Cervical spine clearance has typically required us to address both bones and ligaments. For a long time, this has involved separate steps: imaging for the bones, and exam (or additional imaging) for the ligaments. But this extra step adds complexity and seems to have a low yield.
The number of studies supporting use of only CT to clear both bones and ligaments continues to increase. A poster being presented this week at EAST details the experience with this at Virginia Commonwealth University. They looked at all their blunt trauma patients over a 5 year period. They detailed all fractures, ligamentous injuries, and how they were discovered.
Here are the factoids:
- A total of 5676 patients were entered in the study
- 420 (7%) were diagnosed with cervical fracture
- 53 (1%) had a ligamentous injury
- Of the ligamentous injuries, 21 of 53 were suspected based on the CT. The remaining 32 all had fractures in addition to the ligamentous injury.
Bottom line: Yes, it’s small and retrospective, but it continues to paint the same picture as the other papers. The authors conclude that CT alone is sufficient to clear both bones and ligaments. I presume this excludes the group that can be cleared clinically. Adopting this process will streamline the clearance process, and help avoid complications like pressure sores. What about missed injuries? There will always be a few. We are currently at a point of diminishing returns in terms of how much diagnostic radiation, magnetism, and money we throw at this problem. But the key to successfully and safely implementing this is to make sure to have the most experienced clinicians reading the images.
Reference: CT scan: it’s not just about the fracture. EAST 2014, poster #35.
Radiation exposure from diagnostic imaging remains of high interest to all trauma professionals and the lay public. A number of papers have already been written showing that repeat imaging in transferred patients is high due to issues with transmitting images between sending and receiving trauma centers.
A variety of solutions exist for reducing this problem. One of the more technically oriented ones is LifeImage, a cloud based service. Images from just about any PACS system can be uploaded to the service by a referring hospital. The receiving center can peruse the images using a sophisticated browser based tool, or they can merge the PACS data for any or all studies into their own PACS system.
ShockTrauma in Baltimore receives severely injured patients for the entire state of Maryland. They reported their experience with this cloud service over a 6 month period, and compared it to 6 months before use during the prior year. Here are the factoids:
- A total of 1,950 transfers were reviewed (!). Data was collected prospectively.
- The number of patients undergoing repeat imaging decreased significantly, from 62% to 47%
- Cost also decreased significantly, from $402K to $327K during the study periods
- Hospital length of stay decreased from 4.4 to 3.8 days
- There was no difference in mortality
Bottom line: Cloud solutions for transferring imaging information work! A lot of radiation and money was saved! Frankly, I’m puzzled as to why the decreases were so modest. I suspect that some or many of the potential referring hospitals were not participating at the time of the study. Nevertheless, it looks like the savings should easily pay for the cost of the service. I’ll definitely quiz the authors on this one and return with some answers.
Reference: Reduction in repeat imaging in patients transferred to a Level I urban trauma center decreases cost and radiation exposure. EAST 2014, poster #28.
The group at the University of Arizona has been fooling around with an instant-read hemoglobin monitor manufactured by Masimo Corp, the Pronto-7. Interesting little device. It’s a hand-held unit that looks like it uses near-infrared light to calculate the hemoglobin concentration. An optical probe is applied to a finger (like an oximeter probe), and the result is displayed almost immediately. It can also be printed or emailed.
Previous iterations of this technology for continuous readings did not correlate well with invasive blood draws. Use of an instant-read system in trauma patients has not been explored to date. The Arizona group looked at the correlation between the results of the Pronto-7 and the usual blood draw in acute trauma patients using a prospective design. Three spot-check results were obtained for every invasive blood draw.
Here are the factoids:
- 525 patients were spot-checked, with a success rate of 86% (no explanation why!)
- 173 (38%) of patients had a Hgb <= 8
- The mean difference between spot-check and blood draw results was only 0.1 g/dL (!)
- Sensitivity was 96%, accuracy 77%
Bottom line: This is an interesting new tool for acute trauma care. The only downside that I see is that we may lose sight of the fact that hemoglobin values lag behind the true blood volume in rapidly bleeding patients. We mustn’t be fooled into thinking that everything is fine just because a number is normal. There’s still room for common sense!
