It’s that dreaded mechanism of injury: “found down.” What really happened? Did they fall, or get assaulted? Or did the patient suffer a medical problem that led to them falling down? Trauma professionals rely heavily on what I call “context.” Is the patient elderly and frail? Are they intoxicated? What was their location when found? Are there pre-existing medical conditions?
All of these factors allow us to begin building a story in our mind that tells us what might have happened, and what the injuries might be. But with little or no context, we are flying by the seat of our pants. We end up suspecting everything, which means we image everything. With CT scans. And IV contrast. There is always a chance that we can add to the harm already suffered by this patient, or waste time and money.
The abdomen is a black box in a patient with an unreliable or absent physical exam. The emergency medicine group at Cedars-Sinai in Los Angeles looked at the utlity of CT scanning the abdomen in this group of patients. They retrospectively reviewed 10 years of their data. They found 342 patients, of which 154 underwent some type of abdominal imaging (CT, FAST).
Here are the factoids:
About 60% had alcohol present, and 98% of those had a level greater than 0.08 g/dL
Overall mortality was 10%. 24 were trauma related (severe TBI, traumatic arrest in ED), and 9 were medical (CVA, sepsis)
55% did not undergo any abdominal imaging, and their mortality was 6% (TBI, stroke, MI). None manifested a late abdominal injury.
Of the 45% who did have abdominal imaging, 57% had CT, 24% FAST, and 19% both
14 patients in the imaged group had a positive abdominal CT, but all were minor (Abbreviated Injury Score (AIS) <3)
5 patients had a positive FAST, and all had an abdominal AIS<3
Bottom line: Patients who are “found down” seldom have significant intra-abdominal injuries. Keep in mind that this is a small study group, but it does seem to correlate with personal experience and reviews of many charts. Although you can’t completely ignore the abdomen in this group of patients, you should place a higher priority on head and neck trauma, or CVA/sepsis in patient without other obvious injury.
I just met John Hinds in person only two weeks ago. But that was enough to leave a lasting impression. He was charismatic, energetic, and dedicated to his craft. Witnessing him in action at SMACC Chicago, and watching his enthusiasm for emergency and trauma care was truly inspiring.
Unfortunately, John died on July 4th, doing what he loved. He was involved in an accident while providing medical cover for a practice session of the Skerries 100 motorcycle race in County Dublin.
The trauma world is now a little emptier, but John left a mark that will stay with us for a long time to come.
There is considerable variability in the way that penetrating wounds are approached. Some are located over areas of lesser importance (distal extremities) or are so superficial that they obviously don’t fully penetrate the skin.
Unfortunately, some involve high-value structures (much of the neck and torso), or are too small to tell if they penetrate (ice pick injury). How should these injuries be approached?
Too often, someone just probes the wound and makes a pronouncement based on that assessment. Unfortunately, there are major problems with this technique:
The tract may be too small to appreciate with a finger or even a cotton-tip swab
The tract may be oriented in an unexpected direction, or the soft tissues may have moved after the penetration occurred. In this case, the examiner may not appreciate any significant depth to the wound.
Inserting an object may violate a structure that you wish it hadn’t (resulting in a hissing sound after probing a chest wound, or a column of blood after probing the neck)
A better way to approach these wounds is as follows:
Is the patient unstable? If so, you know the penetration caused the problem and the patient belongs in the OR.
Is there other evidence of deep injury, such as peritonitis with a penetrating abdominal wound? If so, the patient still needs to go to the OR.
Do a legitimate local wound exploration. This entails making the hole bigger with a knife, and using surgical instruments and your eyes to find the bottom of the tract. Obviously, there are some parts of the body where this cannot be done, such as the face, but they probably don’t need this kind of workup anyway.
As one of my mentors, John Weigelt, used to say, “Doctor, do you have an eye on the end of your finger?” In general, don’t use anything that doesn’t involve an eyeball in your local wound explorations!
The standard of care in most high level trauma centers is to involve neurosurgeons in the care of patients with significant traumatic brain injury (TBI). However, not all hospitals that take care of trauma patients have immediate availability of this resource. An interesting paper looked at management of these patients by acute care surgeons.
The authors retrospectively reviewed all their patients who had a TBI and positive head CT managed with or without neurosurgery consultation over a two year period. They matched the patients with and without neurosurgical consultation for age, GCS, AIS-Head and presence of skull fracture and intracranial hemorrhage (parenchymal, epidural, subdural, subarachnoid). Neurosurgeons were available to the no-consult group if things went awry.
A total of 180 patients with and 90 patients without neurosurgical involvement were reviewed. Here are the interesting findings:
Hospital admission rate was identical for both groups (88%)
ICU admission was significantly higher if neurosurgeons were involved (20% vs 44%)
Repeat head CT was ordered more than 3 times as often by neurosurgeons (20% vs 86%)
Post-discharge head CT was ordered more often by neurosurgeons, but was not significantly higher (5% vs 12%)
There were no neurosurgical interventions, in-hospital mortalities, or readmissions within 30 days in either group
Based on this experience, the hospital adopted a set of guidelines for helping determine if neurosurgery should be consulted.
Bottom line: This work raises an interesting question: can general surgeons safely manage select patients with intracranial injury? The answer is probably yes. The majority of patients with mild to moderate TBI with small intracranial bleeds do well despite everything we throw at them. And it appears that surgeons use fewer resources managing them than neurosurgeons do. The keys to being able to use this type of system are to identify at-risk patients who really do need a neurosurgeon early, and having a quick way to get the neurosurgeon involved (by consultation or hospital transfer). Looking at the brain injury guidelines above, I am a little nervous about managing an epidural or contusion without one additional head CT. But this is certainly food for thought. As neurosurgery involvement in acute trauma declines, this concept will become more and more pertinent.