All posts by TheTraumaPro

To Probe or Not To Probe: Penetrating Wounds

There is considerable variability in the way that penetrating wounds are approached. Some are located over areas of lesser importance (distal extremities) or are so superficial that they obviously don’t fully penetrate the skin.

Unfortunately, some involve high-value structures (much of the neck and torso), or are too small to tell if they penetrate (ice pick injury). How should these injuries be approached?

Too often, someone just probes the wound and makes a pronouncement based on that assessment. Unfortunately, there are major problems with this technique:

  • The tract may be too small to appreciate with a finger or even a cotton-tip swab
  • The tract may be oriented in an unexpected direction, or the soft tissues may have moved after the penetration occurred. In this case, the examiner may not appreciate any significant depth to the wound.
  • Inserting an object may violate a structure that you wish it hadn’t (resulting in a hissing sound after probing a chest wound, or a column of blood after probing the neck)

A better way to approach these wounds is as follows:

  • Is the patient unstable? If so, you know the penetration caused the problem and the patient belongs in the OR.
  • Is there other evidence of deep injury, such as peritonitis with a penetrating abdominal wound? If so, the patient still needs to go to the OR.
  • Do a legitimate local wound exploration. This entails making the hole bigger with a knife, and using surgical instruments and your eyes to find the bottom of the tract. Obviously, there are some parts of the body where this cannot be done, such as the face, but they probably don’t need this kind of workup anyway.

As one of my mentors, John Weigelt, used to say, “Doctor, do you have an eye on the end of your finger?” In general, don’t use anything that doesn’t involve an eyeball in your local wound explorations!

Personal Decisions are the Leading Cause of Death

A relatively obscure research paper published in late 2008 by Ralph Keeney at Duke University makes this startling claim: over half of the people who died in this country in the year 2000 did so because of their own personal decisions! If you look at current mortality statistics, the top four causes of death from year to year are heart disease, cancer, stroke and injury. We naturally look at this and think that these people had a heart attack or discovered a cancer or crashed their car. What these statistics fail to show is how the people really ended up with these conditions.

Keeney’s paper looked beyond what was written on the death certificate and looked at how frequently personal choices caused these conditions. For example, smoking leads to heart disease, cancer, stroke, and high blood pressure, to name a few. Being overweight leads to heart disease, diabetes, high blood pressure, and many others. Inappropriate use of alcohol can lead to cancer, liver disease and a tendency to get into accidents.

The top causes of death were analyzed, looking at the percentage that could be caused by personal decisions such as smoking, diet, exercise, and use of alcohol or other drugs. A personal decision was defined as a situation where the individual could make a choice between two or more readily available alternatives (for example, smoking and not smoking) and that they had control over this choice. These choices are not necessarily easy to make because habits, social pressure, or genetic predisposition can make some alternatives hard to select.

Keeney found that about 55% of deaths in 2000 were caused by personal decisions. This compares to about 5% in the year 1900. This is due to the fact that the majority of the causes of death in 1900 were due to infectious diseases, and there were no antibiotics at the time to treat them.

What this paper shows us is that the need for high quality prevention activities is even greater that we thought, and that we may not be focusing on the right areas.Trauma centers habitually direct their prevention programs toward car seats, diving injuries, red light running, falls prevention and others. What we really need to focus on is personal choice, and teaching people how to make the right decisions. For trauma prevention, alcohol-related programs will probably give the greatest result since it is involved in so many of the top causes of death, even causes not related to trauma.

Trauma centers need to scrutinize their own prevention programs, and look critically at ways they can teach wise choices. It may be necessary to chage the focus of existing programs, or move to new programs that find ways to influence personal decision making. That way, trauma centers can have a hand not only in preventing certain types of injuries, but in directly decreasing the overall death rate as well.

Reference: Keeney RL. Operations Research 56:6, 1335-1347, 2008.

