All posts by TheTraumaPro

Return To Baseline After Concussion

Here’s another interesting paper that was presented at the Congress of Neurological Surgeons. There’s a lot of attention being focused on the incidence and management of concussion during sporting events. An international Concussion in Sport Group has been meeting for over 10 years, contemplating classification and management of this injury. They are considering using age to modify management of concussion in young athletes.

The authors looked at their own experience with 200 adolescent and young athletes. They stratified by age (younger = 13-16 year olds, older = 18-22 year olds), with 100 in each group. They matched them by number of previous concussions, and all underwent baseline and post-concussion ImPACT testing. They specifically looked at the number of days needed to return to baseline.

Interestingly, they identified significant differences in recovery time. And strangely enough, the older players did better than the younger ones. Overall, 90% returned to baseline within a month. But the younger players took 2-3 days longer to recover than the older ones. 

Bottom line: Looks like the Concussion in Sport Group is right on! Usually in trauma, older folks do worse than younger ones, so we tend to treat them more carefully. Not so in youngsters with concussions. Sports medicine physicians need to realize that the younger brain takes longer to recover, and they should err on the safe side and keep them out of the game longer. Objective testing to help predict return to play is extremely helpful.

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Reference: Sport-Related Concussion and Age: Number of Days to Neurocognitive Baseline. Oral presentation 145 – Congress of Neurological Surgeons 2012.

Paging And The Trauma Pro

People who work in hospitals, particularly physicians, physician assistants, nurse practitioners and residents are throwbacks who still use old-fashioned paging technology. My colleague, the Skeptical Scalpel, recently lamented this fact in one of his blog posts. But they do seem to be a necessary evil, since cellular coverage is often limited deep inside of buildings.

But how much to trauma professionals get paged? An oral presentation at the recent Congress of Neurological Surgeons described a study that monitored paging practices between nurses and neurosurgical residents.

Medical students were paid to follow neurosurgical residents during 8 12-hour call shifts. They recorded the paging number and location, priority, and what the resident was doing when paged. The results were enlightening but not surprising:

  • 55 pages were received per shift, on average, ranging from 33 to 75
  • An average of 5 pages per hour were received, with a range of 2 to 7
  • A substantial number of pages were received during sleep times (4 per hour)
  • It took an average of 1.4 minutes to return the page
  • 68% of pages were non-urgent
  • 65% interrupted a patient care activity
  • An average of 1.1 hours was spent returning pages per shift

Bottom line: Yes, we are throwbacks using an old technology. But it does serve us well. Unfortunately, it’s an old technology being used in an inefficient manner. I recommend that nursing units make it a practice to maintain a “page list” of nonurgent items. The trauma professional can then stop by or call each unit periodically (every 2 hours or some other appropriate time interval) and deal with all of them at once. Obviously, urgent and emergent problems should still be called immediately. This will ensure that routine issues are taken care of in a timely manner and the trauma pro can attend to their other duties as efficiently as possible.

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Reference: Oral Paper 113: An Observational Study of Hospital Paging Practices and Workflow Interruption Among On-call Junior Neurosurgery Residents. Presented at the Congress of Neurological Surgeons 2012.

CT Scans And Rib Fractures

Last week I discussed the importance of treating rib fractures in older patients with the greatest respect. One reader commented:

“number of rib fratures are not that accurate by x-ray. If further evaluate by CT, more fractures will be identified”

Well, I agree and I disagree. Chest xray is notoriously inaccurate when it comes to diagnosing or counting rib fractures. Some older studies have shown that a plain chest xray may miss as many as 50% of all rib fractures. On the other hand, CT scan is very accurate at diagnosing them.

But the question is, do we need to know exactly how many ribs are fractured? In general, the answer is no. Rib fracture is a clinical diagnosis. A patient with an appropriate mechanism and focal tenderness on the chest wall has a rib fracture unless proven otherwise. Do we need to prove otherwise? No. They still have pain, and it still needs to be treated. The degree of pain and pulmonary impairment determines the need for admission and more advanced therapies, not an exact count of ribs fractured. 

Bottom line: Rib fracture is a clinical diagnosis! CT scan of the chest for diagnosing rib fractures (or pneumothorax, or hemothorax for that matter) is basically not indicated. It delivers a lot of radiation (and IV contrast if you mistakenly order it), but does not change management. For blunt trauma, CT of the chest should only be used for screening for aortic injury. The only possible indication I can think of is to plan ORIF of complicated, displaced rib fractures. But in that case, let your surgical specialist decide if the test is really necessary.

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More On Rib Fractures In The Elderly

In response to my post yesterday, Chris Nickson wrote:

“Is it possible there were physiologically young but chronologically old patients with isolated rib #s that were sent home from ED that were not included in the study?

I suspect that there are patients over 65 years old with isolated rib #s that can be safely discharged if follow up is bullet proof and pain well controlled.

However, I agree with your over riding message to not underestimate the elderly rib fracture!”

Very few authors do anything but stratify the elderly by age when they write research papers. They do not look at frailness, even though there are scoring systems to do just that. Plus, the retrospective nature of most of the literature (including this paper) preclude the use of such a scale.

Most of the elderly patients that we all see in the ED are selected out to be frail. The healthy ones stay at home and tough out a single rib fracture or even two. But the ones who are brought in are most likely having issues with pain or breathing, thus prompting the visit.

Bottom line: I agree that some elderly patients (the younger and healthier ones) could potentially be sent home from the ED with some pain medication. But the trauma professional needs to make sure that they are comfortable and can move about with well controlled discomfort. They also need good discharge instructions regarding returning to their primary physician or ED promptly if they start to have pain control or respiratory problems. If there is any doubt, bring them in to the hospital for a brief visit for pain control and pulmonary management.

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Rib Fractures In The Elderly

Just like children are not small adults, elderly patients are not just old adults. As I mentioned yesterday, mortality increases significantly as we get older such that the same injury is much more likely to kill an elder.

Rib fractures are no exception. A 10 year retrospective cohort study looked at the management and mortality of this problem in patients 65 and older at Harborview in Seattle. When comparing young and old patients with the same number of fractures and injury severity, death and pneumonia were twice as likely in the elderly (22% vs 10% mortality, 31% vs 17% pneumonia). Ventilator days and hospital/ICU length of stay was significantly longer, too. Mortality increased by 19% and pneumonia increased by 27% for each additional rib fracture in the elderly.

Here are some practical tips for management of rib fractures in the elderly:

  • Admit any older patient with even a single rib fracture for pain management and pulmonary toilet
  • Treat their pain well, but watch the narcotics! Consider an epidural if indicated, but monitor carefully.
  • Keep your patient out of bed as much as possible. Chairs are good, walking is better.
  • Encourage coughing and other pulmonary toilet techniques
  • Do not discharge until they pass the “eyeball” test. This means that they have to look well enough to go home and participate in their usual activities. They should be walking around at their usual speed and agility. It does no good to discharge and lay in bed or on the couch. They’ll be back dying of pneumonia before you know it.
  • A general rule of thumb: Length of stay is generally n+1 days, where n is the number of rib fractures (isolated injury). Be wary of trying to send someone home sooner than this.

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Reference: Rib fractures in the elderly. J Trauma 48(6):1040-1046, 2000.

Thanks to Scott Weingart, author of the EMCrit Blog (www.emcrit.org) for suggesting this topic!