Making Matters Worse: Iatrogenic Injuries / Complications During Resuscitation

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Making Matters WorseIatrogenic Injuries /
Complications During Resuscitation

• Scott R. Petersen, MD, FACS
• St. Josephs Hospital and Medical Center
• Phoenix, Arizona

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DOCTORS ARE THE THIRD LEADING CAUSE OF DEATH IN
THE U.S., CAUSING 250,000 DEATHS EVERY 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 Ages transmitted orally
• Thomas Sydenham (1624-1689),
• English Physician
• Common use in U.S. since 1880
• Potent reminder that every medical decision can
  harm the patient

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• Iatrogenesis
• Unfavorable response to medical treatment that is
  induced by the therapeutic 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 study 14 fatality
  rate
• Estimates 180,000 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 mail 16,000 lost pieces / hour
• Banking 32,000 checks deducted from wrong
  account/hour

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Iatrogenesis

• Acts of Commission vs. Acts of Omission
• Study Described errors (acts or omissions in
  which the physicians felt responsible
• 53 errors
• 4 (7.5) malpractice suits
• 30 missed diagnoses
• 8 cancers, 5 trauma, 5 AMI, 4 SBO, 3 meningitis,
  4 others
• 11 surgical mishaps (9 OB)
• 8 medical treatment (drug administration)
• Patient safety should remain focused on potential
  causes of iatrogenic injuries and their
  prevention

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Public Suggestions on Iatrogenesis

• Survey 1,207 adults (telephone)
• Reducing preventable medical errors that result
  in harm
• Giving doctors more time to spend with patients
  78 very effective
• Requiring hospitals to develop systems to avoid
  medical errors 74
• Better training health care professionals 73
• Using only doctors trained in ICU medicine 73
• Requiring hospitals to report all serious medical
  errors- 71
• Increasing the number of nurses 69
• Reducing work-hours of doctors in training 66
• Encouraging voluntary hospital reporting of
  errors 62

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Iatrogenesis

• We need to fundamentally change the way we think
  about errors and why they occur
• Leape LL, JAMA 1994

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Preventable Deaths1991-2004

• Total patients 35,482
• Total deaths 2,216 (6.2)
• Possibly Preventable/Preventable 73
• 3.3 of all deaths

St. Josephs Hospital and Medical Center,
Phoenix, AZ
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Preventable Deaths1991-2004
Number of Deaths
Other
Delay to OR
Prehospital
Quality issues
Technical errors
Delay/Missed Dx
Errors in Judgment
Inadequate resuscitation /monitoring
St. Josephs Hospital and Medical Center,
Phoenix, AZ
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Iatrogenic Complications in Trauma
Preventable deaths Prehospital Errors

• 8.2 overall
• Failure to intubate
• Esophageal intubation
• Technical errors/cricothyroidotomy
• Inability to intubate RSI
• Aspiration with LMA, oral airways

Universally due to failure to appropriately
manage the airway!
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Preventable Deaths1991-2004
Number of Deaths
Other
Delay to OR
Prehospital
Quality issues
Technical errors
Delay/Missed Dx
Errors in Judgment
Inadequate resuscitation /monitoring
St. Josephs Hospital and Medical Center,
Phoenix, AZ
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Preventable DeathsSan Diego Trauma System
n76/1295 deaths (5.9)
Resuscitation Phase
Operative Phase
Critical Care Phase
Davis JW, et al J Trauma 1992 32 660-666.
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Errors in Trauma SystemSan Diego Trauma System
n1032 errors / 22,577 patients 4.5 overall
Resuscitation Phase
Operative Phase
Critical Care 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 overload
• Hypothermia
• Failure to splint control hemorrhage delays
  missed injuries
• Delays / errors in interpretation
• ADEs
• Lines, tubes, drains
• (LTDs)

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Iatrogenic Injuries and Resuscitation Primary
Survey

• Failure to recognize
• Upper airway obstruction
• Tension pneumothorax
• Massive hemothorax
• Open pneumothorax
• Cardiac tamponade
• Flail Chest
• All can lead to cardiopulmonary arrest in the
  trauma room

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Value of Intubating Patients with Suspected Head
Injury

• AVOID HYPOXIA!
• RSI Succinylcholine (1 mg/kg)
• Obtunded
• Head injury (GCS lt 10)
• Shock
• Drugs, ETOH,
• Pitfalls
• Perform a rapid neurologic examination 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 or others, interfere with diagnostic
  imaging (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 dressings
• Pitfalls
• Delay in getting a bleeding patient to the
  operating room for definitive control

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Iatrogenic Complications During Resuscitation

• 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 for resuscitation can
  contribute to acidosis

J 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 becomes and 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 midline spine tenderness
• LIBERAL use of CT (entire cervical spine)
• Clinical clearance only with Trivial Mechanisms
• 15 incidence of additional Fxs in either
  cervical, thoracic or lumbar spine.

