The intraosseous access device (IO) has been a lifesaver by providing vascular access in patients who are difficult IV sticks. In some cases, it is even difficult to draw blood in these patients by a direct venipuncture. So is it okay to send IO blood to the lab for analysis during a trauma resuscitation?
A study using 10 volunteers was published last year (imagine volunteering to have an IO needle placed)! All IO devices were inserted in the proximal humerus. Here is a summary of the results comparing IO and IV blood:
Hemoglobin / hematocrit – good correlation
White blood cell count – no correlation
Platelet count – no correlation
Sodium – no correlation but within 5% of IV value
Potassium – no correlation
Choloride – good correlation
Serum CO2 – no correlation
Calcium – no correlation but within 10% of IV value
Glucose – good correlation
BUN / Creatinine – good correlation
Bottom line: Intraosseous blood can be used if blood from arterial or venous puncture is not available. Discarding the first 2cc of marrow aspirated improves the accuracy of the lab results obtained. The important tests (hemoglobin/hematocrit, glucose) are reasonably accurate, as are Na, Cl, BUN, and creatinine. The use of IO blood for type and cross is not yet widely accepted by blood banks, but can be used until other blood is available.
CT scan is an invaluable tool for evaluating blunt abdominal trauma. Although it is very good at detecting solid organ injury, it is not so great with intestinal and mesenteric injuries. Older studies have suggested that CT can detect mesenteric injuries if done right, but a newly published study has shown good accuracy with a few imaging tweaks.
A Taiwanese study looked at a series of prospectively studied victims of blunt abdominal trauma. Patients with abdominal pain or a positive FAST were entrolled (total 106). IV contrast was given, and scans during the arterial, portal, and equilibrium contrast phases were performed using a multidetector scanner. Images were read in a blinded fashion.
A total of 13 of 23 patients who underwent laparotomy were found to have a bowel or mesenteric injury. Five had bowel injury, 4 had mesenteric hemorrhage, and 4 had both. Mesenteric contrast extravasation was seen in 7 patients, and this correlated with mesenteric bleeding at laparotomy.
The authors found that the following signs on CT scan indicated injury:
Full or partial thickness change in bowel wall appearance
Increased mesenteric density
Free fluid without solid organ injury
Bottom line: This study shows that CT scan can detect bowel and mesenteric injury reliably if you scan the patient 3 times! This seems like over-radiation and overkill. A more intelligent way to approach this would be to perform a normal trauma abdominal scan. If a suspicious area of mesenteric or bowel thickening is seen, then a limited rescan through the affected area only for equilibrium phase images may be warranted. If actual contrast extrvasation is seen, no further scanning is needed. A quick trip to the OR is in order.
Reference: Contrast-enhanced multiphasic computed tomography for identifying life-threatening mesenteric hemorrhage and transmural bowel injuries. J Trauma 71(3):543-548, 2011.
There’s An App For That: Reading Xrays on Your iPhone/iPad
MIM Software has developed an app that allows trauma professionals to view xrays on their mobile device. The app actually received FDA clearance for use earlier this year, and is available as a free download.
The catch is that the software only works with MIM’s cloud-based product for managing radiographic images, called MIMcloud. It is primarily intended for those who do not have access to a full image viewing workstation (MIMfusion).
The Pentagon and the University of Pittsburgh have developed a new technique for growing functional muscle in vivo. The process starts with insertion of an extracellular matrix containing growth factor proteins from pig bladders. Stem cells move to the area and begin the process of wound repair and tissue growth, which normally does not occur in mature muscle.
The really interesting thing about this process is that, after intensive rehab begins, not only does the muscle grow back, but also tendons and nerves to innervate the muscle! The process has been used successfully in four patients so far.
Bottom line: This may become a new standard of care in the next few years. It will simplify soft tissue reconstruction in mangled extremities and motorcycle injuries, to name a few.
Yesterday I wrote about one reader’s experience with a trauma patient on Dabigatran. We’ve all been faced with injured patients who are taking some kind of anticoagulant, and it complicates their care. Why can’t we just stop them in patients at risk for injury (e.g. an elderly patient who falls frequently)?
Two major risk groups come to mind: those taking the meds who have DVT (or a propensity to get it), and patients with atrial fibrillation who take them to decrease stroke risk. I was not able to find much info (yet) on the former category. But there is a series of nicely done studies based on work from the Framingham Heart Study.
The Framingham study started in 1948, and has been following over 5,000 people for the development of cardiovascular disease. In this particular analysis, 5070 patients who were initially free of disease were analyzed for development of atrial fib and occurrence of stroke. Anticoagulants were seldom used in this group.
The authors found that the prevalence of stroke increased with age in patients with atrial fib. The percentage that could be attributed to a-fib also increased. The following summarizes their numbers:
Age 50-59: 0.5 strokes per 100 patients, attributable risk 1.5%
Age 60-69: 1.8 strokes per 100 patients, attributable risk 2.8%
Age 70-79: 4.8 strokes per 100 patients, attributable risk 9.9%
Age 80-89: 8.8 strokes per 100 patients, attributable risk 23.5%
Bottom line: The risk of having a stroke just because a patient has atrial fibrillation goes up significantly with age. So setting an age cutoff for taking an anticoagulant doesn’t make sense. Unfortunately, increasing age also means increasing risk of injury from falls. Warfarin definitely cuts that risk, and it happens to be relatively easily reversbile. However, the newer non-reversible drugs change the equation, shifting the risk/benefit ratio too far toward the dark side. We need some good analyses to see if it really makes sense to move everybody to these new (expensive) drugs just to make it easier to dose and monitor. The existing studies on them only look at stroke, but don’t take injury morbidity and mortality into account.
Reference: Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 22:983-988, 1991.