FAST is a helpful adjunct to the initial evaluation of adult trauma patients. Unfortunately, due to small numbers the usefulness is not as clear in children. In part, this is due to the fact that many children (particularly small children < 10 years old) have a small amount of fluid in the abdomen at baseline. This makes interpreting a FAST exam after trauma more difficult.
Despite this, use of FAST in children is widespread. A survey of 124 US trauma hospitals in 2007 showed an interesting pattern of ultrasound usage. In adult-only institutions 96% use FAST, and at hospitals that see both adults and kids, 85% use it. Most of these centers that use FAST have no lower age limit, and the physician most commonly performing the exam was a surgeon. However, only 15% of children’s hospitals do FAST exams, and they were usually done by nonsurgeons! The reasons for this are not clear. It appears that the pediatric surgeons have not embraced this technology as much as their adult counterparts.
What about that confusing bit of fluid found in kids? Several groups have looked at this (retrospectively). Fluid in the pelvis alone appears to be okay, but fluid anywhere else is a good predictor of solid organ injury. Fluid seen outside the pelvis had a 90% sensitivity and 97% specificity for injury, and positive and negative predictive values were 87% and 97% respectively.
Bottom line: FAST exam is useful in pediatric victims of blunt abdominal trauma. Fluid in the pelvis alone is normal in most children, but fluid seen anywhere else indicates a high probability of solid organ injury.
Use of focused abdominal sonography for trauma at pediatric and adult trauma centers: a survey. J Pediatric Surgery 44:1746-1749, 2009.
Minimal pelvic fluid in blunt abdominal trauma in children: the significance of this sonographic finding. J Pediatric Surgery 36(9):1387-1389, 2001.
Clinical importance of ultrasonographic pelvic fluid in pediatric patients with blunt abdominal trauma. Ulus Travma Acil Cerrahi Derg 16(2):155-159, 2010.
Everyone knows that trauma is the number one killer of anyone age 1-44. The assumption is that if you sustain major injury and survive through discharge from a trauma center, you are home free. Unfortunately, this does not appear to be the case.
Arbabi and others from Harborview in Seattle looked at long term outcomes of 124,000 adult trauma patients treated over a 14 year period at any of Washington’s designated trauma centers.
During this period of time, in-hospital deaths decreased from 8% in 1995 to 4.9% in 2008. However, deaths after discharge increased from 4.7% to 7.4% during the same time interval. It appeared that older patients and those discharged to skilled nursing facilities (SNF) did particularly poorly after discharge. The risk of death after discharge to a SNF was 1.5 to 2x higher than normal. Yet mortality after discharge to an inpatient rehab facility was similar to that of patients sent home.
Bottom Line: Higher mortality in major trauma patients sent to a skilled nursing facility is likely a reflection of their age and severity of injury, as well as the services available there. Although patients with severe injuries may be sent to a rehab center, they typically must be able to participate in therapy for several hours a day. Those with more severe injuries that do not meet rehab criteria are typically sent to a SNF. This also explains why the authors found that patients with high ISS, low GCS, poor Functional Independence Measure and Medicare insurance had a higher likelihood of dying. This association should prompt us to look more thoroughly at these facilities to determine if they need additional oversight, more money or better rehab services.
Reference: Long-term survival of adult trauma patients. JAMA 305(10):1001-1007, 2011.
Deep venous thrombosis is commonplace after multiple trauma. A systemic inflammatory process is activated, which leads to an increase in cytokine production. We know that a process called microvesiculation occurs, where cells undergoing apoptosis shed small particles that contain active tissue factor. These types of microparticles have been shown to lead to thrombosis in cancer patients, but the role in trauma patients has not been clear.
Researchers at the University of Rochester performed a simple study looking at injured or burned patients with an Apache II score >20 compared to normal controls. They examined blood drawn after day 2 in the hospital, and looked for microparticles using fluorescent microbeads. They concentrated on differences between 3 trauma patients who did not develop DVT and 2 who did.
Patients who developed DVT had nearly 300% more circulating microparticles than matched controls. It is likely that the majority of those microparticles expressed tissue factor as well.
Bottom line: This exciting work may help explain why trauma patients have a higher DVT rate. Additionally, it may eventually provide us with a blood test that will help pinpoint patients at high risk so we can provide more intensive surveillance and/or more aggressive prophylaxis or prevention.
Reference: Multisystem trauma patients who develop venous thromboembolism have increased numbers of circulating microparticles. Marlene Mathews MD et al. Presented at the 34th Annual Resident Trauma Paper Competition at the AmericanCollege of Surgeons Spring Meeting, Washington DC, 2011.
On occasion (but not routinely) trauma patients need to have their stomach decompressed. The reflex maneuver is to insert a nasogastric (NG) tube. However, this may be a dangerous procedure in some patients.
Some patients may be at risk for a cribriform plate fracture, and blindly passing a tube into their nose may result in a nasocerebral (NC) tube (see picture). This is a neurosurgical catastrophe, and the outcome is uniformly dismal. It generally requires craniectomy to remove the tube.
The following patients are at risk:
Evidence of midface trauma (eyebrows to zygoma)
Evidence of basilar skull fracture (raccoon eyes, Battle’s sign, fluids leaking from ears or nose)
If you really need the tube, what can you do? If the patient is comatose, it’s easy: just insert an orogastric (OG) tube. However, that is not an option in awake patients; they will continuously gag on the tube. In that case, lubricate a curved nasal trumpet and gently insert it into the nose. The curve will safely move it past the cribriform plate area. Then lubricate a smaller gastric tube and pass it through the trumpet.
And so it begins. I wrote recently about using a special version of a 3D printer to print a skin graft (read it here). I also speculated that we could be seeing 3D printers that could eventually print entire organs at some point. Well, leave it to Wake Forest again.
They demonstrated the concept of printing an organ at the 2011 TED Conference (Technology, Entertainment, Design) last week in Long Beach. Now, this was not a working organ, just a concept demo of sample tissue. Nonetheless, this is a preview of things to come. Imagine when we can print up a new kidney to replace the shattered one in the pan on the back table of the OR.