Category Archives: General

What Is: Bucket Handle Injury Of The Intestine

A bucket handle injury is a type of mesenteric injury of the intestine. The intestine itself separates from the mesentery, leaving a devascularized segment of bowel that looks like the handle on a bucket (get it?).

These injuries can occur after blunt trauma to the abdomen. The force required is rather extreme, so the usual mechanism is motor vehicle crash. In theory, it could occur after a fall from a significant height, and I have seen one case from a wood fragment that was hurled at the abdomen by a malfunctioning lathe.

The mechanics of this injury are related to fixed vs mobile structures in the abdomen. Injuries tend to occur adjacent to areas of the intestine that are fixed, such as the cecum, ligament of Treitz, colonic flexures and rectum. During sudden deceleration, portions of the intestine adjacent to these areas continue to move, pulling on the nearby attachments. This causes the intestine itself to pull off of its mesentery.

Source: personal archive. Not treated at Regions Hospital

The picture above shows multiple bucket handle injuries in one patient. There are 3 injuries in the small bowel, and one involving the entire transverse colon. Note the obviously devascularized segment at the bottom center of the photo.

The terminal ileum is the most common site for bucket handle tears. Proximal jejunum, transverse colon, and sigmoid colon are other possible areas. In my experience, the driver is more likely to sustain an injury to the terminal ileum, and the front passenger to the sigmoid. I think this is due to the location of the buckle, but it’s just my own observation.

Always think about the possibility of this injury in patients with very high speed decelerationSeat belt marks have a particularly high association with this injury. If your patient has an abnormal exam in the right lower quadrant, or if the CT shows unusual changes there (“dirty” mesenteric fat, thickened bowel wall, extravasation), I recommend a trip to the OR. In these cases, an injury will nearly always be present. And since the affected intestine may take a few days to die and leak, look for an unexplained rise in WBC beginning on hospital day 2.

Related posts:

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ACS Trauma Abstracts #1: REBOA! (And CT???)

This paper is from the group at ShockTrauma in Baltimore, who are really pushing the envelope of REBOA. We always worry about distal ischemia after balloon inflation, because the ischemia produced can be detrimental to the gut and lower extremities. This group was curious about what the flow patterns looked like with  inflation of the balloon. So in select cases, they obtained CT scans with contrast in patients while the balloon was fully inflated (!!).

They reviewed their experience over a four year period, looking at patients receiving a CT scan with the REBOA balloon partially or fully inflated.

Here are the factoids:

  • Nine patients were included. This makes sense because unstable patients should not go to CT scan, so this should be a very limited group.
  • Mean injury severity score (ISS) was 48, which makes sense. These patients are hurt bad!
  • Four patients had supraceliac REBOA (aortic zone I) and five had infrarenal (zone III)
  • Contrast was seen below the REBOA balloon in all patients, and was seen distal to the insertion site in half
  • Collateral flow around the balloon was identified in all patients

Bottom line: The authors found that REBOA decreased blood flow to the distal aorta, but certainly did not stop it. Collateral flow is underestimated, and probably provides a protective effect for the viscera and other structures while inflated. This is good news for REBOA proponents, because it suggests that placement may not cause as much risk from ischemia as originally thought.

But why oh why did they have to go to  CT in the first place?

Reference: Assessment of blood flow patterns distal to aortic occlusion (AO) using computed tomography in patients with resuscitative endovascular balloon occlusion of the aorta. JACS 225(4S1):S50, 2017.

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Best Of: Abstracts From The American College of Surgeons

The annual Clinical Congress for the American College of Surgeons will be held at the end of the month. A large number of research papers are presented there, and a smaller subset are related to trauma and critical care.

I’m going to spend the next week and a half or so reviewing many of the ones I believe are the most promising. Keep in mind that these are works in progress, and that many will never see the light of print. I’ll take them apart, trying to see how good each one is. Some are very good, some are hopelessly flawed.

I hope you enjoy the analysis! Let’s see if we learn something new along the way.

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EMS: Scoop and Run or Stay and Play for Trauma Care? The Final Answer?

