In the blunt trauma patient, where we are considering a pan-scan, is there a role for the log roll, the FAST scan or the rectal examination any more?
The ambulance phone rings:
“ETA 15 minutes. We have a 25 year old male involved in a high speed motor vehicle accident. He has come off the road and hit a barrier. His vitals are normal. His GCS is 15, although he did have a loss of consciousness at the scene. He has a scalp laceration and left sided chest wall and abdominal pain, with a probable closed tibial fracture”
The patient arrives and is as described. The surgical registrar has come down to assist you, as you don’t have a trauma call option at your hospital. She completes the primary survey, under your supervision as the team leader and reports: “There are breaths sounds bilaterally, with rib pain on the left side”, which makes you suspicious of some rib fractures. “There is some left sided abdominal pain, extending under the rib cage. The pelvis is normal and there is probably a lower limb fracture, that has been immobilised, with the limb looking neurovascularly intact”.
The FAST Scan
(Focused Assessment with Sonography for Trauma)
The registrar asks “Where’s the ultrasound machine? I need to do a FAST”
Let’s not even pretend for a minute that this patient isn’t getting a pan scan. The question needs to be asked. Does the FAST have anything to offer in blunt abdominal trauma where a CT scan is being done?
The FAST scan is there to give us two pieces of information:
- Is there blood in the peritoneal cavity?
- Is there a pericardial effusion?
The extended FAST includes the chest and gives us information on haemothoraces or pneumothoraces.
It is useful in blunt abdominal trauma as it is:
- Can be used for serial examinations
- Can diagnose hemoperitoneum
- Can diagnose a pericardial effusion.
FAST is useful in haemodynamically unstable patients, its role being to find the source of instability. If there is instability and a haemoperitoneum, the patient should go to the operating room(doesn’t always happen). It therefore has a secondary triage role.
Approximately 600ml of fluid in Morison’s pouch in the supine patient and 400ml in the patient in a Trandelenburg position is needed for a FAST scan to be positive(1,2).
Is it enough for the FAST to be negative and do nothing else? We know that the FAST is very good at detecting a haemoperitoneum. However not all patients have this and the sensitivity of this test at detecting solid organ injury is around 60%(3). In fact, it is associated with a significant false negative rate for detecting intra-abdominal injury and depending on the FAST for this role, without performing a CT abdomen, will result in a significant number of missed injuries(4).
The extended FAST, when used for the detection of a pneumothorax has been shown to be at least twice as sensitive as a chest x-ray for detecting pneumothoraces(5).
In blunt abdominal trauma in the stable patient, especially those getting a CT scan, FAST probably hasn’t got much to offer. The extended FAST may be useful for detecting haemothoraces or pneumothoraces. Currently we are unsure of the management for these conditions when they are not present in a chest xray but found on the EFAST. This can make it confusing. Certainly if found, a CT chest will probably be done.
For me, currently the EFAST stays but not for the stable blunt trauma patient, who is getting a pan scan.
The Log Roll
CT are ready for the patient. You prepare. The same registrar says “No not yet. We need to log roll the patient, so I can palpate the spine and do a rectal”.
You respond: “Do we really need this? If this was a stabbing or gunshot wound, sure, let’s do it, so we don’t miss another wound. But he’s a blunt trauma. Are we really expecting a penetrating injury? Will a bruise over the back tell me anything about abdominal injury? Will palpating the back tell me anything about spinal injury?”
The response you get is: “There are only two reasons for not doing the rectal; No finger or no anus”
You question this, but decide to go ahead.
The patient is log rolled and the spine is palpated. The patient is asked to keep still and just say yes or no when asked if there is any pain. You know what happens, every time he’s asked, he shakes or moves his head in some way.
So how good is the log roll, spinal palpation and rectal exam for giving us any information in trauma?
Is spinal column palpation any good in picking up injuries?
In the unconscious patient the sensitivity of this examination is about 27% and the negative likelihood for abnormalities was 0.8(6). In patients with a GCS of 15, no intoxication and no neurological deficit, the absence of pain or tenderness can exclude a clinically significant lumbar vertebral fracture, but not a thoracic fracture(7).
The issues with the log roll itself, apart from causing pain and having the potential to dislodge formed clots, leading to further bleeding, is that it may induce spinal movement, in the patient with a spinal injury. In a study by Suter(8), five variations of the log roll were radiographically evaluated . There were no rotational differences amongst the variations, however there were substantial differences in lateral displacement. These were more related to body habitus and the amount of periabdominal fat present.
McGuire et al(9) found that backboards and scoop stretchers gave the greatest stabilisation for thoracolumbar spinal instability. The log roll was found to give the greatest possibility of movement of the spine at the unstable thoracolumbar segment.
There is really no need for this manoeuvre if we suspect any spinal injury and if a CT is being done, as we can reconstruct spinal views on the scan. This will give us a better answer than the log roll and spinal palpation.
The Rectal Examination
The rectal examination rarely gives any additional information to the clinical picture and changed management in about 4% of cases(10). Its sensitivity for picking up particular conditions has been described as(11):
- Spinal cord injury: 37%
- Bowel injury: 5.7%
- Rectal injury: 33.3%
- Pelvic fracture: 0%
- Urethral disruption: 20%
In a patient with blunt trauma where CT is being performed:
- EFAST is useful in detecting pneumothoraces/haemothoraces, but will add little except confusion, in some cases as we aren’t sure that small abnormalities of these actually need active treatment.
- The Log Roll, spinal palpation and rectal examination:
- Is almost useless
- Causes spinal movement
- Has a low negative predictive value for ruling out fractures and a low sensitivity for picking them all up.
- The rectal examination is poor in detecting anything useful.
- Branney SW. metal. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma 1995;39(2)375-380
- Abrahams BJ et al. Ultrasound for the detection of intraperitoneal fluid: The role of Trandelenburg positioning. Am J EM 1999;17(2):117-120
- McGahan JP et al. Use of ultrasonography in the patient with acute abdominal trauma. J ultrasound Med 1997;16(10):653-662.
- Carter JW et al. Do we really rely on FAST for decision making in the management of blunt abdominal trauma? Injury 2015;46(5):817-821
- Kirkpatrick AW et al. Hand-held thoracic sonography for detecting post traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma(EFAST). J Trauma 2004;57(2):288-295.
- Singh ™ et al. What is the purpose of the log roll examination in the unconscious adult trauma patient during trauma reception. Emerg Med J 2016;33:632-635.
- Gill DS et al. Can initial clinical assessment exclude thoracolumbar vertebral injury? Emerg Med J 2013; 30:679-682
- Suter RE et al. Thoracolumbar spinal instability during variation of the log roll manoeuvre. Prehospital and Disaster Medicine 1992;7(2);133-138.
- McGuire RA et a. Spinal instability and the log rolling manoeuvre. J of Trauma 1987;27(5):525-531.
- Esposito T et al. Reasons to omit digital rectal exam in trauma patients: No fingers, no rectum, no useful additional information. J Trauma int Inf Crit Care 2005;59(6):1314-1315.
- Shlamovits GZ et al. Poor test characteristics for digital rectal examination in trauma patients. An of EM 2007;50(1):25-33.