All posts by TheTraumaPro

Contrast Blush in Children

A contrast blush is occasionally seen on abdominal CT in patients with solid organ injury. This represents active arterial extravasation from the injured organ. In most institutions, this is grounds for call interventional radiology to evaluate and possibly embolize the problem. The image below shows a typical blush.

Splenic contrast blush

This thinking is fairly routine and supported by the literature in adults. However, it cannot be generalized to children!

Children have more elastic tissue in their spleen and tend to do better with nonoperative management than adults. The same holds true for contrast blushes. The vast majority of children will stop bleeding on their own, despite the appearance of a large blush. In fact, if children are taken to angiography, it is commonplace for no extravasation to be seen!

Angiography introduces the risk of local complications in the femoral artery as well as more proximal ones. That, coupled with the fact that embolization is rarely needed, should keep any prudent trauma surgeon from ordering the test. A recently released paper confirms these findings.

The only difficult questions is “when is a child no longer a child?” Is there an age cutoff at which the spleen starts acting like an adult and keeps on bleeding? Unfortunately, we don’t know. I recommend that you use the “eyeball test”, and reserve angiography for kids with contrast extravasation who look like adults (size and body habitus).

Reference: What is the significance of contrast “blush” in pediatric blunt splenic trauma? Davies et al. J Pediatric Surg 2010 May; 45(5):916-20.

The Seat Belt Sign

Officially, a seat belt sign consists of contusions and abrasions on the abdomen of a restrained occupant involved in a motor vehicle crash. The seat belt syndrome takes this one step further, with injury to the abdominal organs or spine.

Seat belts save lives by reducing the number of people dying from head injury after a car crash. However, they do so by diverting energy from the head to the chest and abdomen. Overall, people who don’t wear seat belts have a 10% chance of abdominal injury. With seat belts in place, this increases to 15%. And if the person is wearing seat belts and has a seat belt sign, the risk of injury increases to 65%!

This isn’t a bad thing, however. We can fix abdominal injuries, but we can’t fix the brain; it has to heal on its own, and slowly at that.

Seat belts are associated with the Chance fracture, an uncommon fracture of the lumbar spine, usually at L1. These usually only occur with the use of lap belts without shoulder restraints, which is found less and less in cars today. These used to be located in the center of the rear seat, but most new cars offer shoulder restraints in this location now.

Chance fractures need to be assessed by a spine surgeon so that stability can be determined. If stable and there is minimal kyphosis, a brace may be appropriate for treatment. However, if the fracture is not stable or there is more than about 15 degrees of angulation, surgery will be necessary.

As seat belt use increases, seat belt signs are becoming more common. Any patient with a seat belt sign must have an abdominal CT. If any abnormal findings are noted, a surgeon must be consulted because it is very likely that operative intervention will be required. 

To view a slideset about seat belt sign, click here.

Seat belt sign

Trauma 20 Years Ago: The MESS Score

This month is the 20th anniversary of the MESS score, a system that helps predict salvageability of mangled extremities (Mangled Extremity Scoring System). Obviously, the acronym was chosen to help describe the clinical problem.

The system was originated at the Harborview Medical Center in Seattle. The development was not very scientific; the authors put their heads together and made a list of the four things that they observed predicted limb salvage:

  • Degree of skeletal and soft tissue injury
  • Presence of limb ischemia
  • Presence of shock
  • Age

The system was used retrospectively in a group of 25 patients(!) and the authors found a nice breakpoint at 7. Any mangled extremities with a MESS of 7 or more required amputation. They then applied this to 26 patients prospectively(!) and got the same result.

As you can see, the numbers were small, and there was no followup information. Nevertheless, MESS still stands today, and the critical MESS score has not changed much. It has been validated by a number of other studies during the past 20 years. It is conceivable that the critical score will slowly creep upward with advancements in flap coverage and surgical technique, but it hasn’t done so yet.

Reference: Objective Criteria Accurately Predict Amputation Following Lower Extremity Trauma. Johansen, et al. J Trauma 30(5): 568, 1990.

Nursing Policy: Cervical Spine Immobilization

The following is a sample nursing policy for c-spine immobilization.

Purpose: 

To outline the procedure for applying immobilizing the upper spine, including application of a cervical collar and “boarding” the patient. 

Policy: 

Application of a cervical collar and placing the patient on a backboard may be indicated for trauma patients with mechanisms of injury that place the patient at risk for spinal injury. This will not be necessary for patients with all of the following:

  • no posterior midline cervical tenderness
  • no evidence of intoxication
  • normal level of alertness (GCS 15)
  • no focal neurological deficit
  • no painful distracting injuries
  1. The MD or RN will maintain manual stabilization of the cervical spine until cervical collar is applied and patient is placed on backboard.
    * talk to the patient and tell them what you are doing- and not to move their head and neck
  2. Place hands on both sides of patient’s head with thumbs along mandible and fingers holding back of head. 
  3. Assistants will help with the rest of the application of the cervical collar and backboard. 
  4. Perform a baseline CMS assessment of the extremities. 
  5. Remove jewelry from the neck and ears. 
  6. Choose an appropriately sized collar by measuring the distance (with fingers) between the top of the shoulder where the collar will rest and the chin. This same number of fingers will fit between the fastener on the collar and the bottom edge of the rigid plastic of the collar. 
  7. Cervical collar is assembled by snapping the fastener into the hole on the side of the collar 
  8. Adjustable rigid cervical collars are measured from the bottom edge of the rigid plastic to the red circle denoting the size of the collar (red circle will move up or down as size of the collar is adjusted) 
  9. Slide the back of the collar behind the right side of the neck until the Velcro tab is visible on the left side of the neck. 
  10. Slide the chin portion up the chest until the chin fits in the collar. 
  11. Secure the Velcro when the collar is on straight (nose, circle on chin portion of collar, and umbilicus are in alignment). 
  12. Place the patient on a slide board with all team members working in a smooth fashion which moves the patient’s spine as little as possible. Patients already in bed will be log rolled and slider board inserted.
    * Do not obtain a rectal temperature while the patient is turned unless the MD specifically requests this.
  13. Recheck CMS. 
  14. The MD or RN can now remove hands from head. 
  15. Document both CMS checks and procedure in patient’s record.

Management of Occult Pneumothorax

Occult pneumothorax is a pleural air collection that is seen only on CT. It is not detected by standard chest xray either because of small size, location of the air, or position of the patient during xray (usually supine).

Approximately 15% of major trauma patients undergoing CT are diagnosed with an occult pneumothorax. The tough question is, what to do about it. Larger pneumothoraces are frequently treated with thoracostomy, but this procedure has its own list of associated complications. Patients undergoing positive pressure ventilation with a visible pneumothorax have an increased risk for progression to tension pneumothorax.

At our trauma center, we manage occult pneumothorax expectantly. If a pneumothorax is seen on the chest portion of a CT scan but not on the initial supine chest xray, a repeat conventional chest xray is scheduled for 6 hours later. Ideally, this xray is taken using the best technique (upright, PA, xray source 6ft from patient). However, this is not always practical for severely injured patients.

If the pneumothorax remains occult on the followup xray, no further monitoring is performed. If the pneumothorax becomes visible, repeat chest xrays are obtained every 6 hours until it is stable or it becomes large enough to warrant insertion of a chest tube.

How large is large enough for a chest tube? That’s the subject for another day.