Category Archives: General

Trauma 20 Years Ago: The MESS Score

June 1, 2010 The Trauma Pro Leave a comment

This month is the 20th anniversary of the MESS score, a system that helps predict salvageability of mangled extremities (Mangled Extremity Scoring System). Obviously, the acronym was chosen to help describe the clinical problem.

The system was originated at the Harborview Medical Center in Seattle. The development was not very scientific; the authors put their heads together and made a list of the four things that they observed predicted limb salvage:

Degree of skeletal and soft tissue injury
Presence of limb ischemia
Presence of shock
Age

The system was used retrospectively in a group of 25 patients(!) and the authors found a nice breakpoint at 7. Any mangled extremities with a MESS of 7 or more required amputation. They then applied this to 26 patients prospectively(!) and got the same result.

As you can see, the numbers were small, and there was no followup information. Nevertheless, MESS still stands today, and the critical MESS score has not changed much. It has been validated by a number of other studies during the past 20 years. It is conceivable that the critical score will slowly creep upward with advancements in flap coverage and surgical technique, but it hasn’t done so yet.

Reference: Objective Criteria Accurately Predict Amputation Following Lower Extremity Trauma. Johansen, et al. J Trauma 30(5): 568, 1990.

General

Nursing Policy: Cervical Spine Immobilization

May 28, 2010 The Trauma Pro Leave a comment

The following is a sample nursing policy for c-spine immobilization.

Purpose:

To outline the procedure for applying immobilizing the upper spine, including application of a cervical collar and “boarding” the patient.

Policy:

Application of a cervical collar and placing the patient on a backboard may be indicated for trauma patients with mechanisms of injury that place the patient at risk for spinal injury. This will not be necessary for patients with all of the following:

no posterior midline cervical tenderness
no evidence of intoxication
normal level of alertness (GCS 15)
no focal neurological deficit
no painful distracting injuries

The MD or RN will maintain manual stabilization of the cervical spine until cervical collar is applied and patient is placed on backboard.
* talk to the patient and tell them what you are doing- and not to move their head and neck
Place hands on both sides of patient’s head with thumbs along mandible and fingers holding back of head.
Assistants will help with the rest of the application of the cervical collar and backboard.
Perform a baseline CMS assessment of the extremities.
Remove jewelry from the neck and ears.
Choose an appropriately sized collar by measuring the distance (with fingers) between the top of the shoulder where the collar will rest and the chin. This same number of fingers will fit between the fastener on the collar and the bottom edge of the rigid plastic of the collar.
Cervical collar is assembled by snapping the fastener into the hole on the side of the collar
Adjustable rigid cervical collars are measured from the bottom edge of the rigid plastic to the red circle denoting the size of the collar (red circle will move up or down as size of the collar is adjusted)
Slide the back of the collar behind the right side of the neck until the Velcro tab is visible on the left side of the neck.
Slide the chin portion up the chest until the chin fits in the collar.
Secure the Velcro when the collar is on straight (nose, circle on chin portion of collar, and umbilicus are in alignment).
Place the patient on a slide board with all team members working in a smooth fashion which moves the patient’s spine as little as possible. Patients already in bed will be log rolled and slider board inserted.
* Do not obtain a rectal temperature while the patient is turned unless the MD specifically requests this.
Recheck CMS.
The MD or RN can now remove hands from head.
Document both CMS checks and procedure in patient’s record.

General

Management of Occult Pneumothorax

May 25, 2010 The Trauma Pro Leave a comment

Occult pneumothorax is a pleural air collection that is seen only on CT. It is not detected by standard chest xray either because of small size, location of the air, or position of the patient during xray (usually supine).

Approximately 15% of major trauma patients undergoing CT are diagnosed with an occult pneumothorax. The tough question is, what to do about it. Larger pneumothoraces are frequently treated with thoracostomy, but this procedure has its own list of associated complications. Patients undergoing positive pressure ventilation with a visible pneumothorax have an increased risk for progression to tension pneumothorax.

At our trauma center, we manage occult pneumothorax expectantly. If a pneumothorax is seen on the chest portion of a CT scan but not on the initial supine chest xray, a repeat conventional chest xray is scheduled for 6 hours later. Ideally, this xray is taken using the best technique (upright, PA, xray source 6ft from patient). However, this is not always practical for severely injured patients.

