Category Archives: General

General

Update: Can TBI Be Managed Without Neurosurgical Consultation?

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This paper was presented at EAST in 2013, and this is an update of that work using the entire manuscript which has now been published.

The standard of care in most high level trauma centers is to involve neurosurgeons in the care of patients with significant traumatic brain injury (TBI). However, not all hospitals that take care of trauma patients have immediate availability of this resource. The University of Arizona at Tucson looked at management of these patients by their acute care surgeons.

The authors did a retrospective cohort study of patients at their center who had a mild TBI and positive head CT, managed with or without neurosurgery consultation, over a two year period. They matched the patients with and without neurosurgical consultation for age, GCS, AIS-Head and presence of skull fracture and intracranial hemorrhage.

A total of 90 patients with and 180 patients without neurosurgical involvement were reviewed. Here are the factoids:

  • Hospital admission rate was identical for both groups (87-89%)
  • ICU admission was significantly higher if neurosurgeons were involved (20% vs 44%)
  • Repeat head CT was ordered more than 3 times as often by neurosurgeons (20% vs 86%)
  • Post-discharge head CT was ordered more often by neurosurgeons, but was not significantly different (5% vs 12%)
  • There were no surgical interventions, in-hospital mortality, or readmissions within 30 days in either group.
  • Cost of the hospital stay was significantly increased if neurosurgery was consulted. 

Bottom line: Can surgeons safely manage select patients with intracranial injury? Granted, this is a small, retrospective study, but the answer is probably yes. The majority of patients with mild to moderate TBI with small intracranial bleeds or skull fractures do well despite everything we throw at them. And it appears that surgeons use fewer resources managing them than neurosurgeons do. The keys to being able to use this type of system are to identify at-risk patients who really do need a neurosurgeon early, and having a quick way to get the neurosurgeon involved (by consultation or hospital transfer). Having a specific practice guideline for management is essential as well. As neurosurgery involvement in acute trauma declines, this concept will become more and more pertinent.

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Reference: The acute care surgery model: managing traumatic brain injury without an inpatient neurosurgical consultation. J Trauma 75(1):102-105, 2013.

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General

Tech: Bandage Indicates Wound Tissue Oxygen Concentration

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Tissue oxygenation is critical to wound healing. But unfortunately, there is no easy way to “see” how healthy the wound is just by looking at it. A research team at the Massachusetts General Hospital is developing a spray-on “smart” bandage that determine, at a glance, shows a map of tissue oxygen levels.

Now, of course, the researchers had to get clever and come up with a lame acronym. So here it is: sensing, monitoring and release of therapeutics (SMART). Get it? SMART bandage. 

Here’s what it looks like:

Okay, so how does it work? There are three components: a sensor molecule that glows over a useful range of oxygenation values, a bandage material to bind it to, and an imaging device for capturing useful images.

The sensor molecule is a phospor derivative that glows longer and brighter as tissue oxygen decreases. The bandage is a viscous liquid that is painted on the skin and dries as a solid film within a minute (think NewSkin). It contains the sensor molecule. In order to keep room air from seeping into the bandage and interfering with the readings, a transparent barrier is placed over it (think Tegaderm). 

Finally, the detector is … a smartphone or camera! No need for other expensive equipment. The flash stimulates the phosphors as the image is recorded. The image can then be analyzed for brightness and color of the phosphors. 

What is this good for? Trauma professionals deal with soft tissue wounds on a regular basis. Some of the more complicated ones require skin grafts or flaps, and maintaining their health is very important. Imagine begin able to identify oxygenation problems early in the edges of a flap or from a small seroma under a skin graft. This could lead to earlier correction of any problems and an increase in graft salvage. And it may allow us to better predict which burns are getting worse or may need grafting. Here are images of burn vs normal skin:

Bottom line: Yet another cool (and probably inexpensive) tool in expanding our senses to appreciate factors that help wound healing. Once the kinks are worked out, expect this to move into clinical care fairly quickly.

Related posts:

Reference: Non-invasive transdermal two-dimensional mapping of cutaneous oxygenation with a rapid-drying liquid bandage. Biomedical Optics Express 5(11):3748-3764, 2014.

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General

What Is: The LisFranc Injury?

