LOG ROLL AND A FINGER UP YOUR BUM – THEN YOU’RE DONE

DREATLS mythbusting time – again. ATLS provides a great structure for talking and working trauma, but many of their procedures have been rethought the last couple of years as our understanding of trauma improves. Now it’s time for rethinking the log roll and digital rectal exam.

The afterthought
It’s a well known scenario: The blunt trauma patient is decided to have a mechanism of trauma that warrants a trauma CT. The primary survey is nearly done. Everyone is ready to move – but, oh no!, we nearly forgot the two final steps of ATLS: the log roll and the digital rectal exam! The momentum stops, everyone repositions to log roll the patient so the surgeon can feel the spine and then embarrass the patient with a finger up where the sun don’t shine. How often has this changed management in your experience? We thought so.

Log roll
For blunt trauma, there isn’t really any good evidence or theory behind the log roll. For penetrating or suspected penetrating trauma, a log roll is necessary for excluding wounds on the back of the patient.

The log roll is also supposed to find spine fractures, but evidence shows that finding them is slightly more reliable than tossing a coin. So, as CT is widespread, and probably next on the list, you might as well wait for the scan.

Another good reason to wait for the scan is that the log roll seems to be the least stable way of moving a patient – both for the spine and for pelvic injuries. The spine will probably be fine, but you don’t want that pelvic injury to bust open again. Whereas lifting the patient straight up to remove clothes underneath or to move them over to where you want them, holds the spine and pelvis in place.

Log-rolling a blunt major trauma patient is inappropriate in the primary survey, Letter to EMJ, 2013.

Transferring patients with thoracolumbar spinal instability: are there alternatives to the log roll maneuver? Spine, 2008

Digital rectal exam
The digital rectal examination (DRE) is useless as a general screening tool in trauma, and only seems to be there for getting back at patients for waking you at 3:30 in the morning. Still, most surgeons are really anal about the digital rectal exam.

The studies done agree that although DRE can have a high specificity if you find something, its sensitivity is very, very low. DRE can be indicated in penetrating trauma to the lower GI area, suspected pelvic fractures, urethral disruption or spinal chord injury – although other clinical indicators will be just as sensitive.

And in the latest version of ATLS, DRE is not mandatory anymore. So, engage brain and include the stats below in your decision making. As expected, the numbers in these studies are small, but here are the results from the pediatric DRE article linked below:

“Two hundred thirteen patients met our selection criteria and were included in the analysis. We identified 3 patients with spinal cord injury (1% prevalence), 13 patients with bowel injury (6%), 5 patients with rectal injury (2%), 12 patients with a pelvic fracture (6%), and 1 patient with urethral disruption (0.5%). The DRE failed to diagnose (false-negative rate) 66% of spinal cord injuries, 100% of bowel injuries, 100% of rectal wall injuries, 100% of pelvic fractures, and 100% of urethral disruption injuries“.

Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information, J Trauma, 2005.

Lack of evidence to support routine digital rectal examination in pediatric trauma patients, Pediatr Emerg Care, 2007.

Dogmalysis?
It’s time to question the blanket use of these two tests. One can be dangerous for the unstable pelvis, the other one an unnecessary embarrassment.

Keep the tests in mind, and use them if you find them clinically indicated and you think a positive or negative finding will change your management of the patient – but don’t do them just to show your superiors that you remember your ATLS and checked all the boxes.

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9 Responses to LOG ROLL AND A FINGER UP YOUR BUM – THEN YOU’RE DONE

  1. nfkb says:

    sometimes french should copy a little bit more anglo-saxon procedures and check lists, sometimes i’m happy that we do not apply blindly a whole package of rules like atls, i’ve never seen a dre in those times of fast echo and easy CT

    • Thomas D says:

      It’s good to hear everything isn’t ATLS-world!

      Come to Norway, and you’ll see a DRE by the surgeon pretty much every trauma call. It makes me cringe sometimes.

      • Well…..have you asked / told the surgeon to stop doing it?

        No means no.

        • Thomas D says:

          Tim, haha, do you mean to me or to the patients?!

          Anyway, come to Norway to see the surgeon being the trauma team leader. With DRE, they refer to ATLS and the hospital’s protocols, and proceed. No need to engage brain. I’ll keep up the fight for the trauma room to be an a$$hole free zone.

        • Rahul says:

          Its the same in Asia. Surgeons not as susceptible to lytics just yet. But we’ll keep on trying…

  2. DocXology says:

    In medicine there is neither never or always.

    http://www.ncbi.nlm.nih.gov/pubmed/15707808

    http://www.scireproject.com/book/export/html/1045

    A few issues to consider pre-test probability, presence of distracting injury, whether you wish to rule- in or rule-out injury, establishing presence of sacral sparing in SCI.

    • Thomas D says:

      Agreed. Those are all things to consider before pretty much any tests.

      Although presence of sacral sparing is only useful if you first find neurological deficits elsewhere. If no neurological deficit – no need to check for sacral sparing.

      Thanks for the links. The article you link to is interesting, but shows nothing more than fractures being common in trauma patients, and therefore also a common co-finding in trauma patients with spine injuries. It also shows the fact that fractures, independent of location, share the same trauma mechanism. Trauma lesson: The more fractures you find, the more likely you are to find another.

      But it’s nice to see that lacerations and soft tissue contusions (which both had a pretty high incidence here) had no association with masked vertebral injury and (as expected) might not be distracting to an axial fracture.

      Lastly, it’s interesting to see the clinical significance of the possible missed vertebral injuries/fractures in this article: Of 336 patients screened for masked spine injury, 8 had findings. NONE of them required any real intervention.

  3. Per says:

    Not to be an ass, but I find no meaning in this sentence:

    “DRE can have a high specificity if you find something”

    • Thomas D says:

      You’re not. Not at all. What I’m trying to say is that the DRE is often found to have a high specificity for the symptoms you find correlating to actual injury. If you feel no sphincter contraction, there’s a high probability of an actual spinal injury. If you feel steps/bone fragments, there’s a likely a fracture, etc. So the DRE have lots of false negatives, but not so many false positives. But I agree the sentence you refer to might not be the best way of explaining that…

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