All posts by TheTraumaPro

Guideline: How To Manage Bleeding In The Anticoagulated Patient

Over the past year, I’ve written about bleeding problems in trauma patients caused or exacerbated by the various anticoagulants now on the market. The field of available drugs keeps growing, and the number of ways to keep blood in liquid form is increasing.

Here’s a link to a set of guidelines for approaching and treating patients who are taking these medications and then develop problematic bleeding. There are few good studies that have actually analyzed the efficacy of these methods, but it’s what we have to work with now. 

If you have any additional maneuvers that you think should be included, please comment or email. And feel free to implement some studies to find the real best practices.

Link: Guideline for bleeding in patients taking anticoagulants

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Not Your Usual Pneumothorax?

You’ve been called to the ED to see a patient with a “spontaneous pneumothorax”, but once you meet him you see that he doesn’t fit the classic profile (tall, slim male). What gives?

After closer questioning, he admits to have been smoking crack cocaine at the time. Freak coincidence?

There are a number of case reports dating from 1984 describing this association. A number of reasons have been cited:

  • A high incidence of tobacco smoking
  • Bullous disease caused by inhaled drug use
  • Inhalation of hot gas followed by frequent Valsalva maneuvers

I’ve seen this presentation about 5 times in my career. I always ask about drug use so I can ensure that a chemical dependency screen is ordered.

Reference: Pneumothorax, pneumomediastinum, and pneumopericardium following Valsalva’s maneuver during marijuana smoking. N Y State J Med 84(12):619-20, 1984.

Pediatric Trauma Case: The Answer

So you’ve been called to the ED to see this 10 year old boy who ran into a buddy on the playground while playing tag. They hit chest to chest, but neither had any apparent injuries at the time. Once home, your patient proceeded to cough up a little blood. Mom promptly brought him to your ED for evaluation.

The first thing to do is a good history and physical. No previous illnesses, nothing like this before. No other obvious injuries, no symptoms of concussion. Just some mild anterior chest wall tenderness in the mid-sternum where he hit the other kid.

Most likely diagnosis: pulmonary contusion. Now, think about what you need to do and the risks and benefits of the tests you could order. What you need to do is rule out a pneumothorax large enough to be treated. A simple chest X-ray will do this. It won’t detect an occult pneumo, but this is not necessary.

A chest X-ray won’t necessarily show you a pulmonary contusion, either. But do you need to see it to make the diagnosis? No! The clinical evidence is enough. A chest CT is almost never indicated in children, and this is certainly not a reason to get one. EKG: not needed unless your pulse exam was abnormal.

if the child has no complaints of dyspnea and appears to be breathing normally, he can go home. This is such a Low energy injury that progression of the contusion is not an issue. Hospitalization offers no benefit, and will certainly inflict more trauma. Instruct the parents to watch for any apparent breathing problems and give typical non-prescription kiddie analgesics if needed. And be sure to tell them that their son may cough up blood for several more days, but it should disappear soon.

Bottom line: unfortunately, we’ve gotten into the habit of ordering lots of tests to confirm things that we already know. We tend to consider the impact in children a little more, especially when it involves radiation. But we really need to start thinking this way for all patients!

Pediatric Trauma Case

Here’s an interesting pediatric trauma case to test your skills. A 10 year old boy was playing tag on the playground at school. He ran head-on into another player, chest to chest. Neither child struck their head.

When the boy arrived home after school, he coughed up some blood. This freaked his mother out, who brought him to your ED for evaluation. He continues to cough up thin, bloody sputum occasionally.

How do you approach this problem? What diagnostic tests do you need? What do you think the diagnosis is? How do you treat, and does he need to be admitted?

Tweet, email or send your comments below. I’ll compile and discuss the replies, and reveal what I think is the correct diagnostic and management sequence.

Source: hypothetical case. Not treated at Regions Hospital.

Trauma Triage Guidelines: There’s An App For That!

The CDC released an iPhone app covering the Field Triage Guidelines for Injured Patients a few months ago. It’s not received much attention, but could be helpful for some trauma professionals.

The app consists of 2 components: a copy of the triage guidelines pocket card, and a quiz about the use and impact of the guidelines. The app is pretty bare-bones, but is a convenient way to keep the guidelines available for immediate reference. It doesn’t look like it’s available for Android yet.

Click the link below to go to the Apple App Store for more information or to download.

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