Followup Cystogram After Bladder Injury

August 12, 2011 The Trauma Pro Leave a comment

I’ve previously written about management of extraperitoneal bladder injuries. One of the tenets is that every injury needs to have a routine followup cystogram to ensure healing and allow removal of any bladder catheter. I routinely like to question dogma, so I asked myself, is this really necessary? A retrospective registry review from the Ryder trauma center in Miami helped to answer this question.

Over 20,000 records were screened for bladder injury and 87 were found in living patients. Fifty were intraperitoneal injuries, and half of them were caused by pelvic fractures (interesting). All were operated on, and 47 were classified as simple (dome disruption or through and through penetrating) and 3 were “complex” (involving trigone). All trackable patients (42 of the 50) had followup cystograms 9-16 days later. All of the simple injuries had a normal followup exam, but a leak was detected on one of the complex injuries.

There were 42 patients with extraperitoneal bladder injuries. All were due to blunt trauma, and 92% were associated with pelvic fractures. Most were found with CT cystogram. Two patients had operative repair, probably due to the need to fix the pubic bones with hardware. 37 of the 42 were available for followup, and 22% of repeat cystograms were positive (average study done on day 9). In the studies that showed a leak, repeat cystograms were done, and they took an average of 47 days to fully heal.

Bottom line: Patients with extraperitoneal or complex intraperitoneal bladder injuries (trigone) really do need a followup cystogram before removing the bladder catheter. Those who underwent a simple repair of their intraperitoneal injury do not.

Reference: Cystogram follow-up in the management of traumatic bladder disruption. J Trauma 60(1):23-28, 2006.

protocols

CIWA Protocol Precautions

August 11, 2011 The Trauma Pro Leave a comment

The post entitled “CIWA Demystified” is one of the most popular on this blog. This type of symptom triggered therapy for alcohol withdrawal applies some degree of objectivity to a somewhat subjective problem. However, it is possible to take it too far.

A retrospective review of registry patients who received CIWA guided therapy was performed. A total of 124 records were reviewed for appropriateness of CIWA useand adverse events. They found that only about half of patients (48%) met both usage criteria (able to communicate verbally, recent alcohol use). And 31% did not meet either criterion! There were 55 nondrinkers in this study, and even though 64% of them could communicate that fact, they were placed on the protocol anyway! Eleven patients suffered adverse events (delirium tremens, seizures, death). Four of them did not meet criteria for use of the protocol.

Bottom line: In order to be placed on the CIWA protocol, a patient must have a recent history of alcohol use, and must be able to communicate verbally. Some physicians assume that patients with autonomic hyperactivity or psychological distress are withdrawing and order the CIWA protocol. This can cover up other causes of delirium, or may make it worse by administering benzodiazepines. This represents inappropriate use of the protocol!

Reference: Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc 83(3):274-279, 2008.

General

Gallery August 10, 2011 The Trauma Pro Leave a comment

Trauma 20 Years Ago: CAVR For Hypothermia

Hypothermia is the bane of major trauma resuscitation, causing mortality to skyrocket. A number of rewarming techniques have been developed over the years. These are classified as passive (the patient generates their own heat) or active (we deliver calories to them), and noninvasive vs invasive. Rewarming speed increases as we move from passive to active and from noninvasive to invasive.

Continuous arteriovenous rewarming (CAVR) is one of the invasive techniques used today. Its use in humans was first reported 20 years ago this month. Larry Gentilello at Harborview in Seattle had experimented with this technique in animals, and reported one case of use in a human who had crashed his car into icy water. After a 20 minute extrication, the patient was pulseless with fixed and dilated pupils, but he regained pulse and blood pressure at the hospital.

The initial core temperature was 31.5C. Peritoneal, bladder and gastric lavage were carried out for warming, as was delivery of warm inspired gas via the ventilator. However, after an hour the temperature had dropped to 29.5C. CAVR was initiated as a last-ditch effort using a jerry-rigged Rapid Fluid Warmer from Level 1 Technologies. The core temperature was raised to 35C after 85 minutes.

The patient did have typical complications (ARDS, acute renal failure), but survived with recovery of his renal and pulmonary function, and a normal neurologic exam. At the time, the authors were unsure whether the complications were due to the near-drowning or the rapid rewarming.

Reference: Continuous arteriovenous rewarming: report of a new technique fo9r treating hypothermia. J Trauma 31(8):1151-1154, 1991.

General

Video August 9, 2011 The Trauma Pro Leave a comment

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Procedural Sedation and Analgesia

The Regions Hospital Multidisciplinary Trauma Conference on August 4 dealt with the use of procedural sedation in the emergency department. The presentation was delivered by Ben Watters MD.

This presentation is 56 minutes long.

Important disclosure information: off-label use of ketamine is discussed.

General

Gallery August 8, 2011 The Trauma Pro Leave a comment

Obit: Max Harry Weil MD – Feb 9, 1927-July 29, 2011

Some people may recognize the name, but few can comprehend how much this man has done for the fields of trauma and critical care. Dr. Weil was a world-class clinician, teacher and researcher, and is believed to have coined the phrase “critical care medicine.”

Some of his many notable accomplishments:

In 1955, Dr. Weil created the first bedside shock cart, which is now known as the crash cart.
In the late 1950’s, he and his colleagues recognized that some patients who were seriously ill or who had undergone major surgery had a propensity to die at night. He hit upon the concept that having an area for closer monitoring of these patients might allow for earlier recognition of acute problems and earlier intervention to correct them. This led to the creation of a four bed “shock ward.” This was the precursor to the first intensive care unit, which opened in 1968.
Introduced automated vital signs monitors in 1961.
Created the first computer assisted diagnosis tools in 1976.
Developed the STAT lab concept for rapid results in critically ill patients in 1981.

He was the co-inventor for 22 patented devices including:

Resuscitation blanket to protect medical personnel from electric shocks when defibrillating patients (2002).
Capnometer for assessing the severity of shock which can be placed in the upper GI tract or under the tongue (2001).
The Weil Mini Chest Compressor (2006)
An IV pump system (1981), detection for occlusion or infiltration (1985)
Osmotic pressure sensor (1977)
High frequency ventilator (1983)
A method for identifying cardiac rhythm even while CPR is in progress (2006)

Dr. Weil established the Institute for Critical Care Medicine in 1961, and worked there full-time after he left the University of Southern California. The institute trains physicians and engineers to discover and develop concepts and methods for more beneficial life-saving medical management. He stepped down as the president of the institute in 2006, but continued to work there full-time until two weeks before he died.

The world has lost a true physician, teacher and innovator.

Link: Weil Institute for Critical Care Medicine

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