The Trauma Professional's Blog

Wounds: When Are They Too Old To Close?

Mon, 20 May 2013 09:00:31 -0500

At some point in their training, every trauma professional is taught that there is a certain period time during which a wound can be safely closed. The exact number varies, but is usually somewhere between 6 and 24 hours. After that, we are told, “bad things happen.”

Always question dogma, I say. Is this true, or is it another one of those “facts” that have been propagated through the ages? Two emergency medicine groups recently performed a meta-analysis to try to answer my question. As usual, they found that much of the published literature is not very good. Out of 418 papers in their original search, only 4 fully met their criteria (laceration repaired primarily, in the ED, with clear early vs delayed criteria.

With the exception of one study with a very limited focus, there was no correlation between wound age and infection or dehiscence after primary closure. None of the studies could reliably provide a specific time beyond which closure was destined to fail. And the use of antibiotics in some of the studies also confounded the results.

Bottom line: It is more likely that infection-prone wounds get infected, not old ones. Although leaving a wound open to heal by secondary intention usually avoids the problem, it’s a big patient dissatisfier, especially with large wounds. Since many patients don’t present to the ED until their wound is “old”, it may be reasonable to try primary closure in all but infection-prone wounds. (The meaning of that phrase is not exactly clear, but most of us know it when we see it.)

Reference: The impact of wound age on the infection rate of simple lacerations repaired in the emergency department. Injury 43(11):1793-1798, 2012.

Best Of: IV Contrast

Fri, 17 May 2013 09:00:29 -0500

We use CT scanning in trauma care so much that we tend to take it (and its safety) for granted. I’ve written quite a bit about thoughtful use of radiographic studies to achieve a reasonable patient exposure to xrays. But another thing to think about is the use of IV contrast.

IV contrast is a hyperosmolar solution that contains some substance (usually an iodine compound) that is radiopaque to some degree. It has been shown to have a significant impact on short-term kidney function and in some cases can cause renal failure.

Here are some facts you need to know:

Contrast nephrotoxicity is defined as a 25% increase in serum creatinine, usually within the first 3 days after administration
There is usually normal urine output and minimal to no proteinuria
In most cases, renal function returns to normal after 3-4 days
Nephrotoxicity almost never occurs in people with normal baseline kidney function
Large or repeated doses given within 72 hours greatly increase risk for toxicity
Old age and pre-existing diabetic renal impairment also greatly increase risk

If you must give contrast to a patient who is at risk, make sure they are volume expanded (tough in trauma patients), or consider giving acetylcysteine or using isosmolar contrast (controversial, may still cause toxicity).

Bottom line: If you are considering contrast CT, try to get a history to see if the patient is at risk for nephrotoxicity. Also consider all of the studies that will be needed and try to consolidate your contrast dosing. For example, you can get CT chest/abdomen/pelvis and CT angio of the neck with one contrast bolus. Consider low dose contrast injection if the patient needs formal angiographic studies in the IR suite. Always think about the global needs of your patient and plan accordingly (and safely).

Related posts:

Acute kidney injury from IV contrast

Reference: Contrast media and the kidney. British J Radiol 76:513-518, 2003.

Trauma Mythbusters: Bathing/Showering And Wound Care

Thu, 16 May 2013 09:00:07 -0500

I love to hate dogma. And there’s probably nothing in surgery more sacred and more ingrained than how to take care of a wound. Everybody knows that you have to keep surgical or traumatic wounds dry, and that once you can get them wet, showers are good at baths are bad. Right?

And for something as common as wound management, there must be some kind of research, right? Not so! I did quite a bit of digging through the literature since 1966 and managed to find only five papers. Here are the highlights:

A prospective study of 100 patients were randomized to shower or bathe postoperatively. Of note, the wounds were sprayed with a clear plastic dressing before getting in the water. The was no difference in infection rates.
Another prospective study of 100 patients with stapled incisions after spine surgery were allowed to bathe after 2 to 5 days. Compared to historical controls, there were no differences in infection rates even though the study patients had more complex operations than controls.
A prospective randomized study of 121 patients after hernia surgery found no difference in infection between shower and dry groups
A large randomized study of 817 patients similarly showed no difference between shower and dry groups
Another randomized trial of 170 patients showed no difference in infections between shower after 24 hours and control groups

Get the picture? And interestingly, the few wound infections documented in any of the studies tended to occur in the dry groups, although this was not statistically significant.

