April 2012
20 posts
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Could Be A Urethral Injury, But The Catheter's...
You’re seeing a trauma patient, probably a transfer from somewhere else. Either they told you there “may have been” some blood at the tip of the urethra, or maybe you see it smearing the outside of a urinary catheter that’s already in place! How do you proceed from here?
First, try not to get into that situation. Make sure that everyone on your team knows that gross blood...
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“The better is the enemy of the good”
– From the poem “The Prude Woman” by Voltaire, 1772.
This adage is particularly important in medicine. Every test and treatment we order has an upside (hopefully) that will reveal something or make our patient better. Unfortunately, we tend to ignore the inescapable downsides, which...
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When Can Your Trauma Patient Stop Taking Warfarin?
I admit it. I read trauma and surgery literature, not medical literature. Imagine my surprise when a fellow physician (internist) told me that there is an objective system for helping us figure out whether anticoagulation is needed for atrial fibrillation. “CHADS2” he said. Am I the last trauma surgeon on earth to hear about this?
CHADS2 is a validated scoring system for predicting...
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Spinal Cord Concussion In Student Athletes
Spinal cord injuries are typically devastating injuries with profound consequences for function and life expectancy. However, a small percentage result in rapidly reversible symptoms. Because these temporary injuries are rare, they tend to cause confusion among clinicians.
Technically, a spinal cord concussion (a “zinger” or “stinger” is an example) is a mild cord injury...
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When To Give Mannitol
Patients with severe head injury need all the help they can get. Mannitol is one tool that is time-tested and cheap. But how do you decide who gets it and when?
Mannitol is a powerful osmotic diuretic that pulls extracellular water from everywhere, including the brain. By reducing the size of the brain overall, it drops pressure inside the skull (ICP) somewhat.
Mannitol can be used anytime...
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Trauma Patient Transport By Police, Not EMS
When I was at Penn 25 years ago, I was fascinated to see that police officers were allowed to transport penetrating trauma patients to the hospital. They had no medical training and no specific equipment. They basically tossed the patient into the back seat, drove as fast as possible to a trauma center, and dropped them off. Then they (hopefully) hosed down the inside of the squad car.
Granted,...
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Trauma Survival and Air vs Ground Transport
Wartime experience has shown that rapid transport from the battlefield scene of injury to definitive care dramatically improves survival. This has been translated into civilian trauma care by making helicopter transport to a trauma center more widely available. But this resource is still somewhat limited, and very expensive compared to ground EMS transport. Is this expense warranted, or in other...
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What The Heck? Hints
Lots of guesses so far, but nobody has the right answer yet. Here are some hints:
Mechanism was car crash
No lower extremity fractures
The patient is supine, not prone
Answer tomorrow!
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Delayed Splenic Rupture: Part 1
This post was prompted by a paper that somehow got into the Journal of Trauma this month on nonoperative management of delayed splenic rupture after trauma. It’s a bad retrospective review of 15 patients which I’ll say more about tomorrow. There’s very little good literature on this topic, so I wanted to share some personal observations.
Back in the days before CT scan (and...
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Best Of: 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...
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Best Of: The Downside Of Not Taking Your...
We’ve all been faced with injured patients who are taking some kind of anticoagulant, and it complicates their care. Many trauma professionals just say, “they just shouldn’t take this stuff any more.” Why can’t we just stop them in patients at risk for injury (e.g. an elderly patient who falls frequently)?
Two major risk groups come to mind: those taking the meds who...
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