All posts by TheTraumaPro

Is Too Much Crystalloid a Bad Thing?

All trauma centers have massive transfusion protocols, and they typically spell out the approximate ratios of blood to plasma to platelets. But they do not address the use (or overuse) of crystalloid during these large volume resuscitations.

A multicenter, prospective study was carried out looking at the outcomes after resuscitation from hemorrhagic shock using massive transfusion (at least 10u PRBC in 24 hrs). The patients were severely injured (average ISS 34), and overall mortality and incidence of multi-organ failure was 21% and 65%, respectively. The median amount of crystalloid given was 17 liters, and median red cell transfusion was 14 units in 24 hours.

The authors found that if the crystalloid to PRBC ratio exceeded 1.5:1, morbidity increased significantly. The incidence of multiple organ failure doubled, ARDS tripled, and abdominal compartment quintupled! The authors suggested further research, and did not provide specific strategies for decreasing early crystalloid.

Bottom line: As expected, giving so much crystalloid that we turn people into the Sta-Puft Marshmallow Man is not good. While waiting for additional research, it is probably prudent to try to rapidly achieve definitive control of bleeding and apply gentle use of pressors to decrease the total crystalloid given during resuscitation.

Reference: The crystalloid / packed red blood cell ratio following massive transfusion: when less is more. Presented at the 24th Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 2011.

Rapid Noninvasive Rewarming Using a Hubbard Tank

Hypothermic patients need to be rewarmed using the most appropriate method. Patients with mild hypothermia (32-35 degrees centigrade) generally only require removal of wet clothing and surface warming. Moderate hypothermia (28-32 degrees C) to severe hypothermia (<28 degrees C) is very serious and requires more aggressive central rewarming techniques.

Basic central rewarming techniques, such as warm inspired gases, warm IV fluids, and gastric or peritoneal lavage can raise the temperature about 3 degrees per hour. 

Rapid central rewarming techniques, like thoracic lavage (6 degrees/hr), AV bypass devices (1-4 degrees/hr), and cardiopulmonary bypass (18 degrees/hr) are typically used on patients with severe hypothermia.

A technique that we use at Regions Hospital involves the use of the Burn Center’s Hubbard Tank. Patients are carefully immersed, torso first, then one extremity at a time to avoid rebound hypothermia. It is possible to increase core temperature using this method faster than bypass (>20 degrees centigrade/hr)! Typical time in the tank is an hour or less for any degree of hypothermia.

Patients can be immersed with EKG monitors and IV lines in place. Temperature monitoring should be performed using a thermistor tipped urinary catheter. Many hospitals don’t have a full Hubbard tank, but do have smaller therapy baths that work nearly as well.

Tips:

  1. A physician must stay with the patient while immersed in case arrhythmias develop.
  2. Position the urinary catheter and collecting bag in such a way that urine in the tubing does not backwash into the bladder. This will falsely and rapidly increase the temperature reading. 

Q & A

I always welcome any questions, comments or requests you may have! However, if you comment anonymously, I have no way or responding to you directly. Every once in a while, I’ll take a moment to answer any comments / questions I’ve received.

Regarding this post on performing retrograde urethrogram from 7 months ago, shadowboxer said:

“tried this. total flail. the ky makes the catheter tip syringe slide out of the foley. The contrast becomes too dilute. The material is too thick and when enough pressure to push it through the foley is placed, the foley, since it is now so slippery with the ky, flies out and gooey contrast sprayed all over the flouro tower. what a mess!!”

Bottom line: I reread my post, and I must have had a senior moment. I do not recommend using the foley catheter! The slip tip syringe goes straight into the meatus, and you then clamp the tip of the penis firmly with your fingers. Here’s how it should read, with the corrected section in bold:

The technique is simple. The following items are needed:

  • A urine specimen cup
  • A tube of KY jelly (not the little unit dose packs)
  • A bottle of renografin or ultravist contrast
  • A 50-60 cc Toomey syringe (slip-tip)
  • A fluoroscopy suite

Pour 25cc of contrast and 25cc of KY jelly in the specimen cup, cap it and shake well. Draw the contrast jelly up into the syringe. Place the tip of the syringe directly into the urethral meatus, make a circle with your thumb and index finger, and use that to clamp the end of the penis around the slip-tip. Pull the penis toward yourself to keep your hand away from the center of the xray field. Slowly inject all the contrast, watching the contrast column on the fluoro screen. Once there is easy flow into the bladder, you can stop the study. If you see extravasation into the soft tissues, stop the study and call Urology.

