Category Archives: Tips

Tips

Management Of Penetrating Neck Trauma: The Way We Were/Are

Leave a comment

The management of penetrating injuries to the neck has changed very little over the years. Could it be time? Today, I’ll review some of the basics of classic diagnosis and treatment. In my next post, I’ll discuss an alternative way to approach it.

First, lets look at the time-honored zones of the neck. Here’s a nice diagram from EMDocs.net:

The zones are numbered in reverse, from bottom to top, and in Roman numerals.

The area below the cricoid cartilage is considered Zone I and contains many large vascular and aerodigestive structures that are relatively difficult to approach surgically. For this reason, diagnostic testing is recommended to assist in determining if an operation is actually needed and what the best surgical exposure would be. Obviously, this can only be considered in the stable patient. Unstable patients must go straight to the OR and the trauma surgeon will determine the surgical approach on the fly.

Similarly, the area above the angle of the mandible is Zone III, and is also difficult to expose. Injuries to this area may involve the distal carotid and vertebral arteries near the base of the skull, as well as the distal jugular vein. Surgical approach may require dislocation of or fracturing the mandible to get at this area. This is  challenging and not that desirable, and few surgeons are familiar with the technique. For this reason, imaging is very desirable and often demonstrates that no significant injury is present. And endovascular / angiographic techniques are now available that may obviate the need for surgery.

Zone II is everything in-between the mandibular angle and cricoid cartilage. This is the surgical Easy Button. Exposure is simple and the operation is fun. In the old days, an injury to this area went straight to the OR regardless of whether there were signs or symptoms of injury. Yes, there were quite a few negative explorations. But we’ve become more selective now with the advent of improved resolution of our CT scans.

Currently, we usually follow a two-step approach to penetrating neck trauma:

  1. Are there hard signs of injury present? These tell us that a structure that absolutely needs to be fixed has been injured. The patient should be taken directly to OR after control of the airway, if appropriate. Typical hard signs are:
    1. Airway compromise
    2. Active air bubbling from wound
    3. Expanding or pulsatile hematoma
    4. Active bleeding
    5. Hematemesis
  2. What zone is the injury in? And don’t just look at the obvious entry point. Gunshots (and long knives) may enter multiple zones. The zone then determines what happens next:
    1. Zone I – CT angio of neck and chest. If positive, proceed to OR for repairs, and perform EGD and/or bronchoscopy as needed
    2. Zone II – Old days: proceed to operating room for exploration, or angiogram, EGD, direct laryngoscopy, and bronchoscopy. Most chief residents chose the former. Current day: CTA of neck, followed by OR, EGD, bronchoscopy only if indicated.
    3. Zone III – CT angio of the neck. If positive, consider angiography/endovascular consultation vs operation.

Changes from old days to more current thinking have been made possible by improvements in speed and resolution of our CT scanners. But why can’t we take this another step forward and streamline this process even more? I’ll propose some changes in my next post!

Reference: Western Trauma Association Critical Decisions in Trauma:
Penetrating neck trauma. J Trauma 75(6):936-940, 2013.

Print Friendly, PDF & Email
Tips

Whaaat? Stuff You Sterilize Other Stuff With May Not Be Sterile??

Leave a comment

When one works in the trauma field, or medicine in general, we deal with the need for sterility all the time. We use equipment and devices that are sterile, and we administer drugs and fluids that are sterile. In surgery, we create sterile fields in which to use this sterile stuff.

In the past few years, we’ve come to the realization that the sterility we take for granted may not always be the case. There have been several cases of contaminated implanted hardware. And a few years ago, supposedly sterile injectable steroids were found to be contaminated with fungus, leading to several fatal cases of meningitis.

An article in the New England Journal of Medicine brings a bizarre problem to light: microbial stowaways in the topical products we use to sterilize things. Most drugs and infused fluids are prepared under sterile conditions. However, due to the antimicrobial activity of topical antiseptics, there is no requirement in the US that they be prepared in this way.

