Tag Archives: tips

Trauma In Pregnancy 3: Tips & Tricks

Here is a list of practical tips for trauma professionals from prehospital and beyond:

  • Apply supplemental oxygen from the get-go, in the field if possible
  • Start an IV or IO and begin crystalloid infusion immediately
  • Bump the patient to her left. This is most easily done with the spine board in place. Just put a rolled up towel under the right side of the board.
  • Quickly estimate how pregnant the patient is if she can’t tell you. Use the fundal height diagram below. Key measurements to remember:
    • Umbilicus = 20 weeks: entering the possible viability range if delivered emergently
    • Xiphoid = approaching full term

  • If the patient is 20 weeks+ pregnant, only transport to a trauma center (Level I or II).
  • At the hospital, reassess fundal height to more accurately estimate viability
  • If the fetus may be viable (23-24 weeks), call OB to the resuscitation area. But remember, they have nothing to offer until the trauma team secures the safety and stability of the mother. So don’t let them in the room until you have finished your entire evaluation.  Nothing they can do (e.g. monitor) is helpful during the acute phase of the resuscitation.
  • Once the mother is stabilized, assess fetal heart tones and apply monitors for fetal heart rate and maternal contractions.
  • Add coag studies to your lab panel. Fetal and placental injury can cause clotting problems.
  • Consider giving Rhogam in all major trauma cases if the mother is Rh negative
  • Obtain a KB test to look at the amount of fetal blood in the maternal circulation. Why do this if you are going to give Rhogam anyway? Answer: sometimes the amount of fetal blood leakage is greater than that covered by a single vial of Rhogam.
  • Plan your imaging intelligently. The next section covers this topic in more detail.
  • If needed, chest tubes should be inserted 1-2 intercostal spaces higher than usual.
  • The life-saving tetanus shot is safe in pregnant patients.


How To See The Unseeable: The Answer

Yesterday I posed a scenario where the surgeon needed to see an area of an open abdomen (trauma laparotomy) that could not easily be visualized. Specifically, there was a question as to whether the diaphragm had been violated just anterior to the liver, just under the costal margin.

Short of putting your head in the wound, how can you visualize this area? Or some other hard to reach spot? Well, you could have an assistant insert a retractor and pull like crazy. However, the rib cage might not bend very well, and in elderly patients it may break. Not a good idea.

Some readers suggested breaking out the laparoscopy equipment and using the camera and optics to visualize. This is a reasonable idea, but expensive. Shouldn’t there be some good (and cheap) way to do this?

Of course, and there is. Think low tech. Very low tech. You just need to see around a corner, right. So get a mirror!

Every OR has some sterile dental mirrors lying around. Get one and have your assistant gently hold the liver down while you indirectly examine the diaphragm. Since you’re probably not a dentist, it may take a minute or two to get used to manipulating the mirror to see just what you want. But if you can manage laparoscopic surgery, you’ll get the hang of it quickly.

And if you need more light up in those nooks and crannies? Shine the OR light directly into the abdomen, then place a nice shiny malleable retractor into the area to reflect light into the area in questions. Voila!

Bottom line: A lot of the things that trauma professionals need to do in the heat of the moment will not be found in doctor, nurse, or paramedic books. Be creative. Look at the stuff around you and available to you. Figure out a way to make it work, and make $#!+ up if necessary.

Trauma Surgery Tip: How To See The Unseeable

Let me present a scenario and first see how you might solve this problem.

A young man presents with a gunshot to the abdomen in the right mid-back. He is hemodynamically stable, and you get a chest xray. It shows a small caliber slug in the right upper quadrant, but no hemo- or pneumothorax. He has peritoneal signs, so you whisk him off to the OR for a laparotomy.

As you prep the patient for the case, you can feel a small mass just above the right costal margin. You incise the area and produce a 22 caliber bullet. Of course, you follow the chain of evidence rules and pass it off for the police. As you explore the abdomen, it appears that there are no gross injuries. You are concerned, however, that there may be an injury to the diaphragm in proximity to the bullet.

So here’s the question: how can you visualize the diaphragm in this area? The bullet was located below the right nipple. But the diaphragm in this area is covered by the liver, and is parallel to the floor. You can’t seem to feel a hole with your fat finger. But short of putting your whole head in the wound, you just can’t get a good angle to see the area in question.

How would you do it? Please tweet or leave comments with your suggestions. I’ll provide the answer(s) Monday!

Nursing Tips for Managing Pediatric Orthopedic Trauma

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.