Paucis Verbis: Blunt cardiac injury

blunt cardiac injury

Do you always get a troponin for patients who sustain blunt chest trauma?

Hopefully your answer is no. Of note, it is also NOT indicated as a screening test for those in whom you suspect a blunt cardiac injury (BCI). It can be normal in the setting of arrhythmias and it can be falsely elevated in the setting of catecholamine release or reperfusion injury from hypovolemic shock.

The initial screening test should include an ECG and a FAST ultrasound exam. If you have abnormal ECG findings, then a troponin is warranted (in addition to hospital admission).

Below summarizes a suggested algorithm from the recent EM Clinics of North America publication series. Definitive statements are challenging because there is no gold standard to diagnose BCI.

PV Card: Blunt Cardiac Injury


Adapted from [1]
Go to the ALiEM (PV) Cards for more resources.

Reference

  1. Bernardin B, Troquet J. Initial management and resuscitation of severe chest trauma. Emerg Med Clin North Am. 2012;30(2):377-400, viii-ix. [PubMed]
By |2021-10-10T08:52:32-07:00Jun 29, 2012|ALiEM Cards, Cardiovascular, Trauma|

Paucis Verbis: Blunt Abdominal Injury, Likelihood Ratios

blunt abdominal injury

This month’s issue of JAMA addresses the question “Does this patient have a blunt intra-abdominal injury?” as part of the always-popular Rational Clinical Examination series.

The systematic review of the literature summarizes the accuracy of findings for your blunt trauma patient in diagnosing intra-abdominal injuries. Specifically, likelihood ratios (LR) are summarized. These LRs can be used to plot on the Bayes nomogram below. You draw a straight line connecting your pretest probability and the LR. This yields your posttest probability.

 

Bayes-1

The most predictive positive LR include: Abdominal rebound tenderness, a “seat belt sign”, ED hypotension, hematocrit < 30%, AST or ALT > 130, urine with > 25 RBCs, base deficit < -6 mEq/L, and a positive FAST ultrasound.

The trouble is that the absence of these findings aren’t as helpful in ruling-out injury, with negative LR’s very close to 1.0. The two exceptions are base deficit and FAST ultrasound with a negative LR of 0.12 and 0.26, respectively.


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

I find it interesting that there are studies on hepatic transaminase levels. Anyone else getting these in their trauma patients? I traditionally don’t. Many of our patients have a history of hepatitis C and underlying alcoholic hepatitis. If suspicious for blunt abdominal trauma, we just get the CT.

Reference

  1. Nishijima D, Simel D, Wisner D, Holmes J. Does this adult patient have a blunt intra-abdominal injury? JAMA. 2012;307(14):1517-1527. [PubMed]
By |2021-10-10T19:02:16-07:00Apr 20, 2012|ALiEM Cards, Gastrointestinal, Trauma|

Paucis Verbis: Distracting injuries in c-spine injuries

Cervical spine assessment distracting injuries

“Distracting injury” is a frequent cited reason for imaging the cervical spine in blunt trauma patients, per the NEXUS study. In the Journal of Trauma in 2005 and 2011, studies aimed to narrow the definition of “distracting injury”. Although both are studies at different sites, both conclude the same:

  • Chest injuries may be considered “distracting injuries” because of their proximity to the cervical spine.

Example

So let’s say you are caring for a non-intoxicated motor vehicle crash patient with an isolated tibia fracture (i.e. a “long bone fracture”), no chest injuries, and no neck pain/tenderness. Per the NEXUS criteria, you might consider this patient to have a “distracting injury” because of the long bone fracture. Instead, the literature now supports your clinically clearing the cervical spine without imaging.

Wait, let’s rethink this. Does this mean that you should get cervical spine imaging for ALL blunt trauma patients with ANY chest wall tenderness?! NO. That’s just crazy. You should still factor in the mechanism of injury, severity of pain, and your clinical gestalt.

So for me, these “distracting injury” studies are helpful such that:

  • If your trauma patient does NOT have chest trauma, it may help you avoid unnecessary cervical spine imaging, as suggested by the NEXUS criteria.
  • If your trauma patient DOES have significant chest trauma, I have a lower threshold to obtain cervical spine imaging despite the neck being non-tender.

PV Card: Distracting Injuries in Cervical Spine Assessment


Go to ALiEM (PV) Cards for more resources.

