones JH. Herndon D, 449-453. (2012): Elsevier. Saunders Philadelphia: Flatt A. “Frostbite.” A. “Frostbite.” Flatt

Brook Phinney, PA-C, Jennifer Niebauer, PA-C, Bethany Zimmerman, PA-C, Ashley Ganzer, PA-C, Lauren Donatelli, DO. Paul Malaspina, MD, McCoy, Tracy DO, Lindsey Roach, DO, David Dexter, MD, Gregory Beard, DO, Gregory English, MD. UPMC H 8 7 6 5 4 3 2 1 References

Close-range entrance gunshot wound with gunshot wound entrance Close-range gunpowder soot and tattooing — vital gunshot soot and tattooing gunpowder be wiped off while that can inadvertently information covering Consider wounds. cleaning or preparing without cleaning with gauze of wounds these types cleaning. prior to or photographing them if possible, Whenever possible, surgical procedures (for procedures surgical possible, Whenever tube insertion) chest should not beexample, Otherwise, if wounds. existing done through this should a wound, will alter a procedure example, 1). For Figure (see be documented a through incision goes if a laparotomy documentation of the gunshot wound, location and description of the wound 1: Figure

may be the result of previous injury. injury. of previous be the result may diagrams or photographs of the injuries can or photographs diagrams a clinical perspective, useful. From be very that the number it is important remember to number of plus the of gunshot wounds equal an should bullets on radiographs Otherwise, either a wound even number. and for or a bullet has not been accounted may and radiographs further examination that bullets may are Caveats indicated. be bone or through pass when they fragment that and it is possible other dense material, scans bodies seen on X-ray foreign retained outside of his or her expertise and training. outside of his or her expertise and training. a classify to not attempt should Physicians From or “exit.” as “entrance” gunshot wound is whether a wound a clinical perspective, of Instead is immaterial. or exit entrance they of travel, speculating about direction should simply document the location of the Inconsistent and its appearance. wound (who the physicians descriptions between and the experts) not forensic are in general case. hinder the legal may medical examiner description withSupplementing the written document the patient’s account of the event, the event, of account document the patient’s medical documentation should be factual; about should not conjecture the physician before what occurred of the injury, the intent at the emergency the patient arrived of the injurydepartment, nature or the

PreservingEvidence

physical findings. Physicians should findings. Physicians physical participated in ordocument only what they to While it is appropriate observed. directly Documentation of injuries in the medical and should be clear and concise, record simple descriptions of the pertinent involves evidence degradation from fungal or fungal from degradation evidence growth. bacterial turned over to legal authorities per hospital legal to turned over Plastic bags should be avoided, protocols. cause and may moisture as these retain be placed into separate paper bags, labeled separate into be placed initials of and date, with patient identifiers, and the items, who collected the person residue and other important evidence residue of Each item the investigation. for necessary clothing and belongings should the patient’s requires cutting clothing off a patient. When requires or defects cutting through avoid possible, gunshot contain may holes, as this area such as metal, glass, paint, and wood. paint, and wood. such as metal, glass, simple requires of evidence Preservation of the Removal and some forethought. steps often bay clothing in the trauma patient’s trauma patients include clothing, bullets, patients trauma bloodstains, weapons, impaled shrapnel, of other material and fragments fibers, hairs, The types of physical evidence that may evidence of physical types The of caring for in the course be encountered Protocols for Collecting and Collecting for Protocols Evidence Documenting Physical cases involving these patients, and appropriate documentation of the injuries, the care provided, and injuries, the care provided, the of documentation patients, these and appropriate cases involving regard. helpful this in obtained extremely is evidence medicine is a discipline that addresses both the legal the and addresses both medical that medicine a discipline is aspects care. Physicians patient of as injury injuries, the documenting for as well responsible are sustain who intentional caring patients for or criminal civil be in called testify upon may to Physicians evidence. andcollecting preserving potential training in the forensic aspects of trauma and may inadvertently discard or handle discard improperly necessary aspects inadvertently forensic and the in trauma may of training Clinical forensic or prosecution. can This hamper an in evidence. investigation legal the authorities care for patients who are victims of interpersonal violence. In addition to our responsibility to treat these treat to our responsibility to violence. In interpersonal addition of victims are who patients care for or no little have Most physicians evidence. forensic the preserve a duty to have patients,injured we by Louisby Alarcon, MD, and Jeffrey Nine, MD Emergency medical emergency service providers, and surgeons trauma medicine often physicians, Saving Lives and Lives Saving Trauma Forensics: Trauma

