All posts by TheTraumaPro

More On CSF Rhinorrhea/Otorrhea

Trauma professionals worry about stuff. Like just about everything, really. Sometimes we have good guidance (research) to help us decide what to do. Many times, we don’t. Management of rhinorrhea and otorrhea from CSF leak after trauma is definitely one of those things.

I’ve seen a variety of treatments used in these patients over the years. Is it really a CSF leak? Let’s get a beta-2 transferrin test (see below). Can’t the patient get meningitis? Their may be concomitant sinus fracture and bacterial contamination, so why not give antibiotics? Or vaccinate them?

The Cochrane library contains a vast number of reviews of common clinical questions. One of those questions just happens to be the utility of giving prophylactic antibiotics in patients with basilar skull fracture. Interestingly, they’ve been reviewing and re-reviewing this question about every 5 years, since 2006. During the three reviews done, there have been no additional research papers published on the topic.

Here are the factoids:

  • Studies that specifically examined the use of prophylactic antibiotics in patients with basilar skull fracture were reviewed. All included meningitis as one of the outcome parameters.
  • There were only 5 high quality (randomized, controlled) trials, with a total of 208 participants
  • There were an additional 17 lower quality trials published, but no conclusions could be reached from them due to methodology problems
  • In the high quality trials, there were no differences in the incidence of meningitis, mortality, or meningitis-related mortality
  • There were no specific adverse effects related to antibiotic administration. But one of the high quality studies did note a shift to higher counts of pathologic bacteria in the posterior nasopharynx in the antibiotic group.
  • No studies on the use of meningitis vaccinations exist. A survey of UK physicians showed that 35% recommend at least one vaccine, typically for Strep Pneumo.

Bottom line: There is still no good evidence to support the use of prophylactic antibiotics or meningitis vaccination in patients with CSF leak from uncomplicated basilar skull fracture. When you see surveys that show some physicians promoting a treatment and others doing nothing, it means there is most likely no significant benefit. If there were a big difference, we would have seen it by now! And giving drugs (antibiotics, vaccines) that have no proven use is expensive and can always lead to unexpected complications. 

Related posts:

References:

  • Immunisations and antibiotics in patients with anterior skull base cerebrospinal fluid leaks. J Laryngol Otol 128(7):626-629, 2014.
  • Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev April 28, 2015.

The Soft Cervical Collar

They are the cliches of the courtroom. The defendant appears before the jury with a cane, a cast, and a soft cervical collar. Looks good, but are they of any use? There are really two questions to answer: does a soft collar limit mobility and does it reduce pain? Amazingly, there’s very little literature on this ubiquitous neck appliance.

First, the mobility question. It’s a soft collar. It’s made of sponge. So it should be no surprise that it doesn’t reduce motion by much, about 17%. But it is better than no collar at all.

What about pain control? One small retrospective review looked at the effect of a soft collar vs no collar at all on pain after whiplash injury. Keep in mind that the definition of “whiplash” is all over the place, so you have to take it with a big grain of salt. But the authors found that there was no difference in subjective pain scoring with or without the collar.

Another much older study (1986) compared a soft collar with active motion after whiplash. Subjects who actively moved their neck around had less subjective pain after 8 weeks.

Bottom line: The soft cervical collar keeps your neck warm. Not much else. And in my experience, prolonged use (more than a few days) tends to increase uncomfortable neck spasms. So use them as an article of clothing in Minnesota winters, but not as a medical appliance.

Related posts:

References:

  • A comparison of neck movement in the soft cervical collar and rigid cervical brace in healthy subjects. J Manipulative Physiol Ther. 34(2):119-22, 2011.
  • The effect of soft cervical collars on persistent neck pain in patients with whiplash injury. Acad Emerg Med. 3(6):568-73, 1996.
  • Early mobilization of acute whiplash injuries. Br Med J (Clin Res Ed). 292(6521):656-7, Mar 8 1986.

Treating Headache After TBI

Most patients with mild traumatic brain injury (TBI) recover quickly and have few sequelae. Headache is common during the first few hours or days. But some patients experience significant and sometimes unrelenting headaches after their injury. How should we treat them? Are they the same as other common headaches?

There are several common types of headaches that are not related to brain injury, but many of these can begin after TBI. These include tension headaches from muscle tension or spasm, cervicogenic headaches from strains, sprains or more significant injury to the neck and cervical spine, musculoskeletal headaches from pain in bone or muscle in the head or neck, and headaches related to the TMJ and jaw.

