So yesterday, we found that our patient was hemodynamically stable, with a knife in his back, positioned prone. An initial chest xray shows the knife (plainly) and haze in the right side of the chest. Obviously, this is a hemothorax.
Key points to note are that the amount of blood present is modest and the knife point is relatively medial, as is the entry seen on the outside. Combined, these data points indicate that you have time to gather more information.
My choice was to go to CT to get the ultimate anatomic information. What, you say, the patient is prone! Well, the scanner doesn’t care. As long has his torso AND the knife fit through, it works. Here’s the representative scan result:
What do you do now? Where do you do it? Answer tomorrow. Tweet or comment your decision!
Yesterday, I presented a case of a young man with a knife in his back. He was brought to your ED in the prone position. The question was, what to do next?
With any trauma patient, regardless of size, shape, or position, the first question is always, “does this patient belong in the ED?” And usually, that question is answered by checking hemodynamic stability.
This patient stays prone while you quickly assess vital signs. If vitals are abnormal, he needs to get rolled to the operating room immediately, while still prone. There is no time to figure out how to reposition, or if the knife can be removed. Get him out of your ED.
But let’s say he is hemodynamically normal and talking to you. You need more information. So start with a physical exam. With him in the prone position! It works. In this case, there are no other puncture wounds, and the anterior part of the body can be examined by carefully logrolling him onto his side. Breath sounds are decreased over the right chest, otherwise there are no other anomalies.
So now what? Well, let’s get some more info! How about a chest xray? Best position? Prone! It’s the easiest, because the patient does not need to be held up next to an xray plate, which would also have to be held manually. The lateral view doesn’t add anything but hassle. Here’s the result:
Now what? What do you see, what do you do? Tweet or comment; more to follow tomorrow.
Here’s an interesting case to consider. A young male is assaulted and stabbed to the back. Paramedics bring him to your ED as a trauma team activation, and the full team is assembled prior to his arrival.
He is brought into the room on the stretcher in the prone position. Here is a representative picture. This is not the actual patient, just a picture I found on another blog site that looks pretty close to the real case.
Let’s walk through the thought processes of managing this over the next few days.
First, what do you need to know right now to navigate your critical decision points? And what are you going to do regarding positioning, evaluation, and imaging?
Tweet or comment with your replies! More on Monday.
We’ve all been faced with injured patients who are taking some kind of anticoagulant, and it complicates their care. Many trauma professionals just say, “they just shouldn’t take this stuff any more." Why can’t we just stop them in patients at risk for injury (e.g. an elderly patient who falls frequently)?
Two major risk groups come to mind: those taking the meds who have DVT (or a propensity to get it), and patients with atrial fibrillation who take them to decrease stroke risk. I was not able to find much info (yet) on the former category. But there is a series of nicely done studies based on work from the Framingham Heart Study.
The Framingham study started in 1948, and has been following over 5,000 people for the development of cardiovascular disease. In this particular analysis, 5070 patients who were initially free of disease were analyzed for development of atrial fib and occurrence of stroke. Anticoagulants were seldom used in this group.
The authors found that the prevalence of stroke increased with age in patients with atrial fib. The percentage that could be attributed to a-fib also increased. The following summarizes their numbers:
- Age 50-59: 0.5 strokes per 100 patients, attributable risk 1.5%
- Age 60-69: 1.8 strokes per 100 patients, attributable risk 2.8%
- Age 70-79: 4.8 strokes per 100 patients, attributable risk 9.9%
- Age 80-89: 8.8 strokes per 100 patients, attributable risk 23.5%
Bottom line: The risk of having a stroke just because a patient has atrial fibrillation goes up significantly with age. So setting an age cutoff for taking an anticoagulant doesn’t make sense. Unfortunately, increasing age also means increasing risk of injury from falls. Warfarin definitely cuts that risk, and it happens to be relatively easily reversbile. However, the newer non-reversible drugs change the equation, shifting the risk/benefit ratio too far toward the dark side. We need some good analyses to see if it really makes sense to move everybody to these new (expensive) drugs just to make it easier to dose and monitor. The existing studies on them only look at stroke, but don’t take injury morbidity and mortality into account.
Reference: Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 22:983-988, 1991.
Click here to download a reference sheet for dabigatran reversal.
This is a perfect example of why you cannot just simply read an abstract. And in this case, you can’t just read the paper, either. You’ve got to critically think about it and see if the conclusions are reasonable. And if they are not, then you need to go back and try to figure out why it isn’t.
A study was recently published regarding bleeding after nonoperative management of splenic injury. The authors have been performing an early followup CT within 48 hours of admission for more than 12 years(!). They wrote this paper comparing their recent experience with a time interval before they implemented the practice.
Here are the factoids. Pay attention closely:
- 773 adult patients were retrospectively studied from 1995 to 2012
- Of 157 studied from 1995 to 1999, 83 (53%) were stable and treated nonoperatively. Ten failed, and all the rest underwent repeat CT after 7 days.
- After a “sentinel delayed splenic rupture event”, the protocol was revised, and a repeat CT was performed in all patients at 48 hours. Pseudoaneurysm or extravasation initially or after repeat scan prompted a trip to interventional radiology.
- Of 616 studied from 2000-2012, after the protocol change, 475 (77%) were stable and treated nonoperatively. Three failed, and it is unclear whether this happened before or after the repeat CT at 48 hours.
- 22 high risk lesions were found after the first scan, and 29 were found after the repeat. 20% of these were seen in Grade 1 and 2 injuries. All were sent for angiography.
- There were 4 complications of angiography (8%), with one requiring splenectomy.
- Length of stay decreased from 8 days to 6.
So it sounds like we should be doing repeat CT in all of our nonoperatively managed spleens, right? The failure rate decreased from 12% to less than 1%. Time in the hospital decreased significantly as well.
Wrong! Here are the problems/questions:
- Why were so many of their patients considered “unstable” and taken straight to OR (47% and 23%)?
- CT sensitivity for detecting high risk lesions in the 1990s was nothing like it is today.
- The accepted success rate for nonop management is about 95%, give or take. The 99.4% in this study suggests that some patients ended up going to OR who didn’t really need to, making this number look artificially high.
- The authors did not separate pseudoaneurysm from extravasation on CT. And they found them in Grade 1 and 2 injuries, which essentially never fail
- 472 people got an extra CT scan
- 4 people (8%) had complications from angiography, which is higher than the oft-cited 2-3%. And one lost his spleen because of it.
- Is a 6 day hospital stay reasonable or necessary?
Bottom line: This paper illustrates two things:
- If you look at your data without the context of what others have done, you can’t tell if it’s an outlier or not; and
- It’s interesting what reflexively reacting to a single adverse event can make us do.
The entire protocol is based on one bad experience at this hospital in 1999. Since then, a substantial number of people have been subjected to additional radiation and the possibility of harm in the interventional suite. How can so many other trauma centers use only a single CT scan and have excellent results?
At Regions Hospital, we see in excess of 100 spleen injuries per year. A small percentage are truly unstable and go immediately to OR. About 97% of the remaining stable patients are successfully managed nonoperatively, and only one or two return annually with delayed bleeding. It is seldom immediately life-threatening, especially if the patient has been informed about clinical signs and symptoms they should be looking for. And our average length of stay is 2-3 days depending on grade.
Never read just the abstract. Take the rest of the manuscript with a grain of salt. And think!
Reference: Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma: early screening leads to a decrease in failure rate. J Trauma 76(6):1349-1353, 2014.