Category Archives: General

The Best (And Worst) Of EAST

The EAST meeting is upon us in just a few weeks! I’ll be attending (and tweeting) during this annual event. But in the meantime, I’d like to provide some commentary on some of the best and worst abstracts that will be presented.

Starting tomorrow, I’ll summarize one interesting paper/poster per day. I’ll also provide some perspective as to why it looks important (or not). Remember, my impressions are based on just an abstract. There is a lot that is left unsaid in the preparation of these brief research summaries. Sometimes, those things are crucial and totally destroy the work promised in the abstract.

I’ll also be listening to the presentations of the papers I critique at the meeting so I can get the real story, and I’ll share those with you as well next month.

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What Would You Do? Final Answer!

Lots of great comments about this case yesterday. So you’re looking for reasons why this 8 year old child is having blood pressure problems while undergoing craniotomy. On first pass through the ABCs, everything looks good. Looks. That’s not enough. 

The airway is definitely good. It’s been physically checked. But what about breathing? Lung sounds seem to be good, but in children they can be transmitted from the other side. There are a few solutions. If you have fluoro or quick access to a chest xray, that could be used. However, quickness is the key. If in doubt and the pressure is really becoming a problem, consider empiric needle decompression or finger thoracostomy if you want to avoid chasing with a chest tube on each side.

What about circulation? We’ve ruled out just about every source of bleeding but the abdomen. No FAST? Then why not fall back on DPL? Sure, it’s been a while since you’ve done it. And probably even longer since you’ve done one on a child.

DPL tips for kids: You’re really interested in the tap, not the lavage. If there’s enough bleeding in the abdomen to cause hypotension, you’ll find it quickly. Use open technique (not Seldinger) and insert the catheter far enough to cover all the tiny holes. One reader suggested using a suction cathether (like a Poole sucker). The only issue is one of control so the amount of blood removed can be measured. (Bonus tip: if you ever do the lavage part in a child, use 10cc saline or lactated ringers per kg).

In this case, the chest was negative, and there was no blood in the abdomen. The culprit was D (disability in ATLS jargon). And unfortunately, hypotension from CNS causes is universally an indicator of impending doom.

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What Would You Do? Part 2

Yesterday, I wrote about an 8 year old bicyclist struck by a car. He had sustained a head injury with a large epidural hematoma and was taken immediately to the OR for evacuation. During the case, the vitals began to suffer. The question was, what would you do as you are called into the room to “fix” this?

There was some excellent chatter on this, and universally, people voted to stick to the ABCs. As taught in ATLS, when the vital signs go awry, the only problems that can cause this degree of sudden derangement start with A, B, C and occasionally D.

The first thing to do is recheck the adequacy of the airway. Sure, the child is intubated. But the neurosurgeon had to position the head, and anesthesia’s access to this area is more limited than in other procedures. Your anesthesiologist is able to put a fiberoptic scope into the mouth and visualize that the tube does indeed pass through the vocal cords. Oxygen saturation is 100% and ETCO2 is 33.

Next, check breathing. The numbers above are helpful, but not the complete answer. Get access to the chest, look and listen. There is good, symmetric chest rise with ventilation, and breath sounds are completely normal bilaterally. The trachea is midline.

Now, is there any circulation problem (bleeding)? There are 5 areas where you can bleed to death:

  • Chest – the initial chest xray and your exam make this unlikely.
  • Fractures – you examine all extremities and can’t find any gross fractures
  • Pelvis – the initial portable xray did not show any fractures, and your exam is normal
  • Floor – your shoes are not getting sticky and the OR table is clean (except for the neurosurgeon’s mess)
  • Abdomen – ???

Hmm, the abdomen appears a bit distended, and it’s a bit tympanitic. This is a problem area! Let’s say FAST is not available to you, and the pressure is not improving with fluid and pressors.

How can you evaluate this child’s abdomen in this situation? I want the gory details, and will provide answers tomorrow.

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What Would You Do?

Here’s an interesting clinical case. How would handle this difficult situation?

An 8 year old boy is struck by a car while riding his bicycle. He has obvious head trauma, and medics quickly transport him to your trauma center. He is comatose and posturing with a GCS of 5 (E1 V1 M3). RSI and intubation is carried out, and a full exam is done. Only head trauma is noted, with the right pupil a few millimeters larger than the left. The remainder of the physical exam is unremarkable, with the exception of a few extremity abrasions. FAST is negative, as are portable chest and pelvis xrays.

The child is quickly transported to CT, and this is discovered:

He is immediately transported to the OR, where your pediatric neurosurgeon immediately begins a craniotomy to evacuate the epidural hematoma. 

Thirty minutes into the case, you are summoned to the OR because the patient’s blood pressure is dropping and is not responding as expected to fluids and a touch of pressor.

What do you need to think about, and what would you do?

Please comment or tweet all the details. Answers tomorrow!

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Keeping Up With Your Literature

I’ve talked a lot about how important (and easy) it is to keep up with the literature in your field. Doing this is critical to staying at the top of your game. I’m posting the link to my short video on how to do this using current technology to make it as easy as possible. 

There are three categories of sources that you should be looking at:

  • Core sources – these contain articles that almost always relate to your area of interest. I read 8 core journals each month.
  • Non-core sources – these journals occasionally contain articles important to your field. I read 15 non-core journals monthly.
  • WTF sources – Yes, WTF! (World TaeKwonDo Federation for those of you who actually don’t know what this means). These are things that are totally off topic, but interesting. They sometimes give you a kick in the head and get you thinking about things that could be important in your field. These are very important! I read 18 WTF sources, most of which are updated daily.

You can download what Scott Weingart calls “show notes” by clicking here. It summarizes and gives some specific recommendations for things discussed in the video. 

If you want to see the full list of what I read every day, click here.

Please feel free to comment and share how you keep up in your field!

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