Tag Archives: trauma

Pneumocephalus

9 May

submitted by Christina Brown, M.D.

Definition – Air in the cranial vault.  

Mechanically speaking, intracranial air becomes trapped and expands due to a ball valve effect resulting in mass effect, can result in headache and signs and symptoms of increased ICP [5].  

Usually associated with neurosurgery, barotrauma, basilar skull fractures, sinus fractures, nasopharyngeal tumor invasion and meningitis [1, 2].

Presentation

  • Headache and altered consciousness are the most common symptoms [3].
  • Tension pneumocephalus = neurosurgical emergency

Imaging

  • X-rays can diagnose pneumocephalus, but CT scan is the modality of choice.
  • Classical CT sign of tension pneumocephalus = “Mount Fuji sign”: the massive accumulation of air that separates and compresses both frontal lobes and mimics the large volcano in Japan.  

 

Management

Conservative 

  • Neurosurgery C/S. In the vast majority, post-operative pneumocephalus is an expected finding in essentially all post-craniotomy patients.  Most cases of pneumocephalus resolve spontaneously, and conservative management should be provided.  
  • Non-operative management involves oxygen therapy, keeping the head of the bed elevated, prophylactic antimicrobial therapy (especially in post-traumatic cases), analgesia, frequent neurologic checks and repeated CT scans. 

 

Operative – In cases of tension pneumocephalus, a burr hole may need to be performed to relieve pressure. 

 

References

  1. Yildiz A, Duce MN, Ozer C, et al. Disseminated pneumocephalus secondary to an unusual facial trauma. Eur J Radiol. 2002;42:65–68. doi: 10.1016/S0720-048X(01)00383-7. 
  2. Jenson MB, Adams HP. Pneumocephalus after air travel. Neurology. 2004;63:400–401.
  3. Kapoor T, Shetty P. J Emerg Med. 2008;35:453–454. doi: 10.1016/j.jemermed.2007.03.046. 
  4. Satapathy GC, Dash HH. Tension pneumocephalus after neurosurgery in the supine position. Br J Anaesth. 2000;84:115–117. 
  5. Satapathy GC, Dash HH. Tension pneumocephalus after neurosurgery in the supine position. Br J Anaesth. 2000;84 (1): 115-7. Br J Anaesth (abstract)
  6. pictures

 

Advertisements

Spinal Fractures in AS vs. DISH

14 Jan

submitted by Matthew Kongkatong, M.D.

FIRST, SOME DEFINITIONS:

Ankylosing spondylitis:

-Chronic inflammation of the spine causes progressive ossification of the paraspinous ligaments

-Prevalence 0.1%-1.4%

-Male>Female

AS

AS: “bamboo spine”, ossification of disc spaces

 

Diffuse Idiopathic Skeletal Hyperostosis (DISH):

-Non-inflammatory process of known etiology causes progressive ossification of paraspinous ligaments.

-Prevalence varies 2.9%-25%

-Associated with obesity, advanced age, and diabetes mellitus

DISH

DISH: “flowing candle wax”, preserved disc spaces

WHY DOES IT MATTER?

Spine fractures in DISH and AS

-Review article of 93 papers including 345 AS patients and 66 DISH patients

65% of AS and 69% of DISH patients sustained fractures via low energy mechanisms life falling from sitting or standing

Most (80% in AS and 60% in DISH) fractures were in the cervical spine and most were hyperextension type injuries.

-67% of AS and 40% of DISH patients had a neurologic deficit on presentation and 13% of AS and 15% of DISH patients had neurologic deterioration ❤ months from presentation (compared to 0.08% in other population studies).

Most spine fractures are considered unstable because they extend into calcified ligaments and surrounding soft tissue, including into the intervertebral discs.

Calcified ligaments can transmit force and cause fractures in areas remote from the area of trauma.

References: Westerveld LA, Verlaan JJ, Oner FC: Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Eur Spine J 2009, 18:145-156.; http://www.orthobullets.com/spine/2045/dish-diffuse-idiopathic-skeletal-hyperostosis

picture of the day: orbital compartment syndrome

18 Dec

via this EM Ireland talk on eye injuries:

hopefully, you’ll be able to see some signs clinically (e.g. proptosis, pain with EOM) if you’re worried about retro-orbital hematoma causing orbital compartment syndrome, but if you’re on the fence, you might see this on CT:

orbital

 

signs of orbital compartment syndrome on CT:

  • loss of contour of globe
  • tenting of the globe
  • proptosis

 

References: EM Ireland post

Spinal Shock

17 Nov

Definition – Spinal cord injury (SCI) that leads to loss of sympathetic tone below level of the injury.  Hypotension, bradycardia are key clinical signs s/p recent trauma.

