You are in the middle of a fast-paced trauma activation. The patient is awake, and mostly cooperative. The x-ray plate is under the patient and everyone stands back as the tech gets ready to fire the x-ray machine. At that very moment, your patient reaches up and places his hand on his chest. Or one of the nurses reaches over to check an IV site.
The x-ray tech swears, and offers to re-shoot the image. What do you do? Is it really ruined? They have an extra plate in hand and are ready to slide it under the patient bed.
The decision tree on this one is very simple. There are two factors in play: what do you need to see, and how hard is it to see? The natural reaction is to discard the original image and immediately get a new one. It’s so easy! Plus, the techs will take heat from the radiologist because of the suboptimal image. But take a look at this example of a “ruined” chest xray.
It’s just the patient’s hand! You can still see everything that you really need to.
Bottom line: You are looking for 2 main things on the chest x-ray: big air and big blood. Only those will change your management in the trauma bay. And they are very easy to see. Couple that with the fact that an arm overlying the image does not add a lot of “noise” to the image. So look at the processed image first. 99% of the time, you can see what you need, and will almost never have to repeat. [Hint: the same holds true for the pelvic x-ray, too. You are mainly looking for significant bony displacements, which are also easy to see.]
Modern day nonoperative management of solid organ injury in adults came to be due to its success rate in children. But if you look at the practice guidelines for adults, they frequently include a path for angioembolization in certain patients. In children, embolization is almost never recommended.
But what about that gray zone where children transition to adults? How young is too young to embolize? Or how old is too old not to consider it?
The adult and pediatric trauma groups at Wake Forest looked at this question by reviewing their respective trauma registry data. They looked specifically at patients age 13-18 who presented with a blunt splenic injury over a 8.5 year period. About halfway through this period, adult patients (> 16 years) were sent for embolization not only for pseudoaneurysm or extravasation, but also for high grade injury (> grade 3). Patients under age 16 were managed by the pediatric trauma team, and those 16 and older by the adult team.
Here are the factoids:
- Of the 133 patients studied, 59 were “adolescents” (age 13-15) and 74 were “adults” (16 or older)
- Patients managed by the adult team sent 27 of their 74 patients for angiography
- Those managed by the pediatric team were never sent to angiography
- The failure rate for nonoperative management was statistically identical, about 4% in adults and 0% in adolescents
- For high grade injuries, the adult team sent 27 of 34 patients to IR, whereas the pediatric team sent none of 36. Once again, failure rate was identical.
Bottom line: We already know that too many adult trauma centers send too many younger patients to angiography for solid organ injury. This study tries to tease out when a child becomes an adult, and therefore when angiography should begin to be considered. And basically, it showed that through age 15, they can still be considered as and treated like children, without angiography.
But remember, these numbers are relatively small, so take this work with a grain of salt. If you are managing a younger patient nonoperatively, and they continue to show evidence of blood loss (ongoing fluid/blood requirements, increasing heart rate), angiography may be helpful in avoiding laparotomy as long as your patient remains hemodynamically stable. But consult with your friendly neighborhood pediatric surgeon first.
Reference: The Spleen Not Taken: Differences in management and outcomes of blunt splenic injuries in teenagers cared for by adult and pediatric trauma teams in a single institution. J Trauma, in press, May 2017.
This tip is for all trauma professionals: prehospital, doctors, nurses, etc. Anyone who touches a trauma patient. You’ve probably seen this phenomenon in action. A patient sustains a very disfiguring injury. It could be a mangled extremity, a shotgun blast to the torso, or some really severe facial trauma. People cluster around the injured part and say “Dang! That looks really bad!”
It’s just human nature. We are drawn to extremes, and that goes for trauma care as well. And it doesn’t matter what your level of training or expertise, we are all susceptible to it. The problem is that we get so engrossed (!) in the disfiguring injury that we ignore the fact that the patient is turning blue. Or bleeding to death from a small puncture wound somewhere else. We forget to focus on the other life threatening things that may be going on.
How do we avoid this common pitfall? It takes a little forethought and mental preparation. Here’s what to do:
- If you know in advance that one of these injuries is present, prepare your crew or team. Tell them what to expect so they can guard against this phenomenon.
