Tag Archives: abdomen

Abdomen, Guidelines

Nonoperative Management Of Abdominal Stab Wounds: The Practice Guideline!

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In my previous post, I reviewed a new paper that examined the appropriate amount of time that patients should be observed for nonoperative manage of an abdominal stab wound. Many of you know that I am a fanatic of properly crafted clinical practice guidelines (CPG). I decided to make a first pass at converting the LAC+USC group’s paper to something that will be helpful at the bedside.

This CPG incorporates the patient selection and timing information published in the paper. It breaks the process down into easily followed tasks, and fills in the blanks for shift to shift management. The CPG is displayed in an “if this, then do that” format. This firms up decision making and makes it easier for your trauma program to monitor compliance with it.

A note about CPGs: they generally cover about 90% of clinical cases. Obviously, they cannot provide guidance for certain rare combinations of circumstance. In that case, the trauma professional should do what they think is right for that situation. Most importantly, they should document this rationale in a progress note.

Here are answers to some of your questions in advance:

  • Patients should not be kept at bed rest. This is always bad.
  • There is no reason to keep the patient NPO. A very small percentage of patients actually fail. It makes no sense to starve everybody for the one or two patients that need to go to the OR each year. Anesthesiologists at trauma centers are very skilled at providing safe intubation in all patients. As you all know, every trauma activation patient coming into your trauma bay needing intubation has just finished a seven course meal!
  • Give your patient clear discharge instructions! They need to know what they can do, and what to look for if things eventually go awry.

And please leave comments and suggestions for improvements in the reply box below or by email to [email protected]. There are always ways to make CPGs even better! I have also included a Microsoft Publisher file so you can modify this guideline to better suit your trauma center.

In my next post, I’ll publish the serial abdominal observation CPG I mention in this one.

Resources:

  1. Download a pdf file of the guideline
  2. Download a Publisher file of the guideline

 

How to

How To: The Serial Abdominal Exam

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How often have you seen this in an admitting history and physical exam note? “Admit for observation; serial abdominal exams.” We say it so often it almost doesn’t mean anything. And during your training, did anyone really teach you how to do it? For most trauma professionals, I believe the answer is no.

Yet the serial abdominal exam is a key part of the management of many clinical issues, for both trauma patients as well as those with acute care surgical problems.

Here are the key points:

  • Establish a baseline. As an examiner, you need to be able to determine if your patient is getting worse. So you need to do an initial exam as a basis for comparisons.
  • Pay attention to analgesics. Make sure you know what was given last, and when. You do not need to withhold pain medications. They will reduce pain, but not eliminate it. You just need enough information to determine if the exam is getting worse with the same amount of medication on board.
  • Perform regular exams. It’s one thing to write down that serial exams will be done, but someone actually has to do them. How often? Consider how quickly your patient’s status could change, given the clinical possibilities you have in mind. In general, every 4 hours should be sufficient. Every shift is not. And be thorough!
  • Document, document, document. A new progress note should be written, dated and timed, every time you see your patient. Leave a detailed description of how the patient looks, vital signs, pertinent labs, and of course, exact details of the physical exam.
  • Practice good handoffs. Yes, we understand that you won’t be able to see the patient shift after shift. So when it’s time to handoff, bring the person relieving you and do the exam with them. You can describe the pertinent history, the exam to date, the analgesic history, and allow them to establish a baseline that matches yours. And of course, make sure they can contact you if there are any questions.
How to

How To: The Serial Abdominal Exam

Leave a comment

How often have you seen this in an admitting history and physical exam note? “Admit for observation; serial abdominal exams.” We say it so often it almost doesn’t mean anything. And during your training, did anyone really teach you how to do it? For most trauma professionals, I believe the answer is no.

Yet the serial abdominal exam is a key part of the management of many clinical issues, for both trauma patients as well as those with acute care surgical problems.

