The radiologist made me order that (unnecessary) test! I’ve heard this excuse many, many times. Do these phrases look familiar?
… recommend clinical correlation
… correlation with CT may be of value
… recommend delayed CT imaging through the area
… may represent thymus vs thoracic aortic injury (in a 2 year old who fell down stairs)
Some trauma professionals will read the radiology report and then immediately order more xrays. Others will critically look at the report, the patient’s clinical status and mechanism of injury, and then decide they are not necessary. I am firmly in the latter camp.
But why do some just follow the rad’s suggestions? I believe there are two major camps:
Those that are afraid of being sued if they don’t do everything suggested, because they’ve done everything and shouldn’t miss the diagnosis
Those that don’t completely understand what is known about trauma mechanisms and injury and think the radiologist does
Bottom line: The radiologist is your consultant. While they are good at reading images, they do not know the nuances of trauma. Plus, they didn’t get to see the patient so they don’t have the full context for their read. First, talk to the rad so they know what happened to the patient and what you are looking for. Then critically look at their read. If the mechanism doesn’t support the diagnosis, or they are requesting unusual or unneeded studies, don’t get them! Just document your rationale clearly in the record. This provides best patient care, and minimizes the potential complications (and radiation exposure) from unnecessary tests.
We see seat belt signs at our trauma center with some regularity. There are plenty of papers out there that detail the injuries that occur and the need for a low threshold for surgically exploring these patients. I have not been able to find specific management guidelines, and want to share some tidbits I have learned over the years. Yes, this is based on anecdotal experience, but it’s the best we have right now.
Tips for surgeons:
Common injuries involve the terminal ileum, proximal jejunum, and sigmoid colon. My observation is that location in the car is associated with the injury location, probably because of the location of the seat belt buckle. In the US, drivers buckle on the right, and I’ve seen more terminal ileum and buckethandle injuries in this group. Front seat passengers buckle on the left, and I tend to see proximal jejunum and sigmoid injuries more often in them.
Seat belt sign on physical exam requires abdominal CT for evaluation, regardless of age. The high incidence of significant injury mandates this test.
Seat belt sign plus any anomaly on CT requires evaluation in the OR. The only exception would be a patient with minimal fluid only in the pelvis with an unremarkable abdominal exam. But I would watch them like a hawk.
In patients who cannot be examined clinically (e.g. severe TBI), a rising WBC count or lactate beginning on day 2 after adequate resuscitation should prompt a trip to the OR. This is an indirect method for detecting injured bowel or mesentery.
Laparoscopy may be used in patients with equivocal findings. Excessive blood, bile tinged fluid, succus, or lots of fibrin deposits on the bowel should prompt conversion to laparotomy. Tip: place all ports distant to the seat belt mark. The soft tissues are frequently disrupted, and gas may leak into this pocket prohibiting good insufflation of the peritoneal cavity.
If in doubt, open the abdomen. It’s bad form to put in the scope, see something odd, and walk away. Remember, any abnormal finding after trauma is related to trauma until proven otherwise. It’s almost never pre-existing disease.
Most trauma professionals will have the opportunity to provide care for victims of domestic violence some time during their career. We are on the front lines and can unfortunately see the damage first hand. From time to time, the abuse escalates to a point where the woman (typically) is murdered. Is there a way to predict this fatal progression so it can be avoided?
The answer is yes! The Danger Assessment Tool (DAT) was developed 25 years ago and has been validated. Even though the instrument is old, it remains extremely helpful. The unfortunate thing is that at least half of the women involved do not recognize the grave peril they are in.
Some key points that were uncovered in the development of the DAT:
If a gun or other weapon is used to threaten, the risk of being murdered increases 20-fold
If there is merely a gun in the house, the risk of murder increases 6 times
If the abuser threatens murder, the risk of being killed increases 15-fold
Other indications of increased risk of death include heavy substance abuse, extreme jealousy, stepchild in the household, attempts to choke and forced sex
Bottom line: Domestic violence is criminal. We must go beyond the physical treatment and make sure these individuals are safe. Use the Danger Assessment Tool routinely to help identify women most at risk of losing their lives and bring all your social services resources to bear to keep them safe!
Campbell, Jacquelyn C., Assessing Dangerousness: Violence by Sexual Offenders, Batterers, and Child Abusers, Newbury Park, CA: Sage Publications, 1995.
Campbell, Jacquelyn C. , Phyllis W. Sharps, and Nancy Glass, “Risk Assessment for Intimate Partner Violence,” in Clinical Assessment of Dangerousness: Empirical Contributions, ed. Georges-Franck Pinard and Linda Pagani, New York: Cambridge University Press, 2000: 136–157.
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