Category Archives: General

Best Of: Why Did The Trauma Team Cut Off My Clothes?

The fifth highest priority taught in the ATLS course is exposure. This generally means getting the patient’s clothes off so any hidden injuries can be identified. Early in my career, I was called to see a patient who had a gunshot to the chest that had been missed because the consulting physician had neglected to cut off her bra. A small caliber wound was found under the elastic strap in her left anterior axillary line after a chest xray showed a bullet in mid-thorax.

The usual trauma activation routine is to cut off the clothes. There are several tips and tricks we use to do this quickly. And a number of commercial products are out there to make it even easier.

But do we really need to cut everyone’s clothes off? I’m not disputing the fact that it’s important to be able to examine every square inch. But do we need to destroy everything our patient is wearing? I once saw a sequined wedding dress cut off (it’s almost as bad as cutting off a down jacket).

The answer is no. The key concept here is patient safety. Can you safely remove the clothing in a less destructive way? For most victims of major blunt trauma, we worry a lot about the spine. Unfortunately, it’s just not possible to allow the patient to wriggle out of their clothes and protect their spine. The same goes for fractures; it may be too uncomfortable to remove clothing because of fracture movement so scissors are required.

Penetrating trauma is a bit different, and in many cases it’s a good idea to try to get the clothing off intact. Once again, if spinal injury is a consideration (gunshots only), the involved clothes should be cut off. A patient with a gunshot to the chest can probably have their pants safely and gently pulled off, but their shirt and coat must be cut.

The police forensic investigators like to have intact clothing, if possible. This is another good reason to try to remove clothing from penetrating injury victims without cutting. 

Bottom line: Think before you cut clothes! Major blunt trauma and bad injuries require scissors. Lesser energy blunt injury may allow some pieces of clothing to be removed in the usual method. Most penetrating injury does not require cutting. But if you must (for patient safety), avoid any holes in the fabric so forensics experts can do their job.

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What Is: Venous Sinus Thrombosis?

Venous sinus thrombosis is in the news now, since Hillary Clinton is currently hospitalized and being treated for it. Most trauma professionals have probably never heard of it, let alone seen one. Here’s a quick primer on what you need to know about this problem.

Blood circulation from the cerebral veins drains into the various venous sinus systems around the brain. Additionally, CSF is reabsorbed by the arachnoid villi, which in turn drain into the superior sagittal sinus. A clot in any part of this sinus system (see image below) results in a partial or complete obstruction, which can lead to rapidly increasing pressure in the brain.


The condition is very rare, with only about 3 cases per million people recognized. Although most occur in people with clotting abnormalities, trauma is always on the list. The most common traumatic issue is head injury, and almost always involves a skull fracture near the involved venous sinus.

Clinically, awake patients complain of a steadily increasing headache that is not touched by any of the usual analgesics. Some describe a headache with very sudden onset, the so-called “thunderclap headache.” Any number of neurologic abnormalities can then occur, ranging from nothing to seizures to rapid onset of coma.

Diagnosis is difficult. CT scan unreliably shows the lesion, and subtle venous changes may be overshadowed by findings from the original trauma. However, it should be performed first to accurately diagnose the more common problems that are most likely to be present. If the CT comes up clean, the gold standard is MRI with magnetic resonance venography (MRV)

Patients with significant swelling problems may require hyperosmotic therapy and/or decompressive craniectomy. Milder cases can be treated with anticoagulation, but a thorough risk/benefit assessment must be carried out. Remember, these people usually have brain injury that has resulted in bleeding somewhere it shouldn’t be, so anticoagulation can be dangerous! A few rare case reports of thrombolysis (!!) and clot extraction are out there, too, but these are for extreme cases only.

Bottom line: It’s likely that Ms. Clinton suffered a temporal bone fracture from her fall, and did well initially like most patients. However, increasing symptoms (headache), likely prompted a repeat CT followed by the MRI which showed thrombosis of her transverse sinus. Luckily, she did not have significantly increased intracranial pressure leading to more serious neurologic problems. Judicious anticoagulation with warfarin and very close monitoring were instituted, and seem to be working well so far.


  • Thrombosis of the cerebral veins and sinuses. NEJM 352:1791-1798, 2005.
  • Cerebral venous sinus thrombosis complicating traumatic head injury. J Clin Neurosci 19(7):1058-1059, 2012.
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Don’t Ignore The Naughty Bits

A major part of any patient encounter is the physical exam. This is particularly true in the trauma patient, because it allows trauma professionals to identify potential life and limb threatening injuries quickly and deal with them. Unfortunately, we tend to mentally block out certain parts of the body, typically the genitalia and perineum, and may not do a complete exam of the area. I call these areas the naughty bits. For those of you who don’t get the reference, here’s the origin of this phrase:

Specifically, the naughty bits are the penis, vagina, perineum, anus and natal cleft (aka the butt crack or arse crack). These areas are more likely to remain covered when the patient arrives, and are less likely to be examined thoroughly.

In penetrating trauma, a detailed exam of these areas is extremely important in every patient to avoid hidden injuries and to determine if nearby internal structures (rectum, urethra) might have been injured.

Here are some tips for each of the areas:

  • Penis – Always look for any blood at the meatus (or a little blood in the underwear) as a possible sign of urethral injury. This is frequently associated with pelvic fractures.
  • Scrotum – Blood staining here is usually from blood dissecting away from pelvic fractures. Patients with this finding are more likely to need angiographic embolization of pelvic bleeding.
  • Vagina – external exam should always be done. Internal and/or speculum exam should be done in pregnant patients, and those with external bleeding or pelvic fractures
  • Perineum – Also associated with pelvic fracture and significant bleeding. Skin tears in this area are usually lacerations indicating an open pelvic fracture. Alert your orthopaedic surgeons early, and do a good, clean rectal exam (carefully wipe away all external blood). Rectal injuries are common with this finding, and a formal proctoscopic will probably be required.
  • Anus – Skin tears virtually guarantee that a deeper rectal injury will be found. Proctoscopic exam in the OR is mandatory.
  • Natal cleft – Usually not a lot going on in this area, except in penetrating injury. This is the only area of the naughty bits that can be safely examined in the lateral position. 

Bottom line: The naughty bits are important because the occasional missed injury in this area can be catastrophic! Do your job and force yourself to overcome any reluctance to examine them.

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LifeBot The Next Generation

Over a year ago, I wrote about a product called LifeBot. This technology provides a way to join the ED and prehospital teams as they work on patients. This involves special monitoring equipment in the ambulance (cameras and other telemedicine equipment), a special tablet computing system for data input and imaging, and equipment at the ED base station.

Using the original LifeBot system, medics could relay vitals and EKG data to the base station in real time, receive orders from emergency physicians, and send video feeds and photos from the ambulance.

LifeBot Technology has now released LifeBot 5, the next generation of this system. The unit is now portable, and can be taken out of the ambulance at the scene. It is ruggedized and weighs only 15 pounds, which isn’t bad for field medical equipment. The system now includes a web interface that can mesh with some electronic medical record systems. 

Expect to see more improvements (a defibrillator is slated as the next addition) as well as competing products soon.

What does it cost, you ask? A lot! As always, it’s tough to get exact numbers. The LifeBot 5 should be about $20,000. However, this does not include equipment cost for the base station, which is at least that much, if not more!

Bottom line: Expect further progress in blending the prehospital and emergency department environments. More products like this will become available, extending the senses of emergency physicians and providing additional assistance to prehospital providers.

Related post: The “super ambulance” of the future


Disclosure: I have no financial interest in Lifebot Technology

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