Category Archives: Technique

Technique, Thorax

The “Backward Finochietto” Problem

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Resuscitative thoracotomy is a (sometimes) life-saving procedure reserved for trauma patients in extremis. Thankfully, most trauma centers do very few of these a year. However, that makes it one of those “high severity – low frequency” procedures that generate many, many quality improvement problems. Many of these issues are due to operator unfamiliarity or equipment availability.

Today, I’ll highlight a problem that crops up occasionally at various trauma centers across the US: the “backward Finochietto.” One of the most essential components of the resuscitative thoracotomy is rapid access to the chest. A large skin incision is typically made, the thoracic wall and intercostal musculature are divided, and the pleural space is entered.

It’s not easy to insinuate your arm between the ribs in an average person. But, of course, there’s a retractor for that! Von Mikulicz presented the first rib spreader at a German surgical society meeting in 1904.  Various versions of this instrument were devised over the next three decades to make it easier and faster to use.

The Finochietto retractor was introduced in 1936 and boasted several enhancements. It used a rack and pinion system to make it easier for the surgeon to spread the chest wall and made it unlikely to close on its own. The turning lever was hinged so it could flattened and placed out of the surgical field. The blades contained fenestrations so chest wall tissue could protrude into them and keep it from slipping when opened. It remains a workhorse instrument for us today and is found in most instrument packs for resuscitative thoracotomy.

But there is a potential problem. Some Finochietto retractors consist of only two pieces: a blade with the linear gear teeth (the rack) and another blade that fits onto it with the turning handle (the pinion). See the image below:

Looks great, right? However, there is one downside. The retractor parts that hook into the soft tissue are of a fixed depth. What if your patient has a more generous body habitus? Placing multiple sets of this retractor into the thoracotomy pack is not practical.

The solution is to allow detachable blades of various sizes. Here’s a modern-day example:

The good news is that the retractor tips are interchangeable. The bad news is that they are sometimes interchangeable with the wrong arm of the retractor! Hence the “backward Finochietto” problem. It’s impossible to use the retractors with the blades on the wrong side, and it takes time the trauma professional does not have to figure out how to snap them off and switch them around.

So what’s the solution? This is clearly an instrument reprocessing quality issue. These instruments are expensive, so your hospital may not be excited about purchasing new ones just for the trauma bay. It all boils down to foolproofing it in as many ways as possible.  Here are some tips:

  • Provide an educational session for all of the reprocessing techs. Unfortunately, this effect will wear off as staff turnover occurs.
  • Post a photograph of a properly assembled retractor for the techs to use when processing the tray.
  • Use colored instrument marking tape on each piece of the instrument. For example, a green tape strip should be placed on both the rack arm of the retractor and the left blade. Use red tape for the pinion arm and the right blade. All the tech needs to do now is match the colors as they assemble the retractor.

Bottom line: This problem is more common than you may think. Ask one of your old-timer trauma surgeons and I’ll bet they can tell you some stories. But it is easily avoided with a little creativity and some tape! Be sure to do it now so it doesn’t pop up in the heat of a resuscitative thoracotomy .

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Technique

Preperitoneal Packing Vs Angioembolization: Part 3

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In the previous post in this series, I described an early review article summarizing several older studies comparing these two hemorrhage control techniques for pelvic fractures. Today, I’ll review another paper fresh off the press, published just this month.

This paper comes from the orthopedics and neurosurgical groups at the University of Texas-San Antonio. They scanned five years of data from the National Inpatient Sample, which included data from 35 million inpatient admissions in the US. They separated all patients with acetabular and pelvic ring fractures using ICD-10 codes.

They further narrowed their dataset to patients with angioembolization (AE) or peri-pelvic packing (PPP) as their primary procedure. This eliminated patients who might have received other additional management that could cloud the data. Various hospital outcomes were tabulated, including hospital charges, mortality, and discharge location.

Here are the factoids:

  • Of the 3,780 patients identified, only 160 underwent PPP, and the remaining 3,620 had AE. This is probably a function of PPP’s newer and more novel nature.
  • The AE patients were significantly older than the PPP patients (66 vs 53 years). This suggests that trauma professionals have a lower threshold to order AE in older patients.
  • Time to procedure start was similar for both interventions
  • Overall, there was no difference in mortality between the AE and PPP patients
  • There was no difference in unfavorable discharge (other than home)
  • Hospital charges were significantly lower in the AE group ($369K vs $250K)!

Bottom line: This is the largest comparison of AE and PPP to date. It mostly confirms earlier work and adds significant insights about cost and discharge status.

AE and PPP have equivalent outcomes. This is true even though the AE group is larger and significantly older. However, it is possible that the number of PPP cases was too low for the authors to demonstrate any significant differences. 

What should you do when faced with these patients? First, hemodynamic instability means that PPP is the only choice. You can feel comfortable that outcomes will be the same as AE. If there is concern that there could be ongoing bleeding, PPP can be followed by a trip to the interventional radiology suite. This is a common practice.

I shouldn’t have to say it, but AE should never even be considered in an unstable patient. 

What about stable patients? AE seems to be the way to go. It is tolerated even by older patients. And it ends up saving a lot of money when compared to PPP. 

There is still room for research in this space. As our PPP experience grows, we should hopefully be able to confirm the conclusions  in this paper. If any are refuted, I’ll revisit this post and make the needed updates. Which is what you should also do in your practice!

