121-140 of 222 results with category "Trauma"
A study looking at patients over age 65 with head injuries from falls assessed the association of alcohol use with severity of injury. The alcohol use was self-reported which does limit the findings. The study found “Of 3128 study participants, 18.2% (n = 567) reported alcohol use: 10.3% with occasional use, 1.9% with weekly use, and 6.0% with daily use.” Those daily drinkers had a higher incidence of intercranial injuries.
The authors concluded: “Alcohol use in older adult emergency department patients with head trauma is relatively common. Self-reported alcohol use appears to be associated with a higher risk of ICH in a dose-dependent fashion. Fall prevention strategies may need to consider alcohol mitigation as a modifiable risk factor.”
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A reminder of two validated tools used to determine the need for cervical spine imaging in adult blunt trauma patients. A recent meta analysis concluded:
“Based on studies, both CCR and NEXUS were sensitive rules that have the potential to reduce unnecessary imaging in cervical spine trauma patients. However, the low specificity and false-positive results of both of these tools indicate that many people will continue to undergo unnecessary imaging after screening of cervical SCI using these tools. In this meta-analysis, CCR appeared to have better screening accuracy.”
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A just released study published in the Lancet gives us guidance on which pediatric blunt trauma patients need cervical spine imaging. Age range was 0-17 years.
“Out of 22,430 children included in the study, 433 (1.9%) were found to have Cervical spine injury (CSI). The study identified 4 high risk factors for CSI to be used to triage children to CT (12% risk for a cervical spine injury):
- Glasgow Coma Scale scores of 3-8
- Unresponsiveness to on the AVPU scale
- Abnormal airway/breathing/circulation
- Focal neurologic deficits
In children without high-risk findings, 5 additional findings identified children with intermediate, non-negligible risk of CSI (3.6% risk of a cervical spine injury):
- Altered mental status
- Substantial head
- Substantial torso injury
- Midline neck pain
- Midline neck tenderness”
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A cut-off of 35mm on CT scan has been shown to be predictive of which traumatic pneumothoracies require thoracostomy tube placement vs. safety of observation. This retrospective study looked at chest X-ray findings to see if there was a similar size cut-off where patients could be safely observed rather than undergo this invasive procedure. They found 38mm was the size over which observation failed. Of note, lactic acidosis and need for supplemental oxygen also predicted the need for chest tube placement
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In this prospective, observational study of trauma patients with isolated head trauma, 62% of patients developed post-intubation hypotension. Comparing patients receiving hypertonic saline, vasopressors, crystalloid, or blood those receiving hypertonic saline and vasopressors had less post-intubation hypotension.
TBI patients who develop hypotension have worse outcomes. This study reminds us the use of vasopressors in trauma patients to maintain blood pressure is appropriate in the correct circumstances.
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According to this study, no TXA 2g bolus was not found to increase the number of seizures in TBI pts.
TXA has been shown to improve mortality in inter cranial hemorrhage trauma patients if given within 2 hours. TXA is also known to lower seizure threshold. This study was a secondary analysis of a larger study comparing placebo to 1 g TXA bolus plus 8 hour infusion or 2g bolus TXA in the prehospital setting. There was no difference in the number of pts experiencing seizure or outcome in those receiving the 2g bolus of TXA.
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Question
Patient struck in left eye. The patient was asked to look up during exam and this is the finding. What imaging modality would you order if so inclined, what is the injury, and what is the disposition/plan?
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192 trauma patients who were receiving pre-hospital fentanyl for moderate to severe pain were randomized to placebo or intranasal 50 mg ketamine as an adjunct for pain control. There was no difference between the two groups in decrease in pain scale.
The authors concluded: “In our sample, we did not detect an analgesic benefit of adding 50 mg intranasal ketamine to fentanyl in out-of-hospital trauma patients.”
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A prospective European study of patients over age 65 presenting with a ground level fall obtained troponin levels to ascertain if myocardial infarction was a cause of the ground level fall. Troponin levels were elevated in a majority of patients however only 0.5% were defined as having a myocardial infarction. Of the 3% who died within 1 year, troponin was found to be higher than those that survived the one-year study period. The authors concluded “Our data do not support the opinion that falls may be a common presenting feature of MI. We discourage routine troponin testing in this population. However, hs-cTnT and hs-cTnI were both found to have prognostic properties for mortality prediction up to 1?year.”
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Appropriately, a great deal of time and energy is being expended to educate on the use of tourniquets to prevent mass hemorrhage. Are the current generation of tourniquets the best that we can have? These authors performed a Delphi study to assess needs with tourniquet design.
They concluded the next generation of tourniquets should have the following: “Capable of being used longer than 2 hours, applied and monitored by anyone, data displays, semiautomated capabilities with inherent overrides, automated monitoring with notifications and alerts, and provide recommended actions.”
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This study used the modified Brain injury Guidelines retrospectively to assess whether the guidelines would have saved transfers to their level one facility safely. They concluded the guidelines would have effectively prevented unnecessary mBIG 1 and mBIG2 transfers with no patient harm.
