All posts by The Trauma Pro

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Trauma Flow Sheets vs the Electronic Medical Record

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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

General

Do Trauma Patients Need A Rectal Exam?

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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.

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Use of Abdominal CT in Stab Wounds to the Anterior Abdomen

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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!

General

A Quick and Dirty Test for Traumatic Brain Injury

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Traumatic brain injury (TBI) is an extremely common diagnosis in trauma patients. The majority are minor concussions that show no evidence of injury on head CT. Despite normal findings, however, a short conversation with the patient frequently demonstrates that they really do have a TBI.

Scoring systems can help quantitate how significant the head injury is. The Glasgow Coma Scale (GCS) score is frequently used. This scoring system is not sensitive enough for minor head injuries, since a patient may be perseverating even with a GCS of 15.

The Short Blessed Test (SBT) is a 25 year old scoring system for minor TBI that has been well-validated. It takes only a few minutes to administer, and is very easy to score.

The most important part of the administration process is choosing a threshold for further evaluation and testing. We administer this test to all trauma patients with a suspected TBI (defined as known or suspected loss of consciousness, or amnesia for the traumatic event). If the final score is >7, we refer the patient for more extensive evaluation by phsyical and occupational therapy. If the score is 7 or less but not zero, consideration should be given to offering routine followup in a minor neurotrauma clinic as an outpatient. In all cases, patients should be advised to avoid situations that would lead to a repeat concussion in the next month.

Reference: Katzman R, Brown T, Fuld P, Peck A, Schechter R, Schimmel H. Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry. 1983 Jun;140(6):734-9.

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Spine Immobilization in Penetrating Trauma: More Harm Than Good?

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The EMS standard of care for blunt trauma patients has been to fully immobilize the spine before transporting to an emergency department. This is such a common practice that it is frequently applied to victims of penetrating trauma prior to transport.

A recent study in the Journal of Trauma calls this practice in question, and suggests that it may increase mortality! The authors reviewed data in the National Trauma Data Bank, looking at information on penetrating trauma patients. They found that approximately 4% of these patients underwent spine immobilization.

Review of mortality statistics found that the mortality in non-immobilized (7%) doubled to 14% in the immobilized group!

The authors also found that medics would have to fail to immobilize over 1000 patients to harm one who really needed it, but to fully immobilize 66 patients who didn’t need it to contribute to 1 death.

Although this type of study can’t definitely show why immobilization in these patients is bad, it can be teased out by looking at related research. Even the relatively short delays caused by applying collars and back boards can lead to enough of a delay to definitive care in penetrating trauma patients that it could be deadly. The assumption in all of these patients is that they are bleeding to death until proven otherwise.

A number of studies have suggested that a “limited scene intervention” to prehospital care is best. The assumption is that the most effective treatment can only be delivered at a trauma center, so rapid transport with attention to airway, breathing and circulation is the best practice.

While interesting, some real-life common sense should be applied by all medics who treat these types of patients. The reality is that it is nearly impossible to destabilize the spine with a knife, so all stab victims can be transported without a thought to spine immobilization. Gunshots can damage the spine and spinal cord, so if there is any doubt that the bullet passed nearby, at least simple precautions should be taken to minimize spine movement.

Reference: Spine Immobilization in Penetrating Trauma: More Harm Than Good? Haut et al, Johns Hopkins. J Trauma 68(1): 115-121, 2010.