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Medicine is full of conditions with eponyms. Trauma is no exception. There’s the Mattox maneuver and the Cushing response, to name two. Many times, the name is just a kind of vanity plate for the discoverer of the condition. But in the case of the LisFranc injury (or fracture), it makes some sense. This injury is tough to describe in a sentence or two, let alone a few words. 

Jacques LisFranc de St. Martin was a French surgeon and gynecologist (!) who described this condition in about 1815. It entails the fracture of the heads of the metatarsal bones and possible dislocation from the tarsals (the cuboid, navicular, and three cuneiform bones). This area is known as the LisFranc joint complex.

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The injury can involve any or all of the metatarsals. The typical mechanism applies high energy across the midfoot, which can often be seen in head-on motor vehicle crashes. Crush injury to the proximal foot can also do this, such as running the foot over with a car. Occasionally, this injury pattern is produced with lower energy during sports play. In this case, the top of the foot is typically contacting the ground, plantar flexing it. At the same time, another player steps on the heel, grinding the foot into the ground (ouch). Interestingly, LisFranc did not describe the injury pattern or mechanism. His name is associated with the joint complex, and it is an injury to his joint complex.

image

Most of the time, the injury is obvious. There is usually notable pain and swelling of the foot. X-ray findings are generally not subtle. However, lower energy mechanisms may not cause much displacement, and initial imaging may not show the injury. If your patient starts to complain of pain in the midfoot when they begin to ambulate, think of LisFranc.

Treatment depends on the degree of displacement and the amount of disruption of the tarso-metatarsal joints. If minimal, a trial of nonoperative, non-weight bearing may be sufficient. But frequently, surgical reconstruction is required. 

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General

… And The Ultimate Retained Foreign Bodies

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Sponges are unfortunately one of the most common retained foreign bodies. This is due to their small, flimsy nature. The surgeon usually looks at the obviously visible areas of the abdomen or other body cavity before closing. She can also feel around in the “nooks and crannies”, but sponges feel very similar to the other organs surrounding it.

But what about more substantial items, like surgical instruments? Surely these are so obvious as to not leave behind?

Unfortunately, not so. Take a look at these items. This is a large pari of surgical forceps.

This is a malleable retractor, a long, thin sheet of pliable metal that can be bent to any desired shape.

And finally, a pair of Metzenbaum scissor, a common surgical instrument for cutting tissue.

Bottom line: It doesn’t matter how small or large, anything can and will be left behind in emergent and trauma cases. Recognizing that this can occur, no matter how confident you are that it has not, is the key. Always count, but followup with an x-ray that covers all areas of the surgical field before closing.

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General

What Does A Retained Surgical Sponge Look Like?

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It’s the bane of any surgeon’s existence. And the reason why OR personnel take such great pains to account for everything in the room. It is a catastrophe, and always a preventable one, when some piece of equipment goes missing and ends up left inside a patient.

A number of methods have been developed to try to eliminate this problem. They include careful counts, having someone record anytime anything is placed inside, x-rays, and most recently, RFID tags. 

After counting, x-ray is the most common way to try to find missing objects. One would think that these foreign bodies would be easy to see. Metallic instruments are rather easy to spot. But many trauma professionals, even those who work in the OR, have never seen what a positive image of a sponge actually looks like. So here they are. You should never miss one on an xray now.

Surgeons typically use two types of sponges in the OR: Ray-Tec sponges and standard lap pads. Ray-Tecs look like a 4×8 piece of gauze with a mysterious blue string woven throughout it. The string is the only part that shows up on x-ray, and it is very thin and somewhat hard to see. Here are some Ray-Tec sponges outside the body:

And here’s one that was left inside. Note the little squiggle in the left lower quadrant and how easy it is to over look.

On the other hand, a laparotomy pad is a 4×4 folded cloth pad that unfolds into a larger pad. It has a blue tag sewn in the corner, extending along one edge of the pad. Here’s what they look like:

And here’s one inside a patient. Note the irregular object in the right upper quadrant.

Bottom line: It’s important for anyone who works in the OR on any body part to be familiar with the appearance of these tags on x-rays. Since it’s generally impossible to get accurate counts before or after a trauma procedure, always image the involved body cavity looking for these telltale signs before closing the patient.

Note: These images taken from the internet. Patients not treated at Regions Hospital.

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