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, is medical , is medical Louis Alarcon, MD, MD, Alarcon, Louis FCCM FACS, of Trauma director at UPMC Surgery and Presbyterian of the co-director Blood Patient UPMC Management Program. Nine, MD Jeffrey forensic pathologist, forensic years 20 he has over chief of UPMC Autopsy Autopsy chief of UPMC and professor Services of pathology at the of Pittsburgh. University A board-certified experience working as a medical examiner as a medical working experience New jurisdictions including Arizona, in many and the West Pennsylvania, Ohio, Mexico, from degree medical his earned Nine Dr. Indies. Medicineof College NortheastUniversities Ohio in pathology at the his residency and completed Center. Health Sciences of Pittsburgh University in forensic his fellowship He also completed of the Medicalpathology at the Office Mexico. New Albuquerque, Investigator, He is also a professor in the department of He is also a professor Medicine at the Care and Critical Surgery School of Medicine. of Pittsburgh University from degree earned his medical Alarcon Dr. he also where of Pittsburgh, the University research residency, his surgical completed fellowship. care critical and surgical fellowship, Trauma Trauma

Ch 54. New York, McGraw-Hill, 2017. McGraw-Hill, York, Ch 54. New (8th edition), Aspects of Practical Gunshot Wounds: DiMaioVJ. 2nd ed. Techniques. Ballistics and Forensic Firearms, 1999. Press; FL: CRC Boca Raton, MA, Hanzlick RL. Forensic CH, Graham Wecht & Criminal Cases. 4th edition. in Civil Pathology Inc.; 2017. Juris Publishing, care of trauma patients should have an patients should have of trauma care medicine. of clinical forensic understanding departments Hospital and emergency manage to in place protocols should have In addition to evidence. forensic potential also have we lives, save to our responsibility and preserve collect to a responsibility evidence. forensic Reading Additional and the Medicine Trauma, SA. KL, Mitchell Mattox KL (ed): Mattox DV, EE, Feliciano in Moore Law, for the whereabouts of the evidence at all of the evidence whereabouts the for the legal to times, until it is turned over maintain a clear chain to authorities. Failure in a it inadmissible render may of evidence protocols have should Hospitals law. of court documenting and securing all for in place bodies, belongings, foreign Any such items. patient the from removed or bodily fluids evidence. potential should be considered Conclusion in the involved providers Health care forensic examination of the wound. Impaled of the wound. examination forensic during surgery removed are objects that same manner asshould be handled in the any avoid and to bullets, carefully retrieved or object. the weapon to damage extraneous of ain the possession found weapons Any a patient should be from patient or removed security. handled by in the handling ofAn important concept of the is the preservation evidence potential means accounting This chain of evidence. these injuries immediately if encountered. If if encountered. injuries immediately these or of knife the type documenting possible, pocket knife, butcher knife, object (serrated can aid in later etc.) arrow, rebar, knife,

Recovered bullet with rifling marks bullet with rifling marks — Recovered surgeon should be prepared to manage manage to should be prepared surgeon become active if the object is removed. The The if the object is removed. active become blood vessels or other organs. The embedded The or other organs. blood vessels tamponade bleeding, which may object may room. The object may have injured major injured have object may The room. Impaled knives or other foreign bodies in or other foreign Impaled knives in the operating should be removed general removed from. from. removed each bullet was found or the site it was or the site found each bullet was to authorities according to hospital policy. hospital policy. to authorities according to where should document physician The with patient identifiers, and turned over and turned with patient identifiers, Each bullet should be placed in a separate Each bullet should be placed which is labeled specimen container, gun from which it was shot (see Figure 2). Figure shot (see it was which gun from doing so may alter the rifling marks in the the rifling marks alter doing so may soft identify the be used to metal that can should not be used to handle bullets, asshould not be used to hand or 4”x4” gauze should be used to hand or 4”x4” gauze Metal instruments body. handle the foreign without damaging or deforming. A gloved A gloved without damaging or deforming. and accessible, not simply for forensic forensic not simply for and accessible, objects should be removed These reasons. patient may be important physical evidence, evidence, be important physical patient may if clinically indicated but should be removed Bullets and other projectiles embedded in a Bullets and other projectiles in the procedure reports. in the procedure wounds, this should be clearly documented wounds, if surgical instruments (sutures, clamps, instruments (sutures, if surgical skin the altered have etc.) retractors, before it was altered should occur. Likewise, Likewise, should occur. altered it was before important forensic evidence that can easily be evidence important forensic precautions. surgical without proper damaged Figure 2: Figure Trauma Care for Blunt Cerebrovascular Injuries

by Shelley Reynolds-Hill, MD, and Lindsey Roach, DO

Defined as any traumatic injury to the carotid or vertebral arteries as a result of non-penetrating trauma,1 blunt cerebrovascular injuries (BCVIs) carry true risks for neurologic morbidity and mortality. Once thought to be rare injuries occurring in approximately 0.1% of all trauma patients, the incidence is now known to be anywhere from 1.0-2.7%, thanks to increased awareness and the development of screening and treatment protocols.2-4 Despite this increase in awareness and the development of practice management guidelines for screening and treatment from both the Eastern Association for the Surgery of Trauma (EAST) and the Western Trauma Association (WTA), there is some controversy in the trauma literature regarding which patients to screen and how best to treat them.

Screening for Blunt tests, reported as up to 45-47% in one Treatment of BCVI series.1 As CT technology has improved, so Cerebrovascular Injuries Treatment of BCVI depends upon the grade has the sensitivity of CTA for BCVI. Injury The incidence of cerebrovascular injuries of the injury. Injuries are graded on a scale of detection rates are improved with the use has been reported in 15-25% of penetrating I to V according to the Biffl criteria, ranging of scanners that capture 64 or more slices neck injuries and up to 2.7% of blunt head from mild intimal injuries or irregularities per rotation, as well as when the test is and neck trauma injuries.5 It is important to to vessel transection, with risk of stroke | 6 | TRAUMA ROUNDS | ROUNDS | 6 TRAUMA read by an experienced neuroradiologist. recognize these injuries, as failure to identify increasing with increasing severity of injury.2 The major benefits of CTA include wider and treat BCVIs in asymptomatic patients Grade I injuries include mild intimal injuries availability, speed, decreased invasiveness, results in an increased risk of a neurologic or irregularities; grade II injuries occur and ability to be read remotely by an ischemic event. The risk of developing a when dissection with raised intimal flap/or offsite neuroradiologist. There are several significant neurologic deficit in a previously intramural hematoma result in >25% acknowledged risks of DSA including, but asymptomatic patient with an untreated luminal narrowing or intraluminal thrombosis. not limited to, complications related to BCVI is thought to be highest in the first 10 Grade III injuries include pseudoaneurysms; catheter insertion (incidence of 1-2%), to 72 hours after injury, so timely evaluation grade IV, vessel occlusion or thrombosis; contrast reactions including kidney injury and management is essential.5 Stroke rates and grade V, vessel transection.2 Grade I-II and anaphylaxis (1-2%), or cerebrovascular of up to 15% for vertebral injuries and 30- injuries can be treated with anticoagulation accident (CVA) resulting from thrombo­ 40% for carotid injuries have been reported.1 or antiplatelet therapy alone and may heal emboli from the procedure itself.2 Stroke resulting from BCVI carries a spontaneously, while grade III and IV injuries significant morbidity and mortality risk, sometimes require endovascular or surgical BCVI Screening Protocols 58% and 33%, respectively.3 If the injury treatment. Grade V injuries always require is diagnosed after symptoms appear, Despite the high morbidity and mortality, intervention if not immediately lethal. WTA neurologic morbidity increases to 80% and choosing which patients to screen remains recommends full anticoagulation for grades mortality to 40%.6 Early screening for these somewhat controversial. According to the I-IV for the first seven to 10 days after detec­ injuries and treating appropriate patients can EAST practice management guideline, there tion if able to be followed by repeat CTA. significantly reduce the risk of stroke. is no Level 1 evidence to support specific risk Heparin is preferred in the acute setting due factors that should result in screening. In to easy reversibility for patients at high risk While digital subtraction angiography general, risk of BCVI increases with trauma for bleeding. Grade I and II injuries may heal (DSA), which provides an image of blood mechanisms associated with hyperextension, within that timeframe and anticoagulation vessels in the brain, was the gold standard exaggerated rotation, or hyperflexion of may be able to be discontinued. for detection of BCVI, there is concern the cervical spine as well as direct blows 6 regarding its availability and invasiveness. to the neck. If the injury is stable, treatment is antiplatelet Because of this, screening protocols have therapy for three months, followed by a When a screening protocol is put into practice, been developed replacing DSA with surveillance CTA. If the injury progresses the detection of these injuries increases computed tomography angiography (CTA). to >75% luminal narrowing or a pseudo­ 10-fold.6 The 2016 updated Denver Health There was initially concern due to a high rate aneurysm remains, endovascular therapy Medical Center BCVI screening guideline4 of false negative tests in CTA studies, but should be considered at that time. The more recent studies have shown that there recommends screening asymptomatic seems to be a higher rate of false positive patients using the criteria shown in Table 1. CTA is the preferred screening modality. SPRING 2019 | 7 | UPMC TRAUMA CARE SYSTEM |

