All right, you’re good! Many people concluded that this was blunt trauma, and that there was something wrong with the diaphragm. Several people went so far as to say it was a motor vehicle crash.
Great so far! But take it one step further and tell me exactly what happened in this crash. You know, speed, direction, mass, all that physics stuff! Final answer tomorrow!
Here’s another one to test your powers of deduction. The question is not “what’s the diagnosis on this x-ray,” but rather, “what was exact mechanism of injury?”
Hints tomorrow if no one guesses today. Please respond via comments below or Twitter!
Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps to ensure quality care and provide good communication between caregivers and patients / families.
We have disseminated a set of guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.
In order to deliver the highest quality and most cost-effective care, we request that services we consult do the following:
- Please introduce yourself to our patient and their family, and explain why you are seeing them.
- Although you may discuss your findings with the patient, please discuss all recommendations with a member of the trauma service first. This avoids patient confusion if the trauma team chooses not to implement any recommendations due to other patient factors you may not be aware of.
- Document your consultation results in writing (paper or EMR) in a timely manner.
- If additional tests, imaging or medications are recommended, discuss with the trauma service first. We will write the orders or clear you to do so if appropriate, and will discuss the plan with the patient.
- We round at specific times every day and welcome your attendance and input.
- Please communicate any post-discharge instructions to us or enter in the medical record so we can expedite the discharge process and ensure all followup visits are scheduled.
Bottom line: A uniform “code of behavior” is important! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature, and they will not be familiar with how their recommendations may impact other injuries.
Click here to download the full copy of the Regions Hospital Trauma Services consultant guidelines.
There is some variability in how neurosurgeons manage ventriculostomy when it comes to antibiotic coverage. The catheter can become a conduit for bacterial infections of the meninges or brain, which can be life threatening. Most neurosurgeons will begin coverage at the time of catheter insertion, but the duration of treatment varies. What is the right answer, if any?
As is typical with most things related to head trauma, there are not a lot of good studies out there. Columbia University published a fairly comprehensive review of previous studies last year to help clarify this issue. They applied rigorous criteria to identify 10 relevant studies (3 randomized clinical trials and 7 observational studies) out of a pool of 347. Yes folks, this gives you an idea of how tough it is to answer good clinical questions from the stuff that gets published.
The study found that the use of either prophylactic antibiotics or antibiotic-coated external ventricular drains (EVD) decreased the number of infections by 68%. This result was consistent across both study designs. The authors could not show that one mode of antibiotic administration (systemic vs catheter coating) was better than the other. About half of the studies used antibiotics for the duration of the catheter; the other half did not specify.
Bottom line: Head injury patients with an EVD should receive antibiotics, either systemically or as a coating on the EVD catheter itself. Although not entirely clear, they should probably be given for the entire time the catheter is in place. Judgment must be used if this will be a long time, because there may be other adverse effects from giving long term antibiotics.
Reference: Prevention of Ventriculostomy-Related Infections With Prophylactic Antibiotics and Antibiotic-Coated External Ventricular Drains: A Systematic Review. Neurosurgery 68(4):996-1005, 2011.
Looks like I failed to give the link to the August TraumaMedEd newsletter. But thanks for all the new subscriptions. I’ve corrected the original post, and here’s the link again!
Download the newsletter here!