Kenji Inaba is one of the most published trauma surgeons on the planet. When it comes to trauma, he has more pearls than an oyster bed. We caught up with him at the Essentials of Emergency Medicine conference in Las Vegas.
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Kenji’s Trauma Pearls
If a hemodynamically stable trauma patient has pericardial fluid on ultrasound, does treatment differ if the trauma was blunt or penetrating?
Penetrating: presence of fluid equals blood around the heart and your patient needs to go to the OR immediately.
If you can’t get your patient to the OR right away and they start to become unstable, a pericardiocentesis with pericardial catheter placement may be an option. The catheter can allow for intermittent drainage until the patient can get definitive care in the operative theater. If that’s not an option or your patient is crashing, crack the chest.
Does the amount of pericardial effusion matter?
No. In penetrating thoracic trauma, even a small amount of fluid can rapidly increase leading to rapid decompensation.
Blunt: Cardiac injury resulting in hemopericardium is much less common than with penetrating trauma. If the patient is stable, the likelihood of the fluid representing blunt cardiac rupture is less likely than the fluid having been there before the trauma. It can be hard to tell acute bleeding from a chronic effusion, just ask the ultrasound podcast guys -even they can’t tell. The first thing you want to know is whether or not there is tamponade physiology. What’s that look like? Like there’s a little man bouncing on the RV as if it were a trampoline. See video below.
Is there utility getting dedicated thoracic and lumbar spinal images on a patient who is going to get a CT scan of the chest, abdomen and pelvis?
No. You can get sufficient information about significant thoraco-lumbar spinal fractures from the bone windows and reconstructed images from a CT of the chest, abdomen and pelvis. Dedicated imaging of the spine adds a significant amount of radiation without giving additional actionable information.
What is blood volume cutoff for draining hemothorax?
300cc is a rough estimate, but there is no absolute cutoff. Compared with CXR, CT is much better at estimating amount of blood in the chest, but measuring exact volume is easier said than done. In the end, it often comes down gestalt.
Looks like a little bit of blood: watch and wait
Looks like more than a little bit of blood: chest tube
What are the risks of retained hemothorax?
Empyema and adhesions/fibrothorax. These are rare complications.
Kenji Bonus Pearl
When draining a hemothorax, give a single dose of antibiotics before placing the chest tube. What is the ideal antibiotic? Unknown, but currently under study.
References from Kenji’s lecture: Blunt cardiac injury
Schultz JM and Trunkey DD. Blunt cardiac injury. Crit Care Clin. 2004;20(1):57-70.
Sybrandy KC et al. Diagnosing cardiac contusion. Heart. 2003;89:485-489.
Bansal MK et al. Myocardial contusion injury. Emerg Med J. 2005;22:465-469.
Velmahos GC et al. Normal electrocardiography and serum Troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma. 2003;54:45-51.
References from Kenji’s lecture: The role of FAST in penetrating trauma
Mandavia DP and Joseph A. Bedside echocardiography in chest trauma. Emerg Med Clin North Am. 2004;22(3):601-619.
Rozycki GS et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma. 1999;46(4):543-551.
Ball CG et al. A caveat to the performance of pericardial ultrasound in patients with penetrating cardiac wounds. J Trauma. 2009;67(5):1123-1124.
Udobi KF et al. Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma. 2001;50(3):475-479.
Quinn AC and Sinert R. What is the utility of the FAST exam in penetrating torso trauma? Injury. 2011;42(5):482-7.