All posts by TheTraumaPro

Spinal Cord Concussion In Student Athletes

Spinal cord injuries are typically devastating injuries with profound consequences for function and life expectancy. However, a small percentage result in rapidly reversible symptoms. Because these temporary injuries are rare, they tend to cause confusion among clinicians.

Technically, a spinal cord concussion (a “zinger” or “stinger” is an example) is a mild cord injury that results in transient neurologic disturbances. The deficits can be sensory, motor or both, and typically resolve in less than 48 hours. The injuries tend to involve the mid-portion of the cervical cord or the cervico-thoracic junction, since these are the areas of maximum mobility. In a few cases, the athlete has congenital narrowing of the spinal canal which predisposes them to injury. In most cases, the injury probably occurs due to the flexibility of the young spine.

The usual management consists of an MRI of the spine followed by admission and frequent neurologic checks to ensure ongoing resolution. MRI is typically negative in a true concussion. If a signal change is seen, then technically a cord contusion is present. Management is the same for both. There is no indication to give steroids. Evaluation of the ligaments is critical to determine if a collar will be necessary.

Recovery is rapid and complete. But what is the answer to the inevitable question, “when can he/she return to play?” In adult players, the literature suggests that it may be safe to return once they have fully recovered. There is little guidance for kids.

Here’s what I tell the parents: This event has shown that, given the right force applied to your child’s neck, the bones can move enough to injure their spinal cord. This time, the cord was just tickled a little bit. But if the bones had moved just another millimeter or two, this injury could have been permanent and they would never have walked again. I recommend that they do not play this sport again.

Some of you may disagree. I’d be very interested in hearing your comments. 

Reference:

  • First mention: About concussion of the spinal cord. Wein Med Jahrb 34:531, 1879.

But The Radiologist Made Me Do It!

The radiologist made me order that (unnecessary) test! I’ve heard this excuse many, many times. Do these phrases look familiar?

  1. … recommend clinical correlation
  2. … correlation with CT may be of value
  3. … recommend delayed CT imaging through the area
  4. … may represent thymus vs thoracic aortic injury (in a 2 year old who fell down stairs)
Some trauma professionals will read the radiology report and then immediately order more xrays. Others will critically look at the report, the patient’s clinical status and mechanism of injury, and then decide they are not necessary. I am firmly in the latter camp.
But why do some just follow the rad’s suggestions? I believe there are two major camps:
  • Those that are afraid of being sued if they don’t do everything suggested, because they’ve done everything and shouldn’t miss the diagnosis
  • Those that don’t completely understand what is known about trauma mechanisms and injury and think the radiologist does
Bottom line: The radiologist is your consultant. While they are good at reading images, they do not know the nuances of trauma. Plus, they didn’t get to see the patient so they don’t have the full context for their read. First, talk to the rad so they know what happened to the patient and what you are looking for. Then critically look at their read. If the mechanism doesn’t support the diagnosis, or they are requesting unusual or unneeded studies, don’t get them! Just document your rationale clearly in the record. This provides best patient care, and minimizes the potential complications (and radiation exposure) from unnecessary tests.
Related post: 

Reference: Pitfalls of the vague radiology report. AJR 174(6):1511-1518, 2000.

Tips For Surgeons: Seat Belt Sign

We see seat belt signs at our trauma center with some regularity. There are plenty of papers out there that detail the injuries that occur and the need for a low threshold for surgically exploring these patients. I have not been able to find specific management guidelines, and want to share some tidbits I have learned over the years. Yes, this is based on anecdotal experience, but it’s the best we have right now.

Tips for surgeons:

