All posts by TheTraumaPro

How Long Do Trauma Patients Need To Be On A Backboard?

EMS is very good about immobilizing the spine in trauma patients prior to transporting them to the Emergency Department. Healthcare personnel in the ED are not as good about getting people off of those rigid boards.

As always, it boils down to a risk and benefit assessment. What is the risk of keeping someone on a board, especially if they may have a spine injury? There is a well-known downside to spine immobilization: skin breakdown, which can occur in as little as 2 hours. Less appreciated is the fact that it is very uncomfortable lying on one’s back on any type of board, be it a spine board or even a simple plastic slider board.

What is the risk to the spine if it is indeed injured? In a cooperative patient, essentially zero. Think about it this way: what are spine-injured patients placed on once they are admitted to the hospital? A regular bed with a standard hospital mattress! They are kept on logroll precautions until they have an operative procedure or receive a brace.

The bottom line: All patients should be moved off the EMS spine board onto the ED cart unless they are being transferred to another hospital within an hour or less. The ED cart should have a regular mattress, but the patient must be cooperative. If they cannot or will not cooperate, and the probability of spine injury is high, they may need to be chemically restrained. A plastic slider board may be placed under the patient when they are ready to go to diagnostic studies, and should be removed immediately when they are complete. No board of any kind should ever be left under a patient for more than 2 hours.

How to Predict the Need for Massive Transfusion in the ED

Massive transfusion is needed in about 3-5% of trauma patients. All Level I and II trauma centers are required to have a massive transfusion protocol.However, the protocol must be triggered in a timely manner to best benefit the major trauma patient.

Trauma surgeons at Vanderbilt validated a simple scoring system that allows accurate prediction of the need for massive transfusion in patients as they arrived in the ED. The system was called the ABC score (Assessment of Blood Consumption). It consists of the following 4 yes/no parameters:

  • Penetrating mechanism (0=no, 1=yes)
  • ED SBP <= 90 (0=no, 1=yes)
  • ED heart rate >= 120 (0=no, 1=yes)
  • Positive FAST (0=no, 1=yes)

The results of ABC when applied to trauma patients in the ED was as follows:

ABC Score         % requiring massive transfusion
0                                1%
1                               10%
2                               41%
3                               48%
4                             100%

This scoring system is simple, easy to use and easy to remember. No laboratory tests are needed, and the information needed can be gathered quickly.

Bottom Line: This is a simple and accurate prediction system for determining the need for massive transfusion in trauma patients. Recommended!

Reference: Cotton et al. J Trauma 66(2) 346-352, 2009.

Trauma Flow Sheets vs the Electronic Medical Record

There is a big push nationwide to move toward the use of electronic medical record (EMR)systems in hospitals. There are a number of benefits from using such systems, including but not limited to:

  • Comprehensive and permanent data collection
  • Easily accessed system-wide
  • Reduction in human errors
  • Increased throughput once the initial learning curve has been completed
  • Multifaceted reporting capabilities

Many hospital or hospital system IT departments are insistent in moving all charting to the EMR, including the trauma flow sheet. For some, it is a revenue enhancement tool. For others, it is a result of the urge to make everything paperless.

As a trauma center reviewer, I have had the privilege of visiting many hospitals and inspecting their trauma flow sheet charting tools. The bottom line is that I have never seen an electronic medical record system that can replace a handwritten trauma flow sheet.

A trauma team activation is a complex, fast-paced, finely orchestrated performance that does not lend itself well to being recorded electronically. There are two major problems:

  • Accurate and timely data entry
  • Intelligible reports

There is so much information being transferred nearly simultaneously (vital signs, physical findings, procedures, fluid volumes given, laboratory and radiology orders, narratives) that it is not possible to record it completely and accurately using any current computer data entry interface or medical record system. Frequently, it ends up being recorded by hand on another piece of paper and is then entered later into the EMR.

The reporting features of virtually all EMRs allow for a nice event listing sorted by time. It is rarely graphical in nature, and typically spans multiple pages of text output. Charts that I have reviewed have “reports” ranging from 8 to 20 pages. It is virtually impossible for a human being to read through this type of output and reconstruct the flow of a trauma resuscitation. In many PI review cases, the trauma program manager is reduced to transcribing the individual data items from the EMR back onto a paper trauma flow sheet in order to conceptualize the resuscitation.

IT personnel may claim that the problem is an “end user failure.” I defy any of them to come to a trauma resuscitation and rapidly and accurately transcribe all of the information presented, or try to review a PI case based on a printed EMR report.

The real bottom line: trauma flow sheets (and other similar code sheets) can not and should not be reduced to electronic data entry. It is not only frustrating, but will hamper the trauma PI process to the point of jeopardizing a trauma center’s verification status!

Related post: More on the EMR/trauma flow sheet debate

Do Trauma Patients Need A Rectal Exam?

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.

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

Use of Abdominal CT in Stab Wounds to the Anterior Abdomen

In general, stab wounds to the anterior abdomen (like any penetrating injury to the area) demand further evaluation to make sure there are no significant injuries. In the old days, a stab to the abdomen mandated a trip to the operating room. Fortunately, we recognized that more than half of these operations led to negative explorations.

Nowadays we can be much more selective. Here is my approach to evaluating these patients.

First, are there any indications that the patient needs to go to the OR right now?Check the vital signs. If there is any hemodynamic instability, operate! Check the abdomen. If there is obvious peritonitis, or significant tenderness more distant from the actual stab site, off you go to the OR!

Next, after finishing all of the usual ATLS protocol it’s time to evaluate further.Several options exist:

  • Observation – this is good for busy trauma centers that have lots of penetrating injury and busy ORs
  • DPL – not used too much any more, but certainly is legitimate. I recommend that your RBC count threshold be reduced to 25,000 or 50,000
  • Local wound exploration – this works in thinner people. Doing a LWE on an obese patient requires an incision that approaches the size of a small laparotomy. Might as well do it in the OR. Look for any violation of the anterior fascia.
  • CT scan – the new kid on the block

To use CT, the patient must be stable (remember, they should be in the OR if otherwise) and have had a full ATLS evaluation. They should also not be terribly thin. Too little fat makes it difficult to gauge depth of the injury.

The entry site(s) should be marked with a small marker to minimize streak artifact. Resist the temptation to just scan the area around the stab itself. Do a full IV contrast (no GI needed) abdomen/pelvis scan.

Look closely for blood outlining the wound tract. If it reaches the anterior abdominal fascia, the exam is positive. You do not need to see specific injury to the muscle or abdominal viscera. Violation of the anterior fascia is an absolute indication to proceed to the OR. On occasion, the knife will not penetrating the posterior fascia, or penetrates but does not injury any organs. In these cases it is best to have operated and found nothing rather than delaying and increasing the risk of intra-abdominal complications or infections.

Scan 1 shows blood tracking to the anterior fascia, as well as an increase in size of the rectus muscle.

Scan 2 shows penetration of the posterior rectus sheath with intra-abdominal fat herniating into it. The transverse colon is only 2 cm away deep to it. Scan 1 alone is enough to prompt you to take the patient to the OR!