What would you do? - trauma scenario

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opr8n

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  1. Attending Physician
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80 y/o lady
MVC
GCS 14 confused
Obvious femur fx
abdominal tenderness
FAST + for fluid in morrisons pouch and pelvis
pt mild hypotensive in bay, gets 1L of fluid and is responsive, BP comes up

next move - OR or CT scanner?
 
opr8n said:
80 y/o lady
MVC
GCS 14 confused
Obvious femur fx
abdominal tenderness
FAST + for fluid in morrisons pouch and pelvis
pt mild hypotensive in bay, gets 1L of fluid and is responsive, BP comes up

next move - OR or CT scanner?
Click to expand...

I'd have to know more (PMHx, labs if available, plain films, etc), but in the case you're presenting I'd usually go to the CT scanner.

Responsive hypotension doesn't get me too excited.
 
80yo lady doesnt have too much of a margin of error.
If shes hemodynamically stable I would go to the CT. I think in an old lady a negative exlap can get you in trouble--
less is more

never really thought much of the FAST scans unless the patient was unstable
 
At Shock, we were very fond of FAST. However, since the CT scanner is only a few steps away and the patient responded to crystalloid, I would escort her to the scanner.

All for now, go back to your dim sum,
I am the Great Saphenous!!!
 
ESU_MD said:
80yo lady doesnt have too much of a margin of error.
If shes hemodynamically stable I would go to the CT. I think in an old lady a negative exlap can get you in trouble--
less is more

never really thought much of the FAST scans unless the patient was unstable
Click to expand...

I haven't dealt with Trauma for quite a while, but I think this is the important point.
 
IMHO, the "obvious femur fracture" really shouldn't play much of a role in your treatment algorithm for this patient (that is assuming you are not the treating orthopedist).

If you are taking the patient to the OR emergently to explore the abdomen, we can come in after your case to provide some form of temporary stabilization -- either with an external fixator or skeletal traction. We could try to definitively fix the fracture at this time, but you'd have to consider adding another 500cc to >1L of blood loss and at least another 1hour of operative time; I'm not sure if an 80y/o would be able to tolerate that immediately following an ex-lap.

If you are not taking the patient to the OR emergently for the abdomen she can be placed in some form of traction until she is stabilized and adequately resuscitated.

One question that I have is what would y'all do for anticoagulation? Should she just get an IVC filter? She's at high risk for DVT, but given the "fluid" in the abdomen I imagine she might start bleeding out when she's started on DVT prophy?
 
scanner, OR with ortho, I get to round on her everyday and check her HCT for her grade 2 liver lac, then she goes into afib w/ RVR, she won't eat or move, Cr bumps, ortho signs off pod1, her kids show up pod5 and wanting to know why she is not turning cartwheels, pneumonia or DVT or infection POD6, PICC placed POD7, scramble for placement for 2 days before sending her to a "rehab"
 
Scanner for sure. I think the line about the obvious femur fracture was thrown in to give a logical outside the belly source of blood loss. In the absence of this I am a little more worried about that transient hypotension, but likely not enough to want to go racing into her belly. The GCS worries me a lot less if she was the passenger (maybe it is her baseline?-would still want a scan). If she was the driver, it would make me want the scan that much more (especially if she is on coumadin/plavix/etc) to the point that I might even risk at least the head even if you threw in some other things that would tip the scales more toward OR (like a worrisome exam, or BP borderline-as long as it is not dropping). Also, as quickly as possible I would talk to her (if her confusion improves) or her family about the possibility of a decline in condition and try to get an idea of how aggressively she should be treated in that case. If she has a bazillion medical problems, had poor functional status already, and had talked about not wanting to be on "machines" I want to sort that out now rather than after she crashes and gets intubated and family tosses her wishes out the window because they think she will magically get better.
 
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Tender abdomen with appropriate response to fluid bolus - I would definitely scan her. Odds are good that any intra-abdominal injuries can be managed non-operatively, if she even has any.
 
