All posts by TheTraumaPro

Followup Cystogram After Bladder Injury

I’ve previously written about management of extraperitoneal bladder injuries. One of the tenets is that every injury needs to have a routine followup cystogram to ensure healing and allow removal of any bladder catheter. I routinely like to question dogma, so I asked myself, is this really necessary? A retrospective registry review from the Ryder trauma center in Miami helped to answer this question.

Over 20,000 records were screened for bladder injury and 87 were found in living patients. Fifty were intraperitoneal injuries, and half of them were caused by pelvic fractures (interesting). All were operated on, and 47 were classified as simple (dome disruption or through and through penetrating) and 3 were “complex” (involving trigone). All trackable patients (42 of the 50) had followup cystograms 9-16 days later. All of the simple injuries had a normal followup exam, but a leak was detected on one of the complex injuries.

There were 42 patients with extraperitoneal bladder injuries. All were due to blunt trauma, and 92% were associated with pelvic fractures. Most were found with CT cystogram. Two patients had operative repair, probably due to the need to fix the pubic bones with hardware. 37 of the 42 were available for followup, and 22% of repeat cystograms were positive (average study done on day 9). In the studies that showed a leak, repeat cystograms were done, and they took an average of 47 days to fully heal.

Bottom line: Patients with extraperitoneal or complex intraperitoneal bladder injuries (trigone) really do need a followup cystogram before removing the bladder catheter. Those who underwent a simple repair of their intraperitoneal injury do not.

Related posts:

Reference: Cystogram follow-up in the management of traumatic bladder disruption. J Trauma 60(1):23-28, 2006.

Enoxaparin And Pregnancy

Lovenox

Pregnant women get seriously injured, too. And pregnancy is an independent risk factor for deep venous thrombosis. We reflexively start at-risk patients on prophylactic agents for DVT, the most common being enoxaparin. But is it safe to give enoxaparin during pregnancy?

Studies have looked at drug levels in cord blood when the mother is receiving enoxaparin, and none has been found. No specific bleeding complications have been identified, either. So from the baby’s standpoint, administration is probably safe.

However, there are two other issues to consider. In a study looking at the use of enoxaparin for prophylaxis in women with a mechanical heart valve, 2 of 8 women (and their babies) died. Both suffered from clots that developed and blocked the valves. Most likely, the standard dose of enoxaparin was insufficient, so monitoring of anti-Factor Xa levels must be done.

The other problem lies in the multi-dose vial of Lovenox (Sanofi-Aventis). Each 100mg vial contains 45mg of benzyl alcohol, which has been associated with a fatal “gasping syndrome” in premature infants. The individual dose syringes do not have this preservative.

Bottom line: It is probably safe to give enoxaparin to pregnant women after trauma. However, it is unclear if the dose needs to be increased to achieve adequate prophylaxis. Only consider using this medication after consultation with the patient’s obstetrician, and use only the individual dose syringes. Otherwise fall back to standard subcutaneous non-fractionated heparin (even though it is a Category C drug by FDA; it is still considered the anticoagulant of choice during pregnancy).

How To Keep Up With Your Literature

This short, 12 minute video shows you how to stay current with the literature in your field of expertise. It works for everyone in any discipline, and demonstrates a 5 step system that uses current technology to minimize time and maximize your learning.

My video is accompanied by a reference guide with details on the technique, as well as recommended hardware and software. Click here to download the pdf file.

This video is a sample of the type of content that will be presented at the Trauma Education: The Next Generation (TETNG) conference on September 5 in St. Paul, MN. All content presented at the conference will also have a downloadable reference guide. To view my post on that conference, click here.

For more information on TETNG, including live streaming and registration, click here.

Trauma Education: The Next Generation

I’d like to share some exciting news about a trauma conference unlike any other! This is a total remodel of a conference we’ve put on annually in the Twin Cities for over a decade (Emergency Medicine and Trauma Update). We’re bringing it, kicking and screaming, into the digital age.

No more stodgy presenters reading from bullet-heavy PowerPoint slides! Away with the sore backside from sitting through an hour-long talk where the presenter goes over their time limit another 15 minutes!

The conference is now fast paced and to the point, with topics of interest to all trauma professionals (doctors, nurses, EMS, and anyone else who loves trauma). It consists of concise, 20 minute presentations interspersed with 5 minute videos of things you need to know. There are curbside consults, where we ask specialists the things you always wanted to. We’ll be taking questions for presenters from the audience and from Twitter using #TETNG13.

Here is a sample of some of the presentations:

  • Scott Weingart (EMCrit) joins us live from his studio in NYC, talking about finger thoracostomy
  • Michael McGonigal discusses why so much of what we think we know is wrong!
  • Felix Ankel talks about the future of trauma education
  • Field amputation, dislocated hip reduction, IO lines and more!

For those of you in the upper Midwest of the US, please join us live in St. Paul for this 4 hour program. It is located at the Minnesota History Center in a beautiful 300 seat auditorium. There is a fee to attend the live program to cover CME/CEU, food and parking. 

For those who cannot attend the live event, it will be streamed live on the internet beginning at 8am CST. Obviously, this is free but no CME/CEU’s will be offered. Park in your garage and get food from your own kitchen. 

And for anyone who just can’t tear themselves away from work on the morning of September 5, all content will be available for free on YouTube shortly after the conference.

For more information, and to register for the live event, go to TETNG.org 

Tomorrow, I’ll post instructions for testing your live streaming reception and a video of sample content. I’ll also provide instructions on how to receive the live stream closer to the meeting date.

Please feel free to email or comment with questions and suggestions!