POTD: Free Fluid in the Belly (Trauma Tuesday!)

This POTD was inspired by a morning report I was present for in Shock Trauma. The case was a 40ish male involved in an MVA. Patient was "shan scanned" for blunt traumatic mechanism. Surgeons saw a ton of free fluid on the scan and took patient directly to the OR. No intra abdominal injuries nor hemoperitoneum were found in the OR. It was later discovered, the patient had a drinking history w/ a cirrhotic liver and the free fluid initially assumed to be blood was actually acetic fluid.

PODT: Free Fluid in the Belly

So you have a trauma patient with a history of alcoholic cirrhosis.  Your FAST is positive but your are unsure whether the free fluid you are seeing is blood from the trauma or the patient's chronic ascites.

You Pan-CT the patient and again all you see is free fluid, unable to tell if what you're seeing is blood or ascites. Your vitals, labs may help guide you. You can also potentially do a diagnosis parenthesis if there is a big enough fluid pocket but this is a very invasive procedure.

What you should do, is look at the Hounsfield Units (HU)!

HU are built into most imaging software and can be used to measure the radiodensity of the material on CT to help distinguish various structures.

Uncoagulated blood typically measures 30 to 45 HU

Clotted blood measures higher at 60 to 100 HU

Ascites/ Plasma measures around 0 to 20HU

So there you have it. You can use HU while looking at your CT images to help you determine whether your trauma patient is bleeding into their belly or what your seeing is more chronic. 

TR Adam

An example of hemoperitoneum

An example of hemoperitoneum

An example of plasma/ ascetic fluid

An example of plasma/ ascetic fluid

TXA in Trauma

Going to take a quick break from the PSA for #traumatuesday

 What is TXA and how does it work?

Tranexamic Acid is a medication used to treat or prevent excessive bleeding.

It works by reversibly binding receptor sites on plasminogen, which reduces conversion of plasminogen to plasmin, further preventing fibrin degradation making up the clot's framework.

Here's a cute animated video showing the mechanism of TXA: https://www.youtube.com/watch?v=emAHFC-Aidg

What role does TXA play in trauma?

CRASH-2 Trial (Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-2)

• Double-blinded RCT published in 2010

• 20,211 patients with traumatic hemorrhage (SBP < 100 and/or HR > 110) or at risk of significant hemorrhage, within 8 hours of injury

• Dose used was 1g TXA over 10 minutes + 1g over 8 hours

• All-cause mortality significantly reduced with TXA

• Risk of death due to bleeding on day of presentation significantly reduced with TXA

• No significant difference in vascular occlusive events

• No significant reduction in blood transfusion requirements

• Greatest benefit seen with early administration (< 1 hour after injury but also < 3 hours). Increased risk of death due to bleeding if administered after 3 hours.

MATTERs (Military Application of TXA in Trauma Emergent Resuscitation)

• Retrospective observational cohort study published in 2012

• 896 military personnel who received at least 1 Unit of PRBCs within 24 hours of admission following a combat-related injury

• Dose used was 1g TXA IV bolus, repeated as deemed necessary by provider

• All-cause mortality significantly reduced at 48 hours and 30 days especially in patients requiring massive blood transfusion due to their injury

CRASH-3 Trial (Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-3)

• Double-blinded RCT published in 2019

• 12,639 patients with traumatic brain injury (< 3 hours after injury, GCS < 13 or ICH on CT). Patients excluded had major extracranial bleeding, GCS of 3, bilateral unreactive pupils.

• Dose used was 1g TXA over 10 minutes + 1g over 8 hours

• Death due to head injury significantly reduced at 24 hours but not at 28 days

• No significant difference in disability or vascular occlusive events

Bottom Line (based on the literature above):

• In adult trauma patients in severe hemorrhagic shock for which you are transfusing blood, administer TXA 1g IV over 10 minutes, followed by 1g infused over 8 hours.

