One of the tenets of trauma surgery, handed down for generations, is that we should pack the abdomen to help manage major abdominal hemorrhage. “All four quadrants were packed” reads the typical operative note. But how exactly do you do that? Sounds easy, right?
Well, there are nuances not found in the surgery textbooks. Here are some practical tips for the trauma surgeon:
- Prepare. Have your scrub nurse fluff up about 20 laparotomy pads in advance. The point of packing is two-fold: soak up blood, and stop bleeding. Fluffed up pads work better than the flat, rolled up pads shown above. And you will need them fast, so have a supply ready.
- Do you really need to pack? Your patient is hypotensive, and you are convinced the abdomen is the source. You run to the OR, open it and… no blood. So don’t pack. It won’t slow down the (lack of) bleeding, but it is possible to cause serosal tears or worse. Just figure out where the bleeding is really coming from.
- Be careful. Don’t just jam them in there. Carefully place pads over and under the liver. Carefully place a hand on the spleen and push toward the hilum so you can place pads between spleen and body wall. Try not to cause more damage than is already there.
- Penetrating trauma: Pack where you know (or think) the penetrations are first. Basically, if it’s not bleeding there, don’t pack there.
- Blunt trauma: Pack the upper quadrants first. This is where the money is, because the liver and spleen are the top culprits. Then pack the lower quadrants to soak up shed blood.
- Once packed, check for successful control. If bleeding has stopped (or at least decreased significantly) stop and wait for anesthesia to catch up and continue your massive transfusion protocol. If bleeding continues, remove packs from the offending area and try to obtain definitive control. This is now the patient’s only chance, since you have now determined that you can’t stop the bleeding with packing.
- Remove packs in the proper order. In blunt trauma, remove the lower quadrant packs first. They’re not doing anything and just take up valuable space. In penetrating trauma remove the packs in the area of the injury first.
- Get an xray to confirm that all packs are out at the end of the case. Self explanatory. It’s easy to lose a few in the heat of the moment. I’ve seen two bundles (10 pads) left over the liver in one case decades ago!
On Monday, I’ll write about the importance of the final x-ray when the abdomen is closed.
Your patient is at their healthiest as they roll in through the emergency department door
Yes, major trauma patients are sick, but they are going to get sicker over the next few hours to days. No matter how bad they look now, they will tolerate more at the time you first see them than they will tomorrow.
Too often, we look at them and delay because “they are too sick to operate.” This is usually not the case.
Bottom line: Move quickly, get surgical clearances done promptly, and perform all interventions (especially major surgery) early before your trauma patient gets really sick!
Other Laws of Trauma:
Many readers may have noticed that the blog site has looked different for the past week. The good news is that I’ve migrated all my content (and more) to a standalone website, TheTraumaPro.com.
But the bad news was that all of the search engines only know of the original site, regionstraumapro.com, the original blog hosted on Tumblr. So a lot of people ended up being directed to an old post (on the new site) and not knowing why or how they got there. Confusing! Furthermore, links to related posts on the Tumblr site took readers to the same old random post on the new site. Even more confusing!
In order to stem the confusion while the search engines catch up, I’ve decided to run both sites in parallel. All posts will be cross-posted to both sites simultaneously. The Twitter notification will link to the post on the new site, but it will still be on Tumblr as well.
Please check out all the extra content on the new site at:
but just be aware that searches for content will probably direct you to Tumblr at:
Thanks for reading, whichever one you choose!
The July Trauma MedEd newsletter is just around the corner! The topic is: Practice Guidelines. I’ll be sharing a number of updated guidelines for diagnostic imaging, head injury, anticoagulated patients, and more.
I see so many trauma programs that recognize the need for a practice guideline, but then insist on taking a huge amount of everyone’s time designing it from scratch. Chances are that 50 other trauma centers already have done this! So take a look at the ones in the newsletter, tweak to your heart’s content, and use them! In addition to printable copies in the newsletter pdf, I’ll share a link to Microsoft Publisher file versions so you can customize them, add your own logo, etc.
The newsletter will be released over the US Independence Day weekend. Subscribers will receive it then. Everyone else will have to wait until the following week.