Gallery June 28, 2011 The Trauma Pro Leave a comment

What The Heck Is It? Final Answer!

Yesterday, I posted the physical exam findings on this mystery object. A tiny puncture wound was present just to the right of the xiphoid on the lower chest wall, and a small sharp point was palpable.

Here’s how to deal with it:

Step 1. (Image 1) Don’t let it move or try to pull it out immediately! I didn’t want this thing to go in any further, or work it’s way out in case it was in the heart. I snapped a hemostat on the end of it for stabilization.

Step 2. (Images 2 and 3) Find out where it is exactly. You need to know what if any vital structures it may have pierced so you can plan for removal. In this stable patient, CT was the best option. If he had been unstable, it would have meant an immediate trip to the OR. Note how the object is within the chest wall, BUT it had penetrated at least as deep as the lung since a pneumothorax was present.

Step 3. (Image 4) Get it out! Off to the operating room for removal, just in case some unexpected bleeding or hemodynamic changes were to occur. After the patient was asleep, a chest tube was inserted. The object was a fine nail from a commercial nail gun mishap and pulled out easily with the hemostat. He was discharged two days later after the tube was pulled.

Photo source: personal archive. Patient not treated at Regions Hospital

General

What The Heck Is It: Part 2

June 27, 2011 The Trauma Pro Leave a comment

Last Friday I posted an xray that showed a long, thin metallic foreign body projecting from the right chest area toward the right side of the heart. What is it?

The patient declined to tell us what he had been doing. And looking at the xray, which is a 2D representation of a 3D object, it’s impossible to tell where the object is in the z axis. It could be in his back, in his clothes, or in his heart.

A complete physical exam showed a pinhole just to the right of the xiphoid process. By gently running a (gloved) finger across the hole, something thin and sharp was palpable.

What should we do next? More images and the final answer tomorrow!

General

Gallery June 24, 2011 The Trauma Pro Leave a comment

What The Heck Is It?

This patient presented to an ED after work complaining of mild shortness of breath.

Answer and more images on Monday.

Source: Personal archive photo. Patient not treated at Regions Hospital.

General

Results – Blunt Trauma Radiographic Imaging Protocol

June 23, 2011 The Trauma Pro Leave a comment

In my previous post (click here to view) I discussed an imaging protocol that we developed and implemented last year. Today, I’ll detail what it has accomplished in our patients.

We looked at 229 patients who had their imaging performed according to the new protocol during a 3 month period and compared them to 215 patients who were imaged the previous year. Each scan administered to each body area (head, chest, abdomen/pelvis, c-spine, t-spine, l-spine, face, neck angio) were tabulated separately.

We found that the overall number of scans performed decreased significantly. We looked at our data and generated numbers per 100 patients. During the control period, we did 298 CT scans per 100 patients. This decreased to 271 during the study period. The number of head scans remained the same (82 per 100 patients during control, 85 per 100 during the study), as did the cervical spine scans (84 vs 86).

The biggest declines were seen in chest CT (53 per 100 control vs 33 per 100 study) and abdominal CT (57 vs 43).

We did see an increase in conventional xrays of the thoracic and lumbar spines to offset the absence of reformatted spine images that would have been generated from the chest and abdominal CT scans. We also noted small increases in CT of the head, cervical spine, and neck angio. This was likely due to better adherence to specific guidelines.

Bottom line: we believe that our work shows that careful adoption of well thought out guidelines can make a difference in practice and significantly decreases radiation exposure in our blunt trauma patients.

To read the post on this protocol, or to download it, click here.

Click here to download the Blunt Trauma Radiographic Imaging Protocol Worksheet

General

Blunt Trauma Radiographic Imaging Protocol

June 21, 2011 The Trauma Pro Leave a comment

Last year, we developed an evidence-based protocol for deciding what radiographic images to order in our blunt trauma patients. For some body regions, there is fairly good literature available for guidance (i.e. Canadian head and cervical spine rules). For other areas, there is not nearly as much.

We convened a small group of people, including trauma surgeons, emergency physicians, radiologists and a radiation physicist to combine the information into a practical tool.

You can view or download the worksheet we use by clicking the link at the bottom of this post. The protocol has been in use for about 9 months, and has significantly decreased the use of higher radiation dose imaging (CT). As a result, there has been a small increase in the use of lower dose conventional imaging (plain spine studies), but no missed injuries.

Tomorrow, I’ll write about the specifics of how this protocol has changed our ordering habits. Click here to view it.

Click here to download the Blunt Trauma Radiographic Imaging Protocol Worksheet

Click here to download a bibliography of the literature used to develop the protocol

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