The Eastern Association for the Surgery of Trauma has published guidelines on the nonoperative management of penetrating abdominal trauma.
RECOMMENDATIONS
Patients who are hemodynamically unstable or who have diffuse abdominal tenderness should be taken emergently for laparotomy (level 1).
Patients who are hemodynamically stable with an unreliable clinical examination (i.e., brain injury, spinal cord injury, intoxication, or need for sedation or anesthesia) should have further diagnostic investigation performed for intraperitoneal injury or undergo exploratory laparotomy (level 1).
A routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds (SWs) without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centers with surgical expertise (level 2).
A routine laparotomy is not indicated in hemodynamically stable patients with abdominal gunshot wounds (GSWs) if the wounds are tangential and there are no peritoneal signs (level 2).
Serial physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen, if performed by experienced clinicians and preferably by the same team (level 2).
In patients selected for initial nonoperative management, abdominopelvic CT should be strongly considered as a diagnostic tool to facilitate initial management decisions (level 2).
Patients with penetrating injury isolated to the right upper quadrant of the abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination, and minimal to no abdominal tenderness (level 3).
The majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness (level 3).
Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration (level 2).
Practice Management Guidelines for Selective Nonoperative Management of Penetrating Abdominal Trauma J Trauma. 2010 Mar;68(3):721-733
Prolonged collar use and spinal immobilisation in ICU patients can contribute to pressure sores, increased intracranial pressure, venous obstruction, difficulties with airway management, difficulties with central venous access, respiratory complications, and DVT, so a reliable investigation to rule out unstable cervical spine injury is required. Several studies demonstrate the high sensitivity of CT, and now a prospective study from Canada attempts to lend further support to this.
Comparing against their chosen gold standard of dynamic radiography, ie. flexion/extension views (F/E) in 402 patients who received both tests, there was one case of injury detected by F/E but not by CT, leading to quoted sensitivity of 99.75%. However this negative CT turned out to be a reporting error – the scan, which the authors include in their article, was clearly abnormal.
One weakness of this study is that they excluded patients who died on ICU. More worrying are the stats quoted. The authors stat ‘four hundred one patients (99.75%) had normal CT and F-E images facilitating clinical clearance of their C-spine and discontinuation of spinal precautions‘. So in other words, there was only one patient in their series of 402 with an injury (according to the gold standard), and this was missed. The sensitivity is therefore zero percent, not 99.75%. What seems to be a further error is the reporting in a table of 401 patients who had ‘Positive CT and Negative F-E’, which if true, would give a specificty of zero too!
This paper covers an important topic for intensivists but it seems to me to be too flawed to add meaningfully to the existing evidence that necks can be ‘cleared’ by CT in patients without signs of cervical spine injury, in whom it has been said that the risks of prolonged collar use and immobilisation may outweigh the risks of missed cervical injury. Cervical spine clearance in obtunded blunt trauma patients: a prospective study J Trauma. 2010 Mar;68(3):576-82
A retrospective study from Italy compared outcomes of head injured patients cared for by a ground ambulance service (GROUND) with those managed by a HEMS team that included an experienced pre-hospital anaesthetist. Interestingly 73% of the ground group were also attended by a physician, but one ‘with only basic life-support capabilities and no formal training in airways management’. Despite these limited skills a results table shows that 36% of the GROUND group were intubated on scene (compared with 92% of the HEMS group), although without the use of neuromuscular blockers.
The HEMS group consisted of 89 patients and the GROUND group of 105 patients. There were no statistical differences in age, ISS, aISShead, or GCS, although arterial hypotension at arrival at the ER was present in 18% of HEMS patients and in 36% of GROUND patients (P < 0.001).
