Physical exam is not an accurate predictor of injury in geriatric patients with low-energy blunt trauma - A retrospective cohort study

Background

When evaluating trauma patients, many centers perform computed tomography of the head, cervical spine, chest, abdomen, and pelvis, the so-called “pan-scan.” Here, we evaluate the utility of physical exam against pan-scan in geriatric patients who sustained ground-level falls.

Methods

We performed a single-centered retrospective cohort review of consecutive patients from the trauma registry of a large, urban Level 1 trauma center. Inclusion criteria were registration during the 2019 calendar year, age ≥65, mechanism of fall from either sitting or standing, and performance of “pan-scan” at time of assessment. The sensitivity, specificity, positive and negative predictive values of the physical exam for significant injuries were calculated. The effect of such injuries on disposition from the emergency department and hospital were determined.

Results

An initial query for patients age ≥65 yielded 1280 patients. After exclusion of patients who did not undergo pan-scan or who had GCS <14, 751 patients were included in analysis. Median age was 84 years old. 351 patients had at least one injury identified on pan-scan. Physical exam was determined to have a sensitivity of 0.69 when compared to pan-scan as a gold standard. Patients with injury identified on CT scan had significantly more admissions, mortalities, and ICU and OR requirements.

Conclusion

Approximately half of all patients were found to have at least one injury on pan-scan. Physical examination was insensitive at identifying such injuries which ultimately altered patient management, disposition, and outcomes. Pan-scan is recommended in this vulnerable population.

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A selective approach to CT scan may not be appropriate for elderly patients with low-energy blunt falls.

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Approximately half of all elderly patients who fall from sitting or standing have at least one traumatic injury.

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Traumatic injuries alter the hospital course and disposition of elderly fall patients.

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Physical exam is neither sensitive nor specific enough to detect these injuries.

Transverse versus longitudinal blunt extension of the uterine incision during cesarean section in women with a uterine scar of previous cesarean delivery: A randomized controlled trial

OBJECTIVE

To compare two different blunt extension techniques of the lower segment transverse uterine incision at cesarean delivery in women with a uterine scar of previous cesarean delivery.

METHODS

Study design: Prospective single-blinded parallel multi-center randomized controlled trial involving 392 cases equally divided into two groups. Group one had their incision extended transversely, while group two had their incision extended longitudinally.

OUTCOME MEASURES

The primary outcome was the unintended extension of the uterine incision, while the secondary outcomes included the need for additional stitches to achieve hemostasis, the drop in hemoglobin level, uterine vessels injury, and the need for blood transfusion.

RESULTS

No significant difference between the transverse and longitudinal extension of the uterine incision during cesarean section as regards unintended uterine extension (P=0.860), uterine vessel injury (P=0.501), and cases requiring blood transfusion (P=0.814). Significantly lower drop in hemoglobin level (P≤0.001) and significantly less need for additional stitches (P≤0.001) in cases with the longitudinal extension of uterine incision.

CONCLUSION

In women with a uterine scar of previous cesarean delivery, the blunt longitudinal extension of the uterine incision in the lower segment cesarean section didn't differ from the blunt transverse extension as regards unintended uterine extension but is associated with less hemoglobin drop and less need for additional stitches as compared to transverse extension of the incision. Further studies are needed to assess the long-term complications of both techniques.