All posts by The Trauma Pro

Prehospital

Trauma Activation vs Stroke Code

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Let’s look at an uncommon scenario that crops up from time to time. Most seasoned trauma professionals have seen this one a time or two:

An elderly male is driving on a sunny afternoon, and crashes his car into a highway divider at  25 miles per hour. EMS responds and notes that he has a few facial lacerations, is awake but confused. They note some possible facial asymmetry  and perhaps a bit of upper extremity weakness. No medical history is available. Witnesses state that he was driving erratically before he crashed. Medics call the receiving trauma center in advance to advise them that they have a stroke code.

Is this a reasonable request? Stroke centers pride themselves on the speed of their stroke teams in assessing, scanning, and when appropriate, administering thrombolytics to resolve the problem. But if there are suspicions of stroke in a trauma patient, which diagnosis wins? Trauma team or stroke team?

Lets analyze this a bit further, starting with diagnosis. Remember the first law of trauma:

Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

Could the symptoms that the paramedics are observing be due to the car crash? Absolutely! The patient could have a subdural or epidural hematoma that is compressing a cranial nerve. There might be a central cord injury causing the arm weakness. His TBI might be the source of his confusion. The facial asymmetry could be due to a pre-existing Bell’s palsy, or he could have had a stroke years ago from which he has only partially recovered.

If the stroke team is called for the patient, they will focus on the neuro exam and the brain. They will not think about trauma. They will follow the patient to CT scan looking for the thing that they do best with. If they don’t see it, the patient will return to the ED for (hopefully) a full trauma workup. If there are occult injuries in the abdomen, then the patient may have been bleeding for an hour by then. This elderly patient will then be way behind the eight ball.

And let me pose the worst case scenario. The patient is taken to CT by the stroke team, and lo and behold he has a thrombotic stroke!  This patient had a stroke, which caused him to lose control of his car and explains most of his findings. Again, the stroke team will do what they are trained to do and give a thrombolytic. They are still not thinking about trauma. Within minutes the patient becomes hypotensive and his abdomen appears a bit more distended. He is rushed back to the ED (remember, no CT in hypotensive patients even if you are in the scanner) and a FAST exam is very positive for free fluid throughout the abdomen. Imagine the look you will get from the surgeon as they run to the OR to perform a splenectomy on this fully anticoagulated patient!

Bottom line: If you have a patient who is trauma vs stroke, trauma always wins! Remember the first law and try to find traumatic reasons for all signs and symptoms. Perform your standard trauma workup and incorporate the appropriate head scans into your evaluation. Then and only then should the stroke team be called.

Guidelines

Solid Organ Injury Practice Guideline Updated

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Regions Hospital developed a clinical practice guideline for solid organ management in 2002-2003. It has been revised a few times over the years, as any good guideline should with the availability of new data.

I’ve just put the finishing touches on the latest revision as a result of the updated organ scaling rules published by the American Association for the Surgery of Trauma. I reviewed the new scales for both liver and spleen earlier this year (links below). In the previous iteration of the scaling system, the importance of contrast pooling (pseudoaneurysm) or extravasation beyond the organ was not well defined. 

The new guideline explicitly includes these injuries in the high grade group, which for us is grade IV or V. Technically, pseudoaneurysm of the liver is only grade III, but in my opinion demands angiographic investigation and embolism. Thus the inclusion in the high grade / angiography arm of our guideline.

For those of you who have not seen this guideline before, there are several important directives that are listed on the left side of the page:

  • Patients are NOT made NPO
  • They do NOT have activity restrictions (such as bed rest)
  • Serial hemoglins are NOT drawn
  • An abdominal CT scan is NOT repeated

These changes were made in 2015 based on our clinical experience that properly selected patients almost never fail. And they still don’t, so why starve, restrain, poke, and re-irradiate them?

Additionally, we included explicit impact activity restrictions for post-discharge so that patients would get the same message from all members of our team.

Click the image below to download the guideline and have a look. I’m interested in your comments!

Related posts:

Thorax

Tension Pneumothorax From Inside The Chest: The Video

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This video shows what it looks like from the inside when a needle thoracostomy is inserted into the chest. Note that it takes about a minute for the lung to expand, so be patient when you insert the needle. You can also get an idea of why the needle is only a temporary measure as the inflating lung begins to kink the catheter.

Don’t ask why there was a thoracoscope in the chest with a tension pneumo in the first place, though!

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Imaging

IV Contrast and Trauma – Revisited

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We use CT scanning in trauma care so much that we tend to take it (and its safety) for granted. I’ve written quite a bit about thoughtful use of radiographic studies to achieve a reasonable patient exposure to xrays. But another thing to think about is the use of IV contrast.

IV contrast is a hyperosmolar solution that contains some substance (usually an iodine compound) that is radiopaque to some degree. It has been shown to have a significant impact on short-term kidney function and in some cases can cause renal failure.

Here are some facts you need to know:

  • Contrast nephrotoxicity is defined as a 25% increase in serum creatinine, usually within the first 3 days after administration
  • There is usually normal urine output and minimal to no proteinuria
  • In most cases, renal function returns to normal after 3-4 days
  • Nephrotoxicity almost never occurs in people with normal baseline kidney function
  • Large or repeated doses given within 72 hours greatly increase risk for toxicity
  • Old age and pre-existing diabetic renal impairment also greatly increase risk

If you must give contrast to a patient who is at risk, make sure they are volume expanded (tough in trauma patients), or consider giving acetylcysteine or using isosmolar contrast (controversial, may still cause toxicity).

Bottom line: If you are considering contrast CT, try to get a history to see if the patient is at risk for nephrotoxicity. Also consider all of the studies that will be needed and try to consolidate your contrast dosing. For example, you can get CT chest/abdomen/pelvis and CT angio of the neck with one contrast bolus. Consider low dose contrast injection if the patient needs formal angiographic studies in the IR suite. And finally, consider what changes will be made if the study is positive. For example, if a CT angio of the neck for blunt carotid/vertebral injury is being considered, the intervention for a positive result is usually just aspirin. Since this is a very benign medication, why not forgo the scan and just start aspirin if there is a significant risk of kidney injury from the contrast. Always think about the global needs of your patient and plan accordingly (and safely).

Reference: Contrast media and the kidney. British J Radiol 76:513-518, 2003.