By now, everyone probably knows that texting while driving is bad. So legally banning texting is good, right? It seems that way, since everyone is doing it. Thirty states plus the District of Columbia currently ban texting while driving, and a third of those laws were passed just this year.
Talk about the law of unintended consequences. The Highway Loss Data Institute compared collision insurance claims before and after bans were put into effect in four states (CA, LA, MN, WA). Crash rates actually rose in three of the four states after the bans were passed.
How can this be? Unfortunately, the claim data can’t tell us what the increase is due to. They speculate that texting drivers are trying harder to conceal their habit, keeping their phones out of sight and taking their eyes off the road even more. Or, it could just be a statistical fluke.
The federal Transportation Secretary disagrees. He stated that distracted driving fatalities increased from 2005 to 2008, but stopped rising in 2009. I’m not clear on where this data comes from.
In either case, texting remains a bad thing to do. This debate just points out that bans are not the complete answer. Prevention programs and behavior modification need to be developed to comprehensively address this problem.
Arterial bleeding from a pelvic fracture is more common than previously thought. The doctor books used to say that 10% of bleeding was arterial and 90% was venous, so angiographic techniques were seldom used unless there was clinical evidence of blood loss.
It looks like arterial bleeding occurs more frequently than we think. Here are tips that help you identify patients at risk:
What type of mechanism caused the fracture? Anterior-posterior compression and vertical shear are the most common.
Are the vital signs stable? If not, rule out the other four likely sources first (chest, abdomen, multiple extremity fractures, external). Then blame the pelvis.
Is the fracture open? Arterial bleeding is very likely.
How old is the patient? Elderly patients are more likely to have arterial bleeding, especially from gluteal artery branches.
What part of the pelvis is broken? If major sacral fractures, SI joint disruption or separation of the symphysis is present, think arterial bleeding.
Are there CT abnormalities? A vascular blush or large hematoma indicates significant bleeding.
The most common bleeding sites are the gluteal and pudendal arteries. The gluteal is in proximity to the SI joint, so this can be torn if the SI joint is damaged or the sacrum is fractured. The pudendal can be injured with ramus fractures, especially when the symphysis is widened.
If the patient can be reasonably stabilized, then a trip to interventional radiology is mandatory. Operative management is not very successful, so patients with blood pressure lability or controllable hypotension should go to IR. All active bleeding and arterial cutoffs should be embolized thoroughly.
Images: On the left is the portable plain image of a vertical shear pelvic fracture. The arrows on the right point to two areas of vascular blush.
IO lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.
But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.
This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC). During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line closed, there could be.
Scoop and run vs stay and play are traditionally EMS concepts. Do I stay at the scene to perform invasive procedures, or do I perform the minimum I can and get to the nearest hospital?
For trauma patients time is the enemy and there is a different flavor of scoop and run vs stay and play. Do I take the patient to a nearby hospital that is not a high level trauma center to stay and play, or do I scoop and run to the nearest Level I or II center?
Admissions to a group of 8 trauma centers were analyzed over a 3 year period. A total of 1112 patients were studied. Patients were divided into two groups: those who were taken directly to a Level I trauma center (76%), and those who were transferred from another hospital (24%).
Patients who were taken to a non-trauma center first received 3 times more IV crystalloid, 12 times more blood, and were nearly 4 times more likely to die!
Obviously, the cause of this increased mortality cannot be determined from the data. The authors speculate that patients may undergo more aggressive resuscitation with crystalloid and blood at the outside hospital making them look better than they really are, and then they die. Alternatively, they may have been under-resuscitated at the outside hospital, making it more difficult to ensure survival at the trauma center.
Bottom line: this is an interesting paper, but there are a number of flaws that prevent us from mandating that all trauma patients should go directly to the trauma center. The authors never really define a “nontrauma hospital.” Does a Level III or IV center count? How did patients who stayed at the outside hospital do?
A lot of work needs to be done to add detail to this work. In the meantime, we have to trust our experienced prehospital providers to determine who really needs to go to the closest appropriate center, and what that really is.
Reference: Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer’s effect on mortality. J Trauma 69(3):595-601, 2010.
There is always debate about which lacerations can be closed, but not a lot of literature to back it up. Here are some good rules to follow:
In general, close all face and scalp lacerations. They almost never get infected. Complicated ones may need extra care, debridement, or involvement of a plastic surgeon.
Closing lacerations that are more than 24 hours old is risky (except for the face). They tend to be colonized with skin flora and become infected much more frequently.
Most other lacerations can be closed primarily within 24 hours. For the most part, it doesn’t matter what the cutting instrument was. One exception is an object that is heavily contaminated (e.g. freshly used pitchfork). Most knives don’t fall into this category. They are clean, but not sterile and the risk of infection is low.
All wounds should be inspected for foreign bodies. On occasion, this may require an xray. But remember that many foreign objects (wood, glass) are not radiopaque and will be invisible. Next, the wound should be copiously irrigated with sterile saline to flush out any small particles and reduce bacterial counts. Finally, if the edges are ragged the wound should be sharply debrided.
Antibiotics are not usually needed, since the few bacteria left will be rapidly taken care of by the patient’s immune system. If there are worries about contamination or the patient is immunocompromised, a very brief course of antibiotic is recommended. Tetanus toxoid should be given if indicated.
The most important issue is patient education. The signs and symptoms of early wound infection should be explained, and a phone number or location for followup should be clearly listed.
Bottom line: All lacerations can be safely closed within 24 hours, with a few exceptions.
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