Category Archives: Technique

Technique

The Evolution Of Penetrating Neck Trauma Management – Part 1

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“When the facts change, I change my mind. What do you do, sir?”

This is a famous quote from John Maynard Keynes. (Or is it? There is some debate over its authenticity, but you get the idea it tries to convey.) Our knowledge base continually changes, so we must be willing to change our minds (and practices) based on new, reliable information.

The management of penetrating neck injury is one of those facets in trauma care that has undergone slow but steady progress over the past 40 years of my career. In the old days, we quickly identified the zone of injury and proceeded to the operating room for Zone II injuries. We had to think a little harder about the other zones to be certain that we needed to be in the OR. But overall, the threshold for surgery was low.

Things have been changing. Five years ago, I published a post detailing new work by Inaba et al. at LAC+USC. This started a move toward using more straightforward criteria and advanced imaging to assist decision-making with these injuries.

In this post, I’ll summarize the original paper. In the next section, I will describe the group’s paper, which is currently in press and outlines the full framework for workup or penetrating neck injury.

The advance that makes this new method possible is based on the high degree of accuracy that CT angiography of the neck provides. It is very sensitive for identifying even minor injuries to the aerodigestive tract and vascular system.

The trauma group at LAC+USC organized a prospective, multicenter study using a multidetector CT angiography of the neck for initial screening of penetrating neck injury. This allows the evaluation of the neck as a single unit, not as three zones. It also solves the problem of trying to apply zones to injuries that cross several of them.

The new algorithm that was tested utilized an initial physical exam, first looking specifically for “hard signs” of injury.  The following were considered the hard signs:

  • Active hemorrhage
  • Expanding or pulsatile hematoma
  • Bruit or thrill over the injured area
  • Unresponsive shock
  • Hemoptysis or hematemesis
  • Air bubbling from the wound

These patients were immediately taken to the OR and explored through an appropriate incision.

Patients with no signs or symptoms were admitted and observed for at least 24 hours. All other patients were considered to have “soft signs.” They underwent multidetector CT angiography of the neck, with a scanner having at least 40 slices. Further evaluation of these patients was based on the exam and CT scan.

Here are the factoids:

  • 453 patients with penetrating neck injuries were identified during the 31-month study period
  • 9% had hard signs and were taken to the OR; 50% had soft signs and underwent CT; 41% had no signs and were observed
  • For soft sign patients, 86% of scans were negative, and all were true negatives after observation
  • 12% of soft sign patients had a positive scan, and of those, 81% were true positives
  • four patients (2%) with soft signs had too much artifact for an accurate CT, and other tests were performed; 1 of the 4 had an injury
  • Sensitivity of CTA was 100%, and specificity was 97.5% in the soft sign patients
  • The authors concluded that CTA is very reliable for identifying injuries in patients with soft signs and that patients with no signs do not require scanning, only observation

Bottom line: This was an intriguing paper that utilized both physical examination and CT angiography. The results were impressive, and they supported the argument that CTA is not required in all stable patients. With additional numbers and time, it has become clear that we can safely adopt this algorithm. My next post will flesh out the details.

Reference: Evaluation of multidetector computed tomography for
penetrating neck injury: A prospective multicenter study. J Trauma 72(3):576-584, 2012.

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Abdomen, Technique, Video

Video: Minimally Invasive Repair Of Rectal Injuries

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Extraperitoneal rectal injury repair has evolved considerably over the past 40 years. Way back when, this injury automatically triggered exploration, diverting colostomy with washout of the distal colon, and presacral drain insertion (remember those?).

We eventually backed off on the presacral drains (pun intended), which didn’t make a lot of sense anyway. And we gave up on dissecting down deep into the pelvis to approach the injury. This only served to contaminate an otherwise pristine peritoneal cavity. Ditto for the distal rectal washout. So we have been performing a diverting colostomy as the primary method of treatment for years.

A Brief Report in the British Medical Journal Open shows us what may very well be the next stage in treating these injuries. Whereas they were previously left to heal on their own followed by colostomy closure after a few months, these authors from Sunnybrook Health Sciences Centre in Toronto are promoting a minimally invasive approach to definitive management.

They detail two cases, one an impalement by a steel rod through the rectum and bladder, and one stab to the buttock. The authors dealt with the non-rectal injuries using conventional techniques. The rectal injuries were repaired using trans-anal minimally invasive surgery (TAMIS). Both were discharged without complications.

Here is a video of the technique used in the stab victim (no audio):

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Bottom line: It’s about time! As long as there is not a destructive injury to the extraperitoneal rectum, this seems like a great technique to try. It may very well eliminate the need for a diverting colostomy.

