Over the years, I’ve written about solid organ injury management many times. Here is a summary of some practical pointers and tips, some old and some new. They are as evidence-based as I can get them. This kind of stuff is not always in the doctor and nursing books.
Ward and ICU branches are order sets at my hospital, not necessarily admitting locations. If you have a special unit or step-down area that can provide ICU-level monitoring, use it for the ICU order set.
Strongly consider interventional radiology (IR) and angiography in all adult patients with contrast extravasation (children generally do not qualify unless they show signs/sx of ongoing volume loss). Consider also in high grade injuries, because they may have active bleeding that isn’t quite brisk enough to see on CT.
Serial hemoglobin measurements are not part of the protocol. They are only used to help decide if transfusion might be needed. Vital signs will always signal failure before the hemoglobin does.
Nearly all patients may be up and eating immediately, or certainly by the next morning. No need for protracted NPO status or bed rest. Really no need for it at all!
Failure really falls into 2 types: hard and soft. Hard failure is a single episode of definitive hypotension (usually 80s or less) or development of peritoneal signs, and requires an emergency trip to the OR. Soft failure is transient or modest hypotension that responds rapidly to a fluid bolus. If IR has not already been used, a quick trip there may obviate the need for operation. However, another one of these bouts makes it a hard fail. Time for OR.
Hard failure can only be treated with blood, some crystalloid, and a knife. Pressors, steroids, or other drugs can only be used if they come in liter bags and can be given at over 1000cc/hr. That means never.
In IR, give the radiologist 30 minutes to stop the bleeding. Don’t let them dawdle for hours. If the patient has a hard fail, abort and go to OR; do not let the radiologist persist.
After discharge, our usual orders are:
Normal activity (non-impact) for 6 weeks
All activity (except high impact) thereafter
High impact activity (tackle football, rugby, serious extreme sports) only after 12 weeks (no good data for this one)
No repeat CT scanning to judge healing
Warn patients of the good possibility of a transient increase in pain on days 7-10. This is common in many unless they’ve been embolized.
Patient to call if unrelenting increase in pain, or increasing orthostatic symptoms, fevers chills
A set of guidelines for management of blunt solid organ injury in children developed by the American Pediatric Surgical Association was originally published in 1999. One of the elements of the guideline was to place the child on bedrest for a period of time after the injury. Arbitrarily, this period was defined as the injury grade plus one day. So for a grade 3 spleen injury, the child would have to stay in bed for 4 days (!).
A paper published this month looked at the impact of shortening this time interval. Over a 6 year period, all pediatric liver and spleen injuries from blunt trauma were identified and an abbreviated bedrest protocol was implemented. For low grade injuries (grade 1-2), children were kept in bed for 1 day, and for higher grade injuries this was extended to 2 days.
Here are the factoids:
249 patients were enrolled (about 40 per year) with an average age of 10. “Bedrest was applicable for 199 patients, 80%.” Huh? Does that mean that 50 patients were excluded due to surgeon preference?
The organ injured was about 50:50 for spleen vs liver. Twelve children injured both.
Mean injury grade was 2.7, which is fairly high
Mean bedrest was 1.6 days, and mean hospital stay was 2.5
Bedrest was the limiting factor for hospital stay in 62% of cases
There were no delayed complications of the injury
Bottom line: Come on! Most centers don’t keep adult patients at bedrest this long, and we learned about solid organ injury management from kids! Children almost never fail nonop management, so why treat them more restrictively than adults? And have you ever tried to keep a child at bedrest? Impossible! This study is too underpowered to give real statistically valid results, but it certainly paints a good picture of what works. We’ve recently removed bedrest and NPO status from our protocol, and our average length of stay for isolated solid organs is about 1.5 days in adults. But really, who says that staying in bed for any period of time avoids complications? There are lots of other evil things that can happen!
This video reviews the proper treatment of agitation that you may encounter in trauma patients. It features JJ Rasimas MD, a psychiatrist at Regions Hospital. He is interviewed by our illustrious Jessie Nelson MD. This video was first broadcast at Trauma Education: The Next Generation.
Nurses have a complementary role with physicians in caring for children with orthopedic injuries. Typically, the child will have been evaluated and had some sort of fracture management implemented. In children, nursing management is easer than in adults since a child is less likely to need an invasive surgical procedure. Many fractures can be dealt with using casts and splints alone.
Here are a few tips for providing the best care for your pediatric patients:
Ensure adequate splinting / casting. You will have an opportunity to see the child at their usual level of activity. If it appears likely that their activity may defeat the purpose of the cast or splint, inform the surgeon or extender so they can apply a better one.
Focus on pain control. Nothing aggravates parents more than seeing their child in pain! Make sure acetominophen or ibuprofen is available prn if pain is very mild, or scheduled if more significant. Ensure that mild narcotics are available if pain levels are higher. Remember, stool softeners are mandatory if narcotics are given.
Monitor compartments frequently. If a cast is used, check the distal part of the extremity for pain, unwillingness to move, numbness or swelling. If any are present, call the physician or extender and expect prompt attention to the problem.
Always think about the possibility of abuse. Fractures are rarely seen in children under 3, and almost never if less than 1 year old. If you have concerns about the physical findings or parent interactions, let the physician and social workers know immediately.
How often have you seen this in an admitting history and physical exam note? “Admit for observation; serial abdominal exams.” We say it so often it almost doesn’t mean anything. And during your training, did anyone really teach you how to do it? For most trauma professionals, I believe the answer is no.
Yet the serial abdominal exam is a key part of the management of many clinical issues, for both trauma patients as well as those with acute care surgical problems.
Here are the key points:
Establish a baseline. As an examiner, you need to be able to determine if your patient is getting worse. So you need to do an initial exam as a basis for comparisons.
Pay attention to analgesics. Make sure you know what was given last, and when. You do not need to withhold pain medications. They will reduce pain, but not eliminate it. You just need enough information to determine if the exam is getting worse with the same amount of medication on board.
Perform regular exams. It’s one thing to write down that serial exams will be done, but someone actually has to do them. How often? Consider how quickly your patient’s status could change, given the clinical possibilities you have in mind. In general, every 4 hours should be sufficient. Every shift is not. And be thorough!
Document, document, document. A new progress note should be written, dated and timed, every time you see your patient. Leave a detailed description of how the patient looks, vital signs, pertinent labs, and of course, exact details of the physical exam.
Practice good handoffs. Yes, we understand that you won’t be able to see the patient shift after shift. So when it’s time to handoff, bring the person relieving you and do the exam with them. You can describe the pertinent history, the exam to date, the analgesic history, and allow them to establish a baseline that matches yours. And of course, make sure they can contact you if there are any questions.
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