You’re running a trauma activation, and everything is going great! Primary survey – passed. Resuscitation – lines in, fluid going. You are well into the exam in the secondary survey.

Then it happens. The automated blood pressure cuff shows a pressure of 72/44. But the patient looks so good!

You recycle the cuff. A minute passes and another low pressure is noted, 80/52. You move the cuff to the other arm. Xray comes in to take some pictures. You roll the patient. 76/50. Well, you say, they were lying on the cuff. Recycle it again.

A minute later, the pressure is 56/40, and the patient looks gray and is very confused and diaphoretic. It’s real! But how long as it been real? An easy 5 minutes have passed since the first bad reading.

Bottom line: Sometimes it’s just hard to believe that your patient is hypotensive. They look so good! But don’t be fooled. If you get a single hypotensive reading, STOP! You have 90 seconds to figure out if it’s real, so don’t do anything else but. Check the pulse rate and character with your fingers. Do a MANUAL blood pressure check. It’s fast and accurate. If you have the slightest doubt, ASSUME IT’S REAL. Remember, your patient is bleeding to death until proven otherwise. And it’s your job to prove it. Fast!

Over the years, I’ve written about solid organ injury management many times. Here is a summary of some practical pointers and tips, some old and some new. They are as evidence-based as I can get them. This kind of stuff is not always in the doctor and nursing books.

• Please refer to our solid organ injury protocol, which you can download here.
• Ward and ICU branches are order sets at my hospital, not necessarily admitting locations. If you have a special unit or step-down area that can provide ICU-level monitoring, use it for the ICU order set.
• Strongly consider interventional radiology (IR) and angiography in all adult patients with contrast extravasation (children generally do not qualify unless they show signs/sx of ongoing volume loss). Consider also in high grade injuries, because they may have active bleeding that isn’t quite brisk enough to see on CT.
• Serial hemoglobin measurements are not part of the protocol. They are only used to help decide if transfusion might be needed. Vital signs will always signal failure before the hemoglobin does.
• Nearly all patients may be up and eating immediately, or certainly by the next morning. No need for protracted NPO status or bed rest. Really no need for it at all!
• Failure really falls into 2 types: hard and soft. Hard failure is a single episode of definitive hypotension (usually 80s or less) or development of peritoneal signs, and requires an emergency trip to the OR. Soft failure is transient or modest hypotension that responds rapidly to a fluid bolus. If IR has not already been used, a quick trip there may obviate the need for operation. However, another one of these bouts makes it a hard fail. Time for OR.
• Hard failure can only be treated with blood, some crystalloid, and a knife. Pressors, steroids, or other drugs can only be used if they come in liter bags and can be given at over 1000cc/hr. That means never.
• In IR, give the radiologist 30 minutes to stop the bleeding. Don’t let them dawdle for hours. If the patient has a hard fail, abort and go to OR; do not let the radiologist persist.

After discharge, our usual orders are:

• Normal activity (non-impact) for 6 weeks
• All activity (except high impact) thereafter
• High impact activity (tackle football, rugby, serious extreme sports) only after 12 weeks (no good data for this one)
• No repeat CT scanning to judge healing
• Warn patients of the good possibility of a transient increase in pain on days 7-10. This is common in many unless they’ve been embolized.
• Patient to call if unrelenting increase in pain, or increasing orthostatic symptoms, fevers chills

Related posts:

• Download the solid organ protocol
• The undergrading of spleen injury
• Complications of splenic embolization
• Spleen vaccines

During the past several years, it has finally begun to dawn on us that radiation is not very good for us. This is especially true in pediatric patients, where they may not feel the full effect of over-irradiation for years to come. We’ve made efforts to decrease or eliminate studies when possible. We’ve adopted the principles of ALARA (doses as low as reasonably achievable).

But there are some areas of the body that demand evaluation using CT after blunt trauma. The head is one, since MRI is not as immediately available, studies take a long time, and they may demand sedation to the point of intubation in smaller children.

Unfortunately, we have found another way to increase radiation exposure when using head CT. The repeat scan. The concern is that pathology noted on the first scan may worsen, indicating that a more specific (and usually invasive) intervention is needed. 

A study was presented at the AAST this year examining the use of specific clinical criteria to determine whether a repeat head CT was necessary after blunt head trauma in children. Here are the factoids:

• This was a retrospective cohort review of a pool of 435 patients admitted to a pediatric trauma center over 8 years (!) with accidental TBI
• Only 120 were eligible (!), with both some type of intracranial hemorrhage and a GCS of 14-15
• Fourteen patients did not receive repeat head CT; the remaining 106 did
• Pediatric age was not defined in the abstract, but repeat CT kids were older than no repeat kids (8 years vs 3 years)
• None of the children not receiving a repeat scan had worsening symptoms
• Seven children with repeat CT worsened; 5 had an epidural and 2 had subarachnoid hemorrhage. One of the epidurals showed an increase in mental status

Bottom line: Another poorly constructed study. Although it agrees with my bias toward using physical exam in place of repeat CT in select adult head trauma, I just can’t add this study to my personal library. There is a small but growing body of literature about this in adults, but this pediatric one is nowhere good enough to alter my practice. Too few patients, retrospective (we don’t know why they chose to scan or not scan), and major age variances are only a few of the problems. And the fact that one child with a repeat scan and no change in exam showed an increasing epidural that needed operative intervention is frightening.

Let’s keep looking for ways to decrease radiation exposure. But first, let’s craft some really good, prospective studies so we can be sure we’re not jeopardizing the well-being of our children.

Related posts:

• Radiation exposure in pediatric trauma
• CT scanning before pediatric transfers – Bad!

Reference: Is routine repeat brain CT necessary in all children with mild traumatic brain injury? AAST 2013, paper 56.