It happens all the time. You get that initial chest and/or pelvic xray in the resuscitation room while evaluating a blunt trauma patient. A few minutes later the tech returns with another armful of xray plates to repeat them. Why? The patient was not centered properly and part of the image is clipped.
Do you really need to go through the process of setting up again, moving the xray unit in, watching people run out of the room (if they are not wearing lead, and see my post below about how much radiation they are really exposed to), and shooting another image? The answer to the question lies in what you are looking for. Let’s address the two most common (and really the only necessary) images needed during early resuscitation of blunt trauma.
First, the chest xray. You are really looking for 3 things:
Big air (pneumothorax)
Big blood (hemothorax)
Big mediastinum (hinting at aortic injury)
Look at the clipped xray above. A portion of the left chest wall is off the image. If there were a large pneumothorax on the left, would you be able to see it? What about a large hemothorax? And the mediastinum is fully included, so no problem there. So in this case, no need to repeat immediately.
The same thing goes for the pelvis. You are looking for gross disruption of the pelvic ring, especially posteriorly because this will cause you to intervene in the ED (order blood, consider wrapping the pelvis). So if parts of the edges or top and bottom are clipped, no big deal.
Bottom line: Don’t let the xray tech disrupt the team again by reflexively repeating images that are not technically perfect. See if you can use what you already have. And how do you decide if you need to repeat it later, if at all? Consider the mechanism of injury and the physical exam. Then ask yourself if there is anything you could possibly see that was not imaged the first time that would change your management in any way. If not, you don’t need it. But it certainly will irritate the radiologists!
Time for some more philosophy! After doing anything for an extended period, one begins to see the common threads and underlying principles of their area of expertise. I’ve been trying to crystallize these for years, and today I’m going to share one of the most basic laws of trauma care.
The First Law of Trauma: Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.
An elderly patient who crashes his car and presents with arrhythmias and chest pain is not having a heart attack. Nor does he need a cardiologist or a trip to the cath lab.
A spot in the liver after blunt trauma is not a cyst or hemangioma; it is a laceration until proven otherwise.
A patient found at the bottom of a flight of stairs with blood in their head did not have a stroke and then fall down.
Bottom line: The possibility of trauma always comes first! It is your job to rule it out. Only consider non-traumatic problems as a last resort. Don’t let your non-trauma colleagues try to steer you down the wrong path, only to have your patient suffer.
Trauma professionals tend to focus on the two extremes of TBI: mild concussive injury because we see so much of it, and very severe injury that we have to work so hard to keep the patient alive. Today I’ll write about the one in the middle, diffuse axonal injury (DAI). People don’t talk about it nearly as much, and it seems kind of mysterious.
DAI is also known as a shear injury, because that’s what we think happens to the brain at the time of injury. Officially, it is diagnosed when a patient remains in a coma for more than 6 hours without a demonstrable mass lesion from bleeding seen on CT. It is seen in about 15% of trauma ICU patients with head injury. Essentially the substance of the brain moves around enough to disrupt a critical mass of axonal connections that results in prolonged unconsciousness. It then takes time to try to rebuild those connections and restore consciousness and some degree of cognition. Mechanisms which result in sudden acceleration or deceleration of the brain may cause this condition, and rotational forces which spin the head suddenly seem to be even worse.
CT scan of the head frequently shows no unusual findings. On occasion, small punctate hemorrhages may be seen. These are generally bad prognostic signs, because CT is so much less sensitive in showing these compared to MRI. Here are some key points about DAI:
If the head CT is negative,and all recreational drugs have worn off and the patient still doesn’t wake up, DAI is likely.
MRI can confirm the diagnosis, but is not good for giving a prognosis
Slow recovery of consciousness or failure to recover correlates with death
Hyperglycemia and the presence of a subdural also are highly correlated with mortality
Bottom line: The diagnosis of DAI can generally be made clinically with the assistance of head CT. MRI is not very useful, unless it is needed to confirm the diagnosis. It does not predict speed or degree of recovery so is otherwise not very useful. Supportive care, avoidance of complications and early therapy and rehab are the best treatments we have to offer.