  • Common injuries involve the terminal ileum, proximal jejunum, and sigmoid colon. My observation is that location in the car is associated with the injury location, probably because of the location of the seat belt buckle. In the US, drivers buckle on the right, and I’ve seen more terminal ileum and buckethandle injuries in this group. Front seat passengers buckle on the left, and I tend to see proximal jejunum and sigmoid injuries more often in them.
  • Seat belt sign on physical exam requires abdominal CT for evaluation, regardless of age. The high incidence of significant injury mandates this test.
  • Seat belt sign plus any anomaly on CT requires evaluation in the OR. The only exception would be a patient with minimal fluid only in the pelvis with an unremarkable abdominal exam. But I would watch them like a hawk.
  • In patients who cannot be examined clinically (e.g. severe TBI), a rising WBC count or lactate beginning on day 2 after adequate resuscitation should prompt a trip to the OR. This is an indirect method for detecting injured bowel or mesentery.
  • Laparoscopy may be used in patients with equivocal findings. Excessive blood, bile tinged fluid, succus, or lots of fibrin deposits on the bowel should prompt conversion to laparotomy. Tip: place all ports distant to the seat belt mark. The soft tissues are frequently disrupted, and gas may leak into this pocket prohibiting good insufflation of the peritoneal cavity.
  • If in doubt, open the abdomen. It’s bad form to put in the scope, see something odd, and walk away. Remember, any abnormal finding after trauma is related to trauma until proven otherwise. It’s almost never pre-existing disease.

Related posts:

Predicting Escalation Of Domestic Violence

Most trauma professionals will have the opportunity to provide care for victims of domestic violence some time during their career. We are on the front lines and can unfortunately see the damage first hand. From time to time, the abuse escalates to a point where the woman (typically) is murdered. Is there a way to predict this fatal progression so it can be avoided?

The answer is yes! The Danger Assessment Tool (DAT) was developed 25 years ago and has been validated. Even though the instrument is old, it remains extremely helpful. The unfortunate thing is that at least half of the women involved do not recognize the grave peril they are in.

Some key points that were uncovered in the development of the DAT:

  • If a gun or other weapon is used to threaten, the risk of being murdered increases 20-fold
  • If there is merely a gun in the house, the risk of murder increases 6 times
  • If the abuser threatens murder, the risk of being killed increases 15-fold
  • Other indications of increased risk of death include heavy substance abuse, extreme jealousy, stepchild in the household, attempts to choke and forced sex

Bottom line: Domestic violence is criminal. We must go beyond the physical treatment and make sure these individuals are safe. Use the Danger Assessment Tool routinely to help identify women most at risk of losing their lives and bring all your social services resources to bear to keep them safe!

Download: Danger Assessment Tool

References:

  • Campbell, Jacquelyn C., Assessing Dangerousness: Violence by Sexual Offenders, Batterers, and Child Abusers, Newbury Park, CA: Sage Publications, 1995.
  • Campbell, Jacquelyn C. , Phyllis W. Sharps, and Nancy Glass, “Risk Assessment for Intimate Partner Violence,” in Clinical Assessment of Dangerousness: Empirical Contributions, ed. Georges-Franck Pinard and Linda Pagani, New York: Cambridge University Press, 2000: 136–157.

Prehospital Lift-Assist Calls

Here’s something I was completely unaware of until just a few years ago. A number of 9-1-1 calls (quite a few, I am told) are made, not for injury or illness, but because the caller needs help getting back into bed, chair, etc. It is also common that prehospital providers are frequently called back to the same location for the same problem, or a more serious one, within hours or days.

Yet another study from Yale looked at the details of lift-assist calls in one city in Connecticut (population 29,000) during a 6 year period. The town has a fire department based EMS system with both basic and advanced life support, and they respond to 4,000 EMS calls per year. 

Some interesting results:

  • Average crew time was about 20 minutes
  • 10% of cases required additional fire department equipment, either for forced entry or for assistance with bariatric patients
  • About 5% of all calls were for lift-assist, involving 535 addresses
  • Two thirds of all calls went to one third of those addresses (174 addresses)
  • There were 563 return calls to the same address within 30 days (usual age ~ 80)
  • Return calls were for another lift-assist (39%), a fall (8%), or an illness (47%)

Bottom line: It looks to me that we are not doing our elderly patients any favors by picking them up and putting them back in their chair/bed. Lift-assist calls are really a sentinel event for someone that is getting sick or who has crossed the threshold from being able to live independently to someone who needs a little more help (assisted living, etc). Prehospital personnel should systematically look at and report the home environment, and communities should automatically involve social services to help ensure the health and well being of the elder. And a second call to the same location should mandate a medical evaluation in an ED before return to the home.

Reference: A descriptive study of the “lift-assist” call. Prehospital Emergency Care, online ahead of print, September 2012.