Here are the key points:

  • Establish a baseline. As an examiner, you need to be able to determine if your patient is getting worse. So you need to do an initial exam as a basis for comparisons.
  • Pay attention to analgesics. Make sure you know what was given last, and when. You do not need to withhold pain medications. They will reduce pain, but not eliminate it. You just need enough information to determine if the exam is getting worse with the same amount of medication on board.
  • Perform regular exams. It’s one thing to write down that serial exams will be done, but someone actually has to do them. How often? Consider how quickly your patient’s status could change, given the clinical possibilities you have in mind. In general, every 4 hours should be sufficient. Every shift is not. And be thorough!
  • Document, document, document. A new progress note should be written, dated and timed, every time you see your patient. Leave a detailed description of how the patient looks, vital signs, pertinent labs, and of course, exact details of the physical exam.
  • Practice good handoffs. Yes, we understand that you won’t be able to see the patient shift after shift. So when it’s time to handoff, bring the person relieving you and do the exam with them. You can describe the pertinent history, the exam to date, the analgesic history, and allow them to establish a baseline that matches yours. And of course, make sure they can contact you if there are any questions.
Abstracts, Complications

AAST 2019 #2: Predicting Abdominal Operation After Blunt Trauma – The RAPTOR Score

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Patients with blunt abdominal injury, particularly those with seat belt signs, can be diagnostically very challenging. If the patient is stable and does not have peritonitis, CT scan is typically the first stop after the trauma resuscitation room. As many trauma professionals know, the radiographic findings can be subtle and/or not very convincing.

The trauma group at the University of Tennessee in Memphis sought to identify specific findings that might help us better identify patients that will need laparotomy. They retrospectively identified all their mesenteric injuries over a five-year period. A single blinded radiologist (is this an oxymoron or not?) reviewed all 151 patient images who underwent laparotomy, looking for predictors of bowel or mesenteric injury.  All of the predictors were then converted into a scoring system called RAPTOR (radiographic predictors of therapeutic operative intervention; kind of a stretch?). These predictors were then subjected to multivariate regression analyses to try to tease out if there were any independent predictors of injury.

Here are the factoids:

  • A total of 151 patients were identified over the 5 year period; 114 underwent laparotomy
  • Of the 114 operated patients, two thirds underwent a therapeutic laparotomy and the other third were nontherapeutic
  • There no missed injuries in the non-operated patients
  • The components of the RAPTOR score were culled from all the potential findings, and were determined to be
    • Multifocal hematoma
    • Acute arterial extravasation
    • Bowel wall hematoma
    • Bowel devascularization
    • Fecalization (of what??)
    • Free air
    • Fat pad injury (??)
  • Linear regression then showed that only three of these, extravasation, bowel devascularization, and fat pad injury to be independent predictors of injury
  • If three or more RAPTOR variables were present, then the sensitivity, specificity, and positive predictive values for injury were 67%, 85%, and 86%, and an area under the receiver operating characteristic curve (AUROC) of 0.91

The authors concluded that the RAPTOR score provided a simplified approach to detect patients who might benefit from early laparotomy and not serial abdominal exams. They go further and say it could potentially be an invaluable tool when patients don’t have clear indications for operation.

It looks like there are two things going on here at the same time. First, a new potential scoring system is being piloted. And second, a regression analysis is being used to examine the data as well. 

But first, let’s back up to the beginning. This is a retrospective study, with a relatively small size. This makes it far harder to ensure that the results will be significant, or at least meaningful. Use of a single radiologist can also be problematic, especially since many of the CT findings with this mechanism of injury are subtle. 

The reported performance of the RAPTOR score is a bit weak. The listed statistics show that it accurately identified only two thirds of those who needed an operation and 85% of those who didn’t. The AUROC for the regression is very good, though. Could a good old-fashioned serial exam scenario be better?

Bottom line: It will be interesting to hear the background on RAPTOR vs regression, and find our how the authors will use or are using these tools.

Here are my questions for the presenter and authors:

  • Why did you decide to create a scoring system that uses a set of variables that may be dependent on each other? Isn’t the regression equation better?
  • Has this information changed your practice? It seems that the two of the three regression variables are fairly obvious reasons to operate (active extravasation and devascularization). Do you really need the rest?
  • Has this study helped you decrease the non-therapeutic laparotomy rate for blunt abdominal injury?
  • And please define fecalization and fat pad injury!

I’m looking forward to hearing this presentation!

Reference: RADIOGRAPHIC PREDICTORS OF THERAPEUTIC OPERATIVE INTERVENTION AFTER BLUNT ABDOMINAL TRAUMA: THE RAPTOR SCORE. AAST 2019 Oral Paper 6.