The Trauma Professional's Blog

Pediatric Trauma Case

Tue, 22 May 2012 08:47:38 -0500

Here’s an interesting pediatric trauma case to test your skills. A 10 year old boy was playing tag on the playground at school. He ran head-on into another player, chest to chest. Neither child struck their head.

When the boy arrived home after school, he coughed up some blood. This freaked his mother out, who brought him to your ED for evaluation. He continues to cough up thin, bloody sputum occasionally.

How do you approach this problem? What diagnostic tests do you need? What do you think the diagnosis is? How do you treat, and does he need to be admitted?

Tweet, email or send your comments below. I’ll compile and discuss the replies, and reveal what I think is the correct diagnostic and management sequence.

Source: hypothetical case. Not treated at Regions Hospital.

Trauma Triage Guidelines: There's An App For That!

Mon, 21 May 2012 09:28:42 -0500

The CDC released an iPhone app covering the Field Triage Guidelines for Injured Patients a few months ago. It’s not received much attention, but could be helpful for some trauma professionals.

The app consists of 2 components: a copy of the triage guidelines pocket card, and a quiz about the use and impact of the guidelines. The app is pretty bare-bones, but is a convenient way to keep the guidelines available for immediate reference. It doesn’t look like it’s available for Android yet.

Click the link below to go to the Apple App Store for more information or to download.

Part 2: FAST Is Fast And FAST Is Last

Fri, 18 May 2012 08:49:24 -0500

I’ve received a fair amount of commentary on Twitter and via email regarding my statements about FAST. Many people said that FAST and physical exam can and should happen simultaneously.

In principle, I agree. My previous statements were based on the way that we organize our trauma team and trauma activations at this hospital. The reality is that everyone’s team is different and they may run their trauma activations differently.

The goal is to get all information critical to keeping your patient alive as quickly as possible. In some cases, knowing if there is a significant amount of fluid in the abdomen can be very important. Most trauma resuscitation schemes at trauma centers make use of multiple personnel so that various portions of the patient evaluation can be carried out simultaneously.

But there is also a tradeoff between speed, trauma team size and number of trainees. Centers with fewer or no trainees will have a leaner team with experienced examiners and more room around the patient. At our hospital, we have 8 people clustered immediately around the patient, with half of them being surgery or emergency medicine residents. This means it is more difficult for a physician to step in and do a FAST exam easily. So typically, this physician is the same resident doing the torso portion of the physical exam. This is the main reason for my exhortation to wait until the end of the physical exam and do the FAST quickly.

So it is really up to each center to determine their priorities for the FAST exam based on the people who make up their trauma team. At ours, it will have to remain fast and last.

Please comment or tweet your thoughts!

DVT In Children

Thu, 17 May 2012 08:50:35 -0500

Deep venous thrombosis has been a problem in adult trauma patients for some time. Turns out, it’s a problem in injured children as well although much less common (<1%). However, the subset of kids admitted to the ICU for trauma have a much higher rate if not given prophylaxis (approx. 6%). Most trauma centers have protocols for chemical prophylaxis of adult patients, but not many have similar protocols for children.

The Medical College of Wisconsin looked at trends prior to and after implementation of a DVT protocol for patients < 19 years old. They used the following protocol to assess risk in patients admitted to the PICU and to determine what type of prophylaxis was warranted:

The need for and type of prophylaxis was balanced against the risk for significant bleeding, and this was accounted for in the protocol. The following significant findings were noted:

The overall incidence of DVT decreased significantly (65%) after the protocol was introduced, from 5.2% to 1.8%
The 1.8% incidence after protocol use is still higher than most other non-trauma pediatric populations
After the protocol was used, all DVT was detected via screening. Suspicion based on clinical findings (edema, pain) only occurred pre-implementation.
Use of the protocol did not increase use of anticoagulation, it standardized management in pediatric patients

Bottom line: DVT does occur in injured children, particularly in severely injured ones who require admission to the ICU. Implementation of a regimented system of monitoring and prophylaxis decreases the overall DVT rate and standardizes care in this group of patients. This is another example of how the use of a well thought out protocol can benefit our patients and provide a more uniform way of managing them.

Related posts:

Reference: Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma 72(5):1292-1297, 2012.

Intracranial Hypertension In Pediatric Head Trauma This 44...

Wed, 16 May 2012 08:48:21 -0500

Intracranial Hypertension In Pediatric Head Trauma

This 44 minute video is a good introduction to pediatric head trauma and intracranial hypertension. It covers physiology, diagnosis, as well as management using medications, position, decompression and hypothermia.

