All posts by TheTraumaPro

(In)appropriate Neurosurgical Consultation

Emergency physicians and trauma surgeons routinely assess patients with potential neurotrauma and decide whether to obtain CT scans and/or neurosurgical consultations. The criteria they use to make these decisions are not always clear.

The neurosurgery department at the University of California – Davis performed a prospective study that looked at the appropriateness of consults they received and of CTs of the head ordered by other physicians in trauma and non-trauma patients. A total of 99 patients entered the study (32 head trauma, 29 spine trauma, 34 other disease, 4 not documented).

After reviewing the consultations, they found that 69 were appropriate, 32 were not appropriate, and 7 could not be classified. Additionally, they felt that 10 of the head CTs in injured patients (31%) were not indicated.

“Appropriateness” was difficult to define well in this study, and there is certainly a great deal of subjectivity involved. The authors recommend using the Canadian CT Head Rule to fine-tune use of head CT in trauma patients.

The bottom line: 1 in 4 consults were not appropriate, and 1 in 3 head CTs were not indicated. Despite its flaws, this study shows that we need to be better at evaluating our patients to reduce unnecessary consults and radiation!

Reference: (In)appropriate neurosurgical consultation. van Essen et al. Clinical Neurology and Neurosurgery. In press, for publication 10/2010.

GI Contrast In CT Scanning for Blunt Trauma

Torso CT scanning has become a mainstay in the evaluation of major blunt trauma. The question of using GI contrast in these CTs arises from time to time. There is an ongoing battle between the ED physician/trauma surgeon, who want quick clinical and relevant results, and the radiologist, who wants nice pictures and a comprehensive list of diagnoses.

IV contrast is so helpful and immediately available that it is virtually a no-brainer to use. The only exception is in patients who have a known allergy to it. GI contrast is more complicated. Ideally, it should be given in divided doses over about an hour, and there just isn’t time for it in trauma patients.

We designed a prospective, randomized study more than 10 years ago that looked at groups of patients who either did or did not receive oral contrast. We studied 394 patients and looked a the need for laparotomy based on study results, delayed diagnoses, and nausea/vomiting.

Thirteen percent of the patients in each group vomited. There were two aspirations, both in the non-contrast group. There were 50 abnormal scans in the contrast group and 55 in the no-contrast group. Nineteen contrast and 14 no-contrast patients were taken to OR.

Most interesting, there were 6 bowel injuries in the contrast group and one was not seen by CT. There were 3 bowel injuries in the no-contrast group and all were seen on CT. We found that there were always other signs of injury, such as mesenteric stranding or bubbles. 

Bottom line: Oral contrast is not necessary in acute blunt trauma patients undergoing CT of the abdomen. 

How To: Retrograde Urethrogram

One of the hallmarks of urethral injury is blood and the meatus in males. The standard answer to the question “how do you evaluate for it?” is “retrograde urethrogram.” Unfortunately, too few people know how to perform this test, and not all radiologists are familiar. Many times it falls to the urologist, who may not be immediately available.

The technique is simple. The following items are needed:

  • A urine specimen cup
  • A tube of KY jelly (not the little unit dose packs)
  • A bottle of renografin or ultravist contrast
  • A 50-60 cc Toomey syringe (slip-tip)
  • A fluoroscopy suite

Pour 25cc of contrast and 25cc of KY jelly in the specimen cup, cap it and shake well. Draw the contrast jelly up into the syringe. Under fluoro, insert the tip of the syringe into the penis and pull the penis toward yourself, pinching the meatus around the tip of the syringe. Slowly inject all the contrast, watching the contrast column on the fluoro screen. Once there is easy flow into the bladder, you can stop the study. If you see extravasation into the soft tissues, stop the study and call Urology.

The advantages to using this technique are:

  • The contrast/jelly mix creates a contrast gel that is less likely to leak from the meatus when injected
  • The jelly makes it easy to insert the catheter if no urethral injury is detected

Normal urethrogram:

Normal urethrogram

Abnormal urethrogram:

Abnormal urethrogram

CIWA Demystified

What exactly is the CIWA protocol?

It is a tool used commonly in the US that helps clinicians assess and treat potential alcohol withdrawal. A significant amount of injury in this country is due to the overuse of alcohol. A subset of these patients are admitted and do not have access to alcohol. They may begin to withdraw within a few days, and this condition can lead to dangerous complications.

The Clinical Institute Withdrawal Assessment measures 10 items that are associated with withdrawal:

  • Nausea / vomiting
  • Anxiety
  • Paroxysmal sweats
  • Tactile disturbances (itching, bugs crawling on skin, etc)
  • Visual disturbances
  • Tremors
  • Agitation
  • Orientation
  • Auditory disturbances
  • Headache

All items are measured on a scale of 0-7 with the exception of orientation, which uses a scale of 0-4. All subscores are tallied to arrive at the final score.

The total score is used to determine whether benzodiazepines should be given to ameliorate symptoms or avoid seizures. Typically, a threshold is selected (8 or 10) and no medications are needed as long as the patient is under it. Once it is exceeded, graduated doses of lorazepam or diazepam are given and vital signs and CIWA scores are repeated regularly. The protocol is discontinued once the patient has three determinations that are under the threshold.

The individual dosing scale and monitoring routine varies by hospital. Look at your hospital policy manual to get specifics for your institution.

For a copy of the CIWA scoring criteria, click here.

Trauma 20 Years Ago: Intraosseous Access

The pre-hospital concept of “scoop and run” was first popularized in the mid-1980’s. It came about because there was recognition that significant delays were occurring on scene. A big time sink was obtaining IV access. The failure rate for IV starts in the field was 10-40% and typical start times were in excess of 10 minutes!

As a result of “scoop and run”, the emphasis shifted to airway protection, c-spine stabilization and control of external hemorrhage. A quicker alternative to IV access was sought, and the idea of intraosseous access was revived.

IO access was first described in 1941, and was used in children due to the higher degree of difficulty in obtaining IV access in kids. It did not require visualization of the site and could be inserted in moving ambulances, including helicopters.

The authors of this paper looked at IO infusion using a sternal insertion site. This site was chosen due to the belief that only areas with red marrow were suitable. They found that delivery of fluids and drugs was virtually identical to IV. The authors did cite contraindications to using this device, including previous sternotomy, sternal fracture, osteoporosis, and congenital anomalies like pectus.

Ultimately, this paper revived interest in IO access for adults, which has now evolved to easy-to-insert tibial devices that are inserted with a power drill.

Reference: Evaluation of an Intraosseous Infusion Device for the Resuscitation of Hypovolemic Shock. Holcroft, Blaisdell et al. J Trauma 30(6): 652. 1990.

EZ IO device