ATLS 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.
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.
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.
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“.
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.