More information is needed. Are the chest and pelvic films normal? If so, then you haven't ruled out cavitary hemorrhage in her belly causing her shock. If you don't believe in FAST (and hence wont lap the patient based on its findings) then why do it? You wouldn't do it in a stable patient, regardless. In this case, it is an adjunct that would lead to surgery if positive.

I would wait. Wait in the bay. Back off of fluids. If she stays stable then go ahead and scan and I agree with the above. Chances are, if she does have that grade 2 liver lac that she would stay stable.

If she drops, she gets a laparatomy. The CT scanner is a cold, dark and lonely place. You do not want to code her while she is crashing and burning there. Trust me.
 
Chemdocx said:
scanner, OR with ortho, I get to round on her everyday and check her HCT for her grade 2 liver lac, then she goes into afib w/ RVR, she won't eat or move, Cr bumps, ortho signs off pod1, her kids show up pod5 and wanting to know why she is not turning cartwheels, pneumonia or DVT or infection POD6, PICC placed POD7, scramble for placement for 2 days before sending her to a "rehab"
Click to expand...

LOL! so true, yet so sad.
 
Rony said:
More information is needed. Are the chest and pelvic films normal? If so, then you haven't ruled out cavitary hemorrhage in her belly causing her shock. If you don't believe in FAST (and hence wont lap the patient based on its findings) then why do it? You wouldn't do it in a stable patient, regardless. In this case, it is an adjunct that would lead to surgery if positive.

I would wait. Wait in the bay. Back off of fluids. If she stays stable then go ahead and scan and I agree with the above. Chances are, if she does have that grade 2 liver lac that she would stay stable.

If she drops, she gets a laparatomy. The CT scanner is a cold, dark and lonely place. You do not want to code her while she is crashing and burning there. Trust me.
Click to expand...
I agree completely. This is a situation where I trained where we would utilize an ABG and a base deficit, and not go to the scanner if the base deficit was over 6 in an elderly patient. We would use DPL if we were not going to scan, and resuscitate in the ICU. Even though the scanner was across the hall from the resusc room, it was a long long way if you were coding the patient. Ortho utilized cross tables to pin the femur in the ICU.
 
blue2000 said:
I agree completely. This is a situation where I trained where we would utilize an ABG and a base deficit, and not go to the scanner if the base deficit was over 6 in an elderly patient. We would use DPL if we were not going to scan, and resuscitate in the ICU. Even though the scanner was across the hall from the resusc room, it was a long long way if you were coding the patient. Ortho utilized cross tables to pin the femur in the ICU.
Click to expand...

What would a positive DPL add to a positive FAST scan? Or was this the pre-FASTing era?
 
I think the answer to this question depends quite a bit on the hospital resources available. At my institution, with the trauma scanner in close proximity to the trauma bay and trauma OR, this patient would probably go to the scanner IF she was responsive to fluid (with the trauma senior and probably trauma attending as an escort). Obviously if she isn't responsive to fluid, or having worsening hemodynamic instability, I would proceed instead to the OR.

However, back in my intern days when we had to go up three floors and to another building to get a scan....I think this would have been a much tougher question to answer and I think we were a lot faster to pull the trigger on laparotomy.

I think the imaging here is key because, as has been mentioned previously, if you can get away with nonoperative management of a low-to-mid-grade solid organ injury you're saving an elderly frail patient from a big ol' midline incision. Also, you can add a head CT and rule out a catastrophic intracranial bleed.
 
blue2000 said:
I agree completely. This is a situation where I trained where we would utilize an ABG and a base deficit, and not go to the scanner if the base deficit was over 6 in an elderly patient. We would use DPL if we were not going to scan, and resuscitate in the ICU. Even though the scanner was across the hall from the resusc room, it was a long long way if you were coding the patient. Ortho utilized cross tables to pin the femur in the ICU.
Click to expand...

BD is a good endpoint of resuscitation, but using it as the only indication for a DPL is a stretch for me.
Most CT scan catastrophe stories tend to be "war stories" that are pumped into us as interns to scare us into respecting the trauma evaluation and use good judgement in determining stability.
 
