All posts by TheTraumaPro

Gunshots And CT Scan Of The Abdomen

Abdominal gunshots and CT scanning are usually thought to be mutually exclusive. The usual algorithm generally means a prompt trip to the operating room. But as with many things in the management of trauma, there are always exceptions. The key is to understand when exactly one of those exceptions is warranted.

Exception 1: Did it really enter the abdomen? Gunshots have enough energy that they usually do get inside. However, freaky combinations of trajectory and body habitus do occur. There are three tests that must be passed in order to entertain the possibility that the bullet may not have made it inside your patient: physiology, anatomy, and physical exam. For physiology, the patient must be completely hemodynamically stable. Anatomically, the trajectory must make sense. If the known wounds and angles allow a tangential course make sense, then fine. But if there is a hole in the epigastrium and another next to the spine, you have to assume the bullet went straight through. Finally, the physical exam must be normal. No peritonitis. No generalized guarding. Focal tenderness only in the immediate area of any wounds. If all three of these criteria are passed, then a CT can be obtained to demonstrate the trajectory.

Exception 2: Did it enter an unimportant area of the abdomen? Well, there’s really only one of these, and that’s the area involving the right lobe of the liver and extending posteriorly and lateral to it. If the bullet hole(s) involve only this area, and the three tests above are passed, CT may confirm an injury that can be observed. However, there should only be a minimal amount of free fluid, and no soft tissue changes of any kind adjacent to bowel.

Exception 3: A prompt trauma lap was performed, but you think you need more information afterwards. This is rare. The usual belief is that the eyes of the surgeon provide the gold standard evaluation during a trauma lap. For most low velocity injuries with an easily understood trajectory, this is probably true. However, high velocity injuries, those involving multiple projectiles, or complicated trajectories (side to side) can be challenging for even the most experienced surgeon. Some areas (think retroperitoneum or deep in the pelvis) are tough to visualize completely, especially when there’s blood everywhere. These are also the cases most likely to require damage control surgery, so once the patient has been temporarily closed, warmed and resuscitated, a quick trip to CT may be helful in revealing unexpected shrapnel, unsuspected injuries, or other issues that may change your management. Even a completely unsurprising scan can provide a higher sense of security.

Bottom line: CT of the abdomen and gunshots to that area may actually coexist in some special cases. Make sure the physiology, anatomy and physical exam criteria are passed first. I also make a point of announcing to all trainees that taking these patients to CT is not the norm, and carefully explain the rationale. Finally, apply the concept of the null hypothesis to this situation. Your null hypothesis should state that your patient does not need a CT after gunshot to the abdomen, and you have to work to prove otherwise!

Practice Guidelines And Tincture Of Time

Most trauma centers have at least a few practice guidelines to help the standardize the way they manage common injuries. Solid organ injury. Elder trauma. Chest tube management. But they are all designed for use in patients who present shortly after their injury.

What about someone who presents a day or two, or more, after their injury?  That changes the picture entirely. Most guidelines have a time component built in. A TBI protocol requires a repeat head CT after a certain period of time. Solid organ injury patients may have restricted activity or frequent vital signs for a while. 

But all too often, trauma professionals treat the patient with delayed presentation exactly the same as fresh trauma. For example, a patient falls and bumps their head. They have a persistent headache, and after two days decide to visit their local ED. The CT scan shows a small amount of subarachnoid blood in the area of the impact. Your practice guidelines says to admit for observation, frequent neruo checks, and repeat head CT in 12 hours.

Or a young male playing sports took a hit to his left flank. After 3 days, he’s just tired of the pain and comes to the ED for some pain medication. CT scan shows a grade III spleen injury with a small amount of hemoperitoneum. Your protocol says to admit, make NPO, liimit activity, and observe for 2 days.

What would I do in these cases? Think about it! If the patients had presented right after the event, they would have gone through your guideline and would have been discharged already. So I would review the images, talk to the patients about their injuries, then send them home from the ED with followup. They’ve already passed!

Bottom line: Remember, practice guidelines are not etched in stone. Variances are possible, but need to be well thought out in advance. And hopefully documented in the chart to expedite the inevitable trauma performance improvement inquiry. If the requisite amount of time has gone by, and the history and exam are reasonable, the patient has already passed your protocol. Send them home.

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The Fifth Law Of Trauma – Pediatric

I knew there was a fifth law! Any time I give a pediatric talk, I mention it. This one applies to anyone who takes care of children, and is particularly important to EMS / prehospital providers and emergency physicians.

On occasion, medics are called to a home to treat a child in extremis, or occasionally in arrest. Similarly, extremely sick children are often brought to the ED by parents or other caregivers.

Here’s the fifth law:

A previously healthy child who is in arrest, or nearly so, is a victim of child abuse until proven otherwise.

Bottom line: It’s so easy to go down the sepsis path with sick kids, especially those who can’t talk yet. But healthy children tend to stay healthy, and don’t easily get sick to the point of physiologic collapse. If you encounter one as a prehospital provider, glance around at the environment, and evaluate the caregivers. In the ED, ask pointed questions about the circumstances and do a full body examination. What you hear and what you see may drastically alter how you evaluate the patient and may save their life.

Other Laws of Trauma:

November Trauma MedEd Newsletter Released!

The November newsletter is now available! Click the link below to download. This month’s topic is “History”, and I look at the impact of articles written 20-25 years ago on your current practice.

In this issue you’ll find articles on:

  • Trauma and critical care
  • CT imaging of the aorta
  • ED intubation for head injury
  • Seatbelt injuries
  • CAVR for hypothermia
  • Early or delayed femur fracture fixation

Subscribers received the newsletter last Monday night. If you want to subscribe to get early delivery in the future (and download back issues), click here.

Click here to download newsletter.

Making The Trauma Team Time Out Even Better!

Over the past two days, I’ve discussed a method for optimizing the hand-off process between prehospital providers and the trauma team. Besides improving the quality and completeness of information exchange, it also fosters a good relationship between the two. All too often, the medics feel that “the trauma team is not listening to me” if the procedure is to move the patient onto the ED bed as quickly as possible.

And they are right! As soon as the patient hits the table, the trauma team starts doing what they do so well. It’s impossible for humans to multi-task, even though they think they can (look at texting and driving). We switch contexts with our brain, from looking at the patient to listening to EMS, back and forth. And it takes a few extra seconds to switch from one to the other. Team members will not be able to concentrate on the potentially important details that are being relayed.

What should you do if the team doesn’t want to wait?

First, educate them. Except for those who are in extremis or arrest, the patient can wait on the EMS stretcher for 30 seconds. Nothing harmful is going to happen in that short period.

Then, create a hard stop. The easiest way to do this is to place a laminated copy of the timeout procedure on the ED bed. And the rule is that the card doesn’t move until the timeout is done. This is very similar to what happens in the OR. The process should take only 30 seconds, then it’s over and the team can start.

Here’s a copy of a sample TTA Timeout card:

Download a TTA timeout card

Modify it to suit your hospital and process, and try it out!

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Thanks to the trauma team at Ridgeview Hospital in Waconia MN for telling me about this cool trick!