Category Archives: Procedures

Procedures

Preperitoneal Packing Vs Angioembolization: Part 1

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In this series, I will review the two major techniques for addressing troublesome bleeding from pelvic fractures. This post will review the evolution of packing techniques and more fully describe the concept of preperitoneal packing. Next, I’ll review an early paper that compared the snippets of information we had to angioembolization. In the last post in the series, I’ll discuss a paper in press that compares the efficacy and hospital charges of the two techniques.

A multi-center trial published in 2015 showed an astounding 32% mortality rate for patients with shock from pelvic fracture. As I continue to preach, going anywhere but the OR is dangerous for the patient. Unfortunately, it’s generally not feasible to operatively fix the pelvis acutely, and external fixation has limited impact on ongoing hemorrhage.

If the patient can be stabilized to some degree, interventional radiology can be very helpful. Unfortunately, access after hours involves some degree of time delay. Ideally, the team arrives in 30 minutes or less. But the patient may not be ready, so time to procedure may increase significantly.

Preperitoneal packing of the pelvis (PPP) has now become popular. Years ago, we tried to pack the pelvis from the inside (peritoneal cavity), but it never worked very well. You can push sponges deep into the pelvis as firmly as you want, but the intestines will not keep them from expanding back out of the pelvis.

PPP entails making a lower midline incision but not entering the peritoneal cavity. A hand is then slid along the anterior surface of the peritoneum around the inside of the iliac wing. Sponges can then be pushed around toward the sacrum, applying direct pressure over bleeding fracture sites and the overlying tissues.

preperitoneal-packing

Image courtesy of ACSSurgery.com

But does it work? Denver Health performed an 11 year retrospective review of their experience with 2293 patients with pelvic fractures. They looked at time to intervention, blood product usage, and mortality.

Here are the factoids:

  • A total of 128 patients underwent PPP
  • Most were younger (mean age 43) and badly injured (mean ISS 48)
  • Median time from door to OR was 44 minutes
  • Patients received an average of 8 units of RBCs intraoperatively, and an additional 3 units in the ensuing 24 hours
  • Overall mortality was 21% (27 of 128), but 9 (7%) were due to severe head injury

Bottom line: Compared to other published studies, time to “definitive management” with PPP was very short. Blood usage also dropped quickly after the procedure. Mortality seems to be much better than expected at about 13%. These results suggest that if you have to wait for angiography, or your patient is too unstable to go there, run to the OR first to do some PPP.

And don’t forget these other important management tips:

  • If you see any posterior pelvic fracture on the initial pelvic x-ray, call for blood
  • If the blood pressure softens at any point activate your massive transfusion protocol
  • Apply a binder, especially for open book type fractures
  • Always get a CT in stable patients to help your orthopedic surgeons plan, and to identify contrast blushes
  • If the patient has to go to OR first to stabilize them, consider angiography afterwards. You’ll probably find something they can fix.
  • Think about using your hybrid OR!

Reference: Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. The Journal of Trauma and Acute Care Surgery, 82(2), 233–242.

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Pelvis, Procedures

Preperitoneal Packing vs Angioembolization For Pelvic Fracture

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In my last post, I laid out the various options available for initial management of major pelvic fracture bleeding. Today, I’ll compare two of the newer tools: embolization (AE) and preperitoneal packing (PPP). In the next post, I’ll look at the data available for REBOA.

Interestingly, the use of AE and PPP vary geographically. Angioembolization has been a mainstay in the US for some time, and PPP has been more commonly used in Europe. The use of both is becoming more widespread, and each has its pros and cons.

Angioembolization requires the presence of a special interventional radiology team and a reasonably stable patient. The procedure can take some time, and the IR suite is not really the place to house an unstable patient. Preperitoneal packing requires a reasonably stable pelvis to hold the packs in place for optimal tamponade, which may require application of an external fixator at the time of the procedure.

But is one better than the other? A number of relatively small studies have been performed, which means that it is time to synthesize them and see if some clearer answers can be found. The trauma group in Newcastle, Australia did just this. They performed a systematic search of the literature, analyzing the impact of each procedure on in-hospital mortality.

Here are the factoids:

  • A total of 18 studies met the authors’ inclusion criteria: 6 studies on AE, 9 studies of PPP, and 3 that compared them to each other
  • ISS was significantly higher in the PPP group vs AE (41 vs 36)
  • Average time to OR in the PPP patients was 60 minutes vs 131 minutes to IR in the AE group (statistically significant)
  • A quarter (27%) of the PPP patients did not get adequate hemorrhage control and required AE
  • In-hospital mortality in the PPP papers was 23% vs 32% in the AE research
  • Mortality in the papers that compared AE directly to PPP wasno different

Bottom line: What does this all mean? Is packing “better” than embolization? The simple answer is that we don’t know yet. Due to the way this study was performed, it is not possible to tease out all of the possible confounders. 