 

Pathophysiology/Mechanism

  • Fracture of spinal element
  • Dislocation
  • Ligamentous Rupture
  • Disc herniation
  • GSW indirectly (Kinetic energy)

 

Clinical Signs/Symptoms

  • Paralysis
  • Anesthesia
  • Hypotension
  • Bradycardia (Unopposed Vagal activity).
  • Absent bowel and bladder control

 

Phases of spinal shock

Phase Time Physical exam finding Underlying physiological event
1 0–1d Areflexia/Hyporeflexia Loss of descending facilitation
2 1–3d Initial reflex return Denervation supersensitivity
3 1–4w Hyperreflexia (initial) Axon-supported synapse growth
4 1–12m Hyperreflexia, Spasticity Soma-supported synapse growth

 

Emergency Management

  • A/B: patient with a high cervical cord injury may breathe poorly and may require airway suction or intubation.
  • C: Hypotension may occur due to blood loss from other injuries or due to blood pooling in the extremities lacking sympathetic tone because of the disruption of the autonomic nervous system (neurogenic shock).
    • Vasopressors are usually required. Levophed has been used widely amongst patient’s with TSCI with hypotension and bradycardia. Phenylephrine is theoretically taught as 1st line treatment but studies recommend goal of MAP > 85 – 90 (4,5). 
    • Elevation of the legs, the head-dependent position, blood replacement, and/or vasoactive agents may be required (1).
  • Secondary: check for bladder distension by palpation or ultrasound. A urinary catheter should be inserted as soon as possible.

 

Further Management

  • Cardiovascular complications— Neurogenic shock refers to hypotension, usually with bradycardia, attributed to interruption of autonomic pathways in the spinal cord causing decreased vascular resistance. Patients with TSCI may also suffer from hemodynamic shock related to blood loss and other complications.
    • An adequate blood pressure is believed to be critical in maintaining adequate perfusion to the injured spinal cord and thereby limiting secondary ischemic injury (goal MAP > 85 – 90 mmHg).
  • Respiratory complications – Weakness of the diaphragm and chest wall muscles leads to impaired clearance of secretions, ineffective cough, atelectasis, and hypoventilation.

Glucocorticoids — Methylprednisolone is the only treatment that has been suggested in clinical trials to improve neurologic outcomes — however, the evidence is limited, and its use is debated.  Methylprednisolone is contraindicated in patients with moderate to severe traumatic brain injury.

Surgery — Goals for surgical intervention in TSCI include stabilization of the spine, as well as reduction of dislocations and decompression of neural elements.

 

Submitted by Christina Brown.

 

References:

  1. http://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury?source=search_result&search=neurogenic+shock&selectedTitle=2%7E17
  2. Jia X, Kowalski RG, Sciubba DM, Geocadin RG. Critical care of traumatic spinal cord injury. J Intensive Care Med 2013; 28:12.
  3. Vale FL, Burns J, Jackson AB, Hadley MN. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg 1997; 87:239.
  4. Blood pressure management after acute spinal cord injury. Neurosurgery 2002; 50:S58.
  5. Levi L, Wolf A, Belzberg H. Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome. Neurosurgery 1993; 33:1007.
  6. Stevens RD, Bhardwaj A, Kirsch JR, Mirski MA. Critical care and perioperative management in traumatic spinal cord injury. J Neurosurg Anesthesiol 2003; 15:215.
  7. Breslin K, Agrawal D. The use of methylprednisolone in acute spinal cord injury: a review of the evidence, controversies, and recommendations. Pediatr Emerg Care 2012; 28:1238.
  8. Breslin K, Agrawal D. The use of methylprednisolone in acute spinal cord injury: a review of the evidence, controversies, and recommendations. Pediatr Emerg Care 2012; 28:1238.
  9. TABLE: http://www.nature.com/sc/journal/v42/n7/full/3101603a.html

Resuscitative Thoracotomy

17 Sep

A thoracotomy can be a life-saving procedure in a select group of patients.  This specific subset of patients is stillcontroversial. 

Resuscitative thoracotomy may be justified in trauma patients with shock.  The beneficial aspects of the procedure include:

  • decompressing cardiac tamponade
  • cross-clamping the aorta
  • controlling exsanguinating cardiac or large vascular injuries. 

