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!
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.
This is an uncommon injury. But when encountered it can cause the trauma professional (and the patient) some major headaches. The majority of the vertebral artery injuries you are likely to encounter are caused by blunt trauma. They are generally diagnosed using CT angiography, and the treatment usually consists of low dose anti-platelet agents like aspirin. Occasionally, coiling or stenting using interventional radiology is needed.
But penetrating trauma is a totally different animal. Gunshot is the most common mechanism, because of the small windows available to access the artery within the vertebral canal using a knife. See the course of the artery in the picture below:
Unfortunately, this bony cage also makes it difficult to surgically approach the artery, especially if the field is continually filling with blood.
The techniques for dealing with this injury according to the doctor books are:
Send the patient to interventional radiology. Cutting off flow using coils is the preferred technique. Gelfoam and other products are not used because of the concern for distal embolization (to the brain). Stenting may be a consideration for blunt trauma, but not for penetrating.
Or, obtain proximal control by ligating the vertebral artery as it takes off from the subclavian. Hmm, this requires either a separate incision, or a supraclavicular extension of your neck incision. It takes time and is not as easy as it sounds.
Generally, the trauma surgeon stumbles upon this injury while doing a trauma neck exploration. Bleeding can be pesky, and may serve to obscure the field. My preferred method of control is:
Jam a wad of bone wax into the vertebral canal right where the bleeding is coming from.
Then jam another wad into the canal in the space below it. Proximal control!
Jam one final wad into the space above, if accessible. Distal control!
End of problem. Then do a thorough evaluation for all other injuries and address them. Feel free to share any additional tips that you may have!
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