The December newsletter is here! Click the image below or the link at the bottom to download. This month’s topic is How To, providing practical tips on things like:
Subscribers had the newsletter emailed to them on Tuesday. If you want to subscribe (and download back issues), click here.
Management of bladder injury seems straightforward. For many years, the gold standard was the cystogram. But for best results, this study had to be done a certain way. This included bladder instillation, imaging in two planes (AP and lateral), and a post-void view.
As CT scan use became more prevalent, we discovered that diagnosis of bladder injury became even more accurate. However, we also soon discovered that even though the pictures looked very good, some bladder injuries were being missed. It turns out that allowing passive filling of the bladder by clamping the urinary catheter (or not inserting one) missed upwards of 50% of injuries.
So the standard became the “CT cysto” technique. It is performed similar to a non-CT cystogram, by infusing contrast into the bladder under pressure. With this modification, the accuracy of the study approaches 100%. But do we all do it this way? No!
A study from the University of Utah reviewed registry data from all Utah Level I trauma centers over a 15 year period. A total of 124 patients with bladder injuries were identified. Interesting results include:
Bottom line: Compliance in this 15 year study was low. Unfortunately, they lumped conventional cystogram with CT cysto. These days, fewer conventional studies are performed and the error rate may be higher. However, current day compliance is still low in my experience. A bladder evaluation guideline should be developed and disseminated to emergency physicians, surgeons and radiologists (see the CT cysto link below). This is the only way we’ll be able to decrease the number of missed injuries for this problem.
Related posts:
Reference: Process improvement in trauma: traumatic bladder injuries and compliance with recommended imaging. J Trauma 74(1):264-269, 2013.
Heads up to all my readers in the Middle East! I’m attending the Arab Health healthcare exhibition and congress in Dubai at the end of January.
This huge event is in its 38th year, making it the longest running meeting in the area. It will be located at the Dubai International Convention and Exhibition Centre, from Jan 28-31. I’ll be at the Minnesota International Medicine exhibit located in Hall 1 on Monday through Wednesday. Stop by and see me! I’d love an opportunity to meet my readers! I would also enjoy an opportunity to visit the Trauma Centre at Rashid Hospital, if possible!
Feel free to email, tweet or Skype me (skype:Michael.D.McGonigal)
Well, the holidays slowed me down a bit, but the December issue of TraumaMedEd is finally ready to go! It’s another How To issue, with tips on stabs, occult pneumothorax and more!
Subscribers will get the issue delivered tomorrow evening (Central time). It will be available to everybody on the Thursday blog post.
Check out back issues, and subscribe now and get it first by clicking here!
Airway management is one of the most anxiety provoking procedures performed by trauma professionals. The main fear is that the airway will be lost during attempts to secure it and patient demise will soon follow. Add some facial fractures, bleeding, and an “unfavorable body habitus”, and the average prehospital or ED provider is really on edge.
The next most common fear is that providing a definitive airway in a patient with a known (or even suspected) cervical spine injury could cause a catastrophic neurologic injury. This was first addressed back in 1989 (before the time of video laryngoscopy, and when flexible scopes were rarely available in the ED). The authors found no verifiable reports of such an injury in the entire English literature.
Over the years, a few case reports have cropped up. As in so much of the medical literature, causality is hard to prove. The patient was normal before anesthesia, and afterwards they were not. Had to be the intubation, right?
Not so fast! Let’s break it down and look at what we do know. Biomechanical studies have shown that the manipulation that occurs in direct laryngoscopy isn’t as bad as it looks. Studies in uninjured models are enlightening (minimal movement with blade insertion, slight rotational movements with blade elevation, and a little more rotation during the intubation). Most of this (slight) movement occurs from occiput to C2, with little motion at all at C3 and below.
But that was on an uninjured model. What about ones that simulate an injured spine? Specifically an injury in the upper spine area that we know moves?
References: