The Trauma Professional's Blog

Repeating the head CT in patients with head injury has almost become routine. This practice varies greatly and depends on the neurosurgeon’s preference in many centers. It occurs most commonly when there is blood inside the skull, any type of blood. But does this practice make sense? Sure, if you’ve got a small epidural it seems reasonable. But what about that wisp of subarachnoid blood?

Another paper being presented at the Congress of Neurologic Surgeons this fall describes a review of 445 cases at their hospital and a meta-analysis of 15 studies in the literature. The authors looked at the practice of repeat CT scanning with respect to the good old clinical exam. They stratified all patients who underwent an intervention after repeat CT into two groups, based on changing clinical exam or CT findings.

They found that a significant number of patients required some management change based on deteriorating neurologic exam, whereas very few required it based on the repeat CT. The authors concluded that it is not necessary to rescan a head trauma patient if their neurologic status is stable or improving. 

Bottom line: This is preliminary data, and it is only available in abstract form, so don’t change your practice yet. We need more information on how many patients were reviewed and how good the meta-analysis was. However, you should begin to question whether rescanning everyone is necessary or prudent. Not all head injuries are alike, and some of the trivial ones, like subarachnoid blood in a young adult probably don’t need a repeat scan. More to come when this is presented and/or published.

Reference: The Value of Scheduled Repeat Cranial Computed Tomography Following Mild Head Injury: Single Center Experience and Meta-Analysis. Paper 152, presented at the Congress of Neurologic Surgeons, October 2012.

There’s a lot of confusion about subdural pathology after head trauma. All subdural collections are located under the dura, on the surface of the brain. In some way they involve or can involve the bridging veins, which are somewhat fragile and get more so with age.

Head trauma causes a subdural hematoma by tearing some of these bridging veins. Notice how thick the dura is and how delicate the bridging veins are in the image below.

When these veins tear, bleeding ensues which layers out over the surface of the brain in that area. If the bleeding does not stop, pressure builds and begins compressing and shifting the brain. A subdural hematoma is considered acute from time of injury until about 3 days later. During this time, it appears more dense than brain tissue.

After about 3-7 days, the clot begins to liquefy and becomes less dense on CT. Many hematomas are reabsorbed, but occasionally there is repeated bleeding from the bridging veins, or the hematoma draws fluid into itself due to the concentration gradient. It can enlarge and begin to cause new symptoms. During this period it is considered subacute.

It moves on to a more chronic stage over the ensuing weeks. The blood cells in it break down completely, and the fluid that is left is generally less dense than the brain underneath it. The image below shows a chronic subdural (arrows).

Hygromas are different, in that they are a collection of CSF and not blood. They are caused by a tear in the meninges and allow CSF to accumulate in the subdural space. This can be caused by head trauma as well, and is generally very slow to form. They can lead to slow neurologic deterioration, and are often found on head CT in patients with a history of falls, sometimes in the distant past. CT appearance is similar to a chronic subdural, but the density is the same as CSF, so it should have the same appearance as the fluid in the ventricle on CT.

Related posts:

• TBI testing
• Repeat head CT scans after TBI

Here’s another interesting paper that was presented at the Congress of Neurological Surgeons. There’s a lot of attention being focused on the incidence and management of concussion during sporting events. An international Concussion in Sport Group has been meeting for over 10 years, contemplating classification and management of this injury. They are considering using age to modify management of concussion in young athletes.

The authors looked at their own experience with 200 adolescent and young athletes. They stratified by age (younger = 13-16 year olds, older = 18-22 year olds), with 100 in each group. They matched them by number of previous concussions, and all underwent baseline and post-concussion ImPACT testing. They specifically looked at the number of days needed to return to baseline.

Interestingly, they identified significant differences in recovery time. And strangely enough, the older players did better than the younger ones. Overall, 90% returned to baseline within a month. But the younger players took 2-3 days longer to recover than the older ones. 

Bottom line: Looks like the Concussion in Sport Group is right on! Usually in trauma, older folks do worse than younger ones, so we tend to treat them more carefully. Not so in youngsters with concussions. Sports medicine physicians need to realize that the younger brain takes longer to recover, and they should err on the safe side and keep them out of the game longer. Objective testing to help predict return to play is extremely helpful.

