All posts by TheTraumaPro

What The Heck? Bicycle Trauma Answer

So a young male jammed a handlebar into his abdomen, and a CT image demonstrating his problem was shown. But what did it actually show?

By now, you probably realize that clinical information is key. On exam, he had an obvious bulge in his left lower quadrant, more obvious with straining. Looking at the CT (now with a nice arrow), there is a problem over the left side of the abdomen. 

image

This child has so little fat, that it’s difficult to see the problem. If you track the thin layer of fat across the abdomen to the right side of the image, you’ll see that it disappears over the bowel gas. This represents a complete tear through all fascial layers, not just a Spigelian hernia as some readers guessed.

Management consisted of primary repair of the defect. An uneventful recovery can be expected. Unless more bicycle tricks are anticipated.

Reference: Traumatic handlebar hernia: a rare abdominal wall hernia. J Ped Surg 39(10):e20-e22, 2004.

What The Heck? Bicycle Trauma Part 2

Yesterday’s puzzle involved a young male who drove a handlebar into his abdomen. Little additional information was given, other than one slice of his abdominal CT scan. So what’s the problem?

The textbooks always associate handlebars with pancreatic and duodenal injuries, and these should always be looked for. However, the scan slice in this case was taken lower, within the pelvis. Too low to show you either of those organs.

As I’ve said before, be systematic when reading xray images. We automatically focus on the viscera and bones. Look at those areas, make sure you can identify each structure that you see, and look for any anomalies. 

But don’t forget the soft tissue! In this case, the child doesn’t have much. Take a closer look at the same slice and see if you can figure it out by tomorrow.

ICP Monitoring: Less Is More?

Management of severe traumatic brain injury (TBI) routinely involves monitoring and control of cerebral perfusion pressure. Monitoring is typically accomplished with an invasive monitor, with the extraventricular drain (EVD) and fiberoptic intraparenchymal monitors (IP) being the most common.

The extraventricular drain is preferred in many centers because it not only monitors pressures, but it can also be used to drain cerebrospinal fluid (CSF) to actively try to decrease intracranial pressure (ICP). But could less really be more? Surgeons at Massachusetts General reviewed 229 patients with one of these monitors, looking at outcomes and complications. They found the following interesting results:

  • There was no difference in mortality between the two monitor types
  • The EVD patients did not require surgical decompression as often, possibly because of the ability to decrease ICP through drainage
  • The EVD patients were monitored longer, and had a longer ICU length of stay. This was also associated with a longer hospital length of stay.
  • Complications were much more common in the extraventricular drain group (31%). The most common complications were no drainage / thrombosis (15%) and malposition (10%). Hemorrhage only occurred in 1.6% of patients. 
  • Fiberoptic monitors had a lower complication rate (8%). The most common was malfunction leading to loss of monitoring (12%). Hemorrhage only occurred in 0.6% of patients.

Bottom line: Don’t change your monitoring technique yet. Much more work needs to be done to flesh out this small retrospective study. But it should prompt us to take a critical look for better indications and contraindications for each type of monitor.

Reference: Intraparenchymal versus extracranial ventricular drain intracranial pressure monitors in traumatic brain injury: less is more?J Am Coll Surg 214(6):950-957, 2012.

Family Presence During Trauma Resuscitation

There’s a lot of talk in trauma nursing circles about family presence during trauma resuscitation (FPDR). But after searching far and wide, I have not been able to find much literature about it. There are a few papers about family reaction to it, and a few more about healthcare providers’ reactions. But the science is not yet very good.

Typical arguments against it from (mainly) doctors and some nurses, and my rebuttals, are as follows:

  • Family members will think the trauma resuscitation is chaoticthen fix your trauma team; you’ve got a problem
  • They will slow the team down – an analysis has shown no such effect
  • Family will be traumatized by seeing what we do – family members have seen simulations on TV, so they have a pretty good idea of what’s going on
  • The doctors and hospital are more likely to be sued – actually, this is probably less likely, because the family has actually seen that you’ve done everything possible for their loved one

Personally, I’m very much for it, especially in the pediatric age group. I encourage all trauma programs to develop a policy to enable FPDR. Here are some key pointers:

  • Only allow one key family member in the resuscitation room. Have them decide who it will be. This limits confusion and congestion.
  • Assign a “medical interpreter” to stand with them in the room, preferably a nurse. The role of this person is twofold: to explain what is being done and why, and to make sure that they remain safe. If they have a hard time coping, appear to be getting faint, or misbehave in any way, it’s time for them to leave.
  • Involve the family member as much as practical. Have them stand near the patient’s head so they can communicate with them, or at least see them.
  • Keep the trauma team organized and professional. It’s been my experience that having family in the room puts everybody on their best behavior.

Bottom line: Surveys have shown that family members tend to be more satisfied with care and more convinced that everything possible was done if they are able to witness what may be the final moments of their loved one’s life. A little planning goes a long way in allowing FPDR in your emergency department.

References:

  • Health care providers’ attitudes regarding family presence during resuscitation of adults: an integrated review of the literature. Clin Nurse Spec 24(3):161-174, 2010.
  • Attitudes of healthcare staff and patients’ family members towards family presence during resuscitation in adult critical care units. J Clin Nurs. 21(13-14):2083-2093, 2012.
  • Family presence during pediatric trauma team activation: an assessment of a structured program. Pediatrics 120(3):e565-574, 2007.