Category Archives: General

Physical Exam And Thoracolumbar Spine Fractures

The physical exam is an important part of the initial evaluation of trauma patients. Sometimes it actually makes the diagnosis, but much of the time it focuses further studies like x-rays or lab tests. But we can also use it as a tool to avoid further imaging. For example, consider clinical clearance of the cervical spine. A negative exam in a reliable patient allows us to remove the cervical collar.

Can we apply the same thinking to the thoracic and lumbar spines? Many of us do. No pain or tenderness equates to no imaging or log-roll precautions.

The trauma group at LAC+USC looked at this one a few years ago. They studied every blunt trauma patient over a 6-month period, and first determined if they were “evaluable.” This meant not intoxicated, head injured (GCS<15), and no distracting injury (determined very subjectively). All underwent a standard exam of the TL spine by a resident or attending surgeon.

Here are the factoids:

  • 886 patients were enrolled, and 218 (25%) were not evaluable using the criteria above
  • 11% of the non-evaluable patients were found to have a TL spine fracture by CT, whereas only 8% of the evaluable group did
  • Of the evaluable patients, half (29) had no signs or symptoms of fracture
  • Of those 29 without signs or symptoms, two had a “clinically significant” fracture. Both were younger (20 and 59). One had a T7 compression and a transverse process fracture, the other a T9 compression fracture. Both were treated with a TLSO brace.
  • Of the 27 who could not be examined, 11 had “clinically significant” fractures; 8 were treated with TLSO and 6 with surgery (obviously some overlap there)

Bottom line: So physical exam of the thoracic and lumbar spine sucks, right? Not quite so fast! First, this is a small-ish study, but with enough patients to be intriguing. The biggest issue is that we don’t really know what is “clinically significant.” Treatment of stable fractures of the spine is controversial, and our friendly neighborhood neurosurgeons vary tremendously in how they do it. Ask five neurosurgeons and you’ll get six different answers.

Braces are expensive, and the optimal choice is not clear yet. At my hospital, we are treating select ones with a binder for comfort or a simple backpack brace. The fancier ones like the TLSO easily cost over $1000!

At this point, I recommend that you use a good blunt imaging practice guideline like the one below, coupled with a good physical exam. If the patient has sufficient mechanism to break something (which decreases with patient age), then image them. If they don’t, but have an abnormal exam, image them anyway. And we’ll wait for the next bigger/better study!

Related posts:

Reference: Clinical examination is insufficient to rule out thoracolumbar spine injuries. J Trauma 70(1):174-179, 2011.

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Aspirin For DVT Prophylaxis In Trauma

The use of mechanical and pharmacologic prophylaxis for prevention of deep venous thrombosis (DVT) and venous thromboembolism (VTE) in trauma patients is nearly universal. However, no matter how closely we adhere to existing guidelines, some patients will develop these conditions. Indeed, about 80% of patient who suffer some type of VTE event were receiving prophylaxis at the time.

Trauma is a major factor in causing hypercoagulability. Although current chemoprophylaxis focuses on clotting factors, platelets play a big part in the clot formation process. Our usual drugs, though (various flavors of heparin), have no effect on them.

What about adding aspirin to the regimen? My orthopedic colleagues have been requesting this for years. There is a reasonable amount of data in their literature that it is effect in patients with knee arthroplasty only. As usual, it is misguided to try to generalize management based on experience from one specific body region or operation.

A single Level I trauma center reviewed its data on aspirin prophylaxis for trauma patients. They reviewed their registry data from 2006 to 2011. They identified 172 trauma patients with duplex ultrasound proven DVT. These patients were matched with 1,901 control patients who underwent at least one duplex and never developed DVT. Matching was performed carefully to ensure that age, probability of death, number of DVT risk factors, and presence of TBI were similar. The total number of matched patients studied was 110.

And here are the factoids:

  • About 7% of patients with DVT were on aspirin at the time of their injury, vs 14% of the matched controls
  • 7% were taking warfarin, and 4% were taking clopidogrel
  • Analysis showed that patients taking aspirin had a significantly decreased chance of DVT after injury
  • On further analysis, it was found that this effect was only significant if some form of heparin was given for prophylaxis as well.

Bottom line: So before you run off and start giving your patients aspirin, think about what this study really said. Patients taking aspirin before their injury and coupled with heparin after their injury have a lower rate of DVT. It gives us no guidance as to whether adding aspirin after the fact, or using aspirin alone, are useful.  And we still don’t know if any of this decreases pulmonary embolism or mortality rates.

Related posts:

Reference: Aspirin as added prophylaxis for deep vein thrombosis in trauma: a retrospective case-control study. J Trauma 80(4):625-30, 2016.

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Geriatric Outcome Prediction From The P.A.L.LI.A.T.E Consortium

The continuing rise in geriatric trauma cases seen at trauma centers has necessitated the creation of new infrastructure for evaluating, treating, and assessing outcomes in injured elders. The ability to predict the likely outcome after trauma is extremely important in shaping the management of these patients after discussion with them and their families. Unfortunately, the tools we have for those prognostications are rather complicated, yet rudimentary.

The gold standard to date is TRISS, which combines physiologic data (revised Trauma Score) at the time of first encounter with anatomic injury information (Injury Severity Score). This allows the calculation of a validated probability of survival (Ps).

However, TRISS is unwieldy and frequently cannot be calculated due to missing data. A consortium was created to address these shortcomings. Of course, they chose a name with an unwieldy acronym: Prognostic Assessment of Life and LImitations After Trauma in the Elderly (PALLIATE).

This group developed the Geriatric Trauma Outcome Score (GTOS) in 2015. They recently published a study comparing GTOS with the gold standard TRISS. This could be important since GTOS is easier to calculate, with less opportunity for missing data since it relies only on age, ISS, and presence of blood transfusion.

They calculated outcomes of nearly 11,000 patients at three centers, and found that GTOS worked as well as TRISS. The major advantage was that GTOS requires only three variables:

GTOS = Age + (ISS x 2.5) + (22 if blood transfused in first 24 hours)

Then, just to make your head spin a little more, the GTO score value gets plugged into this logistic model equation:

Bottom line: GTOS is helpful in some ways, but not in others. It does allow calculation of the probability of survival in elderly patients as well as traditional methods, but with more readily available data points. 

However, it is just a probability. It may predict that someone like your patient has a 3% probability of survival, but it cannot tell specifically that your patient is in the 3% vs the 97%. The consortium was trying to make it easier and more objective for clinicians to discuss care plans with family. But this is not really the case. 

And a bigger problem is that it gives us no guidance as to quality of life or level of independence for those patients who will probably survive. These factors are, by far, the most important ones when having those hard discussion with patient and/or family. We still need a tool that will guide us on functional outcomes, not just life or death.

Related posts:

Reference: A comparison of prognosis calculators for geriatric trauma: A P.A.L.LI.A.T.E. consortium study. J Trauma, publish ahead of print DOI: 10.109, 2017.

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What The Heck? Part 2: Progressive Back Pain After Heavy Lifting

Yesterday, I described a case of a young athlete who developed progressive back pain after rapidly increased his deadlift weights. He presented to the hospital with back pain and inability to get up from a supine position. He had firm and tender paraspinal muscles in his lower back, but no other findings.

What to do next? Obviously, we need a bit more information on the bony structures. Other than run of the mill muscle strain, a compression fracture would be the next most common diagnosis. In this young, healthy athlete, a simple set of AP and lateral spine images should be sufficient. But if you opted for a CT scan, I won’t argue. In either case, the images were normal.

Since there is significant muscle pain and tenderness, a lab panel with a few extras is in order, as well. The usual electrolytes, etc were normal. Creatinine was 0.9, but CPK was 60,000!

Now what are you thinking? What’s the diagnosis, and what is the decision tree for treatment?

Add your comments below, or tweet them out. I’ll finish this topic up in the next post.

 

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Autotransfusing Blood Lost Through The Chest Tube

Autotransfusing blood that has been shed from the chest tube is an easy way to resuscitate trauma patients with significant hemorrhage from the chest. Plus, it’s usually not contaminated from bowel injury and it doesn’t need any fancy equipment to prepare it for infusion.

It looks like fresh whole blood in the collection system. But is it? A prospective study of 22 patients was carried out to answer this question. A blood sample from the collection system of trauma patients with more than 50 cc of blood loss in 4 hours was analyzed for hematology, electrolyte and coagulation profiles.

The authors found that:

  • The hemoglobin and hematocrit from the chest tube were lower than venous blood (Hgb by about 2 grams, Hct by 7.5%)
  • Platelet count was very low in chest tube blood
  • Potassium was higher (4.9 mmol/L), but not dangerously so
  • INR, PTT, TT, Factor V and fibrinogen were unmeasurable

Bottom line: Although shed blood from the chest looks like whole blood, it’s missing key coagulation factors and will not clot. Reinfusing it will boost oxygen carrying capacity, but it won’t help with clotting. You may use it as part of your massive transfusion protocol, but don’t forget to give plasma and platelets according to protocol. This also explains why you don’t need to add an anticoagulant to the autotransfusion unit prior to collecting or giving the shed blood!

Reference: Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood? Am J Surg 202(6):817-822, 2011.

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