internal bleeding and high tech non-surgery

Monday, December 14, 2015

A year ago, Alex Smith of the Kansas City Chiefs fractured his spleen. A month ago, Indianapolis Colts’ quarterback, Andrew Luck, broke his kidney. Last week, San Jose Shark Logan Couture, tore an artery in his thigh.  A generation ago, all three would have undergone major surgery, but technology advances quickly in medicine and has made these disastrous injuries, potentially less disastrous.

ct abdomen

It comes down to being able to look inside the body without having to make an incision. The clinical decision to operate was once  made by a surgeon at the bedside, based upon history, physical exam and the stability of the patient. Exploratory surgery in the stable patient has been replaced with CT scans and angiograms. The ability to stop internal bleeding has become part of the skillset of the interventional radiologist. In trauma situations, the surgeon and radiologist are able to sometimes decrease the need for emergency operations and save some organs, like the spleen and kidney, that only a few years ago had to be removed.

Surgeons like to operate and no doubt that is why they tolerate years of training, to be able to hone skills that lets them cut into the body. In trauma, though, many patients are relatively stable when they present to the emergency department. That means they are awake and have normal vital signs including blood pressure and pulse rate. This gives time to figure out whether what injuries are present and whether a trip to the operating room is needed. All bets are off when the patient is hypotensive (low blood pressure) and seems to be bleeding to death. In this situation, going to the OR emergently seems most prudent, reasonable and the lifesaving thing to do. But if the patient is stable, technology can help look inside the body and sort things out.

In the trauma situation, a FAST scan (Focused Assessment with Sonography in Trauma) can use ultrasound at the bedside to look for blood in the abdomen, chest and surrounding the heart. If the ultrasound shows blood and the patient is unstable, it’s off to surgery as soon as possible. If, however, the patient is stable, a CT scan may be used to look inside the abdomen for injuries to the solid organs like the liver, spleen or kidney. Once upon a time, damage to those organs meant an automatic trip to the OR, but research and experience has shown that the body can heal itself relatively well and damaged organ parts may not need to be removed. With a dye injection that is part of the trauma CT, bleeding arteries can also be identified and instead of rushing to the operating room to tie off a bleeding artery, an interventional radiologist may become the hero of the moment. Threading a catheter though the femoral artery in the groin, the specific bleeding blood vessel can be identified and clotted off, sometimes preventing major surgery.

Spleen injuries are not uncommon, especially if the lower left ribs that protect the organ are damaged. Often the bleeding is contained within the spleen and nothing more needs to be done, other than watch it heal. This is the Alex Smith situation. The diagnosis led to close observation and a few months of healing. The spleen is an important organ that helps filter damaged cells from the blood stream and also plays an important role in the body’s immune system. It is much preferable to have a spleen than not.

For Andrew Luck, he was unlucky enough to fracture his kidney. The kidneys sit in the right and left flank and are protected by the lower ribs and thick back muscles. Still, a blow to the area can damage the kidney by breaking it and causing extensive bleeding. It is better to preserve a kidney instead of having it taken out, and CT can check out the anatomy, injury pattern and risk of bleeding. often, the kidney does fine if it’s left alone. But if needed to be removed, it is fortunate that the kidneys come in pairs and losing one is not necessarily a disaster.

The anatomy of the kidney and the spleen are somewhat similar in that both have segments or poles that have distinct blood supplies. If only part of the organ is damaged and continues to bleed, the radiologist can intervene and control that bleeding and still preserve the rest of the kidney or spleen by the threading technique to find and clot the offending artery.. The organ part without blood supply dies but this is a much better situation than needing to cut into the body. and hack it out. This ability to attack a single blood vessel also saved Logan Couture from having his thigh sliced open to find the bleedig artery in his thigh and tie it off. Instead, the internal bleeding was control in a very high tech way.

