VALUE OF CLINICAL EXAMINATION OF THE TRAUMA PATIENT

Transcription

1 VALUE OF CLINICAL EXAMINATION OF THE TRAUMA PATIENT

2 DISCLOSURES No Disclosures

3 OBJECTIVES Discuss how the injured patient are examined Discuss the value of repeating the clinical examination Discuss how to use the clinical examination to reduce harm for the patient

4 PRE-HOSPITAL Algorithm- Protocol guided physical exam Blunt trauma patients with repeat episode of hypotension (crump factor)have significantly greater mortality( Fresno 2011) Value of mechanism of injury and scene information as adjunct to physical exam

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6 PRIMARY SURVEY A. B. C. D. E. F

7 SECONDARY SURVEY Head to toe evaluation Inspection Palpation Percussion Auscultation

8 . Scalp Occipital area Neck Under the collar Penetrating neck injury Extremity Swelling Torso Chest, Abdomen & Pelvis BACK

9 Genital Elderly female assaulted Head and neck CT shows multiple face and mandible fractures Artifact on C-spine CT MRI under general anesthesia Admitted to the floor The nurse noted Right labial bruising, inner thigh bruising and vaginal bleeding

10 TERTIARY SURVEY. Comprehensive reevaluation and repeated head to toe examination and review of all laboratory and radiologic studies completed within 24 hour of admission Every C/O, every sign elucidated can point to a direct injury or injury underneath The big picture come together The jigsaw puzzle should be complete What is the optimal time for the tertiary survey

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12 AREA OF CONTROVERSY Vitals Automated vs Manual BP ( ABP were higher) Is systolic BP of 90mmhg appropriate for penetrating injury(manchester UK.2011) In the elderly(>65y) Normotension is not reassuring( H&H) Vital signs on presentation are less predictive of mortality in geriatric blunt trauma victims It warrants increased vigilance despite normal vital signs on presentation New set point need to be considered(rhode Isand 2010) Normal heart rate in an athlete

13 AREA OF CONTROVERSY Systolic BP of 90mmhg vs 80mmhg vs 110 mmhg( Detroit 2007) The presence of PEA at any time during the initial resuscitation is a grave prognostic indicator(yale 2009) FAST is a useful test to identify contractile cardiac activity

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15 AREA OF CONTROVERSY Blood pressure as a surrogate for perfusion Systolic Blood Pressure of the elderly

16 AREA OF CONTROVERSY TBI Clinical examination vs CT scan Repeat Head CT is beneficial in patient with acute deterioration or unknown neurological exam It is of little value in patient with normal or persistently abnormal neurological exam(newark 2011)

17 AREA OF CONTROVERSY Clearance of C-spine The patient is awake, alert, GCS14 and above, with no drugs and no distracting injury Distracting injury (head, torso & long bone fractures) The concept of distracting injury in the context of CS examination is Invalid?/Valid? University of Southern Alabama

18 AREA OF CONTROVERSY Abdominal examination Is the physical examination completely accurate 50 year old male hit by a truck while on bicycle He was brought to the ER with C/O left wrist pain and left chest pain Negative head and c-spine CT and positive left distal radius along with left 8 th& 9 th rib fractures Pt was discharged home

19 AREA OF CONTROVERSY Pt came back 2 days later with left flank pain CT scan shows a 4mm left UPJ stone

20 AREAS OF CONTROVERSY Grade III Splenic Laceration

21 AREA OF CONTROVERSY Inova fairfax % of trauma activation patient with negative abdominal exam have occult abdominal/pelvic injuries Even with absent abdominal pain and negative abdomen/pelvis/lower rib exam 5.7% have occult injuries that would change management

22 AREA OF CONTROVERSY The Eastern Association for the Surgery of Trauma (EAST) guidelines for evaluation of blunt abdominal trauma patients recommend an objective evaluation of the abdomen (OEA) for patients with a major trauma mechanism who are hemodynamically stable, but have an equivocal physical examination (exam), depressed level of consciousness, or multiple extra-abdominal injuries.

