All posts by The Trauma Pro

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The Lucas CPR Device And Pregnancy

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A reader posed an interesting question last week: can you use the Lucas chest compression device in a pregnant patient?

The official company answer is “no.” Obviously, this is one those areas that is tough to get research approval on, and the number of pregnant patients who might need it is very small. So basically, we have little experience to go on.

That being said, the reality is that prehospital agencies can and do use it for these patients on occasion. There is only one published case report that I could find (see reference below). The thing that makes using this device a little more challenging is that, to optimize blood pressure, late term pregnant patients need to have the uterus rolled off of the vena cava. This means tipping the patient to her left. 

As you can see from the picture above, the design of the Lucas makes this a bit difficult. However, it can be done, either by tipping the board the patient is on or wedging something under the right side of the back plate.

And as always, make sure that you adhere to your local policies and procedures, or have permission from your medical director to use this device in this particular situation.

Reference: Cardiac arrest and resuscitation with an automatic mechanical chest compression device (LUCAS) due to anaphylaxis of a woman receiving caesarean section because of pre-eclampsia. Resuscitation 68(1):155-159, 2005.

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Autotransfusing Blood Lost Through The Chest Tube

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Autotransfusing blood that has been shed from the chest tube is an easy way to resuscitate trauma patients with significant hemorrhage from the chest. Plus, it’s usually not contaminated from bowel injury and it doesn’t need any fancy equipment to prepare it for infusion.

It looks like fresh whole blood in the collection system. But is it? A prospective study of 22 patients was carried out to answer this question. A blood sample from the collection system of trauma patients with more than 50 cc of blood loss in 4 hours was analyzed for hematology, electrolyte and coagulation profiles.

Here are the factoids:

  • The hemoglobin and hematocrit from the chest tube were lower than venous blood (Hgb by about 2 grams, Hct by 7.5%)
  • Platelet count was very low in chest tube blood
  • Potassium was higher (4.9 mmol/L), but not dangerously so
  • INR, PTT, TT, Factor V and fibrinogen were unmeasurable

Bottom line: Although shed blood from the chest looks like whole blood, it’s missing key coagulation factors and will not clot. Reinfusing it will boost oxygen carrying capacity, but it won’t help with clotting. You may use it as part of your massive transfusion protocol, but don’t forget to give plasma and platelets according to protocol. This also explains why you don’t need to add an anticoagulant to the autotransfusion unit prior to collecting or giving the shed blood!

Related post: Chest tubes and autotransfusion

Reference: Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood? Am J Surg 202(6):817-822, 2011.

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How To See The Unseeable: The Answer

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Yesterday I posed a scenario where the surgeon needed to see an area of an open abdomen (trauma laparotomy) that could not easily be visualized. Specifically, there was a question as to whether the diaphragm had been violated just anterior to the liver, just under the costal margin.

Short of putting your head in the wound, how can you visualize this area? Or some other hard to reach spot? Well, you could have an assistant insert a retractor and pull like crazy. However, the rib cage might not bend very well, and in elderly patients it may break. Not a good idea.

Some readers suggested breaking out the laparoscopy equipment and using the camera and optics to visualize. This is a reasonable idea, but expensive. Shouldn’t there be some good (and cheap) way to do this?

Of course, and there is. Think low tech. Very low tech. You just need to see around a corner, right. So get a mirror!

Every OR has some sterile dental mirrors lying around. Get one and have your assistant gently hold the liver down while you indirectly examine the diaphragm. Since you’re probably not a dentist, it may take a minute or two to get used to manipulating the mirror to see just what you want. But if you can manage laparoscopic surgery, you’ll get the hang of it quickly.

And if you need more light up in those nooks and crannies? Shine the OR light directly into the abdomen, then place a nice shiny malleable retractor into the area to reflect light into the area in questions. Voila!

Bottom line: A lot of the things that trauma professionals need to do in the heat of the moment will not be found in doctor, nurse, or paramedic books. Be creative. Look at the stuff around you and available to you. Figure out a way to make it work, and make $#!+ up if necessary.

General

The  May Trauma MedEd Newsletter Is Available!

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This month’s newsletter addresses the electronic trauma flow sheet, and more generally, the electronic health record (EHR) in trauma. Here are the topics covered:

  • History Of The Electronic Health Record (EHR)
  • EHRs By The Numbers
  • The EHR And Productivity In The ED
  • Trauma Patient Stay In The ED After EHR
  • The EHR Trauma Flow Sheet
  • What’s The Real Bottom Line?

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