All posts by The Trauma Pro

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Tips For Surgeons: Seat Belt Sign

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We see seat belt signs at our trauma center with some regularity. There are plenty of papers out there that detail the injuries that occur and the need for a low threshold for surgically exploring these patients. I have not been able to find specific management guidelines, and want to share some tidbits I have learned over the years. Yes, this is based on anecdotal experience, but it’s the best we have right now.

Tips for surgeons:

  • Common injuries involve the terminal ileum, proximal jejunum, and sigmoid colon. My observation is that location in the car is associated with the injury location, probably because of the location of the seat belt buckle. In the US, drivers buckle on the right, and I’ve seen more terminal ileum and buckethandle injuries in this group. Front seat passengers buckle on the left, and I tend to see proximal jejunum and sigmoid injuries more often in them.
  • Seat belt sign on physical exam requires abdominal CT for evaluation, regardless of age. The high incidence of significant injury mandates this test.
  • Seat belt sign plus any anomaly on CT requires evaluation in the OR. The only exception would be a patient with minimal fluid only in the pelvis with an unremarkable abdominal exam. But I would watch them like a hawk.
  • In patients who cannot be examined clinically (e.g. severe TBI), a rising WBC count or lactate beginning on day 2 after adequate resuscitation should prompt a trip to the OR. This is an indirect method for detecting injured bowel or mesentery.
  • Laparoscopy may be used in patients with equivocal findings. Excessive blood, bile tinged fluid, succus, or lots of fibrin deposits on the bowel should prompt conversion to laparotomy. Tip: place all ports distant to the seat belt mark. The soft tissues are frequently disrupted, and gas may leak into this pocket prohibiting good insufflation of the peritoneal cavity.
  • If in doubt, open the abdomen. It’s bad form to put in the scope, see something odd, and walk away. Remember, any abnormal finding after trauma is related to trauma until proven otherwise. It’s almost never pre-existing disease.

Related posts:

General

Predicting Escalation Of Domestic Violence

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Most trauma professionals will have the opportunity to provide care for victims of domestic violence some time during their career. We are on the front lines and can unfortunately see the damage first hand. From time to time, the abuse escalates to a point where the woman (typically) is murdered. Is there a way to predict this fatal progression so it can be avoided?

The answer is yes! The Danger Assessment Tool (DAT) was developed 25 years ago and has been validated. Even though the instrument is old, it remains extremely helpful. The unfortunate thing is that at least half of the women involved do not recognize the grave peril they are in.

Some key points that were uncovered in the development of the DAT:

  • If a gun or other weapon is used to threaten, the risk of being murdered increases 20-fold
  • If there is merely a gun in the house, the risk of murder increases 6 times
  • If the abuser threatens murder, the risk of being killed increases 15-fold
  • Other indications of increased risk of death include heavy substance abuse, extreme jealousy, stepchild in the household, attempts to choke and forced sex

Bottom line: Domestic violence is criminal. We must go beyond the physical treatment and make sure these individuals are safe. Use the Danger Assessment Tool routinely to help identify women most at risk of losing their lives and bring all your social services resources to bear to keep them safe!

Download: Danger Assessment Tool

References:

  • Campbell, Jacquelyn C., Assessing Dangerousness: Violence by Sexual Offenders, Batterers, and Child Abusers, Newbury Park, CA: Sage Publications, 1995.
  • Campbell, Jacquelyn C. , Phyllis W. Sharps, and Nancy Glass, “Risk Assessment for Intimate Partner Violence,” in Clinical Assessment of Dangerousness: Empirical Contributions, ed. Georges-Franck Pinard and Linda Pagani, New York: Cambridge University Press, 2000: 136–157.
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Prehospital Lift-Assist Calls

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Here’s something I was completely unaware of until just a few years ago. A number of 9-1-1 calls (quite a few, I am told) are made, not for injury or illness, but because the caller needs help getting back into bed, chair, etc. It is also common that prehospital providers are frequently called back to the same location for the same problem, or a more serious one, within hours or days.

Yet another study from Yale looked at the details of lift-assist calls in one city in Connecticut (population 29,000) during a 6 year period. The town has a fire department based EMS system with both basic and advanced life support, and they respond to 4,000 EMS calls per year. 