Presented at Multidisciplinary Trauma Conference at Regions Hospital on May 3, 2012 by Debbie Song MD, a pediatric neurosurgeon.

How To Jerry Rig A Rapid Infusion System

Tue, 15 May 2012 08:42:36 -0500

Rapid infusion systems of some type are available in most EDs. However, this equipment is not routinely available in the field or in ground ambulances. Here’s a creative way to fashion one in a pinch for my overseas readers.

Note: The system described relies on an IV infusion set called the Intrafx SafeSet, available in Europe. The drip chamber in this set has a hydrophilic filter membrane integrated into the drip chamber that prevents air from passing through. This is critical for avoiding air embolism. Any product that traps air bubbles will work.

Here are the key components:

A - a fluid bottle with your choice of resuscitation fluid
B - an Intrafix SafeSet, or other drip chamber containing an air trap
C - another infusion set, spiked into A to pressurize it
D - a bulb from a sphygmomanometer for pressurizing A

Bottom line: This barebones, low cost rapid infuser can be used in hostile environments and can achieve rapid flow rates. But remember, the drip chamber (B) must be of an air-trapping type!

Reference: Novel rapid infusion device for patients in emergency situations. Scand J Trauma Resus Emerg Med 19:35, 2011.

FAST IS Fast, And FAST Is Last!

Mon, 14 May 2012 08:54:55 -0500

Ever been in a trauma activation where it seems like the first thing that happens is that someone steps up to the patient with the ultrasound probe in hand? And then it takes 5 minutes of pushing and prodding to get the exam done?

Well, it’s not supposed to be that way. The whole point of adhering to the usual ATLS protocol is to ensure that the patient stays alive through and well after your exam. And FAST is not part of the primary or secondary surveys, it is an adjunct.

As always, there are a few exceptions to the rule above.

If an unstable patient arrives without an obvious source of bleeding, FAST of the abdomen should be able to detect if a large hemoperitoneum is present. This will expedite the patient’s transfer to the OR.
A patient in cardiac arrest may benefit from a quick FAST to determine if cardiac activity is present. If not, it may be time to terminate resuscitation.

Bottom line: With the exceptions noted above, always complete the ATLS primary and secondary surveys first. Then pull out the ultrasound machine, but be quick about it. If it takes more than about 60 seconds to do the exam, someone probably needs a little more practice.

But The Radiologist Made Me Do It!

Fri, 11 May 2012 08:49:00 -0500

The radiologist made me order that (unnecessary) test! I’ve heard this excuse many, many times. Do these phrases look familiar?

… recommend clinical correlation
… correlation with CT may be of value
… recommend delayed CT imaging through the area
… may represent thymus vs thoracic aortic injury (in a 2 year old who fell down stairs)

Some trauma professionals will read the radiology report and then immediately order more xrays. Others will critically look at the report, the patient’s clinical status and mechanism of injury, and then decide they are not necessary. I am firmly in the latter camp.

But why do some just follow the rad’s suggestions? I believe there are two major camps:

Those that are afraid of being sued if they don’t do everything suggested, because they’ve done everything and shouldn’t miss the diagnosis
Those that don’t completely understand what is known about trauma mechanisms and injury and think the radiologist does

Bottom line: The radiologist is your consultant. While they are good at reading images, they do not know the nuances of trauma. Plus, they didn’t get to see the patient so they don’t have the full context for their read. First, talk to the rad so they know what happened to the patient and what you are looking for. Then critically look at their read. If the mechanism doesn’t support the diagnosis, or they are requesting unusual or unneeded studies, don’t get them! Just document your rationale clearly in the record. This provides best patient care, and minimizes the potential complications (and radiation exposure) from unnecessary tests.

Guidelines for consultants

Reference: Pitfalls of the vague radiology report. AJR 174(6):1511-1518, 2000.

Spine Clearance For Nurses This 11 minute video provides...

Thu, 10 May 2012 09:39:13 -0500

Spine Clearance For Nurses

This 11 minute video provides information on the cervical spine clearance process in awake patients, reviews activity restrictions associated with the use of cervical collars, and discusses information about specific type of collars. It is designed for ED nurses and non-ED nurses who may encounter cervical spine collars.

What The Heck? Answer! The patient was a 27 year old intoxicated...

Wed, 09 May 2012 08:53:19 -0500

What The Heck? Answer!

The patient was a 27 year old intoxicated male who was uncooperative with police in France. The offending object is a Taser dart, which was fired at him for control. The dart was not noticed when he was released from custody, and he later presented to hospital with a headache! The dart was removed by a neurosurgeon and he was discharged uneventfully a week later.

