A common dogma in trauma training is: “Watch out for the box!” This area on the anterior chest is purported to indicate high risk of cardiac injury in patients with penetrating trauma.
Where is it, exactly? Technically, it’s the zone extending from nipple to nipple, and from sternal notch to xiphoid.
But is the dogma true? A number of (old) papers mapped out the location and incidence of cardiac injury in stabs to the chest and upper abdomen. And there is a pretty good correlation. For stab wounds. But what about gunshots?
A team at Emory University ran a retrospective review of their trauma registry data over a three year period.
Here are the factoids:
They saw nearly 90 patients per year with penetrating chest wounds. Of these, 80% were gunshots (!) Many had more than one penetration.
Of the 233 gunshots inside “the box”, 34% injured the heart
The remaining 44 gunshots outside “the box” hit the heart 32% of the time
The authors suggest shifting the definition of “the box” toward the left, so that it extends from anterior midline, wraps around the left chest, and ends in the posterior midline (see below)
Bottom line: Here’s the problem. Knives are attached to a handle which tends to stay outside your patient. Thus, it can only go so deep. But a bullet will keep going until something stops it, or it runs out of gas. So it makes sense that the traditional boundaries of “the box” don’t apply. But extending it to include the left lateral chest and exclude everything on the right side? It may make statistical sense in this study, but common sense dictates that the trauma professional needs to think about the heart any time a gunshot goes anywhere near the chest or upper abdomen. Do not limit yourself to any “box!”
Reference: Redefining the cardiac box: evaluation of the relationship between thoracic gunshot wounds and cardiac injury. AAST 2016 Paper #12.
Most trauma programs tend toward using low molecular weight heparin (LMWH) products for VTE prophylaxis over plain, old-fashioned unfractionated heparin (UH). How did this happen? LMWH is more expensive than UH, and there is precious little high quality research supporting it.
But, LMWH is very convenient, as it only needs to be given only once or twice daily via subq injection, whereas UH is given as a continuous infusion or subq three times a day. And a fair amount of lower quality data suggests that it is effective in decreasing deep venous thrombosis (DVT) and pulmonary embolism (PE).
This abstract comes from Sunnybrook in Toronto. The authors used sophisticated statistical models to compare centers that predominantly use LMWH to prevent VTE vs those that use UH.
Here are the factoids:
This was a huge data analysis from the ACS Trauma Quality Improvement Program database (~ 110,000 records from 214 trauma centers)
LMWH was most commonly used, 74% of the time
Patients who were more likely to need rapid reversal were more often given UH (older patients, severe TBI, early intracranial interventions)
Pulmonary embolism was significantly lower with LMWH (1.8% vs 2.4%)
This significant effect was present across all subgroups, including patients with shock, blunt multisystem injury, penetrating trunk injury, isolated orthopedic injury, and severe TBI
Trauma centers that predominantly used LMWH had significantly lower PE rates compared to UH (1.2% vs 1.8%)
Bottom line: Even given the vagaries of using huge, retrospective database reviews, this is pretty good data. The use of LMWH appears to be superior to UH in reducing the incidence of pulmonary embolism. It does not prevent it completely. But it’s a good start.
What the authors do not say, and I am curious about, is the impact on DVT. That is a much more common problem than PE. Was there any difference? Did they run out of room to comment on it in the abstract? I kind of doubt it. The devil will be in the details. Listen in on the presentation at the meeting!
Reference: Efficacy of low molecular weight heparin vs unfractionated heparin to prevent pulmonary embolism following major trauma: results from the American College of Surgeons Trauma Quality Improvement Program. AAST 2016 Paper #5.
The 75th annual meeting of the American Association for the Surgery of Trauma (AAST) is just around the corner. It’s being held on the big island of Hawaii, which pretty much guarantees a large turnout. Hard to resist a little vacation time tacked on to the meeting!
Starting tomorrow, there are 17 weekdays left until the end of the meeting. This year, there are a lot of interesting abstracts, and I’ll be posting info and my commentary about the best of the best (and maybe some worst of the worst?).
Here are some of the topics I’ll be covering:
Which is better for pulmonary embolism prevention: Unfractionated vs low molecular weight heparin?
The cardiac “box”
Which ICU is better for neurotrauma patients: neuro-ICU, trauma-ICU, or med/surg-ICU?
A scoring system for identifying appropriate patients for air transport
The Cribari Matrix and over/undertriage
Preperitoneal pelvic packing
Are graduating surgery residents qualified to take trauma call?
Nurses who take care of trauma patients run into this all the time. “The cervical spine is cleared,” they say. But who is “they?” How did “they” do it? What is the patient now allowed to do? And what’s the deal with this funky collar?
This 11 minute video will provide the answers to these questions and more! Enjoy!