All posts by TheTraumaPro

Trauma Patient Transport By Police, Not EMS

When I was at Penn 30+ years ago, I was fascinated to see that police officers were allowed to transport penetrating trauma patients to the hospital. They had no medical training and no specific equipment. They basically tossed the patient into the back seat, drove as fast as possible to a trauma center, and dropped them off. Then they (hopefully) hosed down the inside of the squad car.

Granted, it was fast. But did it benefit the patient? The trauma group at Penn decided to look at this to see if there was some benefit (survival) to this practice. They retrospectively looked at 5 years of data in the mid-2000’s, thus comparing the results of police transport with reasonably state of the art EMS transport.

They found over 2100 penetrating injury transports during this time frame (!), and roughly a quarter of those (27%) were transported by police. About 71% were gunshots vs 29% stabs.

Here are the factoids:

  • The police transported more badly injured patients (ISS=14) than EMS (ISS=10)
  • About 21% of police transports died, compared to 15% for EMS
  • But when mortality was corrected for the higher ISS transported by police, it was equivalent for the two modes of transport

Although they did not show a survival benefit to this practice, there was certainly no harm done. And in busy urban environments, such a policy could offload some of the workload from busy EMS services.

Bottom line: Certainly this is not a perfect paper. But it does add more fuel to the “stay and play” vs “scoop and run” debate. It seems to lend credence to the concept that, in the field, less is better in penetrating trauma. What really saves these patients is definitive control of bleeding, which neither police nor paramedics can provide. Therefore, whoever gets the patient to the trauma center in the least time wins. And so does the patient.

Related posts:

Reference: Injury-adjusted mortality of patients transported by police following penetrating trauma. Acad Emerg Med 18(1):32-37, 2011.

Submental Intubation – The Video!

Yesterday, I described a novel technique for providing a secure yet short-term airway tailored to patients who can’t have a tube in their mouth or nose. Patients undergoing multiple facial fracture repair are probably the best candidates for this procedure.

A picture may be worth a thousand words, but a video is even better. Please note that it is explicit and shows the blow by blow surgical procedure. Of note, it is a quick and relatively simple advanced airway technique. Note the cool music!

Related post:

By Request: Submental Intubation

I keep getting requests regarding this technique, so I’m reposting  this updated article today and tomorrow.

Here’s one of the weirder procedures I’ve seen in some time. Imagine that you need a definitive airway, but you can’t use the face for some reason (mouth or nose). The usual choice would be a tracheostomy, right? But what if you only need it for a few days? Typically, once placed, trachs must be kept for a few weeks before decannulation is safe.

Enter submental intubation. This technique involves passing an endotracheal tube through the anterior floor of the mouth, and then down the airway. This leaves the facial bones, mandible, and skull base untouched.

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The technique is straightforward:

  • After initially intubating the patient  orotracheally, a 1.5cm incision is created just off the midline in the submental area under the chin.
  • Using a hemostat, all layers are penetrated, entering the oropharynx just lateral to the tongue.
  • A 1.5cm incision is then made at the puncture site, parallel to the gum line of the lower teeth.
  • The ET tube is removed from the ventilator circuit, and the connector at the proximal end of the tube is removed.
  • The hemostat is placed through the chin incision again. The proximal end of the ET tube is curled into the oropharynx and grasped with the hemostat, then pulled out through the skin under the chin, leaving the distal (balloon) end in the trachea.
  • The connector is reinserted, and the tube is then hooked up to the anesthesia circuit again.
  • The tube is then secured using a stitch under the chin.

After a final position check, the surgical procedure can commence. Cool!

 

There are a number of variations on this technique, so you may encounter slightly different descriptions. The tube can be pulled at the end of the procedure, or left for a few days to ensure safe extubation, if needed.

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A small series of 10 patients undergoing this technique was reviewed, and there were no short or long term problems. Scarring under the chin was acceptable, and was probably less noticeable than a trach scar.

Bottom line: This is a unique and creative method for intubating patients with very short-term airway needs while their facial fractures are being fixed. Brilliant idea!

Tomorrow: Submental intubation – the video!

Reference: Submental intubation in patients with panfacial fractures: a prospective study. Indian J Anaesth 55(3):299-304, 2011.

Photo source: internet

Update: The Rectal Exam In Trauma Continues to “Pass”?

This topic continues to come up from time to time. I still see trauma programs that perform the good, old-fashioned digital rectal exam on nearly every trauma patient. But is it really necessary?

In the not so distant past, it was standard operating procedure to perform a digital rectal exam in all major trauma patients. The belief had always been that valuable information about blood in the GI tract, the status of the urethra, and the neuro exam (rectal tone) could be gleaned from this exam.

Unfortunately, a finger in the bum also serves to antagonize or even further traumatize some patients, especially those who may be intoxicated to some degree. On a number of occasions I have seen calm patients become so agitated by the rectal exam that they required intubation for control.

So is it really necessary? A study in 2001 conducted over a 6 month period (1) showed that the rectal exam influenced management in only 1.2% of cases. The authors felt that there was some utility in 3 special cases:

  • Spinal cord injury – looking for sacral sparing
  • Pelvic fracture – looking for bone shards protruding into the rectum
  • Penetrating abdominal trauma – looking for gross blood

A more recent 2005 study (2) was also critical of the rectal exam and found that using “other clinical indicators” (physical exam and other diagnostic study information) was at least equivalent, changing management only 4% of the time. They concurred with the first two indications above as well.

And what is the best patient position for the exam? I continue to see people try to do it when the patient is in the logroll position! This is substandard for two reasons:

  • It is not a stable position, and no one likes a finger in their butt. Awake patients will squirm and withdraw, defeating any attempt at spinal precautions.
  • It’s not ideal for the examiner, either.  Access to the male prostate is subpar because the examiner’s finger is generally pointed posteriorly, away from this organ. In order to rotate anteriorly, the examiner must spin around, putting “reverse English” (billiards reference) on their arm.

To do a proper rectal exam when indicated, make sure the patient is supine, warn them that you are going to do it, and use the same hand as the side of the patient you are standing on. Right side, right hand to avoid the “reverse English” thing again.

Bottom line: For most major trauma patients, the rectal exam is not worth the patient aggravation it causes. I still recommend it for the 3 special cases listed above, however, as there are no equivalent and effective exams for these potentially serious patient problems. And remember, DON’T do it while the patient is in the logroll position

References:
1. Porter, Urcic. Am Surg. 2001 May;67(5):438-41.
2. Esposito et al. J Trauma. 2005 Dec;59(6):1314-9.

The May 2019 Trauma MedEd Newsletter Has Been Released!

Here’s the most recent newsletter that was released at the end of May; the topic is Spleen Injury Update.

In this issue, I cover:

  • Update To Spleen Injury Scaling / Grading
  • Overwhelming Post-Splenectomy Infection
  • Spleen Vaccines
  • Early Mobilization In Solid Organ Injury

To download the current issue, just click here! Or copy this link into your browser: http://bit.ly/TME201905

The next newsletter will contain an analysis of the results of my Trauma PI Coordinator survey. It will be released only to subscribers at the end of June.  This one will not be released on the blog, but will be available as a subscriber sign-up bonus beginning next month.  Click this link right away to sign up now and/or download back issues.

Got a suggested theme for later issues? Just let me know what you’d like to read about by emailing or leaving a comment here.