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The

Journal (2016) , joined UPMC , joined UPMC 172:27-30. (2018). 172:27-30. 24(4): 456-461. 456-461. 24(4): Shelley B. Reynolds- Shelley Hill, MD Hamot in October as a Trauma 2018 physician. attending Hill earned her Dr. from degree medical University Virginia West DO K. Roach, Lindsey attending is a Trauma at UPMC physician Roach Hamot. Dr. her general completed and residency surgery earned her medical Philadelphia from degree 128:1642-1647 (Jun. 2018). (Jun. 128:1642-1647 cademic Radiology. Radiology. cademic The American Journal of Surgery of Surgery Journal American The 68(2): 471-477. (Feb. 2010). (Feb. 68(2): 471-477. The Journal of TRAUMA Injury, Infection, and Critical Infection, Injury, Journal of TRAUMA The Care. Grandhi, Ramesh, et al. “Limitations of Multidetector Ramesh, Grandhi, the for Angiography Tomography Computed Injury.” Blunt Cerebrovascular Diagnosis of of Neurosurgery. Association Trauma L., et al. “Western Biffl, Walter and for Screening Critical Decisions in Trauma: Injuries.” of Blunt Cerebrovascular Treatment Care. and Critical Infection, Injury, Journal of TRAUMA (Dec. 2009). 1150-1153. 67(6): in Use of High-Risk Criteria et al. “The Xiao, Wu, Injury: Blunt Cerebrovascular for Patients Screening A A Survey.” 2017). (Apr. for criteria screening Geddes AE, et al. Expanded impact than a bigger injury: blunt cerebrovascular anticipated. 212, 1167-1174. Angiography of CT et al. “Utility Hilary L.P., Orlowski, Injury.” Cerebrovascular Traumatic for in Screening and Neurosurgery. Neurology Clinical et al. “Blunt Cerebrovascular J., William Bromberg, The Guidelines: Management Injury Practice of Trauma.” the Surgery for Association Eastern

College of Osteopathic Medicine. She of Osteopathic College fellowship care critical her surgical completed Health System. at Christiana Care School of Medicine, where she also completed she also completed School of Medicine, where she Additionally, residency. surgery her general fellowship care critical a surgical completed of Michigan. at the University References 1 2 3 4 5 6

4 and mortality from neurologic ischemic neurologic from and mortality to of a protocol and implementation events, ­ develop patients prior to identify high-risk reduce significantly may ment of symptoms the gold remains this risk. While DSA diagnosis of BCVI, definitive for standard is the screening CTA or greater 64-slice can be and most injuries of choice, modality alone. of CTA based on the results managed cases or in equivocal useful remains DSA is required. intervention when endovascular Conclusion cerebrovascular undetected In general, morbidity a substantial risk of injuries carry Vol. 212, 1167-74. Geddes AE, Burlew CC, Wagenaar AE, Wagenaar CC, Geddes AE, Burlew 212, 1167-74. Vol. TBI with thoracic injuries TBI with thoracic Scalp degloving injuries vascular Thoracic rupture Blunt cardiac Upper rib fractures High-energy transfer mechanism transfer High-energy II or III) (LeFort fracture mid-face Displaced Mandible fracture fracture/occipital skull fracture/basilar skull Complex injury (TBI) with GCS <6 brain traumatic Severe injury or ligamentous subluxation spine fracture, Cervical injury brain Near hanging with anoxic with significant injury or seat belt abrasion Clothesline-type Focal neurologic defect: transient ischemic attack (TIA), transient defect: neurologic Focal condyle fracture condyle level at any mental status pain, or altered swelling, hemiparesis, vertebrobasilar symptoms, Horner’s syndrome Horner’s symptoms, vertebrobasilar hemiparesis, •  •  •  •  •  •  •  •  •  •  •  •  •  • Potential arterial hemorrhage from neck/nose/mouth from arterial hemorrhage • Potential old bruit in patient <50 years • Cervical hematoma • Expanding cervical •  CT with head deficit inconsistent • Neurologic or MRI on CT • Stroke

2 The American Journal of Surgery, Journal of Surgery, American The but in practice, low-grade injuries low-grade but in practice, 6 Updated Denver BCVI Screening Guideline (2016). Screening BCVI Denver Updated Risk Factors for BCVI for Risk Factors Signs/Symptoms of BCVI Signs/Symptoms Biffl WL, Johnson JL, Pieracci FM, Campion EM, Moore EE, "Expanded screening criteria for blunt criteria EE, "Expanded screening FM, Campion EM, Moore Pieracci Biffl WL, Johnson JL, Elsevier. from permission with (2016), Copyright anticipated." than impact bigger a injury: cerebrovascular Reprinted from from Reprinted Table 1: Table patients who are able to be anticoagulated be anticoagulated able to patients who are after detection. ischemia drops from 21% to 0.53% in 0.53% 21% to from ischemia drops have concomitant injuries, which preclude injuries, which preclude concomitant have but the risk of cerebral full anticoagulation, It is notable that several of these patients It is notable that several likely to be treated with endovascular with endovascular be treated to likely antithrombotics. with conjunction in stenting alone while grade III and IV injuries are more more and IV injuries are III grade alone while detection, anticoagulation with managed generally are extracranial and accessible injuries should injuries and accessible extracranial at the initial surgery for be considered WTA suggests that all grade II or above II or above all grade that suggests WTA Nonprofit Org. U.S. Postage PAID 200 Lothrop St. Pittsburgh, PA Pittsburgh, PA 15213-2582 Permit No. 3834

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THE UPMC TRAUMA CARE SYSTEM Trauma Rounds is published for • UPMC Presbyterian, Level I • UPMC Hamot​, Level II emergency medicine and trauma professionals by UPMC. • UPMC Mercy, Level I and Burn Center • UPMC Altoona, Level II • UPMC Children’s Hospital of Pittsburgh, Executive Editor Level I Pediatric Andrew B. Peitzman, MD, FACS

Editor Louis Alarcon, MD, FACS, FCCM UPMC MedCall — 412-647-7000 or 1-800-544-2500 24-hour emergency consultation, referral, and transport arrangements Senior Outreach Liaison, Physician Services Division Cynthia A. Snyder, MHSA - NREMT-P, CONTINUING EDUCATION CCEMT-P, FP-C Trauma Rounds is published for For EMS Providers emergency medicine and trauma Instructions: For EMS Providers Director, Prehospital Care Instructions To take a Pennsylvania Department of Health-accredited professionals by UPMC. UPMC prints Trauma Rounds with an eye toward helping Myron Rickens, EMT-P UPMC prints Trauma Rounds with an eye toward helping emergency To continuingtake a Pennsylvania education Department test for one ofhour Health-accredited of credit for FR and EMT-B, emergency medicine professionals improve their preparedness continuing education test for one hour of credit for FR and EMT-B, medicine professionals improve their preparedness and practice. EMT-P, and PHRN, visit UPMC.com/TraumaRounds. Executive Editor and practice. EMT-P, and PHRN, visit UPMC.com/TraumaRounds. Managing Editor UPMC Prehospital Care also hosts numerous continuing education Andrew B. Peitzman, MD, FACS For Physicians, APPs, and Nurses Diana Carbonell For Physicians, APPs, and Nurses UPMCclasses Prehospital in western Care Pennsylvania. also hosts numerous For a full, up-to-datecontinuing calendareducation and Please see front cover for details on CME credit from the Please see page 1 for details on CME credit from the Accreditation classesonline in registration, western Pennsylvania. visit UPMC.com/PrehospitalClasses For a full, up-to-date calendar. and Editor Accreditation Council for Continuing Medical Education (ACCME). Council for Continuing Medical Education (ACCME). online registration, visit UPMC.com/PrehospitalClasses. Louis Alarcon, MD, FACS, FCCM

