Several readers asked me to dust off this video yet again. Enjoy this parody of the Dos Equis “Most Important Man In The World” commercials. I love poking fun at myself, and the slow motion shot on the helipad is hysterical.
This video was part of the Trauma Education: The Next Generation conference produced several years ago. Enjoy, and please comment or give it a thumbs up on YouTube!
Here’s a quick, 3 ½ minute video for physicians and paramedics on how to decompress the chest when you suspect a tension pneumothorax.
The ATLS course now adds a consideration to use an alternative site. That location is the 5th intercostal space around the mid-axillary line. This has come about because shorter needles may not reach the pleural space when inserted under the clavicle in larger patients. The new spot is the typical location for placement of the inevitable chest tube that has to be inserted after needle decompression.
If you’ve got a few tips or tricks that you’d like to share on this procedure, please comment on the YouTube video.
I’ve previously written about the difficulties estimating how much blood is on the ground at the trauma scene. In general, EMS providers underestimated blood loss 87% of the time. The experience level of the medic was of no help, and the accuracy actually got worse with larger amounts of blood lost!
A group in Hong Kong developed a color coded chart (nomogram) to assist with estimation of blood loss at the scene. It translated the area of blood on a non-absorbent surface to the volume lost. A convenience study was designed to judge the accuracy that could be achieved using the nomogram. Sixty one providers were selected, and estimated the size of four pools of blood, both before and after a 2 minute training session on the nomogram.
Here’s what it looks like:
Note the areas across the bottom. In addition to colored square areas, the orange block is a quick estimate of the size of a piece of paper (A4 size since they’re in Hong Kong!)
Here are the factoids:
The 61 subjects had an average of 3 years of experience
Four scenarios were presented to each: 180ml, 470ml, 940ml, and 1550ml. These did not correspond exactly to any of the color blocks.
Before nomogram use, underestimation of blood loss increased as the pool of blood was larger, similar to the previous study
There was a significant increase in accuracy for all 4 scenarios using the nomogram, and underestimation was significantly better for all but the 940ml group
Median percentage of error was 43% before nomogram training, vs only 23% after. This was highly significant.
Bottom line: This is a really cool idea, and can make estimation of field blood loss more accurate. All the medic needs to do is know the length of their shoe and the width of their hand in cm. They can then estimate the length and width of the pool of blood and refer to the chart . Extrapolation between colors is very simple, just look at the line. The only drawback I can see occurs when the blood is on an irregular or more absorbent surface (grass, inside of a car).
EMS providers are the trauma professional’s eyes and ears when providing transportation from the scene of an accident. We rely on their assessment of the mechanism of injury and the amount of blood lost. We tend to believe in the accuracy of those assessments.
A study was carried out that tested EMS personnel on their ability to accurately estimate specific amounts of blood that were left at a simulated accident scene. The blood volumes tested were 500cc, 1000cc, 1500cc and 2100cc. A total of 92 professionals participated, and there was an even split into basic EMTs (34%), intermediate/critical care EMTs (33%) and paramedics (31%). Experience levels were as follows: 0-5 years 43%, 6-10 years 30%, >10 years 31%.
The results were as follows:
87% underestimated the quantity of blood
4% guessed the exact amount
Experience or credentialing level did not matter
Only 8% of the subjects were within 20% of the actual volume, and an additional 19% were within 50%. In general, most medics underestimated the amount of blood lost, and their guesses were worse with higher volumes. The median guess for the 2100cc loss group was only 700cc!
Bottom line: Visual estimates of blood loss are extremely inaccurate, and are most likely underestimates. Physicians in the ED should rely on exam and physiology to help determine the amount of blood loss. For safe measure, multiply the reported blood loss of the EMT or paramedic by 2 or 3 to get a realistic number.
Reference: Patton et al. Accuracy of Estimation of External Blood Loss by EMS Personnel. J Trauma 50(5), 914, 2001.
Today’s post is another review of some of the practice guidelines published by the Eastern Association for the Surgery of Trauma (EAST). This one covers the evaluation and management of diaphragmatic injury.
Diaphragm injury is a troublesome one to diagnose. It is essentially an elliptical sheet of muscle that is doubly-curved, so it does not lend itself well to diagnosis by axial imaging. Addition of sagittal and coronal reconstructions to a thoraco-abdominal CT has been helpful, but still has a far from perfect diagnostic record.
From an evaluation standpoint, there are several possibilities:
Observation – not generally recommended. It is usually combined with imaging such as chest x-ray to see if interval changes occur that would indicate the injury.
Chest x-ray – this is not often diagnostic, but when herniation of abdominal contents is obvious the patient most assuredly has an operative problem.
Thoraco-abdominal CT scan – this technology keeps getting better, especially with thinner cuts and different planes of reconstruction. Sometimes even subtle injuries can be detected. But this exam is still imperfect.
Laparoscopy or thoracoscopy – this technique yields excellent accuracy when the injury is in an area that can be viewed from the operative entry point chosen.
Laparotomy or thoracotomy – this is the ultimate choice and should be nearly 100% accurate. It is almost the most invasive and has more potential associated complications.
EAST reviewed a large body of literature and selected 56 pertinent papers for their quality and design. They critically reviewed them and applied a standard methodology to answer several questions.
Here are the questions with the recommendations from EAST, along with my comments:
Should laparoscopy or CT be used to evaluate left-sided thoraco-abdominal stab wounds? First, these patients must be hemodynamically stable and not have peritonitis. If either is present, there is no further need for diagnosis; a therapeutic procedure must be performed. Left sided diaphragm injuries from stabs are evil. The hole is small, and since the pressure within the abdomen is greater that the chest, things always try to wiggle their way through this small hole. It can remain asymptomatic if the wiggler is just a piece of fat, but can be catastrophic if a bit of the stomach or colon pushes through and becomes strangulated. Furthermore, these holes enlarge over time, so more and more stuff can push up into the chest. EAST recommends the use of laparoscopy for evaluation to decrease the incidence of missed injury. However, if the injury is in a less accessible location (posterior), the patient has body habitus issues, or adhesions from previous surgery may lead to incomplete evaluation, laparotomy should be strongly considered.
Should operative or nonoperative management be used to evaluate right-sided thoraco-abdominal penetrating wounds? Note that this is different than the last question. All penetrating injuries are included (stabs and gunshots), and this one is for management, not evaluation. And the same caveats regarding hemodynamic stability and peritonitis apply. It applies to both stabs and gunshots. Unlike left-sided injuries, right-sided ones are much more benign. The liver keeps anything from pushing up through small holes, and they do not tend to enlarge over time due to this protection. For that reason, EAST recommends nonoperative management to reduce mortality and morbidity related to operation.
Should stable patients with acute diaphragm injury undergo repair via an abdominal or thoracicapproach? This question applies to any diaphragm injury that requires operation, such as right-sided penetrating injury or any blunt injury. EAST recommends an approach from the abdomen to reduce morbidity and mortality. Since abdominal injury frequently occurs in these cases, an approach from the chest limits the ability to identify and repair abdominal injuries. Otherwise, you may find yourself doing a laparotomy in addition to the thoracotomy.
Should patients with delayed visceral herniation through a diaphragm injury undergo repair via an abdominal or thoracic approach?For years, the preferred approach for delayed presentations has been through the chest because the injury is easier to appreciate and repair. However, if ischemic or gangrenous viscera are present, it will be more difficult to manage and repair from the chest. EAST does not make a specific recommendation for this question and suggests the surgical approach be determined on a case by case basis.
Should patients with an acute diaphragm injury from penetrating injury without concern for other intra-abdominal injuries undergo open or laparoscopic repair? The quality and quantity of data addressing this question were very low, but EAST recommends laparoscopy for repair of these injuries to reduce morbidity and mortality. This includes blunt injuries, which tend to be larger. There were some conversions to an open procedure, especially in the blunt cases. The usual caveats on exposure, injury location, body habitus and previous surgery apply.
Reference: Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma 85(1):198-207.
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