Prehospital providers follow protocols for securing and transporting trauma patients. These may include cervical spine stabilization and short or long backboards. Every once in a while they can’t follow protocol, and in my experience it usually means that something is very wrong.
There are three typical problems leading to nonstandard transport positions:
- Occult airway injury – These patients have either blunt injury to the neck, smoke inhalation, or penetrating injury to the submandibular area. They tend to have problems protecting their own airway when they are supine, so they insist on being transported in an upright position.
- Impalement – Since the general rule is to leave foreign objects in place to avoid potential bleeding, the patient is positioned in an odd way to accommodate both them and the impaling object.
- Life-threatening bleeding – Patients with exsanguinating hemorrhage who are awake tend to insist on transport in certain positions. Most with serious chest hemorrhage complain that they can’t breathe and want to sit upright. Those with severe pelvic fractures complain of pelvic or back pain and may prefer lying on their side during transport.
Bottom line: If prehospital providers bring a trauma patient to you in a non-supine position, be very afraid. If not done already, activate your trauma team. Talk to the medics to find out why they had to use a nonstandard position. Then rapidly assess the patient to rule out life-threatening issues.
CT scan is a valuable tool for initial screening and diagnosis of trauma patients. However, more attention is being paid to radiation exposure and dosing. Besides selecting patients carefully and striving for ALARA radiation dosing (as low as reasonably achievable) by adjusting technique, what else can be done? Obviously, shielding parts of the body that do not need imaging is simple and effective. But what about simply changing body position?
One simple item to consider is arm positioning in torso scanning. There are no consistent recommendations for use in trauma scanning. Patients with arm and shoulder injuries generally keep the affected upper extremity at their side. Radiologists prefer to have the arms up if possible to reduce scatter and provide clearer imaging.
A recently published article looked at arm positioning and its effect on radiation dose. A retrospective review of 690 patients used dose information computed by the CT software and displayed on the console. Radiation exposure was estimated using this data and was stratified by arm positioning. Even though there are some issues with study design, the results were impressive.
The dose results were as follows:
- Both arms up: 19.2 mSv (p<0.0000001)
- Left arm up: 22.5 mSv
- Right arm up: 23.5 mSv
- Arms down: 24.7 mSv
Bottom line: Do everything you can to reduce radiation exposure:
- Be selective with your imaging. Do you really need it?
- Work with your radiologists and physicists to use techniques that reduce dose yet retain image quality
- Shield everything that’s not being imaged.
- Think hard about getting CT scans in children
- Raise both arms up during torso scanning unless injuries preclude it.
Reference: Influence of arm positioning on radiation dose for whole body computed tomography in trauma patients. J Trauma 70(4):900-905, 2011.