All posts by TheTraumaPro

FAQ: Trauma Education – The Next Generation 9/17/15


Why did you move the conference from the History Center?

Metropolitan State University is a little less expensive and, most importantly, they let you drink beverages in the auditorium. They have a new parking ramp as well. And it’s college, let’s all pretend we are young again.

Will I have colleagues from my department that I can support/heckle?

Of course! As it has been for the last two years, Emergency Medicine has been the majority contributor of in-kind faculty support for this conference.  Here’s who is contributing this year:

  • Dr. Robert LeFevere and his documentation tips and pitfalls
  • Dr. Ryan Bourdon helps you not trip up while taking care of the frail falling elderly patient
  • Dr. Charles Bruen is handling the pediatric airway and the little itty bitty tools needed for that – and that, my friends, is 0.25 hr of pediatric trauma CME!
  • Elise Haupt, PA-C and Martha Serbus, RN will be talking about “talking down” that agitated patient.
  • Dr. Rasimas from Tox & Psychiatry has got some back-up plans if the “talk down” didn’t work.
  • Dr. Alan Sazama is getting some serious screentime and hands-on education about ankle reduction and splinting.
  • Dr. Kevin Kilgore is in charge of the pre-show slides and break slides.  He’s got a small handful of decent pictures and teaching points, I’ve heard.
  • Dr. Michael Zwank is teaming up with Kris Norman, RN to make a little video about IV placement.
  • A couple of surprises
  • And you’ll see way, way too much of Jessie Nelson.

Those people are great, but that’s not enough to fill 4 hours.  What else you got?

Yes, we have other specialties represented.  I’m not going to tell you the entire schedule. I need to keep some of the mystery alive, right? Got some Burn stuff, some Neurosurgery, some Ortho.  Even got a hospitalist to talk Palliative Care in Trauma.  And maybe, just maybe, that trauma patient does NOT need to be transferred here.

Hey, you’ve gotten all fancy (and cheap) in the past and had keynote speakers present from New York and Australia over that there internet thing.  Are you doing that again?

Yes, Virginia, we do have another live remote speaker.  I am continually surprised at the fact that we can talk someone into giving a live lecture in their closet talking to a microphone.  But we’ve done it again.  Dr. Brian Lin from California is talking.  He is the mastermind behind the website (Closing the Gap: Wound Closure for the Emergency Practitioner).  

He comes highly recommended, and you may have heard him on EM:RAP. If his website is any guide, I’m assuming they’ll be some great pictures.  If you fix wounds, you want to see this.  

Can I get CME/CEU credits?

Yep, if you show up.  Watching live remotely? Also yes, if you register and pay a $49 fee. Watching it later? I’m going to go with maybe for now.  We had talked about some quiz questions to allow for credit, but I don’t know the status of that now. The person who does know is on a well-deserved vacation (I can be needy).  If you definitely want the credit, come to the conference!

What if I’m working/post-nights/pre-eve/super tired/need to watch the kids/out of town/haven’t showered in a week, etc?

Watch it remotely!  Go to on the day of the conference. Click the link that will be there. That will take you to:

Warning: You may not get to see Kevin Kilgore’s break slides. You can watch it later in its entirely or wait for us to break it into manageable chunks.  Or get the handouts on the website and read them.

What exactly were you doing at the Happy Gnome in St. Paul last Friday?

I don’t want to discuss that. You’ll have to come to the conference and find out.  

Best Of: Finding Rib Fractures On Chest XRay

A lot of people have been viewing and requesting this post recently. 

Here’s a neat trick for finding hard to see rib fractures on standard chest xrays.

First, this is not for use with CT scans. Although chest CT is the “gold standard” for finding every possible rib fracture present, it should never be used for this. Rib fractures are generally diagnosed clinically, and they are managed clinically. There is little difference in the management principles of 1 vs 7 rib fractures. Pain management and pulmonary toilet are the mainstays, and having an exact count doesn’t matter. That’s why we don’t get rib detail xrays any more. We really don’t care. Would you deny these treatments in someone with focal chest wall pain and tenderness with no fractures seen on imaging studies? No. It’s still a fracture, even if you can’t see it.

