Bleeding from scalp wounds may seem like a trivial problem, but I have personally seen someone die from unrecognized hemorrhage over time from one. All too often, these are covered up with a crude dressing when the patient arrives in the ED and is not looked at for some time.
Here are some tips to stop scalp bleeding:
Use direct pressure. This seems obvious but is frequently done incorrectly. Direct pressure involves a small diameter piece of gauze (stack of 2x2s or double folded 4×4) and only one or two fingers. Larger dressings or the palm of the hand do not provide enough pressure to stop all the bleeding. Direct pressure for 5 minutes (no peeking) will stop all bleeding that doesn’t need more advanced techniques.
Inject local anesthetic with epinephrine. This increases vasoconstriction and helps the direct pressure work even better. Be cautious if there is a large skin flap that does not have a nice pink color. Degloved skin has been crushed and small vessel vascular injury has occurred. Further reducing blood flow with epinephrine may kill the skin flap in this type of injury.
Apply Raney clips. Neurosurgeons use these to stop scalp bleeding during brain procedures. Caution! Only apply to unconscious patients, and only to the scalp (not face)! These hurt!
Oversew the scalp. Use a large silk or nylon suture and insert a large running stitch to close the wound. This will stop all bleeding from the skin edges. However, any arterial bleeders underneath will continue to be a problem.
Ligate individual bleeders. Use a small absorbable suture and attack each small arterial bleeder with a figure of 8 stitch. Don’t suture large chunks of tissue; make sure that you are attacking just the artery and not any adjacent nerves.
Interventional radiology (IR) can be a very helpful adjunct to the evaluation and management of trauma patients. I’m going to talk specifically about using it for blunt trauma today because the use in penetrating trauma can be a little more nuanced.
For blunt trauma, IR is used primarily to stop bleeding. In a smaller subset of patients, this tool is used to evaluate pulse deficits. There are two basic principles that apply in either case, and I’ve wrapped them up into a single concept: the 30:60 rule for interventional radiology.
Of course, the second law of trauma still applies: hypotensive patients cannot leave the ED to go anywhere but the OR. Once you make sure you are not violating that one, you can start the process of going to IR.
The two portions of the rule are times: the time for the IR team to arrive to start the evaluation, and the maximum time allowed for them to succeed, hence the 30:60 numbers.
The maximum acceptable time for the patient to wait until the IR team is ready for them is typically 30 minutes. US trauma center verification requires a reasonable arrival time frame, and the vast majority of hospitals have a 30 minute expectation if the team is not already in place. This response time needs to be monitored by the trauma performance improvement program (PI) and addressed if it ever exceeds the limit.
The second number is the maximum time the radiologist is given to be successful. Like other physicians, radiologists like to do a good job and finish the work they start. If they find a particularly tortuous splenic artery to navigate, they will persist at trying to get through it in order to do a selective embolization and kill the smallest piece of spleen possible. Unfortunately, this takes time and radiation (lots).And a bleeding patient is running out of time.
The good thing is that there are surgical alternatives to most of the tasks the radiologist is working on. True, some are much more difficult surgically, like managing a shattered liver or dealing with a bleeding pelvis. In those cases, I may let the interventionalist work a little longer while I keep up with blood transfusions and monitor patient status.
Expect a 30 minute response time from the IR team
Let the radiologist know they have about 60 minutes to succeed. If it looks like they can’t make that, have them go to plan B (e.g. main splenic artery embolization instead of selective)
Make sure an experienced trauma physician is watching the patient for decompensation and is managing fluids and blood products (no pressors!)
If the patient decompensates at any point, they are done in IR and must proceed to OR
We see seat belt signs at our trauma center with some regularity. There are plenty of papers out there that detail the injuries that occur and the need for a low threshold for surgically exploring these patients. I have not been able to find specific management guidelines, and want to share some tidbits I have learned over the years. Yes, this is based on anecdotal experience, but it’s the best we have right now.
Tips for surgeons:
Common injuries involve the terminal ileum, proximal jejunum, and sigmoid colon. My observation is that location in the car is associated with the injury location, probably because of the location of the seat belt buckle. In the US, drivers buckle on the right, and I’ve seen more terminal ileum and buckethandle injuries in this group. Front seat passengers buckle on the left, and I tend to see proximal jejunum and sigmoid injuries more often in them.
Seat belt sign on physical exam requires abdominal CT for evaluation, regardless of age. The high incidence of significant injury mandates this test.
Seat belt sign plus any anomaly on CT requires evaluation in the OR. The only exception would be a patient with minimal fluid only in the pelvis with an unremarkable abdominal exam. But I would watch them like a hawk.
In patients who cannot be examined clinically (e.g. severe TBI), a rising WBC count or lactate beginning on day 2 after adequate resuscitation should prompt a trip to the OR. This is an indirect method for detecting injured bowel or mesentery.
Laparoscopy may be used in patients with equivocal findings. Excessive blood, bile tinged fluid, succus, or lots of fibrin deposits on the bowel should prompt conversion to laparotomy. Tip: place all ports distant to the seat belt mark. The soft tissues are frequently disrupted, and gas may leak into this pocket prohibiting good insufflation of the peritoneal cavity.
If in doubt, open the abdomen. It’s bad form to put in the scope, see something odd, and walk away. Remember, any abnormal finding after trauma is related to trauma until proven otherwise. It’s almost never pre-existing disease.
Diaphragm injuries are notoriously hard to detect, and there is a significant rate of delayed or missed diagnosis. Today I’ll offer a few practical tips on finding and managing this rare injury.
Mechanism is important. Penetrating injury is more common, and it can be really tough to diagnose this injury in stabs to the lower chest. Anything below the nipples is suspect. Blunt injury requires substantial force. This is seen in deceleration injuries, usually with a crush component to the abdomen. Ejection and partial ejection is common.
Left sided injury is much more common than right. The liver probably diffuses the force more evenly, protecting the right diaphragm. Be very skeptical if a radiologist tries to tell you the patient has a right diaphragm injury.
Patients have significant symptoms with blunt injury. Respiratory distress is common on the left, and deep visceral pain on the right if the liver partially herniates into the chest. Serious associated injuries are common due to the high energy involved.
Diagnosis is difficult. CT is a very good, but imperfect, tool. Coronal and sagittal reconstructions can be very helpful.
If you are inclined to explore for a possible diaphragm injury in a stable patient, consider laparoscopy first. But warn the anesthesiologist! If your patient has the injury, they will rapidly develop a complete pneumothorax, so you need to be ready to quickly insert a chest tube.
Caress the diaphragm to find small holes. Place your hand in the palm up position so your fingers will drop into any defect. Be thorough, since small knife and bullet wounds are easy to miss, especially when located posteriorly.
I’ve written a lot about chest tubes, but there’s actually a lot to know. And a fair amount of misinformation as well. Here’s some info you need to be familiar with:
Chest trauma generally means there is some blood in the chest. This has some bearing on which size chest tube you choose. Never assume that there is only pneumothorax based on the chest xray. Clot will plug up small tubes.
Chest tubes for trauma only come in two sizes: big (36Fr) and bigger (40Fr). Only these large sizes have a chance in evacuating most of the clot from the pleural space. The only time you should consider a smaller tube, or a pigtail type catheter, is if you know for a fact that there is no blood in the chest. The only way to tell this is with chest CT, which you should not be getting for diagnosis of ordinary chest trauma.
When inserting the tube, you have no control of the location the tube goes once you release the instrument used to place it. Some people believe they can direct a tube anteriorly, posteriorly, or anywhere they want. They can’t, and it’s not important (see next tip).
Specific tube placement is not important, as long as it goes in the pleural space. Some believe that posterior placement is best for hemothorax, and anterior placement for pneumothorax. It doesn’t really matter because the laws of physics make sure that everything gets sucked out of the chest regardless of position except for things too big to fit in the tube (e.g. the lung).
Tunneling the tube tract over a rib is not necessary in most people. In general, we have enough fat on our chest to ensure that the tract will close up immediately when the tube is pulled. A nicely placed dressing is your insurance policy.
Adhere to an organized tube management protocol to reduce complications and the time the tube is in the chest.
And finally, amaze your friends! The French system used to size chest tubes is the diameter of the tube in millimeters times three. So a 40Fr chest tube has a diameter of 13.3mm.