Category Archives: Tips

Practical Tips: Transferring The Mangled Extremity

Managing the mangled extremity is both challenging and intense. There is always pressure to do all we can to save that threatened limb. But as you know, different levels of trauma centers have different capabilities and specialists that are needed to fully manage these injuries.

Level I centers have a comprehensive set of specialists to deal with the managed extremity, including trauma surgeons, vascular surgeons, orthopedic surgeons comfortable with complex injury, plastic surgeons, and interventional radiologists. The expectation is that a mangled extremity can be completely managed at such a center.

Level III centers have much more limited resources, and may only have a trauma surgeon to perform the initial evaluation. Definitive management can only occur after transfer to a Level I center.

Level II centers often find themselves in a kind of limbo. They have most of the specialties required, but those specialists may have varying comfort levels regarding addressing complex injuries. Some Level II centers may be able to keep these patients, but many will find that they need to transfer to their upstream Level I partner.

What do transferring trauma centers need to do before actually moving the patient? Here are some practical tips.

  • Evaluate quickly. The bottom line is to try to preserve function, so time is of the essence. Do a thorough evaluation of the anatomy, as well as vascular and neurologic status. These are the major determinants of salvageability.
  • Don’t ignore the rest of the patient. Make sure that injuries more critical than the extremity are identified and addressed. See the “Dang Factor!” below.
  • Make a decision. Now. Decide whether you need to transfer the patient based on your knowledge of your consultants’ skill levels and comfort.
  • Once you decide you will transfer, do no further imaging. It’s not going to change anything you do, and may not be very helpful to the receiving center.
  • Give IV antibiotics and the life-saving tetanus shot early.
  • Optimize salvageability. Do what you can to keep tissue healthy during the transfer. You must take transfer time into account for this! If you are sending your patient across town, just do it quickly. However, if he or she must travel long distance, there are a few more things to consider:
    • Try removing the tourniquet (if any). You’d be surprised at how many times the bleeding has stopped already. Or maybe wasn’t needed in the first place.
    • Selectively try to control bleeding if possible. Carefully ligate small vessels if you can. Don’t clamp and tie large masses of tissue.
    • Consider a vascular shunt. If there is an obvious large vessel injury, and if you have a trauma or vascular surgeon who is comfortable with inserting a vascular shunt, do it prior to transfer. This will increase the likelihood of salvage in long-distance transfers. But don’t waste a lot of time doing this! If you can’t get it done within about 30 minutes or so, don’t delay the transfer.
    • Quickly rinse off the area. Try to minimize the time that noxious stuff (dirt, gasoline, etc) is in contact with the tissues.
    • Splint well. You’ll need to be creative. But you don’t want additional tissue injury due to the extremity just flopping around.
  • Inquire about followup. Find out how the patient did, and discuss anything you could have done differently with the receiving center. As always, performance improvement is important!

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Thoughts On Traumatic Hematuria: Part 1

I’ve seen a number of patients recently with bloody urine, and that is prompting me to provide some (written) clarity to others who need to manage this clinical problem. I’ll try to keep it organized!

There are two kinds of hematuria in trauma: blood that you can see with the naked eye, and…

Okay, so there’s only one. Trauma professionals do not care about microscopic hematuria. It does not change clinical management. Sure, your patient might have a renal contusion, but you won’t do anything about that. Or, he/she might have an infarcting kidney. And you can’t do anything about that. If you order a urinalysis, you might see a few RBCs. Don’t let this lead you down the path of looking for a source. You’ll end up ordering lots of tests and additional imaging, and generally will have nothing to show for it at the end. It’s not your job to spend good money on the very rare chance of finding something clinically significant.

Both of these specimens have blood in them. You can’t see it on the left, so don’t go looking for it with a microscope.

There are four sources of blood in the urine.

1. The first source does not generally cause hematuria, but can occasionally cause a few visible wisps of blood. That source is a urethral injury. The textbook teaching, and it’s good advice, is to look at the urethral meatus in your trauma patient, especially if you are contemplating insertion of a urinary catheter. If you see a few drops of blood, pause to consider. Sometimes, the blood is no longer visible, but might be present as a few well-placed drops on the patient’s underwear. So have a look at that, too, especially in patients with high risk injuries such as A-P compression pelvic fractures (think, lots of ramus fractures or pubic diastasis).

