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Making Matters Worse: Iatrogenic Injuries / Complications During Resuscitation. Scott R. Petersen, MD, FACS St. Joseph’s Hospital and Medical Center Phoenix, Arizona. DOCTORS ARE THE THIRD LEADING CAUSE OF DEATH IN THE U.S., CAUSING 250,000 DEATHS EVERY YEAR. Deaths per year

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Making matters worse iatrogenic injuries complications during resuscitation l.jpg

Making Matters Worse:Iatrogenic Injuries / Complications During Resuscitation

Scott R. Petersen, MD, FACS

St. Joseph’s Hospital and Medical Center

Phoenix, Arizona


Doctors are the third leading cause of death in the u s causing 250 000 deaths every year l.jpg
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 ADE’s

      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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Pandora’s 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 O’Hare/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. Joseph’s Hospital and Medical Center, Phoenix, AZ


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Causes of Preventable Deaths

n = 73 / 2,216 (3.3%)

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. Joseph’s Hospital and Medical Center, Phoenix, AZ


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Iatrogenic Complications in Trauma

8.2% overall

Failure 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 the airway!


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Causes of Preventable Deaths

n = 73 / 2,216 (3.3%)

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. Joseph’s Hospital and Medical Center, Phoenix, AZ


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Preventable DeathsSan Diego Trauma System n=76/1295 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 n=1032 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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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

ADE’s

Lines, tubes, drains

(LTD’s)

Iatrogenic Injuries and Resuscitation


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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 < 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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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


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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


  • Filmless radiology potential problems misinterpretations l.jpg
    “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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    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

    Adverse Drug Events (ADE)Resuscitation


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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 > 80


    Lines tubes drains ltd l.jpg
    “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 < IJ < Femoral

  • AVOID problems:

    • Use Trendelenberg’s 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 LTD’S 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 LTD’S 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


  • Missed injuries the trauma surgeon s nemesis l.jpg
    Missed Injuries – The Trauma Surgeon’s 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

      • Don’t make the same mistake twice

  • It happens!!

    • Even in the best of hands


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    Petersen’s 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


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