Related post:

• Field concussion testing for trauma

Reference: Sport-Related Concussion and Age: Number of Days to Neurocognitive Baseline. Oral presentation 145 - Congress of Neurological Surgeons 2012.

People who work in hospitals, particularly physicians, physician assistants, nurse practitioners and residents are throwbacks who still use old-fashioned paging technology. My colleague, the Skeptical Scalpel, recently lamented this fact in one of his blog posts. But they do seem to be a necessary evil, since cellular coverage is often limited deep inside of buildings.

But how much to trauma professionals get paged? An oral presentation at the recent Congress of Neurological Surgeons described a study that monitored paging practices between nurses and neurosurgical residents.

Medical students were paid to follow neurosurgical residents during 8 12-hour call shifts. They recorded the paging number and location, priority, and what the resident was doing when paged. The results were enlightening but not surprising:

• 55 pages were received per shift, on average, ranging from 33 to 75
• An average of 5 pages per hour were received, with a range of 2 to 7
• A substantial number of pages were received during sleep times (4 per hour)
• It took an average of 1.4 minutes to return the page
• 68% of pages were non-urgent
• 65% interrupted a patient care activity
• An average of 1.1 hours was spent returning pages per shift

Bottom line: Yes, we are throwbacks using an old technology. But it does serve us well. Unfortunately, it’s an old technology being used in an inefficient manner. I recommend that nursing units make it a practice to maintain a “page list” of nonurgent items. The trauma professional can then stop by or call each unit periodically (every 2 hours or some other appropriate time interval) and deal with all of them at once. Obviously, urgent and emergent problems should still be called immediately. This will ensure that routine issues are taken care of in a timely manner and the trauma pro can attend to their other duties as efficiently as possible.

Related posts:

• The Skeptical Scalpel on pagers

Reference: Oral Paper 113: An Observational Study of Hospital Paging Practices and Workflow Interruption Among On-call Junior Neurosurgery Residents. Presented at the Congress of Neurological Surgeons 2012.

Last week I discussed the importance of treating rib fractures in older patients with the greatest respect. One reader commented:

“number of rib fratures are not that accurate by x-ray. If further evaluate by CT, more fractures will be identified”

Well, I agree and I disagree. Chest xray is notoriously inaccurate when it comes to diagnosing or counting rib fractures. Some older studies have shown that a plain chest xray may miss as many as 50% of all rib fractures. On the other hand, CT scan is very accurate at diagnosing them.

But the question is, do we need to know exactly how many ribs are fractured? In general, the answer is no. Rib fracture is a clinical diagnosis. A patient with an appropriate mechanism and focal tenderness on the chest wall has a rib fracture unless proven otherwise. Do we need to prove otherwise? No. They still have pain, and it still needs to be treated. The degree of pain and pulmonary impairment determines the need for admission and more advanced therapies, not an exact count of ribs fractured. 

Bottom line: Rib fracture is a clinical diagnosis! CT scan of the chest for diagnosing rib fractures (or pneumothorax, or hemothorax for that matter) is basically not indicated. It delivers a lot of radiation (and IV contrast if you mistakenly order it), but does not change management. For blunt trauma, CT of the chest should only be used for screening for aortic injury. The only possible indication I can think of is to plan ORIF of complicated, displaced rib fractures. But in that case, let your surgical specialist decide if the test is really necessary.

Related posts:

• Rib fracture management
• Rib fractures in the elderly
• More on rib fractures in the elderly

In response to my post yesterday, Chris Nickson wrote:

“Is it possible there were physiologically young but chronologically old patients with isolated rib #s that were sent home from ED that were not included in the study?

I suspect that there are patients over 65 years old with isolated rib #s that can be safely discharged if follow up is bullet proof and pain well controlled.

However, I agree with your over riding message to not underestimate the elderly rib fracture!”

Very few authors do anything but stratify the elderly by age when they write research papers. They do not look at frailness, even though there are scoring systems to do just that. Plus, the retrospective nature of most of the literature (including this paper) preclude the use of such a scale.

Most of the elderly patients that we all see in the ED are selected out to be frail. The healthy ones stay at home and tough out a single rib fracture or even two. But the ones who are brought in are most likely having issues with pain or breathing, thus prompting the visit.

