All posts by TheTraumaPro

How To: Deal With Fence Impalement (Part 2)

In the last post, I discussed a patient who had impaled himself on top of a wrought iron fence.The questions revolved around proper management in the field. Here are my thoughts.

First of all, the patient stays impaled until delivered to the hospital. This will require a fair amount of creativity, as outlined by the comments by Medic97 in my last post. There are two main components: extrication and transport. The two are closely related.

Extrication will require some heavy equipment not carried by your typical EMS prehospital providers. The fire department or other agency can bring the equipment to the scene. I’ve actually seen rescue teams raid nearby construction trailers for tools!

It then boils down to finding the best spots to cut the fence while protecting the patient. Cutting equipment vibrates, gets hot, and can potentially cause abrupt movements of the fence. Shielding or bracing appropriate to the type of equipment being used is very important. Analgesia and sedation are encouraged. And once the piece of fence is detached, moving it and the patient in unison takes quite a few people.

The last challenging task is getting the patient into the rig (transport). Make sure that the section of fence removed will actually fit through the rear door while attached to the patient. If this is a problem, it’s easy to trim off sections at this point to allow a fit. The other difficulty is securing the patient for the ride, mainly because they may not be able to assume the usual supine position. I’ve seen patients who had to be transported on their side or even prone because of the orientation of the foreign object. Once again, creativity is the key!

Finally, call ahead and notify the emergency department. This will allow them to plan ahead for positioning and imaging needs, and will let them get an OR ready for eventual removal of the object.

The fence posts went over and under the right femur, with the lower one impaling the posterior thigh and the upper one resting on the groin.

Tomorrow, I’ll finish with some tips you can use once the patient arrives at the hospital.

How To: Deal With Fence Impalement (Part 1)

The first part of this post is for my prehospital colleagues. We’ve probably all seen one of these at least once. Someone decides that want to take the short cut. Over a wrought iron fence. Alcohol is usually involved. They get to the top, but just before they can get over, they slip. The top of the fence impales their thigh!

This example comes from a TV news site in Los Angeles.

Let’s say you are one of the first responders at the scene. What do you do? Pull him off or leave him impaled? What equipment do you need? How do you avoid further harm? How do you fit him into your rig? How do you even secure it? Tweet you answers or leave comments below.

I’ll share some of my ideas on Monday, as well as the xray. Then we’ll talk about the in-hospital management piece. 

New Technology: Artificial Bones

Most orthopaedic injuries are very handily fixed by our friendly neighborhood orthopaedic surgeons. But occasional patients have bony injuries so severe that they challenge even the best of them. Think motorcycle crashes, mangled extremities and bone loss.

Researchers at universities in Edinburgh and Southampton have developed an experimental product that may facilitate rebuilding these challenging injuries. They created a plastic polymer that is honeycombed with small holes. These holes allow blood to flow through it, enabling stem cells from the bone marrow to take up residence and rebuild bone. Once new bone has formed, the plastic slowly degrades, leaving only the patient’s own tissues.

This image show proteins from skeletal stem cells that have been cultured on a plastic scaffold

This new product has been tested successfully in animals, and work is underway to get approval for human testing.

Bottom line: Although many years away, this product may increase the number of limbs salvaged after mangling type injuries to the extremities.

Related post: 

Reference:Discovery and Evaluation of a Functional Ternary Polymer Blend for Bone Repair: Translation from a Microarray to a Clinical Model.  Advanced Functional Materials ePub Jan 25, 2013.

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.

What To Do? Small Hospital, Unstable Patient

It’s the situation that physicians in smaller hospitals dread. A major trauma patient gets dropped off at the door. You do your evaluation, quickly determining that they need services that you don’t just have (head injury and positive FAST in the abdomen, let’s say). You call your community EMS service to transport to a Level I trauma center, which is about 30 minutes away by ground. And just as they are rolling out the door to the rig, the blood pressure drops to 60! What to do?!

The ATLS course is very clear, and very correct. Back into the ED for a quick re-evaluation. The most common cause for a significant disturbance in vitals or exam lies within the primary survey. You will almost always find a problem with Airway, Breathing, or Circulation. (A Disability problem can cause a problem on rare occasion (hypotension from impending herniation), but there’s not much that you can do about it, really. Hyperventilate, hyperosmolar therapy, okay but probably a poor outcome for the patient anyway.)

So you didn’t find any airway or breathing issue. But the abdominal stripe(s) you saw on FAST are larger, so it’s circulation. Now what? And does it matter if you have a surgeon available on call? The answer is simpler than you think.

ATLS says that, if you have surgical support available you have to use it in this type of situation. If you don’t have it, package the patient with a lot of blood and plasma and send. If you have a physician or nurse to spare you could consider sending them along to help during transport, but for small community hospitals this is not practical.

But if you do have a surgeon, does it make sense to use them? Not always! You must take into account response times and transport times. Let’s say it’s 2:00 am and you call your surgeon for this hypotensive patient. They may take up to 30 minutes to get in and see the patient. They then agree that the patient needs a laparotomy and she proceeds to call in the OR team. Yet another 30 minutes tick by.  Will the patient still even be alive when they roll into the OR?

Or you could just put the patient back in the ambulance (air preferably, but ground if you have to) and get them to your trauma center quickly. They can then be whisked directly into a waiting OR in less than 30 minutes from your door. This is probably the ideal solution here. Obviously this doesn’t work as well if you are a few hours away from your resource trauma center. 

Bottom line: Deciding what to do with a patient that needs urgent treatment that you can’t immediately deliver is tough! That’s why it’s always a calculus problem when you’re faced with this situation. But take all of the response and transport times into account, and do what’s best for your patient! 

Thanks to EM Res for posing this question!