Technology has changed how medicine is practiced, especially with the ability to look inside the body. Future generations of physicians and surgeons will look at the care provided in the 21st century as barbaric, yet it’s what we have and it’s better than what we had. The only people who might bemoan the advances are surgeons who marshal their enthusiasm to operate with the understanding that it’s important to pick their patients wisely. In the right situation, the mantra of  “a chance to cut is a chance to cure” has been replaced with “good things come to those who wait”  and “patience is a virtue”.

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collapsed lung

Sunday, December 7, 2014

The concept of transparency does not exist when it comes to trauma. For that reason, docs need a high index of suspicion when any victim walks or is carried through the door. The idea is this…most injuries can be taken at face value, but complications can exist, even in the most stable patient. For that reason, the concept of ruling out bad things is a routine thinking pattern in medicine. It does not mean that every test known to man has to be ordered, history and physical exam are powerful tools, but at least the doctor has to go through the mental gymnastics to be comfortable with the patient’s stability.

Every week, the NFL provides medical teaching moments. This time, it was learning that Dallas quarterback, Tony Romo, may have been playing for weeks with broken ribs. Bear receiver, Brandon Marshall goes down after a tackle, struggles to get up and ends up in the hospital with broken ribs and a collapsed lung. Same injury but Romo escapes without the complication that beset Marshall.

Breathing seems so simple and yet becomes very complicated when the chest wall is damaged. Normally, we breathe like a bellows, the ribs swing up and out, the diaphragm pushes down and air gets sucked into the lungs. That happens because the lungs are held against the chest wall by negative pressure between the two pleura, one lines the lung and the other lines the chest wall. Most people recognize pleural as the shiny skin when eating ribs. A pneumothorax or collapsed lung occurs when air gets into the space between those two linings and breaks the seal between the two. In trauma, a broken rib can cause a small tear into the lung tissue allowing that air leak to happen, but not always.

pleural-cavity-location

The pneumothorax is just one of the complications that have to be considered. It’s easy to be distracted by the pain of the broken fib and not concentrate on what’s important, the ability of the patient to breathe. The lung collapse is not all or nothing, it may be tiny and only seen as an incidental finding on a chest x-ray or Ct scan, it can be a complete collapse or the collapse can be somewhere in between. A smaller pneumothorax may not be appreciated on physical examination and for that reason a plain chest x-ray is an important screening tool in patients with chest injury. In addition to the collapsed lung, the doc will be looking for a contusion or bleeding in the chest. It is not meant to look for broken ribs. While more broken ribs presume increased force of trauma and increased risk of pneumothorax, the purpose of the test is to look for the lung damage and not any rib injury.

http://www.dreamstime.com/royalty-free-stock-photography-pneumothorax-image26701217

So Tony Romo keeps playing and Brandon Marshall goes to the hospital and gets a tube put in his chest. The way a traumatic pneumothorax is treated depends on how much air has escaped into the pleural space and how much the lung has collapsed. A tiny pneumothorax can be watched but larger ones need to have the air sucked out and the negative pressure re=established for the breathing mechanism to work again. A chest tube is placed through a stab incision in between the ribs and threaded into place. It is then hooked up to suct8ion and the patient is observed. If all goes well, the lung injury heals itself, the air leak stops and the tube can be removed in a couple of days. If all doesn’t go well, surgery may be required to repair the lung.

cchest tube

Aside from the lung, the ribs protect all sorts of vital structures from the heart and great vessels (think aorta, vena cava and others) in the chest, to the liver and spleen in the abdomen. Predicting the future is a fool’s game for doctors caring for trauma patients. Some, like Romo, will have an injury and do well. Others like Marshall will gradually decompensate with complications. Trauma is a worthy adversary and can lull doctors into a false sense of security when victims initially don’t look “too” injured. Just a reminder why medicine is a combination of science and art.

 

Image attriburions:

education-portal.com, dreamstime.com. @bmarshall twitter feed

 

 

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