But remember, this is only a case report. We don’t know about antibiotic duration, followup imaging, longer term complications, or anything really. A larger series of cases is warranted to provide these answers. This will take some time due to the low frequency of this injury. So if you try it, build your own series and publish it so we all can learn!

Reference: Minimally invasive approach to low-velocity penetrating extraperitoneal rectal trauma. Trauma Surg Acute Care Open. 2020 May 12;5(1):e000396. doi: 10.1136/tsaco-2019-000396. PMID: 32426526; PMCID: PMC7228675.

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Technique, Video

By Request: Submental Intubation – The Video!

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In my last post, I dusted off an old post that described a novel technique for providing a secure yet short-term airway tailored to patients who can’t have a tube in their mouth or nose. Patients undergoing multiple facial fracture repair are probably the best candidates for this procedure.

A picture may be worth a thousand words, but a video is even better. Please note that it is explicit and shows the blow by blow surgical procedure. Of note, it is a quick and relatively simple advanced airway technique. Note the cool music!

YouTube player

Related post:

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Technique

By Request Again!: Submental Intubation

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I keep getting requests regarding this technique, so I’m reposting  this updated article today, and a video of the technique next week.

Here’s one of the weirder procedures I’ve seen in some time. Imagine that you need a definitive airway, but you can’t use the face for some reason (mouth or nose). The usual choice would be a tracheostomy, right? But what if you only need it for a few days? Typically, once placed, trachs must be kept for a few weeks before decannulation is safe.

Enter submental intubation. This technique involves passing an endotracheal tube through the anterior floor of the mouth, and then down the airway. This leaves the facial bones, mandible, and skull base untouched.

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The technique is straightforward:

  • After initially intubating the patient  orotracheally, a 1.5cm incision is created just off the midline in the submental area under the chin.
  • Using a hemostat, all layers are penetrated, entering the oropharynx just lateral to the tongue.
  • A 1.5cm incision is then made at the puncture site, parallel to the gum line of the lower teeth.
  • The ET tube is removed from the ventilator circuit, and the connector at the proximal end of the tube is removed.
  • The hemostat is placed through the chin incision again. The proximal end of the ET tube is curled into the oropharynx and grasped with the hemostat, then pulled out through the skin under the chin, leaving the distal (balloon) end in the trachea.
  • The connector is reinserted, and the tube is then hooked up to the anesthesia circuit again.
  • The tube is then secured using a stitch under the chin.

After a final position check, the surgical procedure can commence. Cool!

 

There are a number of variations on this technique, so you may encounter slightly different descriptions. The tube can be pulled at the end of the procedure, or left for a few days to ensure safe extubation, if needed.

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A small series of 10 patients undergoing this technique was reviewed, and there were no short or long term problems. Scarring under the chin was acceptable, and was probably less noticeable than a trach scar.

Bottom line: This is a unique and creative method for intubating patients with very short-term airway needs while their facial fractures are being fixed. Brilliant idea!

Tomorrow: Submental intubation – the video!

Reference: Submental intubation in patients with panfacial fractures: a prospective study. Indian J Anaesth 55(3):299-304, 2011.

Photo source: internet

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Technique

Chest Tube Repositioning – Final Answer

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So you’re faced with a chest tube that “someone else” inserted, and the followup chest xray shows that the last drain hole is outside the chest. What to do?

Well, as I mentioned, there is very little written on this topic, just dogma. So here are some practical tips on avoiding or fixing this problem:

  • Don’t let it happen to you! When inserting the tube, make sure that it’s done right! I don’t recommend making large skin incisions just to inspect your work. Most tubes can be inserted through a 2cm incision, but you can’t see into the depths of the wound. There are two tricks:
    • In adults with a reasonable BMI, the last hole is in when the tube markings show 12cm (bigger people need bigger numbers, though)
    • After insertion, get into the habit of running a finger down the radiopaque stripe on the tube all the way to the chest wall. If you don’t feel a hole (which is punched through the stripe), this will confirm that the it is inside, and that the tube actually goes into the chest. You may laugh, but I’ve seen them placed under the scapula. This even looks normal on chest xray!
  • Patients with a high BMI may not need anything done. The soft tissue will probably keep the hole occluded. If there is no air leak, just watch it.
  • If the tube was just put in and the wound has just been prepped and dressed, and the hole is barely outside the rib line, you might consider repositioning it a centimeter or two. Infection is a real concern, so if in doubt, go to the next step.
  • Replace the tube, using a new site. Yes, it’s a nuisance and requires more anesthetic and possibly sedation, but it’s better than treating an empyema in a few days.
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