Intriguing research findings suggest there may be a place for a new type of activation and response for patients who exhibit both symptoms of stroke and trauma.

Such an approach, called STRAUMA, has been in use at UCHealth Memorial Hospital in Colorado Springs, CO, since 2018. In data presented at the virtual American College of Surgeons Clinical Congress in October 2021, investigators reported the novel approach is safe, feasible, and guards against the potential for catastrophic bleeding in cases where stroke treatment is provided prior to a thorough trauma review.1,2 “[The STRAUMA activation] was developed after we noted several cases where a patient had a delay in either stroke or trauma care,” explains Janet Lee, MD, the lead author of the research and a fourth-year surgical resident at UCHealth Memorial. “One of our index cases involved a patient who arrived after developing stroke-like symptoms while speaking to law enforcement following a motor vehicle accident.”

In that case, only the stoke alert was called, and the patient received IV tissue plasminogen activator (tPA) before trauma scans were reviewed. This can be a dangerous situation because tPA is contraindicated in patients with bleeding risks, such as in the case of head trauma or intra-abdominal injuries. To ensure such cases are handled appropriately, researchers designed STRAUMA specifically for patients who exhibit symptoms of stroke and show visible signs of trauma. Typically, EMS activates the protocol, but other emergency providers can call for it after an appropriate patient has presented to the ED. An activation pages stroke and trauma teams to respond so they can evaluate the patient jointly.

For example, when EMS activates STRAUMA, ED providers are ready to receive such patients, along with a neurologist and a trauma team. “The trauma team and the ED team will quickly evaluate the patient to see if there is any risk of bleeding,” Lee observes. “We do a chest X-ray, and then if we have real concerns for trauma the patient gets a CT scan expeditiously, and they undergo a neurologic exam.”

However, considering time to treatment is such a critical issue in the case of stroke, Lee and colleagues wanted to determine whether this joint evaluation process interferes with expeditious treatment. In a retrospective review, they studied the medical records of 580 patients who had triggered either a stroke or STRAUMA activation within 15 minutes of arrival to the ED at UCHealth Memorial, a level I trauma center and a comprehensive stroke center, between January 2019 and September 2020. Among the participants, 111 triggered STRAUMA and 469 triggered a stroke activation. Although patients receiving stroke alerts experienced a shorter time-to-CT scan, there was no observed difference between the groups in time-to-tPA or time-to-thrombectomy. Specifically, the time-to-CT scan for stroke alert patients was 17 minutes vs. 23 minutes for the STRAUMA patients. Following a multivariable analysis, investigators also concluded the STRAUMA activation did not increase the risk of mortality.

Lee observes that while the STRAUMA activation added six minutes to the process overall, the risk of patients with trauma receiving clot-busting drugs and experiencing catastrophic bleeding outweighs the slight delay in receiving CT scans, considering there were no differences between the two groups in time to treatment. “Our study showed that utilizing the STRAUMA protocol is safe and feasible,” Lee says.

The STRAUMA protocol was fine-tuned in 2020. Before that change, a STRAUMA activation could be called just on a suspicion of trauma. However, investigators found too many STRAUMA activations were called. “Essentially, we were just overtriaging ... and we found that no patients had an injury severity score greater than 9 without signs of trauma,” Lee says.

Consequently, the protocol changed so STRAUMA activations are appropriate only in cases where the patient exhibits stroke symptoms and visible signs of trauma. “The [STRAUMA] activation mobilizes a lot of people ... and, of course, we want to minimize undertriage, but overtriage can also become an issue with resource utilization,” Lee says.

Currently, the ED at UCHealth Memorial handles about two STRAUMA activations every week, or about 80 per year. Lee anticipates additional studies and more data will be forthcoming.

“For us to develop this protocol, we had participation not only from the trauma team, but also the ED and the neurology department,” Lee explains. “Having that collaboration is very important, and continuing to monitor for volume, compliance, and other metrics is important as well to improve the protocol.”

REFERENCES

  1. American College of Surgeons. Patients with stroke symptoms are evaluated safely for both stroke and trauma with new “STRAUMA activation.” Oct. 23, 2021.
  2. Lee JS, Finch H, Higa K, et al. Strauma alert: A novel alert system for a combined stroke and trauma. Scientific Forum presentation. American College of Surgeons Clinical Congress 2021.