Bottom line: In general, it is not harmful to get a wound wet after 24 hours. We don’t know exactly why because of the paucity of the literature, but think about it. The water that we shower or bathe in is the same water that we drink. It’s very close to sterile. When we do shower or bathe, the bacteria that come in contact with the wound are our normal skin flora, which are already in and on the wound. Plus, most incisions that have been closed are water-tight within about 24 hours. It’s more likely that using soap and water is good for you because it washes away tons of bacteria, including the pathogens!

References:

Prospective randomised trial of the early postoperative bathing. BMJ 19 in June 1976: 1506-1507, 1976.
Wound care after posterior spinal surgery. Does early grading affect the rate of wound complications? Spine (Phila PA 1976) 21(18):2160-2162, 1996.
Does a shower with postoperative wound healing at risk? Chirurg 68(7): 715-717, 1997.
Modification of postoperative wound healing by showering. Chirurg 71(2):234-236, 2000.
Postoperative wound healing in wound-water contact. Zentralbl Chir 125(2):157-160, 2000.

Don't Ignore The Naughty Bits

Wed, 15 May 2013 09:00:17 -0500

A major part of any patient encounter is the physical exam. This is particularly true in the trauma patient, because it allows trauma professionals to identify potential life and limb threatening injuries quickly and deal with them. Unfortunately, we tend to mentally block out certain parts of the body, typically the genitalia and perineum, and may not do a complete exam of the area. I call these areas the naughty bits. For those of you who don’t get the reference, here’s the origin of this phrase:

Specifically, the naughty bits are the penis, vagina, perineum, anus and natal cleft (aka the butt crack or arse crack). These areas are more likely to remain covered when the patient arrives, and are less likely to be examined thoroughly.

In penetrating trauma, a detailed exam of these areas is extremely important in every patient to avoid hidden injuries and to determine if nearby internal structures (rectum, urethra) might have been injured.

Here are some tips for each of the areas:

Penis - Always look for any blood at the meatus (or a little blood in the underwear) as a possible sign of urethral injury. This is frequently associated with pelvic fractures.
Scrotum - Blood staining here is usually from blood dissecting away from pelvic fractures. Patients with this finding are more likely to need angiographic embolization of pelvic bleeding.
Vagina - external exam should always be done. Internal and/or speculum exam should be done in pregnant patients, and those with external bleeding or pelvic fractures
Perineum - Also associated with pelvic fracture and significant bleeding. Skin tears in this area are usually lacerations indicating an open pelvic fracture. Alert your orthopaedic surgeons early, and do a good, clean rectal exam (carefully wipe away all external blood). Rectal injuries are common with this finding, and a formal proctoscopic will probably be required.
Anus - Skin tears virtually guarantee that a deeper rectal injury will be found. Proctoscopic exam in the OR is mandatory.
Natal cleft - Usually not a lot going on in this area, except in penetrating injury. This is the only area of the naughty bits that can be safely examined in the lateral position.

Bottom line: The naughty bits are important because the occasional missed injury in this area can be catastrophic! Do your job and force yourself to overcome any reluctance to examine them.

Related posts:

Pop Quiz! Final Answer

Tue, 14 May 2013 09:00:23 -0500

Our patient with the steak knife to the head has been evaluated by CT. The scan shows that the blade enters the right orbit, passing through the medial orbital wall into the ethmoid sinus, turbinates and nasal septum. It then passes into the left orbit along the posterior floor and exits the apex. The optic nerves are not involved, but there may be involvement of the rectus or oblique muscles to the globe. There does not appear to be any involvement of the maxillary sinus.

See why a good exam is important? Gross visual acuity and extra-ocular muscle testing is very important here. Miraculously, all are intact. So now what?

Just yank it out? Absolutely not! Although there is no gross bleeding from the nose or mouth, and none is seen on CT, that doesn’t mean there won’t be! The patient needs to go to the OR, and it may be helpful to have a facial surgeon present just in case. Scopes for evaluating the sinuses and packing materials should be readily available.

Under sedation, the knife can be smoothly withdrawn. An awake patient can tell you how it feels, and whether he is experiencing any bleeding or ocualr changes. If in doubt, the sinuses can be scoped and the globes re-examined.

Note: If troublesome bleeding does occur, this is not an area that is amenable to surgical exploration. The only realistic options available are packing and angioembolization.

