All posts by TheTraumaPro

Coming Tuesday! TraumaMedEd Newsletter For November!

Subscribers to the TraumaMedEd newsletter will receive their copy Tuesday by email. It will be distributed via the blog on Monday, December 3.

This month’s topic is Trauma Mythbusters. I’ll be reviewing and debunking some commonly held beliefs. Some of the topics covered will include:

  • Bathing and showering with wounds
  • NSAIDs and fracture healing
  • Cognitive rest after TBI
and more!

If you want to get your copy early, go to www.TraumaMedEd.com and sign up for a subscription now. You can also download past issues from the site.

Subdural Hematoma: How Well Do They Really Do?

The common teaching is that patients with traumatic subdural hematoma don’t do well. This is generally due to the presence of more direct injury to the brain compared with patients who have epidural hematoma. Outcomes data tends to bear this out. However, this data is at least 20 years old and it would be nice to know if we’ve made any progress in the management of this injury.

Harborview Medical Center retrospectively reviewed four years worth of its trauma registry data on patients with subdural hematoma. They scrutinized the usual outcomes data, looking at patients with and without surgical decompression. During the study period, clinical management routines remained basically the same.

A total of 1427 patients were included in the study. The average age was 58. Interesting facts from the study include:

  • Falls were by far the most common mechanism (57%)
  • Most patients (58%) had a GCS of 13 or higher
  • The TRISS probability of survival was slightly lower in the evacuated group (85%) versus the non-evacuated group (91%), yet
  • Mortality rate was 14%, with traumatic brain injury the most common cause of death
  • 29% had positive urine toxicology testing. Marijuana was most prevalent.
  • Slightly more than half were discharged home. Independence was higher in the group who had undergone evacuation of their hematoma.

Bottom line: Patients with subdural hematoma do better these days than they used to. This is probably due to better imaging (CT), which leads to earlier and more accurate management. Additionally, these injuries are now treated at regional trauma centers like Harborview, which may also improve survival.

Related posts:

Reference: Acute traumatic subdural hematoma: Current mortality and functional outcomes in adult patients at a Level I trauma center. J Trauma 73(5):1348-1354, 2012.

Best Of: IV Contrast

We use CT scanning in trauma care so much that we tend to take it (and its safety) for granted. I’ve written quite a bit about thoughtful use of radiographic studies to achieve a reasonable patient exposure to xrays. But another thing to think about is the use of IV contrast.

IV contrast is a hyperosmolar solution that contains some substance (usually an iodine compound) that is radiopaque to some degree. It has been shown to have a significant impact on short-term kidney function and in some cases can cause renal failure.

Here are some facts you need to know:

  • Contrast nephrotoxicity is defined as a 25% increase in serum creatinine, usually within the first 3 days after administration
  • There is usually normal urine output and minimal to no proteinuria
  • In most cases, renal function returns to normal after 3-4 days
  • Nephrotoxicity almost never occurs in people with normal baseline kidney function
  • Large or repeated doses given within 72 hours greatly increase risk for toxicity
  • Old age and pre-existing diabetic renal impairment also greatly increase risk

If you must give contrast to a patient who is at risk, make sure they are volume expanded (tough in trauma patients), or consider giving acetylcysteine or using isosmolar contrast (controversial, may still cause toxicity).

Bottom line: If you are considering contrast CT, try to get a history to see if the patient is at risk for nephrotoxicity. Also consider all of the studies that will be needed and try to consolidate your contrast dosing. For example, you can get CT chest/abdomen/pelvis and CT angio of the neck with one contrast bolus. Consider low dose contrast injection if the patient needs formal angiographic studies in the IR suite. Always think about the global needs of your patient and plan accordingly (and safely).

Related posts:

Reference: Contrast media and the kidney. British J Radiol 76:513-518, 2003.

Yes, Smoking is Bad!

Everybody knows that smoking is bad. But how often have you stopped by to see one of your trauma patients and have been told “they’re out smoking?” Well, it turns out it’s bad for their injuries as well.

A German group looked at the effects of smoking on healing of a “simple” tibial fracture. They looked at 103 patients who underwent treatment for an isolated tibial shaft fracture at a trauma center. Patients with more complicated problems like extension into a joint, open fracture (Gustilo III), or significant soft tissue injury were excluded. 

Patients were divided into non-smokers and smokers (including previous smokers). A total of 85 patients were studied, and there were roughly half in each group. The nonsmoking group experienced no delayed or non-unions of their fractures. The smoking group reported 9 delayed unions and 9 non-unions in 46 patients! As expected, time off work and eventual functional outcome was worse as well.

Bottom line: The exact mechanism for impairment of fracture healing by smoking is unclear. It may be due to physiologic effects of inhaled tobacco components on blood flow, blood vessels, transforming growth factor levels or collagen formation. It could also be a secondary effect of socioeconomic variables, patient compliance, or a host of other factors. Regardless, it’s bad. Smoking should be forbidden while in hospital, and should be strongly discouraged after discharge.

Reference: Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures. Injury 42:1435-1442, 2011.