We are taught that control of hemorrhage is paramount. The time to definitive management in the AE group was twice that of the PPP patients. This could have a major impact on mortality. Two hours of bleeding can certainly kill. And the lower mortality in the PPP group occurred even though their injury severity was higher.

Many trauma centers have both of these interventions available to choose from. How should we approach their use? Unfortunately the literature is still to scarce to come to strong conclusions. Until we have better research to learn from, I suggest the following:

  • Time is of the essence. Which procedure can you get the fastest? In many cases, this will be preperitoneal packing since it’s just a trip to your trauma OR, which should be ready and waiting. If you have an IR team standing by or available very quickly, you could consider them first.
  • Pay attention to hemodynamic stability. An IR suite is no place for an unstable patient. The resuscitation equipment is not on par with the OR, and one never knows exactly how long the procedure will last.
  • If you have a hybrid room, use it! This is the ideal situation. The surgeon can start the PPP while the orthopedic surgeon applies a fixator. And the radiologist can be preparing to finish it off with a quick squirt as soon as they move away from the groin.
  • The use of one does not rule out the other. If one fails and the patient has increasing fluid and blood requirements move immediately to the other procedure to try to get control.

Reference: Preperitoneal packing versus Angioembolization for the initial management of hemodynamically unstable pelvic fracture – A Systematic Review and Meta-Analysis. J Trauma, publish ahead of print, Jan 4 2022, doi: 10.1097/TA.0000000000003528.

 

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Procedures

Cricothyrotomy In The COVID Age

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COVID-19 has changed everything. Our patients and even our co-workers could be harboring the virus. Workplace precautions have changed. Many of the minutiae of living have changed. All trauma professionals are concerned with protecting themselves from contagion in order to continue providing vital care to more patients.

We have a fairly good understanding of how the virus spreads. Aerosols and aerosolizing procedures are a major risk factor for involved personnel. In general, hospitals already have processes and policies in place for the most common aerosolizing procedure, endotracheal intubation. Even in emergency circumstances, this is a relatively controlled procedure.

But what about cricothyrotomy? This is far less commonly performed, and as such is prone to more variability. Surgeons at Northwestern University in Chicago tested several techniques for more safely performing this procedure. They placed three different types of draping materials commonly found in or around a trauma bay over their hands in an attempt to decrease aerosolization produced during the procedure.

They tested these drapes using a cricothyrotomy simulator based on a porcine trachea. To identify aerosolization, they atomized fluoroscein into the trachea and monitored the procedure with an ultraviolet light.

The first drape tested was a clear plastic x-ray cassette holder. The advantage of using this as a drape is its transparency. The surgeon does not need to peek under the plastic while performing the crich. Unfortunately, the stiffness and slipperiness of the plastic makes it prone to sliding off the procedure site.

A dry blue surgical towel was used next. This performed a bit better, but still slipped off the operative field. Black light inspection showed a significant amount of aerosol contamination of the edge of the towel and the surgeon’s gown.

Finally, a wet blue surgical towel was tested. The towel easily stayed in place and retained nearly all of the aerosolized fluoroscein. There was a negligible amount on the surgeon’s gown.

Bottom line: The authors recommended that wet surgical towels be placed over their hands and used as a barrier when performing a cricothyrotomy in a COVID positive or unknown patient. The reality is that this will apply to this procedure in just about any acute trauma patient you see. Obviously, this trick does not eliminate aerosolization. Rather, it dramatically reduces the amount and hence, the risk to the surgeon and other personnel in the room. It’s not perfect, but definitely worth it!

To view a video demonstrating the technique and results for each of the drapes, click here.

Reference: Emergency cricothyrotomy during the COVID-19 pandemic: how to suppress aerosolization. Trauma Surgery Acute Care Open 5(1):e000482, 2020.

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Procedures

ED Thoracotomy: Kids ARE Just Small Adults

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You’ve undoubtedly read this trite phrase somewhere in your training: “Kids aren’t just small adults!” There are many examples where this is absolutely true. Think about arterial extravasation in solid organ injury. Or severe traumatic brain injury. There are major differences in treatment aggressiveness for both of these.

But what about the code situation? I’ve noted a peculiar phenomenon over the years with regard to pediatric codes of all kinds. Adults tend to persist far longer at resuscitative efforts over children than they normally would on other adults. And what about that most extreme code situation, the emergency thoracotomy?