Pop Quiz: The Case, Part 3

Mon, 13 May 2013 09:00:04 -0500

So our patient has presented to your ED, on foot, with a steak knife sticking out of his head! You’ve activated your trauma team, so now what do you do?

As always, start with a thorough physical exam. A good exam of the head is imperative, as is a scrupulous neurologic exam. In this case, the blade enters just below the right eye, traveling front to back and staying just about level.

Make sure there are no other injuries. Remember the Dang Factor! Don’t focus on the knife and miss other important injuries. And by all means, don’t take it out in the ED!

Since this patient is stable and neurologically intact, the surgeons will want a better idea of the structures involved under the skin. CT is the best tool for this, although there will be scatter from the metal. Here is a representative image:

So now, think about how you will get this out. Tweet and comment your answers.

Related post:

The Dang! Factor

Pop Quiz! The Case, Part 2

Fri, 10 May 2013 10:46:25 -0500

Yesterday I presented the case of a young man who shows up at the triage desk in your ED with “something wrong with his head.” I showed an AP skull film, which shows some kind of metallic foreign object. What is it? Where is it? What to do?

First, look at the image carefully. The object is metallic density and appears very thin. But remember, any diagnostic image you view is a 2D representation of a 3D space. You have no idea of the orientation of the object, or exactly where (front to back) it is located. He could be lying on top of it, or it could be stuck in his brain.

At the far left side of the image, the thin metal appears to get even thinner. Dead giveaway! Look at the diagram below.

The knife tang is the thin part of a knife that the handle is fastened to. @andrewjtagg tweeted that he wouldn’t mind seeing a lateral, so here it is.

Yes, it’s a knife. A steak knife to be exact. Somewhere in the middle of the face.

First off, you didn’t need to see these to start doing the right things. Since this is a penetrating injury to the “head, neck or torso” it should trigger any trauma center’s highest level of activation. He is whisked off to the trauma bay and quickly evaluated. He’s obviously awake and alert (he walked in), so what do you need to treat him, and how would you manage it?

Tweet or leave comments. More discussion (and pictures) on Monday.

Pop Quiz! The Case

Thu, 09 May 2013 09:00:18 -0500

A young man presents to your emergency department walk-in area. Something is wrong with his head. Here is an AP skull film (when is the last time you got one of those?)

I’ll walk you through my thought processes over the next several days. First, what’s going on? And what should you do now? And next, and so on.

Please tweet and leave comments! My explanation of the initial steps tomorrow.

How To: Secure An Endotracheal Tube To... Nothing!

Wed, 08 May 2013 09:00:22 -0500

Several decades ago I took care of a patient who posed an interesting challenge. He had been involved in an industrial explosion and had sustained severe trauma to his face. Although he was able to speak and breathe, he had a moderate amount of bleeding and was having some trouble keeping his airway clear.

Everyone frets about getting an airway in patients who have severe facial trauma. However, I find it’s usually easier because the bones and soft tissue move out of your way. That is, as long as you can keep ahead of the bleeding to see your landmarks.

In this case, the intubation was easy. The epiglottis was visible while standing above the patient’s head, so a laryngoscope was practically unnecessary! But now, how do we secure the tube so it won’t fall out? Sure, there are tube-tamer type securing devices available, but what if they are not available to you? Or this happened in the field? Or it was in the 1980’s and it hadn’t been invented, like this case?

The answer is, create your own “skin” to secure the tube to. Take a Kerlix-type stretchable gauze roll and wrap it tightly around their head. Remember, they are sedated already and they can breathe through the tube. This also serves to further slow any bleeding from soft tissue. Once you have “mummified” the head with the gauze roll, tape the tube in place like you normally would, using the surface of the gauze as the “skin.”

Be generous with the tape, because the tube is your patient’s life-line. Now it’s time for the surgeons to surgically stabilize this airway, usually by converting to a tracheostomy.

The Newest Trauma MedEd Newsletter Is Available!

Tue, 07 May 2013 09:00:08 -0500

The April newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is Protocols (again). You’ll need a QR code reader if you want to download to your mobile device. Or just use the web URLs provided to download to your desktop/notebook.

In this issue you’ll find articles on:

Chest tube management
Solid organ injury
Rapid reversal of warfarin
Reversal of other anticoagulants
Massive transfusion

Subscribers had the newsletter emailed to them over the weekend. If you want to subscribe (and download back issues), click here.

Download the newsletter here!

