All posts by TheTraumaPro

How Fast Can You Warm Up A Hypothermic Patient?

For most places, including Minnesota, hypothermia time is just about over! However, this trauma problem can occur nearly anywhere and at any time. And especially during a massive resuscitation. The optimal way to warm paitients has been debated for years. A number of very interesting techniques have been devised. Ever wonder how fast / effective they are?

I’ve culled data from a number of sources, and here is a summary what I found. And of course, the disclaimer: “your results may vary.”

Warming Technique Rate of Rewarming
Passive external (blankets, lights) 0.5° C / hr
Active external (lights, hot water bottle) 1 – 3° C / hr
Bair Hugger (a 3M product, made in Minnesota of course!) 2.4° C / hr
Hot inspired air in ET tube 1° C / hr
Fluid warmer 2 – 3° C / hr
GI tract irrigation (stomach or colon, 40° C fluid, instill for 10 minutes, then evacuate) 1.5 -3° C / hr
Peritoneal lavage (instill for 20-30 minutes) 1 – 3° C / hr
Thoracic lavage (2 chest tubes, continuous flow) 3° C / hr
Continuous veno-venous rewarming 3° C / hr
Continuous arterio-venous rewarming 4.5° C / hr
Mediastinal lavage (thoracotomy) 8° C / hr
Cardiopulmonary bypass 9° C / hr
Warm water immersion (Hubbard or therapy tank) 20° C / hr

In The Next Trauma MedEd Newsletter: Potpourri

The next issue of Trauma MedEd will be sent out to subscribers at the end of the week, and will cover a whole bunch of what I call Potpourri. These are some tidbits that I find fascinating and sometimes odd.

Topics will include:

  • Trauma and the gut microbiome
  • “Single look trauma laparotomy” (as opposed to damage control laparotomy) and postop complications
  • Pneumothorax: how big is too big?
  • The best prehospital stretchers for rapid extraction in MCIs
  • and more!

I’ve pushed the solid organ injury update issue out to next month. There’s a lot of stuff to cover, and quite a few changes have occurred over the years.

As always, this month’s issue will go to all of my subscribers first. If you are not yet one of them, click this link right away to sign up now and/or download back issues.

Unfortunately, non-subscribers will have to wait until I release the issue on this blog, in mid-April. So sign up now!

The Lead Gown Pull-Up: Part 2

Okay, so you’ve seen “other people” wearing perfectly good lead aprons lifting them up to their chin during portable x-rays in the trauma bay. Is that really necessary, or is it just an urban legend?

After hitting the medical radiation physics books (really light reading, I must say), I’ve finally got an answer. Let’s say that the xray is taken in the “usual fashion”:

  • Tube is approximately 5 feet above the xray plate
  • Typical chest settings of 85kVp, 2mAs, 3mm Al filtration
  • Xray plate is 35x43cm

The calculated exposure to the patient is 52 microGrays. Most of the radiation goes through the patient onto the plate. A very small amount reflects off their bones and the table itself. This is the scatter we worry about.

So let’s assume that the closest person to the patient is 3 feet away. Remember that radiation intensity diminishes as the square of the distance. So if the distance doubles, the intensity decreases to one fourth. By calculating the intensity of the small amount of scatter at 3 feet from the patient, we come up with a whopping 0.2 microGrays. Since most people are even further away, the dose is much, much less for them.

Let’s put it perspective now. The background radiation we are exposed to every day (from cosmic rays, brick buildings, etc) amounts to about 2400 microGrays per year. So 0.2 microGrays from chest x-ray scatter is less than the radiation we are exposed to naturally every hour!

The bottom line: unless you need to work out you shoulders and pecs, you probably don’t bother to lift your lead apron every time the portable x-ray unit beeps. It’s a waste of time and effort! Just stand back and enjoy!

The Lead Gown Pull-Up?

Trauma Team members typically wear a lead gown under their personal protective equipment so they don’t have to run out of the room when x-rays are taken. How often do you see people do this?

Is it really necessary? Or is it just a way to exercise your pecs and biceps? Tomorrow I’ll talk about how much radiation team members are really exposed to so you can decide if this is really necessary.

So You Want Your Own Hybrid Room?!

You’re hooked! You are thinking back to a number of cases that you think might have done better with a hybrid room. And now let’s assume you already have one in your OR suite. Now what do you do?

The key is to avoid jumping right in and sending your next eligible patient straight to that room. You absolutely must take some time to develop policies and guidelines to make sure things go smoothly.

Here are some important things to think about:

  • Identify which specific patients are eligible so you don’t squander this resource
  • Who calls the OR to secure the room (surgeon, resident, other)?
  • Who calls the interventional radiologist?
  • What if another case (TEVAR, etc) is already on the table?
  • What if another case is getting ready to use the OR? How are conflicts resolved?
  • Develop an initial in-room report process so all the teams know the game plan
  • Assign an extra circulator to the room. You’ll need them!
  • Make sure all retractor systems (abdomen, head) fit the table! Remember that little asterisk in the previous section? Some retraction systems may need adaptors to work with your table. Don’t find this out at the last minute!
  • What about lithotomy position? How will this work with your hybrid table? They don’t have sections that break away.
  • Ensure radiation protection for all, including thyroid shields.
  • Bag the bottom x-ray detector, otherwise it will get very, very gross!
  • Create an external fixator equipment cart that can be moved into the hybrid room.
  • Create an embolization cart with appropriate wires, catheters, coils, etc. This stuff may not be stocked normally in the hybrid room

And I’m sure there are more details that I haven’t thought of. If you have some helpful suggestions, policies, or protocols, please share them with me!