I’m currently in Montreal, and just finished some presentations at McGill University / Montreal General Hospital on pediatric trauma. I’ll be wandering around the city today and will finish the stab to the back case tomorrow. Looking for fans!
So yesterday, we found that our patient was hemodynamically stable, with a knife in his back, positioned prone. An initial chest xray shows the knife (plainly) and haze in the right side of the chest. Obviously, this is a hemothorax.
Key points to note are that the amount of blood present is modest and the knife point is relatively medial, as is the entry seen on the outside. Combined, these data points indicate that you have time to gather more information.
My choice was to go to CT to get the ultimate anatomic information. What, you say, the patient is prone! Well, the scanner doesn’t care. As long has his torso AND the knife fit through, it works. Here’s the representative scan result:
What do you do now? Where do you do it? Answer tomorrow. Tweet or comment your decision!
Yesterday, I presented a case of a young man with a knife in his back. He was brought to your ED in the prone position. The question was, what to do next?
With any trauma patient, regardless of size, shape, or position, the first question is always, “does this patient belong in the ED?” And usually, that question is answered by checking hemodynamic stability.
This patient stays prone while you quickly assess vital signs. If vitals are abnormal, he needs to get rolled to the operating room immediately, while still prone. There is no time to figure out how to reposition, or if the knife can be removed. Get him out of your ED.
But let’s say he is hemodynamically normal and talking to you. You need more information. So start with a physical exam. With him in the prone position! It works. In this case, there are no other puncture wounds, and the anterior part of the body can be examined by carefully logrolling him onto his side. Breath sounds are decreased over the right chest, otherwise there are no other anomalies.
So now what? Well, let’s get some more info! How about a chest xray? Best position? Prone! It’s the easiest, because the patient does not need to be held up next to an xray plate, which would also have to be held manually. The lateral view doesn’t add anything but hassle. Here’s the result:
Now what? What do you see, what do you do? Tweet or comment; more to follow tomorrow.
Here’s an interesting case to consider. A young male is assaulted and stabbed to the back. Paramedics bring him to your ED as a trauma team activation, and the full team is assembled prior to his arrival.
He is brought into the room on the stretcher in the prone position. Here is a representative picture. This is not the actual patient, just a picture I found on another blog site that looks pretty close to the real case.
Let’s walk through the thought processes of managing this over the next few days.
First, what do you need to know right now to navigate your critical decision points? And what are you going to do regarding positioning, evaluation, and imaging?
Tweet or comment with your replies! More on Monday.
We’ve all been faced with injured patients who are taking some kind of anticoagulant, and it complicates their care. Many trauma professionals just say, “they just shouldn’t take this stuff any more." Why can’t we just stop them in patients at risk for injury (e.g. an elderly patient who falls frequently)?
Two major risk groups come to mind: those taking the meds who have DVT (or a propensity to get it), and patients with atrial fibrillation who take them to decrease stroke risk. I was not able to find much info (yet) on the former category. But there is a series of nicely done studies based on work from the Framingham Heart Study.
The Framingham study started in 1948, and has been following over 5,000 people for the development of cardiovascular disease. In this particular analysis, 5070 patients who were initially free of disease were analyzed for development of atrial fib and occurrence of stroke. Anticoagulants were seldom used in this group.
The authors found that the prevalence of stroke increased with age in patients with atrial fib. The percentage that could be attributed to a-fib also increased. The following summarizes their numbers:
- Age 50-59: 0.5 strokes per 100 patients, attributable risk 1.5%
- Age 60-69: 1.8 strokes per 100 patients, attributable risk 2.8%
- Age 70-79: 4.8 strokes per 100 patients, attributable risk 9.9%
- Age 80-89: 8.8 strokes per 100 patients, attributable risk 23.5%
Bottom line: The risk of having a stroke just because a patient has atrial fibrillation goes up significantly with age. So setting an age cutoff for taking an anticoagulant doesn’t make sense. Unfortunately, increasing age also means increasing risk of injury from falls. Warfarin definitely cuts that risk, and it happens to be relatively easily reversbile. However, the newer non-reversible drugs change the equation, shifting the risk/benefit ratio too far toward the dark side. We need some good analyses to see if it really makes sense to move everybody to these new (expensive) drugs just to make it easier to dose and monitor. The existing studies on them only look at stroke, but don’t take injury morbidity and mortality into account.
Reference: Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 22:983-988, 1991.