Conference Notes 7-25-2018

Lovell     Trauma Study Guide

Perimortem cesarean delivery should be performed only when the gestational age is greater than 24 weeks.

Some find that an incision from the umbilicus to the public symphysis is large enough to accomplish fetal delivery. The uterine incision should be vertical as well.

Perimortem cesarean delivery might actually improve maternal circulation and is better performed early rather than too late. There have been reports of maternal survival after perimortem cesarean delivery, even when the mother has been in cardiac arrest. Theoretically, delivery of the fetus can help restore maternal circulation and remove pressure from the inferior vena cava.  The primary goal is improvement of maternal, not fetal, resuscitation.

The procedure is ideally performed within 4 to 5 minutes of the loss of maternal circulation. Survival of the mother and the fetus is unlikely if the procedure is performed too late and is virtually futile if performed after 20 minutes of maternal cardiac arrest.

Handlebar injury in kids and adults:  look for pancreatic injury (CT, labs)

Seatbelt sign:  look for intra-abdominal trauma, especially small bowel injury. 

CT may be normal or nonspecific in both pancreatic and small bowel injury, so if persistent pain/tenderness, observe in hospital even with negative CT.

 SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) associated with pediatrics due to hyper-flexibility of spine, and in elderly secondary to spondylosis.  Refers to spinal cord injury with negative plain xrays and/or CT.  Currently an ambiguous term, as majority of SCIWORA has abnormal MRI imaging.  Important entity that can present with transient or delayed neurologic symptoms; do careful history, exam.

 Those hypermobile kids can also tear off the renal pedicle in blunt trauma, especially MVC, so a lower threshold of hematuria is used to prompt CT imaging.  For kids, if >50 RBCs/HPF in blunt trauma and hemodynamically stable get a CT abdomen.

Harwood comment:  Handlebar injuries are also associated with duodenal hematoma.  Vertical falls are also associated with renal pedicle injuries.

Cochrane Review September 2017: Lewis SR, et al. 

Hypothermia (body temperature cooling) for people with an injury to the brain

Review question

What is the effect of mild hypothermia (body temperature cooling) following a brain injury on whether a person dies, has a poor outcome, or gets a type of severe chest infection (pneumonia)?

Background

Hypothermia has been used for many years to treat people who have had a severe brain injury. This involves cooling the head or the whole body to a temperature below normal body temperature. We aimed to assess whether people treated with hypothermia after a brain injury are less likely to die or have a poor outcome (which we defined as death, coma or severe disability) and whether using hypothermia might increase the risk of a severe chest infection called pneumonia.

Study characteristics

We included 37 studies with 3110 participants. In each trial, patients were randomly divided into two groups: one group remained at normal body temperature of 36.5 to 38 °C, and the other group was cooled to a maximum of 35 °C for at least 12 hours.

Key results

We did not combine results of these studies to assess whether hypothermia improves patient outcome. This was because the results had large differences which we could not explain. We identified some differences in the ways in which the studies were carried out and the participants that study authors had recruited, but we did not assess whether this could explain the differences in results. We did not have enough good quality evidence that was sufficiently similar to be confident that treating people who have had a severe brain injury with hypothermia will reduce the incidence of death or severe disability, or increase the incidence of pneumonia.

Quality of evidence

Many of the studies were not well reported and we were unable to assess whether differences between the quality of the studies may also have affected our results. We used the GRADE approach to judge the quality of evidence. We judged the evidence for death or severe disability to be very low quality, and the evidence for pneumonia to be low quality.

Authors' conclusions: 

Despite a large number studies, there remains no high-quality evidence that hypothermia is beneficial in the treatment of people with TBI. Further research, which is methodologically robust, is required in this field to establish the effect of hypothermia for people with TBI.

Although the appropriate length of time to observe a child with a concussion in the emergency department for worsening signs and symptoms has not been definitively established, the PECARN authors recommend a 4- to 6-hour observation period; the likelihood of missing a delayed clinically important traumatic brain injury during this time seems to be rare. Inpatient observation, unless the family is not able to observe the patient at home and follow appropriate instructions, is generally not necessary.

Harwood comment:  Rule of thumb for return to play following concussions is: 1 week out of sport for first concussion.  1 month out of sport for second concussion. 1 year out of sport for third concussion.

 

 Chance Fracture

Chance Fracture

A Chance fracture is a flexion-distraction injury, associated with MVC and flexion over a lap-belt (seatbelt).  There is complete disruption through the vertebral body and associated structures in a horizontal plane.  They are commonly misdiagnosed as compression fractures.   There is a high rate of associated intraabdominal injuries.  As the disruption is in the horizontal plane, sagittal CT images are more sensitive than axial CT for diagnosis

 

   Burst fractures    are associated with  motor vehicle crashes,   as well as falls from height.   Burst fractures are inherently unstable due to the potential for the retropulsion of bone fragments into the spinal canal secondary to disruption of the posterior column; about half of patients with this injury will have  neuro deficits.   For this reason, additional imaging should be performed if there is clinical suspicion for a burst fracture, and neurosurgery consultation is required.

Burst fractures are associated with motor vehicle crashes, as well as falls from height.  Burst fractures are inherently unstable due to the potential for the retropulsion of bone fragments into the spinal canal secondary to disruption of the posterior column; about half of patients with this injury will have neuro deficits.  For this reason, additional imaging should be performed if there is clinical suspicion for a burst fracture, and neurosurgery consultation is required.

