EMS in the field and physicians in the ED are faced with rapidly assigning some degree of stability to the patients they treat. What exactly are the shades of stability, and what considerations are there for each degree?
In my mind, there are three levels of “stability”:
- Unstable – this one is easy to figure out. The patient has obvious physiologic compromise, which may be objective (low blood pressure, low GCS or poor neuro exam, etc) or subjective (just plain looks bad).
EMS: These patients need transport to an appropriate level trauma center (I or II) immediately. If they need airway control or IV access that can’t be obtained in the field, stop at the nearest Level III or IV for assist, then continue on your way FAST.
ED: These patient must be a trauma activation. If not activated as your top-tier trauma, activate or upgrade now! These patients must be seen by a trauma surgeon immediately, and can only go to the OR. No diagnostics outside the resuscitation room are allowed unless they can be converted into one of the two stability levels below.
- Stable – this one is usually easy to figure out, too. These patients look good, have good vitals, and a low to moderate energy mechanism for their trauma. Look out for those few patients that may be hiding something like moderate bleeding into some body cavity.
EMS: Follow your usual transport protocols to select the closest, appropriate hospital.
ED: Follow your standard protocols for trauma activation if needed. Transport for standard imaging is fine.
- Metastable – this is a term I invented. It describes patients who have evidence of ongoing volume loss that can be controlled with infusion of crystalloid and/or blood products. It is possible to maintain a certainly level of stability using higher than normal volume infusions. This allows physicians to consider diagnostics or interventions outside of an OR.
EMS: Ensure adequate IV access and give fluids and/or blood per your local protocols. Transport to a Level I or II trauma center as quickly as possible.
ED: Activate or upgrade to your highest level of trauma activation. The trauma surgeon needs to be present to help direct diagnostics or interventions. These patients may go to CT, IR or other appropriate areas with nurse and physician accompaniment to diagnose and possibly treat bleeding. If the patient changes to unstable at any point, they must immediately be taken to the OR.
There were lots of interesting guesses regarding this photo! Some were very creative, and thought I might be throwing a curve ball. Alas, this was much more straightforward.
What you see is a pair of wounds located just at or slightly above the iliac crest on the right side. If you look carefully, you will see a powder burn around the anterior wound, indicating a close range gunshot. So this would appear to be a run of the mill gunshot to the abdomen; just run to the OR, right?
Not so fast! There are some nuances when dealing with this type of wound. The first things to look at are the vital signs. If they’re not stable, then there is major bleeding present and the patient needs to go to the OR now. Next, do a good exam. As always, stick to the ATLS protocol to make sure you’re not focusing on the abdomen and missing other significant findings. If the abdominal exam is abnormal (tenderness, peritoneal signs) there is either bleeding or contamination and once again it’s time to go to OR. About 98 times out of 100, that’s where you’ll be with a picture like this.
However, if you’ve gotten to this point with none of the above, there is the small possibility that this might be a tangential injury. The flanks (“love handles”) tend to be fairly fatty in some men, especially the obese. And since most civilian gunshots are low velocity, there is less likelihood of deeper injury from blast effect. Local wound exploration is tough in this area due to the amount of fat and the deeper musculature.
My preferred method for evaluating this (rare) type of patient is a quick CT scan of the abdomen and pelvis. The pelvic part is important, because you are looking for obvious penetration and blood in the pelvis. If you see either, it’s time to head to the OR. Very rarely (on the right side) you may see a contusion or superficial laceration of the liver, meaning that there was penetration. However, if there is no possible way the bowel was injured, it is acceptable to closely observe the patient.
Oh, and the board? Back in the day before everything was made of plastic, they actually made backboards out of fairly nice wood!
Hmm, no correct answers yet. It’s all about the “location.” And what about the wooden board thing?. Hint: someone put him on the wood, and it’s an old photo. Answer Monday!
Okay, here’s a picture of an injury. First, what happened? Then, what’s your management approach? And why are they lying on a piece of wood?!
It’s not as straightforward as you might think! Answer tomorrow.
Source: personal archive. Not treated at Regions Hospital.
We love our CT scans! They’re so high tech, with such detailed images popping up on the monitor so quickly. To take advantage of the detail, we’ve come up with fancy grading systems that can be used to direct care. But are they all they’re cracked up to be?
CT grading of spleen injury is a prime example. We’ve got a nice, detailed system that looks at laceration depth, subcapsular hematoma size and vascular injury. We can use it to predict the likelihood of needing an operation and where we should admit someone in the hospital (ICU vs ward). And when we see the injury on the screen, we believe that we can accurately apply the scoring system to these beautiful images.
But unfortunately, it’s not that simple.Scanning obtains multiple images in an axial plane and lays them out for us to look at. However, the spleen (and most other organs) and not shaped like a cube. It is curved, with complex nooks and crannies that can look like cracks. Moderate to large hematoma around the spleen can obscure lacerations. And the hilum is even more complicated and variable in shape.
Because of this, CT scans of the abdomen tend to underestimate the true extent of injury, especially in the higher grades. Grade I and II injuries are usually accurate, but in Grades III-V, the scan tends to undergrade by 1 (30% of cases) or 2 grades (45% of cases) when re-graded at surgery.
Bottom line: Grade I and II injuries are generally managed in a lower intensity setting and almost never require operation. But beware of the higher grades! It is very likely that it’s higher than you think. This means that if your patient slowly becomes tachycardic or their blood pressure softens, believe the clinical evidence. Don’t rely on a CT scan that was done hours ago that may be hiding a more severe injury than you think! (This applies to liver injuries as well)
Reference: Correlation of operative and pathological injury grade with computed tomographic grade in the failed nonoperative management of blunt splenic trauma. Euro J Trauma Emerg Surg – Online First 2 Mar 2012.