May 2013
19 posts
2 tags
Treating Numbers: Pulse Oximetry
How many times has this happened to you? You walk into a young, healthy trauma patient’s room and discover that they have nasal prongs and oxygen in place. Or better yet, these items appear overnight on a patient who never needed them previously. And the reason? The pulse oximeter reading had been low at some point.
This phenomenon of treating numbers without forethought has become one of...
5 tags
PAs and NPs In Level I Trauma Centers
Trauma service staffing is important to maintaining trauma center status. Teaching centers in the US have been grappling with resident work hour rules, and non-teaching centers have always had to deal with how to adequately staff their trauma service. What is the impact of staffing a trauma center with midlevel practitioners (MLPs) such as physician assistants and nurse practitioners?
A state...
2 tags
Prehospital Attitudes About Analgesia
Pain relief is important for two reasons: it’s the humane thing to do for someone who is suffering, and just as importantly, it assists in the physiologic response to trauma. There are several papers that have shown that prehospital providers may not use pain medications as much as they should. Why would this be?
Researchers at Yale released a paper describing a number of interviews with...
4 tags
The EMS Second IV In Trauma
One of the critical maneuvers that EMS providers perform is establishing initial vascular access. This IV is important for administering medications and for initiating volume resuscitation in trauma patients. Prehospital Trauma Life Support guidelines state that every trauma patient should receive two large bore IV lines. But is this really necessary?
The upside of having two IVs in the field is...
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Wounds: When Are They Too Old To Close?
At some point in their training, every trauma professional is taught that there is a certain period time during which a wound can be safely closed. The exact number varies, but is usually somewhere between 6 and 24 hours. After that, we are told, “bad things happen.”
Always question dogma, I say. Is this true, or is it another one of those “facts” that have been propagated...
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Best Of: IV Contrast
We use CT scanning in trauma care so much that we tend to take it (and its safety) for granted. I’ve written quite a bit about thoughtful use of radiographic studies to achieve a reasonable patient exposure to xrays. But another thing to think about is the use of IV contrast.
IV contrast is a hyperosmolar solution that contains some substance (usually an iodine compound) that is radiopaque...
3 tags
Trauma Mythbusters: Bathing/Showering And Wound...
I love to hate dogma. And there’s probably nothing in surgery more sacred and more ingrained than how to take care of a wound. Everybody knows that you have to keep surgical or traumatic wounds dry, and that once you can get them wet, showers are good at baths are bad. Right?
And for something as common as wound management, there must be some kind of research, right? Not so! I did quite a...
2 tags
Don't Ignore The Naughty Bits
A major part of any patient encounter is the physical exam. This is particularly true in the trauma patient, because it allows trauma professionals to identify potential life and limb threatening injuries quickly and deal with them. Unfortunately, we tend to mentally block out certain parts of the body, typically the genitalia and perineum, and may not do a complete exam of the area. I call these...
1 tag
Pop Quiz! Final Answer
Our patient with the steak knife to the head has been evaluated by CT. The scan shows that the blade enters the right orbit, passing through the medial orbital wall into the ethmoid sinus, turbinates and nasal septum. It then passes into the left orbit along the posterior floor and exits the apex. The optic nerves are not involved, but there may be involvement of the rectus or oblique muscles to...
Pop Quiz: The Case, Part 3
So our patient has presented to your ED, on foot, with a steak knife sticking out of his head! You’ve activated your trauma team, so now what do you do?
As always, start with a thorough physical exam. A good exam of the head is imperative, as is a scrupulous neurologic exam. In this case, the blade enters just below the right eye, traveling front to back and staying just about level.
Make...
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Pop Quiz! The Case, Part 2
Yesterday I presented the case of a young man who shows up at the triage desk in your ED with “something wrong with his head.” I showed an AP skull film, which shows some kind of metallic foreign object. What is it? Where is it? What to do?
First, look at the image carefully. The object is metallic density and appears very thin. But remember, any diagnostic image you view is a 2D...
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Pop Quiz! The Case
A young man presents to your emergency department walk-in area. Something is wrong with his head. Here is an AP skull film (when is the last time you got one of those?)
I’ll walk you through my thought processes over the next several days. First, what’s going on? And what should you do now? And next, and so on.
Please tweet and leave comments! My explanation of the initial steps...
2 tags
How To: Secure An Endotracheal Tube To... Nothing!
Several decades ago I took care of a patient who posed an interesting challenge. He had been involved in an industrial explosion and had sustained severe trauma to his face. Although he was able to speak and breathe, he had a moderate amount of bleeding and was having some trouble keeping his airway clear.
