All posts by TheTraumaPro

Do You Really Need To Repeat That Xray?

It happens all the time. You get that initial chest and/or pelvic xray in the resuscitation room while evaluating a blunt trauma patient. A few minutes later the tech returns with another armful of xray plates to repeat them. Why? The patient was not centered properly and part of the image is clipped.

Do you really need to go through the process of setting up again, moving the xray unit in, watching people run out of the room (if they are not wearing lead, and see my post below about how much radiation they are really exposed to), and shooting another image? The answer to the question lies in what you are looking for. Let’s address the two most common (and really the only necessary) images needed during early resuscitation of blunt trauma.

First, the chest xray. You are really looking for 3 things:

  • Big air (pneumothorax)
  • Big blood (hemothorax)
  • Big mediastinum (hinting at aortic injury)

Look at the clipped xray above. A portion of the left chest wall is off the image. If there were a large pneumothorax on the left, would you be able to see it? What about a large hemothorax? And the mediastinum is fully included, so no problem there. So in this case, no need to repeat immediately.

The same thing goes for the pelvis. You are looking for gross disruption of the pelvic ring, especially posteriorly because this will cause you to intervene in the ED (order blood, consider wrapping the pelvis). So if parts of the edges or top and bottom are clipped, no big deal.

Bottom line: Don’t let the xray tech disrupt the team again by reflexively repeating images that are not technically perfect. See if you can use what you already have.  And how do you decide if you need to repeat it later, if at all? Consider the mechanism of injury and the physical exam. Then ask yourself if there is anything you could possibly see that was not imaged the first time that would change your management in any way. If not, you don’t need it. But it certainly will irritate the radiologists!

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Elderly Trauma and the Frailty Index

Worldwide, the population is aging. Currently in the US, about 1 in 8 people are considered elderly (age >= 65). In 15 years, this number is expected to double to 1 in 4.

But as every trauma professional knows, there are the elderly, and then there are the elderly. What do I mean by this? I’ve seen 50 year olds who look and act like they are 80, with a medication list 10 deep. And I’ve also seen 90 year olds who are still ballroom dancing with the ladies.

Can we tell these cohorts apart, and do we need to? Sure, you can apply the “eyeball” test, but it’s not always accurate. Well, there are a number of frailty indexes that have been developed that try to make this process a bit more objective. The trauma group in Tucson looked at frailty index as a predictor of hospital disposition to see if it could offer any assistance in discharge planning.

Here are the factoids:

  • 100 consecutive patients aged 65 or more were studied over a one year period at a Level I trauma center
  • Frailty was calculated using the Canadian Study of Health and Aging Frailty Index, using 50 of the demographic, comorbidity, medication, social history, activities of daily living, and general mood variables
  • Overall, patients had moderate injury with average ISS 14, AIS-Head 2, and GCS 3
  • 69% of patients had a favorable outcome (discharged to home or rehab) vs 31% unfavorable outcome (skilled nursing facility or death)
  • Frailty index was highly and significantly correlated with unfavorable outcome
  • Age 65 or more alone was not predictive of unfavorable outcome

Bottom line: Just the fact that a patient is older does not mean that they are more likely to do poorly. The frailty index (FI) used in this study includes 50 variables, which indicates how complex this concept is. This scale has been used in non-trauma patients, and is now validated for trauma. Although somewhat complicated due to the sheer number of variables, it appears that this tool may be valuable in predicting discharge disposition if applied soon after admission. And it also raises the interesting question of whether hospital interventions may be able to change a predicted unfavorable outcome into a favorable one.

Related post:

Reference: Predicting hospital discharge disposition in geriatric trauma patients: is frailty the answer? J Trauma 76(1):196-200, 2014.

Evaluation of Hematuria in Blunt Trauma

Hematuria ranges from microscopic to gross. Microscopic means blood that can only be seen with a microscope, and gross means visible to the naked eye. In trauma, we only care about gross hematuria, which ranges from the faintest of pink to the deepest red.

In trauma, gross hematuria is a result of an injury to kidney, ureter or bladder. Blunt injury to the ureter is so rare it’s reportable, so you can pretty much forget that one unless the mechanism is extreme. So you really just need to focus on kidney and bladder.

Any victim of blunt trauma that presents with visible hematuria needs to be evaluated by CT of the abdomen and pelvis with an added CT cystogram. Standard CT technique is done without a urinary catheter, or with the catheter clamped. Only 50% of bladder injuries show up with this technique.