A number of cases of contamination have been reported over the years:

  • Iodophor – contamination with Burkholderia and Pseudomonas occurred during manufacture, leading to dialysis catheter infection and peritonitis
  • Chlorhexidine – contaminated with Serratia, Burkholderia and Ralstonia by end users, leading to wound infections, catheter infections, and death
  • Benzalkonium chloride – contaminated with Burkholderia and Mycobacteria by end users, causing septic arthritis and injection site infections

Bottom line: Nothing is sacred! This problem is scarier than you think, because our most basic assumptions about these products makes it nearly impossible for us to consider them when tracking down infection sources. Furthermore, they are so uncommon that they frequently may go undetected. The one telltale sign is the presence of infection from weird bacteria. If you encounter these bugs, consider this uncommon cause. Regulatory agencies need to get on this and mandate better manufacturing practices for topical antiseptics.

Reference: Microbial stowaways in topical antiseptic products. NEJM 367:2170-2173, Dec 6 2012.

Print Friendly, PDF & Email
Tips

How To Remove A Tourniquet

Leave a comment

Tourniquets had been banished for several decades due to the misconception that they caused more harm than good. But thanks to the experience of the US military, they have made a resurgence again in civilian use. If handled properly, they can literally be a life-saver.

More and more often, our prehospital trauma professionals are applying a tourniquet in the field. The question once they arrive in your trauma bay is “now what?”

Well, obviously it’s got to come off. But there is a lot of nuance around how to do that. And I don’t just mean the technical aspects of releasing it. It’s important to understand what injuries your patient has, and what the capabilities of your trauma center are first. Here is a framework to help you think through the details.

  1. How long has the tourniquet been up? Hopefully that has been recorded somewhere, or written on the tourniquet. If you don’t know exactly, assume that medics applied it upon arrival at the scene.
    1. If < 90 minutes and you have surgical support available, call the surgeon! If they believe the patient needs to be in the OR right away, make it happen.
    2. If < 90 minutes and you do not have surgical support, transfer your patient ASAP to a center that has it. If the transfer will take more than 2 hours (due to distance / weather and not a slow transfer on your part, consider dropping the tourniquet as described below.
    3. If > 120 minutes regardless of transfer status, consider dropping the tourniquet as described below.
  2. Is there a contraindication to removal?
    1. Traumatic amputation with the tourniquet nicely placed just proximal to an amputation stump. It may slip off after releasing the tension.
    2. Decompensated shock or near arrest. The patient is trying to die and the tourniquet is helping to prevent them from doing just that.
    3. Inability to closely monitor for rebleeding. If the patient needs to be transported in a relatively unsupervised setting, new bleeding may not be treatable.

If there are no contraindications and there is a need to at least temporarily release the tourniquet, then prepare your area appropriately.  Ideally, this should be done in an OR or ICU, but that is not always practical. Otherwise, make your trauma bay look like one. Make sure you have at least one new tourniquet in case the old one can’t be reapplied for some reason. Ensure there is plenty of hemostatic gauze and dressing materials. Have the crash cart nearby and make the ACLS drugs readily available, just in case.

Then release the tension on the tourniquet and note the time. Three things can happen:

  1. There is no bleeding. This happens about 80% of the time in my experience. Either there was no surgical bleeding in the first place, or it has clotted. Place a nice dressing that can be monitored easily.
  2. There is only “non-surgical” bleeding. This is typically oozing or pesky venous bleeding. These should be controlled with sutures or hemostatic dressings. Pressure dressings are also wonderful in the situation. Craft them carefully.
  3. Life threatening bleeding resumes. Reapply the tourniquet and get the patient to definitive care ASAP (OR or another center that has one).

Bottom line: There is very little magic to dealing with tourniquets on the receiving end. But get a very clear picture of what your patient needs and what your center has to offer them. If these factors don’t match up, initiate the transfer as fast as you possibly can. Otherwise move to your OR to fix the problem!

Reference: Removal of the Prehospital Tourniquet in the Emergency Department. J Emerg Med 60(1):98-102, 2020.

Print Friendly, PDF & Email
Tips

The Ultimate Distracting Injury?

