Category Archives: General

But The Radiologist Made Me Do It!

The radiologist made me order that (unnecessary) test! I’ve heard this excuse many, many times. Do these phrases look familiar?

  1. … recommend clinical correlation
  2. … correlation with CT may be of value
  3. … recommend delayed CT imaging through the area
  4. … may represent thymus vs thoracic aortic injury (in a 2 year old who fell down stairs)
Some trauma professionals will read the radiology report and then immediately order more xrays. Others will critically look at the report, the patient’s clinical status and mechanism of injury, and then decide they are not necessary. I am firmly in the latter camp.
But why do some just follow the rad’s suggestions? I believe there are two major camps:
  • Those that are afraid of being sued if they don’t do everything suggested, because they’ve done everything and shouldn’t miss the diagnosis
  • Those that don’t completely understand what is known about trauma mechanisms and injury and think the radiologist does
Bottom line: The radiologist is your consultant. While they are good at reading images, they do not know the nuances of trauma. Plus, they didn’t get to see the patient so they don’t have the full context for their read. First, talk to the rad so they know what happened to the patient and what you are looking for. Then critically look at their read. If the mechanism doesn’t support the diagnosis, or they are requesting unusual or unneeded studies, don’t get them! Just document your rationale clearly in the record. This provides best patient care, and minimizes the potential complications (and radiation exposure) from unnecessary tests.
Related post: 

Reference: Pitfalls of the vague radiology report. AJR 174(6):1511-1518, 2000.

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Liver Laceration And Liver Function Tests

Over the years I’ve seen a number of trauma professionals, both surgeons and emergency physicians, order liver transaminases (SGOT, SGPT) and bilirubin in patients with liver laceration. I’ve never been clear on why, so I decided to check it out. As it turns out, this is another one of those “old habits die hard” phenomena.

Liver lacerations, by definition, are disruptions of the liver parenchyma. Liver tissue and bile ducts of various size are both injured. Is it reasonable to expect that liver function tests would be elevated? A review of the literature follows the typical pattern. Old studies with very few patients.

From personal hands-on observations, the liver tissue itself tears easily, but the ducts are a lot tougher. It is fairly common to see small, intact ducts bridging small tears in the substance of the liver. However, larger injuries can certainly disrupt major ducts, leading to major problems. But I’ve never seen obstructive problems develop from this injury.

A number of papers (very small, retrospective series) have shown that transaminases can rise with liver laceration. However, they do not rise reliably enough to be a good predictor of either having an injury, or the degree of injury. Similarly, bilirubin can be elevated, but usually not as a direct result of the injury. The most common causes are breakdown of transfused or extravasated blood, or from critical care issues like sepsis, infection, and shock.

Bottom line: Don’t bother to get liver function tests in patients with known or suspected injury. Only a CT scan can help you find and/or grade the injury. And never blame an elevated bilirubin on the injury. Start searching for other causes, because they will end up being much more clinically significant.

References:

  • Evaluation of liver function tests in screening for intra-abdominal injuries. Ann Emerg Med 20(8):838-841, 1991.
  • Markers for occult liver injury in cases of physical abuse in children. Pediatrics 89(2):274-278.
  • Combination of white blood cell count with liver enzymes in the diagnosis of blunt liver laceration. Am J Emerg Med 28(9):1024-1029, 2010.
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July Newsletter Is Here!

The July newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is x-rays. 

In this issue you’ll find articles on:

  • CT scan images simplified
  • CT scans for rib fractures?
  • A trick for finding rib fractures on chest xray
  • Futility of the lateral view for pneumothorax
  • Do you really need to repeat that xray?
  • How often are outside images repeated?
  • Repeat imaging: what good is it?

Subscribers had the newsletter emailed to them over the weekend. If you want to subscribe (and download back issues), click here.

Download the newsletter here!

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Pedestrian Struck!

The pedestrian struck by a car presents challenges to trauma professionals for a number of reasons. Due to the size mismatch between the two, serious injuries are fairly common. And unfortunately, many injuries are occult, so it’s easy to dismiss patients who may be hiding serious problems.

The National Highway and Traffic Safety Administration (NHTSA) recently published its Traffic Safety Facts report for 2011. This 232 page tome contains a wealth of interesting and thought-provoking data. One of the more interesting tidbits that caught my eye had to do with pedestrians struck by cars.

Most normal people do not get hit by cars. There is nearly always some additional factor that allows this to occur:

  • Don’t understand cars – this is a typical reason for small children, and I’ve also seen foreign visitors from countries with little auto traffic fall victim to this one. The developmentally disabled also fall into this category.
  • Not paying attention – this category is growing rapidly due to smart phone use
  • Can’t clear the intersection in time – this one gets the elderly. Due to physical constraints, they can’t move fast enough (4 ft/sec for most intersections) to get across in time
  • Intoxicated – this basically puts an adult back into the first category above. These incidents tend to be clustered around bars, and the numbers peak at night, typically from midnight to 3am.

The NHTSA report has always detailed the age breakdown of pedestrians struck, but now they are reporting the number of “impaired walkers” as well.

  • Overall, death by motor vehicle (occupants and pedestrians) involved alcohol 31% of the time (!!)
  • 4,432 pedestrians were killed and about 69,000 were injured
  • About one third of pedestrians killed tested positive for alcohol, and most were legally intoxicated!
  • 14% of the nonintoxicated pedestrians were struck by an intoxicated driver vs 19% of intoxicated pedestrians

Bottom line: There are many reasons for getting hit by a car, and being intoxicated is an entirely avoidable one. These patients can be seriously injured, so don’t just shrug off complaints as being due to intoxication. Additional prevention efforts should be developed using the interesting patterns outlined in the NHTSA report.

Reference: NHTSA Traffic Safety Facts 2011

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Hare Traction – Putting It On, Taking It Off

Femoral traction devices have been around for a long time. One reader has asked about the timing of removal of these devices after they arrive at the hospital. I learned a number of things while reviewing the literature to answer this question.

Most importantly, there is really only one indication for applying a traction splint to the femur: an isolated, relatively mid-shaft femur fracture. Unfortunately, there are lots of contraindications. They consist of other injuries or fractures that could sustain further damage from traction. Specifically, these include:

  • Pelvic or hip fracture
  • Hip dislocation
  • Knee injury
  • Tib/fib, ankle or foot fracture

I did find one interesting study from 1999 that looked at how useful these splints really were. Of 4,513 EMS runs, only 16 had mid-thigh trauma and 5 of these appeared to have a femur fracture. Splint application was attempted in 3, and only 2 were successful. This was the experience in only one city (Evanston, IL) for one year. However, it mirrors what I see coming into our trauma center.

Unfortunately, when it comes to removal, there are very few guidelines out there. My advice is to have your orthopedic surgeon evaluate as soon as imaging is complete. They can help decide whether converting to some type of definitive traction is necessary, or whether it can be changed to a more conventional splint. In any case, the objective is to minimize the total amount of time in the traction splint to avoid any further injury to other structures.

Reference: Prehospital midthigh rauma and traction splint use: recommendations for treatment protocols. Am J Emerg Med, 19:137-140, 2001.

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