I’ve been discussing the little research there is on stay and play vs scoop and run. And now, hot off the press, we have a paper about the ultimate version of scoop and run, the “drive-by ambulance.” This one looks at outcomes in patients who are dropped at the emergency department by private vehicle. This is the most basic form of prehospital care, with no interventions, just transportation. This type of transport is used by parents with their injured children, police who act as very basic first responders in some cities, and on occasion, gang members.

A multi-institutional group of authors used data in the National Trauma Databank to try to answer this question. They used three years worth of data, comparing outcomes from patients with ground EMS vs private transport who were treated at Level I and Level II trauma centers. Only gunshots and stabs were included, and all patients were 16 or older.  The  authors were focused on only one thing: mortality. This included death in the ED, and a model was developed to adjust risk based on vital signs, injury severity score (ISS), race, and insurance status. Just over 100,000 were included in he final analysis.

Here are the factoids:

  • Black and hispanic patients were more frequently transported by private vehicle, but only by about 3%
  • White patients were more frequently taken by ground EMS, by about 6%
  • Stabs were more likely to be brought by private car than gunshots, 56% vs 44%
  • Mean ISS was significantly higher for those transported by ground EMS (10 vs 5.5)
  • Unadjusted mortality was lower overall for private vehicle, 2% vs 12%
  • The chance of dying in the ED was also decreased in the private transport patients, from 7% to 1%
  • Mortality from both gunshots and stabs were also significantly lower (5% vs 9%, and 0.2% vs 3% respectively)
  • Once adjusted for risk, the lower mortality with private transport remained, with a 60% risk reduction of death. This persisted in the gunshot and stab cohorts as well.

Bottom line: Wow! Although this study has the usual limitations of using a large external database, it was very well designed to compensate for that. And the degree of improvement in survival is surprising. What this study can’t tell us is why. Certainly, some patients benefit from a little extra time to give fluid or blood, intubate, or provide some other treatments. But the patient with penetrating frequently does not need this, they just need definitive control of hemorrhage. The authors even go so far as to suggest that at-risk populations receive education on “scoop and run” if people they know suffer penetrating injury.

The next step is to tease out which components of the stay and play paradigm are the most valuable, and which contribute to the increased mortality in penetrating injury patients.

Reference: Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma A Trauma System–Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services. JAMA Surgery, Published online September 20, 2017.

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Is Applying Or Removing That Cervical Collar Dangerous?

Cervical collars are applied to blunt trauma patients all the time. Maybe a bit too often. And most of the time, the neck is fine. It’s just those few patients that have fracture or ligamentous injury that really, truly need it.

I’ve previously written about how good some of the various types of immobilization are at limiting movement (click here). But what happens when you are actually putting them on or taking them off? Could there be dangerous amounts of movement then?

Several orthopaedics departments studied this issue using an electromagnetic motion detector on “fresh, lightly embalmed cadavers” (!) to determine how much movement occurred when applying and removing 1- and 2-piece collars. Specifically, they used an Aspen 2-piece collar, and an Ambu 1-piece. They were able to measure flexion/extension, rotation and lateral bending.

Here are the factoids:

  • There were no significant differences in rotation (2 degrees) and lateral bending (3 degrees) when applying either collar type or removing them (both about 1 degree)
  • There was a significant difference (of 0.8 degrees) in flexion/extension between the two types (2-piece flexed more). Really? 0.8 degrees is significant? Not clinically!
  • Movement was similarly small and not significantly different in either collar when removing them

Bottom line: Movement in any plane is less than 3-4 degrees with either a 1-piece or 2-piece collar. This is probably not clinically significant at all. Just look at my related post below, which showed that once your patient is in the rigid collar, they can still flex (8 degrees), rotate (2 degrees) and move laterally (18 degrees) quite a bit! So be careful when using any collar, but don’t worry about doing damage if you use it correctly.

Related post:

Reference: Motion generated in the unstable cervical spine during the application and removal of cervical immobilization collars. J Trauma 72(6):1609-1613, 2012.

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