Trauma Pearls

  1. After laparoscopic abdominal surgury or laparotomy, how long may pneumoperitoneum be seen on an upright CXR?
    7 days
  2. After laparoscopic abdominal surgury or laparotomy, how long may pneumoperitoneum be seen on abdominal CT?
    Up to 3 WEEKS
  3. What is the rate of re-expansion of a spontaneous pneumothorax?
    A spontaneous pneumothorax resolves at a rate of 2% per day in patients breathing room air (NEJM, volume 342:868-874).
  4. What is catamenial pneumothorax?
    It is recurrent PTX that occurs during the first 3 days of menses.

    It has been linked to concurrent endometriosis; it is thought that endometrial tissue spreads to the thorax by the transperitoneal or hematogenous route (JEM,In Press, Online 8/17/09)
  5. Most common injury in blunt thoracic trauma?
    Pulmonary contusion
  6. True or False: Patients with pulmonary contusion have a low cardiopulmonary reserve. Maintain a low threshold for initiating mechanical ventilation is these patients.
  7. When starting mechanical ventilation, think about the following:
    • -Patients are at high risk for developing ARDS
    • -Most centers use a low tidal volume ventilatory strategy
    • -Higher levels of PEEP may be necessary to recruit collapsed alveoli
    • -High frequency oscillatory ventilation (HFOV) and airway pressure release ventilation (APRV) are modes of ventilation that are gaining in popularity for ventilating patients with pulmonary contusions.
  8. How do you perform a median nerve block?
    The median nerve is located at the proximal flexor crease of the wrist, between the palmaris longus (PL) and flexor carpi radialis (FCR) tendons. The FCR lies radial to the PL tendon

    Use a 25 or 27 gauge needle, inserted to a depth of 1 cm, to inject 3-5 mL of plain lidocaine proximal to the distal wrist flexor crease, just ulnar to the PL tendon

    If the PL tendon is absent, as is the case in 25% of people, direct the needle in line with the ring finger

    If distal paresthesias result, withdraw and reposition the needle as this suggests that the median nerve was directly struck, which should be avoided.
  9. When Does A Traumatic Pneumothorax NOT Need a Chest Tube?
    Occult pneumothorax is defined as a pneumothorax seen on CT but not apparent on plain radiography. Existing evidence indicates that observation is at least as safe and effective as tube thoracostomy for management of occult pneumothorax (1,2).

    A subset of patients with who have a small traumatic pneumothorax on plain radiography (variably defined as <15% or less than 1 cm) and are minimally symptomatic may be treated conservatively without tube thoracostomy. These patients may be admitted for observation with administration of high flow oxygen which promotes resolution. Approximately 10% of these patients will eventually require a chest tube (3,4).
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Trauma Pearls
Trauma Pearls