External chest compressions can provide a maximum of 30% of cardiac output and is dependent on venous return to the heart (1).  Chest compressions in the trauma patient are ineffective, may increase cardiac trauma by causing blunt myocardial injury and obstruct access for performing definitive manoeuvers (1).

Penetrating Thoracic Injury — Resuscitative thoracotomy may be justified in patients with:

  1. Hemodynamically unstable on arrival AND after appropriate fluid resuscitation.
  2. Pulseless patients, receiving CPR for less than 15 minutes, and if appropriate resources (eg, appropriately-trained surgeon, operating room) are available [4].

Blunt Thoracic injury — controversial.  According to the American College of Surgeons the sector of patients who may benefit include:

  1. Cardiac arrest in a trauma patient occurring prior to ED arrival, during resuscitation or observation
  2. Profound hypotension (BP<70mmHg) due to truncal wound in an unconscious patient or unavailable operating room.

Contraindications — Resuscitative thoracotomy is likely to be futile if:

  • No signs of life at the scene of injury
  • Asystole is presenting rhythm and no pericardial tamponade on U/S.
  • Prolonged pulselessness (>15 minutes)
  • The patient requires >10 minutes of prehospital CPR
  • Multiple, massive non-survivable injuries.
  • Severe head injury (1)

PREPARATION — One member of the trauma team should be designated to lead the ongoing resuscitation effort while an experienced member of the trauma team is performing the thoracotomy.

General Approach

A left sided approach is used in all patients in traumatic arrest and with injuries to the left chest. Patients who are not arrested but with profound hypotension and right sided injuries have their right chest opened first (4)

  • An anterior lateral incision is made, the chest is entered, and a retractor is placed. Left or right incision based on location of thoracic injury.
  • If tamponade is present, perform pericardiotomy – The pericardial sac is opened and temporizing measures are used to control any cardiac injuries.
  • The aorta is cross-clamped to allow filling of the heart and facilitate ongoing fluid resuscitation.
  • Open cardiac massage using a two hand approach (operator’s thumb can perforate right ventricle) is initiated once the heart has filled sufficiently.

Outcomes — Clinical data evaluating the outcomes of resuscitative thoracotomies are derived primarily from retrospective cases (3-5). Much heterogeneity in the populations and outcomes were present.

COST — Resuscitative thoracotomy is expensive.  Costs associated with other aspects of resuscitative thoracotomy include expenditures related to community EMS, hospital resources including supplies, personnel and transfusion services, and consequences of blood-borne pathogen exposures. Furthermore, the patient neurological outcome plays a critical role in the long-term outcome of patient population.

Submitted by Christina Brown.

References:

  1. http://www.trauma.org/index.php/main/article/361/
  2. http://www.uptodate.com/contents/resuscitative-thoracotomy-technique?source=search_result&search=thoracotomy+adult&selectedTitle=1%7E150#H536270528
  3. Seamon MJ, Shiroff AM, Franco M, et al. Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers. J Trauma 2009; 67:1250.
  4. Karmy-Jones R, Namias N, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating chest trauma. J Trauma Acute Care Surg 2014; 77:994.
  5. Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis. Ann Emerg Med 2015; 65:297.
  6. Powell DW, Moore EE, Cothren CC, et al. Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation? J Am Coll Surg 2004; 199:211.
  7. Photo credit via < http://www.trauma.org/index.php/main/article/361/

visual aid: ultrasound for pneumothorax

21 Jul

great visual aid reminders for the ultrasound findings for a normal lung vs. pneumothorax via June’s Emed Journal:

Linear probe

2nd intercostal space, mid-clavicular, anterior chest wall

NORMAL LUNG (“waves on the beach”)

 

PNEUMOTHORAX (barcode sign)

References: emed journal article

quick exposure with trauma shears: cut & tear

19 May

something I learned by trial & error and watching others along the way, but nicely addressed in this EMT Spot blog post:

NOT ROCKET SCIENCE:

cut at the edges (hemmed areas like the cuffs, collar, waist, etc)

tear with your hands (most fabrics will tear along that line fairly well)

 

quicker than cutting down each entire sleeve/pant leg

– less likely to cut through cords/leads/IVs, since there’s less cutting

 

 

BONUS TIPS:

– to remove shoes, cut the laces, and/or cut down the sides

be careful when cutting near pockets (a cloud of white powder in the resus bay complicates things)

cut around penetrating trauma holes in clothing (may be useful evidence)

– if pt moveable (e.g. not immobilized), cut midline at collar in front and back, then pull from the sides.

 

REMINDER:

– once you’re done with the assessment, cover ’em back up 

 

There you go.

 

References: EMT spot blog + pictures