All posts by TheTraumaPro

How Long Should We Watch Intracerebral Hemorrhage?

Patients with traumatic brain injury (TBI) severe enough to cause bleeding are usually admitted to the hospital for observation and in many cases, repeat CT scanning. Those with small intracranial hemorrhages (ICH) may experience progression of the bleeding, and a small percentage of cases may need operative intervention (1-3%). Questions we typically face are, how long should we watch for progression, and how often should we scan?

A retrospective cohort study was carried out at UMD-NJ, looking for answers for a specific subset of these patients. Specifically, they had to have a mild blunt TBI (loss of consciousness and/or retrograde amnesia, GCS in the ED of 13-15) and a positive head CT. They classified any type of hemorrhage into or around the brain as positive.

During a 3 year period, 474 adults were enrolled but only 341 were eligible for the study. They were excluded due to previous injury, presence of a mass (not trauma), need for immediate neurosurgical intervention, or failure to get a second CT scan. The authors found:

  • 7% of patients were taking anticoagulants! This is surprisingly high. Interestingly, 15 were subtherapeutic, 3 were therapeutic and 2 were supratherapeutic.
  • Subarachnoid hemorrhage was the most common finding on CT (54%). Intraparenchymal hemorrhage was next most common (48%) Many patients had more than one type of bleed.
  • The injury worsened between the first and second scans in 31% of patients. This number increased to 46% in patients taking anticoagulants.
  • About 97% of bleeds stopped progressing by 24 hrs post-injury.

Bottom line: Most centers are probably overdoing the observation and repeat scan thing. More than two thirds of bleeds are stable by the first scan (first and second scans identical), and nearly all stop progressing within 24 hours. It’s very likely that patients who are not on anticoagulants and who have a stable neuro exam and stable symptoms can get just one scan and 24 hours of observation. Persistent headache, nausea, failure to ambulate well, or other symptoms warrant a repeat scan and longer observation.

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Reference: The temporal course of intracranial haemorrhage progression: How long is observation necessary? Injury 43(12):2122-2125, 2012.

How To Remove An Impaling Object

The books all say “transport the patient with an impaling object in place” and “only take the impaling object out in the operating room.” Is this realistic? How do you actually take that knife out?

First, you need to decide if the patient belongs in the OR right now. Are they hemodynamically unstable? Is there obvious arterial bleeding? If so, don’t dawdle. Proceed to the operating room and surgically expose the problem completely.

If the patient is safe to stay in the ED, do what you need to figure out the exact anatomy of the wound (and object). This may involve imaging, usually CT scan. Once the exact position of the object is understood, build an anatomical picture of the situation in your mind. What named arteries might be involved? What other vital structures?

Given this anatomic information, a decision can then be made regarding the best location for removal. The majority of the time, this will be in the operating room. It is best to obtain optimum surgical exposure prior to pulling it out. In the abdomen, this is easy. However, some areas (skull, sinuses) are tricky and may not require exposure of the end of the tract. Visualization of the remaining hole(s) is key so that bothersome bleeding can be recognized immediately.

The object should be grasped firmly and carefully and removed in one smooth motion. Visual monitoring for five minutes will virtually eliminate the presence of bleeding. If it does occur, then deeper exploration is warranted. In the awake patient, I generally push gently on either side of the entry point prior to and during the pull to provide some sensory distraction. Then I hold pressure on the site for 5 minutes (no peeking) to assure myself that there is no bleeding.

And don’t forget the forensics! Let the police photograph the patient. Handle the object carefully so as not to disturb any fingerprints. Place it carefully in a paper bag, labelled appropriately. And always make sure that a chain of evidence form is properly filled out so it and the object itself can be handed over to the proper authorities.

Subdural Hematomas and Hygromas Simplified

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.

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Trauma MedEd Newsletter Released To Subscribers This Weekend!

The April Trauma MedEd Newsletter will be released to subscribers Sunday. This month’s theme is “ED Stuff.” Articles include:

  • Travails of the electronic trauma flow sheet
  • Designing your trauma team
  • Dressing your trauma team
  • Trauma activation levels and triage criteria
  • And more!

Anyone on the subscriber list as of noon (CST) Sunday will receive it that night. Everybody else will have to wait for me to release it here at the end of next week. So sign up for early delivery now by clicking here!

Pick up back issues here!

Technology: Airbags For Motorcyclists?

A manufacturer of high-end protective gear for motorcycle and auto racing has developed a fully self-contained airbag system that can be worn. The airbag is easily zippered and connected into a compatible outer jacket, made only by Alpinestars (of course). The airbags expand in much the way that auto airbags do, and they offer protection to the back, shoulders, kidneys, chest, and upper abdomen. A set of colored LEDs on the left sleeve show the rider the status of the system at all times.

A built-in microprocessor samples a set of accelerometers 500 times per second. If any linear or rotational force occurs that is outside of allowed parameters, the airbags inflate well before any impact to the torso occurs. The system is powered by a rechargeable battery that allows for about 25 hours of riding time between charges.

Will this be adopted by the general riding public? Probably not in the near future. The airbag system costs over US $2000, and requires service every two years (US $225). And if it deployed? Another US $550 to repack it. But it’s just a matter of time before similar protective devices worn under a riding jacket make their way to the market at an affordable price.

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