Category Archives: General

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.

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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.

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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.

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EAST Evidence Based Review: Distracted Driving

EAST is branching out from one of its core areas, creating trauma practice guidelines. They are now beginning to address other problems using the same techniques for developing their practice guidelines. Instead of generating guidelines for clinical care, they are creating action statements based on the best available literature.

This Distracted Driving review was one of a group of new EBRs was presented last week at the EAST Annual Scientific Assembly. The panel reviewed information from government agencies and studies based on crash databases and simulations. The number of cellphone subscribers has surpassed 250 million, and the number of deaths from distracted driving has followed a similar curve. 

Distracted driving is implicated in 20% of injury crashes and 16% of fatal crashes. Drivers under age 20 has the highest proportion of distracted drivers. 

EAST made three Level II recommendations, which means that they are reasonably justifiable by available scientific evidence and strongly supported by expert opinion. They are:

  • Drivers should minimize all distractions while on the road
  • Cell phone use and texting should not be performed while driving
  • Younger inexperienced drivers should not use cell phones during their probation period (if such a period is mandated by their state)

Future areas of interest will include studying the impact of legislation regarding cell phones and texting, development of crash avoidance systems, and evolving cell phone technologies.

Reference: Evidence Based Review on Distracted Driving, presented at the 2011 EAST Annual Scientific Assembly. Note: this information is preliminary and may be changed prior to publication.

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Distracting Injury and Cervical Spine Clearance

One of the tenets of clinical c-spine clearance is that there be no “distracting injury.” What does this mean exactly? Can the clinician adequately judge which injuries are too distracting?

The Loyola group prospectively looked at 160 patients needing c-spine clearance over a 9 month period. GCS had to be 14 or 15, and the patients were excluded if they were intoxicated or received an analgesic prior to the clearance attempt. A total of 84% had no neck pain, and 82% of those had no peripheral, potentially distracting pain. Patients with perceived distracting pain and those without had very similar Visual Analog Scores (VAS) for pain. 

Overall, the majority of patients and physicians did not believe that distracting pain was present, and when pain was present there was little agreement whether it was distracting. The few patients who did have spine fractures had a VAS for pain >5. The use of physician judgment for distracting pain and clearance worked just fine in this study.

Bottom line: The authors recommend using clinician judgment as to the degree of distracting pain when clearing the c-spine. If you want to be more objective, if the patient complains of a Visual Analog Score for pain of more than 5, then you may want to delay clearance. Note: this is a small study that really needs to be replicated before widespread use.

Reference: C-spine clearance: don’t be distracted – just trust your judgment. Presented at the 24th annual scientific assembly of EAST, Session II, Paper 9. Click here to see the abstract. 

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