Category Archives: General

EAST 2017 #2: CT Scan After Recent Operative Exploration for Penetrating Trauma

The general rule for penetrating trauma, especially gunshots to the abdomen, is that you don’t need to obtain a CT scan to help you decide to go to the OR. (Of course, there are a few exceptions.) And the corollary has always been that you don’t need to get a CT scan after you operate for penetrating trauma.

But the group at UCSF is questioning this. They retrospectively looked at 5 years of data on patients who underwent trauma laparotomy without preoperative imaging. They focused on new findings on CT that were not reported during the initial operation.

Here are the factoids:

  • 230 of 328 patients undergoing a trauma lap did not have preop imaging
  • 85 of the 230 patients (37%) underwent immediate postop CT scan. These patients tended to have a gunshot mechanism and higher injury severity score.
  • Unreported injuries were found in 45% (!) and tended to be GU and orthopedic in nature
  • 47% of those with unreported injuries found required some sort of intervention

Bottom line: This is a very interesting and potentially practice changing study. However, there is some opportunity for bias since only select patients underwent postop scanning. Nevertheless, one in five patients who did get a postop scan had an injury that required some sort of intervention. This study begs to be reworked to further support it, and to develop specific criteria for postop scanning.

Questions/comments for the authors/presenters:

  • Be sure to break down your results by gunshot vs stab. This will help formulate those criteria I mentioned above.
  • Specifically list the occult injuries and interventions required. In some studies, those “required interventions” are pretty weak (urology consult vs an actual procedure).
  • How exactly did the operating surgeons determine who to send to CT? Was it surgeon-specific (i.e. one surgeon always did, another never did)? Was it due to operative findings (hole near the kidney)? This is also needed when developing specific criteria for postop imaging.
  • Nice poster!

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: Routine tomography after recent operative exploration for penetrating trauma: what injuries do we miss?  Poster #14, EAST 2017.

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EAST 2017 Page on The Trauma Pro Blog

Hello all! I’ve created a separate page for posts regarding the upcoming meeting of the Eastern Association for the Surgery of Trauma.

I will be reviewing a baker’s dozen abstracts over the next 2 weeks, giving my own analysis and commentary. I’ll also provide some suggestions and questions to anticipate for the authors to refer to.

Click here to visit the EAST 2017 page!

And if you are a presenter and would like me to look at your paper, just email, tweet, or connect via your method of choice.

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The Best of EAST! Starts tomorrow!

Starting tomorrow, and continuing through the annual meeting of the Eastern Association for the Surgery of Trauma, I will be analyzing one of the upcoming presentations each day. That’s 13 papers, and I’ll be picking some of the notable ones.

Remember, abstracts are teasers to get you to read/listen to the full paper. I’ll be reviewing them in detail, putting them into context, and this year I’ll be providing a list of questions that the presenters should be prepared to field from the audience. And I’ll be in that audience, so I will probably ask a few of them!

Enjoy the commentary, and I’ll see many of you at EAST in sunny Hollywood, Florida!

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Next Trauma MedEd Newsletter Is Coming Next Week!

As promised, the next Trauma MedEd newsletter will be released next week. Just in time for some light Christmas reading!

The topic is “Prevention.” Here are the areas I’ll be covering:

  • The American College of Surgeons requires all US trauma centers to engage in prevention activities. Unfortunately, there is frequently confusion about the role of the injury prevention coordinator, what kinds of programs are acceptable, and how local data needs to be included in prevention planning. I will cover all of this, and more, in the first part of the newsletter.
  • Curious about what others are doing out there? I’ll give you an idea of the most common prevention programs, and whether they are national programs or home grown.
  • I’ll review a few papers on the efficacy of trauma prevention programs.
  • Finally, I’ll give some tips on how to optimize the performance of your injury prevention coordinator and design effective programs.

As always, this issue will go to all of my subscribers first. If you are not yet one of them, click this link to sign up and/or download back issues.

Unfortunately, non-subscribers will have to wait until I release the issue on this blog, sometime during the week after Christmas. So sign up now!

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The Cribari Grid And Over/Undertriage

I’ve spent some time discussing undertriage and overtriage. I frequently get questions on the “Cribari grid” or “Cribari method” for calculating these numbers. Dr. Cribari is a previous chair of the Verification Review Subcommittee of the ACS Committee on Trauma. He developed a table-format grid that provides a simplified method for calculating these numbers.

But remember, the gold standard for calculating over- and undertriage is examining each admission to see if they met any of your trauma activation triage criteria. The Cribari method is designed for those programs that do not check these on every admission. It is a surrogate that allows you to identify patients with higher ISS that might have benefited from a trauma activation.

So if you use the Cribari method, use it as a first pass to identify potential undertriage. Then, examine the chart of every patient in the undertriage list to see if they meet any of your activation criteria. If not, they were probably not undertriaged. However, you must then look at their injuries and overall condition to see if they might have been better cared for by your trauma team. If so, perhaps you need to add a new activation criterion. And then count that patient as undertriage, of course.

I’ve simplified the calculation process even more and provided a Microsoft Word document that automates the task for you. Just download the file, fill in four values in the table, update the formulas and voila, you’ve got your numbers! Instructions for manual calculations are also included. Download it by clicking the image below or the link at the end of this post.

cribarigrid

Download the calculator by clicking here

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