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.
For penetrating neck trauma:
Does it violate the platysma if no, close wound and discharge
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
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.
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.”
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
| Grade | Injury Type | Description of Injury |
|---|---|---|
| I | Hematoma laceration | Hematoma or hematoma without devascularization Partial-thickness laceration |
| II | Laceration | Laceration <50% of circumference |
| III | Laceration | Laceration ?50% of circumference |
| IV | Laceration | Full-thickness laceration with extension into perineum |
| V | Vascular | Devascularized segment |
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.”
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.
PEARL # 2 – ADEQUATE LOCAL ANESTHESIA: This can obviate the need for sedation.
PEARL #3 – DILATING: Do it in a controlled manner.
PEARL #4 – USING THE OBTURATOR: Needless to say, it is there for a reason.
PEARL #5 – INTERPLEURAL BLOCK: Provide your patient with ongoing analgesia.
PEARL #6 – STOPCOCK AND ONE-WAY VALVE IN THE CORRECT POSITIONS
PEARL #7 – USE A GOOD SUTURE: Don’t let that chest tube come out.
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.
| Result of Application | Paramedics’ Interpretation | Investigators’ Interpretation |
|---|---|---|
| Injury | No Injury | Injury |
| --- | --- | --- |
| Immobilization required (N) | 10 | 1,342 |
| Immobilization not required (N) | 1 | 2,668 |
| Sensitivity, % (95% CI) | 90.9 (58.7–99.8) | 90.9 (58.7 to 99.8) |
| Specificity, % (95% CI) | 66.5 (65.1–68.0) | 68.2 (66.7 to 69.7) |
| Positive likelihood ratio, (95% CI) | 2.7 (2.2–3.4) | 2.9 (2.4 to 3.5) |
| Negative likelihood ratio (95% CI) | 0.1 (0.0–0.9) | 0.1 (0.0–0.9) |
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.
This study attempts to validate the use of the Geriatric Fever Score to predict 30 day mortality in patients over age 65 presenting to an emergency department with fever.
The Geriatric Fever Score uses: leukocytosis, severe coma, and thrombocytopenia. One point is award for each abnormality.
Not surprisingly, mortality went up with the higher the score (33%, 42% and 57% for 0,1,2 points)
For me, I’m not discharging anyone with severe coma, leukocytosis or thrombocytopenia in this patient population therefore I’m not sure this scale has much utility for the practicing emergency physician.
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.
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
| GRADE | FINDING |
|---|---|
| 1 | Isolated mesenteric contusion without associated bowel wall thickening or adjacent interloop fluid collection |
| 2 | Mesenteric hematoma?<?5 cm without associated bowel wall thickening or adjacent interloop fluid collection |
| 3 | Mesenteric hematoma?>?5 cm without associated bowel wall thickening or adjacent interloop fluid collection |
| 4 | Mesenteric contusion or hematoma (any size) with associated bowel wall thickening or adjacent interloop fluid collection |
| 5 | Active vascular or oral contrast extravasation bowel transaction or pneumoperitoneum |
This review reminds us that discharging emergency department patients with abnormal vital signs is a risk for the patient and the provider. The more abnormal vital signs that are present, the higher the risk of adverse event and subsequent return to the emergency department.
“Hypotension at discharge was associated with the highest odds of adverse events after discharge. Tachycardia was also a key predictor of adverse events after discharge and may be easily missed by ED clinicians.”
Always address abnormal vital signs in your medical decision making portion of the chart and be very wary of discharging anyone with tachycardia or other abnormal vital signs.
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.
| Citation | **Bhandari et al.**3 | **Khurana et al.**18 | **Loder et al.**12 | **Porter et al.**13 | **Kavak et al.**7 | **Thomas et al.**17 |
|---|---|---|---|---|---|---|
| Division of injury locations | Fingers, wrist, shoulder dislocation, humerus fracture | Finger, hand, wrist, forearm, elbow, humerus, shoulder | Finger, hand, wrist, forearm, elbow, humerus, shoulder | Radius/ulna, humerus, upper extremity, right/left | Phalanx, radius, ulna (diaphysis/metaphysis, distal/proximal) | Phalanges (distal/medial/proximal), hand/finger, forearm, arm/shoulder right/left |
| Most common UEF location | Fingers (n = 11) | Finger (34.3%) | Finger (9.9%) | Radius and ulna (n = 80; 5.9%) | Ulna (14.5%) | Finger (46%) |
| Most common injury type‡ | Musculoskeletal sprains (all n = 21; 28% back n = 7; neck n = 6) | UEF (27.2%) | Contusions/abrasion (43.4%) | Rib fracture (17.5%) | Soft-tissue lesions (n = 1,007, 82.2%) | UEF (52%) |
* 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.
This retrospective study of Swiss trauma patients looked at blood gas oxygen levels within 3 hours of arrival to the trauma bay in severely injured patients over age 16. When comparing hypoxic, hyperoxic and normo-oxic patients there was no difference in 28 day mortality. Those with above normal oxygen levels tended toward longer hospital stays. The above normal oxygen cohort also were more likely to be intubated in the field.
This study fits with others showing around 20% of trauma patients arrive to our trauma bays over oxygenated. More research is needed to see the impact this has on care. Be mindful of over oxygenation especially in intubated trauma patients.
Deciding who needs exposure to radiation after blunt head injury has been looked at by both the Canadian Head Injury Guidelines as well as NEXUS. This website has excellent graphics outlining the rules. Note age over 65 alone is predictive of significant intracranial injury. All recent studies indicate age over 65 even with a low suspicion mechanism such as fall from standing is still a significant risk for intracranial pathology.
A study looking at patients over age 65 with head injuries from falls assessed the association of alcohol use with severity of injury. The alcohol use was self-reported which does limit the findings. The study found “Of 3128 study participants, 18.2% (n = 567) reported alcohol use: 10.3% with occasional use, 1.9% with weekly use, and 6.0% with daily use.” Those daily drinkers had a higher incidence of intercranial injuries.
The authors concluded: “Alcohol use in older adult emergency department patients with head trauma is relatively common. Self-reported alcohol use appears to be associated with a higher risk of ICH in a dose-dependent fashion. Fall prevention strategies may need to consider alcohol mitigation as a modifiable risk factor.”
A reminder of two validated tools used to determine the need for cervical spine imaging in adult blunt trauma patients. A recent meta analysis concluded:
“Based on studies, both CCR and NEXUS were sensitive rules that have the potential to reduce unnecessary imaging in cervical spine trauma patients. However, the low specificity and false-positive results of both of these tools indicate that many people will continue to undergo unnecessary imaging after screening of cervical SCI using these tools. In this meta-analysis, CCR appeared to have better screening accuracy.”