TABLE 1 - Modified Brain Injury Guidelines Radiologic Stratification, as per Kahn et al.
| mBIG 1 | mBIG 2 | mBIG 3 | |
|---|---|---|---|
| Skull fracture | No | Non-displaced | Displaced |
| SDH | ?4 mm | 4–7.9 mm | ?8 mm |
| EDH | No | No | Yes |
| SAH | ?3 sulci and <1 mm | Single hemisphere or 1–3 mm | Bihemisphere or >3 mm |
| IVH | No | No | Yes |
| IPH | ?4 mm | 4–7.9 mm | ?8 mm or multiple |
EDH, epidural hematoma; IPH, intraparenchymal hemorrhage; IVH, intraventricular hemorrhage; SAH, subarachnoid hemorrhage.
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In this Scandinavian study looking at 2,362 head injury patients on oral anticoagulants, the authors found only 5 cases of delayed hemorrhage and none of the five underwent neurosurgery. The authors concluded:
“In patients with head trauma, on oral anticoagulation, the incidence of clinically relevant delayed intracranial hemorrhage was found to be less than one in a thousand, with detection occurring four days or later after initial presentation.”
It would appear based on this study and others that it is safe to discharge these patients with a normal head CT and giving strict return precautions for headache, nausea, vomiting or other changes.
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On exam, assess for facial instability and airway patency. CT scan is the imaging of choice. The higher the number, the more complex the fracture, the more unstable and the more difficult the airway managment will be. Look for open lacerations or blood in the sinuses and treat with antibiotics if these are found. Consult ENT or plastics urgently for further management.
The reference is a nice review of these fractures
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In this podcast, the concept of vasopressor use in hemorrhagic shock is discussed. Key take away points:
- US and UK literature is much less supportive of vasopressor use in hemorrhagic shock than continental European literature.
- Concept is while filling the tank with blood, getting some squeeze in the venous system to keep it circulating.
- If a young trauma patient has cool extremities, they are already vasogenic and unlikely to benefit from vasopressors. Warm extremities mean they may benefit from vasopressors.
- Norepinephrine is the drug of choice. Aim for a maintenance dose of 3-5 mcg/min and no need to titrate because you are not looking for arterial constriction, just venous tone.
- Low dose Vasopressin drip may be beneficial as well, however more literature is needed.
- Blood is still the answer in these patients! Vasopressors are an adjunct to creating a balanced resuscitation.
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Hemodynamic instability in trauma patients is most often associated with hemorrhagic shock, however, there is an entity known as brain injury associated shock (BIAS). BIAS is thought to be associated with catecholamine surges secondary to brain injury. BIAS is found in both isolated head injury pts as well as multi-trauma patients. Studies have identified BIAS in 13% of adult trauma patients and up to 40% of pediatric major trauma patients.
We know hypotension in brain injury worsens outcome. We should assume hemorrhagic etiology until we prove otherwise. Once we suspect BIAS and have excluded hemorrhagic etiology our strategy should switch to blood pressure support using non-blood product management.
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Blunt Cardiac Injury is a continuum from asymptomatic, not clinically relevant to catastrophic, life ending disease . Consider blunt cardiac injury in patients with significant force to the chest wall or sudden deceleration injuries (motor vehicle crashes, motorcycle crashes, falls from height etc.). This algorithm is helpful when working up patients suspected of having significant blunt cardiac injury.
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A small study retrospectively looking at recorded calls to a level 1 trauma center transfer line specifically looking at patients who died or were discharged to hospice without surgical intervention found only 10% had goals of care discussed prior to transfer. Most were brain hemorrhage patients.
As a transferring facility, clearly outlining goals of care and addressing futility of care can have a major impact on trauma transfers and the cost and family burden associated with transfers.
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PECARN has a decision tool to identify blunt trauma patients under age 18 who are low probability for important intra-abdominal injuries. The questions to ask are:
- Evidence of abdominal wall trauma/seatbelt sign
- GCS <14 with abdominal trauma
- Abdominal tenderness
- >1 of thoracic wall trauma, vomiting, complaint of abdominal pain, decreased breath sounds
Answering no to all yields <0.1% chance of intra-abdominal trauma requiring intervention. (See MedCalc link for other calculations)
A prospective validation study in the Lancet yielded 100% sensitivity and negative predictive value in 7542 patients under age 18
This tool can likely be used to guide imaging choices in pediatric blunt abdominal trauma patients
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This study looked at survival pre and post implementation of an airway guideline for prehospital traumatic brain injury (TBI) patients who received positive pressure airway interventions. The guideline “focused on the avoidance and aggressive treatment of hypotension and 3 airway-related goals: (1) prevention or treatment of hypoxia through early, high-flow oxygen administration; (2) airway interventions to optimize oxygenation or ventilation when high-flow oxygen was insufficient; and (3) prevention of hyperventilation or hypocapnia by using ventilation adjuncts (ie, rate timers, flow-controlled ventilation bags, end-tidal carbon dioxide monitoring).”
Post implementation, survival to admission increased in all severity levels of TBI and in the most severely injured, survival to discharge improved.
Useful for those involved in prehospital education and as a reminder for in hospital airway management in TBI patients.
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Traditionally, a systolic blood pressure (SBP) of 90 has been used as a marker of severe illness in trauma patients. This study looked at a large database and found shock index (SI) and systolic blood pressure were the best predictors of early mortality in trauma patients.
They found:
prehospital SI 0.9 and SBP 110,
ED SI 0.9 and SBP 112,
and
in elderly
prehospital SI 0.8 SBP 116
ED SI 0.8 SBP 121
were the cutoffs to predict early mortality.
We should rethink our protocols and approach to trauma patients using a higher systolic blood pressure than 90. Also note elderly had a different number than younger trauma patients.