If you didn’t notice it and inserted the catheter anyway, you might see a few wisps of blood in the tubing as you place it. More often than not, this is just run of the mill irritation of the mucosa by the catheter, but always keep the possibility of an injury in mind.

Tomorrow, I’ll discuss the remaining three sources, and what to do about them.

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Tongue Piercings And Emergency Intubation

Urgent and emergent intubation is challenging enough, but what if your patient is sporting some type of tongue piercing? Does it make a difference? Do you need to do anything differently?

Obviously, the jewelry may physically impede the process of intubating the patient, impairing visualization of structures or getting in the way of inserting the tube. It can also cause complications later down the road, such as pressure necrosis from the tube coming into contact with it.

The anesthesia literature recommends removing all oral jewelry prior to elective intubation, or declining to do the case if the patient refuses. Unfortunately, trauma professionals do not have that option when the patient needs an emergency airway.

Here are some pointers for dealing with oral jewlry:

  • Is the item going to impede insertion of the airway? Is it large, or obstructing the usual tube pathway? If so, remove it quickly (see below).
  • Sweep the tongue well to the side during tube insertion to avoid the jewelry. You may need an assistant to grasp it with gauze to keep it out of the way.
  • Once the airway is secured, remove the item. This takes two people! The ET tube should be moved to the side, and one person will grasp the tongue with a gauze pad and extend it. The other person can then grasp the jewelry with gloved fingers, and unscrew the ball on one side. It can then be removed and saved in an envelope.

Note: both hands must always be in contact with the jewelry at all times! It is slippery, and if the pieces are not controlled, this can happen!

Sharp stud foreign body in the bowel from tongue piercing that came apart and was swallowed (arrow). Images courtesy of Intermountain Medical Imaging, Boise, Idaho.

 

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How To Remember To Give The TXA!

The CRASH-2 study did a good job of demonstrating the value of giving tranexamic acid (TXA) in patients with major hemorrhage. The kicker is that the data seemed to show that the effect was best if given early, and might even be detrimental after 3 hours.

The reality is that most patients with major hemorrhage will present as a trauma activation. And if they really are bleeding badly, they will probably trigger your massive transfusion protocol (MTP). But at the same time, they will probably keep you very busy, and it’s easy to forget to order the TXA.

How can you make sure to start the TXA promptly on these patients? Easy! Check out this picture:

Yes, that’s a cheat sign right on top of the first cooler for the MTP! Have the blood bank include this sign in the cooler, so that everyone can see it when you crack the cooler open to give the first units of blood products.

In most hospitals, TXA is a pharmacy item. It should be stocked in the ED, and not in a far away pharmacy satellite. And don’t forget that TXA is given twice, 1 gram given over 10 minutes (or just IV push for speed), followed by another gram infused over 8 hours.

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Best Practice: Laundry Basket In The Resus Room?

How do you get patients out of their clothes during a trauma resuscitation? Most of the time, I bet your answer is “with a pair of scissors.” And once they are off, what do you do with them? Admit it. You just throw them on the floor. And sometime later, someone’s job is to find it all, put it in a bag, and store it or hand it over to the police.

There are more problems than you might think with this approach. First, and most importantly to the patient, their stuff can get lost. Swept up with all the other detritus from a trauma activation. And second, their belongings may become evidence and it’s just been contaminated.

So here’s an easy solution. Create a specific place to put the clothes. Make it small, with a tiny footprint in your trauma room. Make it movable so it can be kept out of the way. And make sure it is shaped so it can contain a large paper bag to preserve evidence without contamination.

And here’s the answer:

Yes, it’s a plain old laundry basket. The perfect solution. And best of all, these are dirt cheap when you are used to seeing what hospitals charge for stuff. So your ED can buy several ($14.29 ea on Amazon.com) in case they can’t be cleaned anymore or just disappear.

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