Do we really need to do a rectal exam on EVERY trauma patient?

All trauma patients that present to the trauma unit get the old “county handshake”, the digital rectal exam as part the secondary survey, regardless of what their mechanism is.  But is it really necessary in all cases? Does it really provide useful information? Is it worth the torment, especially in those already difficult patients that are agitated or intoxicated that may become more belligerent and worsen the situation?  Popular belief is that rectal exam provides useful information on G.I./bowel injury, urethral injury and neuro status.  Currently there is no published studies that support this recommendation

A retrospective study done from 2003 to 2005 of over 1400 trauma patients that presented to a level one trauma center after blunt or penetrating trauma who had a digital rectal exam as part of their secondary survey showed that overall rectal exam had a sensitivity of 23% and a specificity of 95% for detecting injury.  Overall the false-negative rates for DREs were significantly high for detecting pelvic fractures, urethral injuries, bowel injuries and spinal cord injuries.

In another study done in 2001 over a six month period showed that the rectal exam effected management in only 1-2% of cases. There seemed to be some evidence that the DRE can be useful in certain types of trauma such as penetrating abdominal trauma( looking for gross blood on rectal),  pelvic fractures(looking for bone shards in the rectum),  and spinal cord injuries(looking for sacral sparing).  Moreover, it has been showed that standard diagnostic radiographic modalities and physical exam are just as or even more influential as the DRE in guiding management in trauma patients.

To date there isn’t enough evidence-based literature to support the standard use of digital rectal exam on all trauma patients. At the same time there isn’t enough evidence to change traditional teaching and practice when it comes to DREs either. We work in a protocol-driven environment but sometimes you have to use clinical judgment. So the next time you get that heavily intoxicated, agitated BHT with LOC s/p fall from standing think twice before further traumatizing your trauma patient.

 

References:

Shlamovitz GZ et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med 2007 Jul; 50:25-333.

Guldner G, Babbitt J, Boulton M, O’Callaghan T, Feleke R, Hargrove J. Deferral of the

Rectal Examination in Blunt Trauma Patients: A Clinical Decision Rule. Academic
Emergency Medicine. 2004,11(6):635-641.

This post submitted by Dr. Zahid Khalid

 

Editor's Note-
Current CCH teaching is that every trauma patient should get a "trauma handshake" aka DRE.  It is a low risk study that, despite its high false negative rate, gives good information when positive.  One brief exam can give information about spinal cord injury (rectal tone), urethral injury (prostate position) and lower GI injury (gross blood) - all without radiation.  Certainly it should continue to be performed in any patient with risk of those injuries.