Category Archives: Equipment

CT Contrast Via Intraosseous Catheter

The standard of care in vascular access in trauma patients is the intravenous route. Unfortunately, not all patients have veins that can be quickly accessed by prehospital providers. Introduction of the intraosseous device (IO) has made vascular access in the field much more achievable. And it appears that most fluids and medications can be administered via this route. But what about iodinated contrast agents via IO for CT scanning?

Physicians at Henry Ford Hospital in Detroit published a case report on the use of this route for contrast administration. They treated a pedestrian struck by a car with a lack of IV access sites by IO insertion in the proximal humerus, which took about 30 seconds. They then intubated using rapid sequence induction, with drugs injected through the IO device. They performed full CT scanning using contrast injected through the site using a power injector. Images were excellent, and ultimately the patient received an internal jugular catheter using ultrasound. The IO line was then discontinued.

This paper suggests that the IO line can be used as access for injection of CT contrast if no IV sites are available. Although it is a single human case, a fair amount of studies have been done on animals (goats?). The animal studies show that power injection works adequately with excellent flow rates.

The authors prefer using an IO placement site in the proximal humerus. This does seem to cause a bit more pain, and takes a little practice. A small xylocaine flush can be administered to reduce injection discomfort in awake patients. Additionally, the arm cannot be raised over the head for the torso portion of the scan.

Bottom line: CT contrast can be injected into an intraosseous line (IO) with excellent imaging results. Insert the IO in a site that you are comfortable with. I do not recommend power injection at this time. Although the marrow cavity can support it, the connecting tubing may not. Have your radiologist hand-inject and time the scan accordingly. And don’t be surprised if your radiology department doesn’t have a protocol for this!

Note: long term effects of iodinated contrast in the bone marrow are not known. For this reason, and because of smaller marrow cavities, this technique is not suitable for pediatric patients.

Reference: Intraosseous injection of iodinated computed tomography contrast agent in an adult blunt trauma patient. Annals Emerg Med 57(4):382-386, 2011.

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Don’t Have A Pelvic Binder? Make Your Own! (Video)

During the past two posts, I’ve reviewed the various pelvic binders available and how much they cost. But what can you do if you find yourself in a situation where you need a binder but don’t have one?

It’s time to go MacGyver!

You need three things:

Yes, that’s right. A simple and cheap SAM splint, a tourniquet, and some kind of blade to cut the SAM splint with. Essentially, the SAM splint is the binder and the tourniquet is used to cinch it down in the correct position.

Here’s a video that demonstrates how to do it. Enjoy!

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What’s The Best Pelvic Binder? Part 2

Yesterday, I detailed some pelvic binders commonly available in the US. Today, I’ll go through the (little) science there is regarding which are better than others.

And remember, tomorrow I’ll show you how to make a free pelvic binder out of stuff that all medics have in their rig.

There are a number of factors to consider when choosing one of these products. They are:

  • Does it work?
  • Does it hurt or cause skin damage?
  • Is it easy to use?
  • How much does it cost?

It’s difficult to determine how well binders work in the live, clinical setting. But biomechanical studies can serve as a surrogate to try to answer this question. One such cadaver study was carried out in the Netherlands a few years ago. They created one of three different fracture types in pelvis specimens. Special locator wires were placed initially so they could measure bone movement before and after binder placement. All three of the previously discussed commercial binders were used.

Here are the factoids:

  • In fracture patterns that were partially stable or unstable, all binders successfully closed the pelvic ring.
  • None of the binders caused adverse displacements of fracture fragments.
  • Pulling force to achieve complete reduction was lowest with the T-POD (40 Newtons) and highest with the SAM pelvic sling (120 Newtons). The SAM sling limits compression to 150 Newtons, which was more than adequate to close the pelvis.

So what about harm? A healthy volunteer study was used to test each binder for tissue pressure levels. The 80 volunteers were outfitted with a pressure sensing mat around their pelvis, and readings were taken with each binder in place.

Here are the additional factoids:

  • The tissue damage threshold was assumed to be 9.3 kPa sustained for more than 2-3 hours based on the 1994 paper cited below.
  • All binders exceeded the tissue damage threshold at the greater trochanters and sacrum while lying on a backboard. It was highest with the Pelvic Binder and lowest with the SAM sling.
  • Pressures over the trochanters decreased significantly after transfer to a hospital bed, but the Pelvic Binder pressures remained at the tissue damage level.
  • Pressures over the sacrum far exceeded the tissue damage pressure with all binders on a backboard and it remained at or above this level even after transfer to a bed. Once again, the Pelvic Binder pressures were higher. The other splints had similar pressures.

And finally, the price! Although your results may vary due to your buying power, the SAM sling is about $50-$70, the Pelvic Binder $140, and the T-POD $125.

Bottom line: The binder that performed the best (equivalent biomechanical testing, better tissue pressure profile) was the SAM sling. It also happens to be the least expensive, although it takes a little more elbow grease to apply. In my mind, that’s a winning combo. Plus, it’s narrow, which allows easy access to the abdomen and groins for procedures. But remember, whichever one you choose, get them off as soon as possible to avoid skin complications.

References:

  • Comparison of three different pelvic circumferential compression devices: a biomechanical cadaver study. JBJS 93:230-240, 2011.
  • Randomised clinical trial comparing pressure characteristics of pelvic circumferential compression devices in healthy volunteers. Injury 42:1020-1026, 2011.
  • Pressure sores. BMJ 309(6959):853-857, 1994.
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What’s The Best Pelvic Binder? Part 1

Several products for compressing the fractured pelvis are available. They range from free and simple (a sheet), to a bit more complicated and expensive. How to decide which product to use? Today, I’ll discuss the four commonly used products. Tomorrow, I’ll look at the science. And on Wednesday, I’ll show you a creative way to make your own free pelvic binder.

First, let’s dispense with the sheet. Yes, it’s very cheap. But it’s not easy to use correctly, and more difficult to secure. Click here to see my post on its use.

There are three commercial products that are commonly used. First is the Pelvic Binder from the company of the same name (www.pelvicbinder.com). It consists of a relatively wide belt with a tensioning mechanism that attaches to the belt using velcro. One size fits all, so you may have to cut down the belt for smaller patients. Proper tension is gauged by being able to insert two fingers under the binder.

Next is the SAM Pelvic Sling from SAM Medical Products (http://www.sammedical.com). This device is a bit fancier, is slimmer, and the inside is more padded. It uses a belt mechanism to tighten and secure the sling. This mechanism automatically limits the amount of force applied to avoid problems with excessive compression. It comes in three sizes, and the standard size fits 98% of the population, they say.

Finally, there is the T-POD from Pyng Medical (http://www.pyng.com/products/t-podresponder). This one looks similar to the Pelvic Binder in terms of width and tensioning. It is also a cut to fit, one size fits all device. It has a pull tab that uses a pulley system to apply tension. Again, two fingers must be inserted to gauge proper tension.

So those are the choices. Tomorrow, I’ll go over some of the data and pricing so you can make intelligent choices about selecting the right device for you.

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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!

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