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Fri Sep 3 21:02:10 BST 2004

 Thanks for adding to to the discussion. 

2 points...

1. just b/c it has been drilled into our heads doesnt necessasarily make it
the right thing to do...again what is the evidence to suggest that this
improves care or adds value. I am not suggesting that we shouldnt do the
exam just not in all trauma patients...

2. routinely rectal exams are being deffered for blunt trauma. routinely
people in minor mvcs or assaults do not get this assesment... question is is
there a way to safely deffer this assesment... we routinely deffer ct of the
head (based on sound evidence)if there is no loc. we can safely clear
c-spines w/o imaging (based on sound evidence). why cant we spare a patient
this relative indignanty...

believe me if I am in a tauma and I know what is going on (i.e. i realize my
injuries arent severe) aint no one doing that to me. I will simply say that
if you do that I will charge you with assault...

scott...

-----Original Message-----
From: trauma-list-bounces at trauma.org
To: 
Sent: 9/3/2004 2:59 AM
Subject: RE: The Trauma Rectal exam...

This article concluded (my underline):  Adult patients with blunt trauma
and a normal neurologic examination, with no blood at the urethral
meatus, and who are less than 65 years old have an exceedingly low
likelihood of a true-positive abnormal DRE. If validated, patients who
meet these three criteria may have the DRE safely deferred.
Pardon me, but in all my years I have had it drilled into me by my
medical peers that a full 'gold standard' neuro exam will always include
full assessment of sacral nerves which is incomplete without DRE to
assess bulbocavernosus reflex, ano-rectal sensation, anal sphincter tone
and competence. What the author is suggesting is an 'abbreviated' exam
but at what level do you stop. Sacral nerves travel the entire length of
the spinal cord and sacral impairment can indicate trauma / compression
at any point, not just T12 and below. Lumbar/Sacral cord injuries remain
second only to cervical injuries. Absent/reduced anal tone remains a
valid indicator of potential SCI in the trauma patient and whilst its
appropriateness of DRE in the field is limited to the circumstances of
the scenario it should never be omitted from a standard
in-hospital/centre examination, even if the vast majority prove
negative. 
Paul Harrison
Clinical Development Officer
Princess Royal Spinal Injuries Unit
Sheffield

> -----Original Message-----
> From:	Gordon S. Doig [SMTP:gdoig at med.usyd.edu.au]
> Sent:	01 September 2004 23:47
> To:	Trauma & Critical Care mailing list
> Subject:	Re: The Trauma Rectal exam...
> 
> 
> Although PubMed does an excellent job at mapping common English to
MeSH 
> headings, it is still very sensitive to the initial search terms used.
> 
> When I repeat your search using the terms 'rectal exam' and 'trauma' I

> find only 3 references.
> 
> If I expand this search to 'rectal examination' and 'trauma' I find
197 
> references.
> 
> If I make my search more specific and use the terms 'digital rectal 
> examination' and 'trauma' I find 30 more useful refs.
> 
> One of which addresses your question:
> 
> Deferral of the rectal examination in blunt trauma patients: a
clinical 
> decision rule. Acad Emerg Med. 2004 Jun;11(6):635-41.
> 
>
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dop
t=Abstract&list_uids=15175201
> 
> Don't forget to appraise its utility using the appropriate EBM Users'g

