This xray is a classic for a specific trauma surgical injury. Give it your best shot! Tweet of leave comments with your impressions.
This image is especially appropriate for surgical residents / registrars.
Answer in the next post!
All posts by The Trauma Pro
Blunt Duodenal Injury In Children
Blunt injury to hollow organs is rare in adults, but a little more common in children. This is due to their smaller muscle mass and the lack of protection by their more flexible skeleton. Duodenal injury is very rare, and most trauma professionals don’t see any during their career. As with many pediatric injuries, there has been a move toward nonoperative management in selected cases, and duodenal injury is no exception.
What we really need to know is, which child needs prompt operative treatment, and which ones can be treated without it? Children’s Hospital of Boston did a multicenter study of pediatric patients who underwent operation for their injury to try to tease out some answers about who needs surgery and what the consequences were.
A total of 16 children’s hospitals participated in this 4 ½ year study. Only 54 children had a duodenal injury, proven either by operation or autopsy. Some key points identified were:
- The injury was very uncommon, with one child per hospital per year at best
- 90% had tenderness or marks of some sort on their abdomen (seatbelt sign, handlebar mark, other contusions).
- Free air was not universal. Plain abdominal xray showed free air in 36% of cases, while CT showed it only 50% of the time. Free fluid was seen on CT in 100% of cases.
- Contrast extravasation was uncommon, seen in 18% of patients.
- Solid organ injuries were relatively common
- Amylase was frequently elevated
Although laparoscopic exploration was attempted in about 12% of patients, it was universally converted to an open procedure when the injury was confirmed. TPN was used commonly in the postop period. Postop ileus was very common, but serious complications were rare (wound infection <10%, abscess 3%, fistula 4%). There were 2 deaths: one child presented in extremis, the other deteriorated one day after delayed recognition of the injury.
Bottom line: Be alert for this rare injury in children. Marks on the abdomen, particularly the epigastrium, should raise suspicion of a duodenal injury. The best imaging technique is the abdominal CT scan. Contrast is generally not helpful and not tolerated well by children. Duodenal hematoma can be managed nonoperatively. But any evidence of perforation (free fluid, air bubbles in the retroperitoneum, duodenal wall thickening, elevated serum amylase) should send the child to the OR. And laparotomy, not laparoscopy, is the way to go.
Reference: Operative blunt duodenal injury in children: a multi-institutional review. J Ped Surg 47(10):1833-1836, 2012.
Trauma Activation vs Stroke Code
Let’s look at an uncommon scenario that crops up from time to time. Most seasoned trauma professionals have seen this one a time or two:
An elderly male is driving on a sunny afternoon, and crashes his car into a highway divider at 25 miles per hour. EMS responds and notes that he has a few facial lacerations, is awake but confused. They note some possible facial asymmetry and perhaps a bit of upper extremity weakness. No medical history is available. Witnesses state that he was driving erratically before he crashed. Medics call the receiving trauma center in advance to advise them that they have a stroke code.
Is this a reasonable request? Stroke centers pride themselves on the speed of their stroke teams in assessing, scanning, and when appropriate, administering thrombolytics to resolve the problem. But if there are suspicions of stroke in a trauma patient, which diagnosis wins? Trauma team or stroke team?
Lets analyze this a bit further, starting with diagnosis. Remember the first law of trauma:
Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.
Could the symptoms that the paramedics are observing be due to the car crash? Absolutely! The patient could have a subdural or epidural hematoma that is compressing a cranial nerve. There might be a central cord injury causing the arm weakness. His TBI might be the source of his confusion. The facial asymmetry could be due to a pre-existing Bell’s palsy, or he could have had a stroke years ago from which he has only partially recovered.
If the stroke team is called for the patient, they will focus on the neuro exam and the brain. They will not think about trauma. They will follow the patient to CT scan looking for the thing that they do best with. If they don’t see it, the patient will return to the ED for (hopefully) a full trauma workup. If there are occult injuries in the abdomen, then the patient may have been bleeding for an hour by then. This elderly patient will then be way behind the eight ball.
And let me pose the worst case scenario. The patient is taken to CT by the stroke team, and lo and behold he has a thrombotic stroke! This patient had a stroke, which caused him to lose control of his car and explains most of his findings. Again, the stroke team will do what they are trained to do and give a thrombolytic. They are still not thinking about trauma. Within minutes the patient becomes hypotensive and his abdomen appears a bit more distended. He is rushed back to the ED (remember, no CT in hypotensive patients even if you are in the scanner) and a FAST exam is very positive for free fluid throughout the abdomen. Imagine the look you will get from the surgeon as they run to the OR to perform a splenectomy on this fully anticoagulated patient!