Reference: A brain penetration after Taser injury: controversies regarding Taser gun safety. Forensic Science International, ePub 21 April 2012 ahead of print.

What The Heck? What is the foreign object seen in this head CT?...

Tue, 08 May 2012 09:01:27 -0500

What The Heck?

What is the foreign object seen in this head CT? Hint: the patient has not been seen by a neurosurgeon. Yet.

Papers To Change Our Practice 3: Bio-Printing

Mon, 07 May 2012 09:01:45 -0500

This is the third and final topic that I discussed at the 25th Penn Trauma Reunion last Friday. Printer technology has progressed from dot-matrix printers (pushing ink out of a cloth ribbon with little metal pins) to laser printers (fusing dye rolled onto the paper) to inkjet printers (blowing little dots of ink onto paper out of a cartridge).

The next logical step was to go beyond printing with small flat dots of ink and using small spheres of plastic. These tiny spheres can be layered on top of each other using a 3D printer using the the same inkjet type technology and then fused together using a laser. These printers are popular in manufacturing, where they can be used to quickly create prototypes or small parts. Orthopedic surgeons have been using them to print out 3D representations of complex fractures to plan reconstructive surgery (click here for details).

Now consider replacing the little plastic spheres with various cell types cultured from a patient. Load up the “ink” cartridges and start printing some tissue! Anthony Atala runs the Institute for Regenerative Medicine at Wake Forest University and is a pioneer in using this technique. He is able to print 10x10 cm skin grafts on pigs with good results (read about it here). Atala demonstrated the concept of printing whole organs at the TED2011 conference last year. Watch the YouTube video of a kidney being printed here. At this stage of development, it is not a functioning organ, but it’s a great proof of concept.

I believe that this technology is extremely promising. Printing simple human tissues like skin will not be far off. Although it seems farfetched, the picture below shows what is in store in the future. Hopefully, the days of donated organ shortages is coming to an end.

Papers To Change Our Practice 2: Radiation Exposure

Thu, 03 May 2012 12:21:47 -0500

The second paper I’ll be discussing at the Penn Trauma reunion tomorrow deals with radiation exposure in trauma. Specifically, I’ll be talking about the amount of radiation the patient is exposed to during their initial evaluation. A lot of work is being published on this topic, but the paper I selected took a different and more accurate approach.

The trauma group at Sunnybrook in Toronto measured surface radiation exposure in a group of 172 major trauma patients. Dosimiters were placed on the neck, chest and groin, and were ideally kept there during the entire hospital stay. A software algorithm was used to calculate organ dose based on the surface measurements. This differs from the more commonly used method of counting studies and calculating dose based on published averages of radiation delivery.

The study was weakened by the number of patients that were excluded or who decided to remove their dosimeter at some point. But a number of interesting facts were revealed:

Patients received an average of 5 CT scans and 14 plain xrays during their stay
The average total effective dose was 23mSv, about 10 times the normal background exposure for an entire year
A surprisingly high dose was delivered to the thyroid, which is more sensitive to radiation exposure
A total of 190 extra cancer mortalities would be expected per 100,000 patients, given these exposure numbers
Radiation was underestimated using non-dosimeter techniques

Bottom line: We know radiation exposure occurs in our patients, and we know that it’s increasing. It won’t be that long until we start to see the after-effects of these imaging studies, especially in younger patients. What you can’t see does hurt your patients! We need to quickly strike a balance between avoiding missed injuries and irradiating the patient. Specific guidelines to direct ordering of radiographic studies must be developed, and our radiology colleagues need to continue to strive for techniques that adhere to the ALARA (as low as reasonably achievable) philosophy.

Reference: Radiation exposure from diagnostic imaging in severely injured trauma patients. J Trauma 62(1):151-156, 2007.

Papers To Change Our Practice 1: Tranexamic Acid

Wed, 02 May 2012 08:44:39 -0500

The first paper I’ll be presenting on Friday at the Penn Reunion deals with tranexamic acid (TXA). This drug works differently than the quick clotting agents out there. It’s an antifibrinolytic, so it actually prevents clot breakdown. It has been approved by the FDA for use in hemophiliacs undergoing dental work and for menorrhagia. Thrombotic complications have been described, so it cannot be used with prothrombin complex concentrate or recombinant activated factor VII.