  A “no-zone” approach to all penetrating neck trauma, with stability and presence/absence of hard findings informing the decision of CTA or surgery (hard signs indicate surgery, soft signs indicate CTA)  has gained favor compared to a zoned approach, with comparable outcomes.  Two other reasons to adopt no-zone:  injuries may  cross zones, and no-zone approach leads to fewer unnecessary neck explorations.

A “no-zone” approach to all penetrating neck trauma, with stability and presence/absence of hard findings informing the decision of CTA or surgery (hard signs indicate surgery, soft signs indicate CTA)  has gained favor compared to a zoned approach, with comparable outcomes.  Two other reasons to adopt no-zone:  injuries may  cross zones, and no-zone approach leads to fewer unnecessary neck explorations.

Lovell/Logan    Oral Boards

Case 1. 78 yo male bleeding from tracheostomy site.  Patient had tracheostomy placed within the last 2 weeks.

 Use hyperinflation of trach tube balloon initially to compress the innominate artery. If that is ineffective, use your finger to hold pressure.  Third maneuver is apply traction to the tracheostomy tube to compress the vessel.

Use hyperinflation of trach tube balloon initially to compress the innominate artery. If that is ineffective, use your finger to hold pressure.  Third maneuver is apply traction to the tracheostomy tube to compress the vessel.

Any bleeding of more than a few milliliters of blood should raise concern for a possible fistula of the innominate artery. Prompt critical resuscitation measures and emergent consultation with a Vascular Surgeon and Otolaryngologic Surgeon is required. Definitive management is surgical. Techniques for temporarily controlling bleeding from the innominate artery include local digital pressure, hyperinflation of the tracheostomy tube cuff, and traction on the tracheostomy tube. An alternative method is to deflate the tracheostomy tube cuff, reposition the cuff at the bleeding site, and then reinflate or hyperinflate the cuff. When bleeding occurs, the tracheostomy tube should not be removed until the airway is secured by another means from above (orally or nasally).

Peak incidence is 1-2 weeks after tracheostomy surgery. 75% within 4 weeks post-op. Emergently consult thoracic surgery to take the patient to OR.

Case 2. 55yo female with weakness. HR=130. Other vitals OK.  Started chemotherapy for non-hodgkins lymphoma 3 days ago.

 

 If you consider tumor lysis syndrome be sure to order phosphate and uric acid levels in addition to your usual CBC, CMP.

If you consider tumor lysis syndrome be sure to order phosphate and uric acid levels in addition to your usual CBC, CMP.

Treat tumor lysis syndrome with IV fluids, Hyperkalemia management, Rasburicase for elevated uric acid, phosphate binders, and dialysis if needed. 

Case 3. 8 month old male who won't stop crying.  Vitals all OK except for HR=110.  Patient appears fussy. Physical exam demonstrates a hair tourniquet on the toe.

 Hair Tourniquet

Hair Tourniquet

Two standard approaches to salvage the compromised digit are to either unwind the hair or thread if possible or, otherwise, make a midline longitudinal incision along the extensor surface of the toe to cut the hair or thread.42 To cut the hair, it will often be necessary to split the fibers of the extensor ligament, but avoid transecting the fibers. The multiple strands of hair or thread are then removed using fine forceps without teeth. The toe often retains the initial appearance, making the physician uncertain whether all of the strands have been removed or cut. A novel but unvalidated method is to apply hair-dissolving compounds.43 Hair-thread tourniquet syndrome can cause deep cutaneous lacerations that result in tendon lacerations requiring operative repair.44 Hair-thread tourniquet syndrome is not the result of intentional injury and does not warrant reporting as suspected child abuse.   (Tintinalli 8th Ed)

Faculty comments:  Nair seems to work pretty well. It takes about 15 minutes to dissolve the hair fiber.  Otherwise a small incision on the lateral aspect of the digit down to bone will cut the fibers.

 Incision to cut hair tourniquet

Incision to cut hair tourniquet

 

Hawkins       EKG's

Have a system to approaching EKG's the same way each time.

Snip20180725_8.png
 V-tach.   Harwood comment you know this is V-tach based on NorthWest axis (down in I and AVF) and QRS >140 ms. 

V-tach.   Harwood comment you know this is V-tach based on NorthWest axis (down in I and AVF) and QRS >140 ms. 

Williamson    AICD/Pacers

Unfortunately I missed a large portion of this outstanding lecture.

1/3 of patients with AICD shock will have troponin elevation. 

For a single shock, check a troponin, check lytes,  get an EKG. If patient is asymptomatic and has normal vitals and labs are consistent with prior levels, the patient can possibly can go home after discussion with cardiologist. 

If patient gets shocked twice they need a higher level of caution because either they are getting multiple appropriate shocks or the device is malfunctioning.  Consult Cardiology and likely admit.

If a patient gets 3 or more shocks that is considered electrical storm and the patient needs emergent cardiology consultation, antiarrythmic therapy, anxiolytic, and ICU admission.

 JAMA 2006 reference.

JAMA 2006 reference.

Lovell    How to Give an Effective Lecture

Be the content expert. Make sure you know your topic.

Be enthusiastic about the topic you are speaking about. Enthusiasm shows and is important for gaining your audience's attention.

Work on your public speaking skills: Most important is to practice your presentation beforehand.     During the presentation, leave the podium and engage the audience.   

Get Creative.  When developing your presentation, think about how to make the content more engaging or interactive.

Pay attention to slide design. Don't put too much info on slide. Big picture/few words.  Make your slides visually appealing. Don't use slides as a crutch.