Trauma Pearl: Unexpected Respiratory Failure After Blunt Trauma

Mon, 06 May 2013 09:00:21 -0500

A 24 year old restrained female is involved in a T-bone type motor vehicle crash. She sustains a moderate to severe traumatic brain injury and is intubated and sedated. On exam, she has a few abrasions over her left flank, and no other physical findings. Head CT shows some subarachnoid blood, and abdominal CT is negative.

She is placed in the ICU and slowly becomes more responsive. However, her FIO2 has to be increased several times due to poor oxygenation. By day 3, she is on 90% O2 and has diffuse infiltrates in her lung fields.

What’s the problem?!

This is a classic presentation of a missed abdominal injury. Restrained patients are at risk for intestinal injuries, even with a t-bone mechanism and little to no seat belt sign. Physical exam may be helpful, but abdominal pain/tenderness may be masked by head injury.

A repeat CT scan was performed, which showed free fluid and a few bubbles of free air. The patient was taken to the OR and a bucket handle injury to the distal ileum was found, with devitalized and leaking intestine. This was resected and primary anastomosis was performed. Within 2 days, the patient was on 40% O2 and was ready for extubation two days later.

Bottom line: Unexplained respiratory failure after blunt trauma, especially if no chest injury has occurred, is nearly always due to a missed abdominal injury. The initial CT is a snapshot that is valid for only a few hours. Re-image with CT or ultrasound, and operate promptly if any significant change in patient condition occurs.

Related posts:

Fictional case, not treated at Regions Hospital.

Next Trauma MedEd Newsletter Available Tomorrow!

Mon, 06 May 2013 07:54:53 -0500

The April issue of Trauma MedEd was sent out to subscribers over the weekend. This issue, like the March issue, is devoted to protocols.

Included are protocols for:

Chest tube management
Solid organ injury
Rapid reversal of warfarin
Reversal of other anticoagulants
Massive transfusion

Be sure to have a good QR code reader for easy retrieval. Otherwise, warm up your fingers so you can enter URLs to download the protocols.

This issue will be available on the blog tomorrow!

Check out back issues, and subscribe now! Get it first by clicking here!

How Does That Work?: Angioembolization Coils

Fri, 03 May 2013 07:33:34 -0500

Ever wonder how interventional radiologists stop bleeding? They are very skilled in getting access to complicated areas of the arterial tree. Once they have located a bleeding point, they’ve got to plug it up with something.

Over the years, a wide variety of things have been used. They include blood clot, tiny metal or plastic spheres, superglue, and a variety of other creative things. One of the more recent additions is the metal coil.

On xray, these look like little pieces of piano wire in various shapes after they are inserted. But how do they work? They’re metal, and fairly smooth. How does that promote fast clotting?

The answer is more obvious when you look at one of these before it’s been inserted. Note the “fuzz”. These are synthetic fibers that are wrapped into the coil itself, and they are what actually promote clotting when the coil is in place.

Why Do They Call It: Extra-axial Blood?

Thu, 02 May 2013 11:10:32 -0500

You’ve seen it on head CT reports. “The patient has a collection of extra-axial blood…” Then it goes on to describe the location and size of a subdural hematoma. But why is it called “extra-axial?”

The answer lies in the embryology of the central nervous system. Yes, it’s been a long time since any of us have read anything about that. Early animals had a straight neural tube, which slowly evolved into a brain and spinal cord. This is known as the axis of the nervous system.

The brains of early vertebrates developed at the end of the neural tube, and were oriented in the same longitudinal axis as the rest of it. As brains got bigger, a 90 degree bend occurred at the cephalic flexure.

So in humans, there is a difference between the body axis and the brain axis. But the brain axis is what really counts. This means that any blood outside of the brain axis is defined as extra-axial.

Bottom line: Extra-axial blood is defined as any bleeding outside of the brain parenchyma. This includes subdural and epidural hematomas, and subarachnoid hemorrhage. It does not include any intraparenchymal bleeding like contusions or hematomas.

Lab Values From Intraosseous Blood

Wed, 01 May 2013 09:04:12 -0500

The intraosseous access device (IO) has been a lifesaver by providing vascular access in patients who are difficult IV sticks. In some cases, it is even difficult to draw blood in these patients by a direct venipuncture. So is it okay to send IO blood to the lab for analysis during a trauma resuscitation?