Reference: Transforming hemoglobin measurement in trauma patients: non-invasive spot check hemoglobin. EAST 2014, poster #20.
I have no financial interest in Masimo Corp.
Not only is the population getting older, many people end up on oral anticoagulants for one reason or another. This is supposed to be good, preventing stroke, pulmonary emobolism, etc. Until you fall down. Or crash your car. Or need emergency surgery.
All EDs are seeing more and more patients who are taking these drugs. But emergency departments are busy places, and if a patient looks okay, they may have to wait a bit for their evaluation. And for an unfortunate few, that wait time can be deadly. What we need is a way to promptly evaluate those patients while being mindful of resource utilization.
A Pennsylvania hospital addressed this problem by creating a special level of team activation called the AnitCoagulation and Trauma alert (ACT). The idea was to identify a subset of patients who were more likely to have problems from their anticoagulation after trauma. They selected the following critieria to trigger the ACT alert:
- Age > 65 and
- Taking an anticoagulant or anti-platelet agent and
- GCS >= 13 and
- Suspected loss of consciousness and
- Fall in the last 24 hours
The ACT alert is called overhead and the patient is immediately ushered into a room. They must be seen by ED physician, nurse and phlebotomist within 15 minutes. A point-of-care INR must be performed within 20 minutes, and a head CT obtained within 30 minutes. Further management is then based on the CT result.
The hospital looked at their experience and reported these factoids:
- A total of 426 patients had an ACT alert over a 10 month period and were compared to a similar control group from the previous year
- Significantly fewer ACT alert patients who were admitted stayed more than 5 days compared to admitted control patients (38% vs 52%)
- More ACT alert patients were discharged from the ED directly (56% vs 30%)
- Patients discharged from the ED were out more quickly than controls (faster throughput)
Bottom line: The analyses in this abstract make me suspect that there is some slicing and dicing of data. Why not just report hospital length of stay rather than the percentage who were in hospital more than 5 days? And I think their criteria should be tightened up a bit. Nevertheless, their research illustrates an approach that addresses a real need in all trauma centers. Anticoagulated “minor” trauma patients (those that don’t meet trauma activation criteria) can quickly develop life-threatening problems. Every center should have a system for rapidly identifying and evaluating these patients. And not using the full trauma team is a good idea, because the amount of wear and tear on the team if they had to respond to every one of these patients would be counterproductive.
Concussion evaluation is a very common reason for presentation to the ED. Many centers discharge patients from the ED with a normal GCS and a normal head CT. But is this enough? How many of these patients would benefit from further outpatient evaluation and possible treatment?
Another study from Grant Hospital in Columbus looked at a subset of mild TBI patients from the ED who also underwent more robust neurocognitive evaluation within 48 hours of their discharge.
Here are the factoids:
- of the 6000+ trauma patients seen over a 17 month period, only 396 met the inclusion criteria (age >13, GCS 15, normal head CT, blunt trauma, no psych issues) and had a neurocognitive eval within 48 hours
- 41% were cleared for discharge without any followup or supervision. 88% of these had known or suspected loss of consciousness.
- 25% required outpatient therapy or were not safe for discharge. 81% of these had possible LOC.
- Only 28% of patients who required ongoing therapy would have met traditional ED discharge guidelines
Bottom line: First, this abstract is very poorly written. The concept comes across (barely), but is presented badly. Obviously, loss of consciousness is not much of an indicator of anything. The question is, how can we more reliably determine if a patient will need further cognitive evaluation or therapy? Gross GCS and head CT results do not seem to be enough. One solution may be to have ED nurses administer a basic cognitive screen to identify more subtle problems. The Short Blessed Test is ideal for this, and takes only a few minutes of time. And the key is to have some type of TBI clinic available to refer these patients to if they fail the test!
Reference: You can’t go home: routine concussion evaluation is not enough. EAST 2014, poster abstract #12.