All posts by TheTraumaPro

Part 2: FAST Is Fast And FAST Is Last

I’ve received a fair amount of commentary on Twitter and via email regarding my statements about FAST. Many people said that FAST and physical exam can and should happen simultaneously.

In principle, I agree. My previous statements were based on the way that we organize our trauma team and trauma activations at this hospital. The reality is that everyone’s team is different and they may run their trauma activations differently.

The goal is to get all information critical to keeping your patient alive as quickly as possible. In some cases, knowing if there is a significant amount of fluid in the abdomen can be very important. Most trauma resuscitation schemes at trauma centers make use of multiple personnel so that various portions of the patient evaluation can be carried out simultaneously.

But there is also a tradeoff between speed, trauma team size and number of trainees. Centers with fewer or no trainees will have a leaner team with experienced examiners and more room around the patient. At our hospital, we have 8 people clustered immediately around the patient, with half of them being surgery or emergency medicine residents. This means it is more difficult for a physician to step in and do a FAST exam easily. So typically, this physician is the same resident doing the torso portion of the physical exam. This is the main reason for my exhortation to wait until the end of the physical exam and do the FAST quickly.

So it is really up to each center to determine their priorities for the FAST exam based on the people who make up their trauma team. At ours, it will have to remain fast and last.

Please comment or tweet your thoughts!

DVT In Children

Deep venous thrombosis has been a problem in adult trauma patients for some time. Turns out, it’s a problem in injured children as well although much less common (<1%). However, the subset of kids admitted to the ICU for trauma have a much higher rate if not given prophylaxis (approx. 6%). Most trauma centers have protocols for chemical prophylaxis of adult patients, but not many have similar protocols for children.

The Medical College of Wisconsin looked at trends prior to and after implementation of a DVT protocol for patients < 19 years old. They used the following protocol to assess risk in patients admitted to the PICU and to determine what type of prophylaxis was warranted:

The need for and type of prophylaxis was balanced against the risk for significant bleeding, and this was accounted for in the protocol. The following significant findings were noted:

  • The overall incidence of DVT decreased significantly (65%) after the protocol was introduced, from 5.2% to 1.8%
  • The 1.8% incidence after protocol use is still higher than most other non-trauma pediatric populations 
  • After the protocol was used, all DVT was detected via screening. Suspicion based on clinical findings (edema, pain) only occurred pre-implementation.
  • Use of the protocol did not increase use of anticoagulation, it standardized management in pediatric patients

Bottom line: DVT does occur in injured children, particularly in severely injured ones who require admission to the ICU. Implementation of a regimented system of monitoring and prophylaxis decreases the overall DVT rate and standardizes care in this group of patients. This is another example of how the use of a well thought out protocol can benefit our patients and provide a more uniform way of managing them.

Related posts:

Reference: Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma 72(5):1292-1297, 2012.

Intracranial Hypertension In Pediatric Head Trauma

This 44 minute video is a good introduction to pediatric head trauma and intracranial hypertension. It covers physiology, diagnosis, as well as management using medications, position, decompression and hypothermia.

Presented at Multidisciplinary Trauma Conference at Regions Hospital on May 3, 2012 by Debbie Song MD, a pediatric neurosurgeon.

How To Jerry Rig A Rapid Infusion System

Rapid infusion systems of some type are available in most EDs. However, this equipment is not routinely available in the field or in ground ambulances. Here’s a creative way to fashion one in a pinch for my overseas readers.

Note: The system described relies on an IV infusion set called the Intrafx SafeSet, available in Europe. The drip chamber in this set has a hydrophilic filter membrane integrated into the drip chamber that prevents air from passing through. This is critical for avoiding air embolism. Any product that traps air bubbles will work.

Here are the key components:

  • A – a fluid bottle with your choice of resuscitation fluid
  • B – an Intrafix SafeSet, or other drip chamber containing an air trap
  • C – another infusion set, spiked into A to pressurize it
  • D – a bulb from a sphygmomanometer for pressurizing A

Bottom line: This barebones, low cost rapid infuser can be used in hostile environments and can achieve rapid flow rates. But remember, the drip chamber (B) must be of an air-trapping type!

Reference: Novel rapid infusion device for patients in emergency situations. Scand J Trauma Resus Emerg Med 19:35, 2011.

FAST IS Fast, And FAST Is Last!

Ever been in a trauma activation where it seems like the first thing that happens is that someone steps up to the patient with the ultrasound probe in hand? And then it takes 5 minutes of pushing and prodding to get the exam done?

Well, it’s not supposed to be that way. The whole point of adhering to the usual ATLS protocol is to ensure that the patient stays alive through and well after your exam. And FAST is not part of the primary or secondary surveys, it is an adjunct.

As always, there are a few exceptions to the rule above.

  • If an unstable patient arrives without an obvious source of bleeding, FAST of the abdomen should be able to detect if a large hemoperitoneum is present. This will expedite the patient’s transfer to the OR.
  • A patient in cardiac arrest may benefit from a quick FAST to determine if cardiac activity is present. If not, it may be time to terminate resuscitation.

Bottom line: With the exceptions noted above, always complete the ATLS primary and secondary surveys first. Then pull out the ultrasound machine, but be quick about it. If it takes more than about 60 seconds to do the exam, someone probably needs a little more practice.