When To Remove a Chest Tube

Chest tubes are needed occasionally to help manage chest injuries. How do you decide when they are ready for removal?

Unfortunately, the literature is not very helpful in answering this question. To come up with a uniform way of pulling them, our group looked at any existing literature and then filled in the blanks, negotiating criteria that we could all live with. We came up with the following.

Removal criteria:

  • No (or a minimal, stable) residual pneumothorax
  • No air leak
  • Less than 150cc drainage over the past 3 shifts. We do not use daily numbers, as it may delay the removal sequence. We have moved away from the “only pull tubes on the day shift” mentality. Once the criteria are met, we begin the removal sequence, even in the evening or at night.

Removal sequence:

  • Has the patient ever had an air leak? If so, they are placed on water seal for 6 hours and a followup AP or PA view chest x-ray is obtained. If no pneumothorax is seen, proceed to the next step.
  • Pull the tube. Click here to see a video demonstrating the proper technique.
  • Obtain a followup AP or PA view chest x-ray in 6 hours.
  • If no recurrent pneumothorax, send the patient home! (if appropriate)

Click here to download the full printed protocol.

Off-Label Use of the Foley Catheter

Foley catheters are a mainstay of medical care in patients who need control or measurement of urine output. Leave it to trauma surgeons to find warped, new ways to use them!

Use of these catheters to tamponade penetrating cardiac injuries has been recognized for decades (see picture, 2 holes!). Less well appreciated is their use to stop bleeding from other penetrating wounds.

foleyinheart

Foley catheters can be inserted into just about any small penetrating wound with bleeding that does not respond to direct pressure. (Remember, direct pressure is applied by one or two fingers only, with no flat dressings underneath to diffuse the pressure). Arterial bleeding, venous bleeding or both can be controlled with this technique.

In general, the largest catheter with the largest possible balloon should be selected. It is then inserted directly into the wound until the entire balloon is inside the body. Inflate the balloon using saline until firm resistance is encounted, and the bleeding hopefully stops. Important: be sure to clamp the end of the catheter so the bleeding doesn’t find the easy way out!

Use of catheter tamponade buys some time, but these patients need to be in the OR. In general, once other life threatening issues are dealt with in the resuscitation room, the patient should be moved directly to the operating room. In rare cases, an angiogram may be needed to help determine the type of repair. However, in the vast majority of cases, the surgeon will know exactly where the injury is and further study is not needed. The catheter is then prepped along with most of the patient so that the operative repair can be completed.

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Syncope Workup in Trauma Patients

Syncope accounts for 1-2% of all ED visits, and is a factor in some patients with blunt trauma, especially the elderly. If syncope is suspected, a “syncope workup” is frequently ordered. Just what this consists of is poorly defined. Even less understood is how useful the syncope workup really is.

Researchers at Yale retrospectively looked at their experience doing syncope workups in trauma patients. They were interested in seeing what was typically ordered, if it was clinically useful, and if it impacted length of stay. 

A total of 14% of trauma patients had syncope as a possible contributor to their injury. The investigators found that the following tests were typically ordered in these patients:

  • Carotid ultrasound (96%)
  • 2D Echo (96%)
  • Cardiac enzymes (81%)
  • Cardiology consult (23%)
  • Neurology consult (11%)
  • EEG (7%)
  • MRI (6%)

Most of this testing was normal. About 3% of cardiac enzymes were abnormal, as were 5% of carotid imaging and 4% of echocardiograms. 

Important! Of the patients who underwent an intervention after workup, 69% could have been identified based on history, physical exam, or EKG and did not depend on any of the other diagnostic tests.

Conclusion: Syncope workup is not needed routinely in trauma patients with syncope as a contributing factor. Need for intervention can usually be determined by history, exam and EKG performed in the ED. In this study, $216,000 in excess costs would have been saved!

Reference: Routine / protocol evaluation of trauma patients with suspected syncope is unnecessary. Davis, et al, Yale University. Presented at the 23rd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 2010.