The key to this technique is the 50:50 KY/contrast mix, which is thin enough to flow but thick enough to keep from spraying all over. Also, the finger clamp technique is important, because the contrast will ooze out if you don’t do it tightly. However, if you’ve pulled the penis over to the side, any leakage will not contaminate the xray field.

I’ve personally used this technique about 50 times and have never had a problem.

Sorry, shadowboxer, hope you’ll try again with my revised / corrected technique. If you do, please let me know.

Cervical Spinal Cord Injury: Who Needs A Tracheostomy?

The sad truth is that patients with cervical spine injury may need a tracheostomy. In very high lesions (C1-2) the need may be permanent. Lower injuries (C3-5) frequently need a trach for a limited period of time while they develop enough reserve to compensate for the lost of chest wall muscle power.

It’s not always easy to tell which patient is likely to need intubation upon arrival in the ED. I’ve seen occasional patients fail while getting their CT scans, which is poor planning. Is there a way to predict who might fail, thus benefiting from early intubation and an early plan for tracheostomy?

The trauma group at LAC + USC Medical Center undertook a National Trauma Databank review to try to answer this question. They identified 5256 patients with cervical spinal cord injuries without a severe traumatic brain injury that would otherwise require intubation. About 21% received tracheostomies, and the common predictors were:

  • Intubation at the scene by EMS (they’ve done the job of deciding for us!)
  • Intubation in the ED
  • Complete cord injury at any level
  • Facial fractures
  • Chest trauma
  • Injury Severity Score >=16

Patients who received a tracheostomy generally spent more days on the vent, in the ICU and in the hospital than those who did not. However, their mortality was lower.

It’s generally recognized that patients with complete injuries from C1-C5 routinely require tracheostomy. The surprising thing about this study was that complete injuries at C6 or C7 did as well.

Bottom line: If you have a patient with a spinal cord injury who meets any of the criteria above, stand ready to intubate. I tell my trainees that, if at any time they see something that makes them think about intubating, they should have already done it. Likewise, the surgical ICU team should have a low threshold to performing an early tracheostomy on these patients.

Reference: Incidence of clinical predictors for tracheostomy after cervical spinal cord injury: a National Trauma Databank review. J Trauma 70(1): 111-115, 2011.

Picture: crossbow bolt through the mouth and cervical spinal cord.

Dysphagia and Cervical Spine Injury

Cervical spine injury presents a host of problems, but one of the least appreciated ones is dysphagia. Many clinicians don’t even think of it, but it is a relatively common problem, especially in the elderly. Swallowing difficulties may arise for several reasons:

  • Prevertebral soft tissue swelling may occur with high cervical spine injuries, leading to changes in the architecture of the posterior pharynx
  • Rigid cervical collars, such as the Miami J and Aspen, and halo vests all force the neck into a neutral position. Elderly patients may have a natural kyphosis, and this change in positioning may interfere with swallowing. Try extending your neck by about 30 degrees and see how much more difficult it is to swallow.
  • Patients with cervical fractures more commonly need a tracheostomy for ventilatory support and/or have a head injury, and these are well known culprits in dysphagia

A study in the Jan 2011 Journal of Trauma outlines the dysphagia problem seen with placement of a halo vest. They studied a series of 79 of their patients who were treated with a halo. A full 66% had problems with their swallowing evaluation. This problem was associated with a significantly longer ICU stay and a somewhat longer overall hospital stay.

Bottom line: Suspect dysphagia in all patients with cervical fractures, especially the elderly. Carry out a formal swallowing evaluation, and adjust the collar or halo if appropriate. 

Reference: Swallowing dysfunction in trauma patients with cervical spine fractures treated with halo-vest fixation. J Trauma 70(1):46-50, 2011.