Smaller trauma hospitals, both designated and undesignated, are the front line for the initial care of the majority of trauma patients. Many patients can be evaluated and sent home or admitted to the initial hospital. More severely injured patients are commonly transferred to the nearest Level I or Level II trauma center for care of injuries requiring specialists.
Imaging studies such as conventional xray and CT scan are a necessary part of the initial trauma evaluation. But is it necessary to do a full radiographic evaluation, even when it is known that the patient will have to be transferred?
Researchers at Dartmouth Hitchcock Medical Center examined the issue of repeat imaging at their Level I center. They looked at 138 patients that were transferred to them from other rural hospitals. They found that 75% underwent CT scanning prior to transfer, and 58% underwent repeat scanning upon arriving at Dartmouth.
The authors discovered the following:
Head CTs were repeated 52% of the time, primarily due to clinical indications
Spine reconstructions were repeated 33-50% of the time due to inadequate reconstruction technique
Chest (31%) and abdomen (20%) were repeated due to inappropriate use of IV contrast
13% of image disks used incompatible software
7% of images were not sent with the patient
Here are my recommendations for imaging by hospitals that refer patients to Level I or II trauma center:
Obtain the essential plain films recommended by ATLS (chest, pelvis)
If an obvious injury requiring transfer is found on exam (e.g. open fracture) do no further studies
Obtain any imaging studies needed to decide if you can admit the patient to your own hospital (example: abdominal CT for abdominal pain and negative FAST. Keep if no injury, transfer if solid organ injury)
As soon as an injury is identified that mandates transfer, do no further studies
Always send image disks with the patient
Work with your referral trauma center to obtain a copy of their CT imaging protocols so if you do need to perform a study you can duplicate their technique
Reference: Gupta et al. Inefficiencies in a Rural Trauma System: The Burden of Repeat Imaging in Interfacility Transfers. J Trauma 69(2):253-255, 2010.
Minor complications from nasogastric tube insertion occur relatively frequently. Emesis is fairly common when the gag reflex is stimulated by the tube in the back of the oropharynx. An infrequent but possibly fatal one is insertion through the cribriform plate.
The cribriform plate is located directly posterior to the nares and is part of the ethmoid bone. It is very porous in nature and weaker than the surrounding portions of the ethmoid. It is easily fractured, and can be seen is association with basilar skull fractures. This is one source for rhinorrhea in patients with these fractures.
Cribriform fracture is a contraindication to unprotected insertion of a nasogastric tube. If you look at the sagittal section below, the plate lies directly behind the nares. When inserting the NG tube, we are usually taught to aim the tube straight back. Unfortunately, this aims it directly at the cribriform. If a fracture is present, it is possible that you may be inserting a nasocerebral tube!
The usual symptoms when this occurs consist of immediate neurologic deterioration to coma, and a unilateral or bilateral blown pupil. The tube must not be withdrawn, because it will cause significant injury to the base of the brain. A stat neurosurgical consultation must be obtained, and if the patient is salvageable, the tube must be withdrawn through a craniectomy.
To avoid this dreaded complication, identify patients at risk for cribriform injury. They are:
patients with signs of trauma from eyebrows to zygoma
patients with signs of basilar skull fracture (Battle’s sign, raccoon eyes, oto- or rhinorrhea)
If your patient is at risk, follow these guidelines:
first, does the patient really need a gastric tube?
if comatose, insert an orogastric tube
if awake, don’t put the tube in their mouth, as they will gag continuously. Instead, place a lubricated, curved nasal airway. Then lube up a slightly smaller Salem sump tube and pass it through the airway.
Some people experience vertigo after suffering a TBI. This may occur because small calcium carbonate crystals that are normally attached to a membrane in the middle ear are dislodged by the trauma. They can then settle within the semicircular canals. When the head is turned or moved, they brush against the sensitive hairs, sending false signals to the brain. This can result in dizziness, nausea and vertigo.
The Epley maneuvers were designed to move the crystals back out of the semicircular canals, where they can adhere to the membrane again. They consist of a pattern of head movements that should be performed by a trained professional. This is very important because the maneuvers may induce nausea requiring antiemetics. Certain head movements must be limited for a few days after the maneuvers to make sure the crystals stay in position. The overall success rate is about 80%, but on occasion the maneuvers must be repeated for success.
The video demonstrates the basics of the maneuvers. Remember, don’t try this at home by yourself. Seek out a therapist who is experienced with them.
The obvious diagnosis is an easy one! An NG tube is seen curled in the stomach, which is located above the diaphragm! This patient has a traumatic rupture of the left diaphragm.
The other, slightly less obvious finding is a spleen injury. Wait, this is a plain chest x-ray. How can we tell there is a spleen injury?
Look at the inside edge of the ribs and the outside of the lung on the patient’s left chest. There is a big, radio-dense gap representing a moderate hemothorax. With injuries to the left diaphragm, the rent is rather large allowing much of the stomach to float up into the chest. The spleen is attached to the greater curve of the stomach by the short gastric vessels. As the stomach moves into the chest, the spleen is dragged up there as well. Typically, it has to squeeze through the hole in the diaphragm and commonly sustains significant injury as it does.
Spleen injury is commonly associated with left diaphragm injury. The usual mechanism for both is blunt force to the left chest and abdomen. It takes major force to rupture the diaphragm, and this is usually associated with t-bone type car crashes on the driver’s side and pedestrians struck on their left side.
Diagnosis is difficult to make by physical exam alone. Breath sounds are decreased on the left, and patients are frequently dyspneic. The most frequent cause for this constellation of symptoms is a pneumothorax or hemothorax, and a chest tube may be inserted on clinical grounds alone. Unfortunately, the tube will not make the symptoms any better. Chest x-ray helps enormously, and an NG tube can be inserted to decompress the stomach and allow better inflation of the left lung when the diaphragm injury is recognized. This will relieve symptoms, but the patient will still need to go promptly to the OR to fix the diaphragm and deal with the spleen.
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