Category Archives: Philosophy

Use Of Radio-opaque Markers In Penetrating Trauma

As I was browsing through my journal list this week, I ran into an interesting title for an article that is currently in press.

“The use of radio-opaque markers is medical dogma”

Catchy, especially since I love writing about dogma vs what is really supported by the literature. The author questions the justification of this practice and posits that there are risks to extrapolating information based on radiographs with markers placed by the trauma team.


The author first reviewed the literature on the use of markers for penetrating injury, which started only recently, in 2002. Markers were initially used to precisely locate the penetration site since skin wounds (obviously) don’t show up on X-rays. Typically, these were just plain old paper clips. Some trauma professionals placed them directly over the wound. Others un-bent them and fashioned them into shapes that pointed to the exact location of the wound.

With the growing usage of CT scans to evaluate stable patients, modifications to the marker were made. Small arrow markers designed for use on x-rays were frequently used. However, even the very small ones could cause enough scatter on a CT scan to interfere with diagnosis. At some centers, Vitamin E capsules were taped on top of the wound. But thankfully, there are now special markers that can pinpoint the wound without degrading the tomographic image.

The author goes on to describe how gunshot wounds specifically are difficult to assess with a marker. Although the exact surface location may be noted, the underlying injuries vary due to size, distance, velocity, and trajectory change from tissue density or bone strikes. He also notes that it may not be wise to place a marker into a bloody field in a potentially combative patients.

The article concludes that the use of this technique for identifying anything other than surface location of penetrations lacks clinical evidence and is based only on expert opinion. Which essentially makes it dogma.

Bottom line: Here are my thoughts. First, the use of markers on penetrating wounds has been going on for much longer than the 20 years found in the trauma literature reviewed here. It has been a common practice among trauma surgeons for many, many decades. Most “seasoned” (old) trauma surgeons have been doing and teaching this for their entire careers. 

I concur that we have techniques like CT scan available to us now that provide an excellent view of the penetration trajectory. The skin wound is usually apparent on the scan, but may be improved with the use of a CT-approved marker.

So why still do this for the patient arriving in your trauma bay? An experienced trauma surgeon can get a good sense of the trajectory based on the entry point, the exit wound, and the location of any retained bullet or fragments. Rapid placement of some kind of marker on all wounds followed by a quick image allows them to roughly predict what was hit, and assess the possibility that there might be bleeding that would drive the team straight to the operating room. It can help direct the surgical exploration if imaging was unnecessary or contraindicated. 

So yes, this is dogma. The reality is that no one will ever be able to design a study that definitively evaluates the very soft outcomes that result from using this technique. But every senior trauma surgeon can easily cite numerous examples in their career when this method has been extremely useful. The lack of a study only means that there will never be any evidence-based guideline for the use of this technique. However, it is still acceptable to have a protocol based on substantial clinical experience. But as with all dogma, once that definitive study finally does comes along, the protocol must be modified to adhere to the findings of the study.

For now, keep using those markers! And I’m very interested in comments from both old and young trauma professionals on this topic.

Reference: The Use of Radio-opaque Markers is Medical Dogma, doi:10.1111/acem.1485, Dec 2023.

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FAST Is Fast, and FAST Is Last

Ever been in a trauma activation where it seems like the first thing that happens is that someone steps up to the patient with the ultrasound probe in hand? And then it takes 5 minutes of pushing and prodding to get the exam done?

Well, it’s not supposed to be that way. The whole point of adhering to the usual ATLS protocol is to ensure that the patient stays alive through and well after your exam. And FAST is not part of the primary or secondary surveys, it is an adjunct.

As always, there are a few exceptions to the rule above.

  • If an unstable patient arrives without an obvious source of bleeding, FAST of the abdomen should be able to detect if a large hemoperitoneum is present. This will expedite the patient’s transfer to the OR.
  • A patient in cardiac arrest may benefit from a quick FAST to determine if cardiac activity is present. If not, it may be time to terminate resuscitation.

Many people say that FAST and physical exam can and should happen simultaneously.

In principle, I agree. My previous statements were based on the way that we organize our trauma team and trauma activations at this hospital. The reality is that everyone’s team is different and they may run their trauma activations differently.

The goal is to get all information critical to keeping your patient alive as quickly as possible. In some cases, knowing if there is a significant amount of fluid in the abdomen can be very important. Most trauma resuscitation schemes at trauma centers make use of multiple personnel so that various portions of the patient evaluation can be carried out simultaneously.

But there is also a tradeoff between speed, trauma team size and number of trainees. Centers with fewer or no trainees will have a leaner team with experienced examiners and more room around the patient. At our hospital, we have 8 people clustered immediately around the patient, with half of them being surgery or emergency medicine residents. This means it is more difficult for a physician to step in and do a FAST exam easily. So typically, this physician is the same resident doing the torso portion of the physical exam. This is the main reason for my exhortation to wait until the end of the physical exam and do the FAST quickly.

Bottom line: With the exceptions noted above, always complete the ATLS primary and secondary surveys first. Then pull out the ultrasound machine, but be quick about it. If it takes more than about 60 seconds to do the exam, someone probably needs a little more practice.

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Do I Have To Call My Trauma Team For Incoming Transfers?

Some trauma centers receive a significant number of transfers  from referring hospitals. Much of the time, a portion of the workup has already been done by the outside hospital. If the patient meets one or more of your trauma activation criteria, do you still need to activate your team when they arrive?

