Gunshots to the abdomen have a very high likelihood of causing damage that needs to be repaired. For this reason, the vast majority are immediately transported to the OR for laparotomy (celiotomy).
But there are a few situations in which advanced diagnostics can be justified prior to operation. Do you know what they are? Tweet or comment your answers. I’ll explain the details tomorrow.
The April newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is TBI.
In this issue you’ll find articles on:
- Is the GCS scale getting too old?
- Non-surgeons placing ICP monitors
- Management of CSF leaks
- Pneumocephalus and air transport
- Fever and head injury
Subscribers had the newsletter emailed to them over the weekend. If you want to subscribe (and download back issues), click here.
Download the newsletter here!
Orthopedic surgeons have long found inlet and outlet views (I/O) of the pelvis to be helpful in their management of pelvic fractures. However, for the last decade we’ve seen an inexorable creep in diagnostic imaging from plain xrays to computed techniques. Have the conventional inlet and outlet views lost their luster?
San Francisco General Hospital and UCSF recently published a registry-based study looking at conventional pelvic I/O images and virtual I/O images reconstructed from CT scans. Two years of registry data were reviewed, and included patients had both conventional I/O images and CT imaging. Images were evaluated by two orthopedic traumatologists for their quality.
Sadly, only 20 patients were available for this study, which makes it an interesting pilot at best. The most interesting results were as follows:
- Quality of imaging was judged to be equal except when pelvic rotation was present. CT fared better in these cases.
- Both inlet and outlet views were judged to be better when reconstructed by CT
- Overall, imaging of all portions of the pelvis was about equal in both types of study
- The need for repeat studies was identified in nearly half of conventional images, but in only 8% of CT images
Bottom line: CT scanning is slowly becoming the preferred modality for just about any type of trauma imaging. In the 1980’s, head CTs became widespread, followed rapidly by abdominal imaging. Chest CT for definitive diagnosis became commonplace around 2000, and spine imaging by CT has now become the gold standard. Although there are a few throwbacks where conventional imaging has been thought to be better, they are vanishing rapidly. Computing technology can now reconstruct inlet and outlet views of the pelvis, correcting for rotation and angulation in any study of the abdomen/pelvis. And if the reconstructed image is not quite right, the tech can change a few parameters and generate it again and again until the image is perfect.
Orthopedic surgeons should now expect a nicely formatted set of inlet/outlet CT reconstructions in all trauma patients with pelvic fractures.
Reference: Are conventional inlet and outlet radiographs obsolete in the evaluation of pelvis fractures? J Trauma 74(6):1510-1515, 2013.
Traumatic brain injury (TBI) is a common injury world-wide, but neurosurgeons are scarce. Traditionally, neurosurgeons are the ones to place invasive monitors to watch intracranial pressure (ICP). But what about injured people who are taken to a hospital where there is no available neurosurgeon?
A group at Wichita, Kansas looked at their 10 year experience with ICP monitor placement, where it can be done by neurosurgeons, trauma surgeons or general surgical residents (under trauma surgeon supervision). A total of 63 were placed by neurosurgeons, 30 by trauma surgeons, and 464 by residents under supervision. The usual demographics, including hospital stay, were the same across groups. There were essentially no significant differences based on who placed the monitor. Curiously, the article does not state whether the monitors were extradural or intraventricular, or both. The discussion section alludes to the fact that they were “parencyhmal.”
There were only three iatrogenic bleeds, and all occurred with resident placed monitors. None were clinically significant. Malfunction rate was about 5% across all groups. Monitors had to be replaced at some point in about 11% of all three groups. One CNS infection occurred in a patient with a resident-placed monitor.
Bottom line: With proper training and supervision, ICP monitors can be placed by just about anyone. This is particularly important in more rural locations where there are few if any neurosurgeons. But as always, this process needs to be monitored carefully by the hospital’s Trauma Performance Improvement / Patient Safety program (PIPS).
Reference: Placement of intracranial pressure monitors by non-neurosurgeons: excellent outcomes can be achieved. J Trauma 73(3):558-563, 2012.
The May issue of Trauma MedEd is ready to go! Subscribers will receive it overnight tonight. This issue is devoted to Traumatic Brain Injury.
Included are articles on:
- Brain injury and DVT prophylaxis
- Controlling fever in brain injury
- An alternative to the GCS?
- Pneumocephalus and air transport
- and more!
As mentioned above, subscribers will get the issue delivered tonight to their preferred email address. It will be available to everybody else on next Wednesday’s blog post.
Check out back issues, and subscribe now! Get it first by clicking here!