Leave a comment

By now, we are all very familiar with the concept of the distracting injury. Some of our patients sustain injuries that are so painful that they mask the presence of others. The patient is so distracted by the big one that others just slip their notice.

This concept has been notoriously difficult to test, but there is a reasonable amount of data that suggests it is true. One of the more common and disturbing injury patterns occurs when there is a significant amount of chest wall trauma. When there are fractures focused around the upper chest, cervical spine injuries may be masked, then missed during the exam by trauma professionals.

I’d like to introduce a new concept: the ultimate distracting injury. This goes beyond an injury distracting the patient from another painful problem.

The ultimate distracting injury is one that is so gruesome that it distracts the entire trauma team! It could actually be so distracting that the team might miss multiple injuries!

It’s just human nature. We are drawn to extremes, and that goes for trauma care as well. And it doesn’t matter what your level of training or expertise, we are all susceptible to it. The problem is that we get so engrossed (!) in the disfiguring injury that we ignore the fact that the patient is turning blue. Or bleeding to death from a small puncture wound somewhere else. We forget to focus on the other life threatening things that may be going on.

What are some common ultimate distracting injuries?

  • Mangled extremity
  • Traumatic amputation
  • Impalement
  • Severe soft tissue injury

How do we avoid this common pitfall? It takes a little forethought and mental preparation. Here’s what to do:

  • If you know in advance that one of these injuries is present, prepare your crew or team. Tell them what to expect so they can guard against this phenomenon.
  • Quickly assess to see if it is life threatening. If it bleeds or sucks, it needs immediate attention. Take care of it immediately.
  • If it’s not life threatening, cover it up and focus on the usual priorities (a la ATLS, for example).
  • When it’s time to address the injury in the usual order of things, uncover, assess and treat.

Don’t get caught off guard! Just being aware of this common pitfall can save you and your patient!

Print Friendly, PDF & Email
Head, Tips

Antihypertensive Treatment In Acute TBI

Leave a comment

Yes, we know high blood pressure can be bad. Over the long term, it can accelerate atherosclerotic heart disease and pound away at the kidneys and brain. And when it is acutely elevated to critical levels, it can lead to stroke.

But is it always bad in trauma? Trauma hurts like hell, so it’s no wonder than many of our patients (not suffering blood loss of course) are hypertensive.  But how often have you seen this scenario occur:

An elderly patient fell from standing, striking her head. She is brought to your ED by ground EMS. She has a GCS of 8 (E1 V3 M4) with a BP of 200/130 and pulse of 56.  This meets your trauma activation criteria and the team assembles to meet the patient.

As you move her onto the bed, one of your colleagues calls out for some nicardipine to control the pressure. Is this a wise move? Remember the First Law of Trauma:

Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

What else can cause hypertension and bradycardia in your trauma patient? In this case, certainly a subdural or epidural hematoma.

And why is that happening? Because the intracranial pressure is elevated from the space-occupying lesion. Remember the formula for cerebral perfusion pressure (CPP):

CPP = MAP – ICP

Where MAP = mean arterial pressure and ICP = intracranial pressure.  Normally the MAP is around 90 torr and ICP is about 10 torr. Thus, the normal CPP is approximately 80. The range is 60  to well over 100 torr, and flow autoregulation keeps brain perfusion constant over this range.

But let’s say that we are psychic and know the ICP of our patient to be 60 because of a large subdural hematoma. Her current CPP is 150 – 60 or about 90 torr. What happens if we start her on a nicardipine drip or some other antihypertensive medication? We can certainly normalize the blood pressure to 120/80. But now her CPP drops to 90  – 60 = 30 torr!

Congratulations, you have just shut down circulation to her brain!

Bottom line: Think first before calling for antihypertensive medications in patients who may have increased intracranial pressure. You may be sabotaging the only mechanism protecting their brain while you are calling your neurosurgeon for help. Your top priority is to get them to the CT scanner while permitting that pressure. If it turns out that there is no evidence for pathology that would lead to increased ICP, then turn to the antihypertensive agents to help protect against stroke. 

Print Friendly, PDF & Email