CT cystogram is an add-on to the standard CT, and consists of the administration of contrast into the bladder which is then kept under pressure while the scan is done. Delayed slices through the pelvis after the bladder is depressurized and emptied is routine. Nearly 100% of bladder injuries are detected using this technique.

If the CT shows a renal laceration or hematoma, the patient should be admitted and managed according to your solid organ injury protocol. Kidney injuries fare better that livers and spleens, and only rarely require surgery. If no kidney or bladder injury is seen, the default diagnosis of a renal contusion is the culprit. No treatment is needed, and the patient can be discharged if no other injuries are present. The blood will clear over a few days, but may disappear and reappear a few times in the process. The patient can followup with their primary care physician in a week or two.

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Displaced Proximal Humerus Fractures – To Operate Or Not?

Sometimes you may look at a fracture on an x-ray and cringe. It just seems intuitive that an orthopaedic surgeon should do something about it.

image

But as with many things in the field of medicine, what seems intuitive is not always right. For quite some time, many of these fractures have been managed without surgery, but there has been a more recent trend toward operation. 

Is it the right thing to do? Many patients with this injury are old, with pre-existing medical problems that increase the risk of surgery. A consortium of hospitals in the UK decided to examine this issue with a multi-center trial. They recruited patients from 33 hospitals that could provide either operative or nonoperative management of these fractures.

Here are the factoids:

  • 1250 patients were recruited, and 1000 were excluded. The patients were predominantly elderly (average age 66), and many had comorbidities, insufficient mental capacity, an associated dislocation or clear indication for surgery, or fracture of the other upper extremity.
  • The remaining 250 patients were equally randomized between operative and nonoperative groups.
  • All patients received surgery or a sling, as well as rehabilitation therapy afterwards.
  • After attrition over the 2 year followup period, 114 patients remained in the surgical group and 117 in the nonsurgical group. Overall, they remained well matched.
  • There was no difference in shoulder function or physical well-being between the 2 groups at any time during the 2 years as measured by the Oxford Shoulder Score of the SF-12 Health Survey and the SF-12. Both are self-reported and were administered by a separate examiner.
  • There were 30 complications in the surgical group vs 23 in the nonsurgical group (not significant). One in each group required later surgery.

Bottom line: This is a decent randomized study of a specific clinical question. The large exclusion numbers are a little bothersome, but the authors believed that they had adequate statistical power with their final number of patients. Interestingly, a Cochrane review from 2012 showed similar results with self-reported functional scores, but found a significant number of the nonop patients went on to require surgery. But note that the Cochrane review was an analysis of 6 separate studies, which may weaken their conclusions a bit.

Ultimately, I think that we don’t have any solid conclusions yet. But given the quality of this study, we should start to seriously question whether patients with this fracture, especially elderly ones, really need operative treatment.

Related posts:

Reference: Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus. JAMA 313(10):1037-1047, 2015.

Are “Routine” Vital Signs Really So Routine?

Trauma professionals, particularly physicians, tend to take vital signs for granted on patients who are admitted to the hospital. And we tend to assume that our patients won’t ask questions, either. Unfortunately, they usually don’t.

“Routine” vital signs tend to get measured by the nurses once a shift. But think about that for a minute. In the US, the typical shifts run from 7 am to 3 pm, 3 pm to 11 pm, and 11 pm to 7 am. This means that at some point in the night, they will be disturbed to take their blood pressure and pulse. At least! And what if they need to have a neuro exam, pulse checks, or to have that beeping pulse oximeter hooked up?

And even though the shift runs from 11 pm to 7 am, does that mean the vitals will be take at the beginning or end of shift? No way! The nurse has to receive report for a safe handoff and get organized at the start of the shift. And how many patients does he or she have? They may not be able to check vitals on everybody until after midnight. And what if vitals are ordered to be taken more than once a shift? How can any patient get decent sleep? 

Bottom line: Once again, think carefully about the orders! It’s no wonder some of our elderly patients sundown when they are admitted to the hospital. How can anyone get a good night’s sleep there? 

Don’t just reflexively write for a frequency. Think about how often your patient really needs to be disturbed, especially at night. If they are recovering uneventfully from an orthopedic procedure, why bother them at all at night? And nurses, make it your responsibility to advocate for your patient and bring up these crazy orders so they can be fixed.