- Quickly assess to see if it is life threatening. If it bleeds or sucks, it needs immediate attention. Take care of it immediately.
- If it’s not life threatening, cover it and focus on the usual priorities (a la ATLS, for example).
- When it’s time to address the injury in the usual order of things, uncover, assess and treat.
Don’t get caught off guard! Just being aware of this common pitfall can save you and your patient!
In trauma surgery, operative management of liver injury is usually messy business, with little time for nice anatomic resections. However, an understanding of the basic anatomy, especially that of the vascular supply is crucial for saving your patient.
A cool tool for remembering Couinaud’s segments and the overall layout of liver anatomy was published in the Archives of Surgery recently. It makes use of a model, which consists of your hand! Just make a fist with your right hand and tuck the thumb behind the other fingers.
The fingers can then be numbered according to the Couinaud segments, with the caudate lobe (segment 1) represented by the thumb that is tucked away. The PIP joints represent the plane that the portal vein runs through, with branches going to upper and lower segments. Note how the ring finger normally lies a little more anterior than the little finger in this position, just like the sectors of the right lobe.
The creases between the fingers represent the left, middle and right hepatic veins.
The right hepatic vein is located between the right anterior and posterior sectors and the left hepatic vein sits between the left medial and lateral sectors. The middle hepatic vein is in between the left and right hemi-liver.
Bottom line: This “handy” liver model is available immediately in the OR and is already sterile. It can help visualize liver structures that may be injured quickly and accurately to speed your operative approach to the problem.
Reference: A Handy Tool to Teach Segmental Liver Anatomy to Surgical Trainees. Arch Surg 147(8):692-693, 2012.
The physical exam is an important part of the initial evaluation of trauma patients. Sometimes it actually makes the diagnosis, but much of the time it focuses further studies like x-rays or lab tests. But we can also use it as a tool to avoid further imaging. For example, consider clinical clearance of the cervical spine. A negative exam in a reliable patient allows us to remove the cervical collar.
Can we apply the same thinking to the thoracic and lumbar spines? Many of us do. No pain or tenderness equates to no imaging or log-roll precautions.
The trauma group at LAC+USC looked at this one a few years ago. They studied every blunt trauma patient over a 6-month period, and first determined if they were “evaluable.” This meant not intoxicated, head injured (GCS<15), and no distracting injury (determined very subjectively). All underwent a standard exam of the TL spine by a resident or attending surgeon.
Here are the factoids:
- 886 patients were enrolled, and 218 (25%) were not evaluable using the criteria above
- 11% of the non-evaluable patients were found to have a TL spine fracture by CT, whereas only 8% of the evaluable group did
- Of the evaluable patients, half (29) had no signs or symptoms of fracture
- Of those 29 without signs or symptoms, two had a “clinically significant” fracture. Both were younger (20 and 59). One had a T7 compression and a transverse process fracture, the other a T9 compression fracture. Both were treated with a TLSO brace.
- Of the 27 who could not be examined, 11 had “clinically significant” fractures; 8 were treated with TLSO and 6 with surgery (obviously some overlap there)
Bottom line: So physical exam of the thoracic and lumbar spine sucks, right? Not quite so fast! First, this is a small-ish study, but with enough patients to be intriguing. The biggest issue is that we don’t really know what is “clinically significant.” Treatment of stable fractures of the spine is controversial, and our friendly neighborhood neurosurgeons vary tremendously in how they do it. Ask five neurosurgeons and you’ll get six different answers.
Braces are expensive, and the optimal choice is not clear yet. At my hospital, we are treating select ones with a binder for comfort or a simple backpack brace. The fancier ones like the TLSO easily cost over $1000!
At this point, I recommend that you use a good blunt imaging practice guideline like the one below, coupled with a good physical exam. If the patient has sufficient mechanism to break something (which decreases with patient age), then image them. If they don’t, but have an abnormal exam, image them anyway. And we’ll wait for the next bigger/better study!
Reference: Clinical examination is insufficient to rule out thoracolumbar spine injuries. J Trauma 70(1):174-179, 2011.