CT or not before transfer?

[Rambro]

Just had a quick question.

I was covering at a rural ED and had a patient with suspected blunt abd trauma (tractor backed up into his chest and he was knocked to the ground).

First....some background about this ED, it's about 85 miles from a community hospital that would take about 60 mins by ground EMS for a transfer, and they don't take multi-system trauma or traumatic aortic ruptures.
The ED is also 110 miles away from a regional referral center than can take most traumas but has vascular surgery coverage about 70% of the time....90 mins by ground EMS 35 by helicopter.
Finally the ED is about 180 miles away from a major city that has 4 Level 1 EDs and can handle everything (not sure helicopter time) but EMS time about 140 mins.

So this patient had mild abd pain, didn't even want pain meds. Neg rectal exam x 2, no gross or microscopic blood (hemoccult neg). Took his metoprolol couple hours earlier and had poor PO intake for a couple days prior.

BP was 90s systolic, HR 70s (don't know if tachycardia blunted due to metoprolol/b-blocker)..
Did an acute abd series, read as neg.
Facility doesnt have ultrasound, so no FAST exam.

I have suspicion about intra-abdominal injury (blunt trauma) but come to find out by his brother that he has an aortic aneurysm that he's been watching...

Here's my dilemma....
-Should I transfer out to the community hospital by ground EMS that can take some trauma? However if vascular (aortic trauma) they'd have to transfer him out?

-Should I transfer out to the Regional Referral Hospital by ground EMS?
-Should I get a CT abd/pelvis to help determine extent of intra-abdominal injuries, if any..and possibly aortic injury? If aortic involvement I'd fly him out to the Regional Referral Hospital rather than EMS (assuming it was a day they had vascular surgery coverage)...

I know they say not to delay transfer for ancillary testing, but the given the limited resources this ED had (no ultrasound, no surgeon) and neg acute abd series in a patient feeling ok (but slightly hypotensive and low-normal HR)... would getting the CT be appropriate, as the result of the scan would help determine injury severity and destination and method of transport?

Any literature on this??

Thanks in advance.

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[GeneralVeers]

Depends. If you are not going to delay transfer by scanning, then yes, I would would scan.

 

[diphenyl]

^Agree 100% with veers. One and only goal is not have this guy die in your department. If there's enough time to get a scan while transfer is in process, get it. If it's going to delay the transfer DO NOT do it because all you will have is a possible dead patient with a pre mortem scan for the lawyers.

 

[gman33]

Never get a test you can't act on.
If you have no surgeon, what are you going to do with the results?

That said, if you can get the scan with NO delay, I'd get it.

 

[Perrin]

Agree with above.

You have a blunt abdominal trauma that is hypotensive and you suspect blunt abdominal injury. Call the second hospital to verify vascular coverage. If yes, by helicopter he goes. If no, transfer to ED in major city. Don't try to rationalize the vital signs in your head, because being right may mean a shorter transfer and being wrong means a dead patient.

 

[Arcan57]

So there's one thing missing from your presentation that I think would be a deciding factor. How worried are you that the guy is injured? Did tractor knock him down or run him over? Does he have a tender abdomen and is minimizing his pain because he's stoic by nature? If you're dealing with him as a "well, maybe, he could be injured" a CT may allow you to discharge him. If you're actually concerned he has blunt abdominal injury then I would say that it would depend on whether the helicopter is flying. If it is flying, get them in the air and do the scan while waiting for them to get there. You should be able to do a quick look for significant aortic pathology, free fluid, solid organ injury etc while pt is still on table. Than once you know yes/no on vascular injury you know where the patient needs to fly. It would also be good (although not fixable right that second) to know ahead of time what capabilities the regional trauma center has each day since if they can handle vascular I'd just fly without testing unless I could be sure the CD would be complete prior to patient being packaged in the copter.

 

[e30ftw]

so you have a fairly well-appearing man with h/o abd trauma, stableish VS and a mild abd pain.. I agree with Arcan, we need more info re: mech of injury and abd exam.. any signs of trauma? can he walk? is his abd distended, ttp, etc?

I agree the pt needs CT imaging (CT thorax/abd/pelvis), however.. he's been in your ED long enough to get an abd xray read and 2 rectal exams. Couldn't you have gotten the CT by now? I moonlight in a rural ED and if anyone is sick they go straight to CT and it takes about 5 minutes since anyone else in line can just be bumped. If the guy really had a ruptured AAA he would probably be showing signs of dying by now. I assume since you got an xray, etc that he had at least an iStat hct? if his crit was stable and he looks comfortable,etc he probably doesn't have any impending traumatic abdominal catastrophe. He still definitely needs CT imaging and repeat abd exam but I'm not sure I would call for a $15k aeromedical ride just yet. Chance are if you do, he's going to end up getting discharged from the lvl 1 trauma center 200 miles from home with no ride.

 

[GeneralVeers]

Why would you get a rectal exam? Why would you get two of them?

 

[Birdstrike]

Why would you get a rectal exam? Why would you get two of them?

Patient satisfaction most certainly.

 

[GeneralVeers]

Patient satisfaction most certainly.

True. Some patients would be most satisfied with it.

 

[Arcan57]

Bad enough that you had a tractor (maybe) run over you. Now you're in Our Lady of Faint Hope and some doctor is serially sodomizing you. I'd be tempted to pay the bill just to get helivac'd prior to the third rectal.

