A digest of Dr. Herbert’s monthly audio CME series
edited by Chris Feier, MD
1. Hemodynamically unstable with a pelvic fracture, what do you do?
Tom Scalea says that there are five “Talk and die diagnoses,” aortic dissection, MI going to VF, sepsis, and epidural hemotoma, and pelvic fractures. Why the last one? Rupture of the iliolumbar ligaments that hold the pelvic together can lead to life threatening exanguinations. So DON’T ROCK THE PELVIS IN A SUSPECTED FRACTURE! It may open the pelvis and lead to further bleeding. Instead, he recommends grabbing the iliac crests and pushing IN to evaluate for stability. And look for blood in all the wrong places, urethra (with high riding prostate) and/or scrotum.
What’s the best X-ray? CT with 3D reconstruction. But if you don’t have this capability use inlet, outlet and Judet views in addition to your standard AP. If you can’t see it on these views it’s not clinically important.
Stable or unstable? First, there is hemodynamic stability followed by skeletal stability. Fractures from lateral compression, such as being T-boned in a MVC, may implode the pelvis, but don’t usually bleed, except in the elderly. Hypotension in LC fractures should cause you to look for other trauma. Similarly, vertical shear fractures, while showing no widening the pelvic diameter, may completely dislocate the legs from the axial skeleton. But since this injury doesn’t usually disrupt the iliolumbar ligaments, this fracture may not be associated with exanguination. However, fractures resulting from AP compression, such as a head on MVC, may have little bony involvement, but the pelvis explodes. This ligamentous rupture is associated with severe bleeding. In hemodynamically instable patients, other sources of hemorrhage must be considered, such as thorax, long bone fracture, abdominal and/or retroperitoneal trauma. Assessment of the abdomen should include a FAST exam, being aware that the first exam may be false negative in up to 30% of cases. Supraumbilical, open DPL may help, it is time consuming. CT is definitive, but can be difficult in the unstable patient. Resuscitation should include early use of PRBCs and FFP, in a 1:1 ratio, and platelets, avoiding large volumes of crystalloid. Some studies have even shown the benefit of permissive hypotension. Management includes early intubation, when appropriate, looking for associated injuries, massive transfusions, and assessing for neurologic injury. If you are still in doubt about the source of hemorrhage, it’s time for the OR where the surgeons can tie off bleeders while preparing for the angiogram. Until then, external compression from pelvic binders, MAST, or even a crisscrossed sheet may stabilize the pelvis, reduce the bleeding and buy some time.
The goal in open pelvic fractures is simply hemorrhage control, fracture reduction. Fibrin glue on vicryl mesh in the open wounds with pressure may help. And move to the OR with all speed. Do not explore the wound, unpack, or delay for definitive testing. Source: Tom Scalea MD
2. Hypertensive encephalopathy management
In the setting of mean arterial pressure (MAP) > 150, mental status changes (confusion, lethargy, or coma), visual changes (cortical blindness, scotoma, hemianopsia), and rarely seizure, focal neuro deficit, or pappilledema may be diagnostic of hypertensive encephalopathy. This failure of autoregulation, if not treated, leads to death. But subarrachnoid hemorrhage, intracranial hemorrhage, subdural hemorrhage, epidural hemorrhage, infection, drugs, and uremia must be considered first.
Once these are considered and ruled out, management should include fluid replacement with normal saline and blood pressure reduction. Why the former? Hypertensive emergencies cause a pressure induced natriuresis by increasing the forces exerted on the renal afferent arterioles. The increased pressure activates the rennin/angiotensin/aldosterone system, causing diuresis and volume depletion, which can be easily corrected. Administration of saline may cause a decrease in blood pressure by itself before institution of blood pressure lowering medication. Pressure reduction should aim for a 25% reduction in the first two hours, 15% in the first, and 10% in the second. But don’t overshoot! A 40% reduction in blood pressure will lead to its own neurologic event. Use titratable meds only to achieve the lowered pressure. Sublingual, transdermal, and oral meds can cause a precipitous decline and can’t be reversed.
Don’t give clonidine. It has CNS depressant effects. Don’t give diruretics. The patient is already sodium depleted. And don’t give hydralazine. The BP drop could be sharp. Nitroprusside should be avoided due to its link to increased ICP and CNS toxicity. Use labetalol 20 mg IV and double the dose every 5-15 minutes until you achieve your target BP. Other drugs to consider are nicardipine and fenoldopam. Source: Michael Winters MD
3. Bleeding from a tracheostomy site should not be disregarded
Tracheo-innominate fistulas usually present in the first few weeks after tracheostomy. Although relatively rare (0.6-1%), the diagnosis cannot be missed because of the high mortality rate- 80-100%. They are thought to occur because of pressure necrosis by the tracheostomy cannula on the tracheal wall and innominate artery, causing a fistula. Fifty percent of these present with a sentinel bleed, usually described as a brief episode of brisk, bright red bleeding hours to days before massive hemorrhage. If suspicion for tracheo-innominate fistula is high, thoracic surgery should be consulted for evaluation by rigid bronchoscopy. On the other hand, if the patient presents with massive hemorrhage, some simple maneuvers can be life-saving. First, over-inflating the trach cuff is successful in about 85% of cases in controlling hemorrhage. If unsuccessful, a small endotracheal tube should be inserted either orotrachealy or via the stoma site. Then, the artery can be digitally compressed against posterior sternum with a finger through the stoma site.
Source: Michael Winters MD
4. Pacifiers with sucrose may aid in infant analgesia
Previous studies on infant analgesia were done in the NICU setting for the heel lance procedure. This is the first study in the emergency department for infants (0-6 months) undergoing venipuncture and compared the efficacy of pacifier, sucrose, or the combination versus placebo. Sucrose did not significantly improve outcome variables which were FLACC score, crying time, and heart rate. Pacifier alone had modest effects on FLACC score and crying times, but not on heart rate. When subgroup analysis was done, they were able to show a statistically significant effect for infants < 3months old and especially less than 1 month old. The authors conclude that the use of pacifier with sucrose as procedural analgesia is effective in reduction of pain in infants 0-3 months old and is a safe and easy method for infant analgesia.
Source: BMC Pediatrics 2007, 7:27
5. IV Dextrose decreases return visits for pediatric gastroenteritis
This was a case controlled study of children 6 months to 6 years who presented to an emergency department with gastroenteritis and dehydration that required intravenous rehydration. Patients that received no IV dextrose had a 3.9 times greater odds of having a return visit than those who received some dextrose. The effect of IV dextrose showed a dose response curve with maximal effect seen with 1000 mg/kg. The authors theorize that dextrose, independent of fluid volume, may contribute to faster resolution of ketosis, which is partly responsible for nausea and vomiting. Dextrose can be easily given as a D5 NS bolus of 20ml/kg or D5 at 1.5 times the maintenance rate for 90 minutes after normal saline bolus. Either way, the child will receive the optimal dextrose infusion of 1000 mg/kg.
Source: Academic Emergency Medicine 2007;14:324-331