Bottom line: I agree that some elderly patients (the younger and healthier ones) could potentially be sent home from the ED with some pain medication. But the trauma professional needs to make sure that they are comfortable and can move about with well controlled discomfort. They also need good discharge instructions regarding returning to their primary physician or ED promptly if they start to have pain control or respiratory problems. If there is any doubt, bring them in to the hospital for a brief visit for pain control and pulmonary management.

Related post:

• Rib fractures in the elderly

Just like children are not small adults, elderly patients are not just old adults. As I mentioned yesterday, mortality increases significantly as we get older such that the same injury is much more likely to kill an elder.

Rib fractures are no exception. A 10 year retrospective cohort study looked at the management and mortality of this problem in patients 65 and older at Harborview in Seattle. When comparing young and old patients with the same number of fractures and injury severity, death and pneumonia were twice as likely in the elderly (22% vs 10% mortality, 31% vs 17% pneumonia). Ventilator days and hospital/ICU length of stay was significantly longer, too. Mortality increased by 19% and pneumonia increased by 27% for each additional rib fracture in the elderly.

Here are some practical tips for management of rib fractures in the elderly:

• Admit any older patient with even a single rib fracture for pain management and pulmonary toilet
• Treat their pain well, but watch the narcotics! Consider an epidural if indicated, but monitor carefully.
• Keep your patient out of bed as much as possible. Chairs are good, walking is better.
• Encourage coughing and other pulmonary toilet techniques
• Do not discharge until they pass the “eyeball” test. This means that they have to look well enough to go home and participate in their usual activities. They should be walking around at their usual speed and agility. It does no good to discharge and lay in bed or on the couch. They’ll be back dying of pneumonia before you know it.
• A general rule of thumb: Length of stay is generally n+1 days, where n is the number of rib fractures (isolated injury). Be wary of trying to send someone home sooner than this.

Related posts:

• Thoughts on geriatric trauma
• Rib fracture management
• Trauma 20 years ago: continuous epidural analgesia for rib fractures

Reference: Rib fractures in the elderly. J Trauma 48(6):1040-1046, 2000.

Thanks to Scott Weingart, author of the EMCrit Blog (www.emcrit.org) for suggesting this topic!

I’ve had several requests for a piece on geriatric trauma. We know that elderly patients (officially age > 55) have worse outcomes for the same degree of injury. And as they get older, mortality rises rapidly. Here are some practical tips for trauma professionals. 

• For EMS: As I mentioned yesterday, heed the CDC trauma triage guidelines. Older patients have better outcomes at trauma centers, so take advantage of it.
• In the ED: Ask immediately about anticoagulation. This can cause life threatening situations, especially in the face of intracranial hemorrhage. If your patient is taking anything that interferes with clotting, treat them like a STEMI or stroke patient. Time is of the essence. Draw coags and get rapid access to the CT scanner. Refer to the guidelines I previously published on reversing the usual culprits.
• Most elderly patients with any degree of head trauma need a head CT. They can hide bleeding well, until it’s too late to save them.
• Once admitted, treat them very carefully. Even minor errors (too much fluid, unneeded IV contrast) can cause significant complications.
• Use as little narcotic as possible. Acetominophen and ibuprofen work great. Lidocaine patches may be helpful in may cases. Steer away from narcotics and muscle relaxants as much as possible to avoid altering mental status.
• Watch sleep patterns. Sleeping meds are bad, but reducing interruptions in the middle of the night  is good (do they really need vital signs taken at 2AM?).
• Look at the patient’s baseline status. Are they a spry 90 year old, or a demented 70 year old who falls all the time? Have realistic expectations and communicate them with the family if major procedures or intubation are considered. Sure, we have the technology to fix many things, but at what cost to the patient? The family needs to understand the real likelihood of ICU, tracheostomy, and prolonged or permanent debilitation. Don’t make them as miserable as you can make the patient.

