There was a lot of chatter regarding my practical tip yesterday, rotating the chest xray to better visualize rib fractures. Here’s the quiz xray from yesterday:
And here’s the lateral view:
The fracture is perfectly placed on the most lateral aspect of the left 9th rib. You can download the full size rotated jpg here if you are having a hard time seeing it on the reduced size image above. Piece of cake!
Here’s a neat trick for finding hard to see rib fractures on standard chest x-rays.
First, this is not for use with CT scans. Although chest CT is the “gold standard” for finding every possible rib fracture present, it should never be used for this. Rib fractures are generally diagnosed clinically, and they are managed clinically. There is little difference in the management principles of 1 vs 7 rib fractures. Pain management and pulmonary toilet are the mainstays, and having an exact count doesn’t matter. That’s why we don’t get rib detail x-rays any more. We really don’t care. Would you deny these treatments in someone with focal chest wall pain and tenderness with no fractures seen on imaging studies? No. It’s still a fracture, even if you can’t see it.
So most rib fractures are identified using plain old chest xray. Sometimes they are obvious, as in the image of a flail chest below.
But sometimes, there are only a few and they are hard to distinguish, especially if the are located laterally. Have a look at this image:
There are rib fractures on the left side side on the posterolateral aspects of the 4th and 5th ribs. Unfortunately, these can get lost with all the other ribs, scapula, lung markings, etc.
Here’s the trick. Our eyes follow arches (think McDonald’s) better than all these crazy lines and curves on the standard chest x-ray. So tip the x-ray on its side and make those curves into nice arches, then let your eyes follow them naturally:
Much more obvious! In the old days, we could just manually flip the film to either side. Now you have to use the rotate buttons to properly position the digital image.
Final exam: click here to view a large digital image of a nearly normal chest xray. There is one subtle rib fracture. See if you can pick it out with this trick. You’ll have to save it so you can manipulate it with your own jpg viewer. If you find it, tweet it out to me! Let’s see who gets it first!
The standard of care in most high level trauma centers is to involve neurosurgeons in the care of patients with significant traumatic brain injury (TBI). However, not all hospitals that take care of trauma patients have immediate availability of this resource. A paper to be presented at the upcoming EAST meeting looked at management of these patients by acute care surgeons.
The authors retrospectively reviewed all patients who had a TBI and positive head CT managed with or without neurosurgery consultation over a two year period. Although the authors were from the University of Arizona, a Level I ACS trauma center, the abstract does not explicitly state whether the patients were seen in their hospital or another lower level one.They matched the patients with and without neurosurgical consultation for age, GCS, AIS-Head and presence of skull fracture and intracranial hemorrhage.
A total of 90 patients with and 90 patients without neursurgical involvement were reviewed. Here are the interesting findings:
- Hospital admission rate was identical for both groups (87-90%)
- ICU admission was significantly higher if neurosurgeons were involved (20% vs 41%)
- Repeat head CT was ordered more than 3 times as often by neurosurgeons (20% vs 72%)
- Post-discharge head CT was ordered more often by neurosurgeons, but was not significantly higher (5% vs 12%)
Nothing is said about complications or mortality, or whether neurosurgeons were available in case things went awry.
Bottom line: This abstract raises an interesting question: can surgeons safely manage select patients with intracranial injury? The answer is probably yes, although this abstract is not complete enough to fully support the idea. The majority of patients with mild to moderate TBI with small intracranial bleeds do well despite everything we throw at them. And it appears that surgeons use fewer resources managing them than neurosurgeons do. The keys to being able to use this type of system are to identify at-risk patients who really do need a neurosurgeon early, and having a quick way to get the neurosurgeon involved (by consultation or hospital transfer). As neurosurgery involvement in acute trauma declines, this concept will become more and more pertinent.
Reference: The acute care surgery model: managing traumatic brain injury without an inpatient neurosurgical consultation. EAST Annual Scientific Assembly, Paper 10, January 2013.
Angioembolization of the spleen (AES) is part of our armementarium in the management of spleen and liver trauma. However, there are no good guidelines to help us decide exactly which patients would benefit from it. An abstract to be presented at the EAST meeting in January 2013 gives us a little more information on the actual benefits of this procedure.
