All posts by TheTraumaPro

Using The Slide Board In The ED

I’ve written several times on the importance of getting patients off the backboard promptly in the ED, but the topic keeps coming up! Many hospitals use slide boards to facilitate patient movement on and off the ED cart when undergoing imaging studies. How should we manage the use of this device?

There is no difference between a backboard and a slide board to the patient. It’s hard and uncomfortable to lie on for any period of time, and can cause soft tissue injury. To trauma professionals in the ED it is thinner, less bulky, easier to manipulate, and does not interfere with xrays as much. We tend to pay less attention to it than a backboard. Although it does not immobilize the spine as well as a backboard does, the difference is not clinically significant (in a cooperative patient). Remember, if your patient actually has a spine fracture, they will be placed on logroll precautions on a soft mattress only somewhere in your hospital! No stiff boards of any kind!

Slide board management tips:

  • Slide boards are for blunt trauma only! Patients with penetrating injury may need an upright chest xray in the ED and the board won’t flex enough.
  • Insert the slide board in any patient who will be getting several diagnostic studies. For trauma activation patients, this can occur as you roll them off the backboard.
  • As soon as diagnostic studies are done, remove the slide board
  • If there are unforeseen delays, remove the slide board and reinsert when ready to move
  • Remember that the soft tissue timer is counting down as soon as the patient is placed on a backboard or slide board
  • Plan an efficient road trip through diagnostic studies for your patient. This allows you to minimize time on the board. 
  • Repeated logrolls onto and off of the slide board are discouraged. Every roll is an opportunity for mishap.

The Chest Tube Autotransfuser

Autotransfusing blood that has been shed from the chest tube is an easy way to resuscitate trauma patients with significant hemorrhage from the chest. Plus, it’s usually not contaminated from bowel injury and it doesn’t need any fancy equipment to prepare it for infusion. 

It looks like fresh whole blood in the collection system. But is it? A prospective study of 22 patients was carried out to answer this question. A blood sample from the collection system of trauma patients with more than 50 cc of blood loss in 4 hours was analyzed for hematology, electrolyte and coagulation profiles.

The authors found that:

  • The hemoglobin and hematocrit from the chest tube were lower than venous blood (Hgb by about 2 grams, Hct by 7.5%)
  • Platelet count was very low in chest tube blood
  • Potassium was higher (4.9 mmol/L), but not dangerously so
  • INR, PTT, TT, Factor V and fibrinogen were unmeasurable

Bottom line: Although shed blood from the chest looks like whole blood, it’s missing key coagulation factors and will not clot. Reinfusing it will boost oxygen carrying capacity, but it won’t help with clotting. You may use it as part of your massive transfusion protocol, but don’t forget to give plasma and platelets according to protocol. This also explains why you don’t need to add an anticoagulant to the autotransfusion unit prior to collecting or giving the shed blood!

Related post: Chest tubes and autotransfusion

Reference: Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood? Am J Surg 202(6):817-822, 2011.

Interesting Case: The Answer

As described last Friday, this patient was found at home bloodied, obtunded, with his hand amputated. He was taken to the hospital (with the hand properly dressed, in a bag), then went to OR for reimplantation. The exact mechanism (assault vs self-mutilation) was not known at the time.

What happened to the patient? Inspection of the scene revealed no forced entry and no evidence of an intruder in all of the blood at the scene. It appeared to be self-inflicted. The hand surgeon determined that the hand could not be reattached. Postoperatively, the patient did not wake up appropriately. He was taken to CT scan and this image was obtained:

This explains the small laceration beneath the right eye. The neurosurgeon deemed the injury nonsurvivable and the patient rapidly progressed to brain death.

Was prehospital care appropriate? Absolutely! They stopped the bleeding, packaged the hand nicely for an attempt at reimplantation, and transported to the hospital quickly. By the way, physicians are usually involved in prehospital care in Europe, where this event occurred.

Is it likely the hand can be reattached? No. Although clean amputations have the best chance, this was likely a ragged wound because a table knife was used to saw off the hand. This takes a lot of force and effort and usually results in severe damage to the severed ends.

What other diagnostic tests should be performed, and when? The patient had two problems: a hand injury with easily controlled bleeding, and a brain injury (remember, the initial GCS was 11). A full evaluation should have occurred before transport to the OR, and this would have prompted an early CT scan of the head. Whether this would have changed the outcome can’t be determined.

Bottom line: this is another example of the “dang!” factor at work. Everybody sees this bloody patient with a mangled, severed hand and focuses on it. The rest of the ABC(D)s go out the window, and the patient is rapidly taken to OR to save the hand. But the knife used to sever the hand is hidden in his brain, and the team is unaware until attention returns to the mental status postop. Don’t let this happen to you!

Related posts:

Reference: An unexpected intracranial blade. Prehospital Emergency Care, online ahead of print, September 2012.

Interesting Trauma Case

Here’s an interesting case that was published recently (not taken care of at my hospital). EMS was called by a family who had returned home to find their son covered with blood. He had a history of mental illness and the prehospital providers found the young man awake but obtunded (GCS 11: eyes 4, verbal 1, motor 6). He was spontaneously breathing with an intact airway. Vital signs were BP 130/80, P110, R22, Sat 99% on O2.

On exam, his right hand was completely amputated. He was covered with blood, and he had bilateral periorbital hematomas and a 2cm laceration under his right eye. Evaluation of the scene could not determine if this was an assault or self-inflicted. There was a history of mental illness.

Bleeding was easily controlled with direct pressure. An IV was inserted and fluids were given. The amputated hand was dressed with moist gauze and placed in a plastic bag, which in turn was placed in a bag of ice. He was then taken to a hospital for further evaluation. He was rapidly taken to the OR for debridement and reimplantation of the hand. 

Here are my questions:

  • What happened to the patient?
  • Was the prehospital care appropriate?
  • Is it likely that the hand can be reattached?
  • What other diagnostic tests should be performed, and when?

Comments please, or tweets. Hints over the weekend and answers on Monday!

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.