All posts by TheTraumaPro

When Is It Too Late To Call A Trauma Activation?

Admit it. It’s happened to you. You get paged to a trauma activation, hustle on down to the ED, and get dressed. The patient is calmly and comfortably lying on a cart, staring at you like you’re from Mars. Then you hear the story. He has a grade V spleen injury. But he just got back from CT scan. And his car crash was yesterday

Is this appropriate? The answer is no! But, as you will see, the answer is not always as obvious as this example. The top thing to keep in mind in triggering a trauma activation appropriately is the reason behind having them in the first place.

The entire purpose of a trauma activation is speed. The assumption must be that your patient is dying and you have to (quickly) prove that they are not. It’s the null hypothesis of trauma.

Trauma teams are designed with certain common features:

  • A group of people with a common purpose
  • The ability to speed through the exam and bedside procedures via division of labor
  • Rapid access to diagnostic studies, like CT scan
  • Availability of blood products, if needed
  • Immediate access to an OR, if needed
  • Recognition in key departments throughout the hospital that a patient may need resources quickly

Every trauma center has trauma activation triage criteria that try to predict which patients will need this kind of speed. Does the patient in the example above need this? NO! He’s already been selected out to do well. Why, he’s practically finished the nonoperative solid organ management protocol on his own at home.

Here are some general rules:

  • If the patient meets any of your physiologic and/or anatomic criteria, they are or can be sick. Trigger immediately, regardless of how much time has passed.
  • If they meet only mechanism criteria and it’s been more than 6 hours since the event, they probably do not need the fast track.
  • If they only meet the “clinician / EMS judgment” criteria, think about what the suspected injuries are based on a quick history and brief exam. Once again, if more than 6 hours have passed and there are no physiologic disturbances, the time for needing a trauma activation is probably past.

If you do decide not to trigger an activation in one of these cases, please let your trauma administrative team (trauma medical director, trauma program manager) know as soon as possible. This may appear to be undertriage as they analyze the admission, and it’s important for them to know the reasoning behind your choice so they can accurately document under- and over-triage.

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What To Do? Small Hospital, Unstable Patient

It’s the situation that physicians in smaller hospitals dread. A major trauma patient gets dropped off at the door. You do your evaluation, quickly determining that they need services that you don’t just have (head injury and positive FAST in the abdomen, let’s say). You call your community EMS service to transport to a Level I trauma center, which is about 30 minutes away by ground. And just as they are rolling out the door to the rig, the blood pressure drops to 60! What to do?!

The ATLS course is very clear, and very correct. Back into the ED for a quick re-evaluation. The most common cause for a significant disturbance in vitals or exam lies within the primary survey. You will almost always find a problem with Airway, Breathing, or Circulation. (A Disability problem can cause a problem on rare occasion (hypotension from impending herniation), but there’s not much that you can do about it, really. Hyperventilate, hyperosmolar therapy, okay but probably a poor outcome for the patient anyway.)

So you didn’t find any airway or breathing issue. But the abdominal stripe(s) you saw on FAST are larger, so it’s circulation. Now what? And does it matter if you have a surgeon available on call? The answer is simpler than you think.

ATLS says that, if you have surgical support available you have to use it in this type of situation. If you don’t have it, package the patient with a lot of blood and plasma and send. If you have a physician or nurse to spare you could consider sending them along to help during transport, but for small community hospitals this is not practical.

But if you do have a surgeon, does it make sense to use them? Not always! You must take into account response times and transport times. Let’s say it’s 2:00 am and you call your surgeon for this hypotensive patient. They may take up to 30 minutes to get in and see the patient. They then agree that the patient needs a laparotomy and she proceeds to call in the OR team. Yet another 30 minutes tick by.  Will the patient still even be alive when they roll into the OR?

Or you could just put the patient back in the ambulance (air preferably, but ground if you have to) and get them to your trauma center quickly. They can then be whisked directly into a waiting OR in less than 30 minutes from your door. This is probably the ideal solution here. Obviously this doesn’t work as well if you are a few hours away from your resource trauma center. 

Bottom line: Deciding what to do with a patient that needs urgent treatment that you can’t immediately deliver is tough! That’s why it’s always a calculus problem when you’re faced with this situation. But take all of the response and transport times into account, and do what’s best for your patient! 

Nail In The Neck: A Novel Removal Option

Here’s a post from my archive describing a different way to remove the foreign body. This is the technique I used, instead of the standard neck incision. The final incision was just a slight extension of the puncture wound, measuring only 1cm. I was able to grasp the head and pull it out without difficulty. The surprising thing to me was the amount of force I needed to apply to actually pull it out! No bleeding, no problems. The patient was observed for 24 hours and discharged home. He had no complications.

A Cool Way To Remove Embedded Foreign Bodies

Many of us have had the experience of digging into bloody tissue for long periods of time trying to locate the object, even with fluoroscopy. Well, there’s a better way of doing this.

