All posts by TheTraumaPro

How To: Deal With Fence Impalement (Part 1)

The first part of this post is for my prehospital colleagues. We’ve probably all seen one of these at least once. Someone decides that want to take the short cut. Over a wrought iron fence. Alcohol is usually involved. They get to the top, but just before they can get over, they slip. The top of the fence impales their thigh!

This example comes from a TV news site in Los Angeles.

Let’s say you are one of the first responders at the scene. What do you do? Pull him off or leave him impaled? What equipment do you need? How do you avoid further harm? How do you fit him into your rig? How do you even secure it? Tweet you answers or leave comments below.

I’ll share some of my ideas on Monday, as well as the xray. Then we’ll talk about the in-hospital management piece. 

New Technology: Artificial Bones

Most orthopaedic injuries are very handily fixed by our friendly neighborhood orthopaedic surgeons. But occasional patients have bony injuries so severe that they challenge even the best of them. Think motorcycle crashes, mangled extremities and bone loss.

Researchers at universities in Edinburgh and Southampton have developed an experimental product that may facilitate rebuilding these challenging injuries. They created a plastic polymer that is honeycombed with small holes. These holes allow blood to flow through it, enabling stem cells from the bone marrow to take up residence and rebuild bone. Once new bone has formed, the plastic slowly degrades, leaving only the patient’s own tissues.

This image show proteins from skeletal stem cells that have been cultured on a plastic scaffold

This new product has been tested successfully in animals, and work is underway to get approval for human testing.

Bottom line: Although many years away, this product may increase the number of limbs salvaged after mangling type injuries to the extremities.

Related post: 

Reference:Discovery and Evaluation of a Functional Ternary Polymer Blend for Bone Repair: Translation from a Microarray to a Clinical Model.  Advanced Functional Materials ePub Jan 25, 2013.

The 8 Hour Rule For Open Fractures: We’re So Over That

For decades, the standard of care for irrigation and debridement (I&D) of open fractures has been within 8 hours of injury. There is a growing body of orthopedic literature that says this isn’t necessarily so.

A paper being presented at the AAST meeting in Chicago next week retrospectively looked at their experience with early (<8hrs) vs late I&D in a series of 248 patients. They looked at infection rates stratified by time and upper vs lower extremity.

They found that the infection rates overall were not significantly different. However, when subgrouped by extremity and higher Gustilo type >= III, they noted that both delayed I&D and Gustilo type correlated with infection risk. For the upper extremity, only Gustilo type >= III correlated with a higher infection rate.

The authors concluded that all lower extremity open fractures should be dealt with in the 8 hour time frame, whereas upper extremity fractures can be delayed for lower Gustilo classes.

Bottom line: I don’t necessarily buy into all the results from this small study. The orthopedic literature has already refined this concept. At Regions Hospital, we allow up to 16 hours to I&D for open fractures up to and including Gustilo class IIIA. Above that, the 8 hour rule is followed. We periodically review our registry data on all open fracture patients to make sure that the extended time frame patients are not experiencing an increase in wound complications. And they haven’t in our 8 year experience in handling them this way.

Refresher on the Gustilo classification system:

  • Class I – open fracture, clean wound, <1cm laceration
  • Class II – clean wound, laceration >1cm with minimal soft tissue damage
  • Class IIIA – clean wound, more extensive soft tissue damage or laceration, periosteum intact, minimal contamination
  • Class IIIB – extensive soft tissue damage with periosteal stripping or bone damage, significant contamination
  • Class IIIC – arterial injury without regard for degree soft tissue injury

Reference: Open extremity fractures: does delay in operative debridement and irrigation impact infection rates? AAST 2011 Annual Meeting, Paper 22.

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! 

Thanks to EM Res for posing this question!

Above-Knee vs Below-Knee DVT

Deep venous thrombosis (DVT) is a common problem in trauma patients. Many trauma centers have developed practice guidelines for beginning mechanical or chemoprophylactic measures as soon as practical in patients at risk. Some believe that below-knee and above-knee DVT are different, with those located below the knee posing a lower risk for propagation and pulmonary embolism. As always, we need to know, is it true?

The group at Oregon Health and Science University performed a retrospective review of six years of their experience with lower extremity DVT. They identified 308 patients who developed this complication and noted the following interesting findings:

  • Two thirds developed below-knee DVT, one third above-knee
  • Overall rate of pulmonary embolism (PE) was about 4% overall
  • PE occurred with equal frequency in below-knee vs above-knee DVT
  • The rate at which DVT resolved was no different in patients receiving prophylactic doses of enoxaparin vs therapeutic dosing
  • Below-knee DVT did not resolve faster than above-knee. Thus they are not more likely to resolve spontaneously

The point of looking for and giving enoxaparin and similar drugs in trauma patients is to avoid DVT, limit it’s progression, and prevent PE. This study showed that there really is no difference between below-knee and above-knee DVT, and that they should be treated similarly. Unfortunately, it also showed that prophylactic and therapeutic management worked equally as well. This is probably due to the fact that there are major differences across various types of trauma patients and that we still don’t know how to calculate the right dose of enoxaparin. However, we do have some tools to help us make a better guess. 

Bottom line: Trauma patients with any lower extremity DVT need to be treated, and enoxaparin is a common way to do this. Below-knee vs above-knee does not matter. If enoxaparin is used, just selecting a therapeutic dose (e.g. 1mg/kg bid) is not enough. Monitoring with anti-factor Xa levels or thromboelastogram (TEG) may help optimize effectiveness and reduce risk of PE.

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Reference: The effects of location and low-molecular-weight heparin administration on deep vein thrombosis outcomes in trauma patients. J Trauma 74(2):476-481, 2013.