Course Name Date(s) Contact Senior Outreach Liaison, Advanced Trauma Life Support at Full Course: April 22–23, 2019 Stephanie Livingston Physician Services Division UPMC Presbyterian Recertification: April 23, 2019 [email protected], 412-647-6165 Cynthia A. Snyder, MHSA - NREMT-P, Full Course: September 12–13, 2019 CCEMT-P, FP-C Recertification: September 13, 2019 Full Course: December 5–6, 2019 Director, Prehospital Care Recertification: December 6, 2019 Myron Rickens, EMT-P Advanced Trauma Life Support at Full Course: June 24–25, 2019 Anna Murray UPMC Mercy Recertification: June 25, 2019 [email protected], 412-232-7178 Managing Editor Diana Carbonell Advanced Trauma Life Support at Full Course: August 1–2, 2019 Sarah Mattocks UPMC Hamot Recertification: August 2, 2019 [email protected], 814-877-5687 ® Full Course: December 4–5, 2019 Recertification: December 5, 2019 Critical Care Transport 1-800-633-7828 Advanced Trauma Life Support at Full Course: May 2–3, 2019 Amy Stayer UPMC Altoona Recertification: May 3, 2019 [email protected], 814-889-6098 UPMC is a member of the Center John M. Templeton Jr. Pediatric Friday, March 1, 2019 – templetontrauma.org for Emergency Medicine of Western Trauma Symposium Saturday, March 2, 2019 Pennsylvania, Inc.

A $19A $14 billion billion world-renowned world-renowned health health care care provider provider and and insurer, insurer, Pittsburgh-based Pittsburgh-based UPMC UPMC is inventingis inventing new new models models of patient-centered,of patient-centered, cost-effective, cost-effective, accountable accountable Critical Care Transport care.care. UPMC UPMC provides provides more nearly than $900 $900 million million a ayear year in in benefits benefits to to its its communities, communities, including including moremore care care to to the the region’s region’s mostmost vulnerable vulnerable citizens citizens than than any any other other health healthcare careinstitution. institution. The Thelargest largest nongovernmental nongovernmental employer employer in Pennsylvania, in Pennsylvania, UPMC UPMC integrates integrates 65,000 87,000 employees, employees, more 40 than hospitals, 25 hospitals, 700 doctors’ 600 doctors’ offices offices and 1-800-633-7828 outpatientand outpatient sites, and sites, a 3.5 and million-member a 3.2 million-member Insurance Insurance Services Services Division, Division, the largest the largest medical medical insurer and in western behavioral Pennsylvania. health services As UPMC insurer works in western in close Pennsylvania. collaboration with the University of Pittsburgh Schools of the Health Sciences, U.S. News & World Report consistently ranks UPMC Presbyterian Shadyside on its annual Honor Affiliated with the University of Pittsburgh Schools of the Health Sciences, UPMC ranks No. 12 in the prestigious U.S. News & World Report annual Honor Roll UPMC is a member of the Center Rollof of America’s America’s Best Best Hospitals. Hospitals. UPMC UPMC Enterprises Enterprises functions functions as as the the innovation innovation and and commercialization commercialization arm arm of of UPMC, UPMC, while and UPMC International provides hands-on SYS510226 DC/SM 2/19 © 2019 UPMC healthhealth care care and and management management services services with with partners partners around in 12 countriesthe world. on For four more continents. information, For morego to UPMC.com.information, go to UPMC.com. for Emergency Medicine of Western Pennsylvania, Inc. UPMC MedCall — 412-647-7000 or 1-800-544-2500 24-hour emergency consultation, referral, and transport arrangements SYS504323 QD/DC 5/17 © 2017 UPMC