• Reasonable to try TXA for TBI patients with GCS 9-15 and ICH on CT within 3 hours of injury but need more evidence

CRASH-2: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60835-5/fulltext

MATTERs: https://jamanetwork.com/journals/jamasurgery/fullarticle/1107351

CRASH-3: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext

Reviews from FOAMed sources:

https://emcrit.org/pulmcrit/crash3/

https://www.thebottomline.org.uk/summaries/icm/crash-2/

https://rebelem.com/crash-3-txa-for-ich/

https://first10em.com/the-crash-2-trial/

https://first10em.com/crash-3/

https://emcrit.org/wp-content/uploads/2012/02/TXA-in-trauma-How-should-we-use-it.pdf

ED Thoracotomy

It’s a new academic year and we are going to start off with some trauma! Today, we are going to talk about ED thoracotomy. It’s basically surgery but in the ED.

First of all, What is ED thoracotomy? It is a Hail Mary attempt in patients with penetrating chest injuries with signs of life in the field and suffer a subsequent witnessed cardiac arrest to open the chest and temporize a life threatening wound. It can be used to relieve cardiac tamponade, control hilar bleeding, cross clamp the descending aorta, or repair a myocardial laceration, all while on the way to the OR for definitive repair.

Success rate and survival is very poor for patients when thoracotomy is performed for blunt trauma, about 2% survival for patients in shock and less than 1% for patients with no vital signs. Conversely, in penetrating wounds, while still poor, 15% of all patients survived.

Guidelines have been established, the so called East and West guidelines, to help balance the already poor odds of survival with the risks of exposing health care providers to blood borne pathogens and salvaging patients with high odds of anoxic brain injury.

Western Trauma Association guidelines: consider ED thoracotomy in patients arriving with blunt trauma and < 10 minutes of CPR or penetrating trauma and < 15 minutes of CPR.

Eastern Association for the Surgery of Trauma: strongest recommendation to perform ED thoracotomy in patients with initial signs of life after penetrating thoracic injury who now present pulseless.

Other commonly quoted numbers. Also consider thoracotomy when you have unresponsive hypotension SBP < 70 despite aggressive resuscitation, chest tube output > 1500cc’s of blood within 24 hours, or when there is > 200/250 cc/hr output of blood after tube thoracostomy for 2-4 consecutive hours.

What you need: A well-staffed and properly trained team that includes also includes a trauma surgeon. Lots of PPE. Thoracotomy tray (rib spreader, #10 or #21 scalpel, scissors, foreceps, vascular clamps, curved artery forceps, needle driver, internal defibrillation paddles, skin stapler, sutures). I would also add a foley catheter as it can be inserted into the heart and the balloon inflated to stabilize a laceration while sutures are being placed.

How is it done? These are the basic steps. Secure the airway and insert an NGT, it can help distinguish the aorta which lies posterior to esophagus. Then, start with a L sided approach, place a chest tube on the R side concurrently. Incise from the sternum to the posterior axillary line at the 4/5th intercostal space, cutting through skin/soft tissue and muscle in one go. Spread the ribs with the rachet bar down. Pick up the pericardium and open it. Inspect myocardium for lacerations. Cardiac massage, internal defibrillation, and intracardiac epinephrine can be done. The aorta can be cross clamped for up to 30 minutes if hypotension still persists. If no evidence of L sided injury, extend to the R side (clam shell).

Hope this helps next time you get a note about a stab or GSW, active CPR, 3 minutes out!

Sources

https://emcrit.org/emcrit/procedure-of-thoracotomy/

https://i0.wp.com/emcrit.org/wp-content/uploads/2012/10/CJLDP_bW8AAVQ2o.png-large.png

https://westerntrauma.org/documents/PublishedAlgorithms/WTACriticalDecisionsResuscitativeThoracotomy.pdf

https://www.east.org/education/practice-management-guidelines/emergency-department-thoracotomy

https://jamanetwork.com/journals/jamasurgery/fullarticle/391389

https://wikem.org/wiki/Thoracotomy