Fracture healing takes a long time, as many of our patients can attest to. Six or eight weeks, and even more may be required for full healing. Researchers at the University of Georgia and in Houston have completed an animal study on rats using a type of “fracture putty” that dramatically speeds up this process.
The researchers used adult mesenchymal stem cells that produce a protein which is involved in bone healing and regeneration. They created a gel using these cells, and injected them into the fracture sites which were stabilized externally (imagine a rat external fixator!). The fractures healed rapidly, and within 2 weeks the rats could run and stand on their legs normally.
Bottom line: The next step is to translate this work to larger animals. Strength and durability are major concerns. The amount of stress placed on rat legs and human legs is considerably different. If this pans out, it could revolutionize fracture healing, especially in cases where there may be highly disabling segmental bone loss (read: military). It will be several years before this can move to human studies.
The fifth highest priority taught in the ATLS course is exposure. This generally means getting the patient’s clothes off so any hidden injuries can be identified. Early in my career, I was called to see a patient who had a gunshot to the chest that had been missed because the consulting physician had neglected to cut off her bra. A small caliber wound was found under the elastic strap in her left anterior axillary line after a chest xray showed a bullet in mid-thorax.
The usual trauma activation routine is to cut off the clothes. There are several tips and tricks we use to do this quickly. And a number of commercial products are out there to make it even easier.
But do we really need to cut everyone’s clothes off? I’m not disputing the fact that it’s important to be able to examine every square inch. But do we need to destroy everything our patient is wearing? I once saw a sequined wedding dress cut off (it’s almost as bad as cutting off a down jacket).
The answer is no. The key concept here is patient safety. Can you safely remove the clothing in a less destructive way? For most victims of major blunt trauma, we worry a lot about the spine. Unfortunately, it’s just not possible to allow the patient to wriggle out of their clothes and protect their spine. The same goes for fractures; it may be too uncomfortable to remove clothing because of fracture movement so scissors are required.
Penetrating trauma is a bit different, and in many cases it’s a good idea to try to get the clothing off intact. Once again, if spinal injury is a consideration (gunshots only), the involved clothes should be cut off. A patient with a gunshot to the chest can probably have their pants safely and gently pulled off, but their shirt and coat must be cut.
The police forensic investigators like to have intact clothing, if possible. This is another good reason to try to remove clothing from penetrating injury victims without cutting.
Bottom line: Think before you cut clothes! Major blunt trauma and bad injuries require scissors. Lesser energy blunt injury may allow some pieces of clothing to be removed in the usual method. Most penetrating injury does not require cutting. But if you must (for patient safety), avoid any holes in the fabric so forensics experts can do their job.
Click the link above to check out a website with interactive maps and tools for looking at traffic crash patterns across the US. It provides several different ways to search, and allows you to narrow your focus as much as you want. For example, you can search for all night crashes involving unrestrained teenagers and alcohol for a specific state and year. The only downside is that the crash data is current through about 2009.
Check it out! It may help trauma professionals plan prevention programs in their area.
It’s great when you read a study that supports your own biases. But it’s not pleasant at all when you find one that refutes what you’ve been teaching for years. Well, I found one of those and I wanted to share it with you.
I’ve always said that there are only two sizes of chest tube for trauma, big (36Fr) and bigger (40Fr). Although there was no good literature, it seemed that a large tube would help ensure drainage of bigger clots if hemothorax was present.
A multicenter observational study was carried out that looked at 353 chest tube insertions. This work monitored retained hemothorax or pneumothorax, the need for tube reinsertion or invasive procedure due to incomplete drainage, and pain during insertion.
They had roughly 50:50 large (36-40Fr) vs small (28-32Fr) tubes. Tubes inserted for hemothorax were also 50:50 for large vs small. The initial amount of blood out was small and about the same for both groups. There was no significant difference in pneumonia, retained hemothorax, or empyema. The need for an invasive procedure (VATS or thoracotomy) was about 11% in both groups. Interestingly, there was no difference in visual analog pain score between the groups either.
Basically, large tube and small tube were the same.
Bottom line: Chest tube size selection probably doesn’t matter as much as we (I?) think. So it seems to make sense to select a tube size based on your patient’s chest wall, not dogma. Although subjective pain seems to be the same as well, pain and sedation management are key because this is not a fun procedure for the patient, regardless of tube size.
Reference: Does size matter? A prospective analysis of 28–32 versus 36–40 French chest tube size in trauma. J Trauma 72(2):422-427, 2012.
Pelvic Fractures: OR vs Angio In The Unstable Patient
One of the cardinal rules of trauma care is that hemodynamically unstable patients can only go the the operating room from the ED. No trips to CT, xray, etc. Trauma professionals occasionally try to make exceptions to the rule, but it usually doesn’t work out.
Well, what about the patient with severe pelvic fractures who is or becomes unstable? Pelvic fracture bleeding is not always easy or even possible to control in the OR, and angiography offers a way to identify and stop the bleeding, right?
The trauma group at Ryder in Miami did a lengthy (13 year) retrospective review of their experience with these patients. They looked at every patient who underwent angiography, then identified the subset that went to the OR followed by angiography. There were 134 angio patients and 49 OR to angio patients on whom they based their analysis. Obviously, there is plenty of opportunity for bias in this study, and many of the study patients identified had to be excluded due to incomplete records.
Patients who went to the OR first tended to have similar injury severity but were sicker than the angio alone group. Crystalloid and blood resuscitation volumes were significantly higher in the OR group as well. Most of these patients underwent a laparotomy, and 64% had active intra-abdominal bleeding. None died in OR, and most were left with a damage control abdominal closure.
In the angio group, there were really 2 subsets: angio alone, and angio followed by OR. Mortality in the angio alone group was similar to the OR-angio group. But deaths skyrocketed in those who went from angio to OR (67% vs 20%). This is likely due to them failing angiographic management of bleeding. Three patients died in the angio suite.
Bottom line: There’s a lot of data in this paper, and some of the results can be explained by selection bias. However, they appear to support algorithms released by EAST and the WTA (see diagram above). In general, a trauma patient with severe pelvic fractures and hemodynamic instability needs to go to OR to identify and treat any source of intra-abdominal bleeding. If pelvic bleeding remains a problem, preperitoneal packing may be considered, followed by a trip to angio at that point. The rule that unstable patients should only go to OR (or an ambulance bound for a trauma center if there is no OR) still holds!
Reference: Operating room or angiography suite for hemodynamically unstable pelvic fractures? J Trauma 72(2):364-372, 2012.
Quiz: There is just one extremely rare reason that I know of to move to CT with a hemodynamically unstable trauma patient. Leave a comment with your guess.
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