Category Archives: General

General

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.

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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?

Subscribers received this issue last week. Subscribe now and be sure to get the next issue early.  So sign up for early delivery now by clicking here!

Click here to download the current issue

Pick up back issues here!

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General

Trauma Surgery Tip: How To See The Unseeable

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Let me present a scenario and first see how you might solve this problem.

A young man presents with a gunshot to the abdomen in the right mid-back. He is hemodynamically stable, and you get a chest xray. It shows a small caliber slug in the right upper quadrant, but no hemo- or pneumothorax. He has peritoneal signs, so you whisk him off to the OR for a laparotomy.

As you prep the patient for the case, you can feel a small mass just above the right costal margin. You incise the area and produce a 22 caliber bullet. Of course, you follow the chain of evidence rules and pass it off for the police. As you explore the abdomen, it appears that there are no gross injuries. You are concerned, however, that there may be an injury to the diaphragm in proximity to the bullet.

So here’s the question: how can you visualize the diaphragm in this area? The bullet was located below the right nipple. But the diaphragm in this area is covered by the liver, and is parallel to the floor. You can’t seem to feel a hole with your fat finger. But short of putting your whole head in the wound, you just can’t get a good angle to see the area in question.

How would you do it? Please tweet or leave comments with your suggestions. I’ll provide the answer(s) Monday!

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General

How To Evaluate A Stab To The Diaphragm – Part 2

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Yesterday I gave a little perspective on the use of CT in assessing the diaphragm after penetrating injury. Today, I’ll break it down into some practical steps you can follow the next time you see one.

Step 1. Stable or unstable? If your patient arrives with unstable vital signs, and there is no other source but the abdomen, the answer is simple. Go to the OR for a laparotomy. Period. They are exsanguinating and the hemorrhage needs to be stopped.

Step 2. Mark the sites of penetration and take a chest x-ray. This will let you evaluate the potential trajectory of the object, and will give you your first glimpse of the diaphragm.

Step 3. Examine the abdomen. Actually, you should be doing this at the same time you are setting up for Step 2. If your patient has peritoneal signs, no further evaluation is needed. Just go to the OR for laparotomy. Look at the chest x-ray once you get there.

Step 4. Right side? If your appreciation of the path of penetration involves just the liver, take the patient to CT for evaluation of chest, abdomen, and pelvis. You need to see all three of these areas to assess for blood and fluid in both body cavities. After the study, if you still think the injury is limited to the liver, admit the patient for observation.

Step 5. Left side? Look at that chest x-ray again. If there are any irregularities at all, strongly consider going to the OR and starting with diagnostic laparoscopy. These irregularities can be glaring, like in the x-ray above. But they can be subtle, like some haziness above the diaphragm or small hemothorax. Obviously, if the injury is as clear as on the x-ray above, just open the abdomen. But if in doubt, start small.

Step 6. Admit and observe. Check the abdomen periodically, and repeat the chest x-ray daily. If anything changes, consider diagnostic laparoscopy. As a general rule, I don’t keep patients NPO “just in case.” Most will pass this test, and I don’t see a reason to starve my patients for the low likelihood they need to go to the OR.

Step 7. Make sure your patient gets a follow up evaluation. See them in your outpatient clinic, get a final chest x-ray and abdominal exam before you completely clear them.

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General

How To Evaluate A Stab To The Diaphragm – Part 1

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Penetrating injury to the diaphragm, and specifically stab wounds, have been notoriously hard to diagnose since just about forever. Way back in the day (before CT), we tried all kinds of interesting things to help figure out if the patient had a real injury. Of course, we could just go to the OR and lap the patient (laparoscopy did not exist then). But the negative lap rate was significant, so we tried a host of less invasive techniques. 

Remember diagnostic peritoneal lavage? Yeah, we tried that. The problem was that the threshold for red cells per cubic mm was not well defined. Some would supplement this technique with a chest tube to see if lavage fluid would drain out. And one paper described instilling nuclear medicine tracer into the abdomen and sitting the patient under a gamma camera for a few hours to see if any ended up in the chest. Groan!

We thought that CT would save us. Unfortunately, resolution was terrible in the early years. If you could actually see the injury on CT, it was probably because a large piece of stomach or colon had already fallen through it. But as detectors multiplied and resolution improved, we could begin to see some smaller defects. But we still missed a few. And the problem is that left-sided diaphragmatic holes slowly enlarge over time (years), until the stomach or colon falls through it. (See below)

A group of radiologists and surgeons in a Turkish trauma hospital recently published a modest series of patients with left-sided diaphragm injuries evaluated by CT. They looked at about 5 years of their experience in a group of patient who were at risk for the injury due to a thoraco-abdominal stab wound. Unstable patients were immediately taken to OR. All of the remaining patients underwent an initial CT scan, followed by diagnostic laparoscopy after 48 hours if they remained symptom free.

Here are the factoids:

  • A total of 43 stable patients with a left thoraco-abdominal stab were evaluated
  • 30 patients had a normal CT, and 13 had the appearance of an injury
  • Of those who were CT positive, only 9 of 13 (69%) actually had the injury at operation
  • Two of the 30 (7%) who were CT negative were found to have a diaphragm injury during followup laparoscopy
  • So in the author’s hands, there was 82% sensitivity, 88% specificity, a positive predictive value of only  69%, and a negative predictive value of 93%

Bottom line: The authors somehow looked at the numbers and concluded that CT is valuable for detecting left diaphragm injury. Huh? They missed 7% of injuries, only finding them later at laparoscopy. And they had a 31% negative laparotomy rate. 

Now, it could be that the authors were using crappy equipment. Nowhere in their paper do they state how many detectors, or what technique was used. Since it took place over a 5 year period, it is quite possible that the earlier years of the study used equipment now considered to be out of date, or that there was no standardized technique.

CT may not yet be ready for prime time. But it can be a valuable tool. Tune in tomorrow for some tips on how and when to look for this insidious injury.

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Reference: Evaluation of diaphragm in penetrating left thoracoabdominal
stab injuries: The role of multislice computed tomography. Injury 46:1734-1737, 2015.

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