UMEM Educational Pearls - Trauma

This retrospective study illustrates that the use of CT scanning to identify injury in gun shot wounds to the abdomen is not sensitive or specific enough to obviate the need for laparotomy. “Admission hypotension, abdominal pain and/or peritonitis, evisceration, and a transabdominal trajectory were considered clear indications for laparotomy.”  If there is clear indication to go to the OR, stopping in CT does not add any benefit. 

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An out-of-hospital, randomized, placebo-controlled, blinded, parallel group study was conducted in adult patients under the care of the city fire-based emergency medical services and the local level one trauma center.  Adult male patients experiencing moderate to severe pain due to traumatic injuries received either 50mg of intranasal ketamine or placebo in addition to fentanyl after randomization in the field by the paramedic (a novel approach). The primary outcome was reduction of pain by 2 points 30 minutes after study drug administration.

199 patients were randomized with 107 receiving ketamine and 92 with placebo.  Patients were young (30-40), and had a median weight of 83 kg. Pretreatment pain scores were 10/10 and patients presented to the ED 14 minutes after receiving study medication. The most common injuries were falls, MVC, and GSW. Half of the patients received IV fentanyl but others had IM or IN routes.

Ketamine receipt did not lead to a 2 point reduction in pain scores (36% vs 44.7% p = 0.22). There was no difference in pain at 3 hours, additional medications received, or total amount of analgesia received. Notably, there were no differences in adverse events.

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Administration of prehospital TXA was found to improve 28 day mortality and decrease the amount of blood required to be transfused without any increased risk of thromboembolism or seizure. Two grams of TXA was superior to one gram and no TXA. 

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In this small retrospective study comparing outcomes before and after a  prehospital blood administration protocol for penetrating trauma was initiated, the authors found improved survival in those receiving prehospital blood despite a five minute longer on scene time in those receiving blood.  Also note TXA was part of the blood protocol but not the control group. 

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This study used the New York State hospital discharge database to look for factors associated with being the victim of repeat gun violence. 
Unanswered questions include: is it similar in other areas, what interventions at the patient level could prevent this, what other patient level factors (substance use, etc) are involved, however, this is a good start in looking at this preventable disease.   

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Recent studies continue to highlight that Black,  Native American, female, uninsured and Medicaid patients receive disproportionately more substance use screening when they are trauma patients. The authors of this paper point out that this inappropriate application of screening leads to missed opportunities. 

“Screening patients for drug and alcohol use following injury is an evidence-based practice that can trigger wraparound care, such as brief substance use interventions, to prevent reinjury. Adolescents who consume alcohol but are not screened for alcohol use have 2- to 3- fold greater likelihood of reinjury compared with those who were screened and received a brief intervention.”

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There is uncertainty if adding cryopercipitate empirically to all mass hemorrhage protocols has any benefit to mortality, need for transfusion, or any other meaningful outcome. This small study suggests it does not and that we should save the addition of cryopercipitate to those with lab proven low fibrinogen levels.  

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For penetrating neck trauma:

1. Does it violate the platysma if no, close wound and discharge 

2. If yes, are there any hard signs of injury like enlarging hematoma, air from the wound, difficulty swallowing, blood in the airway, respiratory distress then to the OR

3. If no, Ct angio of the neck. If negative and no other findings admit for observation or discharge. If positive, to the OR. If equivocal, endoscopy and broncoscopy. 

   No longer think about the zones of the neck. Treat them all the same. 

This article serves as a reminder that trauma can and will precipitate adrenal insufficiency and crisis in those trauma patients who are on steroids pre-injury. Look for prednisone or hydrocortisone as well as autoimmune or rheumatologic diseases  on pre-injury medication list and history. Consider the diagnosis in trauma patients with refractory hypotension not responsive to vasopressors. Replacement therapy with hydrocortisone is the therapy.

