Hemothorax is a common complication of chest trauma, occurring in about one third of cases. It is commonly treated with a chest tube, which usually takes care of the problem. But in a few cases some blood remains, which can result in an entrapped lung or empyema.
There are several management options. Historically, these patients underwent thoracotomy to peel out the fibrinous collection stuck to lung and chest wall. This has given way to the more humane VATS procedure (video assisted thoracoscopic surgery) which accomplishes the same thing using a scope. In some cases, another tube can be inserted, sometimes under CT guidance, to try to drain the blood.
So what about lytics? It’s fibrin, right? So why not just dissolve it with tissue plasminogen activator (tPA)? There have been very few studies published over the years. The most recent was in 2014. I’ll review it today, and another tomorrow. Finally, I’ll give you my thoughts on the best way to deal with retained hemothorax.
Here are the factoids:
This was a single center, retrospective review of data from 1.5 years beginning in 2009
A total of seven patients were identified, and most had hemothorax due to rib fractures. Three presented immediately after their injury, 4 were delayed.
Median time from injury to chest tube placement was 11 days
Median time the chest tube was in place was 13 days, with an average hospital stay of 14 days
Patients received 1 to 5 treatments, averaging 24mg per dose
There was one death in the group, unrelated to TPA treatment
No patient “required” VATS, but one underwent thoracotomy, which turned out to be for a malignancy
Bottom line: The authors conclude that tPA use for busting retained hemothorax is both safe and effective. Really? With only seven patients? The biggest problem with this study is that it uses old, retrospective data. We have no idea why these patients were selected for tPA in this 5-year old cohort of patients. Why did it take so long to put in chest tubes? Why did the chest tubes stay in so long? Maybe this is why they were in the hospital so long?
Plus, tPA is expensive. A 100mg vial runs about $6000. Does repeatedly using an expensive drug and keeping a patient in the hospital an extra week or so make financial sense? So it better work damn well, and this small series doesn’t demonstrate that.
Tomorrow, I’ll look at the next most recent paper on the topic, from way back in 2004.
Most patients with mild traumatic brain injury (TBI) recover quickly and have few sequelae. Headache is common during the first few hours or days. But some patients experience significant and sometimes unrelenting headaches after their injury. How should we treat them? Are they the same as other common headaches?
There are several common types of headaches that are not related to brain injury, but many of these can begin after TBI. These include tension headaches from muscle tension or spasm, cervicogenic headaches from strains, sprains or more significant injury to the neck and cervical spine, musculoskeletal headaches from pain in bone or muscle in the head or neck, and headaches related to the TMJ and jaw.
But many patients experience significant headaches without any of these factors. Why? Sometimes it is due to blood in or around the brain, irritating the meninges. But often, there is nothing that we can detect using our current diagnostic technology. However, even if we can’t find a reason, the headache is very real and very concerning to the patient.
I’ve seen practitioners treat post-TBI headaches with a variety of drugs ranging from acetominophen and NSAIDs to anti-seizure and psychotropic drugs. Unfortunately, there is little literature support for any of them. A review article published in 2012 found only one article with Class II data that showed no lasting effect from manipulation therapy.
So what do we do? Here is an algorithm suggested by the review article:
Consider a workup to rule out intracranial pathology as a source of the headache
Categorize the headache. If it is one of the non-TBI types listed above, treat appropriately.
If the headache severely limits function, consider time-release opioids
For milder headache, consider adetominophen or NSAIDs
Treat any comorbidities that may contribute to headache
If the headache has migraine-type properties, treat as such
If the headache is associated with cervical spine pain, mobilize the neck as appropriate
Bottom line: There is very little guidance for treatment of headache purely associated with TBI. Time-honored drugs like opioids for severe pain and acetominophen and NSAIDs for mild to moderate pain help, but generally do not entirely relieve the pain. Only tincture of time will make things better. And it’s probably best to stay away from prescription drugs other than opioids recommended for the pain. They have not been shown to work, and there are plenty of side effects to worry about.
Prescription drugs and side effects
Reference: Systematic review of interventions for post-traumatic headache. PM&R. 4(2):129-140, 2012.
