All posts by TheTraumaPro

Best Of: Finding Rib Fractures On Chest X-Ray

A lot of people have been viewing and requesting this post recently.

Here’s a neat trick for finding hard to see rib fractures on standard chest xrays.

First, this is not for use with CT scans. Although chest CT is the “gold standard” for finding every possible rib fracture present, it should never be used for this. Rib fractures are generally diagnosed clinically, and they are managed clinically. There is little difference in the management principles of 1 vs 7 rib fractures. Pain management and pulmonary toilet are the mainstays, and having an exact count doesn’t matter. That’s why we don’t get rib detail xrays any more. We really don’t care. Would you deny these treatments in someone with focal chest wall pain and tenderness with no fractures seen on imaging studies? No. It’s still a fracture, even if you can’t see it.

So most rib fractures are identified using plain old chest xray. Sometimes they are obvious, as in the image of a flail chest below.

But sometimes, there are only a few and they are hard to distinguish, especially if the are located laterally. Have a look at this image:

There are rib fractures on the left side side on the posterolateral aspects of the 4th and 5th ribs. Unfortunately, these can get lost with all the other ribs, scapula, lung markings, etc.

Here’s the trick. Our eyes follow arches (think McDonald’s) better than all these crazy lines and curves on the standard chest xray. So tip the xray on its side and make those curves into nice arches, then let your eyes follow them naturally:

Much more obvious! In the old days, we could just manually flip the film to either side. Now you have to use the rotate buttons to properly position the digital image.

Final exam: click here to view a large digital image of a nearly normal chest xray. There is one subtle rib fracture. See if you can pick it out with this trick. You’ll have to save it so you can manipulate it with your own jpg viewer. 

Related posts:

Off-Label Foley Use In Trauma – Part 2

Yesterday, I wrote about an unusual way to use the Foley urinary catheter to plug a heart wound. This allows you to buy time to get to the operating room to perform the definitive repair. But this cheap and effective tool is very versatile, and can be used in other body areas as well.

Consider a deep penetrating injury to the liver. It takes time to determine which method for slowing/stopping the bleeding is most appropriate. Sure, the doctor books say to occlude the inflow by gently clamping the hepatoduodenal ligament (Pringle maneuver). But this takes time, and can be difficult if there is lots of bleeding.

You may be able to gain some time by placing a properly sized Foley catheter directly into the wound and carefully inflating with saline. You must inflate the balloon to feel, not to its full volume. It should be snug, but not so full that it cracks the liver parenchyma and causes yet more bleeding.

Bottom line: Any time you find yourself facing bleeding from hard to expose places, think about using a balloon catheter like the Foley. Sizing is critical, and the balloon volume is more important than the catheter diameter. Estimate the size of the area that needs to be occluded, and then ask for a catheter with a 10cc or 30cc balloon. If you need smaller, more precise control, try a Fogarty arterial embolectomy catheter instead. 

As with the cardiac Foley, be sure to occlude the end so you don’t create a conduit for the blood to escape. If your patient does well, and you need to leave the catheter in place for a damage control closure, LEAVE THE CATHETER COMPLETELY WITHIN THE ABDOMEN. If you exteriorize the end, some well-meaning person may unclamp it, drop the balloon, or decide that it can be used for tube feedings.

TIP: If the distance between the balloon and the catheter tip is too long, DO NOT TRY TO SHORTEN THE TIP BY CUTTING IT! This will damage the balloon and it will not inflate.

Fogarty catheters

Off-Label Use of the Foley (Urinary) Catheter

Foley catheters are a mainstay of medical care in patients who need control or measurement of urine output. Leave it to trauma surgeons to find warped, new ways to use them!

Use of these catheters to tamponade penetrating cardiac injuries has been recognized for decades (see picture, 2 holes = 2 catheters!). Less well appreciated is their use to stop bleeding from other penetrating wounds.

Foley catheters can be inserted into just about any small penetrating wound with bleeding that does not respond to direct pressure. (Remember, direct pressure is applied by one or two fingers only, with no flat dressings underneath to diffuse the pressure). Arterial bleeding, venous bleeding or both can be controlled with this technique.

In general, the largest catheter with the largest possible balloon should be selected. It is then inserted directly into the wound until the entire balloon is inside the body. Inflate the balloon using saline until firm resistance is encounted, and the bleeding hopefully stops. Important: be sure to clamp the end of the catheter so the bleeding doesn’t find the easy way out!

Use of catheter tamponade buys some time, but these patients need to be in the OR. In general, once other life threatening issues are dealt with in the resuscitation room, the patient should be moved directly to the operating room. In rare cases, an angiogram may be needed to help determine the type of repair. However, in the vast majority of cases, the surgeon will know exactly where the injury is and further study is not needed. The catheter is then prepped along with most of the patient so that the operative repair can be completed.

Tomorrow: an off-label use for this catheter in abdominal trauma!

Do Children With Low Grade Solid Organ Injury Need To Transfer To A Pediatric Trauma Center?

Pediatric trauma centers have an excellent reputation when it comes to caring for children when compared to their adult counterparts. Overall mortality for major trauma is lower. Splenectomy rates and the use of angiography are less in children with solid organ injury. And because of this expertise, it is common for surrounding trauma centers of all levels transfer these patients to the nearest pediatric trauma center.

But is this always necessary? Many of these children have relatively minor injury, and the pediatric trauma centers can be few and far between unless you are on one of the coasts. Researchers at the University of Washington, Harborview, and Seattle Children’s looked at their experience with pediatric transfers (or lack thereof) with spleen injury.

They retrospectively looked at 15 years of transfer data. The Seattle hospitals are the catchment area for a huge geographic area in the northwest, and the state trauma system maintains detailed records on all transfers to a higher level of care. Patients 16 years or younger with low grade (I-III) spleen injury were included. In an effort to narrow the focus to relatively isolated spleen injury, patients were excluded if they had moderate injuries in other AIS body regions.

Here are the factoids:

  • During the study, over 54,000 patients were admitted to hospitals, but only 1,177 had isolated, low grade spleen injury
  • About 20% presented directly to a Level I or II trauma center, 30% presented to a lower level center and were transferred, and 50% stayed put at the lower level center they to which they presented
  • 40 patients (3%) underwent an abdominal operation presumably for their spleen, but there was no difference based on which hospital they presented to or whether they were transferred
  • The incidence of total splenectomy was not different among the three groups
  • Likewise, there was no difference in ICU admission or ICU length of stay
  • The only significant difference was that patients who were not transferred to a pediatric center usually spent an extra day in the hospital

Bottom line: Injured children tend to do well, regardless of where they are treated. This study is huge and retrospective, which can cause analysis problems. And even given the size, the total number eligible for the study was relatively small. But it is the best study to date that shows that it is possible to treat select low grade injuries at non-pediatric, non-high level trauma centers. However, before going down this path, it is extremely important to define specific “safe” injuries to manage, and to have an escape valve available in case the patient takes an unexpected turn.