The overall mortality rate was lower in the HEMS than in the GROUND group (21 vs. 25% , P < 0.05). The survival with or without only minor neurological disabilities was higher in the HEMS than in the GROUND group (54 vs. 44% respectively, P < 0.05); among the survivors, the rate of severe neurological disabilities was lower in the HEMS than in the GROUND group (25 vs. 31%, P < 0.05). The out-of-hospital phase duration was longer in the HEMS group but this group had a faster time to definitive care (neurosurgery or neurocritical care). Influence of prehospital treatment on the outcome of patients with severe blunt traumatic brain injury: a single-centre study Eur J Emerg Med. 2009 Dec;16(6):312-7
German trauma patients are more likely to survive if they have a whole body CT rather than selective scans. Or that’s what this paper would have you believe IF you’re happy with the retrospective comparison, multivariate adjustments, and potential confounders. Still, if it helps you get your radiologists to play ball, the reference is… Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre studyLancet. 2009 Apr 25;373(9673):1455-61
Two major British surgical associations, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the British Orthopaedic Association (BOA) have worked together to create updated multi-disciplinary standards for the treatment of open fractures of the lower limb
The recommendations are summarised as: Standards for Practice Audit: 1. Intravenous antibiotics are administered as soon as possible, ideally within 3 hours of injury: Co-amoxiclav (1.2g) or Cefuroxime (1.5g) 8 hourly and are continued until wound debridement. Clindamycin 600mg, 6 hourly if penicillin allergy 2. The vascular and neurological status of the limb is assessed systematically and repeated at intervals, particularly after reduction of fractures or the application of splints 3. Vascular impairment requires immediate surgery and restoration of the circulation using shunts, ideally within 3-4 hours, with a maximum acceptable delay of 6 hours of warm ischaemia 4. Compartment syndrome also requires immediate surgery, with 4 compartment decompression via 2 incisions 5. Urgent surgery is also needed in some multiply injured patients with open fractures or if the wound is heavily contaminated by marine, agricultural or sewage matter. 6. A combined plan for the management of both the soft tissues and bone is formulated by the plastic and orthopaedic surgical teams and clearly documented 7. The wound is handled only to remove gross contamination and to allow photography, then covered in saline-soaked gauze and an impermeable film to prevent desiccation 8. The limb, including the knee and ankle, is splinted 9. Centres that cannot provide combined plastic and orthopaedic surgical care for severe open tibial fractures have protocols in place for the early transfer of the patient to an appropriate specialist centre 10. The primary surgical treatment (wound excision and fracture stabilisation) of severe open tibial fractures only takes place in a non-specialist centre if the patient cannot be transferred safely 11. The wound, soft tissue and bone excision (debridement) is performed by senior plastic and orthopaedic surgeons working together on scheduled trauma operating lists within normal working hours and within 24 hours of the injury unless there is marine, agricultural or sewage contamination. The 6 hour rule does not apply for solitary open fractures. Co-amoxiclav (1.2g) and Gentamicin (1.5mg/kg) are administered at wound excision and continued for 72 hours or definitive wound closure, which ever is sooner 12. If definitive skeletal and soft tissue reconstruction is not to be undertaken in a single stage, then vacuum foam dressing or an antibiotic bead pouch is applied until definitive surgery. 13. Definitive skeletal stabilisation and wound cover are achieved within 72hours and should not exceed 7 days. 14. Vacuum foam dressings are not used for definitive wound management in open fractures. 15. The wound in open tibial fractures in children is treated in the same way as adults
The full guidelines are available here
This is one of those ‘wow they really do that!?‘ papers…Patients undergoing thoracotomy and aortic clamping for pre-hospital blunt traumatic arrest either in the field or in the ED were evaluated for the outcome of survival to ICU admission. None of the 81 patients who underwent this intervention survived to discharge.
Field thoracotomy resulted in shorter times from arrival of the emergency medical team to performance of the thoracotomy (19.2 vs 30.7 mins). Patients who arrested in front of the team had a greater ICU admission rate than those who were already in cardiac arrest when the team arrived (70% vs 8%).
One may argue against an intervention that seems to have resulted in no benefit to the patient. However a counterargument might be that an ICU admission allows for better end-of-life management for grieving families, and for the possibility of organ donation.
Interestingly, there were some neurologically intact survivors of emergency thoracotomy for blunt trauma by this service, although they were excluded from the study for either (i) receiving the field thoracotomy before full arrest or (ii) arresting after arrival in the ED. Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system Resuscitation. 2009 Nov;80(11):1270-4
In major trauma patients who require blood transfusion, fresh frozen plasma (FFP) to packed red blood cell (RBC) ratios of up to 1:1 have been associated with reduced mortality in retrospective studies, which may be in part due to survival bias (some patients die before they can be given as much FFP as the survivors).
To eliminate this bias, Australian researchers reviewed 331 trauma patients receiving at least 5 units of red cells in the first 4 hours, with a median Injury Severity Score of 36. When deaths in the first 24 hours were excluded, FFP:RBC ratio had no association with mortality. They conclude that prospective randomised controlled trials are needed. Fresh frozen plasma (FFP) use during massive blood transfusion in trauma resuscitation Injury. 2010 Jan;41(1):35-9
Using a sophisticated infrared six camera motion capture system, investigators demonstrated decreased cervical spine movement when collared volunteers self-extricated from a mock smashed up Toyota Corolla, when compared with extrication by paramedics using a backboard.
The authors conclude that in ambulatory subjects who do not complain of back pain, the least motion of the cervical spine may occur when the subject is allowed to exit the car in a c-collar without backboard immobilisation. Cervical spine motion during extrication: a pilot study West J Emerg Med. 2009 May;10(2):74-8 Full text article
