Here’s a short, 5 minute video on how to grade spleen injuries like a pro! Enjoy!
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Here’s a short, 5 minute video on how to grade spleen injuries like a pro! Enjoy!
Related posts:
Yesterday, I wrote about ways to reduce and hopefully eliminate retained foreign bodies (instruments, sponges) during damage control surgery. Today, I’ll provide a sample x-ray and some tips on how to use this tool most effectively.
Here is an abdominal x-ray obtained just prior to closure of a patient who underwent damage control laparotomy. The OR record and surgeon from the initial operation documented that four sponges had been left in place for hemostasis.
Nothing retained, right?
Wrong! This image is not complete. This patient is larger than the x-ray plate used. The area under the diaphragms, the pelvis, and the entire left side of the peritoneal cavity have not been visualized.
Tips for imaging for damage control closure:
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Damage control surgery for trauma is over 20 years old, yet we continue to find ways to refine it and make it better. Many lives have been saved over the years, but we’ve also discovered new questions. How soon should the patient go back for definitive closure? What is the optimal closure technique? What if it still won’t close?
One other troublesome issue surfaced as well. We discovered that it is entirely possible to leave things behind. Retained foreign bodies are the bane of any surgeon, and many, many systems are in place to avoid them. However, many of these processes are not possible in emergent trauma surgery. Preop instrument counts cannot be done. Handfuls of uncounted sponges may be packed into the wound.
I was only able to find one paper describing how often things are left behind in damage control surgery (see reference below), and it was uncommon in this single center study (3 cases out of about 2500 patients). However, it can be catastrophic, causing sepsis, physical damage to adjacent organs, and the risk of performing an additional operation in a sick trauma patient.
So what can we do to reduce the risk, hopefully to zero? Here are my recommendations:
Tomorrow, a sample damage control closure x-ray.
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Reference: Retained foreign bodies after emergent trauma surgery: incidence after 2526 cavitary explorations. Am Surg 73(10):1031-1034, 2007.
One of the tenets of trauma surgery, handed down for generations, is that we should pack the abdomen to help manage major abdominal hemorrhage. “All four quadrants were packed” reads the typical operative note. But how exactly do you do that? Sounds easy, right?
Well, there are nuances not found in the surgery textbooks. Here are some practical tips for the trauma surgeon:
On Monday, I’ll write about the importance of the final x-ray when the abdomen is closed.
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Trauma centers generally design their trauma teams around the type and volume of injured patients they receive. There must be sufficient depth of coverage to handle multiple “hits” at once. But even the best planning can be overwhelmed by the occasional confluence of the planets where multiple, multiple patients arrive during a relatively short period of time (the “crunch”).
As the reserve of available trauma professionals to see new, incoming patients dwindles, it sometimes even becomes necessary to close the center to new patients. Once those who have already arrived have been processed, the trauma center can open again.
This scenario, while hopefully rare, unfortunately introduces a huge opportunity for errors and omissions in care. There is much more clinical activity, lots of patient information to be gathered and processed, and many decisions to be made. How can you reduce the opportunity for these potential problems?
Consider a “post-crunch” debriefing! Once things have quieted down, assemble all team members in one room. Systematically review each patient involved in the “crunch”, going through physical exam, imaging, lab results, and the final plan. It’s helpful to have access to the electronic medical record during this process so everything that is known can be reviewed. Make sure that all clinical questions are answered, and that solid plans are in place and specific people are assigned to implement them.
Once you’ve reviewed all of the incoming, don’t forget your patients already in the hospital. Significant issues may have occurred while you were busy, so quickly review their status as well. Chat with their nurses for updates. Make sure they are doing okay.
Then prepare yourself for the next “crunch”!
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