Category Archives: General

Sonography In Place of CT For Pediatric Abdominal Trauma

Pediatric blunt abdominal trauma is not common, but if present it has the potential to cause significant morbidity or mortality. Evaluation of the abdomen at the trauma center is crucial, and most trauma professionals are aware of the trade-offs in the use of CT scan in children (radiation exposure, need for sedation).

Ultrasound is widely available and allows for imaging of most areas of concern in the abdomen. Could sonography be used in place of CT in specific cases? Pediatric surgeons in Germany (who have been using ultrasound far longer than the US has) published a paper last year looking at their experience with children who were diagnosed with an intra-abdominal organ injury after blunt trauma. Their 7 year experience only produced 35 such children, and they were evaluated with examination and one or more serial FAST ultrasound exams. Equivocal results were scanned with CT.

They found that ultrasound was effective in diagnosing abdominal injury 97% of the time. Although 11 of the 35 children had subsequent CT scanning, it only changed management in one case

Bottom line: Obviously, this is a very small retrospective series, but it is provocative. The German pediatric surgeons go above and beyond the typical FAST exam in the US, using it for diagnostic purposes as well. Could a complete diagnostic ultrasound take the place of CT in select children in the US? Probably so, as they are very sensitive in detecting free fluid and solid organ injury. But what about blunt intestinal injury? I’ll review that tomorrow and sum up my thoughts on a possible algorithm.

Related posts:

Reference: Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma? J Pediatric Surg 45(5):912-915, 2010.

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Trauma 20 Years Ago: Seatbelt Injuries

Seatbelt use has increased from 58% in 1994 to a high of 85% last year. We know that seatbelt use saves lives, but trauma professionals are also aware that they can create their own injuries as well. This is a positive trade-off, because belt use prevents injuries that are difficult to treat (e.g. severe brain injury) and produces a higher number of intra-abdominal injuries that are easy to treat.

The spectrum of injuries attributed to seat belt use was finally appreciated in a journal article published 20 years ago this month. The authors wanted to catalog the various injuries seen in belted and unbelted motor vehicle occupants. They reviewed data from the North Carolina Trauma Registry, one of the most sophisticated state registries at the time. Although there were over 21,000 records in the database, only 3,901 involved motor vehicle crashes and had complete data on seatbelt use.

This study found the following:

  • Mortality was higher in those not wearing their seat belts (7% vs 3.2%)
  • Unbelted had a much higher incidence of severe head injury (50% vs 33%)
  • Overall incidence of any abdominal injury was the same for both (14%)
  • GI tract injuries were more common in the belted group (3.4% vs 1.8%)
  • Solid organ injury was the same

Bottom line: This study sparked the recognition that seatbelts reduce severe head injury but increase the incidence of some hollow viscus injuries. About 514 severe head injuries were prevented in exchange for 21 additional abdominal injuries that were generally easily repaired. Good tradeoff!

Related posts: 

Reference: The spectrum of abdominal injuries associates with the use of seat belts. J Trauma 31(6):821-826, 1991.

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Helicopter Transport of Trauma Patients Saves Lives

Helicopter EMS (HEMS) transport of trauma patients is used primarily to decrease the amount of time between injury and arrival at the trauma center. Unfortunately, efficacy studies have provided conflicting answers as to whether this is actually true. Last year, the CDC completed a large sample study of this issue using the National Trauma Data Bank (NTDB) in an attempt to determine if HEMS flights are effective.

Using almost 150,000 entries in the NTDB for 2007, they were able to isolate over 56,000 adult records with complete data points. They looked for mortality patterns based on age, injury severity, and revised trauma score, comparing patients who were transported by air vs ground.

They found the following:

  • Odds of dying in-hospital were 39% lower overall when transported by helicopter
  • This survival advantaged disappeared for patients age 55 and older, possibly because of decreased reserve, comorbidities, more complications, or medications that interfere with successful resuscitation
  • Regardless of type of transport, males always fared worse than females

Bottom line: This is a large and intriguing study. About 85% of the US population has access to a Level I or II trauma center within an hour. However, a third of those can only get there in that period of time if transported by air. This mode of transport has a significantly lower mortality rate. However, there are cost and safety considerations as well. The key now is to figure out which patients will have the best outcomes after air transport. This will require more work, looking at more than just mortality (e.g. disability, complications).

Reference: Reduced mortality in injured adults transported by helicopter emergency medical services. Prehospital Emerg Care 15(3):295-302, 2011.

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Concussion Testing: There’s An App For That!

Smart phone programmers are becoming more and more creative! The newest trauma app is geared toward helping the user identify individuals who have suffered a concussion. It can be used by parents, coaches or physicians to help identify a concussion at sporting events.

The app is a portable and convenient system for identifying concussions based on established sports medicine research. It queries the user for common signs of concussion, tallies the results of a simple balance test, and looks for other symptoms that suggestion the injury. The exam can also be administered serially to detect changes from baseline.

To get the most from this free app, the user must purchase an optional module for $4.99 that does a more in-depth physiologic and cognitive evaluation. A report can be emailed automatically to your physician, and he or she can then respond and send a message to your team to approve or deny continuing play.

The app is provided by SportSafety Labs LLC. The basic app is free, and the add-on is $4.99. It is published for the iPhone and iPad.

Bottom line: Expect more trauma-oriented apps geared toward a variety of problems in the near future!

To get more information on this app, click here.

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Ambulance 2.0: The “Super Ambulance” of the Future

Lifebot Technology has been working to upgrade the prehospital environment and connect it more closely with trauma professionals in the trauma center. They have done this by developing a so-called “super ambulance.” These ambulances are outfitted with new variations of tried and true technology. This includes a special Hewlett-Packard Slate tablet computer, multiple cameras inside the ambulance, cameras that are wearable by medics, and a state-of-the-art telemedicine system.

The Slate tablet allows for hand-held patient monitoring, GPS positioning, high resolution imaging via its built-in camera, patient medical record charting, and connection to the trauma center base station. At the base, the emergency physician or trauma surgeon can view monitoring information, control any camera in the ambulance to focus in on the action, and even draw on the Slate’s screen to show the crew areas of interest (telestration).

The system is pricey ($50,000 US), but is extremely valuable in rural areas where the nearest trauma center may be quite far away. In theory, a doctor could walk a medic through a procedure to resolve a problem that may kill their patient before they can get to the hospital. The system is already in use in select areas in Arizona, Florida and Texas.

Reference: Displayed at the HIMSS 2011 (Healthcare Information and Management Systems Society) annual meeting, February 20-24, 2011 in Orlando, FL.

Disclosure: I have no financial interest in Lifebot Technology or Hewlett Packard

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