Category Archives: General

Best Of: Finding Rib Fractures On Chest XRay

September 8, 2015 The Trauma Pro Leave a comment

A lot of people have been viewing and requesting this post recently.

Here’s a neat trick for finding hard to see rib fractures on standard chest xrays.

First, this is not for use with CT scans. Although chest CT is the “gold standard” for finding every possible rib fracture present, it should never be used for this. Rib fractures are generally diagnosed clinically, and they are managed clinically. There is little difference in the management principles of 1 vs 7 rib fractures. Pain management and pulmonary toilet are the mainstays, and having an exact count doesn’t matter. That’s why we don’t get rib detail xrays any more. We really don’t care. Would you deny these treatments in someone with focal chest wall pain and tenderness with no fractures seen on imaging studies? No. It’s still a fracture, even if you can’t see it.

So most rib fractures are identified using plain old chest xray. Sometimes they are obvious, as in the image of a flail chest below.

But sometimes, there are only a few and they are hard to distinguish, especially if the are located laterally. Have a look at this image:

There are rib fractures on the left side side on the posterolateral aspects of the 4th and 5th ribs. Unfortunately, these can get lost with all the other ribs, scapula, lung markings, etc.

Here’s the trick. Our eyes follow arches (think McDonald’s) better than all these crazy lines and curves on the standard chest xray. So tip the xray on its side and make those curves into nice arches, then let your eyes follow them naturally:

Much more obvious! In the old days, we could just manually flip the film to either side. Now you have to use the rotate buttons to properly position the digital image.

Final exam: click here to view a large digital image of a nearly normal chest xray. There is one subtle rib fracture. See if you can pick it out with this trick. You’ll have to save it so you can manipulate it with your own jpg viewer.

General

The “Double-Barrel” IO: Can It Work?

September 2, 2015 The Trauma Pro Leave a comment

Intraosseous lines (IO) make life easy. They are quicker to insert, have a higher success rate, and require less experience than a standard IV. And they can be used for pretty much any solution or drug that can be given through an IV.

But there are some limitations. They can’t be inserted into a fractured bone. The manufacturer cautions against multiple insertions into the same bone. A second insertion should not be performed in the same bone within 48 hours.

But, as with so many things in medicine, there is little in the way of proof for these assertions. They seem like good ideas for precautions, but that does not mean they are correct. No real research has been done in this area. Until now.

The concept of using two IO needles in one bone was explored in an animal model by researchers in Canada. They used a swine model (using the foreleg/humerus, to be exact), and tested several infusion setups.

Here are the factoids:

Infusing crystalloid using an infusion pump set to 999ml/hr took 30 minutes with a single IO, and 15 minutes with a “double-barrel” setup
Giving crystalloid using a pressure bag set at 300 mm/Hg took 24 minutes with a single IO, and 23 minutes with double the fun
The double-barrel setup also worked for a blood/drug combo. 250cc of blood and 1 gm of TXA in 100ml of saline infused via pump in 13 minutes.
Simultaneous anesthesia drugs (ketamine infusion in IO #1, fentanyl and rocuronium bolus in IO #2) without problems
Multiple fluid + drug infusion combinations were tested without incident
There were no needle dislodgements, soft tissue injuries, fractures, or macrohistologic damage to the bone or periosteum

Bottom line: Remember, these are pigs. Don’t do this in humans yet. However, this is pretty compelling evidence that the double-barrel IO concept will work in people. And it appears that infusion pumps must be used for effective, fast infusions. I recommend that prehospital agencies with inquiring minds set up a study in people to prove that this works in us, too.

Related posts:

Reference: Double-barrelled resuscitation: A feasibility and simulation study of dual-intraosseous needles into a single humerus. Injury, in press April 30, 2015.

General

Trauma Education: The Next Generation Coming Soon!

September 1, 2015 The Trauma Pro Leave a comment

TE:TNG, version 3.0 is coming soon! Our fast-paced 4 hour program will be available again live this year (but you have to come see me in St. Paul MN), or via LiveStream on Thursday, September 17.

Our guest speaker is Dr. Brian Lin, author of the Closing the Gap – lacerationrepair.com website, talking about “Advanced wound closure tips and tricks.”

We also have a number of other live presenters, delivering 20 minute fact-packed talks on trauma topics applicable to all trauma professionals. Topics include:

Top 10 Pearls of Palliative Care in Trauma
For Level III centers: How to keep more trauma patients at your hospital
De-escalation and takedown in the ED

Peppered among all the live presenters will be curbside consults, where we ask the specialists what you also wished you had asked. We’ll also show a variety of focused, 5 minute how-to videos on:

Using ultrasound to start peripheral IVs
Stabilizing prior to transfer
Small bore chest tubes
And more!

For more information, or to make arrangements to join us live or electronically, please visit our website at www.tetng.org

I’m looking forward to “seeing” you there!

Michael

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