By |2021-10-12T16:03:39-07:00Sep 9, 2011|ALiEM Cards, Orthopedic, Trauma|

Trick of the Trade: Splinting the ear

EarHematomaDressing

One of the hardest bandages to apply well is one for auricular hematomas. After drainage, how would you apply a bandage to prevent the re-accumulation of blood in the perichondrial space?

Traditionally, one can wedge xeroform gauze or a moistened ribbon (used for I&D’s) in the antihelical fold. Behind the ear, insert several layers of gauze, which have been slit half way to allow for easier molding around the ear. Anterior to the ear, apply several layers of gauze to complete the “ear sandwich”. Finally, secure the sandwich in place with an ACE wrap, which ends up being quite challenging because of the shape of the head.

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By |2016-11-11T19:59:20-08:00Aug 10, 2011|ENT, Trauma, Tricks of the Trade|

Paucis Verbis: Blunt cerebrovascular injuries

Blunt Cerebrovascular Injury - AnatomyIn the setting of blunt trauma, it is easily to overlook a patient’s risk for blunt cerebrovascular injuries (BCVI). These are injuries to the carotid and vertebral arteries. Often they are asymptomatic with the initial injury, but the goal is to detect them before they develop a delayed stroke.

  • Who are at risk for these injuries?
  • What kind of imaging should I order to rule these injuries out?
  • Do I really treat these patients with antithrombotic agents even in the setting of trauma to reduce the incidence of CVA?

FYI: A simple seat-belt sign along the neck does not warrant a CT angiogram. Patients with higher risk findings such as significant pain, tenderness, swelling, and/or a bruit probably need imaging.

PV Card: Imaging for Blunt Cerebrovascular Injuries


Adapted from [1-3]
Go to ALiEM (PV) Cards for more resources.

References

  1. Burlew C, Biffl W. Imaging for blunt carotid and vertebral artery injuries. Surg Clin North Am. 2011;91(1):217-231. [PubMed]
  2. Paulus E, Fabian T, Savage S, et al. Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it. J Trauma Acute Care Surg. 2014;76(2):279-83; discussion 284-5. [PubMed]
  3. Bruns B, Tesoriero R, Kufera J, et al. Blunt cerebrovascular injury screening guidelines: what are we willing to miss? J Trauma Acute Care Surg. 2014;76(3):691-695. [PubMed]
By |2021-10-13T08:38:34-07:00Jul 1, 2011|ALiEM Cards, Cardiovascular, Radiology, Trauma|

Trick of the Trade: Fingertip injuries

FignernailGone2sm fingertip injuriesFingertips can get injured in a variety of ways such as machetes, meat grinders, and broken glass. You name it, and we’ve probably seen it. Some don’t actually need anything invasive done because the skin is basically just torn off. The wound just needs to be irrigated, explored, and then bandaged to allow for secondary wound closure.

What do you do if the finger injury keeps oozing and the finger tip is too painful for the patient to apply firm pressure? Poking the finger with 2 needles to perform a digital block seems a bit overkill.

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By |2020-02-12T20:41:43-08:00Jun 8, 2011|Orthopedic, Trauma, Tricks of the Trade|

Paucis Verbis: Head CT clinical decision rules in trauma

HeadCTbleedThe ideal clinical decision tool has a sensitivity and specificity of 100%.

You need a high sensitivity to be sure that your negative result indeed predicts a true negative. That means if your clinical decision tool suggests that you don’t need to get a head CT, then your head CT would have been normal.

On the flip side, this realistically means there is a low-moderate specificity. That means a clinical decision tool with at least 1 positive criterion does not always mean that there will be an abnormal finding on head CT.

There are 3 major clinical decision rules that I’ve heard tossed around in the literature:

  • Canadian CT Head Rules (CCHR)
  • New Orleans Criteria (NOC)
  • National Emergency X-Radiography Utilization Study (NEXUS)-II

There is no perfect tool.

Take a look at these decision rules and their inclusion criteria.

  • The CCHR included patients with GCS 13-15. The NOC initially enrolled only patients with a GCS of 15.
  • All factor in age (≥65 years for CCHR and NEXUS-II; ≥60 years for NOC).
  • Interestingly only the CCHR, for better or worse, take into account mechanism of injury. I’m not sure I would obtain a head CT on a pedestrian with a graze wound on the foot from a slow-moving vehicle.

Which do you use? I use a combination of all 3 and my clinical gestalt.

PV Card: Head CT in Trauma – Clinical Decision Tools


Go to ALiEM (PV) Cards for more resources.

By |2021-10-15T10:59:57-07:00May 13, 2011|ALiEM Cards, Radiology, Trauma|
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