A study using 10 volunteers was published last year (imagine volunteering to have an IO needle placed)! All IO devices were inserted in the proximal humerus. Here is a summary of the results comparing IO and IV blood:

Hemoglobin / hematocrit - good correlation
White blood cell count - no correlation
Platelet count - no correlation
Sodium - no correlation but within 5% of IV value
Potassium - no correlation
Choloride - good correlation
Serum CO2 - no correlation
Calcium - no correlation but within 10% of IV value
Glucose - good correlation
BUN / Creatinine - good correlation

Bottom line: Intraosseous blood can be used if blood from arterial or venous puncture is not available. Discarding the first 2cc of marrow aspirated improves the accuracy of the lab results obtained. The important tests (hemoglobin/hematocrit, glucose) are reasonably accurate, as are Na, Cl, BUN, and creatinine. The use of IO blood for type and cross is not yet widely accepted by blood banks, but can be used until other blood is available.

Related post:

Inserting an IO in the humerus (video)

Reference: A new study of intraosseous blood for laboratory analysis. Arch Path Lab Med 134(9):1253-1260, 2010.

Can Lead Poisoning Occur After A Gunshot?

Tue, 30 Apr 2013 09:31:05 -0500

This is a fairly common question from victims of gunshots and their families. As you know, bullets are routinely left in place unless they are superficial. It may cause more damage to try to extract one, especially if it has come to rest in a deep location. But is there danger in leaving the bullet alone?

One of the classic papers on this topic was published in 1982 by Erwin Thal at Parkland Hospital in Dallas. The paper recounted a series of 16 patients who had developed signs and symptoms of lead poisoning (plumbism) after a gunshot or shotgun injury. The common thread in these cases was that the injury involved a joint or bursa near a joint. In some cases the missile passed through the joint/bursa but came to rest nearby, and a synovial pseudocyst formed which included the piece of lead. The joint fluid bathing the projectile caused lead to leach into the circulation.

The patients in the Parkland paper developed symptoms anywhere from 3 days to 40 years after injury. As is the case with plumbism, symptoms were variable and nonspecific. Patients presented with abdominal pain, anemia, cognitive problems, renal dysfunction and seizures to name a few.

Bottom line: Any patient with a bullet or lead shot that is located in or near a joint or bursa should have the missile(s) promptly and surgically removed. Any lead that has come to rest within the GI tract (particularly the stomach) must be removed as well. If a patient presents with odd symptoms and has a history of a retained bullet, obtain a toxicology consult and begin a workup for lead poisoning. If levels are elevated, the missile must be extracted. Chelation therapy should be started preop because manipulation of the site may further increase lead levels. The missile and any stained tissues or pseudocyst must be removed in their entirety.

Reference: Lead poisoning from retained bullets. Ann Surg 195(3):305-313, 1982.

Pneumothorax: How Big Is Too Big?

Mon, 29 Apr 2013 09:00:32 -0500

One of the big unanswered questions in the management of pneumothorax is, how big is too big? At what size is a chest tube of some type mandatory?

The problem is that we just don’t have any good data. Seems like a simple problem, right? Unfortunately, it’s not. A pneumothorax is a three dimensional collection that surrounds the lung in very random ways. All we had to detect and “measure” them for decades was the lowly chest x-ray. Unfortunately, this is a 2D shadow picture that does not allow us to accurately estimate the size.

A few old papers exist that tried to quantify pneumothorax, but they are of no use now that we have chest CT. Unfortunately this new technology has drawbacks, as well. First, it’s just a stack of 2D images that our minds assemble into a 3D mental model, so it’s still difficult to quantify the air. And second, you shouldn’t be getting a chest CT just to diagnose pneumothorax. In blunt trauma, it’s really just for checking the thoracic aorta for injury.

So we’re left with the original question, and there are three answers. If there is any physiologic compromise (hypoxia, tachypnea, anxiety), then the chest should be drained. If the pneumothorax is enlarging over serial chest x-rays, then it should be drained before it causes physiologic change. And finally, if there is concern that it is so large that it will take too long to absorb, especially in older patients with comorbidities, a chest drain should be inserted. This is a somewhat soft indication, however.

Bottom line: The three reasons above are the usual answers to the question, “how big is too big?” For me, once the pneumothorax pushes the lung 1-2 cm away from the chest wall from apex to base, it’s time for a tube.

Ethics Quiz: The Answer?

Fri, 26 Apr 2013 09:00:25 -0500

The hypothetical question I posed yesterday centered around what to do in a case where a patient is assaulted, sustaining easily survivable injuries, but then dies while being treated in the hospital due to a medical error. The police will escalate the criminal charge from simple assault to manslaughter, but the death was no longer really a direct result of the assault. Yet the assailant and police don’t really know any better. What to do?

