All posts by TheTraumaPro

Doctor, I Fell On That Knife! Really!?

I’ve had this mechanism of injury described about once a year for my entire career.

“I was just washing the dishes, and I dropped a knife while I was drying it. When I went to pick it up, I lost my balance and tripped over the rug in front of my sink. Then I fell down on the knife, and there you have it”.

What does it really mean?

First, think about physics. Most knives do not land standing straight up. They don’t even land on their side with the blade side up. They land flat with the sharp side perpendicular to anything that might fall on top of it.

Then think about Occam’s razor. You remember, Sir William of Occam back in the 1300’s. He popularized the principle of parsimony in problem solving. What does this mean? If you have more than one possible explanation (or hypothesis) for an event, the simplest one should be selected. Well, the falling down “hypothesis” is way too complicated.

What does it really mean? Your patient either stabbed themself (most common reason), or they are trying to protect the person who really did it (significant other). What to do? Interrogate them, asking the same thing over and over. Ask for exact details. Ask until the story changes. Have other people ask. Sooner or later, you’ll get the answer you were expecting. Then get the appropriate professionals involved to help with the problem (psych, law enforcement, etc).

The January newsletter is now available! Yes, it’s a little late due to my travel schedule. Click the image below or the link at the bottom to download. This month’s topic is Pediatric Trauma. 

In this issue you’ll find articles on:

  • Pediatric ATV injuries
  • DVT in children
  • Identifying sick pediatric trauma patients early
  • Pneumothorax in kids
  • Pediatric pneumomediastinum

Subscribers received the newsletter first on Friday. If you want to subscribe (and download back issues), click here.

Download the newsletter here!

Pancreatic Injury Part 4 – Nonop Management For Kids?

Over the past 30 years or so, we’ve made major advances in managing many injuries without operation. Blunt injuries to liver, spleen, and kidney, along with some penetrating injuries to the liver come to mind. But as we have seen many times in medicine, the pendulum sometimes swings too far.

Hopefully, I’ve impressed upon you how strange and potentially treacherous the pancreas is. In recent years, some centers have dabbled with nonoperative management of the pancreas in children. The belief has been that, since kids heal so much better than adults, maybe the pancreas will be more forgiving in that age group. Unfortunately, the only studies to date have been small, single center work.

But now, a collaborative Pancreatic Injuries In Children Study Group has published results of a multi-institutional retrospective review which will hopefully lay this debate to rest (at least for a while).

Here are the factoids:

  • The study reviewed data from 1195-2012 (18 years!) on patients less than 18 years old. Only grade II or III injuries were selected. Grade was determined by CT, ERCP, MRCP or at operation.
  • Fourteen centers participated, submitting data on 167 patients. These are huge numbers for this uncommon injury!
  • 57 underwent distal pancreatectomy, 95 were managed without operation. The remainder were drained and were studied separately.
  • Diet was resumed significantly more quickly (8 days vs 15 days) in the resection group
  • More endoscopic and interventional procedures were needed due to pseudocyst formation in the nonoperative group (26% vs 2%)
  • Patients with Grade III injuries (distal duct) had fewer complications after resection (33% vs 61%)
  • Hospital stay was significantly shorter in the resection group (13 vs 18 days)

Bottom line: Operative resection of distal pancreatic injury in children is the way to go, just as it is in adults. Persistent attempts to treat without surgery keeps the child in the hospital longer, exposes them to additional invasive procedures, and is fraught with more complications. You may think you’re saving them the pain of major abdominal surgery, but you are just prolonging the torture with endoscopy, IR drainage, repeated blood draws, and starvation.

Related posts:

Reference: Operative vs nonoperative management for blunt pancreatic transection in children: multi-institutional outcomes. J Am Coll Surg 218(2):157-162, 2014.

January Newsletter Released To Subscribers Tonight!

Due to my heavy travel schedule last month, I’ve been slow in getting the January newsletter together. But it’s now ready! The topic is Pediatric Trauma. Articles include:

  • Pediatric ATV injuries
  • DVT in children
  • Identifying sick pediatric trauma patients early
  • Pneumothorax in children
  • Pediatric pneumomediastinum

Anyone on the subscriber list as of 8PM tonight (CST) will receive it by email tonight. I’ll release it to everyone else next Monday via the blog. So sign up for early delivery now by clicking here!

Pick up back issues here!

Pancreatic Injury Part 3 – Management

I hate the pancreas. It just doesn’t play by the rules. No matter how good your operation is, there are frequent complications caused by this organ. Thus, my management recommendations are based on simplicity. Easy stuff is good. No anastomoses are better than one or more.

So you’ve already figured out the location and presence or absence of ductal injury, meaning that you know the grade. Let’s look at what you can do by grade.

  • Grade I – somebody rubbed the pancreas. Really, you only need to worry about a little “pancreas sweat”, secretions from roughed up surfaces on the gland. I recommend placing a nice drain in the vicinity to carry this fluid away. This is especially important if there are bowel injuries / anastomoses in nearby areas.
  • Grade II – somebody punched the pancreas. This can also be caused by anatomic issues when removing the spleen. Once again, drainage of (non-ductal) secretions is key, so a nice big fat drain is in order.
  • Grade III – distal duct injury. A simple, distal pancreatectomy is in order. I like to do this with a linear stapler, and I typically do not try to spare the spleen. It just takes too long, and you may push your badly injured trauma patient down the damage control route if you persist with saving the spleen for too long.
  • Grade IV – injury to the proximal pancreas with duct. You can get fancy here and do resections and roux-en-y limbs and all kinds of stuff. But I try to keep it simple, and if the destruction is not too bad, I’ll just drain it. External drains are good, but in some more severe cases I will drain internally via a roux limb (shudder). On rare occasion, a proximal pancreatectomy with roux drainage of the distal portion may be considered. 
  • Grade V – shattered head plus/minus duodenum. Oh crap! The only way out of this is with a pancreaticoduodenectomy, and it’s tough to find a good time with major trauma patients. If they are well-behaved during the initial operation, get started with it. If they are not, or start to have problems during, you can continue to the first damage control takeback. But, to ensure the best quality tissue for anastomoses, you must finish at the first takeback! And expect complications. They always get them.

Friday, I’ll talk about the (foolhardy) idea of trying to treat this injury nonoperatively in children.

Related posts: