The authors looked at 51 patients intubated with both anterior and posterior cervical collar in place and measured the degree of movement within the spine during intubation. They repeated this process in 51 additional patients with just the posterior portion of the collar in place. They found there was one degree of difference in movement between the two groups. This adds evidence that removing the anterior portion of the collar is safe when intubating trauma patients.
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.
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.
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.
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.
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.”
Hypertension in the ED comes in two varieties: emergency and asymptomatic (not urgency!). From this position statement: “Hypertensive emergency involves acute target-organ damage and should be treated swiftly, usually with intravenous antihypertensive medications, in a closely monitored setting.”
Conversely, asymptomatic does not require urgent, aggressive management. “Recent observational studies have suggested potential harms associated with treating asymptomatic elevated inpatient BP, which brings current practice into question.”
Without target organ involvement, we do not need to be initiating IV medications or trying to treat the numbers
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.