A group in China described a technique using a fancy form of needle localization. They employed a set of instruments normally used for lumbar diskectomy (see photo). This set includes a long 18 Ga needle with a removable hub, several dilators and an outer cannula with a 5.8mm diameter. A pair of 3.8mm grasping forceps is also used.

The foreign body is located using a C-arm fluoroscopy unit and the best approach is planned. The 18 Ga needle is then inserted using fluoro until it touches the object. The hub is removed and dilators are inserted over the needle, one after the other. The outer cannula is then placed over them, and the needle and dilators are then removed. The cannula is manipulated until the foreign body (or a part of it) is located within the cannula. It is then grasped and removed, along with the cannula if needed. If the object is too large to enter the cannula, the cannula is pulled back slightly and the grasper introduced past the end of it to grip and remove the foreign body.

The writers shared the details of 76 patients who had a total of 251 foreign bodies removed over a 6 year period. The depth varied from 2.5 to 8.5cm. Procedure time ranged from 8 to 15 minutes, and fluoro exposure varied from 1 to 4 minutes. Success rate was 100% (all foreign bodies were removed) and there were no complications.

Bottom line: This is a very slick technique that promises to dramatically increase the success rate and decrease complications from removing foreign bodies. The amount of time spent is much less than the brute force technique, as is the amount of soft tissue trauma. Large objects that cannot be grasped with these forceps cannot be removed with this method. Although I am a little concerned that the authors’ results were so perfect, it’s certainly worth a try!

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Reference: Percutaneous extraction of deeply-embedded radiopaque foreign bodies using a less-invasive technique under image guidance. J Trauma 72(1):302-305, 2012.

Nail In The Neck: The Operation

We’ve made sure that our victim of the nail gun to the neck did not need an emergent operation. Vitals are stable, there’s no uncontrolled hemorrhage, and the patient is neurologically intact. We’ve imaged him using CT angiography, and the nail does not appear to have injured any vital structures.

How do we get it out of there? There are two things that need to be considered: where and how. 

Rule of thumb: If a foreign body is located anywhere near vital structures, take it out in the OR, no matter how good you think the imaging is. It may be tempting to just pull it out in the ED, but resist! CT scans look so good, and they are so detailed, but they are not perfect. The ED does not have the equipment, personnel, or lighting necessary if something goes awry.

Rule of thumb: Use all information available to plan the removal procedure. In this case, the head of the nail is to the patient’s right. Therefore, it must be removed from the right side. The CT shows that the nail passes very close to the posterior pharynx, so it will need to be evaluated during the procedure.

This patient was taken to the operating room. During the intubation, direct laryngoscopy was carried out to carefully inspect the entire pharynx and larynx. No evidence of penetration was seen. The entire neck, face, and upper chest were prepped and draped (I like to go overboard in trauma cases; you never know what is going to happen). Fluoroscopy was available.

The classic operation would have been to make an incision along the sternocleidomastoid on the right side. The nail head would be approached directly. Since long, thin objects can be notoriously difficult to locate, fluoro can be very helpful. The exact position with respect to the carotid and jugular can be ascertained. Then the nail head is grasped with a clamp, and the nail gently pulled out along its axis. A nice, long wait for any evidence of bleeding should occur. The area can then be irrigated and the incision closed. Skin antibiotics can be given postop, but only one dose at most.

Having said that, I opted for a different approach based on an old blog post here. Tune in tomorrow to see what I really did.

Nail In The Neck: Part 2

This case involves an accidental nail gun injury to the neck. The patient is hemodynamically stable, neurologically intact, the airway is patent and not threatened, and there is no apparent hematoma. There is a small puncture near the sternocleidomastoid muscle on the right, fairly high on the neck. The nail is not palpable on either side. And the patient only complains of a little discomfort when he swallows.

What to do? First, the patient has passed all the initial decision points that would send us straight to the OR (ABC problems in ATLS jargon). But, per physical exam and initial imaging, the nail must obviously come out. We just have to figure out what we need to know before we take it out, and determine the best way to retrieve it.

Given the patient’s stability, additional imaging will be helpful. Views in different planes, and details of what the nail might have passed through will be invaluable. The recommended study is a CT angio of the neck. This will give good information about nearby structures and the vasculature. And software reconstructions will provide good 2D/3D information for removal planning. Here’s a lateral view.

image

The nail is located in front of the body of C2. It appears to be high enough to be near the pharynx, but well above trachea and esophagus. You can also see that the nail entered a little posteriorly, and travels right to left and forward. 

Here’s a representative CT slice.

image

The nail enters behind the carotids (just above the bifurcation) and IJ on the right, and ends anterior to them on the left. It passes very close to the posterior pharynx. So neurovascular structures are intact, and the aerodigestive tract is a maybe (back of the pharynx).

Obviously, this thing has to come out. The question is, how to do it? For you surgeons out there, tell me your choice of approach, incision, and instrumentation. Tweet or leave comments! Answers on Monday.

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