ESU_MD said:
BD is a good endpoint of resuscitation, but using it as the only indication for a DPL is a stretch for me.
Most CT scan catastrophe stories tend to be "war stories" that are pumped into us as interns to scare us into respecting the trauma evaluation and use good judgement in determining stability.
Click to expand...
My answer is a bit confusing -- sorry. Two points

1) We did not use FAST routinely, unless the trauma attending was in the bay doing it
2) ABG was used as quick and dirty way of assessing sick/not sick in the trauma bay -- not for an indication for laparotomy. Transient hypotenion + Base deficit >6 in elderly = DPL and ICU, not CT scanner. I will say that I saw a significant number of patients over 70 who had a few fractures, a pressure of 95, a heart rate of 95 and a base deficit of 10 or 12. In my mind, those are the patients that can do poorly in the scanner. Laparotomy criteria were standard ATLS.
3) We were aggressive with DPL. Depending on attending, any blood pressure less than 90 in ER mandated DPL rather than scanner. Very old school, and very institution and attending dependent.
 
DPL is good skill to have, one that is essentialy a lost art. Btw, dpl stuff is good fodder for absite and the real boards too... Good idea to keep refreshed in what = + dpl
 
blue2000 said:
I agree completely. This is a situation where I trained where we would utilize an ABG and a base deficit, and not go to the scanner if the base deficit was over 6 in an elderly patient.
Click to expand...
We can get a CT scan faster than the results of an ABG.
 
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SocialistMD said:
We can get a CT scan faster than the results of an ABG.
Click to expand...

This.


Everyone acts like CT is a deep, dark dungeon, but I think it's institution-dependent. Our scanners are fast, and close to the Trauma bay. I don't think I'd waste everyone's time watching and waiting for some arbitrary period prior to getting the scan anyway.

Rony's comment, "The CT scanner is a cold, dark and lonely place. You do not want to code her while she is crashing and burning there. Trust me" is dogma that we've all heard since we started in medicine, but I don't know if it will withstand the test of time.

Of course, I do agree that some people get under-treated and under-triaged in the trauma bay, and end up in the scanner inappropriately, only to crash and burn in an inconvenient location.

Since starting residency 5 years ago, I've done a total of 3 DPLs....sure, it's a lost art, but so are a lot of things that have become obsolete. During that same time period, I've done about a million FASTs.
 
SLUser11 said:
Since starting residency 5 years ago, I've done a total of 3 DPLs....sure, it's a lost art, but so are a lot of things that have become obsolete. During that same time period, I've done about a million FASTs.
Click to expand...

as an incoming intern, prepping for my ATLS course, i was actually close to posting this question last night...the current text is from 2008 and makes FAST sound like stem cell therapy in terms of experimental/unproven use. this answers my curiosity though as to how much DPL is actually used in real life versus FAST.

thanks SLUser.
 
DrNick Riviera said:
as an incoming intern, prepping for my ATLS course, i was actually close to posting this question last night...the current text is from 2008 and makes FAST sound like stem cell therapy in terms of experimental/unproven use. this answers my curiosity though as to how much DPL is actually used in real life versus FAST.

thanks SLUser.
Click to expand...

If it helps, I've *never* done a DPL. We had a FAST early on, and a scanner across the hallway from the trauma bays.
 
DPLs are program dependent, obviously.

We did DPLs at my program regularly. Any question of fascial penetration = DPL. Stable thoracoabdominal stab wound (without obvious signs to go to OR) = DPL. I remember as a PGY2 having done enough to supervise ER residents on the trauma service trying to learn them. They *can* be quite frustrating---sometimes you need to put in more fluid to get an adequate fluid return (and then multiply the lab results by 2 to adjust), and in some patients took a lot of jostling and catheter manipulation to get the fluid back. Not necessarily a quick procedure, depending on the patient and their body habitus.
 
SLUser11 said:
Versus the FAST, which takes about 20 seconds.
Click to expand...
Even when we did a FAST, the attendings still wanted a DPL and it was in our protocols. Our FAST ultrasound machine was horribly old, unreliable (i.e. didn't always work) and needed to be replaced and we were a county hospital with no money for new equipment. The budget issues there are a whole other discussion in and of itself. I wasn't trying to advocate that everyone needs to do DPLs and not FAST scans, just was commenting that there are still places that routinely use it, and that it's not always an easy procedure to perform. Certainly FAST is quicker and less invasive.

