Grand Rounds Recap 8.18.21
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r1 Clinical diagnostics: Compartment Syndrome WITH dr. negron
Compartment Syndrome is a condition resulting from increased pressure within a confined body area which can be caused by either extrinsically or intrinsically added pressure. Etiologies are varied and can include trauma, hemophilia, DVT, or iatrogenic (think IV contrast extravasation).
Muscle can tolerate 4-8 hours of decreased blood flow due to compartment syndrome and performance of a fasciotomy within 6 hours leads to a nearly 100% return of function. If performed within 12 hrs, return of function drops to 66%.
Most common cause is fractures (75% of cases); tibial and distal radius fractures associated with highest incidence
Open fractures do not exclude possibility of compartment syndrome
History and Physical Examination
Has the patient received >10L IVF for resuscitation? Sustain a crush injury? Immobility? Recent surgery? Bleeding diathesis? Falls? Increasing analgesia requirements?
Physical Exam findings : edema, deformity, color, coolness of limb, tenderness to palpation, pain with pain w/ passive stretch, decreased two point discrimination. Motor findings are late.
Presence of palpable pulses does not rule out compartment syndrome
Serial exams are critical
Diagnostic Workup
If you have high enough suspicion to measure compartment pressures, consider advocating for just doing the fasciotomy
Ultrasound with doppler has poor diagnostic quality
Cannot miss labs are CK, BMP, and lactate.
Measuring compartment pressures: Stryker Device Set Up and Arterial Line Compartment Pressure Measurement
Do not measure in an area of ecchymosis
Normal muscle compartment pressure is <10mmHg
Confirmed diagnosis if the absolute compartment pressure >30 mmHg in any patient, or if △ pressure is <20-30 mmHg (DBP – compartment pressure)
Interventions:
Call orthopedic surgery early! There is no substitute for this.
Aggressive fluid resuscitation; goal is 200-300mL/hour of urine output
Not enough data to support urine alkalization
If bleeding is etiology, consider factor replacement or reversing if on anticoagulation
Complications and sequelae
Permanent muscle contractions
Necrosis leading to sepsis
Loss of limb (amputation 5-12.9%)
Rhabdomyolysis (address hyperkalemia, hyperphosphatemia and hypocalcemia in addition to renal failure)
For more information on compartment syndrome, please visit Dr. Negron’s excellent Taming the SRU post.
r3 taming the sru WITH dr. meigh
Patient Case: A middle aged male with history of cirrhosis complaining of cranberry-colored vomit, jaundice and abdominal pain. Is hypotensive on arrival and has an episode of massive hematemesis in the ED leading to cardiac arrest. Massive transfusion protocol is activated and ROSC is achieved but the patient still has significant ongoing hematemesis leading to placement of a Minnesota Tube for hemorrhage control.
Indications:
Suspected esophageal or gastric variceal bleed with life-threatening hemorrhagic shock
Stabilization of UGI bleed when medical therapy such as endoscopy is unsuccessful or unavailable
Contraindications:
Esophageal stricture, recent esophageal or gastric surgery, hiatal hernia
Complications:
Pressure necrosis
Re-bleeding
Epistaxis
Arrhythmia or posterior cardiac ischemia due to balloon pressure on coronary arteries
Esophageal rupture
Minnesota Tube Placement Pearls:
Use long acting paralytic if anticipating having to place a Minnesota tube when securing airway
Ice water can be used to stiffen up end of the tube
Bougie-assisted placement can also help with tube passage
See a step-by-step instruction guide on placement here.
Case follow up: Breaking Down the Traumatic Arrest WITH dr. stolz
The clinical scenario: a young male patient presents with a GSW to the head, lost pulses approximately 2 minutes prior to arrival.
What interventions should we do in penetrating trauma patients with no pulse on arrival?
In the prehospital setting, it can be appropriate to withhold resuscitative efforts for certain trauma patients for whom death is the predictable outcome.
In the ED, ATLS and European Resuscitation Council both have guidelines for this scenario focusing on treating reversible causes, volume/product resuscitation. Stance on closed chest compressions is varied.
Dr. Stolz’s recommended interventions: HOTT for traumatic arrest
Hemorrhage control and replacement if needed
Oxygenation
(bilateral finger) Thoracostomies
Tamponade
Keep in mind the cost of resuscitating traumatic arrest patients, not to change management but to be mindful of resource expenditure.
Minimal survival (2-20%) of patients who achieve ROSC post-traumatic arrest
Needlestick injuries in 6% of cases
Multiple OR trips (not just the initial damage control trip but take-backs) as well as prolonged ICU stays
Cost and scarcity of blood products
What GSW injury patterns to the head are non-survivable?
Bihemispheric or transventricular (even if only in 1 hemisphere) injuries carry an ~80% mortality
Other predictors of a poor outcome: low CGS, hypotension, apnea, bilateral fixed and dilated pupils, intracranial hemorrhage
Data is overall minimal and hard to extrapolate from military because shrapnel injury does not have the associated blast injury that we commonly see in civilian GSWs
Do all traumatic arrest patients deserve an endotracheal tube before they can be pronounced?
Per ATLS, an extraglottic device is not a definitive airway
ACLS data suggests leaving a supraglottic device in place if functioning however rationale is more to prevent interruption of compressions but compressions not done in traumatic arrest
RCT of EMS teams randomized to ETT vs LMA showed no difference in outcomes
Special considerations: In trauma, ETT may be preferable as it allows for single lung ventilation if needed
Are we any good at diagnosing cardiac activity with ultrasound?
Bottom line is no. Study comparing many types of practitioners (attendings, nurses, residents, fellows, APPs) showed minimal interrater reliability
Cardiac activity has many definitions but safe bet is to stick to “contraction of the heart”
Red herrings:
Mechanical ventilation leads to movement of the thoracic cavity as a whole
Valve flutter (especially of replacement or mechanical valves)
Bradycardia is often missed
aircare grand rounds with Dr. Connelly
The Air Care crew has switched to the Hamilton-T1 Transport Ventilator. We covered both operations and troubleshooting with some hands-on time but for a refresher or more practice scenarios, please check out the awesome free resources and simulator available at the Hamilton website. Unique to the Hamiton-T1 ventilator is the Adaptive Support Ventilation mode (ASV). Some key features include:
Guarantees minute ventilation, changes parameters to achieve this, attempts to make ventilation as physiologic as possible
Is a combination of PC-CMV, PC-CSV (aka pressure support) and PC-IMV (SIMV)
Lastly, for when the tones drop at 2am, here’s your ventilator set up cheat sheet to cognitively offload! Happy flying.