The most recent and best known study on TXA is the CRASH-2 study. It was extremely well designed and included over 20,000 patients in hospitals spanning 40 countries. The study design has survived serious scrutiny. They found that TXA use in trauma patients reduced the relative risk of death by 9% (from 16% to 14.5%). The risk of death specifically from bleeding was reduced by 15%. And use of TXA in the most severely injured patients, those who would die of bleeding on the day of randomization, was reduced by 20%. CRASH-2 suggested that TXA was of most benefit when given within 3 hours of injury and in patients with a systolic pressure less than or equal to 75 torr. There were no adverse events or differences in thrombotic events, including deep venous thrombosis.

Bottom line: TXA has been shown to be effective, safe and inexpensive (about $200 for treatment using retail pricing). It is the only drug that has been shown to reduce all-cause mortality from bleeding in a high quality trial. And it only needs to be used in 67 major trauma patients before one life will be saved. It has already been adopted by some hospitals in both the US and the UK. Trauma centers should begin to think about incorporating this important drug into their initial treatment protocols now. HOWEVER: Since it is not FDA approved in the US, we may have to wait a little longer here to start using it in earnest. And think about the possibilities when EMS can start giving it in the field!

Reference: Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376:23–32.

25th Reunion Of The Penn Trauma Program

Tue, 01 May 2012 09:01:06 -0500

I’m traveling to Philadelphia this week to celebrate the 25th anniversary of the trauma program at the University of Pennsylvania. I am one of the three founding surgeons and have been asked to speak at the academic forum portion of the program. I’ll be talking about three papers that should have changed our practice.

For the remainder of the week I’ll be writing about those three papers. They involve the use of an agent that helps control bleeding, radiation exposure in trauma imaging, and the use of technology developed outside the field of medicine to treat trauma patients.

Tune in as I work my way through those important studies. And on Friday, I’ll be tweeting any important or interesting info presented at the academic forum.

Could Be A Urethral Injury, But The Catheter's Already In?

Mon, 30 Apr 2012 09:02:00 -0500

You’re seeing a trauma patient, probably a transfer from somewhere else. Either they told you there “may have been” some blood at the tip of the urethra, or maybe you see it smearing the outside of a urinary catheter that’s already in place! How do you proceed from here?

First, try not to get into that situation. Make sure that everyone on your team knows that gross blood at the meatus, male or female, means urethral injury until proven otherwise. If it’s not gross blood, it could be that the patient was incontinent and has hematuria from other causes. The fear with passing a catheter across a urethral injury is that it may convert a partial tear to a complete one. Reconstruction and complications from the latter are far more serious.

But the catheter is there. What to do?

First, leave the catheter in place. You must assume that the injury is present, and you need to rule it in or rule it out in order to decide what to do with the catheter. If the injury is not really there, then you can remove the catheter when indicated. If it really is present, then the urethral injury is being treated appropriately.

Next, do a urethrogram. I’ve previously described how to do it here, but the technique I describe is only appropriate for uncatheterized patients. The technique must be modified to use thin contrast and a method to inject alongside the catheter. To do this, fill a 20-30cc syringe with contrast (Ultravist or similar liquid) and put an 18 gauge IV catheter on the tip (no needles, please). Slide the IV catheter alongside the urinary catheter, clamp the meatus with your fingers, pull the penis to the side and inject under fluoroscopy. The contrast column will not be as vivid as with a regular urethrogram because it is outlining the urinary catheter, so there is less volume.

If the contrast travels the length of the urethra and enters the bladder without leaking out into soft tissue, there is no injury. If there is contrast leakage, stop injecting and plan to call a urologist.

Finally, be on the lookout for associated injuries. Urethral injuries are frequently found in patients with anterior pelvic fractures and perineal injuries.

How To: Retrograde urethrogram

Link: blood at the urethral meatus (Atlas-Emerg-Medicine.org.ua from McGraw-Hill)

Thanks to JP for suggesting this topic!

"The better is the enemy of the good"

Fri, 27 Apr 2012 09:02:45 -0500

“The better is the enemy of the good”

- From the poem “The Prude Woman” by Voltaire, 1772.

This adage is particularly important in medicine. Every test and treatment we order has an upside (hopefully) that will reveal something or make our patient better. Unfortunately, we tend to ignore the inescapable downsides, which include cost and unanticipated consequences. These consequences are the discomfort, side effects, and dangers that come with any medical intervention. And in some cases, the results of an unneeded test may be in error or show some red herring that leads us on a wild goose chase of other interventions that compound the danger.

Bottom line: All trauma professionals need to think about everything they do to a patient, especially the risks they will inflict and the benefits that might accrue. Consider how it will influence your care. Will anything that is revealed change what you do? If not, you don’t need it. And your patient certainly doesn’t need the costs and hidden dangers that go along with it.

