Category Archives: Procedures

Procedures

Air Embolism From an Intraosseous (IO) Line

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IO lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.

But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.

This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC).

During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line is not closed properly, there could be.

Bottom line: Treat an IO line as carefully as you would a regular IV. You can give anything through it that can be given via a regular IV: crystalloid, blood, drugs. And even air, so be careful!

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Procedures

How Do You Dress YOUR Trauma Team?

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Over the years, I’ve seen the trauma teams at quite a few hospitals in action. One thing I have noticed is that most just don’t pay attention to what they wear. I’m talking about wearing personal protective equipment again. It’s one of those things, like hand washing, that everyone knows that they are supposed to do.

There are two reasons to put all that stuff on:

  • To keep potentially contaminated body fluids from getting on you
  • To prevent you from contaminating your patient’s open wounds

The minimum equipment that MUST be worn is a cap of some sort (to keep your hair from falling on the patient), mask and eye protection (mucus membrane protection), gown (protects your clothes), and gloves (obvious). Shoe protection is optional, in my opinion, unless you wear Christian Louboutin to work.

So you’ve been lax with your team. How do you get them to put everything on now? It’s like getting your child to wear a bicycle helmet when they are fourteen.

  • Create an expectation that everyone wear it and empower everyone to point it out. No exceptions. Physicians, this means you.
  • Put all equipment just outside the trauma room door. The farther away it is, the less likely it is to be used.
  • Assign an enforcer. Everyone entering the room must be dressed, or this person will speak up. Ideally, they should be a physician. If not, one of the docs must back this person up.
  • Occasionally, a badly hurt patient gets rolled into the room with little advance notice. In this case the fully dressed people need to relieve those who are not as soon as they dress and walk into the room.

The top picture shows part of our trauma team assembling before a trauma activation. Everyone is dressed. They know that someone will call them on it if they aren’t. Also, note the little pink sticker on the chest of physician at the head of the bed. We have a sticker for every role in the room (bottom picture). At the beginning of a resuscitation I scan the room to make sure everyone has one. It helps identify everyone and makes extraneous personnel stand out so they can be asked to leave the room.

Bottom line: Everyone has to wear their personal protective equipment on every trauma resuscitation. No exceptions.

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Procedures

Chest Tube Tips

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I’ve written a lot about chest tubes, but there’s actually a lot to know. And a fair amount of misinformation as well. Here’s some info you need to be familiar with:

  • Chest trauma generally means there is some blood in the chest. This has some bearing on which size chest tube you choose. Never assume that there is only pneumothorax based on the chest xray. Clot will plug up small tubes.
  • Chest tubes for trauma only come in two sizes: big (36Fr) and bigger (40Fr). Only these large sizes have a chance in evacuating most of the clot from the pleural space. The only time you should consider a smaller tube, or a pigtail type catheter, is if you know for a fact that there is no blood in the chest. The only way to tell this is with chest CT, which you should not be getting for diagnosis of ordinary chest trauma.
  • When inserting the tube, you have no control of the location the tube goes once you release the instrument used to place it. Some people believe they can direct a tube anteriorly, posteriorly, or anywhere they want. They can’t, and it’s not important (see next tip).
  • Specific tube placement is not important, as long as it goes in the pleural space. Some believe that posterior placement is best for hemothorax, and anterior placement for pneumothorax. It doesn’t really matter because the laws of physics make sure that everything gets sucked out of the chest regardless of position except for things too big to fit in the tube (e.g. the lung).
  • Tunneling the tube tract over a rib is not necessary in most people. In general, we have enough fat on our chest to ensure that the tract will close up immediately when the tube is pulled. A nicely placed dressing is your insurance policy.
  • Adhere to an organized tube management protocol to reduce complications and the time the tube is in the chest.

And finally, amaze your friends! The French system used to size chest tubes is the diameter of the tube in millimeters times three. So a 40Fr chest tube has a diameter of 13.3mm.

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Procedures

Where is YOUR Personal Protective Equipment (PPE)?

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Standard or universal precautions are essential in trauma. They serve two purposes: keeping you safe from exposure to body fluids, and keeping you from contaminating any open wounds. Unfortunately, they are not used as “universally” as they should be.

I’ve heard a number of excuses for not wearing them:

  • I don’t have time to put them on
  • They’re so hot!
  • It’s just a kid, I have nothing to worry about

All wrong! It takes less than 30 seconds to put them on. And yes, they may be a little warm, but if you have time to notice, then your trauma activations are taking too long. Anyone, including children, may have diseases you don’t want to share.

There are two major reasons that are legitimate and must be addressed:

  1. They are not conveniently placed. The deeper in the trauma room they are, the less likely anyone is to wear them (see photo). Place them just outside the door to your trauma bay in plain sight.
  2. Their use is not enforced. Assign specific people the role of PPE police. Emergency physicians and surgeons are optimal, but the charge nurse or others in authority positions are fine.

Develop a culture where the expectation is that everyone who enters the trauma bay, no matter what their rank, must be wearing their protective gear. Your philosophy should be “it’s not just a good idea, it’s the law.” 

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Air Embolism From an Intraosseous (IO) Line

IO lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.

But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.

This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC). During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line closed, there could be.

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