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Clinical Clearance - Cervical Spine

• Blunt Trauma
• Patient alert and oriented
• NO distracting injuries
• NO ETOH, drugs, medications
• NO spinal / neurological deficits
• NO neck pain
• NO midline neck tenderness
• Trivial Mechanism

Modified after Hoffman, et al N Engl J Med
2000 343 94-97.
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Bypassing C-Spine Radiographsin Acutely Injured
Patients

• CSR will miss 15 of C-spine Fx
• CT much more sensitive (1-0.4)
• CSR must be perfect if obtained
• May miss obvious injury if skipped

Sanchez, et al J Trauma 2005 59 197-183.
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Cervical Spine Clearance Protocol
Compliance ()
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Iatrogenic ComplicationsDiagnosis

• Abdominal Trauma
• DPL - 0.5 injuries 6-8 negative
  laparotomies
• 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
• Gastrograffin risk of aspiration poor detail
• Barium adjuvant to abscess formation
• Iodinated Intravenous Contrast
• Nephrotoxicity dose related,
• hypovolemia, sepsis, diabetes, antibiotics
  Prevent with IV hydration, NaHCO3,
  acetylcysteine Visipaque Gadolinium (NSF)
• Allergy rash, shellfish allergy serious
  reaction 0.22 (hypotension, dyspnea, cardiac
  arrest
• Local Extravasation compartment syndrome
• Air Embolism power injectors, CTA

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Filmless RadiologyPotential Problems
/Misinterpretations

• Inadequate, inexpensive monitors
• High ambient light in trauma room
• Image misinterpretation / subtle findings

Communication between radiologists 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
• lt 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 the treatment of hypovolemia
• Maybe? w/ neurogenic shock
• Neurogenic shock Rx
• Initial Rx volume expansion
• Bradycardia Rx atropine
• Monitoring CVP, PA catheter
• Vasopressors dopamine, neo
• Keep MAP gt 80

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Lines, Tubes, Drains (LTD)

• Common source of iatrogenic complications
• 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 in vicinity
  lung, vessels, brachial plexus, thoracic duct,
  etc.

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Complications related to central venous 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 lt IJ lt Femoral
• AVOID problems
• Use Trendelenbergs position
• Follow placement with CXR
• Pull lines placed in resuscitation area _at_ 24
  hours
• Use side of chest tube /injury

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High Risk LTDS during resuscitation(other)

• Prehospital All!!
• RSI, cricothyroidotomy, needle thoracostomy, CVP
  lines, tube thoracostomy, Sternal I/O
• Cricothyroidotomy
• ED physicians 36 complication rate
• Tube thoracostomy
• Extrathoracic placement
• Hemorrhage
• Diaphragm injury, lung,
• liver, spleen, stomach

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Chest Trocars

• Blind placement has been associated with injury
  to every intrathoracic organ and many
  intraabdominal ones
• Hazard even greater if traumatic diaphragmatic
  hernia is present
• Avoid by performing digital exploration of
  pleural space

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High Risk LTDS during resuscitation(other)

• Urethral catheter
• Blood at urethral meatus
• Severe pelvic Fx
• High-riding prostate
• Large perineal hematoma
• 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-mediated immunomodulation

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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 to missed injuries
• Study in Arizona
• Trauma and malpractice claims
• Nontrauma hospitals / outpatient facilities - 78
• Level I trauma centers 22

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 clear the
  spine
• CT can be a dangerous place!
• Treatment of obvious arterial injuries should not
  be delayed for unnecessary arteriography
• Repeat the physical exam at intervals
• The Tertiary Survey
• DO NOT use vasopressors in hemorrhagic shock
• The treatment of hemorrhage is hemostasis
• Sometimes, the treatment of hemorrhage must
  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 to
accidentally kill you than gun owners?

• Number physicians in U.S. 700,000
• Accidental deaths caused by physicians/year
  120,000
• Accidental deaths/physcian/year 0.071
• Number of gun owners 80,000,000
• Number of accidental gun deaths 1,500
• Accidental deaths/gun owner 0.000018
• Therefore Doctors are 9000 X more
  dangerous than gun owners