If the pneumothorax remains occult on the followup xray, no further monitoring is performed. If the pneumothorax becomes visible, repeat chest xrays are obtained every 6 hours until it is stable or it becomes large enough to warrant insertion of a chest tube.

How large is large enough for a chest tube? That’s the subject for another day.

General

Pediatric Trauma Mortality and Pediatric Trauma Centers

May 21, 2010 The Trauma Pro Leave a comment

There are only about 45 Pediatric Trauma centers in the United States. They are clustered in the Northeast, in the central Midwest, and along the west coast. This poses a problem for parents located in the rest of the country.

In contrast, there are nearly 500 adult trauma centers, scattered much more evenly across the country. All adult centers that treat more than 100 children per year are required to have basic pediatric trauma resources, such as a pediatric ICU and intensivists to man it.

A growing body of research shows that adults and children with major trauma do better if treated at an adult trauma center. Is there an advantage to having your child treated at a pediatric trauma center?

The answer is yes! A paper published in 2008 looked at children admitted to hospitals in Florida over a 10 year period. They found that children and young adults did better when admitted to a trauma center when compared to a non-trauma hospital, although the effect was less in younger children. The overall survival improvement was about 3%.

When treated at a pediatric trauma center, survival increased an additional 4%! The reasons are not entirely clear, because these studies do not have the ability to discern specifics. However, it appears that a combination of resource availability (present in all Level I and II trauma centers) and specialty capabilities (only present in hospitals with pediatric resources) is key.

Most children with injuries serious enough to require hospitalization can be treated at any trauma center. Those who have critical injuries that require considerable aftercare (severe brain injury, complex orthopedic/pelvic injuries) are best treated at a designated pediatric trauma center if one is available.

Reference: Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? Tepas, Flint et al. J Pediatric Surgery, 43, 212-221, 2008.

General

Initial Management of Blunt Bladder Injury

May 14, 2010 The Trauma Pro Leave a comment

Bladder injury is uncommon after blunt trauma. It is typically seen after high energy events, most commonly a motor vehicle crash with a lap belt in place. During the initial evaluation, the patient may complain of abdominal pain, but this is not universal.

FAST results are also inconsistent. Free fluid may be seen, and an irregular bladder outline may also be appreciated. The key to diagnosis is placement of a urinary catheter. Bloody urine is found nearly 100% of the time.

The character of the bloody urine suggests what type of injury is present. Faint hematuria, primarily shades of pink, is usually associated with renal injury or a bladder contusion. A moderate amount of darkly bloody urine is frequently associated with extraperitoneal bladder injury. A small amount of very dark, bloody urine may mean an intraperitoneal bladder injury. Finally, scant and very dark blood in the catheter suggests a urethral injury or a catheter balloon inflated in the urethra.

Examination of the urine is suggestive but not diagnostic of the type of injury. Determining the real diagnosis requires imaging, and evaluation of the entire GU tract is essential. CT scan is used to evaluate the kidneys, ureters, and to some degree, the bladder. Cystogram is required to fully evaluate the bladder, and a CT technique may be used. Bladder imaging using passive filling by clamping the catheter is accurate only 50% of the time. The bladder must be pressurized using contrast instilled into the bladder by gravity. When performed in this manner, the CT cystogram is 97% accurate.

Once a diagnosis of bladder injury is made, the treatment is usually straightforward. Extraperitoneal injuries usually do not require repair and will heal on their own. However, if the symphysis pubis needs instrumentation to restore anatomic position, concomitant repair of the bladder is frequently necessary to keep the hardware from being contaminated by urine.

Intraperitoneal injuries require operative repair. If possible, the injured area should be opened and the inside visually inspected. If the injury extends anywhere near the trigone, a urology consult should be obtained. Most repairs are simple two layer closures. The mucosal layer must be made with absorbable suture; the outer layer is surgeon’s choice.

For either type of bladder injury, the urinary catheter should be left in place for about 10 days. A cystogram should be obtained, and in most cases there will not be any leakage of urine and the catheter can be removed. In the event of a leak, another 7 days with the catheter is in order and the cystogram can be repeated.

The vast majority of bladder injuries can be easily handled by the trauma surgeon and are healed completely within two weeks.

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