Patients with serious abdominal injury may require a laparotomy, and a subset of these may need a temporary closure for damage control surgery. Concomitant spine injury may have your spine surgeons asking “is it safe to prone the patient who is postop with a midline incision or an open abdomen.” What to tell them?
There’s not much guidance out there in the literature. One paper from 2000 looked at four patients who were proned for severe ARDS and found that one suffered a wound dehiscence. However, this patient had severe generalized edema and was on several pressor agents.
The use of temporary abdominal closure techniques has revolutionized the early management of severely injured trauma patients and has greatly decreased the incidence of complications from abdominal compartment syndrome. Several authors have now demonstrated that putting those patients in the prone position is well tolerated.
As far as patients who have a closed laparotomy, proning appears to be well tolerated as well. One caveat: consider carefully if the patient is having wound complications or if they are morbidly obese.
The bottom line: Consider the risks and benefits carefully in any post-laparotomy patient you are considering prone positioning for. Other than in morbidly obese, it is generally considered safe, even in patients with damage control dressings in place. However, make sure the trauma surgeon re-evaluates the wound again as soon as the patient is returned to the supine position.
1. The “open abdomen” is not a contra-indication to prone positioning for severe ARDS (abstract). Schwab, et al. Chest. 1996;110:142S.
2. Complications of Prone Ventilation in Patients with Multisystem Trauma with Fulminant Acute Respiratory Distress Syndrome. Offner et al. Journal of Trauma-Injury Infection & Critical Care. 48(2):224-228, February 2000.
3. The Management of the Open Abdomen in Trauma and Emergency General Surgery: Part 1-Damage Control. Diaz et al. Journal of Trauma-Injury Infection & Critical Care. 68(6):1425-1438, June 2010.
Members of the trauma team must frequently protect the cervical spine when moving the patient or performing certain procedures. In most cases, a cervical collar is placed which does a fine job of this. Occasionally, though, the collar must be removed to provide access to areas near or under the collar.
When the collar is off, someone must be charged with immobilizing the cervical spine. Sometimes this is incorrectly referred to as providing inline traction and not inline stabilization.There is a big difference!
Inline traction is used to try to realign cervical vertebra that are malpositioned due to fracture or ligamentous injury. This should only be performed under the guidance of a neurosurgeon!
Inline stabilization merely means that the patient (or trauma professional) is restrained from moving the cervical spine. This is commonly needed while intubating the patient, so that the intubator does not extend the neck when trying to visualize the cords.
Why is this important? Check out the images below. If a severe injury has already occurred, traction on the neck may have devastating consequences! Inline stabilization is the only way to go.
Seems like a simple, silly question, right? I dare you to figure it out without reading this post!
On occasion, our brain injured trauma patients have sodium issues. You know, cerebral salt wasting. Trying to maintain or regain the normal range, without making any sudden moves can be challenging. There are a lot of tools available to the trauma professional, including:
- Hypertonic saline
- Salt tablets
- Fluid restriction
- Some combination thereof
Fun times are had trying to figure out how much extra sodium we are giving with any of the first three items. This is important as you begin to transition from the big guns (hypertonic), to regular saline, and then to oral salt tabs.
Below is a quick and dirty conversion list. I won’t make your heads explode by trying to explain the math involved changing between meq, mg, moles, sodium and sodium chloride.
- The “normal saline” bags we use are actually 0.9% saline (9 gm NaCl per liter)
- Hypertonic saline can be 3% or 5% (30 gm or 50 gm per liter)
- Salt tabs are usually 1 gm each (and yummy)
Therefore, a liter of 0.9% normal saline is the same as 9 salt tabs.
A liter of 3% hypertonic saline is the same as 30 salt tabs. The usual 500cc bag contains 15.
A liter of 5% hypertonic saline is the same as 50 salt tabs. The usual 500cc bag contains 30.
To figure out how many tablets you need to give to match their IV input, calculate the number of liters infused, then do the math! And have fun!
Although you may not agree with this at first, communicating with our patients is one of the most important things we do as trauma professionals. You can be the “best” doctor, nurse or paramedic in the world, but if you can’t communicate well your patients will have nothing good to say about your care of them.
The most important skill needed for good communication is empathy. You need to be able to put yourself in their position. Imagine what you would want if you were on the receiving end of the information you are about to deliver. What would you say if you were talking to your spouse, your mother, or your child?
Next, think about what kinds of things they would want to know. In trauma, they obviously want to know information about the injuries. Patients and families also need to hear about the short term and long term plans. What’s going to happen in the next few hours? Will surgery be needed? When? How long will I be in the hospital? How long will I be out of work?
Many of these questions are difficult to answer at the time of admission after trauma. If you don’t know or it’s impossible to determine, say so. Experienced clinicians can make some pretty good guesses, but should always qualify their answers. You should make it clear that you are giving an estimate, and that things may very well change. Also explain that as these changes occur and time passes, you will give better estimates.
One of the most important things to remember is the “keep it simple” mandate. Our patients and their families are smart. Although they may not know the lingo that we are familiar with, they can grasp the concepts of what is happening. Be careful to keep your explanations understandable, and don’t make the mistake of using any complicated medical terms. Imagine the surprise of the patient when they find out what “we’re going to insert a Foley catheter now, sir” really means. Also keep in mind that the patients and their families are stressed, and may not be able to concentrate on or remember everything you say. Repetition is good in these situations.
Communication after major trauma is challenging. Remember, if the families don’t get what you’re saying, it’s your fault, not theirs.
You’re dealing with some type of eye problem/injury in the ED. How do you know when to call the eye doctor? What problems need emergent attention? Which ones require a phone call only? Which ones can just be sent to the ophthalmologist’s office in a few days?
The link below provides a set of guidelines for you to use to help figure this out. As always, it’s a good idea to apply your own expert judgment as well.
When to call the ophthalmologist