All posts by TheTraumaPro

Nursing: When Is Drain Output Too Bloody?

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.

The EMS Second IV In Trauma

One of the critical maneuvers that EMS providers perform is establishing initial vascular access. This IV is important for administering medications and for initiating volume resuscitation in trauma patients. Prehospital Trauma Life Support guidelines state that every trauma patient should receive two large bore IV lines. But is this really necessary?

The upside of having two IVs in the field is that the EMS provider can give lots of volume. However, a growing body of literature tells us that pushing systolic blood pressure up to “normal” levels in people (or animals) with an uncontrolled source of bleeding can increase mortality and hasten coagulopathy.

The downside of placing two lines is that it is challenging in a moving rig, sterility is difficult to maintain, and the chance of a needlestick exposure is doubled. So is it worth it?

A group at UMDNJ New Brunswick did a retrospective review of 320 trauma patients they received over a one year period who had IV lines established in the field. They found that, as expected, patients with two IVs received more fluid (average 348ml) before arriving at the hospital. There was no increase in systolic blood pressure, but there was a significant increase in diastolic pressure with two lines. The reason for this odd finding is not clear. There was no difference in the ultimate ISS calculated, or in mortality or readmission.

Bottom line: This study is limited by its design. However, it implies that the second field IV is not very useful. The amount of extra fluid infused was relatively small, not nearly enough to trigger additional bleeding or coagulopathy. So if another IV does not deliver significant additional fluid and could be harmful even if it did, it’s probably not useful. Prehospital standards organizations should critically look at this old dogma to see if it should be modified.

Reference:

  • Study of placing a second intravenous line in trauma. Prehospital Emerg Care 15:208-213, 2011.

Final Answer: What The Heck Is It #1

Alright, here’s the final answer to the xray I posted last Friday. This patient was using a ThermaCare Menstrual HeatWrap by Pfizer. It was applied to her back, though, for relief from back pain. It was not apparent during the trauma activation exam, even with clothes off, until we logrolled her to examine her back.

Each pocket in the wrap contains a granular mixture of activated carbon, iron powder, salt and a few other ingredients. When the wrap is removed from its vacuum pouch it heats up to 104F (40C) and stays hot for up to 8 hours. The iron shows up on xrays. The regular pattern is a giveaway that this is not some other problem (stones, drug pouches in the colon).

Bottom line: Remember, conventional xrays collapse a 3D space onto a 2D image, so you can’t tell how deep objects are (anterior to posterior). This is another reminder to be thorough when examining your patient. They can hide things anywhere!

Disclaimer: I do not have any financial or other interest in Pfizer Inc.

What The Heck Final Answer

Your Comments

I’d like to thank everyone for their comments. An unregistered user just left a comment on a post on local wound exploration that I published 6 months ago. It poses a good question and I don’t want it to get lost in the archives. Click here to see the old post. I’m going to do a post next Wednesday entitled “The Art of Local Wound Exploration” that should answer everybody’s questions about this.

And so far, no one has figured out the weird pelvic xray below.

Michael