But many patients experience significant headaches without any of these factors. Why? Sometimes it is due to blood in or around the brain, irritating the meninges. But often, there is nothing that we can detect using our current diagnostic technology. However, even if we can’t find a reason, the headache is very real and very concerning to the patient. 

I’ve seen practitioners treat post-TBI headaches with a variety of drugs ranging from acetominophen and NSAIDs to anti-seizure and psychotropic drugs. Unfortunately, there is little literature support for any of them. A review article published in 2012 found only one article with Class II data that showed no lasting effect from manipulation therapy. 

So what do we do? Here is an algorithm suggested by the review article:

  • Consider a workup to rule out intracranial pathology as a source of the headache
  • Categorize the headache. If it is one of the non-TBI types listed above, treat appropriately.
  • If the headache severely limits function, consider time-release opioids
  • For milder headache, consider adetominophen or NSAIDs
  • Treat any comorbidities that may contribute to headache
  • If the headache has migraine-type properties, treat as such
  • If the headache is associated with cervical spine pain, mobilize the neck as appropriate

Bottom line: There is very little guidance for treatment of headache purely associated with TBI. Time-honored drugs like opioids for severe pain and acetominophen and NSAIDs for mild to moderate pain help, but generally do not entirely relieve the pain. Only tincture of time will make things better. And it’s probably best to stay away from prescription drugs other than opioids recommended for the pain. They have not been shown to work, and there are plenty of side effects to worry about.

Related post:

  • Prescription drugs and side effects

Reference: Systematic review of interventions for post-traumatic headache. PM&R. 4(2):129-140, 2012.

Field Amputation: The Final Word

I’ve spent the last week writing about the nuances of field amputation. I’ve heard from a number of readers about who does it at their facility. Keep in mind that this is a very rarely performed procedure. The few times I’ve been called out in the field, the prehospital providers have conveniently managed to extricate the patient just prior to my arrival. Whew!

Various providers (prehospital, emergency physician, surgeon) may provide this “service” at various places around the world. In the US, it is usually a physician, and typically a surgeon. In my opinion, anyone can be trained to do a basic field amputation.

Much depends on local policies and procedures, training, and availability. Prehospital providers are on scene in most cases, so it makes sense that they could do a field amputation with appropriate training. Emergency physicians have more experience with airway management, sedation, and anesthesia, and can thus add value to the process. 

But again, in my opinion, a trauma surgeon is the best choice for performing this procedure. They have the technical skills, and are usually facile with anesthesia and sedation. But they also have a deep understanding of the anatomy involved, and the eventual reconstruction process. This allows them to tailor the amputation to optimize the eventual recovery from this operation. The surgeon does not necessarily have to resort to a guillotine type amputation. And they are better versed in performing amputations that involve the upper extremity, as well as more proximal amputations (shoulder, upper thigh). And if unexpected bleeding occurs that cannot be controlled by a tourniquet, they know what to do.

The only downside to using a physician is availability. There will always be extra time involved in getting them to the scene since they are typically hospital-based, whereas the prehospital providers are already present and are used to working in an austere environment. 

Bottom line: There is no cookbook for developing a field amputation policy and procedure. Look at your local resources, and the logistics imposed by environment, traffic, your hospital, and other factorss. Then look at my previous posts and figure out what works for you. And finally, make the process as simple as possible. Due to the very rare need for field amputation, you will need to periodically review the process and location of your packs so people don’t forget.

Field Amputation for Trauma, Part 4

We’ve covered all the prep for field amputation over the past 3 days. Now, it’s time to do it. What equipment is needed? There are two principles: figure it all out in advance, and keep it simple.

It is crucial that the trauma program design and assemble equipment and drug packs in advance, otherwise critical equipment may not make it to the field. The pack needs to be conveniently located, have fresh instruments and batteries for the equipment, and should have essential anesthetics included. A sample list is available here, and I encourage you to modify it to suit your needs.

Paralytics, sedatives and analgesics are essential. I prefer vecuronium, midazolam and fentanyl, but there are many other choices. I would discourage the use of propofol because it is difficult to titrate outside the hospital and may contribute to hypotension.

The patient must be intubated prior to starting the procedure. This airway may be difficult due to patient positioning, so be prepared to perform a surgical airway. Finally, don’t assume that your patient will be nicely positioned supine. Rescue workers may need to support the patient (or you) if he or she is in an awkward position.

Finally, don’t assume that you will accompany the patient (and possibly their limb) back to the hospital. Based on the specific aircraft used, there may not be room available. You may return by ground transportation or another aircraft. That’s why your backup plan needs to be well thought out!

Resources: