All posts by TheTraumaPro

When Can Your Trauma Patient Stop Taking Warfarin?

I admit it. I read trauma and surgery literature, not medical literature. Imagine my surprise when a fellow physician (internist) told me that there is an objective system for helping us figure out whether anticoagulation is needed for atrial fibrillation. “CHADS2” he said. Am I the last trauma surgeon on earth to hear about this?

CHADS2 is a validated scoring system for predicting stroke risk in people with atrial fibrillation. There are 5 components as follows:

  • C – congestive heart failure – 1 point
  • H – hypertension (treated or untreated) – 1 point
  • A – age >= 75 – 1 point
  • D – diabetes mellitus – 1 point
  • S2 – history of stroke or TIA – 2 points

Stroke risk is directly correlated to the number of points scored. So based on that the recommendations are:

  • Score = 0: low risk, no therapy needed or just take aspirin
  • Score = 1: moderate risk, aspirin or oral anticoagulant
  • Score >= 2: moderate to high risk, take oral anticoagulant

Bottom line: Evaluate every trauma patient on anticoagulation to see if they really need to keep taking it. If it’s for a one-time episode of DVT or PE that happened years ago, they should be able to stop. If it’s for a-fib, check their CHADS2 score and work with their primary care provider to see if they could take aspirin or nothing. Factor in a history of frequent falls or car crashes as well.

Related posts: 

Reference: Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin. Circulation 110 (16): 2287–92, 2004.

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. 


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

When To Give Mannitol

Patients with severe head injury need all the help they can get. Mannitol is one tool that is time-tested and cheap. But how do you decide who gets it and when?

Mannitol is a powerful osmotic diuretic that pulls extracellular water from everywhere, including the brain. By reducing the size of the brain overall, it drops pressure inside the skull (ICP) somewhat.

Mannitol can be used anytime during the acute phase of trauma care for three indications in patients with head trauma:

  • Focal neurologic deficit. This is due to transtorial herniation, and may manifest clinically as unilateral pupil dilation or hemiparesis. It may also be seen on CT scan.
  • Progressive neurologic deterioration. This is typical of rising ICP and can be diagnosed when your previously talking patient becomes lethargic.
  • Clinical evidence of high ICP. This is the Cushing response (hypertension with bradycardia). Do not treat this hypertension with other meds, it is a brain protective mechanism!

The literature does not have any good studies that show effectiveness or survival benefit. However, most trauma professionals have seen the dramatic improvement in neurologic status that can occur after early administration.

Bottom line: Mannitol is cheap and it works! Consider it early if any of the three indications above are seen. And don’t forget to put a urinary catheter in immediately because the diuresis that it causes is impressive. And no studies thus far have been able to prove that hypertonic saline is any better or worse than mannitol.

Simple Tracheobronchial Injury

Injury to the airway has the potential to be a catastrophe, with rapid deterioration and death. Occasionally the injury is less dramatic with a slow air leak, but it can still present a diagnostic and management challenge. 

These lower airway injuries can occur after either blunt or penetrating trauma. The penetrating ones are relatively simple to diagnose because the wound tract is known and, if stable, a trip to CT demonstrates the problem area. 

Blunt lower airway injury is a bit trickier. These typically require a high energy mechanism, such as a motor vehicle crash. Up to half of these injuries are not diagnosed immediately. Typically, unexpected air on the chest xray is identified. Less commonly, subcutaneous emphysema appears and prompts more investigation.

Previously, the gold standard for diagnosis was bronchoscopy. CT has gotten so good that even smaller bronchial injuries can be identified, so CT is now the diagnostic study of choice. Management of injuries that do not threaten the airway consists of close observation. Smaller ones may heal on their own without complication. Larger injuries usually continue to leak and do not heal. If ventilation problems develop, either from persistent large pneumothorax or large amounts of air dissecting into the neck, intubation will be required. However, positive pressure may exacerbate the problem, so low pressure ventilation modalities must be used. A prompt trip to the OR will be required in such cases.

Bottom line: Simple (slow leak) tracheobronchial injuries are uncommon, but are seen after major blunt trauma and any kind of thoracic penetrating injury. The best way to diagnose the exact problem and location is thin cut CT of the chest. Injuries with minor clinical dysfunction can be admitted to the trauma service and observed. If the leak does not resolve, or causes breathing problems, a thoracic surgeon will very likely need to intervene to repair the problem.

Related posts:

Trauma Patient Transport By Police, Not EMS

When I was at Penn 25 years ago, I was fascinated to see that police officers were allowed to transport penetrating trauma patients to the hospital. They had no medical training and no specific equipment. They basically tossed the patient into the back seat, drove as fast as possible to a trauma center, and dropped them off. Then they (hopefully) hosed down the inside of the squad car.

Granted, it was fast. But did it benefit the patient? The group now at Penn decided to look at this to see if there was some benefit (survival) to this practice. They retrospectively looked at 5 years of data in the mid-2000’s, thus comparing the results of police transport with reasonably state of the art EMS transport.

They found over 2100 penetrating injury transports during this time frame (!), and roughly a quarter of those (27%) were transported by police. About 71% were gunshots vs 29% stabs. They found the following interesting information:

  • The police transported more badly injured patients (ISS=14) than EMS (ISS=10)
  • About 21% of police transports died, compared to 15% for EMS
  • But when mortality was corrected for the higher ISS transported by police, it was equivalent for the two modes of transport

Although they did not show a survival benefit to this practice, there was certainly no harm done. And in busy urban environments, such a policy could offload some of the workload from busy EMS services.

Bottom line: Certainly this is not a perfect paper. But it does add more fuel to the “stay and play” vs “scoop and run” debate. It seems to lend credence to the concept that, in the field, less is better in penetrating trauma. What really saves these patients is definitive control of bleeding, which neither police nor paramedics can provide. Therefore, whoever gets the patient to the trauma center in the least time wins. And so does the patient.

Related posts:

Reference: Injury-adjusted mortality of patients transported by police following penetrating trauma. Acad Emerg Med 18(1):32-37, 2011.