Brought to by: Priya Ghelani and Maninder Singh
Trauma Rounds (Dr. Bassi, Dr. Katz, et. al)
- Antibiotics for chest tubes (Ancef or Vanc/Clinda if PCN allergy) –
- The evidence is still debatable but for traumatic chest tubes, should give it.
- Most important way to avoid future empyema is still sterile technique
- Hemothorax
- Remember 400-500 mL of blood is required to blunt the costophrenic angle on CXR
- Indications for surgical exploration:
- Chest tube output >1500 mL/24h or
- 150-200 mL/hour for 2-4 hours,
- Persistent blood transfusion required to maintain hemodynamic stability,
- Persistent hemothorax despite tube thoracostomy.
- Chest tubes- Bigger is not always better(but need at least a 28 French)
- TXA has proven mortality benefit in first three hours, may do more harm than good after 3 hours. General rule of thumb- if activating massive transfusion protocol, give it ASAP.
- Jumper injuries – expect spine injuries (thoracolumbar junction most common area of injury), pelvic injuries, bilateral limbs (including calcaneal/ankle injuries), and chest injuries.
- Head injuries are generally fatal.
- LD50 (50% die) if head/chest injury is 11m or 36 ft (3.3 stories);
- LD50 without head or chest injury is 22m or 72 feet (6.6 stories)
- Rate of miss of pelvic fractures on plain films can range between 4-23%
- 3 broad categories:
- lateral compression injuries (most common post “T-bone” MVC)
- anteroposterior compression injuries (most severe: open book)
- vertical shear injuries (most common MVC when force pushes femur up)
- For pelvic ring fracture, pelvic binders help with unstable fractures (including vertical shear and open book fractures) but may exacerbate other types of unstable fractures
- The binder should be placed over the greater trochanters, NOT over the iliac crests
- For a demonstration on how to place a T-Pod: https://www.youtube.com/watch?v=8dCntKAExBk
- The vast majority of pelvic bleeds are venous
- Blush on CT can go to angio suite/IR for embolization (arterial bleed),
- If delay with IR, discuss preperitoneal packing with surgery in OR to help tamponade bleeding
- In the future: this could be an indication for REBOA: https://lifeinthefastlane.com/ccc/resuscitative-endovascular-balloon-occlusion-aorta-reboa/
- 3 broad categories:
- Trend lactate (via I-STAT, not sent to lab), ETCO2 for patients you are concerned about occult shock
- If you suspect the patient has a subclavian vein injury (GSW/stab wound to upper chest), your 16g IV on that side may not be effective
REACT-2 Debate (Dr. Jones vs Dr. Stone)
- 46% in the selective imaging group ended up undergoing total-body imaging anyways…
- Those who undergo pan-scan far more likely to have clinically insignificant injuries detected
- Study helps validate current tools we use: NEXUS C-spine, Canadian CTH rules
- Pan-scanning significantly increases resource utilization (ex: sick patient who cannot get their CTs because of trauma pan scans)
- The goal for pan-scanned patients should be to discharge if a negative study and clinically stable. Exceptions: Issues with patient safety (e.g. gang violence), poor neurology f/u for severe concussions, high pre-test probability
EBM: HEART Score (Dr. Salama)
- Risk of MACE: low score 0.9-1.7%, moderate score 12-16.6%, high score 50-65%
- Want to get your patient the cardiac tests they need? Remember CCTA sensitivity is significantly higher than stress test (96% vs 70%)
Wellen’s syndrome (Dr. Offenbacher and Dr. Khankel)
- This is a syndrome revealing occlusion and reperfusion of the mid-LAD.
- High risk for anterior wall MI (DO NOT STRESS TEST THEM)
- Stress testing these patients may push them into a life-threatening arrhythmia
- Urgent (not emergent) cath, anticoagulation, disposition to CCU given risk for arrythmias.
- Type A (biphasic T waves)
- Type B (deep, symmetric T wave inversions) of the anterior leads. Examples here.
Further Discussion
- Sensing Issues
- Undersensing: pacemaker fails to sense native cardiac activity
- Result: asynchronous pacing
- Oversensing: electrical signal inappropriately recognized as activity
- Result: pacing is inhibited
- Magnet
- Placing a magnet over a pacemaker:
- Reprograms into asynchronous pacing mode (pacing at a fixed rate)
- Placing a magnet over ICD:
- Inhibits defibrillation
- Placing a magnet over a pacemaker:
- Undersensing: pacemaker fails to sense native cardiac activity
- Check out Siuf’s post on LBBB