When Can Your Trauma Patient Stop Taking Warfarin?

Thu, 26 Apr 2012 09:00:31 -0500

I admit it. I read trauma and surgery literature, not medical literature. Imagine my surprise when a fellow physician (internist) told me that there is an objective system for helping us figure out whether anticoagulation is needed for atrial fibrillation. “CHADS2” he said. Am I the last trauma surgeon on earth to hear about this?

CHADS2 is a validated scoring system for predicting stroke risk in people with atrial fibrillation. There are 5 components as follows:

C - congestive heart failure - 1 point
H - hypertension (treated or untreated) - 1 point
A - age >= 75 - 1 point
D - diabetes mellitus - 1 point
S2 - history of stroke or TIA - 2 points

Stroke risk is directly correlated to the number of points scored. So based on that the recommendations are:

Score = 0: low risk, no therapy needed or just take aspirin
Score = 1: moderate risk, aspirin or oral anticoagulant
Score >= 2: moderate to high risk, take oral anticoagulant

Bottom line: Evaluate every trauma patient on anticoagulation to see if they really need to keep taking it. If it’s for a one-time episode of DVT or PE that happened years ago, they should be able to stop. If it’s for a-fib, check their CHADS2 score and work with their primary care provider to see if they could take aspirin or nothing. Factor in a history of frequent falls or car crashes as well.

Related posts:

Reference: Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin. Circulation 110 (16): 2287–92, 2004.

Spinal Cord Concussion In Student Athletes

Wed, 25 Apr 2012 09:02:00 -0500

Spinal cord injuries are typically devastating injuries with profound consequences for function and life expectancy. However, a small percentage result in rapidly reversible symptoms. Because these temporary injuries are rare, they tend to cause confusion among clinicians.

Technically, a spinal cord concussion (a “zinger” or “stinger” is an example) is a mild cord injury that results in transient neurologic disturbances. The deficits can be sensory, motor or both, and typically resolve in less than 48 hours. The injuries tend to involve the mid-portion of the cervical cord or the cervico-thoracic junction, since these are the areas of maximum mobility. In a few cases, the athlete has congenital narrowing of the spinal canal which predisposes them to injury. In most cases, the injury probably occurs due to the flexibility of the young spine.

The usual management consists of an MRI of the spine followed by admission and frequent neurologic checks to ensure ongoing resolution. MRI is typically negative in a true concussion. If a signal change is seen, then technically a cord contusion is present. Management is the same for both. There is no indication to give steroids. Evaluation of the ligaments is critical to determine if a collar will be necessary.

Recovery is rapid and complete. But what is the answer to the inevitable question, “when can he/she return to play?” In adult players, the literature suggests that it may be safe to return once they have fully recovered. There is little guidance for kids.

Here’s what I tell the parents: This event has shown that, given the right force applied to your child’s neck, the bones can move enough to injure their spinal cord. This time, the cord was just tickled a little bit. But if the bones had moved just another millimeter or two, this injury could have been permanent and they would never have walked again. I recommend that they do not play this sport again.

Some of you may disagree. I’d be very interested in hearing your comments.

Reference:

First mention: About concussion of the spinal cord. Wein Med Jahrb 34:531, 1879.

When To Give Mannitol

Tue, 24 Apr 2012 09:02:00 -0500

Patients with severe head injury need all the help they can get. Mannitol is one tool that is time-tested and cheap. But how do you decide who gets it and when?

Mannitol is a powerful osmotic diuretic that pulls extracellular water from everywhere, including the brain. By reducing the size of the brain overall, it drops pressure inside the skull (ICP) somewhat.

Mannitol can be used anytime during the acute phase of trauma care for three indications in patients with head trauma:

Focal neurologic deficit. This is due to transtorial herniation, and may manifest clinically as unilateral pupil dilation or hemiparesis. It may also be seen on CT scan.
Progressive neurologic deterioration. This is typical of rising ICP and can be diagnosed when your previously talking patient becomes lethargic.
Clinical evidence of high ICP. This is the Cushing response (hypertension with bradycardia). Do not treat this hypertension with other meds, it is a brain protective mechanism!

The literature does not have any good studies that show effectiveness or survival benefit. However, most trauma professionals have seen the dramatic improvement in neurologic status that can occur after early administration.

Bottom line: Mannitol is cheap and it works! Consider it early if any of the three indications above are seen. And don’t forget to put a urinary catheter in immediately because the diuresis that it causes is impressive. And no studies thus far have been able to prove that hypertonic saline is any better or worse than mannitol.