There are many possible answers to this question, and it depends on who is being asked:

The police / prosecuting attorney will say that it makes little difference. The assailant caused the victim to be injured and admitted to the hospital. Medical errors do occur in any hospital, and the assailant placed the victim in the position where this could occur. They will proceed with prosecuting the assailant on the higher charge.
The hospital attorney will say that only the family may be informed of the error and resultant death. It is a privacy violation (in the US) to directly report any specific patient information to the police unless allowed by the family.
The family will inform you that they are hiring an attorney to bring a civil malpractice case against you and the hospital.
The assailant will say that you damn well better report it, and remind you that he’s facing years in prison if you don’t.
The trauma professionals involved in the medical error will say that they should notify the police on ethical grounds so that the assailant will know that he was not responsible, and that he should not be punished as severely.

So what’s the right answer? As with any ethical questions in health care, there are only shades of gray. In the US system, the usual answer is to communicate the error to the family only. The justice system will not alter the charges based on the new information, so reporting the police is of no use and violates privacy laws.

Bottom line: In any situation as complex as the one described, proceed with great care. Seek out the advice of your mentors, the ethics committee, and the hospital attorney. One person’s idea of what is ethical may be very different from another’s, and the legal realities may render some of the arguments moot. Hasty and uninformed action without proper due process can have grave consequences for all.

Ethics Quiz!

Thu, 25 Apr 2013 09:00:34 -0500

What would you do in this case? And better yet, what should you do? And why might the two answers be different?

First, an important note. This is a hypothetical case. It has never happened in any hospital I’ve worked in, and I have not heard of it happening in one. I have completely fabricated it to make a point.

An elderly man is walking to the store in his neighborhood, and he is assaulted and knocked to the ground by a young man. Witnesses restrain the assailant, and police arrive to take him away to jail, while prehospital providers arrive and transport the victim to the hospital. The assailant is charged with assault and released.

The victim has a facial fracture and a very small intraparenchymal hemorrhage. He is expected to be discharged the following day after a repeat CT scan. The fracture does not need treatment. However, while being monitored in the ICU, a medical error occurs and the patient dies.

The police re-arrest the assailant and charge him with manslaughter, which has a much stiffer jail sentence.

Do you (or your hospital) have a responsibility to let the police know that the new charge is not justified? Is there a potential opening for a civil suit against you (or your hospital)? Can you do anything given current privacy laws?

Tweet out your answer or leave comments below. I’m interested in comments from my legal colleagues, too. What would you do?

Management of CSF Otorrhea/Rhinorrhea

Tue, 23 Apr 2013 08:00:32 -0500

The management of CSF leaks after trauma remains somewhat controversial. The literature is sparse, and generally consists of observational studies. However, some general guidelines are supported by large numbers of retrospectively reviewed patients.

Ensure that the patient actually has a CSF leak. In most patients, this is obvious because they have clear fluid leaking from ear or nose that was not present preinjury. Here are the options when the diagnosis is less obvious (i.e. serosanguinous drainage):
- High resolution images of the temporal bones and skull base. If an obvious breach is noted, especially if fluid is seen in the adjacent sinuses, then a CSF leak is extremely likely.
- Glucose testing. CSF glucose is low compared to serum glucose.
- Beta 2 transferrin assay. This marker is very specific to CSF. However, the test is expensive and results may take several days to a few weeks to receive. Most leaks will have closed before the results are available, making this a poor test.
Place the patient at bed rest with the head elevated. The basic concept is to decrease intracranial pressure, which in turn should decrease the rate of leakage. This same technique is used for management of mild ICP increases after head injury.
Consider prophylactic antibiotics carefully. The clinician must balance the likelihood of meningitis with the possibility of selecting resistant bacteria. If the likelihood of contamination is low and the patient is immunocompetent, antibiotics may not be needed.
Ear drops are probably not necessary. They may confuse the picture when gauging resolution of the CSF leak.
Wait. Most tramatic leaks will close spontaneously within 7-10 days. If it does not, a neurosurgeon or ENT surgeon should be consulted to consider surgical closure.

References:

Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol, 1997;18:188-197.
Brodie HA. Prophylactic antibiotics for posttraumatic cerebrospinal fluid fistulas. Arch Otolaryngol Head, Neck Surg. 123:749-752.