All posts by TheTraumaPro

Answer: What The Heck Video! Part 1

Several of you figured this one out! The patient was involved in a high speed car crash and was brought to the ED in respiratory distress.  Decreased left sided breath sounds were noted. The following xray was obtained.

Opacity is noted in the left lung field, and a modest pneumothorax is seen on the right. Bilateral first ribs are fractured, and the left second through fourth ribs are also broken. The patient was intubated and bilateral chest tubes were inserted.

There was minimal blood from the left chest tube, and a small amount of air from the right. Note the extensive subcutaneous emphysema.

What should we do next? Are any other diagnostic tests indicated? Could the endotracheal tube placement be part of the problem?

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Answer: Finding Rib Fractures On Chest Xray

There was a lot of chatter regarding my practical tip yesterday, rotating the chest xray to better visualize rib fractures. Here’s the quiz xray from yesterday: 

And here’s the lateral view:

The fracture is perfectly placed on the most lateral aspect of the left 9th rib. You can download the full size rotated jpg here if you are having a hard time seeing it on the reduced size image above. Piece of cake!

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Practical Tip: Finding Rib Fractures On Chest Xray

Here’s a neat trick for finding hard to see rib fractures on standard chest x-rays.

First, this is not for use with CT scans. Although chest CT is the “gold standard” for finding every possible rib fracture present, it should never be used for this. Rib fractures are generally diagnosed clinically, and they are managed clinically. There is little difference in the management principles of 1 vs 7 rib fractures. Pain management and pulmonary toilet are the mainstays, and having an exact count doesn’t matter. That’s why we don’t get rib detail x-rays any more. We really don’t care. Would you deny these treatments in someone with focal chest wall pain and tenderness with no fractures seen on imaging studies? No. It’s still a fracture, even if you can’t see it.

So most rib fractures are identified using plain old chest xray. Sometimes they are obvious, as in the image of a flail chest below.

 

But sometimes, there are only a few and they are hard to distinguish, especially if the are located laterally. Have a look at this image:

 

There are rib fractures on the left side side on the posterolateral aspects of the 4th and 5th ribs. Unfortunately, these can get lost with all the other ribs, scapula, lung markings, etc.

Here’s the trick. Our eyes follow arches (think McDonald’s) better than all these crazy lines and curves on the standard chest x-ray. So tip the x-ray on its side and make those curves into nice arches, then let your eyes follow them naturally:

 

Much more obvious! In the old days, we could just manually flip the film to either side. Now you have to use the rotate buttons to properly position the digital image.

Final exam: click here to view a large digital image of a nearly normal chest xray. There is one subtle rib fracture. See if you can pick it out with this trick. You’ll have to save it so you can manipulate it with your own jpg viewer. If you find it, tweet it out to me! Let’s see who gets it first!

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Can TBI Be Managed Without Neurosurgical Consultation?

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. A paper to be presented at the upcoming EAST meeting looked at management of these patients by acute care surgeons.

The authors retrospectively reviewed all patients who had a TBI and positive head CT managed with or without neurosurgery consultation over a two year period. Although the authors were from the University of Arizona, a Level I ACS trauma center, the abstract does not explicitly state whether the patients were seen in their hospital or another lower level one.They matched the patients with and without neurosurgical consultation for age, GCS, AIS-Head and presence of skull fracture and intracranial hemorrhage.

A total of 90 patients with and 90 patients without neursurgical involvement were reviewed. Here are the interesting findings:

  • Hospital admission rate was identical for both groups (87-90%)
  • ICU admission was significantly higher if neurosurgeons were involved (20% vs 41%)
  • Repeat head CT was ordered more than 3 times as often by neurosurgeons (20% vs 72%)
  • Post-discharge head CT was ordered more often by neurosurgeons, but was not significantly higher (5% vs 12%)

Nothing is said about complications or mortality, or whether neurosurgeons were available in case things went awry.

Bottom line: This abstract raises an interesting question: can surgeons safely manage select patients with intracranial injury? The answer is probably yes, although this abstract is not complete enough to fully support the idea. 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). As neurosurgery involvement in acute trauma declines, this concept will become more and more pertinent.

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Reference: The acute care surgery model: managing traumatic brain injury without an inpatient neurosurgical consultation. EAST Annual Scientific Assembly, Paper 10, January 2013.