All posts by TheTraumaPro

Don’t Get S#!++y Xrays!

This has probably happened to you. You get a consult to see a trauma patient in your ED. As you walk into the room, you practically run into the massive portable x-ray machine sitting next to the patient. They’ve had some pretty significant blunt force to their leg, and the imaging has been ordered to rule out a fracture.

Sure, it’s convenient. The patient can stay right in the room. And it might be a little faster, especially if the regular x-ray department is a bit backed up. But let’s look at the my favorite indicator again, the juice to squeeze ratio

The control of the x-ray beam is not as good as with the fixed equipment. There just isn’t the same range of control available in the portable machines, which becomes important when nonstandard imaging and techniques are needed (think morbidly obese patient).

Placement of the x-ray plate can also be sub-optimal. This is especially true when biplanar images (i.e. AP and lateral) are requested, which is very common for fracture diagnosis. 

There may be additional exposure to radiation, especially to healthcare personnel or other patients. Someone has to hold that plate for the lateral image. Or other patients may be nearby, and shielding is not the same as in the rooms in the radiology department.

Bottom line: Sure, getting a portable x-ray may be the easy way to go. But only use if for studies that you absolutely must get quickly, and in which fine detail is not important. The standard chest and/or pelvis x-rays during trauma resuscitations fall into this category. But if you want the best quality imaging for diagnosis, and want to avoid repeat imaging, send your patient to the department to get some real images. Don’t settle for crappy ones!

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March Trauma MedEd Newsletter is Available!

The March newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is Imaging.

In this issue you’ll find articles on:

  • CT contrast via IO catheter
  • FAST exams in children
  • CT scanning before transfer to pediatric trauma centers
  • Radiation exposure in pediatric trauma
  • IV contrast in trauma
  • And more!

Subscribers received the newsletter first over the weekend. If you want to subscribe (and download back issues), click here.

Download the newsletter here!

The Logroll: Toward The Fractures Or Away From Them?

You know the routine. Trauma patients get the usual ATLS primary survey secondary survey double play. An important part of the secondary survey is examining the back. Without it, you’ve failed to inspect nearly 50% of the body.

Usually this part is easy, especially if you’ve got a reasonably sized trauma team. Two or three people carefully logroll the patient, one stabilizes the cervical spine, while another inspects and palpates the back. At our center, we routinely logroll to the patient’s left side, because the examiner is normally stationed at their right.

But what if they have fractured extremities? Which way to go?

Once again, this is philosophy unsupported by literature. No one does studies on mundane stuff like this. The real questions are, rolling to which side will create the least additional injury and cause the least pain?

First, let’s address the injury question. The usual rule is that all patients with fractures must have them splinted before they leave the resus room. This decreases pain, bleeding, and the opportunity for additional tissue injury. Ideally, splinting should occur before the logroll, since this maneuver can involve more movement than rolling around the hospital or moving back and forth to x-ray tables.

Next, there’s pain. Make sure that your patient has been given adequate analgesia early in the resuscitation, and sedation if indicated.

Finally, the roll. My rule is that the fractures should be rotated upwards, with helpers stabilizing each splinted extremity to keep them aligned. Avoid rolling the patient onto their own fractures (fractures down). The combination of weight and movement can and will shift the broken bones, causing exactly what you’ve sought to avoid!

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Does Hemostatic Resuscitation Really Work?

Hemostatic resuscitation (HR) is the new buzzword (buzz phrase?) these days. The new ATLS course touts it as a big change, and quite a few publications are being written about it. But, like many new things (think Factor VII), will it stand the test of time?

It has long been recognized that hemorrhage from trauma is bad. Mortality rates are high, and traditional management with crystalloids and then blood products leads to persistent coagulopathy, troublesome bleeding, tissue injury, and finally death. HR was devised to address the early coagulopathy. It concentrates on early coag correction with plasma and platelets, permissive hypotension, and rapid definitive correction of hemorrhage.

The end result of HR has been measured, and both organ perfusion and coagulopathy can be corrected with it. Unfortunately, these measurements are typically taken once hemorrhage control has been achieved. Is looking at (or beyond) the endpoint really the best way to gauge its effectiveness? 

A robust multicenter study scrutinized looked at coagulopathy correction and organ perfusion during active hemostatic resuscitation. They used ROTEM to gauge the former, and lactate levels for the latter. Values were measured on arrival and after administration of every 4 units of blood. Only patients who received at least 4 units were included (106 subjects).

Here are the factoids:

  • Average admission lactate was 6.2 meq/L, so these patients were sick
  • Patients with a lactate > 5 did not clear it until after hemorrhage was controlled and no further blood was needed
  • 43% of patients were coagulopathic by ROTEM on arrival. 
  • Coagulopathy increased for every 4 units of blood given, despite a plasma infusion ratio of close to 1:1 throughout their resuscitation

Bottom line: This was a well-done study on a relatively large number of patients, although a number of weaknesses and potential improvements are pointed out in the discussion. There’s a lot of data in the paper, and I urge you to read it in depth. But it seems to show that hemostatic resuscitation is not necessarily doing what we want it to do during the acute phase of hemorrhage. Both bleeding AND transfusions must be stopped before it appears to work. And even then, there is a delay before ROTEM and lactate parameters return to normal. For now, rapid control of hemorrhage is of utmost importance. We still need to figure out how tools like ROTEM or TEG and various serum markers will help us while we accomplish it.

Reference: Hemostatic resuscitation is neither hemostatic nor resuscitative in trauma hemorrhage. J Trauma 76(3):561-568, 2014.