Everyone frets about getting an airway in patients who have severe facial trauma. However,...
2 tags
The Newest Trauma MedEd Newsletter Is Available!
The April newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is Protocols (again). You’ll need a QR code reader if you want to download to your mobile device. Or just use the web URLs provided to download to your desktop/notebook.
In this issue you’ll find articles on:
Chest tube management
Solid organ injury
Rapid...
1 tag
Trauma Pearl: Unexpected Respiratory Failure After...
A 24 year old restrained female is involved in a T-bone type motor vehicle crash. She sustains a moderate to severe traumatic brain injury and is intubated and sedated. On exam, she has a few abrasions over her left flank, and no other physical findings. Head CT shows some subarachnoid blood, and abdominal CT is negative.
She is placed in the ICU and slowly becomes more responsive. However, her...
1 tag
Next Trauma MedEd Newsletter Available Tomorrow!
The April issue of Trauma MedEd was sent out to subscribers over the weekend. This issue, like the March issue, is devoted to protocols.
Included are protocols for:
Chest tube management
Solid organ injury
Rapid reversal of warfarin
Reversal of other anticoagulants
Massive transfusion
Be sure to have a good QR code reader for easy retrieval. Otherwise, warm up your fingers so you can enter...
2 tags
How Does That Work?: Angioembolization Coils
Ever wonder how interventional radiologists stop bleeding? They are very skilled in getting access to complicated areas of the arterial tree. Once they have located a bleeding point, they’ve got to plug it up with something.
Over the years, a wide variety of things have been used. They include blood clot, tiny metal or plastic spheres, superglue, and a variety of other creative things. One...
1 tag
Why Do They Call It: Extra-axial Blood?
You’ve seen it on head CT reports. “The patient has a collection of extra-axial blood…” Then it goes on to describe the location and size of a subdural hematoma. But why is it called “extra-axial?”
The answer lies in the embryology of the central nervous system. Yes, it’s been a long time since any of us have read anything about that. Early animals had a...
3 tags
Lab Values From Intraosseous Blood
The intraosseous access device (IO) has been a lifesaver by providing vascular access in patients who are difficult IV sticks. In some cases, it is even difficult to draw blood in these patients by a direct venipuncture. So is it okay to send IO blood to the lab for analysis during a trauma resuscitation?
A study using 10 volunteers was published last year (imagine volunteering to have an IO...
April 2013
21 posts
4 tags
Can Lead Poisoning Occur After A Gunshot?
This is a fairly common question from victims of gunshots and their families. As you know, bullets are routinely left in place unless they are superficial. It may cause more damage to try to extract one, especially if it has come to rest in a deep location. But is there danger in leaving the bullet alone?
One of the classic papers on this topic was published in 1982 by Erwin Thal at Parkland...
2 tags
Pneumothorax: How Big Is Too Big?
One of the big unanswered questions in the management of pneumothorax is, how big is too big? At what size is a chest tube of some type mandatory?
The problem is that we just don’t have any good data. Seems like a simple problem, right? Unfortunately, it’s not. A pneumothorax is a three dimensional collection that surrounds the lung in very random ways. All we had to detect and...
1 tag
Ethics Quiz: The Answer?
The hypothetical question I posed yesterday centered around what to do in a case where a patient is assaulted, sustaining easily survivable injuries, but then dies while being treated in the hospital due to a medical error. The police will escalate the criminal charge from simple assault to manslaughter, but the death was no longer really a direct result of the assault. Yet the assailant and...
1 tag
Ethics Quiz!
What would you do in this case? And better yet, what should you do? And why might the two answers be different?
First, an important note. This is a hypothetical case. It has never happened in any hospital I’ve worked in, and I have not heard of it happening in one. I have completely fabricated it to make a point.
An elderly man is walking to the store in his neighborhood, and he is...
4 tags
Management of CSF Otorrhea/Rhinorrhea
The management of CSF leaks after trauma remains somewhat controversial. The literature is sparse, and generally consists of observational studies. However, some general guidelines are supported by large numbers of retrospectively reviewed patients.
Ensure that the patient actually has a CSF leak. In most patients, this is obvious because they have clear fluid leaking from ear or nose that was...
2 tags
In my last post, I discussed the Passy-Muir valve, which allows patients who have a tracheostomy tube in place, and are not on a ventilator, to talk. But what about patients who are still vent dependent? It’s very frustrating for both patient and trauma professionals when we can’t communicate with each other.
