ACS Trauma Abstract #6: Scanning Unstable Trauma Patients???

If you’ve read my stuff for very long, you know I frown on sending unstable patients anywhere but to the OR. Instability tends to get worse, and that always happens at inopportune locations like hallways, elevators, and CT scanners. Imagine my surprise when I noticed an abstract being presented at the Clinical Congress of the American College of Surgeons this week suggesting that it was okay to scan hemodynamically unstable patients before “definitive therapy.”

Here’s the title:

“Computed tomography in hemodynamically abnormal thoracoabdominal trauma safely enhances surgical triage”

The devil is in the details and the language. This group from USC included all patients who were hemodynamically abnormal on arrival to the trauma bay but who normalized to SBP > 90 during the resuscitation were included.  A total of 253 of these patients were reviewed over a 9 year period, and the usual variables were analyzed (mortality, complications, hospital, ICU, and vent days, etc).

Here are the factoids:

  • Of the 253 patients studied, 45 went to straight to OR and 208 were taken to CT
  • Injury severity was identical for the two groups
  • Lengths of stay and mortality were not different, but only p values were given
  • Patients taken to CT cleared their lactic acidosis faster (12 vs 5 hours), and used a bit less plasma and significantly less blood transfusions
  • The OR group underwent more procedures (31% vs 13%), although what these were and when they were performed is not listed

Bottom line: The title of this abstract is misleading, and may fool those who don’t read the rest of the abstract. It should read:

“Computed tomography in previously hemodynamically abnormal thoracoabdominal trauma safely enhances surgical triage”

Someone who just skims through this issue of the journal may get the idea that it’s okay to scan an unstable patient. The authors are not saying this at all. If you read the conclusion carefully, you can see that the patients had to be resuscitated to a SBP > 90 before they considered taking to scan. And they did that for the majority of these patients.

The real question is, why do the scanned patients clear their lactic acidosis faster, need less blood, and undergo fewer procedures? It appears that there is some bias or selection process in play. Otherwise, why not use the magic CT scanner to make them all better?

Reference: Computed tomography in hemodynamically abnormal thoracoabdominal trauma safely enhances surgical triage. JACS 225(4S2):e175-176, 2017.

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