All posts by TheTraumaPro

July Trauma MedEd Newsletter Is Here!

The current newsletter is here! Subscribers will receive the next issue of the Trauma MedEd late tonight. The topic for the month is TBI.

Topics will include:

  • Apps for concussion testing
  • Field concussion testing for athletes
  • Diffuse axonal injury
  • Inappropriate neurosurgical consultation
  • And more!

To ensure you get it ASAP, click here to subscribe and download back issues. Non-subscribers will be able to download it this Friday.

WTF? A Fractured Rudimentary Rib?

Is it real, or just another one of those crazy things that radiologists like to add to their reports? I recently came across one of these for the first time in over 30 years of practice. What is it? And is it significant in your management of a trauma patient?

A rudimentary rib is simply an extra one (supernumerary). They can be found on vertebrae where ribs are not supposed to be present, typically C7 and L1. The most common supernumerary ribs are found at C7, and are a well documented cause of thoracic outlet syndrome. 

Rudimentary ribs are less commonly found on lumbar vertebrae, and they tend to be longer than the transverse processes. This means that it is possible to break them given moderate to high energy blunt torso trauma. The image below shows a person with 2 rudimentary lumbar ribs on L1.

These are very rare congenital variants. It is more likely that your patient is showing abnormal bone formation after a previous fracture, so question them closely for a history of trauma.

What’s the clinical significance? There’s little chance of hemothorax or pneumothorax. But they cause pain like any other fracture. Just apply your usual routine for rib fracture management: analgesia and pulmonary toilet. Since it takes a relatively large amount of energy to break these short little ribs, be on the lookout for other occult injuries as well.

Bottom line: This isn’t just a weird radiology “red herring.” Rudimentary rib fractures can occur, although a history of previous injury should be ruled out. Manage like any other rib fracture, but beware of potential occult injuries.

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The Contaminated Patient

In my last post, I presented the issue of dealing with a surprise patient who was both in arrest and contaminated with gasoline. They are brought into your resuscitation room without warning of the potential hazard. Now that they are here, what do you do?

Thanks for the many online and email responses. This is a tough question, because there are so many variables to think about. And you have to make decisions very quickly. Here’s a rundown on my thought processes.

First, if you get an indication that there might be any type of contamination, insist that your prehospital providers hold the patient outside the ED. Have part of your trauma team waiting at the ambulance dock to do a quick assessment there. Another minute or two of Lucas CPR will not make a difference. Use your best judgment as to how much of a hazard is posed by the fuel/mystery liquid/white powder. But err on the side of being conservative so you don’t end up shutting your entire ED down due to contamination. If in doubt, immediately move to your decontamination area.

If the patient ends up deep in your ED before anyone recognizes that there might be a contamination problem, you must heed three overarching principles:

  • Limit contamination to the rest of your facility. Close the doors to the resuscitation room. Notify security and your hazardous materials team so they can start working on containment and safety issues outside the room. Failure to do this can take your entire hospital offline. If the situation turns out to be a multiple or mass casualty event and your hospital was the only one able to respond, you’ve just created a catastrophe and delayed treatment for the other patients.
  • Ensure the safety of your team. This is a great reason to require and enforce that everyone on the team dress up completely for every resuscitation. You never know where your patients have been, and when one of these will sneak in.
  • Continuously assess the risk:benefit ratio. Is the contamination a minor irritant? What is the danger to the team? The ED/hospital? How likely are your efforts to save the patient to succeed? As soon as the ratio goes bad, rethink the options and act accordingly.

Bottom line: In situations like this, think fast and think globally. Don’t just consider the patient. There may be many more lives at stake, and this can and should factor into your decisions about where and how long to continue resuscitation.

In this case, we were certain it was only gasoline. We closed the doors and quickly stripped the patient, bagging the clothes tightly. We tried not to generate any sparks, but we are surrounded by all kinds of electrical equipment. Defibrillation was out of the question. After the event was finished, it was time to wash everything down and start thinking about what would have happened if this had been something more toxic than fuel!

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