This issue continues to rear its ugly head, so I continue to repost from time to time.
This tip is for all trauma professionals: prehospital, doctors, nurses, etc. Anyone who touches a trauma patient. You’ve probably seen this phenomenon in action. A patient sustains a very disfiguring injury. It could be a mangled extremity, a shotgun blast to the torso, or some really severe facial trauma. People cluster around the injured part and say “Dang! That looks really bad!”
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.
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!
Nurses have a complementary role with physicians in caring for children with orthopedic injuries. Typically, the child will have been evaluated and had some sort of fracture management implemented. In children, nursing management is easer than in adults since a child is less likely to need an invasive surgical procedure. Many fractures can be dealt with using casts and splints alone.
Here are a few tips for providing the best care for your pediatric patients:
Ensure adequate splinting / casting. You will have an opportunity to see the child at their usual level of activity. If it appears likely that their activity may defeat the purpose of the cast or splint, inform the surgeon or extender so they can apply a better one.
Focus on pain control. Nothing aggravates parents more than seeing their child in pain! Make sure acetominophen or ibuprofen is available prn if pain is very mild, or scheduled if more significant. Ensure that mild narcotics are available if pain levels are higher. Remember, stool softeners are mandatory if narcotics are given.
Monitor compartments frequently. If a cast is used, check the distal part of the extremity for pain, unwillingness to move, numbness or swelling. If any are present, call the physician or extender and expect prompt attention to the problem.
Always think about the possibility of abuse. Fractures are rarely seen in children under 3, and almost never if less than 1 year old. If you have concerns about the physical findings or parent interactions, let the physician and social workers know immediately.
A lot of people have been viewing and requesting this post recently.
Here’s a neat trick for finding hard to see rib fractures on standard chest xrays.
First, this is not for use with CT scans. Although chest CT is the “gold standard” for finding every possible rib fracture present, it should never be used for this. Rib fractures are generally diagnosed clinically, and they are managed clinically. There is little difference in the management principles of 1 vs 7 rib fractures. Pain management and pulmonary toilet are the mainstays, and having an exact count doesn’t matter. That’s why we don’t get rib detail xrays any more. We really don’t care. Would you deny these treatments in someone with focal chest wall pain and tenderness with no fractures seen on imaging studies? No. It’s still a fracture, even if you can’t see it.
So most rib fractures are identified using plain old chest xray. Sometimes they are obvious, as in the image of a flail chest below.
But sometimes, there are only a few and they are hard to distinguish, especially if the are located laterally. Have a look at this image:
There are rib fractures on the left side side on the posterolateral aspects of the 4th and 5th ribs. Unfortunately, these can get lost with all the other ribs, scapula, lung markings, etc.
Here’s the trick.Our eyes follow arches (think McDonald’s) better than all these crazy lines and curves on the standard chest xray. So tip the xray on its side and make those curves into nice arches, then let your eyes follow them naturally:
Much more obvious! In the old days, we could just manually flip the film to either side. Now you have to use the rotate buttons to properly position the digital image.
Final exam: click here to view a large digital image of a nearly normal chest xray. There is one subtle rib fracture. See if you can pick it out with this trick. You’ll have to save it so you can manipulate it with your own jpg viewer.
Here’s an operative tip for trauma professionals who find themselves in the OR. Heard of “lunchothorax?” I’m sure most of you haven’t. The term originated in a 1993 paper on the history of thoracoscopic surgery. It really hasn’t been written about in the context of trauma surgery, though.
Lunchothorax is an empyema caused by pleural contamination in patients with concomitant diaphragm and hollow viscus injury. This most commonly occurs with penetrating injuries to the left upper quadrant and/or left lower back. The two penetrations tend to be in close proximity (diaphragm + stomach), but may occasionally be further away (diaphragm + colon).
One of the earlier papers describing the correlation of gastric injury and empyema was written by one of my mentors, John Weigelt. Although gastric repair is usually simple and heals well, his group did note a few severe complications. Of 243 patients with this injury, 15 developed ones that were considered severe, and 10 of those were empyema! What gives?
It turns out that the combination of gastric contents and pleural space is not a good one. It’s not really clear why this is. Is it bacterial? The acid? Undigested food? I’ve seen cases with what I would consider minimal contamination go on to develop a nasty empyema. This is also borne out in a National Trauma Databank review from 2009. It looked at complications in patients with a diaphragm injury and found that a gastric injury increased the probability of empyema by 3x. Interestingly, there was no increased risk of empyema with a concomitant colon injury.
Bottom line: Lunchothorax, or empyema after even minimal contamination from a hollow viscus, is a dreaded complication of thoraco-abdominal penetrating injury. Any time the stomach and diaphragm are violated, I recommend thoroughly irrigating the chest. It’s probably a good idea for concomitant colon injury as well, but there’s less literature support.
This can be done through the diaphragm injury if it is large enough, or through a chest tube inserted separately. Most of the time, you’ll be placing the chest tube anyway because the pleural space has been violated via the abdomen. In either case, copious lavage with saline is recommended to clear all particulate material, with a few extra liters just for good measure. There’s no data on use of antibiotics, but standard perioperative coverage for the abdominal injuries should be sufficient if the lavage was properly performed.
The history of thoracoscopic surgery. Ann Thoracic Surg 56(3):610-614, 1993.
Penetrating injuries to the stomach. SGO 172(4):298-302, 1991.
Risk factors for empyema after diaphragmatic injury: results of a National Trauma Databank analysis. J Trauma 66(6):1672-1676, 2009.
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