Related posts:

• CDC triage guidelines
• Do we follow the triage guidelines?
• Anticoagulation reversal

One of the major components of any trauma system is the prehospital piece. These providers extricate, begin medical treatment, and decide where to take the patient. The choice of hospital can make a big difference, and the number of deaths can potentially be reduced by up to 25% by making the right decision. Where to take the patient is not necessarily clear cut, even though CDC guidelines exist to help. Geographic and weather factors can be a factor, as well as patient choice at times (unfortunately), local medical control, or even time of day (traffic).

Harborview and the University of Washington conducted a large retrospective review of the transport patterns for nearly 12,000 injured patients over a 5 year period. They specifically looked at whether CDC guidelines for field triage were being followed. About half were transported to Harborview, the only Level I center in the state. The remainder were transported to the 7 remaining trauma centers, levels III to V. There were a number of interesting findings:

• Patients transported directly to the Level I center were more likely to be young, male, injured by a penetrating mechanism, have worse vital signs and GCS and higher injury severity
• Older patients were less likely to be transported from scene to a Level I center
• The oldest patients were 89% less likely to be transported to the Level I center, either directly or after initial management at a lower level center

Bottom line: For reasons that are not clear, elderly patients were far less likely to be transported to a Level I trauma center by prehospital providers in Washington state. In fact, the guidelines were obeyed only about 50% of the time! Does this happen in other states or countries? We don’t know. Is this a problem? Unfortunately, we also don’t know how much lower the mortality in these patients is when treated at higher level centers. It seems to be, especially in the more severely injured patients. What we do know is that if the guidelines exist, adhere to them unless you have good reason not to. Their life may depend on it!

Related posts:

• Benefit of transport to a trauma center
• Wallet biopsy when transferring to trauma centers
• CDC Triage guidelines app

Reference: Compliance with Centers for Disease Control and Prevention field triage guidelines in an established trauma system. J Amer Col Surg 215(1):148-156, 2012.

Time for the answer! There were lots of well thought out guesses, and a few correct answers. 

Here’s the story. This is a young male who presented in the trauma room with a small penetrating injury on the lateral aspect of his right arm, and another one just medial to the top of the scapula. If you look at first image last Wednesday, you can see an obvious humeral fracture, a not so obvious lack of lung markings, and a few tiny metallic foreign bodies (bullet fragments picked up by Canuck ER MD, injuries surmised by Kurt Rubach, paramedic). I provided a zoomed in view on Thursday to make them a little more obvious.

What I didn’t tell you (besides the fact that there were bullet holes) was that there were no pulses in the arm. The patient was hemodynamically stable, so after evaluation in the ED and insertion of a chest tube, he was taken to angio to evaluate the injury location. Unlike many penetrating injuries where the location is obvious, this was a deep mediastinal hit possibly involving Zone I of the neck (thanks Traumahst). Angio was selected because this was in the days before chest CT.

This shows a cutoff of the right subclavian artery. The patient was taken to the OR for sternotomy with a right neck extension and resection of the medial third of the clavicle (see Friday’s xray). The injury was successfully repaired with good return of function, and some residual hemothorax. He was discharged home in a week.

Bottom line: This one was tough because I didn’t give you much of what trauma professionals really need: clinical context. An isolated xray without a clinical history is not enough. It’s very easy to see things that really aren’t there and end up on a wild goose chase. Keep that in mind the next time you expect your radiology colleagues to come up with miracle diagnoses while sitting in a darkened room. Give them the whole story, or have them pop over to the ED to see for themselves.

Still no correct answers! Told you it was difficult.

Hint! It was not blunt trauma!

Okay, so here’s the after photo, after everything’s been fixed. What the #*!% did we do?? And why? Answer on Monday! 

And by the way, ignore the shotgun pellets over the left chest. Old injury!

Okay, no correct guesses yet. Time for a hint!

First, look carefully at yesterday’s image. There are clues…

Here’s a magnified image of the injury area. It will provide additional mechanism information.

Leave comments with your guesses, or Tweet for a faster response!

Okay, this one’s tough! This is by far the hardest one I have posted. I don’t think anyone has a clue! It’s so hard, I’m going to post another image as a hint tomorrow. Then on Friday, I’ll show the after photo so you can tell me what the final problem was. Answer Monday!

Have a look at the image below and tell me what you think. Seems simple, right? How did it happen? What other injuries might be present? Comment below or tweet or email your thoughts!

