Category Archives: General

The “Double-Barrel” IO: Can It Work?

Intraosseous lines (IO) make life easy. They are quicker to insert, have a higher success rate, and require less experience than a standard IV. And they can be used for pretty much any solution or drug that can be given through an IV.

But there are some limitations. They can’t be inserted into a fractured bone. The manufacturer cautions against multiple insertions into the same bone. A second insertion should not be performed in the same bone within 48 hours. 

But, as with so many things in medicine, there is little in the way of proof for these assertions. They seem like good ideas for precautions, but that does not mean they are correct. No real research has been done in this area. Until now.

The concept of using two IO needles in one bone was explored in an animal model by researchers in Canada. They used a swine model (using the foreleg/humerus, to be exact), and tested several infusion setups.

Here are the factoids: 

  • Infusing crystalloid using an infusion pump set to 999ml/hr took 30 minutes with a single IO, and 15 minutes with a “double-barrel” setup
  • Giving crystalloid using a pressure bag set at 300 mm/Hg took 24 minutes with a single IO, and 23 minutes with double the fun
  • The double-barrel setup also worked for a blood/drug combo. 250cc of blood and 1 gm of TXA in 100ml of saline infused via pump in 13 minutes.
  • Simultaneous anesthesia drugs (ketamine infusion in IO #1, fentanyl and rocuronium bolus in IO #2) without problems
  • Multiple fluid + drug infusion combinations were tested without incident
  • There were no needle dislodgements, soft tissue injuries, fractures, or macrohistologic damage to the bone or periosteum

Bottom line: Remember, these are pigs. Don’t do this in humans yet. However, this is pretty compelling evidence that the double-barrel IO concept will work in people. And it appears that infusion pumps must be used for effective, fast infusions. I recommend that prehospital agencies with inquiring minds set up a study in people to prove that this works in us, too.

Related posts:

Reference: Double-barrelled resuscitation: A feasibility and simulation study of dual-intraosseous needles into a single humerus. Injury, in press April 30, 2015.

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Trauma Education: The Next Generation Coming Soon!

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TE:TNG, version 3.0 is coming soon! Our fast-paced 4 hour program will be available again live this year (but you have to come see me in St. Paul MN), or via LiveStream on Thursday, September 17.

Our guest speaker is Dr. Brian Lin, author of the Closing the Gap – lacerationrepair.com website, talking about “Advanced wound closure tips and tricks.”

We also have a number of other live presenters, delivering 20 minute fact-packed talks on trauma topics applicable to all trauma professionals. Topics include:

  • Top 10 Pearls of Palliative Care in Trauma
  • For Level III centers: How to keep more trauma patients at your hospital
  • De-escalation and takedown in the ED

Peppered among all the live presenters will be curbside consults, where we ask the specialists what you also wished you had asked. We’ll also show a variety of focused, 5 minute how-to videos on:

  • Using ultrasound to start peripheral IVs
  • Stabilizing prior to transfer
  • Small bore chest tubes
  • And more!

For more information, or to make arrangements to join us live or electronically, please visit our website at www.tetng.org

I’m looking forward to “seeing” you there!

Michael

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Trauma MedEd Newsletter Released To Subscribers Next Week!

The August Trauma MedEd Newsletter will be released to subscribers on September 1. This month is the annual “Potpourri” issue. Articles include:

  • Crowdfunding research
  • Thoughts on TEG/ROTEM
  • Thoughts on REBOA
  • And more!

Anyone on the subscriber list as of midnight (CST) on August 31 will receive it the next day. Everybody else will have to wait for me to release it here the following week. So sign up for early delivery now by clicking here!

And did you catch all the malpractice articles in the last two issues?

Pick up back issues here!

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When To Worry About Subarachnoid Hemorrhage

Neurosurgeons tend to worry about aneurysms a lot. They can cause devastating and lasting neurologic dysfunction. The most common diagnostic finding, besides the classic “worst headache of my life” complaint, is subarachnoid hemorrhage (SAH). And one of the more common CT findings after head trauma is also SAH. 

For that reason, CT angiography tends to get added on to the trauma workup from time to time. Trauma professionals are faced with the “chicken or the egg” question, trying to figure out if a leaking aneurysm caused the subarachnoid blood and then the fall/crash, or the fall/crash caused the blood.

A group at St. Luke’s Hospital in Bethlehem PA looked at this question using 5 years worth of retrospective data from their Level I trauma center. They noted a significant increase in the number of CT angiographic (CTA) studies being ordered in their head trauma patients and wanted to determine which patients would benefit most from this study.

Here are the factoids:

  • 617 patients were identified with traumatic SAH during the study period, and 186 of them (30%) underwent CTA
  • 13 patients (7%) who had CTA actually had an aneurysm
  • Of these 13 patients, 8 were believed to have presented with trauma caused by the aneurysm because they were found to be ruptured
  • All patients who had a ruptured aneurysm had a pattern of central subarachnoid hemorrhage on CTA

  • Of the patients who were “found down”, none had an aneurysm

Bottom line: Pre-existing aneurysms are not any more common in TBI patients than they are in the general population. However, they may be the cause of trauma on occasion. Contrary to what many think, they seem to be uncommon in cases of patients who are found down; it looks like the trauma usually comes first. However, a pattern of central subarachnoid hemorrhage is reasonably predictive of this uncommon yet dangerous problem, so addition of CT angiography of the head when it is seen on non-contrast CT appears to be warranted.

Related posts:

Reference: Selected computed tomographic angiography in traumatic subarachnoid hemorrhage: a pilot study. J Surg Research, in press, 2015.

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Guidelines for Consultants to the Trauma Service

Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps to ensure quality care and provide good communication between caregivers and patients / families.

We have disseminated a set of guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.

In order to deliver the highest quality and most cost-effective care, we request that services we consult do the following:

  • Please introduce yourself to our patient and their family, and explain why you are seeing them.
  • Although you may discuss your findings with the patient, please discuss all recommendations with a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
  • Document your consultation results in writing (paper or EMR) in a timely manner.
  • If additional tests, imaging or medications are recommended, discuss with the trauma service first. We will write the orders or clear you to do so if appropriate, and will discuss the plan with the patient.
  • We round at specific times every day and welcome your attendance and input.
  • Please communicate any post-discharge instructions to us or enter in the medical record so we can expedite the discharge process and ensure all followup visits are scheduled.

Bottom line: A uniform “code of behavior” is important! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature, and they will not be familiar with how their recommendations may impact other injuries.

Click here to download the full copy of the Regions Hospital Trauma Services consultant guidelines.

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