Category Archives: General

Family Presence During Trauma Resuscitation

June 7, 2013 The Trauma Pro Leave a comment

There’s a lot of talk in trauma nursing circles about family presence during trauma resuscitation (FPDR). But after searching far and wide, I have not been able to find much literature about it. There are a few papers about family reaction to it, and a few more about healthcare providers’ reactions. But the science is not yet very good.

Typical arguments against it from (mainly) doctors and some nurses, and my rebuttals, are as follows:

Family members will think the trauma resuscitation is chaotic – then fix your trauma team; you’ve got a problem
They will slow the team down – an analysis has shown no such effect
Family will be traumatized by seeing what we do – family members have seen simulations on TV, so they have a pretty good idea of what’s going on
The doctors and hospital are more likely to be sued – actually, this is probably less likely, because the family has actually seen that you’ve done everything possible for their loved one

Personally, I’m very much for it, especially in the pediatric age group. I encourage all trauma programs to develop a policy to enable FPDR. Here are some key pointers:

Only allow one key family member in the resuscitation room. Have them decide who it will be. This limits confusion and congestion.
Assign a “medical interpreter” to stand with them in the room, preferably a nurse. The role of this person is twofold: to explain what is being done and why, and to make sure that they remain safe. If they have a hard time coping, appear to be getting faint, or misbehave in any way, it’s time for them to leave.
Involve the family member as much as practical. Have them stand near the patient’s head so they can communicate with them, or at least see them.
Keep the trauma team organized and professional. It’s been my experience that having family in the room puts everybody on their best behavior.

Bottom line: Surveys have shown that family members tend to be more satisfied with care and more convinced that everything possible was done if they are able to witness what may be the final moments of their loved one’s life. A little planning goes a long way in allowing FPDR in your emergency department.

References:

Health care providers’ attitudes regarding family presence during resuscitation of adults: an integrated review of the literature. Clin Nurse Spec 24(3):161-174, 2010.
Attitudes of healthcare staff and patients’ family members towards family presence during resuscitation in adult critical care units. J Clin Nurs. 21(13-14):2083-2093, 2012.
Family presence during pediatric trauma team activation: an assessment of a structured program. Pediatrics 120(3):e565-574, 2007.

General

CT Scanning After Gunshot To The Abdomen

June 6, 2013 The Trauma Pro Leave a comment

Yesterday’s question related to ordering a CT scan in patients with a gunshot to the abdomen. Should it ever be needed? In general, if you encounter this question on an exam, the answer should be no. However, medicine in general and trauma in particular are not so black and white. There are always exceptions to the rules.

Generally speaking, gunshots to the abdomen have a 90+ percent chance of causing an injury that requires repair. Pretty good odds that the patient needs a laparotomy. However, there are a few cases where further diagnosis may be okay.

In general, additional imaging is warranted if it will change the decision-making process in some way. In most gunshots to the abdomen, decision-making is very straightforward, and the patient must go to the OR without delay.

In some cases, there is a question as to whether or not the patient even needs an operation. The most common situation occurs when the wound could be tangential and completely extraperitoneal. These patients must be hemodynamically stable and without diffuse abdominal pain or tenderness to be considered for CT. Symptoms over the wound tract are acceptable. CT can show very clearly that the bullet stayed away from critical internal structures. These patients may even be discharged if they have no other injuries.

The other case is applicable in select patients with an obvious need for OR and who are hemodynamically stable. If a roadmap provided by CT would potentially cause the surgeon to limit, focus or expand the exploration, the scan may be justifiable. Most commonly, this occurs in patients with multiple gunshots, in whom the exact trajectories can’t be fully appreciated by looking at the holes and the known bullets seen on plain abdominal images.

Bottom line: CT scan in patients with gunshots to the abdomen should be a rare occurrence. There must be specific indications, and the patient must be hemodynamically stable. If the result may change the procedure in some way, it may be justifiable. Just be ready to explain your rationale to your trauma medical director! They will ask!

General

Pop Quiz: CT Scanning After Gunshot To The Abdomen

June 5, 2013 The Trauma Pro Leave a comment

Gunshots to the abdomen have a very high likelihood of causing damage that needs to be repaired. For this reason, the vast majority are immediately transported to the OR for laparotomy (celiotomy).

But there are a few situations in which advanced diagnostics can be justified prior to operation. Do you know what they are? Tweet or comment your answers. I’ll explain the details tomorrow.

General

Are Inlet / Outlet Views Obsolete In Pelvic Trauma?

June 4, 2013 The Trauma Pro Leave a comment

Orthopedic surgeons have long found inlet and outlet views (I/O) of the pelvis to be helpful in their management of pelvic fractures. However, for the last decade we’ve seen an inexorable creep in diagnostic imaging from plain xrays to computed techniques. Have the conventional inlet and outlet views lost their luster?

San Francisco General Hospital and UCSF recently published a registry-based study looking at conventional pelvic I/O images and virtual I/O images reconstructed from CT scans. Two years of registry data were reviewed, and included patients had both conventional I/O images and CT imaging. Images were evaluated by two orthopedic traumatologists for their quality.

Sadly, only 20 patients were available for this study, which makes it an interesting pilot at best. The most interesting results were as follows:

Quality of imaging was judged to be equal except when pelvic rotation was present. CT fared better in these cases.
Both inlet and outlet views were judged to be better when reconstructed by CT
Overall, imaging of all portions of the pelvis was about equal in both types of study
The need for repeat studies was identified in nearly half of conventional images, but in only 8% of CT images

Bottom line: CT scanning is slowly becoming the preferred modality for just about any type of trauma imaging. In the 1980’s, head CTs became widespread, followed rapidly by abdominal imaging. Chest CT for definitive diagnosis became commonplace around 2000, and spine imaging by CT has now become the gold standard. Although there are a few throwbacks where conventional imaging has been thought to be better, they are vanishing rapidly. Computing technology can now reconstruct inlet and outlet views of the pelvis, correcting for rotation and angulation in any study of the abdomen/pelvis. And if the reconstructed image is not quite right, the tech can change a few parameters and generate it again and again until the image is perfect.

Orthopedic surgeons should now expect a nicely formatted set of inlet/outlet CT reconstructions in all trauma patients with pelvic fractures.

Related post:

Pelvic trauma radiographs demystified

Reference: Are conventional inlet and outlet radiographs obsolete in the evaluation of pelvis fractures? J Trauma 74(6):1510-1515, 2013.

Home of the Trauma Professional's Blog