And the answer is: sometimes. But probably not that often.

Think about it. The reason you should be activating your team is that you suspect the patient may have an injury that demands rapid diagnosis and treatment. The purpose of any trauma activation is speed. Rapid evaluation. Fast lab results. Quick access to CT scan or OR. If a significant amount of time has already passed (transported to an outside hospital, worked up for an hour or two, then transported to you), then it is less likely that a trauma activation will benefit the patient.

There are four classes of trauma activation criteria. I’ll touch on each one and the need to activate in a delayed fashion if present, in priority order.

  • Physiologic. If there is a significant disturbance in vital signs while in transit to you (hypotension, tachycardia, respiratory problems, coma), then you must activate. Something else is going on that needs to be corrected as soon as the patient arrives. And remember the two mandatory ACS criteria that fall into this category: respiratory compromise/need for an emergent airway, and patients receiving blood to maintain vital signs. But a patient who needed an airway who is already intubated and no longer compromised does not need to be a trauma activation.
  • Anatomic. Most simple anatomic criteria (e.g. long bone or pelvic fractures) do not need a trauma activation unless the patient is beginning to show signs of physiologic compromise. However, anatomic criteria that require rapid treatment or access to the OR (proximal amputations, mangled or pulseless extremities, spinal cord injury) should be activated.
  • Mechanism. Most of the vague mechanistic criteria (falls, pedestrian struck, vehicle intrusion) do not require trauma activation after transfer to you. But once again, if the mechanism suggests a need for further rapid diagnosis or treatment (penetrating injury to abdomen), then activate.
  • Comorbidities. This includes underlying diseases, extremes of age, and pregnancy. In general, these will not require trauma activation after they arrive.

Bottom line: In many cases, the patient transferred in from another hospital will not need to be a trauma activation, especially if they have been reasonably assessed there. The patient should be rapidly eyeballed by your emergency physicians, and if there is any doubt about their condition, activate then.

However, if little workup was done at the outside hospital (my preference), and the injuries are “fresh” (less than a few hours old), then definitely call your team. 

And finally, if the patient meets any of the ACS hard criteria for activation (this includes hypotension, transfusing blood, and respiratory compromise), don’t hesitate to trigger the activation!

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The Logroll: Toward The Fractures Or Away From Them?

You know the routine. Trauma patients get the usual ATLS primary survey secondary survey double play. An important part of the secondary survey is examining the back. Without it, you’ve failed to inspect nearly 50% of the body.

Usually this part is easy, especially if you’ve got a reasonably sized trauma team. Two or three people carefully logroll the patient, one stabilizes the cervical spine, while another inspects and palpates the back. At our center, we routinely logroll to the patient’s left side, because the examiner is normally stationed at their right.

But what if they have fractured extremities? Which way to go?

Once again, this is philosophy unsupported by literature. No one does studies on mundane stuff like this. The real questions are, rolling to which side will create the least additional injury and cause the least pain?

First, let’s address the injury question. The usual rule is that all patients with fractures must have them splinted before they leave the resus room. This decreases pain, bleeding, and the opportunity for additional tissue injury. Ideally, splinting should occur before the logroll, since this maneuver can involve more movement than rolling around the hospital or moving back and forth to x-ray tables.

Next, there’s pain. Make sure that your patient has been given adequate analgesia early in the resuscitation, and sedation if indicated.

Finally, the roll. My rule is that the fractures should be rotated upwards, with helpers stabilizing each splinted extremity to keep them aligned. Avoid rolling the patient onto their own fractures (fractures down). The combination of weight and movement can and will shift the broken bones, causing exactly what you’ve sought to avoid!

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Stroke And Fall VS Fall And Bleed

It’s like the old chicken and egg question. When dealing with head trauma and falls, which came first? Did the patient have a stroke and then fall down? Or did they fall and sustain some type of intracranial hemorrhage? And you may ask, does it make a difference? They are going to get a head scan anyway, right?

In my opinion, it makes a big difference! How often have you seen the following scenario? EMS is called to a house or nursing home for someone who has fallen. They notice some extremity weakness on one side and presume the patient is having a stroke. The emergency department is then notified that a stroke patient is inbound.

On arrival, the patient was rapidly assessed and whisked off to CT scan for a CT and angiogram, possibly with neurology present. My experience is that a majority of these scans is negative for CVA. And many are positive for some type of extra-axial hemorrhage like subdural or epidural blood from the real injury.

Unfortunately, something called anchoring bias is likely to occur in this situation. Everyone from the paramedics onward are moving along under the assumption that the patient has had a stroke. They stop considering the more common diagnosis of TBI and other potential injuries in the spine and torso. Even when the CT angiogram is found to be negative, it’s difficult for people to change gears. It then takes longer to address the subdural or epidural. The involved trauma professionals are less likely to activate the trauma team. And further evaluation of the chest, abdomen, and spine may be delayed or forgotten for a time.

Bottom line: In any case of a fall followed by neurological changes that could indicate stroke, always presume a serious TBI first! If EMS requests a stroke code, it should be changed to a trauma activation prior to patient arrival. This takes advantage of the odds (more in favor of TBI) and activates a team that is well versed in evaluating the entire patient. If no evidence of hemorrhagic stroke is present, the team will then order the brain CTA and involve the stroke team as necessary.

And for good measure, every one of these cases that does start as a stroke evaluation should be addressed by the trauma performance improvement process!

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