All posts by TheTraumaPro

The Tertiary Survey for Trauma

Major trauma victims are evaluated by a team to rapidly identify life and limb threatening injuries. This is accomplished during the primary and secondary surveys done in the ED. The ATLS course states that it is more important for the team to identify that the patient has a problem (e.g. significant abdominal pain) than the exact diagnosis (spleen laceration). However, once the patient is ready for admission to the trauma center, it is desirable to know all the diagnoses.

This is harder than it sounds. Physical examination tends to direct diagnostic testing, and some patients may not be feeling pain, or be awake enough to complain of it. Injuries that are painful enough may distract the patient’s attention away from other significant injuries. Overall, somewhere between 7-13% of patients have injuries that are missed during the initial evaluation.

A well-designed tertiary survey helps identify these occult injuries before they are truly “missed.” This survey consists of a structured and comprehensive re-examination that takes place within 48-72 hours, and includes a review of every diagnostic study performed. Ideally, it should be carried out by two people: one familiar with the patient, and the other not. It is desirable that the examiners have some experience with trauma (sorry, medical students).

The patients at highest risk for a missed injury are those with severe injuries (ISS>15) and/or impaired mental status (GCS<15). These patients are more likely to be unable to participate in their exam, so a few injuries may still go undetected despite a good exam.

I recommend that any patient who triggers a trauma team activation should receive a tertiary survey. Those who have an ISS>15 should also undergo the survey. Good documentation is essential, so an easy to use form should be used. Click here to get a copy of our original paper form. We have changed over to an electronic record, and have created a dot phrase template, which you can download here.

Tomorrow: Does the tertiary survey actually work?

Orthopedic Hardware And TSA Metal Detectors

Many trauma patients require implantable hardware for treatment of their orthopedic injuries. One of the concerns they frequently raise is whether this will cause a problem at TSA airport screening checkpoints (Transportation Safety Administration).

The answer is probably “yes.” About half of implants will trigger the metal detectors, and these days that usually means a pat down search. And letters from the doctor don’t help. It turns out that overall, 38% are detected when the scanner is set to low sensitivity and 52% at high sensitivity.

Here is a more detailed breakdown:

  • Lower extremity hardware is detected 10 times more often than upper extremity or spine implants
  • 90% of total knee and total hip replacements are detected
  • Upper extremity implants such as shoulder, wrist and radial head replacements are rarely detected
  • Plates, screws, IM nails, and wires usually escape detection
  • Cobalt-chromium and titanium implants trigger alarms more often than stainless steel

If your patient knows that their implant triggers the detectors, they have two options: request a patdown search, or volunteer to go through the full body millimeter wave scanner. This device looks at everything from the skin outwards, and will not “see” the implant and is probably the preferred choice. If they choose to go through the metal detector and trigger it, they are required to have a patdown. Choosing to go through the body scanner after setting off the detector is no longer an allowed option.

Reference: Detection of orthopaedic implants in vivo by enhanced-sensitivity, walk-through metal detectors. J Bone Joint Surg Am. 2007 Apr;89(4):742-6.

The Fourth Law Of Trauma

And now, the last one in the series (for now).

You’ve just received a young male who had been stabbed under his right arm in your emergency department. He’s awake, talking, and very friendly. He met your trauma activation criteria, so you are cruising through the full evaluation. Lines in, blood drawn, clothes off. He wonders aloud if all this is really necessary.

Then, on FAST exam, you see it. A pericardial stripe that looks like a mix of liquid and clotted blood. Your colleague steps in and verifies the exam. But vital signs are normal, the patient is fine.

What next? CT of the chest to further define this? A formal echo to confirm? Your surgeon says no, we’re going to the OR, now! Reluctantly, you package the patient and send him on his way. In the OR, the anesthesiologist takes his time, putting in an arterial line, asking the patient unrelated questions. A thoracotomy? Really? The patient remains awake and alert through all of this.

So here’s the fourth law:

Even awake, alert, and stable patients die. And it hurts that much more when they do.

Bottom line: You know the diagnosis in this case. And you know what needs to be done. But the awake and alert patient fools us. Fakes us out. Somehow, we equate the ability to talk intelligently with being fine. But evil things can be going on inside that don’t rear their ugly head until it’s too late. Don’t get suckered! Believe your exam, not what the patient thinks they are telling you.

Other Laws of Trauma:

The Third Law Of Trauma

Trauma patients don’t always behave the way we would like. They continually surprise us, sometimes for the better when they recover more quickly and completely than we thought. But sometimes it’s for the worse. They occasionally crash when we think everything is going so well.

The crashing patient is in obvious need of help and most trauma professionals know what to do. But then there’s the hypotensive patient. The BP just dropped to 84, and it’s not budging. Many don’t see this for what it is: a slow motion crash. And they want to do things they wouldn’t think of doing to a crashing patient. Like go to CT, do some more stuff in the ED because that BP cuff just has to be wrong, or call interventional radiology and wait for 45 minutes.

But here’s the thing:

The only place an unstable trauma patient can go is to the OR.

Bottom line: By definition, an unstable trauma patient is bleeding to death until proven otherwise (the second law, remember?). Radiation can’t fix that. Neither can playing around in the resuscitation room, unless the bleeding is spraying you in the face. The surgeon needs to quickly figure out which body cavity is the culprit, and address it immediately. And the only place with the proper tools to do that is an operating room.

Other Laws of Trauma:

The Second Law Of Trauma

There are two broad categories of things that kill trauma patients. No, I’m not talking about violent penetrating injury, falls, car crashes, or any other specific mechanisms. I am referring to the end events (on a macro scale) that take their lives.

These two basic killers are: hemorrhage and brain injury. The vast majority of the time, a dying trauma patient has either suffered a catastrophic brain injury, or has ongoing and uncontrolled bleeding.

Here’s the law:

Your trauma patient is bleeding to death until you prove otherwise. 

Bottom line: Since there is little we can do above and beyond the basics in the ED for severe brain injury, your focus must be on hemorrhage. There are lots of things we can do about that, and the majority involve an operating room. Always assume that there is a source of hemorrhage somewhere, and it just hasn’t shown itself yet. There can be no rest until you prove that the source does not exist. And hopefully, you do that very, very quickly.

Other Laws of Trauma: