All posts by TheTraumaPro

What You Need To Know About Frontal Sinus Fractures

Fracture of the frontal sinus is less common than other facial injuries, but can be more complex to deal with, both in the shorter and longer terms. These are generally high energy injuries, and facial impact in car crashes is the most common mechanism. Fists generally can’t cause the injury, but blunt objects like baseball bats can.

Here’s the normal anatomy:

sinus-fracture-treatment

 

Source: www.facialtraumamd.com

There are two “tables”, the anterior and the posterior. The anterior is covered with skin and a small amount of subcutaneous tissue. The posterior table is separated from the brain by the meninges.

Here’s an image of an open fracture involving both tables. Note the underlying pneumocephalus.

frontal_sinus1

A third of injuries violate the anterior table, and two thirds violate both. Posterior table fractures are very rare. A third of all patients will develop a CSF leak, typically from their nose.

These fractures may be (rarely) identified on physical exam if deformity and flattening is noted over the forehead. Most of the time, these patients undergo imaging for brain injury and the fracture is found incidentally. Once identified, go back and specifically look for a CSF leak. Clear fluid in the nose is, by definition, CSF. Don’t waste time on a beta-2 transferring (see below).

If a laceration is clearly visible over the fracture, or if a CSF leak was identified, notify your maxillofacial specialist immediately. If more than a little pneumocephalus is present, let your neurosurgeon know. Otherwise, your consults can wait until the next morning.

In general, these patients frequently require surgery for the fracture, either to restore cosmetic contours or to avoid mucocele formation. However, these are seldom needed urgently unless the fracture is an open fracture with contamination or there is a significant CSF leak. If in doubt, though, consult your specialist.

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Keeping Patients Warm In Your Trauma Bay

Hypothermia is the enemy of all trauma patients. It takes their potential bleeding problems and makes them exponentially worse. From the time you strip off their clothes in the trauma resuscitation room, they begin to cool down. And if you live in Minnesota like me (or some similar fun place), they start chilling even before that.

What can you do in the trauma bay to help avoid this potential complication? Here are some of the possibilities, and what I think of them. And I’ll also provide a practical tip to help keep your patient warm  while you can still do a full exam.

Outside

– Warming lights in the ambulance unloading area. I know lots of people look at this area and recommend them. Unfortunately, they don’t do a lot. Consider that your patient will move through this space quickly. While it may be cold, they’ll only spend a minute or so getting to the back door to the ED.

– How about the path from the helipad? If this is mostly outside, it can be a problem. If it’s wide open, there aren’t really a lot of options. Cover and heat it? Lots of $$$. Typically, flight crews working in winter climates have bundled up their patient very well, and this is the patient’s primary source of protection from the elements. If the pad is far away from the ED, consider a fancy golf cart to move them quickly, and perhaps get an even fancier one that has a heated enclosure.

Inside

– Heat the room! This only works on a moment’s notice if you have a smaller room or a really good heating system. Otherwise, you must keep it cranked it up at all times.

– Close the door! You will not be able to keep the room toasty unless you make sure the door is closed as much as possible. No doors? Then consider the next tips.

– Use radiant heating systems. Some EDs have lights in the ceiling, others have portable units that can be rolled over to your patient.

– Use hot fluids, especially in the winter. At a minimum, all blood products must be administered through a warmer, since they are only a few degrees above freezing. If it’s winter outside, or your patient is already cool, give all IV fluids through the warmer, too.

– Cover your patient. Keep a blanket warmer nearby, and pull several out at the beginning of each resuscitation.

– What about those fancy air blankets? Unfortunately, they are unwieldy. They’re all one piece, they try to fall of the patient all the time, and they limit access for your exam. But there is a solution!

Here’s a clever way to deal with this problem. Use my two-blanket trick. Don’t use just one warm sheet or blanket. Use two! Fold each one in half, so they are each half-length. Place one on the top half of the patient, the other at the bottom, overlapping slightly at the waist. Your whole patient is now covered and toasty. If you need to look at an extremity, fold the blanket that covers it over from right to left (or left to right) to uncover just the area of interest. To insert a urinary catheter, just open the area at the waist, moving the top sheet up a little, the bottom down a little. Voila!

Trauma Surgery Tip: How To See The Unseeable – The Answer

Yesterday I posed a scenario where the surgeon needed to see an area of an open abdomen (trauma laparotomy) that could not easily be visualized. Specifically, there was a question as to whether the diaphragm had been violated just anterior to the liver, just under the costal margin.

Short of putting your head in the wound, how can you visualize this area? Or some other hard to reach spot? Well, you could have an assistant insert a retractor and pull like crazy. However, the rib cage might not bend very well, and in elderly patients it may break. Not a good idea.

