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Making Matters Worse: Iatrogenic Injuries / Complications During Resuscitation

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Iatrogenic Injuries / Complications During Resuscitation. Scott R. Petersen, MD, FACS ... Iatrogenic errors. Probing wound may dislodge clots and disrupt hematomas ... – PowerPoint PPT presentation

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Title: Making Matters Worse: Iatrogenic Injuries / Complications During Resuscitation


1
Making Matters Worse Iatrogenic Injuries /
Complications During Resuscitation
  • Scott R. Petersen, MD, FACS
  • St. Josephs Hospital and Medical Center
  • Phoenix, Arizona

2
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
3
  • Principle of Medicine
  • PRIMUM NON NOCERE
  • First do no harm
  • Hippocrates

4
  • 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

5
  • 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.
6
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
7
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

8
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

9
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

10
Iatrogenesis
  • We need to fundamentally change the way we think
    about errors and why they occur
  • Leape LL, JAMA 1994

11
Preventable Deaths 1991-2004
  • 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
12
Preventable Deaths 1991-2004
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
13
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!
14
Preventable Deaths 1991-2004
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
15
Preventable Deaths San 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.
16
Errors in Trauma System San 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.
17
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)

18
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

19
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.
20
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 !!
21
AGITATION HYPOXIA Intubation NOT Medication
22
Circulation Controlling 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

23
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
24
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

25
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
26
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.

27
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.
28
Bypassing C-Spine Radiographs in 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.
29
Cervical Spine Clearance Protocol
Compliance ()
30
Iatrogenic Complications Diagnosis
  • 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
31
Iatrogenesis Diagnostic 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

32
Filmless Radiology Potential Problems
/Misinterpretations
  • Inadequate, inexpensive monitors
  • High ambient light in trauma room
  • Image misinterpretation / subtle findings

Communication between radiologists and surgeons
33
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

34
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

35
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.

36
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

37
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

38
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

39
High Risk LTDS during resuscitation (other)
  • Urethral catheter
  • Blood at urethral meatus
  • Severe pelvic Fx
  • High-riding prostate
  • Large perineal hematoma
  • Nasogastric tube

40
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

41
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.

42
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.
43
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

44
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

45
Remember ..
W. Rohlfing MD, FACS, San Francisco, 1975
46
(No Transcript)
47
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
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