What The Heck? Video!
Here’s a very interesting one. This is 2 minute video of a bronchoscopy performed on a patient who was involved in a head-on car crash.
What’s the diagnosis? And be exact, there are many possibilities here. Comment or tweet your best guesses!
Related posts:
Source: Personal archive. Not treated at Regions Hospital.
The standard of care in vascular access in trauma patients is the intravenous route. Unfortunately, not all patients have veins that can be quickly accessed by prehospital providers. Introduction of the intraosseous device (IO) has made vascular access in the field much more achievable. And it appears that most fluids and medications can be administered via this route. But what about iodinated contrast agents via IO for CT scanning?
Physicians at Henry Ford Hospital in Detroit published a case report on the use of this route for contrast administration. They treated a pedestrian struck by a car with a lack of IV access sites by IO insertion in the proximal humerus, which took about 30 seconds. They then intubated using rapid sequence induction, with drugs injected through the IO device. They performed full CT scanning using contrast injected through the site using a power injector. Images were excellent, and ultimately the patient received an internal jugular catheter using ultrasound. The IO line was then discontinued.
This paper suggests that the IO line can be used as access for injection of CT contrast if no IV sites are available. Although it is a single human case, a fair amount of studies have been done on animals (goats?). The animal studies show that power injection works adequately with excellent flow rates.
The authors prefer using an IO placement site in the proximal humerus. This does seem to cause a bit more pain, and takes a little practice see the video above). A small xylocaine flush can be administered to reduce injection discomfort in awake patients. Additionally, the arm cannot be raised over the head for the torso portion of the scan.
Bottom line: CT contrast can be injected into an intraosseous line (IO) with excellent imaging results. Insert the IO in a site that you are comfortable with. I do not recommend power injection at this time. Although the marrow cavity can support it, the connecting tubing may not. Have your radiologist hand-inject and time the scan accordingly.
Note: long term effects of iodinated contrast in the bone marrow are not known. For this reason, and because of smaller marrow cavities, this technique is not suitable for pediatric patients.
Related post: Air embolism from an intraosseous line
Reference: Intraosseous injection of iodinated computed tomography contrast agent in an adult blunt trauma patient. Annals Emerg Med 57(4):382-386, 2011.
Lateral Canthotomy For Orbital Compartment Syndrome
I’ve previously written about the orbital compartment syndrome and described the symptoms in the awake patient. I’d like to share a video of the procedure and provide a tip for diagnosing it in unconscious patients.
Patients at risk will have obvious facial trauma. During your physical exam, look for proptosis. This is caused by swelling or hemorrhage behind the globe pushing it forward. It may manifest itself as uneven opening of the eyelids, with the affected side being “propped” open (get it?). But in trauma, there may be significant edema which keeps the lid closed.
The easiest way to observe proptosis is to stand above the patients head, looking toward their feet. Crouch down so you can look across the lids in a direction horizontal to the floor. You should easily be able to detect if one eye protrudes further that the other.
You can also do a poor man’s compartment pressure test by gently using your thumbs to compress both globes simultaneously. If there is substantial difference in resistance between the two sides, a compartment syndrome may be present. Important note! Do a thorough globe exam first! If there is any evidence of globe rupture (hyphema, irregular pupil, extra tissue in the anterior compartment), don’t press the eye or perform a canthotomy. CT scan of the facial bones can help confirm the diagnosis if a mass effect is seen in the orbit or if the optic nerve appears to be on stretch.
The orbital compartment syndrome is an emergency! Once diagnosed, immediately proceed to canthotomy. Otherwise, damage to the optic nerve and retina is likely, and the patient may become blind in the affected eye.
Related post:
Intracranial Hypertension In Pediatric Head Trauma
This 44 minute video is a good introduction to pediatric head trauma and intracranial hypertension. It covers physiology, diagnosis, as well as management using medications, position, decompression and hypothermia.
Presented at Multidisciplinary Trauma Conference at Regions Hospital on May 3, 2012 by Debbie Song MD, a pediatric neurosurgeon.
Spine Clearance For Nurses
This 11 minute video provides information on the cervical spine clearance process in awake patients, reviews activity restrictions associated with the use of cervical collars, and discusses information about specific type of collars. It is designed for ED nurses and non-ED nurses who may encounter cervical spine collars.