All posts by The Trauma Pro

Trauma MedEd Newsletter: The Best Of EAST Part 2!

I’m still not done reviewing abstracts from next month’s annual meeting of the Eastern Association for the Surgery of Trauma (EAST). There are yet more oral and poster abstracts that I want to pick apart. Here are some that are coming in the January issue:

  • How long is DVT a potential risk in TBI?
  • Measuring volume status using jugular ultrasound
  • Pain as a predictor of tourniquet efficiency p23
  • Nursing interruptions in the SICU p18
  • And more…!

Anyone on the subscriber list when the ball drops on New Year’s Eve (CST) will receive it later that day. Everybody else will have to wait for me to release it here on the blog late next week. So sign up for early delivery now by clicking here!

Pick up back issues here!

Inserting an NG Tube (Not an NC Tube)!

On occasion (but not routinely) trauma patients need to have their stomach decompressed. The reflex maneuver is to insert a nasogastric (NG) tube. However, this may be a dangerous procedure in some patients.

Some patients may be at risk for a cribriform plate fracture, and blindly passing a tube into their nose may result in a nasocerebral (NC) tube (see picture). This is a neurosurgical catastrophe, and the outcome is uniformly dismal. It generally requires craniectomy to remove the tube.

The following patients are at risk:

  • Evidence of midface trauma (eyebrows to zygoma)
  • Evidence of basilar skull fracture (raccoon eyes, Battle’s sign, fluids leaking from ears or nose)
  • Coma (GCS<8)

If you really need the tube, what can you do? If the patient is comatose, it’s easy: just insert an orogastric (OG) tube. However, that is not an option in awake patients; they will continuously gag on the tube. In that case, lubricate a curved nasal trumpet and gently insert it into the nose. The curve will safely move it past the cribriform plate area. Then lubricate a smaller gastric tube and pass it through the trumpet.

Updated Solid Organ Injury Protocol

Over the past several days, I’ve been writing about updates to our solid organ injury protocol. It eliminates orders for bed rest and NPO diet status afterwards. After looking at our experience over the years, the number of early failures is practically zero. So how many days do you need to keep a patient in bed to make sure they have an empty stomach when they need to be whisked away to the OR. And does walking around really make your injured spleen fall apart?

The answers are none and no. So we’ve updated our protocol at Regions Hospital to reflect this. Feel free to download and modify to your heart’s content. If you want a copy of the Microsoft Publisher file, just email me!

Download the protocol here!

Solid Organ Injury Tips

Over the years, I’ve written about solid organ injury management many times. Here is a summary of some practical pointers and tips, some old and some new. They are as evidence-based as I can get them. This kind of stuff is not always in the doctor and nursing books.

  • Please refer to our solid organ injury protocol, which you can download here.
  • Ward and ICU branches are order sets at my hospital, not necessarily admitting locations. If you have a special unit or step-down area that can provide ICU-level monitoring, use it for the ICU order set.
  • Strongly consider interventional radiology (IR) and angiography in all adult patients with contrast extravasation (children generally do not qualify unless they show signs/sx of ongoing volume loss). Consider also in high grade injuries, because they may have active bleeding that isn’t quite brisk enough to see on CT.
  • Serial hemoglobin measurements are not part of the protocol. They are only used to help decide if transfusion might be needed. Vital signs will always signal failure before the hemoglobin does.
  • Nearly all patients may be up and eating immediately, or certainly by the next morning. No need for protracted NPO status or bed rest. Really no need for it at all!
  • Failure really falls into 2 types: hard and soft. Hard failure is a single episode of definitive hypotension (usually 80s or less) or development of peritoneal signs, and requires an emergency trip to the OR. Soft failure is transient or modest hypotension that responds rapidly to a fluid bolus. If IR has not already been used, a quick trip there may obviate the need for operation. However, another one of these bouts makes it a hard fail. Time for OR.
  • Hard failure can only be treated with blood, some crystalloid, and a knife. Pressors, steroids, or other drugs can only be used if they come in liter bags and can be given at over 1000cc/hr. That means never.
  • In IR, give the radiologist 30 minutes to stop the bleeding. Don’t let them dawdle for hours. If the patient has a hard fail, abort and go to OR; do not let the radiologist persist.

After discharge, our usual orders are:

  • Normal activity (non-impact) for 6 weeks
  • All activity (except high impact) thereafter
  • High impact activity (tackle football, rugby, serious extreme sports) only after 12 weeks (no good data for this one)
  • No repeat CT scanning to judge healing
  • Warn patients of the good possibility of a transient increase in pain on days 7-10. This is common in many unless they’ve been embolized.
  • Patient to call if unrelenting increase in pain, or increasing orthostatic symptoms, fevers chills

Related post:

Bedrest After Pediatric Liver/Spleen Injury? Really?

A set of guidelines for management of blunt solid organ injury in children developed by the American Pediatric Surgical Association was originally published in 1999. One of the elements of the guideline was to place the child on bedrest for a period of time after the injury. Arbitrarily, this period was defined as the injury grade plus one day. So for a grade 3 spleen injury, the child would have to stay in bed for 4 days (!).

A paper published this month looked at the impact of shortening this time interval. Over a 6 year period, all pediatric liver and spleen injuries from blunt trauma were identified and an abbreviated bedrest protocol was implemented. For low grade injuries (grade 1-2), children were kept in bed for 1 day, and for higher grade injuries this was extended to 2 days.

Here are the factoids:

  • 249 patients were enrolled (about 40 per year) with an average age of 10. “Bedrest was applicable for 199 patients, 80%.” Huh? Does that mean that 50 patients were excluded due to surgeon preference?
  • The organ injured was about 50:50 for spleen vs liver. Twelve children injured both.
  • Mean injury grade was 2.7, which is fairly high
  • Mean bedrest was 1.6 days, and mean hospital stay was 2.5
  • Bedrest was the limiting factor for hospital stay in 62% of cases
  • There were no delayed complications of the injury

Bottom line: Come on! Most centers don’t keep adult patients at bedrest this long, and we learned about solid organ injury management from kids! Children almost never fail nonop management, so why treat them more restrictively than adults? And have you ever tried to keep a child at bedrest? Impossible! This study is too underpowered to give real statistically valid results, but it certainly paints a good picture of what works. We’ve recently removed bedrest and NPO status from our protocol, and our average length of stay for isolated solid organs is about 1.5 days in adults. But really, who says that staying in bed for any period of time avoids complications? There are lots of other evil things that can happen!

Related posts:

Reference: Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Ped Surg 48(12):2437-2441, 2013.