Pulmodyne, Inc. makes the Blom tracheostomy tube system, which solves this...
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What Is: A Passy-Muir Valve?
Some critically injured patients undergo tracheostomy due to prolonged ventilatory failure. As they recover, the trach tube is usually downsized over time until it can be permanently removed. Unfortunately, this process may take a month or more, and the patient is generally unable to speak during this time. Writing and other forms of communication are both slow and frustrating, so a Passy-Muir...
3 tags
Flying After Pneumothorax
Patients who have sustained a traumatic pneumothorax occasionally ask how soon they can fly in an airplane after they are discharged. What’s the right answer?
The basic problem has to do with Boyle’s Law (remember that from high school?). The volume of a gas varies inversely with the barometric pressure. So the lower the pressure, the larger a volume of gas becomes. Most of us hang...
1 tag
Why People Don't Change Their Minds Despite The...
Has this happened to you?
Your (emergency physician / neurosurgeon / orthopaedic surgeon) colleague wants to (get rib detail xrays / administer steroids / wait a few days before doing a femur ORIF). You question it based on your interpretation of the literature. You even provide a stack of papers to them to prove your point. Do they buy it? Even in the presence of randomized, double-blinded,...
2 tags
The Pan-Scan For Trauma
Diagnostic imaging is a mainstay in diagnosing injuries in major trauma patients. But the big questions are, how much is enough and how much is too much? X-radiation is invisible but not inocuous. Trauma professionals tend to pay little attention to radiation that they can’t see in order to diagnose things they can’t otherwise see. And which may not even be there.
There are two major...
1 tag
If A Tree Falls In A Forest...
Time for a little philosophy today. There seem to be two camps in the world of initial diagnostic testing for trauma: selective scanning vs scan everything. I admit that I am one of the former. Yes, the more tests you do, the more things you will find. Some will be red herrings. Some may be true positives, but are they important? Here’s the key question:
“If a tree falls in a forest...
2 tags
Do You Really Need To Repeat That Xray?
It happens all the time. You get that initial chest and/or pelvic xray in the resuscitation room while evaluating a blunt trauma patient. A few minutes later the tech returns with another armful of xray plates to repeat them. Why? The patient was not centered properly and part of the image is clipped.
Do you really need to go through the process of setting up again, moving the xray unit in,...
Pop Quiz Answer - Jet Ski Injury
This pop quiz involved a young woman who fell from a jet ski at high speed and was initially okay. Later that day, she developed lower abdominal pain and sought evaluation in your ED. There were a number of thoughtful answers via the comments section and Twitter.
According to the First Law of Trauma, the pain is related to the mishap until proven otherwise. You must approach it like any moderate...
Pop Quiz - Jet Ski
The answers to this pop quiz will appear tomorrow, thanks to my earlier tirade against distracted flying.
Michael
4 tags
Medical Helicopter Crash - The Ultimate Distracted...
Yesterday, the NTSB released findings from an investigation of a medical flight that crashed in Mosby, Missouri in 2011. I’ve written about distracted driving before, but this is the worst example I’ve seen.
Apparently, the pilot was having a text conversation during the preflight check and missed the fact that the ship was low on fuel. Once enroute, he finally noticed the situation,...
1 tag
Pop Quiz: Jet Ski Injury
This post is for my readers located near large bodies of water!
Personal watercraft use exploded a decade ago, and they are still heavily used for recreation and vacation fun. However, speed and people don’t always mix well. Here’s an interesting case to ponder.
An 18 year old woman was the rear passenger on a jet ski traveling at a high rate of speed (of course). She fell off and...
1 tag
The First Law Of Trauma
Time for some more philosophy! After doing anything for an extended period, one begins to see the common threads and underlying principles of their area of expertise. I’ve been trying to crystallize these for years, and today I’m going to share one of the most basic laws of trauma care.
The First Law of Trauma: Any anomaly in your trauma patient is due to trauma, no matter how...
1 tag
The Newest TraumaMedEd Newsletter Is Available!
The March newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is Protocols. You’ll need a QR code reader if you want to download to your mobile device. Or just use the web URLs provided to download to your desktop/notebook.
In this issue you’ll find articles on:
Why are protocols important?
ED extubation protocol
CIWA...
3 tags
Blunt Vertebral Artery Injury
Following up on yesterday’s post, I’ll deal with vertebral artery injuries today. These injuries are uncommon, making them hard to study and develop management recommendations. The literature suggests that about 1% of blunt trauma patients may sustain one of these. Most commonly, the method is motor vehicle crash, and just about any mechanism (hyperflexion, hyperextension, distraction...