I’m going to send out the next edition of the Trauma MedEd newsletter this coming weekend. I’m writing about a number of miscellaneous topics (Potpourri) that have intrigued me. And hopefully they will intrigue you as well.
Here are some of the topics:
Aspirin for DVT prophylaxis. A number of my orthopedic colleagues swear that this works, but I’ve been skeptical. What does the literature really say?
Outcomes of thoracic endovascular aortic repair (TEVAR). This has become the treatment of choice in blunt traumatic aortic injury. How do these patients really fare over time?
Does MRI of the cervical spine assist in clearance? A look at the ReCONECT study.
The VIP syndrome occurs in healthcare when a celebrity or other well-connected “important” person receives a level of care that the average person does not. This situation was first documented in a paper published in the 1960s which noted that VIP patients have worse outcomes.
Who is a VIP? It may be a celebrity. A family member. Or even a colleague. VIPs (or their healthcare providers) may have the expectation that they can get special access to care and that the care will be of higher quality than that provided to others. Healthcare providers often grant this extra access, in the form of returned phone calls and preferential access to their clinic or office. The provider tries to provide a higher quality of care by ordering additional tests and involving more consultants. This idea ignores the fact that we already provide the best care we know how, and money or fame can’t buy any better.
Unfortunately, trying to provide better care sets up the VIP for a higher complication rate and a greater chance of death. Healthcare consists of a number of intertwined systems that, in general, have found their most efficient processes and lowest complication rates. Any disturbance in this equilibrium of tests, consultants, or nursing care moves this equilibrium away from its safety point.
Every test has its own set of possible complications. Each consultant feels compelled to add something to the evaluation, which usually means even more tests, and more possible complications. And once too many consultants are involved, there is no “captain of the ship” and care can become fragmented and even more inefficient and dangerous.
How do we avoid the VIP Syndrome? First, explain these facts to the VIP, making sure to impress upon them that requesting or receiving care that is “different” may be dangerous to their health. Explain the same things to allproviders who will be involved in their care. Finally, do not stray from the way you “normally” do things. Order the same tests you usually would, use the same consultants, and take control of all of their recommendations, trying to do things in your usual way. This will provide the VIP with the best care possible, which is actually the same as what everybody else gets.
Reference: “The VIP Syndrome”: A Clinical Study in Hospital Psychiatry. Weintraub, Journal of Mental and Nervious Disease, 138(2): 181-193, 1964.
Your preparation. You should already have full personal protective gear on, right? Right? Your existing gear is just fine. You do not need to change to sterile gown and gloves. The time wasted is probably not worth the low risk of infection in the rare event that the mother survives.
You need at least one assistant, preferably two. They will pass you instruments and provide retraction. Continue CPR throughout the procedure.
At the same time, call your OB and neonatal colleagues, if you haven’t already. If you don’t have any at your hospital, don’t sweat it. If you do, don’t wait for them to arrive.
Patient preparation. Have someone quickly insert a foley catheter.
Do not use sterile technique. It just slows things down. The bladder needs to be empty so you can quickly and easily get to the uterus.
The procedure. Here’s the blow by blow:
Splash some betadine on the skin. The mother is probably not going to survive, so infection is not a concern.
Make a midline, vertical incision from mid-epigastrium to pubis. Extend down to the midline fascia.
Enter the peritoneal cavity near the umbilicus. Extend the incision along the full length of the skin incision using scissors.
Use the scalpel to make a 4cm vertical incision near the top of the uterus. Insert your 2nd and 3rd fingers into the uterus, directed downwards. Use them to protect the fetus from the scissors as you use them to extend the uterine incision downwards.
Rupture the membrane with a clamp and deliver the baby. Remember, the membrane is tough! Insert your hand deep into the lower uterus under the baby’s head. Flex the body as you gently push upwards to deliver the head first. Suction the mouth and nose, then deliver the shoulders and body.
Cut and clamp the cord. Hand off the baby to another team for suctioning and resuscitation.
Continue to try to revive the mother. If circulation is restored, move immediately to an OR for delivery of the placenta, control of the bleeding that was killing her in the first place, and hopefully, closure.
Here’s a video that shows how quickly the procedure can be done (with a few edits). Just watch the first 47 seconds!
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