Some interesting results:

  • Average crew time was about 20 minutes
  • 10% of cases required additional fire department equipment, either for forced entry or for assistance with bariatric patients
  • About 5% of all calls were for lift-assist, involving 535 addresses
  • Two thirds of all calls went to one third of those addresses (174 addresses)
  • There were 563 return calls to the same address within 30 days (usual age ~ 80)
  • Return calls were for another lift-assist (39%), a fall (8%), or an illness (47%)

Bottom line: It looks to me that we are not doing our elderly patients any favors by picking them up and putting them back in their chair/bed. Lift-assist calls are really a sentinel event for someone that is getting sick or who has crossed the threshold from being able to live independently to someone who needs a little more help (assisted living, etc). Prehospital personnel should systematically look at and report the home environment, and communities should automatically involve social services to help ensure the health and well being of the elder. And a second call to the same location should mandate a medical evaluation in an ED before return to the home.

Reference: A descriptive study of the “lift-assist” call. Prehospital Emergency Care, online ahead of print, September 2012.

General

Drugs Are Chemicals??

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One of the cornerstones of allopathic medicine is the use of drugs to treat disease conditions. And unfortunately, one of the side effects of using drugs to treat problems is the production of side effects(!).

In trauma care, even something as simple as treating pain from an injury can create major problems. Give a narcotic pain medication. The patient gets nauseated and vomits. Try a different narcotic. The patient develops constipation. Give stool softeners and cathartics. Diarrhea. Then pseudo-obstruction develops. Give neostigmine. The patient becomes bradycardic. Give… well, you get the picture.

How common are side effects? Very! Did anyone see the first TV commercials for Chantix, the smoking cessation drug? It was about 3 minutes long because of the long list of side effects that were described. I’m surprised anyone was willing to risk them just to stop smoking cigarettes.

A recent study looked at the number of side effects listed on the labels of 5,602 medications approved by the FDA. There were a grand total of 534,125 adverse drug effects described in the packaging. Some interesting statistics:

  • The number of adverse effects for ranged from 0 to 525(!) for a single drug
  • The median number of adverse effects was 49, the average was 70
  • Drugs with the most side effects are used in neurology, psychiatry and rheumatology
  • Newer drugs had significantly more adverse effects than older ones

It’s certainly easy to bash pharmaceutical companies on their products. But some of these findings may be due to more rigorous testing and monitoring, as well as nuances in the populations in which these drugs are used.

Bottom line: Drugs are chemicals! Each chemical has a number of effects, some of which are desirable, and some of which are not. The drug companies choose to market a drug based on one desired effect (e.g. control of nausea). Just remember, when you give that medication, you will probably get the desired effect, but you will just as likely also get some of the other 69 possible side effects. Be prepared, and prescribe sensibly.

Reference: A quantitative analysis of adverse events and “overwarning” in drug labeling. Arch Int Med 171(10):944-946, 2011.

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The “Passing” Of The Rectal Exam In Trauma

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It has long been standard operating procedure to perform a digital rectal exam in all major trauma patients. The belief has always been that valuable information about blood in the GI tract, the status of the urethra, and the neuro exam (rectal tone) could be gleaned from the exam.

Unfortunately, the exam also serves to antagonize or even further traumatize some patients, especially those who may be intoxicated to some degree. On a number of occasions I have seen calm patients become so agitated by the rectal that they required intubation for control.

So is it really necessary? A study in 2001 conducted over a 6 month period (1) showed that the rectal exam influenced management in only 1.2% of cases. The authors felt that there was some utility in 3 special cases:

  • Spinal cord injury – looking for sacral sparing
  • Pelvic fracture – looking for bone shards protruding into the rectum
  • Penetrating abdominal trauma – looking for gross blood

A more recent 2005 study (2) was also critical of the rectal exam and found that using “other clinical indicators” (physical exam and other diagnostic study information) was at least equivalent, changing management only 4% of the time. They concurred with the first two indications above as well.

The Bottom Line: For most major trauma patients, the rectal exam is not worth the patient aggravation it causes. I still recommend it for the 3 special cases listed above, however, as there are no equivalent exams for these potentially serious patient problems. And remember, DON’T do it while the patient is in the logroll position. No patient likes a rectal exam, so they’ll do their best to defeat your attempt at spine precautions if you have them on their side. Supine, frog-leg only.

References:
1. Porter, Urcic. Am Surg. 2001 May;67(5):438-41.
2. Esposito et al. J Trauma. 2005 Dec;59(6):1314-9.