This monumental episode continues with Trauma Pearls & Pitfalls Part 2. Dr. Dave MacKinnon and Dr. Mike Brzozowski go through key management strategies and controversies surrounding head, neck, chest, abdominal, pelvic and extremity trauma, followed by a discussion on how best to prepare the trauma patient for transfer to a trauma centre. They end the Trauma Pearls & Pitfalls podcast with a great rant about ‘pan-scanning’ the multi-trauma patient.
Written Summary and blog post by Lucas Chartiers, edited by Anton Helman January 2011
In this episode Dr. MacKinnon & Dr. Brzozowski debate questions such as: How should we work-up a ‘Neck Seat Belt Sign’? When should we be using X-ray vs CT to clear the T-spine? How good is point of care ultrasound at diagnosing pneumothorax compared to CXR? How should we treat an occult pneumothorax seen only on CT? What are some of the key injuries that FAST ultrasound misses? that CT misses? What are the indications for angiography in patients with pelvic fractures? How good is handheld doppler at ruling out vascular injury in patients with penetrating extremity trauma? What are the priorities of management for the severely traumatized patient at a non-trauma centre? Which trauma patients should be ‘pan-scanned’? and many more….
Quick Trauma Pearls & Pitfalls from our experts
- C‐collars are associated with decubitus ulcers, raised ICP, pneumonia and delirium, on top of providing relatively poor immobilization (compared to sand bags and tape) and leading to increased ICU and hospital length of stay, so whenever possible, clear the C‐spines of patients ASAP
- C‐spines of an intubated patient may be cleared if the CT scan is completely normal, i.e. no bony fractures and no soft tissue abnormalities, realizing that if ligamentous injuries are missed, they should become obvious when the patient regains consciousness and can then be re‐examined, after which an flexion‐extension views x‐rays or MRI can be considered
- Vascular access – 2 large‐bore antecubital peripheral IVs are enough in most cases, and in severely injured patients a femoral cordis may be considered: although there are higher risks of thrombus formation and infection compared with other central line locations, they will be changed rapidly in the ICU and they avoid the difficulties associated with subclavian (i.e. iatrogenic pneumothorax) and intra‐jugular access (i.e. in the way of the intubation, and can’t rotate the neck in trauma patients whose C‐spine has not been cleared)
- Studies have found no difference in mortality in the choice of initial fluid for trauma: normal saline, Ringer’s lactate and even colloids appear to all be similar initially; hypertonic saline may be considered, but our experts are not convinced by the evidence; moreover, there is no role for vasopressors in trauma, except in neurogenic shock when other causes of shock have been excluded
- “Every trauma patient is unstable until proven otherwise”, so recognize occult shock in patients with currently normal vital signs but with physiology (young athlete with low resting heart rate and BP) or pharmacology (elderly on beta‐blocker) that may make their vital signs look normal despite having significant ongoing bleeding; patient’s at extremes of age are especially at risk of rapidly deteriorating
- In CT‐proven intracranial bleed, consider starting anti‐convulsant therapy (Phenytoin) in the ED, which can then be stopped after 1 week if no seizure occurred
- In spinal cord injuries, steroids are not recommended as they appear to have extremely small clinical benefits (if any), and lead to a significant increase in complications (eg, pulmonary infections)
- FAST exam: FAST is a ‘rule‐in’ exam, i.e. a positive scan helps in directing an unstable patient directly to the OR, and not a ‘rule‐out’ exam, i.e. it cannot exclude all injuries, such as
- In order to decrease ICP, raise the head of the bed 30° (if T/L‐spines cleared) or tilt the entire bed, and consider hyperventilation (down to PCO2 of only 35mmHg) only as a palliative measure for the herniating patient (blown pupil, hemiparesis) en route to the operating room – too much or too long hyperventilation results in respiratory alkalosis, which causes cerebral vasoconstriction and resultant decreased cerebral perfusion pressure; mannitol or hypertonic saline may be given as well
- Consider using bedside ultrasound for detection of pneumothoraces, as the sensitivity for detection has shown to be higher than supine CXR (98% versus 75%) when compared to a gold standard of CT scan
- Chest tubes should be inserted in the ‘triangle of safety’, i.e. between the nipple and axilla, anterior to the latissimus dorsi and posterior to the pectoralis muscle [Safe insertion of chest drains. Int J Anesth 2009:19(2)]
- Signs of vascular injury in penetrating trauma:
- Hard signs, mandating surgical exploration: severe arterial bleeding, shock, large pulsatile or expending hematoma, new palpable thrill or audible bruit, and distal ischemia based on the 6 Ps (pallor, poikilothermia, pain, paresthesia, paralysis, pulselessness)
- Soft signs, mandating CT‐angiogram: small bleeding, small and stable hematoma, injury to nerve, and proximity of tract to major vessel
