All posts by TheTraumaPro

Making Aeromedical Flights Safer

There are about 840 EMS helicopters operating nationwide. The fatal accident rate has doubled from the mid-90’s to the growth spurt seen in the earlier part of this decade. Since late 2007, 57 crew members and patients have died in these helicopter crashes. According to the FAA, the most frequent causes of these crashes were controlled flight into terrain, inadvertent flight into instrument conditions, and disorientation during night flight.

The FAA is now proposing to change the rules and add extra equipment to these flights in an attempt to improve safety. These changes would include:

  • Installing a ground proximity warning system
  • Tightening the restrictions that limit proximity to bad weather. Currently, pilots must stay half a mile away from clouds during the daytime and one mile away at night.
  • Boosting bad weather training requirements for pilots so they are better equipped to escape from bad weather
  • Installing flight data recorders. New, lightweight models need to be developed for helicopters first, though.

It looks like this is a win-win proposition. Lawmakers, families of crash victims and the aeromedical industry appear to be on board with these changes. Once approved, they would go into effect next year. Unfortunately for the families of crew and patients killed in these crashes, the changes can’t come soon enough.

Diagnosing Facial Fractures With CT

Facial fractures are common after major blunt trauma. There are a number of diagnostic tests available for their diagnosis, including head CT, conventional facial imaging and facial CT.

Our preference has been to add a facial CT to the list of diagnostics in any patient with external evidence of facial trauma. Subjectively, it appeared that there were not many injuries being identified, and the vast majority did not require operative management. 

A review of the literature shows that head CT alone is sufficient for screening for significant facial fractures. A small retrospective series noted that the accuracy was 92%, with 90% sensitivity and 95% specificity. 

Bottom line: A head CT alone ordered for the usual indications is a very good screening test for facial fractures. If none are seen, it is unlikely that there are any fractures that require specific management. If fractures are seen, consultation with a facial surgeon is needed. However, unless the fractures involve critical areas (e.g. temporal bone near the middle ear) or are significantly displaced, the benefit of a facial CT scan is still very low since most will be treated without operation.

Reference: Computed tomography of the head as a screening examination for facial fractures. Marinaro et al. Am J Emerg Med 25, 616-619, 2007.

Will Our Phones Help Save Us From Being Distracted By Our Phones?

I’ve written many posts on the perils of texting and driving. Everybody knows it’s bad, but they still do it. It’s tough for police to detect, let alone enforce.

How to deal with this problem? Well now, there’s an app for that!

AdelaVoice has released a free app for Android phones that allows the user to interact with their phone without touching or even looking at it. It’s called StartTalking and lets the user send and listen to texts, post to Twitter or Facebook, as well as other tasks. To visit their website, click here.

I think that this app could dramatically improve road safety if it works as advertised. However, I also don’t think it’s the final answer, because research has also shown that just talking on the phone is a distraction and leads to accidents, too.

It will be very interesting to see where this type of solution leads us.

Disclosure: I have no financial interest in AdelaSoft or StartTalking. I don’t even own an Android phone!

Prone Positioning After Laparotomy

Patients with serious abdominal injury may require a laparotomy, and a subset of these may need a temporary closure for damage control surgery. Concomitant spine injury may have your spine surgeons asking “is it safe to prone the patient who is postop with a midline incision or an open abdomen.” What to tell them?

There’s not much guidance out there in the literature. One paper from 2000 looked at four patients who were proned for severe ARDS and found that one suffered a wound dehiscence. However, this patient had severe generalized edema and was on several pressor agents. 

The use of temporary abdominal closure techniques has revolutionized the early management of severely injured trauma patients and has greatly decreased the incidence of complications from abdominal compartment syndrome. Several authors have now demonstrated that putting those patients in the prone position is well tolerated. 

As far as patients who have a closed laparotomy, proning appears to be well tolerated as well. One caveat: consider carefully if the patient is having wound complications or if they are morbidly obese.

The bottom line: Consider the risks and benefits carefully in any post-laparotomy patient you are considering prone positioning for. Other than in morbidly obese, it is generally considered safe, even in patients with damage control dressings in place. However, make sure the trauma surgeon re-evaluates the wound again as soon as the patient is returned to the supine position.

References: 

1. The “open abdomen” is not a contra-indication to prone positioning for severe ARDS (abstract). Schwab, et al. Chest. 1996;110:142S.

2. Complications of Prone Ventilation in Patients with Multisystem Trauma with Fulminant Acute Respiratory Distress Syndrome. Offner et al. Journal of Trauma-Injury Infection & Critical Care. 48(2):224-228, February 2000.

3. The Management of the Open Abdomen in Trauma and Emergency General Surgery: Part 1-Damage Control. Diaz et al. Journal of Trauma-Injury Infection & Critical Care. 68(6):1425-1438, June 2010.