Some readers suggested breaking out the laparoscopy equipment and using the camera and optics to visualize. This is a reasonable idea, but expensive. Shouldn’t there be some good (and cheap) way to do this?

Of course, and there is. Think low tech. Very low tech. You just need to see around a corner, right. So get a mirror!

Every OR has some sterile dental mirrors lying around. Get one and have your assistant gently hold the liver down while you indirectly examine the diaphragm. Since you’re probably not a dentist, it may take a minute or two to get used to manipulating the mirror to see just what you want. But if you can manage laparoscopic surgery, you’ll get the hang of it quickly.

And if you need more light up in those nooks and crannies? Shine the OR light directly into the abdomen, then place a nice shiny malleable retractor into the area to reflect light into the area in questions. Voila!

Bottom line: A lot of the things that trauma professionals need to do in the heat of the moment will not be found in doctor, nurse, or paramedic books. Be creative. Look at the stuff around you and available to you. Figure out a way to make it work, and make $#!+ up if necessary.

Trauma Surgery Tip: How To See The Unseeable

Let me present a scenario and first see how you might solve this problem.

A young man presents with a gunshot to the abdomen in the right mid-back. He is hemodynamically stable, and you get a chest xray. It shows a small caliber slug in the right upper quadrant, but no hemo- or pneumothorax. He has peritoneal signs, so you whisk him off to the OR for a laparotomy.

As you prep the patient for the case, you can feel a small mass just above the right costal margin. You incise the area and produce a 22 caliber bullet. Of course, you follow the chain of evidence rules and pass it off for the police. As you explore the abdomen, it appears that there are no gross injuries. You are concerned, however, that there may be an injury to the diaphragm in proximity to the bullet.

So here’s the question: how can you visualize the diaphragm in this area? The bullet was located below the right nipple. But the diaphragm in this area is covered by the liver, and is parallel to the floor. You can’t seem to feel a hole with your fat finger. But short of putting your whole head in the wound, you just can’t get a good angle to see the area in question.

How would you do it? Please tweet or leave comments with your suggestions. I’ll provide the answer(s) tomorrow!

Liquid Plasma vs FFP: Impact On Your Massive Transfusion Protocol

In my last post, I discussed the growing number of choices for plasma replacement. Today I’ll look at some work that was done that tried to determine if any one of them is better than the others when used for the massive transfusion protocol (MTP).

As noted last time, fresh frozen plasma (frozen within 8 hours, FFP) and frozen plasma (frozen within 24 hours, FP) have a shelf life of 5 days once thawed. Liquid plasma (never frozen, LQP) is good for the 21 days after the original unit was donated, plus the same 5 days, for a total of 26 days.

LQP is not used at most US trauma centers. It is more commonly used in Europe, and a study there suggested that the use of thawed plasma increased short term mortality when compared to liquid plasma. To look at this phenomenon more closely, a group from UTHSC Houston and LSU measured hemostatic profiles on both types of plasma at varying times during their useful life.

All products were analyzed with thromboelastography (TEG) and thrombogram, and platelet count and microparticles, clotting factors, and natural coagulation inhibitors were measured. They chose 10 units of thawed FFP and 10 units of LQP, and assayed them every 5 days during their useful shelf life.

Here are the factoids:

  • Platelet counts were much higher in day 0 LQP (75K) vs day 0 thawed plasma (7.5K). Even at end of shelf life, the LQP was 1.5x higher than thawed (15K vs 10K).
  • Thrombogram showed that LQP had higher endogenous thrombin production until end of shelf life
  • TEG demonstrated that LQP had a higher capacity to clot that gradually declined over time. It became similar to thawed plasma at the end of its shelf life.
                         (TEG MA for liquid (LQP) and thawed (TP) plasma
  • Most clotting factors remained stable in LQP, with the exception of Factors V and VIII, which slowly declined

Bottom line: Liquid plasma sounds like good stuff, right? Although there are a few flaws in the collection aspect of this study, it gives good evidence that never frozen plasma has better coagulation properties when compared to thawed plasma. Will this translate into better survival when used in the MTP for trauma? One would think so, but you never really know until you try it. Our hospital blood bank infrastructure isn’t prepared to handle this product yet, for the most part. What we really need is a study that shows the survival advantage when using liquid plasma compared to thawed. But don’t hold your breath. It will take a large number of patients and some fancy statistical analysis to demonstrate this. I think we’ll have to look to our military colleagues to pull this one off!

Reference: Better hemostatic profiles of never-frozen liquid plasma compared with thawed fresh frozen plasma. J Trauma 74(1):84-91, 2013.