Category Archives: Complications

Bullet In The Disk Space: Big Deal Or Not?

November 16, 2018 The Trauma Pro Leave a comment

In an earlier post, I reviewed the problems with lead poisoning that can occur if a bullet remains in contact with a joint space / synovial fluid, or ends up in the GI tract. But what about if it comes to rest in an intervertebral joint space? They’re dry, right?

The first case report I could find dates back to 1981. A male presented to Parkland Memorial Hospital 12 years after a gunshot to the abdomen in which the bullet lodged in a disk space. He was treated for a GI bleed, but was also noted to have many signs and symptoms of high lead levels. These included irritability, anemia, headache, lethargy, muscle weakness and confusion. A blue line was noted on the gums. X-ray of the lumbar spine showed the bullet fragment in the center of the disk space, and a cystic mass in the prevertebral area that appeared radiodense as well. Blood lead levels were elevated. The patient underwent diskectomy, resection of the mass, chelation therapy, and recovered.

Another case report from 2010 was similar in many ways. The patient was young, had a gunshot 5 years previously, and presented with symptoms of lead poisoning. The appearance of the bullet in the disk space was similar to the last case, in that the bullet could be seen within it, and there appeared to be additional radiopaque material surrounding it. It almost looked like lead was flowing out of the bullet into the disk. This case was also treated with surgical removal and chelation with a successful result.

A literature review was conducted 15 years ago that examined other case reports of bullets in the spine. Over a 25-year period 238 patients were identified with this injury. Only 12 had bullets or fragments in the disk space. All were tested for plumbism, and only one was positive. He underwent diskectomy and resection with resolution of the high lead levels.

Bottom line: We know that a bullet in contact with synovial fluid is bad, with rapid leaching of lead into the circulation. There are also suggestions that lead in contact with CSF can cause a similar problem. However, the intervertebral disk space is usually considered to be “dry” and doesn’t usually cause a problem.

However, patients with a bullet in this location should be cautioned that they do have a small risk of developing lead poisoning. They should be tested about six months post-injury to see if lead levels are on the rise. They should also be cautioned to report the development of new back pain. Structural disruption by the bullet may slowly lead to anatomic changes that result in chronic pain. And be very suspicious if there is radiopaque material in the disk space in addition to the bullet itself!

References:

Acute lead intoxication from a bullet in the intervertebral disk space. JBJS 63A(7):1180-1182, 1981.
Lead Poisoning by Intradiscal Firearm Bullet. Spine 35(4):E140-E143, 2010.
Long-Term Clinical Manifestations of Retained Bullet
Fragments Within the Intervertebral Disk Space. J Spinal Disord Tech 17(2):108-111, 2004.

Abstracts, Complications

Best of AAST #8: Complications After Trauma Laparotomy

September 20, 2018 The Trauma Pro Leave a comment

With the introduction of damage control laparotomy (DCL) in the early 1990s, the trauma literature has focused on the nuances of this procedure. A significant amout of research has looked at patient selection, techniques, optimum time to closure, and complications afterwards. Studies on the single-look trauma laparotomy (STL) seem to have fallen behind. When compared to DCL, it seems to have relatively few complications.

But is that really so? A paper from the 1980s showed a nearly 50% complication rate after STL, but this included some trivial things like atelectasis which padded the numbers. A group at Scripps Mercy in San Diego looked at long-term complications after STL in a state-wide California database. They were able to identify patients who underwent STL who were then readmitted for complications at a later date. They studied this data over an 8-year period.

Here are the factoids:

A total of 2,113 patients had a STL during the study period
One third (712) were readmitted at least once, with a median time to first readmission of 110 days
30% of these patients had a surgery-related complication:
- bowel obstruction 18%
- infection 9%
- incisional hernia 7%
Mechanism of injury was not related to development of complications

Bottom line: More than 10% of patients undergoing single-look trauma laparotomy develop significant complications. This is much higher than the complication rate seen after typical general surgical procedures. The difference between these groups and the reasons are not clear. Additional work must be done to tease out the risk factors, and our patients should be counseled on these potential complications and when to return for evaluation. Finally, the trauma surgeon should always use their best judgment to avoid an unnecessary trauma laparotomy.

Reference: Long-term outcomes after single-look trauma laparotomy: a large population-based study. Session IV Paper 14, AAST 2018.

Complications

Tracheostomy After Anterior Cervical Fusion: Can It Be Too Soon?

September 4, 2018 The Trauma Pro Leave a comment

Early tracheostomy is generally accepted to be a good thing in critically injured patients. A number of papers have shown that it decreases ventilator days and hence ICU and hospital days, and also reduces pneumonia rates, sedation requirements, and saves quite a bit of money.

However, there has been one problematic group in whom critical care surgeons are often forbidden to do an early trach: patients with a recent anterior cervical fusion. These patients typically have unstable cervical fractures, with or without a concomitant spinal cord injury. The spine surgeons argue that doing a trach “too soon” leads to a higher infectious complication rate due to the proximity of the trach to their anterior surgical wound.

But is this really true? The trauma/critical care program at Thomas Jefferson University in Philadelphia looked at their experience. They are a federally sponsored spinal cord injury center, and have a vast experience compared to most trauma centers. They reviewed their experience over a 16 year period. Typically, they performed all of their tracheostomies within 10 days, so they arbitrarily defined “early” as within 4 days, and “late” as > 5 days after the cervical procedure.

