The Newest Trauma MedEd Newsletter Is Here!

The October newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is Resuscitation. 

In this issue you’ll find articles on:

  • Jehovah’s Witnesses and blood transfusion
  • Blood transfusion component therapy
  • What’s the INR of FFP?
  • Evolution of the use of Factor VII
  • And more!

Subscribers received the newsletter first by email last week. If you want to subscribe (and download back issues), click here.

Download the newsletter here!

Stuff You Sterilize Other Stuff With May Not Be Sterile??

When one works in the trauma field, or medicine in general, we deal with the need for sterility all the time. We use equipment and devices that are sterile, and we administer drugs and fluids that are sterile. In surgery, we create sterile fields in which to use this sterile stuff.

In the past few years, we’ve come to the realization that the sterility we take for granted may not always be the case. There have been several cases of contaminated implanted hardware. And most recently, supposedly sterile injectable steroids were found to be contaminated with fungus, leading to several fatal cases of meningitis.

A recent article in the New England Journal of Medicine brings a bizarre problem to light: microbial stowaways in the topical products we use to sterilize things. Most drugs and infused fluids are prepared under sterile conditions. However, due to the antimicrobial activity of topical antiseptics, there is no requirement in the US that they be prepared in this way.

A number of cases of contamination have been reported over the years:

  • Iodophor – contamination with Buckholderia and Pseudomonas occurred during manufacture, leading to dialysis catheter infection and peritonitis
  • Chlorhexidine – contaminated with Serratia, Buckholderia and Ralstonia by end users, leading to wound infections, catheter infections, and death
  • Benzalkonium chloride – contaminated with Buckholderia and Mycobacteria by end users, causing septic arthritis and injection site infections

Bottom line: Nothing is sacred! This problem is scarier than you think, because our most basic assumptions about these products makes it nearly impossible for us to consider them when tracking down infection sources. Furthermore, they are so uncommon that they frequently may go undetected. The one telltale sign is the presence of infection from weird bacteria. If you encounter these bugs, consider this uncommon cause. Regulatory agencies need to get on this and mandate better manufacturing practices for topical antiseptics.

Related posts:

Reference: Microbial stowaways in topical antiseptic products. NEJM 367:2170-2173, Dec 6 2012.

Submental Intubation – The Video!

Yesterday, I described a technique for providing a secure yet short-term airway tailored to patients who can’t have a tube in their mouth or nose. Patients undergoing multiple facial fracture repair are probably the best candidates for this procedure.

A picture may be worth a thousand words, but a video is even better. Please note that it is explicit and shows the blow by blow surgical procedure. Of note, it is a quick and relatively simple advanced airway technique.

Related post:

WTF? Submental Intubation?

Here’s one of the weirder procedures I’ve seen in some time. Imagine that you need a definitive airway, but you can’t use the face for some reason (mouth or nose). The usual choice would be a tracheostomy, right? But what if you only need it for a few days? Typically, once placed, trachs must be kept for several weeks before decannulation is safe.

Enter submental intubation. This technique involves passing an endotracheal tube through the anterior floor of the mouth, and then down the airway. This leaves the facial bones, mandible, and skull base untouched.

The technique is straightforward. After initially intubating the patient  orotracheally, a 1.5cm incision is created just off the midline in the submental area. Using a hemostat, all layers are penetrated, entering the oropharynx just lateral to the tongue. A 1.5cm incision is then made parallel to the gum line of the lower teeth. The connector at the proximal end of the endotracheal tube is removed, and a hemostat is placed through the chin incision again. The proximal end of the ET tube is grasped from within the pharynx and pulled out through the skin, leaving the distal (balloon) end in the trachea. The connector is reinserted, and the tube is then hooked up to the anesthesia circuit again. The tube is secured using a stitch under the chin. After a final position check, the surgical procedure can commence.

There are a number of variations on this technique, so you may encounter slightly different descriptions. The tube can be pulled at the end of the procedure, or left for a few days to ensure safe extubation, if needed.

A small series of 10 patients undergoing this technique was reviewed, and there were no short or long term problems. Scarring under the chin was acceptable, and was probably less noticeable than a trach scar.

Bottom line: This is a unique and creative method for intubating patients with very short-term airway needs while their facial fractures are being fixed. Brilliant idea!

Reference: Submental intubation in patients with panfacial fractures: a prospective study. Indian J Anaesth 55(3):299-304, 2011.

Photo source: internet

New Trauma MedEd Newsletter Released Monday To Subscribers!

The October issue of Trauma MedEd is ready! Subscribers will receive it Monday afternoon. This issue is devoted to resuscitation

Included are articles on:

  • Blood transfusion with component therapy
  • Best INR you can achieve with FFP
  • Predicting the need for massive transfusion
  • Transfusion and Jehovah’s witnesses
  • And more!

As mentioned above, subscribers will get the issue delivered Monday to their preferred email address. It will be available to everybody else at the end of next week on the blog.

Check out back issues, and subscribe now! Get it first by clicking here!