The authors did a retrospective review of the management of blunt splenic injury at four busy Level I trauma centers. They looked at 1275 injured patients over a 3 year period. Here are the interesting tidbits from the study:
- There was considerable variation in the use of AES at the 4 centers, ranging from 1% of patients to 14%. This should be no surprise because there is no real guidance available yet.
- There was also a large degree of variation between the number of initial splenectomy performed at these centers
- Centers that used AES more frequently had lower initial splenectomy rates
- Patients at centers with high AES rates were 3 times more likely to leave with their spleen intact
Bottom line: This abstract correlates with my own personal experience: judicious use of angioembolization saves spleens. The real question is about which patients are best served by it. Our protocol is to strongly consider it in all high grade spleen injuries (Grade 4 and 5), and to always do it if a blush or extravasation is present. Our success rate for nonoperative management currently stands at about 94%.
Reference: Variation in splenic artery embolization a spleen salvage: a multicenter analysis. EAST Annual Scientific Assembly, Paper #1, to be presented January 2013.
Trauma performance improvement is the backbone of any trauma center. And it’s the most common reason that a center runs into problems or deficiencies during a site review. Today, I’ll review the seven most common problems encountered during site surveys and provide some possible solutions for them.
- No loop closure. Closing the loop is talked about all the time. One would think that this should never be a problem, but it is. It becomes evident to the reviewers in two ways: reviewing PI meeting minutes, and sin #2 below. This topic is complicated, so see my four part series on loop closure here.
- Repeat offenses. The same problem keeps coming up again and again. This usually happens because the problem was never really solved in the first place. See the link above on loop closure for the solution to this one.
- Superficial peer review discussions. This means that the minutes don’t reflect any in-depth discussion of PI issues. There are two possible reasons: there wasn’t any meaningful discussion, or the documentation just wasn’t that good (see point 4 below). The discussion must include a summary of the case, identification of the significant quality issues, and a description of what will be done to avoid the problem in the future and who is responsible for carrying it out. If issues are referred to other committees (trauma operations or hospital PI), then this should be stated and it should be possible to follow the PI trail in those minutes as well.
- Poor peer review meeting minutes. This is a carry-on from the last point. Sometimes there is robust discussion on an issue, but the minutes don’t reflect it. This occurs due to concern for discoverability by the public or outside legal counsel in some states, but most frequently happens because the person charged with documenting the minutes is not very good at it. Minutes need not mention specific names, but do need to detail the gist of any discussion, including specific points of concern and remedies. Most discussions will run several paragraphs long; a single brief one just won’t do.
- Poor record organization. All PI activity and documentation regarding a specific patient needs to be organized in a single location. A paper or electronic folder is recommended. A similar folder is recommended for each system issue that involves multiple patients. During a site review, be sure to include the appropriate folder of information with each of the patient charts that are inspected by reviewers. Don’t scatter your records across several file cabinets or notebooks. And make sure several people in the trauma program understand the organization system in case a key person gets sick or quits.
- No cooperation from other hospital services. Your trauma program sends a case to be reviewed out to another department. Two months pass and you finally notice you never received a reply. Repeat a couple of times with the same chart and at that point, no one remembers anything about the case. This is a sure-fire way to keep making the same patient care mistakes. Create the expectation of quick turnaround (2 weeks is reasonable) and start nagging when time is up. Escalate to your trauma medical director if it continues to be a problem. In more extreme cases, you may need to select another liaison to deal with, or enlist hospital administration or hospital PI to help put pressure on them from above.
- No cooperation between trauma program manager and trauma medical director. These two people must work very closely for the trauma PI program to function efficiently. Regular meetings (weekly) are essential so they can review and process the various items that must be addressed. The TMD must deal with any physician related items, such as counseling, verbal discussions, memos and letters. The TPM deals with items involving nursing and other personnel. Dysfunction at this level is somewhat common at Level II trauma centers and quickly drags the program down.
Please feel free to comment or ask questions below!