Here are the factoids:

A total of 98 patients with tracheostomy after anterior fusion were included in the study, some of whom also underwent a concomitant posterior fusion
39 cases were “early”, within 4 days of the anterior fusion procedure, and 59 were “late”
Average time to fusion in the early group was 2 days, and 10 days in the late group
There were no wound infections in the early group
There were 5 wound infections in the late group, and 4 of them involved the posterior fusion site(!)
The only infection of the anterior fusion site occurred in a late patient who suffered an esophageal perforation from the fusion hardware

Bottom line: Although the numbers are still small after 15 years of data, it’s probably the best we will ever get! It is clear that an anterior fusion wound is safe in these procedures. I am at a loss as to why the posterior fusion wounds tend to get infected, though. But the next time your spine surgeons balk about doing an early trach in one of their anterior fusion, show them this paper!

Complications

What Does A Retained Surgical Sponge Look Like?

March 21, 2018 The Trauma Pro Leave a comment

Surgeons and surgical residents rarely see these. And because it’s so uncommon, they frequently don’t recognize the telltale findings on radiographic studies. The TSA runs into the same problem in screening passengers for weapons and other hazards at airports. But it’s the bane of any surgeon’s existence. And it’s a major reason why OR personnel take such great pains to account for everything in the room. It is a catastrophe, and always a preventable one, when some piece of equipment goes missing and ends up left inside a patient.

A number of methods have been developed to try to eliminate this problem. They include careful counts, having someone record anytime anything is placed inside, x-rays, and most recently, RFID tags.

After counting, x-ray is the most common way to try to find missing objects. One would think that these foreign bodies would be easy to see. Metallic instruments are rather easy to spot. But many trauma professionals, even those who work in the OR, have never seen what a positive image of a sponge actually looks like. So here they are. You should never miss one on an xray now.

Surgeons typically use two types of sponges in the OR: Ray-Tec sponges and standard lap pads. Ray-Tecs look like a 4×8 piece of gauze with a mysterious blue string woven throughout it. The string is the only part that shows up on x-ray, and it is very thin and somewhat hard to see. Here are some Ray-Tec sponges outside the body:

And here’s one that was left inside. Note the little squiggle in the left lower quadrant and how easy it is to overlook.

On the other hand, a laparotomy pad is a 4×4 folded cloth pad that unfolds into a larger pad. It has a blue radiopaque tag sewn in the corner, extending along one edge of the pad. Here’s what they look like outside the body:

And here’s one inside a patient. Note the irregular object in the right upper quadrant. Many times the tag is scrunched up and doesn’t look like one.

Bottom line: It’s important for anyone who works in the OR on any body part to be familiar with the appearance of these tags on x-rays. Since it’s generally impossible to get accurate counts before or after a trauma procedure, always image the involved body cavity looking for these telltale signs before closing the patient.

Note: These images were taken from the internet. Patients were not treated at Regions Hospital.

Abdomen, Complications

Consequences Of Embolizing Renal Injuries

March 13, 2018 The Trauma Pro Leave a comment

In my last post, I noted that nonoperative management is the norm for dealing with high grade renal injuries. One of the possible options, angioembolization, was relatively infrequently used at only 6% of the time.

For management of other organs like the spleen, there are several angioembolization options. Depending on the type and severity of injury, selective (partial) or nonselective (main splenic artery) embolization can be carried out. For the liver, only selective embolization can be used. But what about the kidney?

Are there consequences of nonselective renal embolization? Or should we always strive for selective control? The urology group of the University of Tennessee – Knoxville published a series of papers on their experience using embolization in patients with the most severe injuries (Grade 5). They retrospectively examined just over 3 years of admissions with this injury. Numbers were very small (6 men, 3 women).

But they also published a second paper, extending the review dates to capture one more male patient. And they followed this group for 1.5 to 5 years (mean 2.5 years) to determine if any delayed complications surfaced.

Here are the factoids:

Seven patients underwent full, nonselective embolization, and the other three had “super selective” embolization
All patients had control of bleeding without surgical intervention
Followup CT imaging showed no persistent extravasation or expanding hematoma
No patient developed complications, such as a retroperitoneal abscess, prolonged fever, or hypertension while in the hospital or during short-term followup
Most patients showed a very small increase in serum creatinine (mean 0.04), but one patient increased from 1.1 to 1.7
On longer term followup, one patient, age 51, developed hypertension 10 months after his injury. It is not possible to determine whether he was one of the 20% of older adults who develop hypertension, or whether it was due to the procedure. it was well-controlled with a single antihypertensive med.
None developed altered renal function, stones, chronic pain, fistula, or pseudoaneurysm

Bottom line: Obviously, the data is very limited with only 10 patients. However, it is very interesting to note that the majority of these patients underwent nonselective embolization of the renal artery without any adverse event. The one case of hypertension occurred with nonselective embolization, although I have seen several case reports where this occurs with selective embolization as well.

It is now well-accepted that high-grade renal injury can and should be managed nonoperatively if the patient’s hemodynamic status is reasonable. I recommend a trip to interventional radiology if the patient has active extravasation or a high-grade (Grade 4 or 5) injury, as these patients are at risk for loss of the entire kidney otherwise. Selective embolization can be attempted first, but don’t be shy to take out the entire organ if need be.

References:

Percutaneous embolization for the management of Grade 5 renal trauma in hemodynamically unstable patients: initial experience. J Urology 181:1737-1741, 2008.
Intermediate-term follow-up of patients treated with percutaneous embolization for Grade 5 blunt renal trauma. J Trauma 69(2):468-470, 2010.

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