Log-rolling a blunt major trauma patient is ... - Koh Tao EMS

Downloaded from emj.bmj.com on October 20, 2013 - Published by group.bmj.comLog-rolling a blunt major trauma patient isinappropriate in the primary surveyCaroline Leech, Keith Porter and Clare BosankoEmerg Med J published online October 17, 2013doi: 10.1136/emermed-2013-203283Updated information and services can be found at:http://emj.bmj.com/content/early/2013/10/17/emermed-2013-203283.full.htmlReferencesP

Downloaded from emj.bmj.com on October 20, 2013 - Published by group.bmj.comEMJ Online First, published on October 17, 2013 as 10.1136/emermed-2013-203283PostScriptLETTERLog-rolling a blunt majortrauma patient isinappropriate in the primarysurveyThe article by Gill et al 1 provides furtherevidence that a log-roll is not useful formajor trauma patients in the primarysurvey. Even with a GCS 15 and no influencefrom alcohol or opiates only 60% ofpatients with thoracolumbar fractures hadtenderness on log-roll. The authors didnot examine how many false negativeswere found by examination or the impactof a distracting injury.Log-rolling a polytrauma patient in theprimary survey is potentially lifethreateningif the patient has a site ofinternal haemorrhage as this movementmay lead to clot disruption and irretrievableexsanguination. The log-roll causespain in the presence of injury and provokesanxiety, which may worsen thepatient’s physiological state. For blunttrauma, there is no evidence that injuriesmissed by inspection of the back will leadto the patient’s demise (although all penetratingtrauma will require examination ofthe back for occult wounds). Studies havealso shown that the log-roll may inducespinal movement, which may be damagingin the presence of fractures. 23As clinicians at the three adult majortrauma centres in the West Midlands weadvocate no log-roll during the primarysurvey for a blunt trauma patient with amechanism of injury triggering a localmajor trauma triage tool. The patientshould instead be transferred supine usinga suitable device, such as an orthopaedicscoop stretcher onto a vacuum mattress orWolverson transfer mattress. While clinicalexamination in the primary survey isimportant, an immediate CT (from headto pelvis under the supervision of thetrauma team) can rapidly and reliablyexclude life-threatening injuries withoutexamination of the back.When a senior decision has been madethat the patient does not require a CTscan (or a CT scan has been reported asshowing no internal haemorrhage, visceralinjury or pelvic fracture) it is then appropriateto log-roll the patient to assess theback for further injury.Caroline Leech, 1 Keith Porter, 2 Clare Bosanko 31 Emergency Department, University Hospitals Coventry& Warwickshire NHS Trust, Coventry, UK2 Department of Trauma, Queen Elizabeth HospitalBirmingham, Birmingham, UK3 Emergency Department, University Hospital NorthStaffordshire, Stoke, UKCorrespondence to Dr Caroline Leech, UniversityHospitals Coventry & Warwickshire NHS Trust,Emergency Department, Clifford Bridge Road, Coventry,CV2 2DX, UK; caroline.leech@uhcw.nhs.ukCompeting interests None.Provenance and peer review Not commissioned;internally peer reviewed.To cite Leech C, Porter K, Bosanko C. Emerg Med JPublished Online First: [please include Day Month Year]doi:10.1136/emermed-2013-203283Accepted 1 October 2013Emerg Med J 2013;0:1.doi:10.1136/emermed-2013-203283REFERENCES1 Gill DS, et al. Can initial clinical assessment excludethoracolumbar vertebral injury? Emerg Med J2013;30:679–82.2 Suter RE, Tighe TV, Sartori J, et al. Thoraco-lumbarinstability during variations of the log roll maneuver.Prehospital Disaster Med 1992;7:133–8.3 MacGuire RA, Neville S, Green BA, et al. Spinalinstability and the log-rolling maneuver. J Trauma1987;27:525–31.Copyright Article author (or their employer) 2013. Produced by BMJ Publishing Group Ltd under licence.Emerg Med J Month 2013 Vol 0 No 0 1