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Rectal injuries are rare and are usually associated with penetrating trauma or significant pelvic fracture from blunt injury.  Diagnosis starts with physical exam including inspection for signs of trauma as well as a digital rectal exam looking for blood, bony protuberance and abnormal sphincter tone.  Normal digital rectal exam does not exclude injury. 
Imagining is important in making the diagnosis. 

“Findings on CT associated with rectal injury include a wound tract extending to the rectum, a full-thickness wall defect, perirectal fat stranding, extraluminal free air, intraperitoneal free fluid, and hemorrhage within the bowel wall….A CT with any suggestion of rectal injury should therefore be followed up with rigid proctoscopy to confirm the diagnosis and location of injury, as a combination of CT and endoscopy has a sensitivity of 97% in the diagnosis of rectal injury.”

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Rectal injuries are rare. The majority are secondary to penetrating injuries. Trauma care providers “should have a high clinical suspicion of rectal injury with any missile with a trajectory near the rectum; transpelvic gunshot wounds; stab injuries near the perineum, buttocks, groin, or proximal thighs; or open pelvic fractures. A digital rectal examination with a focus on sphincter tone, presence of blood, palpable defect, or bony protrusion should be carried out. Of note, a normal digital rectal examination does not exclude rectal injury.”

Ct scan with IV contrast (not PO or rectal) is used to identify rectal injuries but will be diagnostic in only  33% of injuries. 

Rectal Injury Grading Scale

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The authors reviewed the literature surrounding use of pigtail catheters for traumatic hemothorax and found:

“these data support using percutaneous thoracostomy as a safe and reliable treatment option for hemodynamically stable adult patients with traumatic hemothorax and are backed by major trauma society guidelines including the Eastern Society for the Surgery of Trauma and the Western Trauma Association.1,3 It has the added benefit of the insertion being less painful with the understanding that the percutaneous thoracostomy can always be upsized to a thoracostomy tube.”

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Emergency Medicine Cases offers these excellent tips on pigtail catheters placement. Their video/website is worth a look. 

PEARL # 1 – LOCATION/LANDMARK: Minimize skin to pleural distance.

• Often the region with the least amount of adipose/muscle tissue will be in the 4th to 5th ICS, mid to anterior axillary line. This is often more superior than expected. Palpating along the 5th rib at the level of the nipple/breast fold, and following it posteriorly as it travels superiorly can be helpful.
• In certain circumstances, an anterior approach in the 2nd ICS, mid-clavicular line, may be desired. PITFALL: Remember that the clavicle ends at the acromion, and so the mid-clavicular line is often more lateral than expected.

PEARL # 2 – ADEQUATE LOCAL ANESTHESIA: This can obviate the need for sedation.

• Enter the rib space slightly above the rib below, to avoid major neurovascular bundles running underneath the rib, and collaterals running above the rib.
• Advance your needle in small increments. Aspirate first, and then inject. Once you enter the pleural space, pull back again until you feel resistance once more. Your needle should now be sitting in between the internal intercostal and innermost intercostal muscle. This is where the neurovascular bundles travel – inject the rest of your local anesthesia here.
• BONUS TIP: This should also help you estimate the depth of the chest wall (skin to pleural distance).

PEARL #3 – DILATING: Do it in a controlled manner.

• PITFALL: First make sure to make a big enough nick in the skin. Your guidewire should be able to move side to side through this small nick.
• Once you insert the dilator, avoid the urge to push through the resistance with force. Instead, with a bit of force directed towards the chest wall, twist your dilator to try and catch some of the fascia, and then pull back as if to try and tear it. This will likely require a few attempts, but you should feel the loss of resistance once you are successful.

PEARL #4 – USING THE OBTURATOR: Needless to say, it is there for a reason.

• Insert the obturator all the way into the pigtail catheter with the stop cock, and lock it in place. This will ensure that your chest tube is rigid and make it easy to feed over the guidewire and through the chest wall. This will also assist you in aiming the tube (superiorly and anteriorly for pneumothorax).
• Advance until the second line on the pigtail catheter, then pull back the obturator part way, and advance the pigtail catheter to the third line. Then completely remove the obturator and guidewire.