Reference: Angioembolization Has Similar Efficacy and Lower Total Charges than Preperitoneal Pelvic Packing in Patients With Pelvic Ring or Acetabulum Fractures. J Orthop Trauma 38(5):254-258, 2024.

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Technique

Preperitoneal Packing Vs Angioembolization: Part 2

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In my last post, I reviewed an early paper on preperitoneal packing (PPP). Today, I’ll look at an earlier review article summarizing some smaller studies comparing it to angioembolization. In the next post, I’ll look at a brand new paper that includes a cost analysis as well.

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 was no 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. The Journal of Trauma and Acute Care Surgery, 92(5), 931–939.

 

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Technique

The Evolution Of Penetrating Neck Trauma Management – Part 3: Determining Risk

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In the last post, I described the first crucial step in the contemporary management of penetrating neck trauma, control of obvious external hemorrhage. Let’s move on to the nuts and bolts of figuring out what needs to be done about the injury.

Now, it’s time to triage your patient based on clinical signs that predict the presence or absence of a significant injury. In the old days, the neck was conceptualized as three different zones that dictated the diagnostic and management algorithm.

We are now moving toward considering the neck as a single unit. The next decision point is to determine the risk for vascular or aerodigestive tract injury based on an examination for signs of injury. These signs have been divided into three groups.

Hard signs. These indicate a high risk for deeper injury and consist of the following:

  • Vascular signs
    • Refractory shock
    • Pulsatile or difficult-to-control hemorrhage
    • Large or expanding hematoma
    • Audible bruit or palpable thrill (I hardly ever see anyone actually check the neck for these, so brush up your skills!)
  • Aerodigestive signs
    • Airway compromise or stridor
    • Bubbles from the wound
    • Significant subcutaneous emphysema
    • Major hematemesis
    • Massive hemoptysis
  • Neurologic signs
    • Neurologic deficits that suggest embolic strokes from a vascular injury

Soft signs. These suggest an intermediate risk for injury and are:

  • Vascular signs
    • Small or stable hematoma
    • History of bleeding or hypotension that has resolved
    • Active venous oozing
    • Pulse volume or blood pressure discrepancy (this suggests a thoracic vascular injury)
  • Aerodigestive signs
    • Hoarseness or any voice changes
    • Painful swallowing
    • Difficult swallowing
    • Mild subcutaneous emphysema
    • Minor hematemesis
    • Minor hemoptysis
  • Neurologic signs
    • Local neurologic deficit (direct injury to local nervous structures)

No signs. Obviously, this suggests a low risk of injury.

Once the level of risk has been determined, a course of action can be planned. Most patients with hard signs will require operative intervention. Plain x-rays with skin markers in place may help visualize retained foreign bodies and their relationship to bony structures. If the signs are immediately life-threatening, this step should be skipped, and operative exploration should be performed immediately. If the patient is stable and the injuries may be outside the easily accessible area of the neck (the old Zone II), a multi-detector CT angiogram (MDCTA) may help with operative planning. It may also identify patients eligible for endovascular repair.

Patients with soft signs have a lower risk of injury and should immediately undergo MDCTA. This scan has very high sensitivity and specificity in this group.

Finally, patients with no signs of deeper injury rarely need any intervention. Small series suggest that these patients could potentially be discharged from the ED. However, most trauma professionals will be uncomfortable with the thought of this. MDCTA is a low-risk test; until we know better, it’s probably best to obtain it before discharge.

Bottom line: I have described the initial assessment and management of patients with penetrating neck injury using the newer method using signs of injury in place of the old zones of injury. Nuances are still possible, such as what to do if the MDCTA is indeterminate for a vascular or aerodigestive injury. Fortunately, that is fodder for another post!

Reference: Approach to Penetrating Neck Trauma: What You Need to Know. J Trauma Acute Care Surg. 2024 Mar 25. doi: 10.1097/TA.0000000000004292. Epub ahead of print. PMID: 38523116.

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Technique

The Evolution Of Penetrating Neck Trauma Management – Part 2: Initial Steps

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In my previous post, I described the early days of penetrating neck injury management and introduced a paper suggesting that this concept should be revised. Today, I will summarize a paper by Siletz and Inaba that is currently in press and outlines what the contemporary way of treating these injuries should be.

Step 1. If present, rapidly control external hemorrhage and airway compromise. As always, bleeding should be controlled by direct pressure or packing. Direct pressure does not look like this:

The goal is to create a zone of pressure higher than the systolic BP perfectly in the area of bleeding. Since pressure is force per unit area, a larger area like that show above diffuses the maximum pressure and just doesn’t work. Note the ongoing bleeding shown in the picture.

Here’s what direct pressure looks like:

Or

A single finger (or maybe two) should be placed on or in the wound. If deeper bleeding is a problem, the same kind of pressure can be accomplished by packing with gauze. If gauze is used, however, pressure must usually be applied over the gauze to make sure that the underlying tissues remain pressurized.

If gauze packing is not practical because of this need for additional pressure, a urinary catheter can be inserted into the wound and inflated until the bleeding stops.

Courtesy Core EM

Airway control should ideally occur in the operating room. Given the proximity of this wound to airway structures, it is imperative that an ideal environment is present when the airway is inserted. A skilled anesthesiologist should be present, with difficult airway equipment available if needed. The surgeon should be standing by with all equipment needed to obtain a surgical airway if needed. Even though the patient may be breathing okay, the airway structures may be distorted by hematoma or injury.

You have probably noted that this is the same initial assessment we used in the old three zones approach. In the next post, I will discuss the details of a new assessment approach that considers the neck a single unit.

 

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