Major trauma victims are evaluated by a team to rapidly identify life and limb threatening injuries. This is accomplished during the primary and secondary surveys done in the ED. The ATLS course states that it is more important for the team to identify that the patient has a problem (e.g. significant abdominal pain) than the exact diagnosis (spleen laceration). However, once the patient is ready for admission to the trauma center, it is desirable to know all the diagnoses.
This is harder than it sounds. Physical examination tends to direct diagnostic testing, and some patients may not be feeling pain, or be awake enough to complain of it. Injuries that are painful enough may distract the patient’s attention away from other significant injuries. Overall, somewhere between 7-13% of patients have injuries that are missed during the initial evaluation.
A well-designed tertiary survey helps identify these occult injuries before they are truly “missed.” This survey consists of a structured and comprehensive re-examination that takes place within 48-72 hours, and includes a review of every diagnostic study performed. Ideally, it should be carried out by two people: one familiar with the patient, and the other not. It is desirable that the examiners have some experience with trauma (sorry, medical students).
The patients at highest risk for a missed injury are those with severe injuries (ISS>15) and/or impaired mental status (GCS<15). These patients are more likely to be unable to participate in their exam, so a few injuries may still go undetected despite a good exam.
I recommend that any patient who triggers a trauma team activation should receive a tertiary survey. Those who have an ISS>15 should also undergo the survey. Good documentation is essential, so an easy to use form should be used. Click here to get a copy of our original paper form. We have changed over to an electronic record, and have created a dot phrase template, which you can download here.
Chest trauma is common in trauma patients. Chest tubes are required with some regularity for the management of hemothorax and/or pneumothorax. Occasionally, the amount of blood in the chest is substantial, and when the tube goes in we wish that we were able to transfuse that blood.
Well, you can! Most collection systems have optional autotransfusion canisters that connect to the chest tube inline with the collection system. The canisters are used to collect shed blood and can then be hung like a bag of blood from the blood bank.
A few key points about using autotransfusion canisters:
- I recommend you consider it for any chest tube being inserted for trauma. They will almost always have some blood in their chest.
- If you want to limit use further due to the expense, just add it for trauma activation patients.
- Always add it to the chest tube collection system before the chest tube goes in. Most of the blood will be lost if the chest tube is hooked to the collection system first.
- No need to anticoagulate the blood. Most systems can be used to reinfuse shed blood up to 6 hours after collection without heparin or other products.
- Be sure to use an inline blood filter. There will be some debris and clumps that must be removed.
- Don’t use the blood if it is likely to be contaminated. This most often occurs with penetrating trauma, where a stab or gunshot could injure stomach or colon and violate the diaphragm.
- Follow the manufacturer’s instructions for your brand of collection system.
Here’s a picture of an autotransfuser that attaches to a Pleur-Evac brand system.
Earlier this month I looked at outcome differences in insured and uninsured patients at an urban Level I trauma center. A study published last month looked at a similar type of trauma center but focused only on penetrating trauma. Guess what? Same result.
This study was a lengthy (10 year) retrospective look at only patients who sustained gunshot wounds. Only one fourth of the patients had insurance. The in-hospital mortality was 50% higher for uninsured vs insured patients (9% vs 6%). There was no difference in injury severity, and the mortality difference persisted after controlling for age, gender, race and injury severity.
Interestingly, in this study there was no difference in imaging or operative intervention like there was in the LA study.
Once again, it looks like insurance status does make a difference. There are three possible factors: differences in access to care, physiologic differences, and differences in socioeconomic backgrounds. Access in this case was equal regardless of insurance status, and physiologic differences were minimal. That leaves us with socioeconomic differences. These social factors can lead to baseline differences in health which may have an impact on outcome.
The results of this study and the one I previously commented on will become even more interesting as healthcare coverage legislation is phased in over the next few years. The hope is that mortality rates for insured and uninsured will begin to equalize over the following years. The reality may be that it will take longer than we expect due to the time and effort needed to change basic human behavior.
Examination of the spine in trauma patients is typically not very helpful. We always look for stepoffs. swelling and tenderness, but the correlation with actual injury is poor. A recent paper presented at the American Medical Student Association Annual Convention showed that it actually can be helpful in victims of penetrating injury.
A prospective study of 282 patients was carried out at a Level I Trauma Center, specifically focusing on penetrating trauma. Half had gunshot wounds, and 8% sustained spinal injury with one third left with permanent disability. Stab wounds never led to a spinal cord injury. The most common patterns for cord injury in gunshot wounds was a single shot to the head or neck, or multiple shots to the torso.
The examiners looked for pain, tenderness, deformity and neurologic deficit. They found that the sensitivity was 67%, the specificity was 90%, the positive predictive value was 95% and the negative predictive value was 46%. These numbers are much better than those found during spine examination after blunt trauma. They also determined that prehospital immobilization after penetrating injury would not have helped, which I have also written about here.
The bottom line: a good spine exam in victims of penetrating trauma can accelerate definitive management prior to defining the exact details of the injury with radiographic or MRI imaging. This is particularly helpful in patients who present to non-trauma centers, where imaging or image interpretation may not be readily available.
Reference: American Medical Student Association (AMSA) 60th Annual Convention: Abstract 26: Presented March 11, 2010
An occult pneumothorax is one that is visible on chest CT but not conventional chest xray. The pneumo can be a single bubble, or it can be a larger one that layers out over the lung but cannot be seen on plain xray. This air is generally watched for a period of time, typically 6 hours, then a repeat plain radiograph is obtained to see if it has become visible.
The pneumothorax literature cautions us about watching visible pneumothoraces in patients who are placed on positive pressure ventilation. The rationale is that this may force more air out of an acutely injured lung, resulting in an enlarging pneumothorax. Many have recommended that a chest tube be placed in any patient with a visible pneumothorax on positive pressure ventilation to avoid the possibility of developing a tension pneumothorax.
But what about the occult pneumothorax? Since they are generally very small, do they pose the same risk? A paper from 2008 retrospectively reviewed 79 patients with occult pneumothorax , 20 of whom were placed on ventilators. 51 of 59 of the non-ventilated patients had no change in their occult pneumo (86%), while 16 of 20 of the ventilated patients had no progression (80%).
The study numbers are small, but suggest that occult pneumothoraces can be safely watched. The real question is, how long do you have to watch it? Typically, ventilated patients get regular chest xrays, so monitoring for progression of the pneumo should be easy.
Reference: American Surgeon 74(10):958, 2008.