23 AREA OF CONTROVERSY Abdominal evaluation is not clear when the patient is awake The accuracy of the clinical exam in detecting intra-abdominal injuries has been questioned Some study have reported false negative rates for abdominal exam ranging from 7%- 37%

24 A. Rodriguez, R.W. Dupriest, C.H. Shatney Recognition of intra-abdominal injury in blunt trauma victims: A prospective study comparing physical examination with peritoneal lavage Am Surg, 48 (1982), p. 457 R.C. Mackersie, A.D. Tiwary, S.R. Shackford et al. Intra-abdominal injury following blunt trauma: Identifying the high-risk patient using objective risk factors Arch Surg, 124 (1989), p. 809 G.W. Schurink, P.J. Bode, P.A. van Luijt et al. The value of physical examination in the diagnosis of patients with blunt abdominal trauma: A retrospective study Injury, 28 (1997), p. 261

25 P.C. Ferrera, V.P. Verdile, J.M. Bartfield et al. Injuries distracting from intra-abdominal injuries after blunt trauma Am J Emer Med, 16 (1998), p. 145 P.A. Poletti, S.E. Mirvis, K. Shanmuganathan et al. Blunt abdominal trauma patients: Can organ injury be excluded without performing computed tomography? J Trauma, 57 (2004), p. 1072

26 M.L. Self, A.M. Blake, M. Whitley et al. The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injury Am J Surg, 186 (2003), p. 609 D.H. Livingston, R.F. Lavery, M.R. Passannante et al. Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: Results of a prospective, multi-institutional trial 1. J Trauma, 44 (1998), p. 273

27 AREA OF CONTROVERSY Liberal CT scanning may reveal unexpected findings in 38% of patients with prompt change in treatment in 26% The physical exam alone doesn t have a high negative predictive value CT is superior to physical exam in establishing the diagnosis of Blunt Hollow Viscus Injury.( Hartford)

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30 AREA OF CONTROVERSY Before emergent extra-abdominal trauma surgery In the awake and alert blunt trauma patient Abdominal evaluation with Physical exam is sufficient to identify surgically significant abdominal injury ( USA) 1997 Netherlands published a study about the NPV of the abdominal physical exam was high but reliable physical exam is very infrequent

31 AREA OF CONTROVERSY We need to strike a balance between use and overuse of radiologic and surgical techniques in the era of CT and FAST Factors to be included Surgeon s estimate of the risk of injury, mechanism, risk to patient (radiation, reaction to contrast)cost and efficient use of resources and time

32 AREA OF CONTROVERSY The over triage built in trauma activation criteria is intentional with one of the main goals is not to miss injury Distracting injuries, concomitant injuries, alcohol and drugs Timing of the exam Repeat abdominal exam

33 AREA OF CONTROVERSY Pelvic examination Deferral of RECTAL EXAM Adult patient with blunt trauma Normal neurologic exam, no blood at the urethral meatus(loma Linda 2004)

34 AREA OF CONTROVERSY Body Habitus Obese patient may have an exaggerated injuries. Low Energy Knee dislocation in obese patient are becoming increasingly prevalent with higher incidence of vascular and nerve Among Blunt Trauma patient increasing BMI is associated with higher torso and proximal upper extremity injuries Underweight patients have lower 90 days survival BMI correlates with increased rate of complications and reoperation after operative treatment of pelvic ring injuries

35 AREA OF CONTROVERSY Obese patient are significantly more likely to have more distal femur fractures compared with non obese when involved in MVC No difference in mortality, morbidity or LOS Severe obesity was significantly associated with adverse outcome and increased resource utilization in trauma patient treated with Damage control laparotomy(new Orleans 2009)

36 AREA OF CONTROVERSY Obesity doesn t increase Morbidity and Mortality after Laparotomy for Trauma (Newark NJ)

37 AREA OF CONTROVERSY Broselow tape is an ineffective tool to predict weight in more than 50% of pediatric trauma patients. This may lead to under dosing of emergency medication.

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