The September newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is chest trauma.
In this issue you’ll find articles on:
- Why I didn’t like finger thoracostomy
- Advanced needle thoracostomy
- Trochar vs needle for tension pneumothorax
- Troubleshooting chest tube air leaks
- Chest tube collection systems gone wild
- Managing chest tube air leaks
- Pneumothorax in children
Subscribers received the newsletter first last weekend. If you want to subscribe (and download back issues), click here.
Click here to download and/or subscribe.
Here’s another interesting paper that was presented at the Congress of Neurological Surgeons. There’s a lot of attention being focused on the incidence and management of concussion during sporting events. An international Concussion in Sport Group has been meeting for over 10 years, contemplating classification and management of this injury. They are considering using age to modify management of concussion in young athletes.
The authors looked at their own experience with 200 adolescent and young athletes. They stratified by age (younger = 13-16 year olds, older = 18-22 year olds), with 100 in each group. They matched them by number of previous concussions, and all underwent baseline and post-concussion ImPACT testing. They specifically looked at the number of days needed to return to baseline.
Interestingly, they identified significant differences in recovery time. And strangely enough, the older players did better than the younger ones. Overall, 90% returned to baseline within a month. But the younger players took 2-3 days longer to recover than the older ones.
Bottom line: Looks like the Concussion in Sport Group is right on! Usually in trauma, older folks do worse than younger ones, so we tend to treat them more carefully. Not so in youngsters with concussions. Sports medicine physicians need to realize that the younger brain takes longer to recover, and they should err on the safe side and keep them out of the game longer. Objective testing to help predict return to play is extremely helpful.
Reference: Sport-Related Concussion and Age: Number of Days to Neurocognitive Baseline. Oral presentation 145 – Congress of Neurological Surgeons 2012.
Trauma surgeons frequently place some type of drain in their patients, whether it be a chest tube, a damage control system, or a bulb suction drain near the pancreas. On occasion, nursing may become concerned with the character of the output, wondering if the patient is bleeding significantly. How can you tell if the output is too bloody?
First, most drains are in place to drain serous fluid which may have a little blood in it. Drainage that is mostly bloody is very uncommon from these drains, which are typically placed after orthopedic, spine or abdominal surgery. However, some drains are placed in areas where unexpected bleeding may occur, such as:
- Damage control drain systems – as patients warm up, arterial sources that were not surgically controlled may open up
- Pericardial drains – more common in cardiac surgery, not trauma
- Chest tubes in patients with penetrating trauma
What should you do if you have concerns about your patient’s drain output?
- Familiarize yourself with what kind of drain it is and what it should be draining
- Look at the volume of output – it takes 500cc of pure blood to drop the patient’s hemoglobin by about 1 gram. Low outputs are not dangerous, even if it is pure blood.
- Look at the change in output– if it is increasing significantly or changes color, call the physician to evaluate.
- Look at the color of the output – most drainage ranges from clear to something like cranberry juice and appears to be partially transparent. Look carefully if it appears to be darker or more opaque, and compare it to the blood that you would see in a blood collection tube. Even the darkest drain output usually looks a little watery compared to whole blood. Bright red output needs to be evaluated by a physician.
- If in doubt, check the fluid’s hematocrit. Whole blood has a hematocrit of 30% or more. Most bloody-looking drain output maxes out at about 5%. If the value is closer to whole blood, have a physician evaluate the patient.
Most people recover from major surgical procedures in a predictable fashion. However, as anyone who manages these patients knows, there are always a few outliers. A negative laparotomy patient who has an ileus for over a week. Hip fracture patients who take forever to get out of bed.
We usually chalk this up to human variability or varying degrees of frailty. But could there be more to it? Could it even be predictable?
A group of anesthesiologists and immunologists at Stanford used a new cell-mapping technique to attempt to correlate immune system signatures in blood during the first hours after operation with recovery time. They used a technique called mass cytometry, which flushes different tagged antibodies through a blood sample. This allowed the investigators to determine which immune cells were present, as well as which signalling molecules were being produced.
Here are the factoids:
- 32 patients undergoing hip replacement surgery were studied at various times up to 6 weeks after the procedure
- Antibodies directed at 21 cell surface proteins and 10 intracellular proteins associated with the immune response
- Recovery from fatigue, pain, and recovery of hip motion were quantified using validated objective scoring tools
- As expected, there was a considerable amount of variability in recovery parameters among the patients
- Activation of CD14+ monocytes accounted for 40-60% of the variability in recovery times observed
- Patients with higher activations were more likely to take at least 3 weeks to recover. Those with low activation recovered more quickly.
Bottom line: This is heady stuff, and it is based on a very small group of patients. However, it does suggest that immune system overdrive may be responsible for more evil: slow recovery from surgery. At some point, it may be possible to predict recovery time from a preop blood test. This would be very helpful to know before surgery, and at some point may allow us to give drugs that blunt these processes and speed up surgical recovery.
Reference: Clinical recovery from surgery correlates with single-cell immune signatures. Science Translational Medicine 6(255):255ra131 1-12, 2014.
The September Trauma MedEd Newsletter will be released to subscribers over the weekend. I’ll be covering chest trauma. Articles include:
- Finger vs needle thoracostomy
- Chest tube air leaks and how to manage them
- Pneumothorax in children
- And more!
Anyone on the subscriber list as of 8PM Saturday (CST) will receive it on Sunday, October 5. I’ll release it to everyone else next week via the blog. So sign up for early delivery now by clicking here!
Pick up back issues here!