Bottom line: If you have a patient who is trauma vs stroke, trauma always wins! Remember the first law and try to find traumatic reasons for all signs and symptoms. Perform your standard trauma workup and incorporate the appropriate head scans into your evaluation. Then and only then should the stroke team be called.
An Update On How Fast Can You Warm Up A Hypothermic Patient
It’s wintertime in Minnesota and much of the upper Midwest. Although hypothermia does occur in this region, it’s not as common as you might think. And it does happen in just about any state (well, maybe no Hawaii). But when it does occur, it’s important to know what your options are for rewarming.
I put together a compilation of the average rewarming rates of commonly used techniques quite a few years ago. However, it’s time to update them based on some new data and a few new products.
| Warming Technique | Rate of Rewarming |
| Bladder lavage | no data probably < 0.5° C / hr |
| Passive external (blankets, lights) | 0.5 – 1° 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 |
| Cool Guard system | 1° C / hr |
| Cool Guard system with thoracic lavage | 2° C / hr |
| Cool Guard system with peritoneal lavage | 2.7° 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 |
One of the most important things to consider is the length of time for rewarming. Do the math using the numbers above! For most patients with severe hypothermia, it’s going to take several hours to rewarm. So make sure you are in a suitable location, such as an OR or ICU!
REBOA: A Comparison Of The Hardware From Two Companies
I started off the week describing a study using a new version of the REBOA catheter (Resuscitative Endovascular Balloon Occlusion of the Aorta) that was smaller than the more commonly used one. Today I’ll put both side by side and describe the similarities and differences.
First, let’s start with the current market leader, the ER-REBOA catheter by Prytime Medical in Boerne, TX. Here’s a picture provided by the company:
And here’s a photo of the Frontline Medical Technologies COBRA-OS, based in London, Ontario, Canada. This acronym stands for Control of Bleeding, Resuscitation, Arterial Occlusion System. Now, REBOA is used by surgeons as a general descriptor for this type of technology. I assume that Frontline does not include REBOA in the name of this product since Prytime has incorporated it into theirs.
There are a number of similarities, as well as some key differences. Let’s start at the tip and make our way back to the syringe.
Catheter tip: Prytime has a trademarked “P-tip” which has a little extra curl compared to the Frontline’s flexible j-tip. The Prytime version is designed to “help reduce catheter migration and aid in positioning. Although a guidewire can be inserted into either to assist in repositioning, it does not enter the P-tip. And note, neither device requires a wire for insertion.
Arterial line port: This is only found on the Prytime device. This is located just distal to the balloon so arterial pressures can be measured above the catheter after inflation. This port extends through the catheter, terminating in a hub that can be connected to standard pressure transducer equipment. The Frontline device is too small to incorporate this feature.
Balloon: The Prytime balloon is a more standard ovoid shape. The company provides guidelines of 8cc inflation for Zone I and 2cc for Zone III. This can be adjusted based on confirmation of occlusion provided by the arterial pressure wave form. The Frontline device has an “ice cream cone shaped” balloon with the taper proximally and a “safety shoulder” to protect the balloon. The company claims that this design helps reduce the likelihood of rupture. The balloon will accept 13cc at maximum inflation. Since there is no arterial line, alternate means (palpation, ultrasound, or a transducer in the insertion port) must be used to determine degree of occlusion.
Markers: The Prytime device has radio-opaque markers at either end of the balloon, as well as length markers on the proximal portion of the catheter. The Frontline catheter has the same markers around the balloon, but only two large visible marks on the proximal catheter. These are marked for placement in Zone I (48cm) and Zone III (28cm) in average size patients.
Sheath: The Prytime product has a peel-away sheath that is used to cover the P-tip to straighten it. This unit is then inserted into the previously placed access port. Once inserted the sheath is peeled away after the balloon has passed the end of the port. The Frontline device does not have a sheath, but includes a reusable j-tip straightener on the catheter. This straightens the tip as it passes through the port.
Access port: These are included with both products and are inserted using typical Seldinger technique. Both have a side port for fluid infusion. The side port of the Frontline product can be used as an arterial pressure monitor. The port is 7Fr in the Prytime product and 4Fr for Frontline. This smaller size may decrease the incidence of vascular thrombosis or vessel injury requiring repair after removal.
Bottom line: I’ve described two different products that allow trauma professionals to use the REBOA concept. This evolution demonstrates the usual cycle of new product and feature refinement that we have come to expect in medical devices.
Is one “better” than the other? That’s probably not the right question. More likely, it will boil down to which one is right for a particular patient or situation. Only time, and lots of additional research, will tell.
References:
- Prytime Medical – www.prytimemedical.com
- Frontline Medical Technologies, Inc. – www.frontlinemedtech.com
I have no financial interest in either of these companies