 

[GeneralVeers]

Bad enough that you had a tractor (maybe) run over you. Now you're in Our Lady of Faint Hope and some doctor is serially sodomizing you. I'd be tempted to pay the bill just to get helivac'd prior to the third rectal.

I know a few crazy patients who would crash their cars just to get such a thorough examination.

 

[Arcan57]

I know a few crazy patients who would crash their cars just to get such a thorough examination.

That reminds me of a psych patient we were boarding pending PSW eval. They had been talking for almost an hour calmly, when I see the PSW rush out of the room. I look in and the patient is naked, on his back, spread eagle, and holding his buttocks apart while loudly propositioning the PSW. Me - "You're going to get him admitted?" PSW - "Yep"

 

[TooMuchResearch]

Why would you get a rectal exam? Why would you get two of them?

Both at the same time. It's more efficient.

 

[southerndoc]

so you have a fairly well-appearing man with h/o abd trauma, stableish VS and a mild abd pain.. I agree with Arcan, we need more info re: mech of injury and abd exam.. any signs of trauma? can he walk? is his abd distended, ttp, etc?

I agree the pt needs CT imaging (CT thorax/abd/pelvis), however.. he's been in your ED long enough to get an abd xray read and 2 rectal exams. Couldn't you have gotten the CT by now? I moonlight in a rural ED and if anyone is sick they go straight to CT and it takes about 5 minutes since anyone else in line can just be bumped. If the guy really had a ruptured AAA he would probably be showing signs of dying by now. I assume since you got an xray, etc that he had at least an iStat hct? if his crit was stable and he looks comfortable,etc he probably doesn't have any impending traumatic abdominal catastrophe. He still definitely needs CT imaging and repeat abd exam but I'm not sure I would call for a $15k aeromedical ride just yet. Chance are if you do, he's going to end up getting discharged from the lvl 1 trauma center 200 miles from home with no ride.

Not all rural hospitals have 24/7 in-house CT techs. It might take 15-30 minutes to call a CT tech in to do the scan.

I disagree with the hematocrit. First of all, you would need serial hematocrits before you could say it's stable (or at least an old one to compare it to). I presume you meant to say normal? Second, I've seen plenty of seriously injured patients have near normal to normal hemoglobins when they first presented.

 

[Birdstrike]

Once you tell me "tractor backed up into his chest" blood pressure systolic in the "90s" in a guy who's normally hypertensive and probably runs non-compliantly >140/90 like most people nowadays, on beta-blockers with a likely blunted tachycardia response, my first instinct is "activate chopper." That being said, if the guy is sitting up, smiling, asking for a turkey sando and a meal tray, requesting discharge papers on the way in saying, "It barely touched me" and you have a tech waiting, an empty scanner, 24-hr radiology reading in real time who you can call immediately and get an IV only CT abd/pelvis read in 5 minutes, then that's different.

"Hypotensive-run-over-by-tractor" if legit, could justifiably be a chopper scene call in some places. But everything comes down to clinical judgment, in the particular scenario at hand. I can tell you this: I could probably walk into that room of this patient, and within 20 seconds answer your question with 3 "tests" much quicker than a ct scan:

1-Looking at the guy. Is he pale, looking like a corpse in training, or smiling, unconcerned?

2-Asking the guy, "What happened?" and listening to what he says, but more importantly how he says it. You'll get a tremendous amount of information in the first 3 seconds: Does he seem pained, with quick short of breath answers, with a flail segment sucking in and out, or...calm, relaxed, puzzled and wondering what all the fuss is and why the heck did these guys strap him to a board, collar his neck and don't you dare cut my clothes of dude, I'm fine? Some people say, "Look at the vital signs first." No. Wrong. Look at the patient. You can tell way more about a patients vital signs by looking in their eyes and saying, "Hello," than by looking at their vital signs. Do that first. Then look at their vitals. Trust me, if their BP is 70/50 and their heart rate is 130, you'll know that quicker by taking one look at their face, than that time it will take you to find out what their vitals are, or where they're written down.

3. A hand on the chest and belly. Lodes he have a tense belly, and scream when you push on his chest, is that sub Q air, or...the belly of the Pilsbury Doughboy, with no bruises, no reaction, and not a scratch?

After doing a crap ton of trauma, you can usually tell in about 20 seconds, the answer to the question you're really asking, without any tests: "Does this patient need to go to the OR in the next 30 minutes to stay alive, or not?

Think about this: A CT doesn't really answer that question at all, does it? Even if the patient has a CT that shows some free fluid in the belly, a grade 2 spleen lac, a liver confusion, that doesn't tell you anything about whether he needs to go to the OR in the next 30 minutes to live or not, does it? Most trauma is treated non-operatively. That's not to say you're going to sit on such a patient at your rural hospital for three day. No, not at all. That's not your question, and you would never consider that. Even with a negative scan you could have unseen bowel or duodenal injury from a "truck rolled over me" injury, and your likely going to need to ship the guy if significantly belly tender, anyways.

What you're asking is, "Do I hit the panic button in the first 5 minutes and activate a chopper, in a guy who may be dying, or literally may need no treatment whatsoever other than IV fluids over time?"

I know it's a long winded, non-answer answer, but it really is the answer. So, so much of this is the first 30 second "clinical gestalt" filtered through the capabilities of your particular little corner of the world you happen to be working your shift in. If you have that "gestalt," great. If not, it'll come, eventually. No one ever said it was easy.