4 tags
Outcome After Blunt Cerebrovascular Injury (BCVI)
Blunt injuries to the carotid and vertebral arteries are not as uncommon as we used to think. Unfortunately, there’s a lot of controversy surrounding everything about them: screening, management, and outcome. A paper just out detailed outcomes in a (relatively) large series of these patients.
As expected with this rare injury, it’s a retrospective study. A busy Level I center...
1 tag
April Fool's Day?
Here’s one of my favorite Easter / April Fool’s Day images.
Which one is the Trauma Medical Director and which is the Trauma Program Manager?
March 2013
21 posts
3 tags
Complications of Splenic Embolization for Trauma
Angioembolization has become a common procedure that can increase the likelihood of success for nonoperative management for splenic trauma. It does have its own set of complications to be aware of, however.
The most obvious complication is mechanical injury to the femoral artery. This occurs in 1 to 3% of patients. It is more common in the very young (small caliber artery) and the elderly...
3 tags
The 30:60 Rule For Interventional Radiology
Interventional radiology (IR) can be a very helpful adjunct to the evaluation and management of trauma patients. I’m going to talk specifically about using it for blunt trauma today because the use in penetrating trauma can be a little more nuanced.
For blunt trauma, IR is used primarily to stop bleeding. In a smaller subset of patients, this tool is used to evaluate pulse deficits. There...
Next TraumaMedEd Newsletter Available Soon!
The March issue of TraumaMedEd is ready to go! This issue is devoted to protocols.
Included are protocols for:
Anticoagulation reversal
TBI screening
Chest tube management
Solid organ injury management
And more!
Be sure to have a good QR code reader for easy retrieval. Otherwise, warm up your fingers so you can enter URLs to download the protocols.
Subscribers will get the issue delivered...
Ever Wonder Where The Golden Hour Came From?
Everywhere you turn in the trauma and EMS world, you run into the concept of the “golden hour.” Basically, it refers to the idea that it’s important to get an injured patient to definitive care promptly, or mortality begins to rise. It has been used to justify a lot of what we do in trauma care and trauma systems. But where did this come from? And is it true?
The BTLS course...
Obit: Eric R. (Rick) Frykberg
Sadly, Rick Frykberg passed away yesterday morning at the age of 63. He was the Chief of the Division of General Surgery at the University of Florida and Shands Hospital in Jacksonville, Florida. Rick was a Professor of Surgery and was a great educator and clinician. He did his internship at NYU Medical Center in New York, and completed his residency at the Medical University of South Carolina....
Trauma Coverage By Locum Tenens Surgeons
Trauma call coverage is not always easy to come by, especially at lower level trauma centers and in rural areas. Many centers come to rely on locum tenens surgeons to fill gaps in their call schedules. Unfortunately, this can create some headaches.
There is currently no trauma literature on this topic. Other disciplines, most recently pediatric surgery, have some published suggestions (I hesitate...
3 tags
Repeat Imaging: What Good Is It?
I’ve written previously about how often imaging gets repeated once a trauma patient gets transferred to a trauma center (click here). There are many reasons, including clinical indications, need for advanced imaging (reconstructions), or lack of contrast. But at least 20% have to be repeated because the media is incompatible or not sent with the patient. Sounds like a problem, but is it a...
Clearing The Cervical Spine - Part 2
Yesterday, I wrote about our algorithm for clearing the cervical spine in an adult with normal mental status. Today, I’ll go over our protocol for obtunded patients. You can download it using the link below.
Here are the key points:
MRI is the cornerstone of definitive evaluation of the ligaments once a normal CT spine study has been obtained
There is no time limit for getting the MRI
...
Clearing The Cervical Spine - Part 1
My center is in the process of updating our cervical spine clearance protocols, and I wanted to share this work with you to help those who may be doing the same. Today, I’ll review our new clearance method for patients with normal mental status. Tomorrow I’ll go over the protocol for patients who are obtunded.
Here are the key points:
Clinical clearance is acceptable except in...
OTA Open Fracture Classification System
Yesterday, I wrote about the classic Gustilo and Anderson open fracture classification system. Today, I’ll explain the newer classification system proposed by the Orthopaedic Trauma Association (OTA).
The OTA developed this system using both good and not so good methodology: literature review and panel consensus. It offered an opportunity to refine definitions to try to make the system as...