> guide:
> 
> http://www.cche.net/usersguides/diagnosis.asp
> 
> Cheers
> 
> Gord
> ps - there are some very good tutorial papers on PubMed searching.
Just 
> type 'pubmed tutorial' in the search box and pic one that looks 
> interesting...
> 
> 
> Sherry, Scott :LPH Trauma wrote:
> 
> >I did a literature search on the subject of the trauma rectal exam
and found
> >little to validate this topic. Though this procedure or assessment is
a
> >mantra in the Trauma world..(Pub Med) search phrase "rectal exam and
trauma"
> >and MD Consult (same search) led me to this only article...
> >
> >I cannot see much of a reason to do this on every patient that rolls
into
> >the Trauma unit...especially if conscious and verbal and
appropriate...and
> >in light of inadvertently finding a foreign body on my last one I am
more
> >hesitant to indiscriminately do this...
> >
> >What is the literature say about deferring this on specific types of
> >patients. What are the feeling of those on the list... What is the
evidence
> >that this is important? Cant we do this more focused???
> >
> >This is the only article I have found on the subject...
> >
> >Digital rectal examination for trauma: does every patient need one?
> >Porter JM - Am Surg - 01-MAY-2001; 67(5): 438-41
> >>From NIH/NLM MEDLINE 
> >
> >NLM Citation ID:
> >11379644 (PubMed)
> >
> >Full Source Title:
> >American Surgeon
> >
> >Publication Type:
> >Journal Article
> >
> >Language:
> >English
> >
> >Author Affiliation:
> >Alameda County Medical Center, Oakland, California, USA.> 
> >
> >Authors:
> >Porter JM; Ursic CM
> >
> >Abstract:
> >The digital rectal examination is widely accepted as an essential
component
> >in the initial assessment of trauma. However, no data have been
published
> >that justify its routine use in all seriously injured patients. The
> >objective of this study was to determine what if any impact on
subsequent
> >treatment and management decisions the initial digital rectal
examination
> >had on injured patients arriving at our emergency department (ED). We
> >conducted a prospective observational study of all injured patients
arriving
> >at a Level II trauma center over a period of 6 months. A digital
rectal
> >examination was performed on all patients during the secondary survey
phase
> >of their initial evaluation shortly after arrival to the ED. The
results of
> >the rectal examination were noted for each patient with particular
attention
> >placed on the presence or absence of gross blood, Hemoccult result,
> >prostatic examination, rectal vault integrity, and rectal sphincter
tone. In
> >addition the patient's hemodynamic parameters while in the ED and the
> >injuries that were sustained were noted, as was their final
disposition.
> >Four hundred twenty-three patients were admitted to the ED after
sustaining
> >serious injuries. The mean Injury Severity Score was 9.96. The
prostatic
> >examination was normal in more than 99 per cent of patients; no
high-riding
> >or nonpalpable prostate glands were noted. Twenty-two patients (5.2%)
were
> >Hemoccult positive, but in none of these cases did the presence of
occult
> >blood in the stool lead to a change in the initial management or
diagnostic
> >approach. Three patients (0.7%) with penetrating injuries to the
> >perineal/pelvic area had gross blood on digital rectal examination
that
> >prompted operative exploration to rule out a lower gastrointestinal
injury.
> >All three had rectal injuries confirmed at surgery. Rectal sphincter
tone
> >was normal in 406 (96%) patients, weak in 17 (4%), and absent in
none. The
> >only patient in whom the sphincter tone influenced management was an
> >individual complaining of complete paralysis after a blunt mechanism
of
> >injury. He had normal rectal sphincter tone and admitted to
malingering
> >shortly thereafter. Overall the rectal examination influenced
therapeutic
> >decision making in five cases (1.2%). The digital rectal examination
is
> >unlikely to affect initial management when applied indiscriminately
to all
> >seriously injured patients during the secondary survey. Patients in
whom the
> >rectal examination may have a higher probability of influencing
management
> >are those with penetrating injuries in proximity to the lower
> >gastrointestinal tract, questionable spinal cord damage, and severe
pelvic
> >fractures with potential urethral disruption or open fractures in
continuity
> >with the rectal vault. The Hemoccult test does not add useful
information
> >and should be discontinued as part of the secondary survey of injured
> >patients.
> >
> >Can't say in the couple hundred I have done (except maybe this one)
that the
> >findings changed or altered our course. Though the FB was evident on
the
> >transfer XR and the CT...
> >
> >I am interested in your comments as I am hoping to discuss this in an
> >upcoming conference...
> >
> >Thanks...
> >
> >Scott... 
> >
> >
> >
> >
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