Cardiac arrest in trauma patients is bad. Really bad. There are few survivors, mainly those who have some signs of life when they roll into the resuscitation room. One of the signs we look for is cardiac electrical activity, especially a narrow complex rhythm. But most of the time these patients don’t survive either. Could there be a way to fine tune the use of pulseless electrical activity (PEA) to better determine when further care is futile?

The trauma group at UCSF-East Bay did a nice, retrospective review on the use of the cardiac portion of the FAST exam to assess patients arriving in PEA arrest after either blunt or penetrating trauma. The numbers were a bit thin, but they were able to study 162 patients who had both FAST and EKG upon arrival. Of those patients, 71 had electrical activity, but only 17 had cardiac motion. However, 4 of these 17 survived (24%) vs only 1 of the 54 who did not have cardiac motion.

About a third of these 71 patients suffered blunt trauma, the remainder had penetrating injury. Of the 17 with cardiac activity, 14 were penetrating and 3 were blunt. And of the 4 survivors mentioned above, 3 were penetrating.

Only 1 of the 71 patients with PEA and no cardiac activity survived, and this was a blunt arrest(!).

Bottom line: Traumatic arrest is a generally fatal problem. However, it appears that use of the cardiac portion of the FAST exam in penetrating or blunt trauma can help fine tune the aggressiveness of resuscitation. PEA without cardiac activity is uniformly fatal (although there was one blunt survivor, the authors did specify the quality of this survival). It may be wise to forego further resuscitative efforts in PEA patients without cardiac activity because they will not survive, even as an organ donor.

Reference: The heart of the matter: Utility of ultrasound of cardiac activity during traumatic arrest. J Trauma 73(1):103-110, 2012.

Time to finish up this series on trauma mortality! We discussed the two types of anticipated mortality last week, now it’s time for the final (and worst) one.

Old nomenclature: preventable death
New nomenclature: unanticipated mortality

Note the subtle difference. The old name presumes you could have done something about it, which can lead to legal issues in some cases. The new one implies that death was unexpected, but does not presume that it could have been prevented. A good example would be a trauma patient who suddenly dies from a massive PE, despite DVT prophylaxis done according to the book.

Any unanticipated mortality should launch a full investigation from the trauma performance improvement program. In some cases, hospital PI may get involved. A root cause analysis may be indicated, depending on how many factors are involved. These cases must be discussed by the multidisciplinary trauma PI committee. It’s essential that everyone involved do their homework and become familiar with every aspect of care so that a meaningful analysis can occur at the meeting.

Trauma center reviewers will expect to see detailed documentation of the analysis in the PI committee minutes. And unless the death was a complete and nonpreventable surprise there should be new protocols, policies and practice changes apparent. If these are not present, expect major reverification issues for your trauma center.

Is there an appropriate ratio of the three types of mortality? Obviously, there is a fair amount of variability. But after years of doing reviews, I can offer some guidelines. Here’s my 100:10:1 rule of thumb:

• 100 cases - Anticipated mortality without opportunity for improvement (AMW/OOI)
• 10 cases - Anticipated mortality with opportunity for improvement (AMWOI)
• 0-1 case - Unanticipated mortality (UM)

If your hospital’s numbers are outliers in any group, your clinical care and performance improvement program will get extra scrutiny. If all your cases are AMW/OOI, then your PI process is too lax. This is a complex business, and there a many ways to improve our care. If your AMWOI cases are more frequent, your threshold for improvement may be set too low (see my post on this last week). If you have more than 1 or 2 UM, then there may be some serious care quality issues.

Bottom line: When reviewing trauma mortality, be realistic but brutally honest. We learn from the mistakes we make. But by adhering to the process, you should never make the same mistake twice.

Related posts:

• Anticipated mortality - no opportunity for improvement
• Anticipated mortality - opportunity for improvement
• Unanticipated mortality

Yesterday I tried to clarify the most commonly assigned type of trauma mortality, anticipated mortality without opportunity for improvement (AMW/OOI). Today, I’ll cover another, and I’ll finish the series on Monday.