- Ankle‐brachial index (ABI) of >90‐95% decreases the likelihood of arterial injury
- Pitfall: relying on an extremity pulse that is positive by Doppler to rule out vascular injury
Trauma Pearls with Pelvic fractures
- Be suspicious in the setting of groin/scrotal or suprapubic swelling or hematoma, tenderness at or palpable defect of the symphysis pubis, blood at the urethral meatus, distal peripheral neuropathy, or pelvic fluid on FAST exam, as well as significant mechanism (see Young‐Burgess classification below)
- If gentle inward pressure of the bony pelvis causes movement, DO NOT LET GO and have an assistant wrap the pelvis in a sheet or pelvic binder at the level of the greater trochanters (which is lower than the intuitive location of the iliac crest) before you let go; be sure there are no wrinkles in the sheet to minimize ulcers
- Recognize early pelvic fractures as they can bleed significantly from the venous plexus (most of the times), the canellous bone itself, or from arterial bleeds (which carries the highest mortality, and for which angio‐embolization may be successful)
- Keep a high index of suspicion for pelvic hemorrhage, as the initial trauma pelvic x‐ray does not correlate well with the level of bleeding – i.e. a seemingly small fracture may hemorrhage extensively if arterial structures are affected nearby
- Young‐Burgess classification of pelvis fractures (combined mechanisms may occur):
- Anterior‐posterior compression fractures, i.e. ‘open‐book’ injuries, with more neurovascular complications if the posterior pelvic structures (eg, sacro‐iliac joints) are involved (usually heralded by a wider pubic symphysis on pelvic x‐ray)
- Lateral compression fractures, with more ligamentous disruption leading to worse results
- Vertical shear fractures (worst kind), with hemi‐pelvis dissociation as a result of a fall from height on an extended limb
Transfer of trauma patients to trauma centres from local hospitals
- If the decision to transfer is made early (based on serious mechanism or poor patient condition), DO NOT ‘stay and play’! ‘Less is more’ in very sick patients! No blood work nor CT scans (they are often repeated at the trauma centre and often using different protocols!) are necessary (although IV access is necessary), and only a CXR (to decide whether a chest tube should be inserted) is required, and possibly a pelvic x‐ray (bind it tightly if a fracture is clinically suspected or radiographically present)
- In some rare cases, with a hemodynamically unstable patient and a positive FAST scan, the local general surgeon might elect to perform a damage‐control trauma laparotomy in order to prevent death from intra‐abdominal solid organ exsanguination
- Other key points are to reduce badly displaced fractures and dislocations, and quickly closing (either with sutures or staples) big lacerations, especially on the scalp, after irrigation, as well as to insert a Foley catheter and an NG tube (or OG in the face of severe facial trauma) in the intubated patient
- Have a slightly lower than normal threshold for intubation, as conditions on the road or in the air are austere and the clinical situation may deteriorate quickly; consider sending blood in the ambulance if available
- Spine boards should be used only for the transfer of patients – log‐roll the patient off the spine board ASAP
- Method of transport: the rule of thumb mentioned by our experts is 90min – only if land transport will take more than 90min should you consider using air transport, which is subject to availability, wheather conditions, and night time capabilities
Pan-scanning the Trauma Patient
Our experts do not recommend panscanning all major trauma patients, and feel that studies that have shown an unacceptably high rate of missed injuries with selected CT compared to pan‐scanning were poorly designed; some trauma centres have a protocol whereby they pan‐scan all intubated patients, and do selective x‐rays and CT scans for non‐intubated patients
Dr. Helman, Dr. MacKinnon and Dr. Brzozowski have no conflicts of interest to declare.
American College of Surgeons Committee on Trauma. Advanced trauma life support (8thed.). Chicago, IL: American College of Surgeons.
Barnea Y, Kashtan H, Skornick Y, Werbin N. Isolated rib fractures in elderly patients: Mortality and morbidity. Canadian Journal of Surgery. 2002; 45(1):43-46.
Seamon MJ, Feather C, Smith BP, Kulp H, Gaughan JP, Goldberg AJ. Just one drop: The significance of a single hypotensive blood pressure reading during trauma resuscitations. Journal of Trauma. 2010;68(6):1289-94.
Zehtabchi S, Sinert R, Goldman M, Kapitanyan R, Ballas J. Diagnostic Performance of serial hematocrit measurements in identifying major injury in adult trauma patients. Injury. 2006;37(1):46-52.
For more on Trauma Bay Pearls & Pitfalls download free eBook EM Cases Digest Vol.1 MSK & Trauma
For more on trauma on EM Cases:
Episode 10 Part 1: Trauma Pearls and Pitfalls
Episode 39: Update in Trauma Literature
Best Case Ever 18: Anticoagulant Reversal in Trauma
Best Case Ever 20: CPR in Trauma
Best Case Ever 60 What we can learn from Prehospital Trauma Management
CritCases 3 – GSW to the Chest