You’ve heard the statistics about the graying of our society. The proportion of older people is growing rapidly. Well, there are only about 4400 neurosurgeons in the US, and they are aging as well. Nearly a third are older than 55 years.
This leaves a relatively small number of neurosurgeons tasked with helping to take care of trauma patients. Many Level II centers are hard pressed to maintain their neurotrauma services. Even basic procedures like ICP monitor placement may require transfer to another center.
The group at Miami Valley Hospital in Dayton looked at their experience with training surgeons to insert intraparenchymal ICP monitors (not EVD devices) over a 6 year period. Their trauma surgeons, as well as surgical residents were trained by watching a video, practicing in a cadaver lab under the supervision of a neurosurgeon, and being proctored by a neurosurgeon while placing them in three patients. Surgical residents could place the monitor if directly supervised by a surgeon.
Here are the factoids:
- Of 410 monitors placed, 298 were placed by surgeons and 112 by neurosurgeons
- The surgeons placed 188 Licox monitors and 91 Caminos. The type was not recorded in 19.
- Surgeon complication rate was 3% (9 patients), and the neurosurgeon rate was 0.8% (1 patient). None were major of life-threatening.
- Most of the complications were malfunction of the device. There were 2 dislodgements in the surgical group, and 1 in the neurosurgeon group.
Bottom line: This one’s a little tough to interpret. Yes, the number of complications (malfunction) is higher with the surgeons. But the numbers are small, and this difference does not reach statistical significance. I do worry that the training is a bit too sketchy. But I think that this procedure will soon enter the skillset of many acute care surgeons, especially those working at hospitals in more rural settings. This will be the quickest way to begin high quality neurotrauma care for patients who are injured in areas not served by highest level trauma centers.
Reference: Successful placement of intracranial pressure monitors by trauma surgeons. J Trauma 76(2): 286-291, 2014.
The patient underwent DPL and had an abnormal result, with weird sediment in the tubing.
Since this is, by definition, a positive result, they were taken to the OR. The DPL catheter was left in place to help localize what was going on. This is particularly helpful if an iatrogenic injury to a hollow organ is suspected. Otherwise it may be very difficult to find a tiny puncture wound.
It turns out that the catheter made a beeline for the cecum, resulting in a DCL (diagnostic colonic lavage), not a DPL. The particulate material was stool!
Since the catheter had been left in place, there was no contamination. It was removed under direct vision and a single stitch was placed to close the defect. Finally, a formal exploration was carried out to find the source of the patient’s abdominal pain. A low grade liver laceration was found that did not need any specific therapy. The ultimate source of her initial hypotension? Multiple long bone fractures with attendant bleeding into soft tissue. The abdomen was closed and the patient did well after fixation of her fractures.
It pays to know a little bit about DPL, even though it is seldom used these days. It can be useful, particularly when trying to rule the abdomen in or out as a source of bleeding where FAST is unavailable, indeterminate, or the result is suspect.
Check out this post for some tips and tricks on DPL:
This is a continuation of yesterday’s interesting case involving an unusual DPL result. As you recall, the tap was negative, but the lavage effluent slowly began to show some particulate material.
By definition, this is a positive result, which then requires a trip to the operating room. The catheter was capped and left in place. The patient was then taken to surgery, prepped and draped. Here’s what was found:
What’s your diagnosis now? And what needs to be done about it?
Final answers tomorrow!
Here’s an interesting trauma case, which comes from days of DPL. Although we don’t use this valuable technique very often, this one teaches an interesting lesson.
A middle aged female was involved in a high speed car crash. She was brought to the resuscitation bay as a trauma activation because the medics reported she had bilateral femur fractures, and her systolic pressures were in the 90’s.
As you proceed through the ATLS protocol, you call for blood to supplement your resuscitation fluids, and you also find that her abdomen is tender, with some right upper quadrant guarding. The femurs are placed in traction splints. FAST is generally negative, but the right upper quadrant is equivocal.
At this point, her pressure drops again. You re-evaluate your ABCs and find nothing new. The femurs appear to be nicely reduced, and the thighs are not larger than they were when she arrived. Your surgeon is concerned that the abdomen may be the source despite the (mostly) negative FAST. Due to BP concerns, she proceeds to do a DPL.
The procedure proceeds smoothly while resuscitation with blood products takes place. There is no gross blood on the tap. A liter of saline is infused and is now freely emptying into a bag. For the first 400cc, the effluent is crystal clear. But now you start to see something.
Hmm, is it or isn’t it? Let’s take a closer look.
Yeah, that’s weird. Just of hint of some kind of tiny darkish particles settling to the bottom of the tubing. Hmmm!
So what’s happening here? And what should you do? More information tomorrow. Please comment or tweet your guesses!
This new investigational device has made quite a splash during the past week. Manufactured by an Oregon company, it is designed to control bleeding, and is for use by combat medics and first responders.
Inspired by the old Fix-A-Flat expanding foam tire patch system, the XStat looks like a big syringe, and is filled with small 1cm sponges that expand rapidly when they get wet. It’s designed to stop hemorrhage in small wounds and wound tracts. Just pull back the plunger (which comes fully inserted to save space), push the unit into the wound, then hold the plunger while pulling the syringe out. This serves to leave the load of sponges in the tract and achieve rapid hemostasis.
It would seem that leaving a lot of tiny sponges in a wound could cause problems, especially if they are not removed at the time of definitive surgical management. However, each one is tagged with a radiopaque marker so they can be identified with xray or fluoro.
Preclinical trials have claimed to be successful, and an application has been submitted to the FDA for human use. This has the potential to save lives when bleeding gunshot wounds are encountered, especially in combat situations.
I have no financial interest in RevMedx, the manufacturer of this device.