Tag Archives: complications

Device

Air Embolism From an Intraosseous (IO) Line

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Intraosseous (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!

Abdomen, Complications

Incidental Finding: Gas In The Spleen After Embolization

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Most solid organ injury practice guidelines include angioembolization in part of the pathway. But very few require re-imaging at any point to see how the liver or spleen are coming along.

But every once in a while another condition arises, or symptoms worsen unexpectedly, causing us to get another CT scan that includes the abdomen and pelvis. And sometimes we see things that we wouldn’t normally see, like air bubbles in the organ that was embolized.

So what is okay, and what requires some kind of intervention? Our friends at ShockTrauma in Baltimore looked at this in 2001 and can provide some pretty good guidance. They reviewed patients who underwent CT scan both before and after embolization over about 2.5 years. They performed the post-embolization scans for specific indications like fevers, elevated WBC count (!), increasing abdominal pain, or an episode of hypotension. A total of 53 patients were studied.

Here are the factoids:

  • 24 patients underwent embolization of the main splenic artery, 22 had selective embolization of part of the spleen, and 7 had both
  • Splenic infarcts occurred in 63% of patients with main artery embolization, but were large (> 50% of the parenchyma) in only 20% of those
  • Infarcts occurred in 100% of selective embolizations, but were small (< 50%) in 93% of cases
  • Infarcts occurred in 71% of patients with both main and selective embolization, and most were small (80%)
  • Seven (13%) patients developed gas bubbles in the spleen, and was usually present for 1-7 days before disappearing
  • One patient developed increasing gas with pneumoperitoneum and underwent splenectomy for a splenectomy for abscess

This picture that shows tiny bubbles in the spleen parenchyma that represent “normal” gas after embolization:

And the following one shows an air/fluid collection in the spleen that indicates an abscess:

Bottom line: Tiny bubbles in the spleen (and probably the liver) occur normally after angioembolization. They usually develop within an area of infarction, and most are benign. It is possible for them to evolve into a splenic abscess, but unlikely. Many embolization patients develop fevers at some point, and most have an elevated WBC count. So in most cases, you can ignore this incidental finding, as long as your patient has mild symptoms.

However, if the patient develops high fevers, very elevated WBC (> 25K), increasing abdominal or flank pain, and the spleen develops an air/fluid level, an abscess is forming. Despite what your radiologist might suggest, catheter drainage is not a good idea. The tubes are too small to remove the slurry that is generally found within the abscess. A trip to the OR is the only effective treatment, and splenectomy is generally the only option.

Related posts:

Reference: CT Findings after Embolization for Blunt Splenic Trauma. J Vasc Intervent Radiol 12(2):209-214, 2001.

Complications, Head

EAST 2017 #8: When Is “Mild TBI” Not So Mild?

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Traumatic brain injury (TBI) is very common, with the majority falling into the “mild” category. This is usually defined as patients with injury to the head and a GCS of 13-15. These uncomplicated patients are frequently discharged from the emergency department, or undergo only a brief evaluation if admitted for other reasons.

The group at Shock Trauma focused on a less appreciated subset of mild TBI patients, those whose condition is a little more complicated. Specifically, these are patients with GCS 13-14 with positive findings on head CT leading to a calculated abbreviated injury score (head) of > 2, and some persistence of their symptoms while in the hospital. At many hospitals (including my own), these patients receive an inpatient TBI evaluation. But if they pass this initial screening, they are not consistently referred for any outpatient TBI followup.

Are these mild, complicated TBI patients (mcTBI) unique? Do they behave the same as the uncomplicated ones? The research group performed a prospective study on patients who sustained an mcTBI over a 4 month period.  They excluded patients with mental illness, dementia, and non-English speaking and homeless patients. They tried to contact patients up to three times after discharge to administer several standard tests and determine if they had any specific residual symptoms.

Here are the factoids:

  • Of the 142 patients with mcTBI during the study period, there was substantial attrition over time, with only 25 remaining at 6 months and 10 at one year
  • 64% of patients who responded at 6 months remained symptomatic. Depression, dizziness, and a feeling of impaired health were common.
  • 80% of patients still described symptoms at one year. The same complaints were most common, and some required changes in activities of daily living or assistive devices.

Bottom line: Although small and fraught with the usual problems in long-term tracking of urban trauma patients, this study is eye-opening. We too often dismiss “mild TBI” and being almost nothing, even in patients with positive findings on head CT. This work suggests that we are underestimating the needs of those patients. The authors used this data to design longer-term care processes for this subset of patients. Other centers should follow suit to make sure these patients’ post-injury needs are better met.

Questions and comments for the authors/presenters:

  • Describe the possible biases that patient selection and attrition may have had on the study
  • What type of TBI screening do you use in the hospital?
  • Given that a number of assessments were administered over the phone, I look forward to hearing some of the other details not listed in the abstract
  • Was there any correlation between specific CT findings and later symptoms?
  • Provide details of your long-term care programs for these patients
  • I enjoyed this thought provoking abstract!

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: Mild TBI is not ‘mild’… survivors tell their complicated stories. Quick Shot #3, EAST 2017.

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!

General

Complications of Splenic Embolization for Trauma

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Angioembolization has become a common procedure that can increase the likelihood of success for nonoperative management for splenic trauma. It does have its own set of complications to be aware of, however.

The most obvious complication is mechanical injury to the femoral artery. This occurs in 1 to 3% of patients. It is more common in the very young (small caliber artery) and the elderly (arteries of stone). Rarely, the substance or device that is used for the embolization may migrate or end up on the wrong spot, infarcting something important.

A common issue that occurs is infarction of portions of the spleen. This is actually the desired effect, as it stops the bleeding. Most of the time, we are unaware of the changes that take place in the spleen post-procedure. But every once in a while we get a repeat CT scan days or weeks down the road and see some very interesting things.

The most common finding is a splenic infarct alone. This is an area of the spleen, sometimes wedge shaped, that does not take up contrast. This is normal. In some cases, gas bubbles are seen within the spleen parenchyma, usually within the infarcted area. In others, large areas of gas are present, and an air-fluid level may also be seen. This is definitely not normal.

Note the infarcted area at the arrow, with a tiny gas bubble visible.

Tiny bubbles are normal after this procedure, and can be ignored if the patient does not appear ill and does not have any systemic evidence of inflammation or sepsis. On the other hand, big bubbles or air-fluid levels probably indicate a developing splenic abscess, and the patient will usually appear ill and have a high WBC count. Unfortunately, the only treatment for this is splenectomy. Insertion of drainage catheters does not work and the patient will only become sicker if it is attempted.