IRL, I am inclined to do a dx lap and look at the fascia/diaphragm for injuries. I think the ER docs would freak out if I wanted to do a DPL on a trauma patient.
 
A couple of more points..

If you're not going to operate on a positive FAST...which is very sensitive..then why bother doing it..that's my point guys.

No one should be faulted for a negative laparotomy.
Our scanner is next door too, so is our, OR by the way. But I must admit my training and my institution were anti-FAST.

But an unstable patient in a scanner can end up in disaster...it's not old dogma..just ask anyone who has lost patients there..

A negative FAST is worthless, which is when DPL comes in..there is a place for it...and if you can do open entry for initial laparoscopic trocar insertion (Hasson), then you can do a DPL. There are closed wire-based Seldinger techniques also..You could do one in the time it takes you to adjust the gain and frequency on your ultrasound and while you interpret all 4 nebulograms.

The key point is, if you are going to scan regardless, it is best NOT to infuse (which will save you the time) or analyze microscopically, which is not necessary for anything but test question purposes. This will lead to iatrogenically placed free fluid on CT that will be hard to interpret. Just put the catheter in the pelvis; if you get 10cc of gross blood or enteric contents..then proceed to laparotomy.
 
Rony said:
A couple of more points..

If you're not going to operate on a positive FAST...which is very sensitive..then why bother doing it..that's my point guys
Click to expand...

In a training environment I think its value is for the practice so that you aren't taking more than a minute to do it. Of course that means it shouldn't be done until after your primary survey for sure, and probably after your secondary survey.

In an unstable patient is where you should whip it out earlier. For those that respond to fluids though, AND have reasonable other sources for that initial instability (such as multiple long bone fracture, bad pelvic fractures, extremity vascular injuries, etc) I don't think you need to rush to lap every patient with a tiny stripe of fluid on U/S. Other injuries do not preclude nonoperative management of solid organ injury (although, in the hotel room the answer is of course to slice them open)
 
Rony said:
A couple of more points..

If you're not going to operate on a positive FAST...which is very sensitive..then why bother doing it..that's my point guys.

.....Just put the catheter in the pelvis; if you get 10cc of gross blood or enteric contents..then proceed to laparotomy.
Click to expand...

Well, one reason to do the FAST frequently is so the junior residents become quick and accurate with the ultrasound, and so they see a few positive findings. It's definitely a more benign teaching method than mandatory ER Thoracotomies on all coding patients 🙂:Cough::cough:: LA County).

The FAST is also very useful for detecting pleural slide (or lack thereof) and can indicate the need for a chest tube.

I'm not sure how positive findings on DPL are any different than FAST, and I'm unsure then in your algorithm when DPL would ever be indicated. There's definitely no way you'll convince me it's quicker.

The only advantage would be the finding of enteric contents, and my question to you would be: how many times have you had that in a patient without other indications for laparotomy? Enteric contents in the pelvis (where you're aiming your catheter) after a blunt injury? If there's no enteric contents, does that mean we're off the hook and the patient can have a steak dinner? If you only find blood, are you taking that patient to the OR?

With your reasoning, the patient that would benefit from DPL is someone who 1) has a negative FAST, 2) doesn't need a CT (per your last paragraph), and 3) doesn't have an indication for laparotomy (fascial penetration or peritoneal signs).....pretty small group there....

And, you should be faulted for a negative laparotomy if the surgery wasn't indicated.
 
ESU_MD said:
80yo lady doesnt have too much of a margin of error.
Click to expand...

this is a very good point and one which should not be ignored

blue2000 said:
I agree completely. This is a situation where I trained where we would utilize an ABG and a base deficit, and not go to the scanner if the base deficit was over 6 in an elderly patient. .
Click to expand...

i agree with abg, BD was -5


MediCane2006 said:
I think the answer to this question depends quite a bit on the hospital resources available. At my institution, with the trauma scanner in close proximity to the trauma bay and trauma OR, this patient would probably go to the scanner IF she was responsive to fluid (with the trauma senior and probably trauma attending as an escort). Obviously if she isn't responsive to fluid, or having worsening hemodynamic instability, I would proceed instead to the OR.
.
Click to expand...
agree, our CT scanner is 50 feet away

blue2000 said:
1) We did not use FAST routinely, unless the trauma attending was in the bay doing it
3) We were aggressive with DPL. Depending on attending, any blood pressure less than 90 in ER mandated DPL rather than scanner. Very old school, and very institution and attending dependent.
Click to expand...

