Trauma Drama: Nana Nana Na Its The Motherf***ing D.R.E.

As per Dr. DRE it’s the next episode:

It continues in the trauma bay. A trauma code is called and the room is suddenly full. The initial survey is done. It turns out that the patient is not as bad as the notification phone had said. He has been hit by a car at low speed. He is A&O x3, moving all four extremities and airway and breathing intact. He is able to tell you the entire story and vital signs are unremarkable. He has no injury other then his left arm in a sling placed by EMS, which shows possible forearm boney injury.

He admits to be shaken by the event but glad the worst is behind him. Little does he know!

He proceeds to have two 16 gauge IVs placed, stripped down completely naked, and then he is rolled to the side and gets a finger in his bottom.

So the question I have:
Is the digital rectal exam of any value as a screening tool in a trauma code?

The trauma team will tell you that it is absolutely necessary, but when asked why they say its because their attending won’t let them present without it. They also go on to say that another service having done it doesn’t matter and it must be repeated by them.

So with all this talk about not giving patient fluids who do not need it and not pan scanning people who do not need it, I think trying to avoid a personal, invasive procedure that causes the patient distress should also be considered.

The purpose of the digital rectal exam is to look for blood, rectal tone, high riding prostate, and boney fragments from a pelvis fracture.

ATLS guidelines since its start in 1976 recommended every trauma patient receive a DRE. It wasn’t until the 2008 publication of the 8^th edition of ATLS where the DRE was changed from mandatory to selective. But has it trickled down to trauma patient practices?

The timeline for research going against universal DREs in trauma starts in 2001.

Porter and Ursic in Alameda County Medical Center in Oakland took a look at all patients presenting to their level II trauma center over 6 months. There were 423 patients that were studied and out of these patient 5 (1.2%) had medical decisions made or changed according to the DRE. 3 of these patients were patient with lower abdominal penetrating trauma and gross blood was found on DRE and surgical exploration was done to look for GI injury. In the end it was said that the DRE was not necessary if the following criteria are met:

1. no penetrating injury in proximity to the lower GI tract

2. no questionable spinal cord damage

3. no severe pelvic fractures with potential urethral disruption

4. no open fractures in continuity with the rectal vault.

In 2005 three papers came out with research showing the futility of the digital rectal examination.

Guldner & Brzenski at the emergency department at the Loma Linda University Medical Center and Children’s Hospital looked at the benefit of DRE in identifying patients with spinal cord injury. They looked at every trauma code that came in for 2001. In the study they looked retrospectively at every case and recorded the result of the DRE; normal for good tone and abnormal for weak tone. Then the chart was searched for ICD-9 codes for spinal cord injury. The study 1168 patients and 136 were excluded if the DRE was refused, deferred or if the patient died before it was done. Of the 1032 identified in the study 933 had normal tone on DRE; of those, 27 had a spinal cord injury. 99 patients had documentation of decreased rectal tone and of those another 27 had a spinal cord injury. The data breaks down to a 50% sensitivity and 93% specificity. While this was a retrospective study it does show that the DRE does not add much to the clinical picture of the trauma patient. They did say that they had a high volume of spinal cord injuries in their center and their incidence was 5% and it could have skewed the data due to its high volume, and that centers with low incidence of spinal cord injury would not benefit from DRE during trauma.

Shlamovitz et al. looked retrospectively at patients that presented requiring trauma team activation. These patients were studied over 2 years. 1041 patients charts were identified, 91% due to blunt trauma and the DRE result were searched for. Of these patients, 47(3%) had spinal cord injuries, 35(2%) had bowel injury, 7(0.5%) had rectal injury, and 5(0.4%) had urethral disruption. Their results showed a sensitivity of 23% and specificity of 95%. For their study the DRE missed 63% of spinal injuries, 94% of bowel injuries, 67% of rectal wall injuries, 100% of pelvic fractures and 80% of urethral disruption injuries. There are problems with this study, one being retrospective, another major one is that there was a lot of missing data on the DRE and would put unknown on the parts of the procedure the physician did not document. But the results are impressive in showing the futility of the DRE in trauma patients as a screening tool.

Esposito et al. took a different approach and compared DRE to other clinical indicators (OCIs). All patients requiring trauma team activation over a year were looked at in a prospective study. In these patients a trauma resident performed the DRE and the results were written down in a study data sheet. This sheet contained all possible results for positive DRE. It also contained related clinical findings. The person completing the data sheet also completed the related clinical findings section. These included but no limited to: blood at he meatus, unstable pelvis, positive FAST, Hgb <13, pelvic fracture, perineal hematoma, scrotal hematoma, penetrating abdominal wound below the umbilicus, penetrating flank wound, neurological deficit. The clinical findings were compared to the DRE and the efficacy was found to be equivalent. The negative predictive values for the DRE were 97-100% and the OCI 99-100%. Other studies show that the DRE is not reliable but this study helps show that the DRE is not needed and there are other options.

Ball in 2009 looked at patients who presented with trauma and found to have blunt urethral disruption. In the 13 year study 41 patients were identified. 22% mortality in the group and 98% had concurrent injury. 95% had a concurrent pelvic fracture. 61% had no signs on injury on secondary survey, 2% having a high riding prostate, 20% with blood at the meatus and 17% had intial hematuria. 1 patient in 13 years showed signs of high riding prostate. The incidence is so low and shown not to be reliable as a sign of urethral disruption.

The DRE is supposed to be a screening test done during the secondary survey to help better guide the clinicians on the appropriate management of the patient. These studies show that the DRE has poor sensitivity and has no business as a screening test for the trauma patient. It should be considered for penetrating trauma to the lower abdomen or people with high suspicion for spinal cord injury but is often unreliable. It is shown above that there are clinical indicators that can be used and are as reliable as the DRE.

What do other people think? Should we stop doing DREs on trauma patients? Should we try to prevent them being done in patients that do not require it? Let me know what you think.

References:
Ball et al. Traumatic urethral injuries: Does the digital rectal exam really help us?; Injury: International Journal of the Care of the Injured, 2009

Porter, Ursic. Digital rectal examination for trauma: does every patient need one?; American Journal of Surgery, 2001

Guldner, Brzenski. The sensitivity and specificity of the digital rectal examination for detecting spinal cord injury in adult patients with blunt trauma; American Journal of Emergency Medicine, 2006

Shlamovitz et al. Poor test characteristics for the digital rectal examination in trauma patients; Annals of Emergency Medicine, 2007

Esposito et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information; The Journal of Trauma Injury, Infection, and Critical Care, 2005

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