I’ve also seen the use of this procedure in children who don’t meet the usual adult criteria. But they are kids, right? They can bounce back from more severe insults, right? I hope that I’ve convinced you over the years that one can’t just assume and generalize anything. Things that seem like so much common sense often turn out to be wrong. Think back to the days of the stress / spicy food theory of peptic ulcer disease. This seems so silly now that we recognize the role of H. Pylorii.

Scripps Mercy adult and Rady Children’s Hospital pediatric trauma centers in San Diego performed an extensive review of the National Trauma Data Bank over a three year period. They focused on patients 16 years of age or less who underwent ED thoracotomy within 30 minutes of arrival at the trauma center. They focused on procedure indications and the eventual outcomes.

Here are the factoids:

  • A total of 114 patients were recorded in the NTDB, with a mean age of 10 years and median Injury Severity Score of 26 (this is the three year experience in the entire US in three years!)
  • Males were disproportionately involved at 69%, although this is less than in adults
  • Thoracotomy was performed promptly, with a median time after arrival of 5 minutes
  • Mechanism of injury was almost evenly split between penetrating (56%) and blunt (44%)
  • Blunt mechanism mortality was 94% vs 88% for penetrating
  • Penetrating injury outside of the thorax was uniformly fatal
  • Patients without signs of life on arrival, regardless of mechanism, also had a 100% mortality rate
  • Treatment at an adult trauma center, freestanding pediatric center, or combined center had no impact on these dismal outcomes

Bottom line: This is an interesting paper, and shows that the outcomes after ED thoracotomy in kids is even more dismal than in adults. This is particularly true for children arriving without vital signs and for penetrating abdominal trauma.

However, the authors go on to suggest a practice guideline for pediatric emergency thoracotomy similar to the EAST adult guidelines based on their study findings. However, I think this is ill advised. Have a look at the absolute numbers:

The largest subgroup has only 29 patients in it. These numbers are way too small to consider a guidelines change.

This paper shows that kids are just small adults when it comes to ED thoracotomy. And they seem to do even more poorly with no vital signs or penetrating injuries outside of the chest. So think carefully the next time you must consider this procedure in a child.

Reference: Nationwide Analysis of Resuscitative Thoracotomy in Pediatric Trauma Time to Differentiate from Adult Guidelines? J Trauma published ahead of print, July 6, 2020.

 

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Procedures

Can Chest Tube Insertion Result In Exposure To Coronavirus?

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Endotracheal intubation is considered an aerosol-producing procedure. In this new age of SARS-CoV-2 and COVID-19, most hospitals are stepping up the level of personal protective equipment (PPE) used when performing this procedure. This has also resulted in modifications in the location where intubation is performed and the choice of drugs used.

But what about needle and chest thoracostomy? These are different than intubation in that the respiratory tract is usually not directly accessed. However, there is the opportunity for exposure to pleural fluid. In the case of needle thoracostomy, it is possible that air under pressure in the chest can force tiny droplets or even an aerosol out and into the air. There is less likelihood of aerosolization during tube thoracostomy, where liquid and droplet exposure can be anticipated.

What do we know about pleural fluid and the novel coronavirus? Basically nothing. And there is very little literature out there regarding other respiratory viruses in pleural fluid either. The only paper I could find (reference below) was published five years ago by a Spanish group. They compared the presence of bacteria and viruses in the pleural fluid of patients with community acquired pneumonia against an uninfected control group. They found only one incidence of virus in the pleural fluid in one patient, a human metapneumovirus. Is this comforting? Probably not.

Trauma patients with chest trauma are likely very different. Those with a hemo- or pneumo-thorax, by definition, had some violation of the surface of the lung. to cause the leak This injury is very likely to breach alveoli which are laden with coronavirus, thus contaminating the pleural fluid. Once that occurs, it is possible that the entire thorax surrounding the lung is contaminated. Note: this is one of those “common sense” assumptions with absolutely no data currently to back it up.

Bottom Line: This is yet another of the many questions about SARS-CoV-2 that we just don’t have an objective answer to. However, since we are already limiting exposure during or forgoing laparoscopic procedures altogether to avoid vaporizing viral particles in smoke, it makes sense to protect ourselves during procedures that involve pleural fluid in trauma patients.

Until we have more data, needle and tube thoracostomy procedures should be considered at least a droplet-prone procedure, if not an aerosol-producing one. This means that trauma professionals should don appropriate personal protective equipment as dictated by their local policies and procedures before performing these procedures.

Reference: Detection of bacteria and viruses in the pleural effusion of children and adults with community-acquired pneumonia. Future Microbiology 10(6):909-916, 2015.

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