Reference: Diffuse axonal injury in patients with head injuries: an epidemiologic and prognosis study of 124 cases. J Trauma 71(4):838-846, 2011.
Injury can be a bloody business, and trauma professionals take replacement of blood products for granted. Some patients object to this practice on religious grounds, and their health care providers often have a hard time understanding this. So why would someone refuse blood when the trauma team is convinced that it is the only thing that may save their life?
Jehovah’s Witnesses are the most common group encountered in the US that refuse transfusion. There are more than 20 million Witnesses worldwide, with over 7 million actively preaching. It is a Christian denomination that originated in Pennsylvania during the 1870s.
Witnesses believe that the bible prohibits taking any blood products, including red cells, white cells, platelets or plasma. It also includes the use of any dialysis or pump equipment that must be primed with blood. This is based on the belief that life is a gift from God and that it should not be sustained by receiving blood products. The status of certain prepared fractions such as albumin, factor concentrates, blood substitutes derived from hemoglobin, and albumin is not clear, and the majority of Witnesses will accept these products. Cell saver techniques may be acceptable if the shed blood is not stored but is immediately reinfused.
Why are Witnesses so adamant about refusing blood products? If a transfusion is accepted, that person has abandoned the basic doctrines of the religion, and essentially separates themselves from it. They may then be shunned by other believers.
So what can trauma professionals do to provide best care while abiding by our patient’s religious belief? In trauma care it gets tricky, because time is not on our side and non-blood products are not necessarily effective or available. Here are some tips:
Your first duty is to your patient. Provide the best, state of the art care you can until it is absolutely confirmed that they do not wish to receive blood products. In they are comatose, you must use blood if indicated until the patient has been definitively identified by a relative who can confirm their wishes with regard to blood. Mistaken identity does occur on occasion when there are multiple casualties, and withholding blood by mistake is a catastrophe.
Talk with the patient or their family. Find out exactly what they believe and what they will allow. And stick to it.
Aggressively reduce blood loss in the ED. We are not always as fastidious as we should be because of the universal availability of blood products. Use direct pressure or direct suture ligation for external bleeding. Splint to reduce fracture bleeding.
Aggressively use damage control surgery. Don’t go for a definitive laparotomy which may take hours. Pack well, close and re-establish normal physiology before doing all the final repairs.
Always watch the temperature. Pull out all the stops in terms of warming equipment. Keep the OR hot. Cover every bit of the patient possible with warming blankets. All fluids should be hot. Even the ventilator gases can be heated.
Think about inorganic and recombinant products such as Factor VIIa, tranexamic acid and Vitamin K. These are generally acceptable.
Consider angiography if appropriate, and call them early so their are no delays between ED and angio suite or OR and angio suite.
Bottom line: Do what is right for your patient. Once you are aware of their beliefs, avoid the use of any prohibited products. Speak with them and their family to clarify exactly what you can and cannot do. This is essentially an informed consent discussion, so make sure they understand the consequences. Follow their wishes to the letter, and don’t let your own beliefs interfere with what they want.
For the most part, hypothermia is a bad thing for trauma patients. Its impact on bleeding and mortality has long been known. A paper just out now implicates it in surgical site infections as well. This fact has already been shown for some types of elective surgery (colorectal), but it appears to be a factor in trauma laparotomy as well.
A retrospective review of 524 patients who underwent a trauma lap looked at the correlation of surgical site infection (SSI) and the depth and duration of hypothermia. The mean low temp across all cases was 35.2° C (!). Nearly a third had at least one measurement below 35° C. About 36% of all patients developed an SSI.
Hypothermia is a common problem in these patients!
35 C was the nadir temp most predictive of developing an infection
Every degree below 35 C more than tripled the risk of SSI
Bottom line: Yet one more reason to avoid hypothermia in our trauma patients! This effort begins with prehospital providers doing their best to insulate and keep patients warm. The trauma team also has a responsibility to heat up the room and keep the patient covered as much as possible. Baseline temp should be obtained in all major trauma patients. And if they do end up in the operating room, anesthesia needs to monitor the temp closely and keep the surgeon apprised of any concerning drops.