Tag Archives: Penetrating trauma

General

How Good Is The Spine Exam In Penetrating Injury?

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Examination of the spine in trauma patients is typically not very helpful. We always look for stepoffs. swelling and tenderness, but the correlation with actual injury is poor. A recent paper presented at the American Medical Student Association Annual Convention showed that it actually can be helpful in victims of penetrating injury.

A prospective study of 282 patients was carried out at a Level I Trauma Center, specifically focusing on penetrating trauma. Half had gunshot wounds, and 8% sustained spinal injury with one third left with permanent disability. Stab wounds never led to a spinal cord injury. The most common patterns for cord injury in gunshot wounds was a single shot to the head or neck, or multiple shots to the torso. 

The examiners looked for pain, tenderness, deformity and neurologic deficit. They found that the sensitivity was 67%, the specificity was 90%, the positive predictive value was 95% and the negative predictive value was 46%. These numbers are much better than those found during spine examination after blunt trauma. They also determined that prehospital immobilization after penetrating injury would not have helped, which I have also written about here.

The bottom line: a good spine exam in victims of penetrating trauma can accelerate definitive management prior to defining the exact details of the injury with radiographic or MRI imaging. This is particularly helpful in patients who present to non-trauma centers, where imaging or image interpretation may not be readily available. 

Reference: American Medical Student Association (AMSA) 60th Annual Convention: Abstract 26: Presented March 11, 2010

General

Use of Abdominal CT in Stab Wounds to the Anterior Abdomen

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In general, stab wounds to the anterior abdomen (like any penetrating injury to the area) demand further evaluation to make sure there are no significant injuries. In the old days, a stab to the abdomen mandated a trip to the operating room. Fortunately, we recognized that more than half of these operations led to negative explorations.

Nowadays we can be much more selective. Here is my approach to evaluating these patients.

First, are there any indications that the patient needs to go to the OR right now?Check the vital signs. If there is any hemodynamic instability, operate! Check the abdomen. If there is obvious peritonitis, or significant tenderness more distant from the actual stab site, off you go to the OR!

Next, after finishing all of the usual ATLS protocol it’s time to evaluate further.Several options exist:

  • Observation – this is good for busy trauma centers that have lots of penetrating injury and busy ORs
  • DPL – not used too much any more, but certainly is legitimate. I recommend that your RBC count threshold be reduced to 25,000 or 50,000
  • Local wound exploration – this works in thinner people. Doing a LWE on an obese patient requires an incision that approaches the size of a small laparotomy. Might as well do it in the OR. Look for any violation of the anterior fascia.
  • CT scan – the new kid on the block

To use CT, the patient must be stable (remember, they should be in the OR if otherwise) and have had a full ATLS evaluation. They should also not be terribly thin. Too little fat makes it difficult to gauge depth of the injury.

The entry site(s) should be marked with a small marker to minimize streak artifact. Resist the temptation to just scan the area around the stab itself. Do a full IV contrast (no GI needed) abdomen/pelvis scan.

Look closely for blood outlining the wound tract. If it reaches the anterior abdominal fascia, the exam is positive. You do not need to see specific injury to the muscle or abdominal viscera. Violation of the anterior fascia is an absolute indication to proceed to the OR. On occasion, the knife will not penetrating the posterior fascia, or penetrates but does not injury any organs. In these cases it is best to have operated and found nothing rather than delaying and increasing the risk of intra-abdominal complications or infections.

Scan 1 shows blood tracking to the anterior fascia, as well as an increase in size of the rectus muscle.

Scan 2 shows penetration of the posterior rectus sheath with intra-abdominal fat herniating into it. The transverse colon is only 2 cm away deep to it. Scan 1 alone is enough to prompt you to take the patient to the OR!

General

Spine Immobilization in Penetrating Trauma: More Harm Than Good?

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The EMS standard of care for blunt trauma patients has been to fully immobilize the spine before transporting to an emergency department. This is such a common practice that it is frequently applied to victims of penetrating trauma prior to transport.

A recent study in the Journal of Trauma calls this practice in question, and suggests that it may increase mortality! The authors reviewed data in the National Trauma Data Bank, looking at information on penetrating trauma patients. They found that approximately 4% of these patients underwent spine immobilization.

Review of mortality statistics found that the mortality in non-immobilized (7%) doubled to 14% in the immobilized group!

The authors also found that medics would have to fail to immobilize over 1000 patients to harm one who really needed it, but to fully immobilize 66 patients who didn’t need it to contribute to 1 death.

Although this type of study can’t definitely show why immobilization in these patients is bad, it can be teased out by looking at related research. Even the relatively short delays caused by applying collars and back boards can lead to enough of a delay to definitive care in penetrating trauma patients that it could be deadly. The assumption in all of these patients is that they are bleeding to death until proven otherwise.

A number of studies have suggested that a “limited scene intervention” to prehospital care is best. The assumption is that the most effective treatment can only be delivered at a trauma center, so rapid transport with attention to airway, breathing and circulation is the best practice.

While interesting, some real-life common sense should be applied by all medics who treat these types of patients. The reality is that it is nearly impossible to destabilize the spine with a knife, so all stab victims can be transported without a thought to spine immobilization. Gunshots can damage the spine and spinal cord, so if there is any doubt that the bullet passed nearby, at least simple precautions should be taken to minimize spine movement.

Reference: Spine Immobilization in Penetrating Trauma: More Harm Than Good? Haut et al, Johns Hopkins. J Trauma 68(1): 115-121, 2010.