I think FAST is very important and an easy test to do, i have only done one DPL in residency, it is a lost technique IMO, or atleast at my institution, FAST has replaced it

SLUser11 said:
Well, one reason to do the FAST frequently is so the junior residents become quick and accurate with the ultrasound, and so they see a few positive findings. It's definitely a more benign teaching method than mandatory ER Thoracotomies on all coding patients 🙂:Cough::cough:: LA County).

The FAST is also very useful for detecting pleural slide (or lack thereof) and can indicate the need for a chest tube.

I'm not sure how positive findings on DPL are any different than FAST, and I'm unsure then in your algorithm when DPL would ever be indicated. There's definitely no way you'll convince me it's quicker.

The only advantage would be the finding of enteric contents, and my question to you would be: how many times have you had that in a patient without other indications for laparotomy? Enteric contents in the pelvis (where you're aiming your catheter) after a blunt injury? If there's no enteric contents, does that mean we're off the hook and the patient can have a steak dinner? If you only find blood, are you taking that patient to the OR?
.
Click to expand...
agree


Anyway ... so here is what happened ...

Went to CT scan
while in scanner, pt dropped BP again, got blood
was not in scanner for more than 15 min
immediatly saw massive gross hemoperitoneum and active bleeding in lesser sac (OH MY!)

straight to OR

Found:
massive hemoperitoneum (2L blood loss)
completely transected pancreas
grade 2 spleen
duodenal hematoma x2, one was a perforation
right colonic mesenteric hematoma with right colon devasc

great case, pt still alive at this point

However, M&M was fun trying to explain why I was in CT when I should have been in the OR, and in retrospect ... I thinkl I should have been in the OR, not CT

as stated above, i wanted to r/o grade 2/3 liver or spleen causeing blood in belly that would likely not need an operation and I had a potential source of blood loss from the femur
but it was decided that a neg lap or even a lap/spleen would have been more acceptable than a dead patient in the CT scanner

thoughts?
 
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Damn, 80yo with transected pancreas, bad spleen + other mesenteric injuries AND a long bone fracture.

I would suspect the mortality of this constellation of injuries closes in on 80%, with the chances of returning to a non-nursing home productive life close to 0.

what did you do in the OR and more interestingly postop?
 
opr8n said:
80 y/o lady
MVC
GCS 14 confused
Obvious femur fx
abdominal tenderness
FAST + for fluid in morrisons pouch and pelvis
pt mild hypotensive in bay, gets 1L of fluid and is responsive, BP comes up

next move - OR or CT scanner?
Click to expand...

How can one make a justifiable decision either way given that information?

The possibilities are:

1. she had a little bleed and clotted and is fine, and that's why she responded to the fluids. The exlap may be useless and might kill her.

2. she had a huge bleed which either temporarily clotted, or she has a good amount of functional reserve left( rare but not impossible). The exlap may save her life.

How do you choose?
 
Rony said:
A couple of more points..

If you're not going to operate on a positive FAST...which is very sensitive..then why bother doing it..that's my point guys.
Click to expand...
If the patient is unstable, I think we would operate based on the FAST, but I haven't been in that situation yet. If the patient is stable, we'll do a FAST just for practice.

No one should be faulted for a negative laparotomy.
Our scanner is next door too, so is our, OR by the way. But I must admit my training and my institution were anti-FAST.
Click to expand...
I could wheel the patient from the trauma bay to the scanner or the OR in the same amount of time, but the time required to get our ORs going is much longer than I think it should be. We can get a CT in minutes. We rarely have operative traumas that need to be dealt with emergently though, as we don't have a lot of penetrating trauma.
 
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