So most rib fractures are identified using plain old chest xray. Sometimes they are obvious, as in the image of a flail chest below.

But sometimes, there are only a few and they are hard to distinguish, especially if the are located laterally. Have a look at this image:

There are rib fractures on the left side side on the posterolateral aspects of the 4th and 5th ribs. Unfortunately, these can get lost with all the other ribs, scapula, lung markings, etc.

Here’s the trick. Our eyes follow arches (think McDonald’s) better than all these crazy lines and curves on the standard chest xray. So tip the xray on its side and make those curves into nice arches, then let your eyes follow them naturally:

Much more obvious! In the old days, we could just manually flip the film to either side. Now you have to use the rotate buttons to properly position the digital image.

Final exam: click here to view a large digital image of a nearly normal chest xray. There is one subtle rib fracture. See if you can pick it out with this trick. You’ll have to save it so you can manipulate it with your own jpg viewer. 

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August Newsletter Released!

The August newsletter is now available! Click the link below to download. This month’s topic is “Potpourri”, a bunch of random stuff of interest.

In this issue you’ll find articles on:

  • Crowdfunding medical research
  • McSwain’s rules of patient care
  • What if you don’t have TEG for trauma?
  • REBOA: All it’s cracked up to be?
  • Treating headache after TBI

Subscribers received the newsletter last week. If you want to subscribe to get early delivery in the future (and download back issues), click here.

Click here to download newsletter.

Air Embolism From an Intraosseous (IO) Line

IO lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.

But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.

This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC).

During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line is not closed properly, there could be.

Bottom line: Treat an IO line as carefully as you would a regular IV. You can give anything through it that can be given via a regular IV: crystalloid, blood, drugs. And even air, so be careful!

The “Double-Barrel” IO: Can It Work?

Intraosseous lines (IO) make life easy. They are quicker to insert, have a higher success rate, and require less experience than a standard IV. And they can be used for pretty much any solution or drug that can be given through an IV.

But there are some limitations. They can’t be inserted into a fractured bone. The manufacturer cautions against multiple insertions into the same bone. A second insertion should not be performed in the same bone within 48 hours. 

But, as with so many things in medicine, there is little in the way of proof for these assertions. They seem like good ideas for precautions, but that does not mean they are correct. No real research has been done in this area. Until now.

The concept of using two IO needles in one bone was explored in an animal model by researchers in Canada. They used a swine model (using the foreleg/humerus, to be exact), and tested several infusion setups.

Here are the factoids: 

  • Infusing crystalloid using an infusion pump set to 999ml/hr took 30 minutes with a single IO, and 15 minutes with a “double-barrel” setup
  • Giving crystalloid using a pressure bag set at 300 mm/Hg took 24 minutes with a single IO, and 23 minutes with double the fun
  • The double-barrel setup also worked for a blood/drug combo. 250cc of blood and 1 gm of TXA in 100ml of saline infused via pump in 13 minutes.
  • Simultaneous anesthesia drugs (ketamine infusion in IO #1, fentanyl and rocuronium bolus in IO #2) without problems
  • Multiple fluid + drug infusion combinations were tested without incident
  • There were no needle dislodgements, soft tissue injuries, fractures, or macrohistologic damage to the bone or periosteum

Bottom line: Remember, these are pigs. Don’t do this in humans yet. However, this is pretty compelling evidence that the double-barrel IO concept will work in people. And it appears that infusion pumps must be used for effective, fast infusions. I recommend that prehospital agencies with inquiring minds set up a study in people to prove that this works in us, too.

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Reference: Double-barrelled resuscitation: A feasibility and simulation study of dual-intraosseous needles into a single humerus. Injury, in press April 30, 2015.