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Emergency Medicine & Trauma Update – Bloomington, MN 10/28/10

“Torso Trauma Update” presented at 8:40AM.

For a copy of the slideset, click here.

Bibliography:

  • What is the utility of focused assessment with sonography in trauma (FAST) exam in penetrating torso trauma? Injury, in press, 2010.
  • CT of blunt abdominal and pelvic vascular injury. Emerg Radiology 17:21-29, 2010
  • More operations, more deaths? Relationship between operative intervention and risk-adjusted mortality at trauma centers. J Trauma 69(1):70-77, 2010
(Source: https://www.youtube.com/)
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Can Texting Bans Be Bad?

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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.

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Bleeding and Pelvic Fractures

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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.

Pelvic arterial bleeding

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Air Embolism From an Intraosseous (IO) Line

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.