Old nomenclature: potentially preventable death
New nomenclature: anticipated mortality with opportunity for improvement (AMWOI)

Again, these sound somewhat similar but they are quite different. Potentially preventable death used to be applied to patients who had obvious care issues that had some potential to change outcome. But it also contained a number of patients discussed yesterday who had support withdrawn due to age or degree of injury. There was some nagging doubt that, it something else had been done, maybe they would have recovered. So several of the “potentially preventable” deaths in the old category have been moved to the “without opportunity for improvement” category.

Unfortunately, a larger group of patients from the nonpreventable death category have moved into the “with opportunity for improvement” category. This is actually a good thing, though. The AMWOI category looks at whether there were any care issues, regardless of whether support was eventually withdrawn.

Whereas the vast majority of deaths at any center should fall into the AMW/OOI category, a modest number will be classified as AMWOI. The actual number depends on how broadly or narrowly an opportunity for improvement is defined. If you consider a few areas of missing documentation on the trauma flow sheet an opportunity for improvement, then you’ll have a lot of deaths classified this way. Concentrate on issues that might have actually had an impact on the outcome. The key is to develop a set of criteria that is realistic and that work for you. If the number of AMWOI deaths seems high, go back and look at those criteria and adjust them. You can still work out a system for improving trauma flow documentation without it changing every death in a trauma activation to one with an opportunity for improvement.

Monday, I’ll finish up with a few words on unanticipated mortality.

Related posts:

• Anticipated mortality - no opportunity for improvement
• Anticipated mortality - opportunity for improvement
• Unanticipated mortality

The American College of Surgeons adopted a new naming convention for trauma deaths last year. Of course, anytime you change something up, there will be some confusion. I’m going to compare old and new and give some of my thoughts on the nuances of the changes.

Old nomenclature: Nonpreventable death
New nomenclature: Anticipated mortality without opportunity for improvement (AMW/OOI)

They seem similar, right? But the new name takes into account a growing phenomenon: elderly patients (or younger ones for that matter) who sustain injuries that might be survivable, but are devastating enough to cause the family to withdraw support. Technically, the deaths could be preventable to some degree, but the family did not wish to attempt it. The new system recognizes that it is an expected outcome due to patient or family choice.

There are several key points to handling AMW/OOI. First, if your center is providing great care, the majority of your deaths should be classified this way. Every one of them needs some degree of review, whether from just the trauma medical director and/or program manager or via the full trauma PI committee. However, your full PI committee needs to at least see a summary of the death if it’s not discussed in full.

How to decide on abbreviated review and report vs discussion by full committee? It depends on your trauma volume, and program preference. Higher volume centers do not usually have the luxury of discussing every case due to time constraints.

Tomorrow I’ll discuss the next type of trauma mortality, aniticipated mortality with opportunity for improvement, and I’ll finish the series on Monday.

Related posts:

• Anticipated mortality - no opportunity for improvement
• Anticipated mortality - opportunity for improvement
• Unanticipated mortality

Okay, so you’ve seen “other people” wearing perfectly good lead aprons lifting them up to their chin during portable xrays in the trauma bay. Is that really necessary, or is it just an urban legend?

After hitting the medical radiation physics books (really light reading, I must say), I’ve finally got an answer. Let’s say that the xray is taken in the “usual fashion”:

• Tube is approximately 5 feet above the xray plate
• Typical chest settings of 85kVp, 2mAs, 3mm Al filtration
• Xray plate is 35x43cm

The calculated exposure to the patient is 52 microGrays. Most of the radiation goes through the patient onto the plate. A very small amount reflects off their bones and the table itself. This is the scatter we worry about.

So let’s assume that the closest person to the patient is 3 feet away. Remember that radiation intensity diminishes as the square of the distance. So if the distance doubles, the intensity decreases to one fourth. By calculating the intensity of the small amount of scatter at 3 feet from the patient, we come up with a whopping 0.2 microGrays. Since most people are even further away, the dose is much, much less for them.

Let’s put it perspective now. The background radiation we are exposed to every day (from cosmic rays, brick buildings, etc) amounts to about 2400 microGrays per year. So 0.2 microGrays from chest xray scatter is less than the radiation we are exposed to naturally every hour!

The bottom line: unless you need to work out you shoulders and pecs, don’t bother to lift your lead apron every time the portable xray unit beeps. It’s a waste of time and effort!