Here’s the first in a series of “When To Call” pieces. We sometimes overuse our consultants and call then at inappropriate times. So what if we diagnose an injury in their area of expertise at 2 am? Does it need attention or an operation before morning? If not, why call at that ungodly hour?
Let’s use our consultants wisely! I’ve listed most of the common urologic diagnoses that trauma professionals will encounter. There is also an indication of what you need to do, and exactly when to call your consultant.
Here’s a reference sheet formatted at a 3×5 index card that you can keep in your pocket. I’ve included a printable pdf file, as well as the original Microsoft Publisher file in case you want to make a few modifications to suit your own hospital.
Tomorrow, a reference card for your eye consultant.
Welcome to the current newsletter. This is part 2 of my discussion of the massive transfusion protocol (MTP). Here are the topics I cover:
- What Is The Ideal Blood Product Ratio?
- TEG And Your MTP
- MTP and TXA
- The History Of Fractionated Blood Components
- Use Of Whole Blood For Massive Transfusion
The next issue covers fat embolism syndrome and will be released to subscribers at the end of the month. Non-subscribers will have to wait another week for the public release.
To download the current issue, just click here! Or copy this link into your browser: http://bit.ly/TME201901.
The scenario involved an elderly woman who fell from standing at her care facility 12 hours earlier. They want to send her to your trauma center for evaluation because she seems a bit different from her baseline. You have well defined practice guidelines for patients with head injuries that dictate what type of monitoring and diagnostics they receive.
What do you need to know to determine what you should do? Thanks for all of you who sent in suggestions.
Here are my thoughts:
- Which scans should she get? Usually, you would obtain an initial head CT and, due to her age, a cervical CT regardless of her physical exam due to the high miss rate in these patients. But now the fun begins. Your subarachdoid / intraparenchymal hemorrhage (IPH) practice guideline would have you admit for neurologic monitoring for 12 hours, obtain a TBI screen, then discharge without a followup scan if the screen was passed. But in this case, the clock started 12 hours ago and the guideline would be finished with the exception of the TBI screen. So an initial scan and a TBI screen in the ED are all that are needed. The observation period is already over and the patient could potentially be discharged from ED if a SAH or IPH were found.
Your subdural guideline mandates all of the above plus a repeat scan at 12 hours. But once again, the clock has already started. Do you just get an initial scan, which also serves as the 12 hour scan? Or do you get yet another one? If the neuro exam is normal, I vote for the former, and your evaluation is complete after the TBI screen. If the neuro exam is not quite normal, then admission for continuing exams and a repeat scan are in order.
- Does the patient need to be admitted, and for how long? Hopefully, you’ve figure this out in the previous bullet. The clock started running when she fell down, so in cases where the physical exam is normal, only the first CT is needed and ongoing monitoring is not. Thus, she could return to her care facility from the ED after the scan.
- What other important information do you need to know? Of paramount importance is her DNR status and her/her family’s willingness to have brain surgery if a significant lesion is identified. It is extremely important to know the latter item. If there is never any patient or family intent to proceed to surgery, is there any point to obtaining scans at all? In my opinion, no. The whole reason to obtain the scan and monitor is to potentially “do something.” But if the patient and/or family will not let us “do something,” there is no reason to do any of this. It is crucial that the patient and family understand the typical outcomes from surgery given her age and degree of frailty. This is most important in patients who are impaired with dementia or a high-grade lesion if found from which there is minimal chance of recovery. In most such cases, even if surgery is “successful,” the patient will never recover enough to return to their prior level of care. This should be weighed heavily by the family and care providers.
- Should a patient with DNR or “no surgery” orders even be sent to the ED? Theoretically, no. There is no need from the standpoint of their future care. They are not really eligible to have any studies or monitoring done. However, the facility may try to insist for their own liability issues, but this is not really a valid clinical reason.
I hope you enjoyed this little philosophical discussion. Feel free to agree/disagree through your comments or tweets!
Here are some philosophical musings to keep you thinking over the weekend.
You are the trauma surgeon on duty one evening, and you receive a call from the emergency department. They have received a mildly demented elderly woman who fell at her nursing home 12 hours ago. The staff believes that her mental status is slightly “off” from what it usually is.
Your trauma program has a well-defined practice guideline for elderly TBI care (not on anticoagulants) that involves an initial CT scan, and then a repeat scan after another 12 hours if anything but a simple subarachnoid hemorrhage (SAH) is present. For just SAH, only serial neuro checks are performed for 12 hours and a TBI screen is performed prior to discharge.
Here are my questions for you:
- What scan(s) do you need to perform given that 12 hours have already passed since her injury?
- Does the patient need to be admitted? For how long?
- What other important information do you need to know?
- Should the patient have been sent to the ED at all?
I am very interested in your input on these questions. I’ll discuss them in detail in my next post. Please leave comments below, tweet, or email your responses and I’ll see how much we think alike. Or not!
Contrast extravasation after major trauma can be very problematic. Extravasation into a solid organ (liver, spleen) generally requires a quick trip to interventional radiology or the operating room. Bleeding from the bowel mesentery assures an exploratory laparotomy. Gluteal vessel extravasation is best treated with angioembolization.
But what about extravasation from off the beaten path areas like the psoas muscle? This is an uncommon finding on trauma CT, so less is known about the usual clinical course. A group in Okayama Japan performed a 10-year retrospective review of data from their hospital. They reviewed hematoma size, associated injuries, and the relationship to treatment options.
Here are the factoids:
- 762 contrast CTs were performed due to blunt trauma over the 10 year period (only 76 per year?!)
- About 15% (117 patients) had either lumbar process fracture or psoas hematoma, and about one quarter had obvious contrast extravasation into the muscle
- Patients with contrast extravasation were significantly older, had higher ISS, and were more likely to require transfusion
- There was an association between the number of transverse process fractures and “need for” angioembolization
- Size of the psoas hematoma was predictive of the need for angioembolization
- Angioembolization of the psoas was frequently associated with embolization of the pelvis
The right psoas has both contrast extravasation and a sizable hematoma
Bottom line: This study has many weaknesses, but does show that psoas extravasation occurs somewhat frequently, even at a low volume center. I always worry about studies that state something like “and xx patients required intervention.” Generally, this means that it was performed at the discretion of the clinician and no consistent rules were applied. And even though hematoma size was significantly correlated with angioembolization, it’s probably not worth the effort to have your radiologist calculate it. But it does illustrate one nearly universal trauma rule:
Patients with active extravasation on CT are bleeding to death until proven otherwise
Do not sit back and manage expectantly! The corollary to this rule is:
Contrast extravasation on CT always requires active measures to stop it
These active measures are typically angioembolization for difficult to reach areas in hemodynamically stable patients (gluteal artery for buttock, lumbar artery for psoas muscle, solid organs). Unstable patients absolutely require a trip to the OR for control. Superficial muscular bleeding frequently stops with good pressure dressings or positioning the patient so they lie on the affected area. Just don’t sit around and watch these patients bleed when you see extravasation on the CT.
Reference: Impact of contrast extravasation on computed tomography of thepsoas major muscle in patients with blunt torso trauma. J Trauma 86(2):268-273, 2019.