PEARL #5 – INTERPLEURAL BLOCK: Provide your patient with ongoing analgesia.

• Inject long acting local anesthetic (e.g. bupivacaine) through the pigtail catheter into the pleural space. This provides your patient with ongoing analgesia.
• Common dose: Bupivacaine 0.25% 10-20ml (even up to 30ml).

PEARL #6 – STOPCOCK AND ONE-WAY VALVE IN THE CORRECT POSITIONS

• The tap points to the off position.
• The blue port connects to the patient side.
• Confirm with cup of water and patient cough. Look for bubbles. This confirms the presence of an air leak and the correct positioning of stopcock and one-way valve.

PEARL #7 – USE A GOOD SUTURE: Don’t let that chest tube come out.

• Use a large suture (Size 0 or bigger) with good tensile strength (Silk)

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This Canadian study looked at the safety of paramedics using the modified Canadian C-Spine Rule to determine which pre-hospital blunt trauma patients required immobilization. These were MVC and fall patients predominately. Bottom line: appropriately trained paramedics can use the modified Canadian C-Spine rule to clinically clear cervical spines in the field. 

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This meta analysis looked for studies involving community EMS (CEMS) interventions trying to reduce falls. The authors found: 

“CEMS fall prevention interventions reduced all-cause and fall-related emergency department encounters, subsequent falls and EMS calls for lift assist. These interventions also improved patient health-related quality of life, independence with activities of daily living, and secondary health outcomes.”

Further, prospective work needs to be done to look at this on a larger scale. We know falls in elderly patients lead to significant morbidity and mortality. This could be one way  to improve fall mortality.

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The use of seizure prophylaxes in moderate to severe head injury has been recommended for 7 days post-injury. In general, levetiracetam is used for seizure prophylaxes in this group of patients. This study looked retrospectively at high (over 500 mg BID) vs. low (500 mg bid) dosing and found there was no difference in seizure events in either group.  Overall 6% of patients had a seizure in this seven day window even with medication given.

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Question

Identify this radiographic finding:

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Question

Identify this injury and other associated injuries:

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Predicting which blunt abdominal trauma patients have mesenteric or  bowel wall injuries early in their ED course will decrease morbidity and mortality. It is also a challenge even in the age of advanced CT imaging. This study from India looks at the Bowel Injury Prediction Score as a possible means to catch these injuries early in the course of care. The score uses white blood cell count over 17,000 (1 point), abdominal tenderness at the time of presentation(1 point),  as well as a McNutt's scoring scale grade 4 (1 point) (table). The study found those with a score greater than 2 (out of 0-3) were much more likely to have bowel or mesenteric injury at time of laparotomy.  Tenderness and CT findings were more likely to be predictive of bowel injury than WBC greater than 17,000. “BIPS had 94.5% sensitivity, 72% specificity, 88% PPV, and 86% NPV for identifying patients with sBBMI.”

My take away is an abnormal CT scan or significant tenderness of presentation warrant concern for mesenteric or bowel wall injury and surgical evaluation is appropriate for these patients. An elevated or normal white blood cell count isn't helpful in these patients. Surgeons may use this scale to help them decide if a patient warrants a trip to the operating room  

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In this systemic literature review of orthopedic injuries identified in intimate partner violence (IPV) the authors remind us that finger, hand, and especially isolated ulnar fractures are very commonly associated with IPV.  When we see these injury patterns extra effort is required to determine if IPV is involved.  

* IPV = intimate partner violence, UEF = upper extremity fracture, and UEI = upper extremity injury.

† Summary table demonstrating the location prevalence of UEIs caused by cases of IPV. Fractures were quantified separately from other UEIs in this specific table.

‡ In all included articles the most common injury type was an injury to the head or neck; these are excluded because of the study aim.

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