All posts by TheTraumaPro

Nail Discoloration After Severe Traumatic Brain Injury (TBI)

Occasionally, patients who have had a severe brain injury but recovered relatively quickly may present with complaints of odd nail discoloration. This may involve fingernails and/or toenails. What gives?

This is actually a byproduct of repeated exams to determine the Glasgow Coma Scale score. A common way to determine the motor component is to squeeze the fingertip or toetip. I’ve seen some neurosurgeons use a pen to apply a great deal of force to the nail.

The discoloration is a resolving subungual hematoma. You may see different colors under different nails, depending on the age of the hematoma. Amaze your colleagues with your knowledge on this one!

Clinical Tip: The Flat Vena Cava in Blunt Trauma

Trauma patients who are hypotensive in the Emergency Department can only be transported to one of two places: the operating room or the morgue. With rare exception, they should never be taken outside the department (e.g. CT scan) because of the fear that they may arrest in an area that is not conducive to efficient resuscitation.

Sometimes patients are initially stable but decompensate later. Since most stable blunt trauma patients end up in CT scan, perhaps there is some telltale sign that can predict later deterioration. A recent Japanese paper looked at the “flatness” of the inferior vena cava as seen on the abdominal CT scan as a predictor of hemodynamic decompensation in the first 24 hours.

A small cohort of 114 patients was used in this prospective study. The vena cava was evaluated at the level of the renal veins. The flatness of the IVC was determined by dividing the transverse diameter by the anteroposterior (AP) diameter. A flat IVC was defined as a transverse to AP diameter ratio of more than 4:1. The ratio in normal patients was about 2:1. See the figure for details.

Patients who had a flat IVC required significantly more blood transfusions, crystalloid infusions within 2 hours of admission, and were more likely to proceed to the OR within the first 24 hours of their hospital stay.

Bottom Line: Assuming that you are only taking stable blunt trauma patients to CT, the incidental finding of a flat vena cava should increase your paranoia levels and lower your threshold for ordering blood and getting the trauma surgeons involved. 

Reference: Predictive value of a flat inferior vena cava on initial computed tomography for hemodynamic deteroration in patients with blunt torso trauma. J Trauma 69(6):1398-1402, 2010.

What Is The Cost of the “Personal Freedom” Not To Wear A Motorcycle Helmet?

The Highway Safety Act of 1966 led to a mandate that all states adopt universal helmet laws for all motorcycle riders or risk the loss of federal highway funds. By 1975, all but 3 states had enacted these laws. However, Congress then did an about-face and eliminated the helmet law requirement for receiving the funds. Many states then revisited their laws, and some repealed them. As of now, 20 states (and D.C.) have inclusive helmet laws, 27 have conditional laws, and 3 (IL, IA, NH) have no helmet requirements.

Croce and his group in Memphis looked at the impact of helmet use in motorcyclists using the National Trauma Data Bank from 2002-2007. They found:

  • Helmet use was higher in states with helmet laws (90%), vs conditional laws (61%), vs no laws (53%)
  • Helmeted riders had less severe injuries in nearly all brain and skull trauma. Glasgow Coma Scale and Injury Severity Scores were significantly lower.
  • Cervical spine fractures were less frequent in helmeted patients (3.9% vs 5.9%)
  • Hospital and ICU stays were shorter for riders who wore helmets
  • Mortality was significantly lower in helmeted motorcyclists (3.8% vs 6.7%)
  • Significantly more helmeted riders were insured

Advocacy groups continue to try to repeal or weaken helmet laws, generally based on a 1986 report (ref 2) which stated that helmets decrease peripheral vision and hearing, increase the number of cervical injuries, and have no impact on mortality. Frequently, proponents of helmet law repeal also claim that the laws infringe on personal freedom.

Helmets do decrease peripheral vision by 20 degrees, but research and a DOT report have shown that this has no impact on motorcycle safety or impact rates (refs 3,4). Helmets have been shown to have no impact on hearing at low speeds, and all riders (with or without helmets) have decreased hearing at higher speeds. Helmets do not diminish or enhance hearing at any given speed (ref 4). A number of studies, including this one, have shown that cervical injuries are less frequent in riders who survive the crash.

The insurance and hospital utilization information in this paper is most interesting. Unhelmeted riders have more significant injuries, are more likely to stay in the hospital and ICU longer, and are much less likely to have insurance to pay for it. And this is for the survivors! Deaths create an even greater societal burden, with lost lifetime earnings, tax revenues and other adverse economic effects.

Courts have repeatedly upheld mandatory helmet laws under the Constitution when challenged. A federal court once responded to one of these challenges with this quote: 

“From the moment of injury, society picks the person up off the highway, delivers him to a municipal hospital and municipal doctors; provides him with unemployment compensation if, after recovery, he cannot replace his lost job; and, if the injury causes permanent disability, may assume responsibility for his and his family’s subsistence. We do not understand a state of mind that permits plaintiff to think that only he himself is concerned.”

For a list of current helmet law status by state, click here.

References:

  1. Impact of motorcycle helmets and state laws on society’s burden. J Trauma 250(3):390-394, 2009.
  2. The effect of motorcycle helmet use on the probability of fatality and the severity of head and neck injuries: a latent variable framework. Evaluation Review 10:335-375, 1986.
  3. Motorcycle helmets – medical costs and the law. J Trauma 30:1189-1199, 1990.
  4. The effects of motorcycle helmets upon seeing and hearing. NHTSA Report number DOT HS 808-399, 1994.

EAST Practice Guideline – Geriatric Trauma (2010 Update)

The EAST Practice Management Guideline on management of geriatric trauma was updated early this year. This post gives the details of the proposed changes. Click here to open a copy of the existing PMG for comparison.

Prehospital Triage

  • Level II – Injured patients with advanced age (>=65) and pre-existing medical conditions (PECs) should lower the threshold for field triage directly to a designated/verified trauma center.

Triage Issues

  • Level II – With the exception of patients who are moribund on arrival, an initial aggressive approach should be pursued with the elderly patient.
  • Level III – Patients 70 years of age or greater should receive care under the structure of the highest level of trauma activation and receive liberal application of invasive monitoring.
  • Level III – Elderly patients with at least one body system with an AIS >= 3 should be treated in designated trauma centers, preferably in ICUs staffed by surgeon-intensivists.

Low GCS

  • Level III – In patients 65 years of age or older with a GCS < 8, if substantial improvement in GCS is not realized within 72 hours of injury, consideration should be given to limiting further aggressive therapeutic interventions.

Head injury and anticoagulation

  • Level III – All patients who receive daily therapeutic anticoagulation should have appropriate assessment of their coagulation profile as soon as possible after admission. Those with suspected head injury should be evaluated with head CT as soon as possible after admission. Patient receiving warfarin with post-traumatic intracranial hemorrhage should receive initiation of therapy to correct their INR to normal range within 2 hours of admission.

Base deficit for triage

  • Level III – Base deficit measurements may provide useful information in determining status of initial resuscitation and risk of mortality for geriatric patients. ICU admission should be considered for patients >=65 with an initial base deficit >= -6.

Deleted guidelines – the following have been recommended for deletion from the PMG.

  • Attempts should be made to optimize cardiac index > 4L/min/M2 and/or oxygen consumption index of 170 cc/min/M2.
  • Complications negatively impact survival. Specific therapies to reduce complications should lead to optimal outcomes.
  • Admission trauma score < 7 is associated with 100% mortality and aggressive therapeutic interventions should be limited. 
  • Admission respiratory rate < 10 is associated with 100% mortality and aggressive therapeutic interventions should be limited. 

What Happens When An Axle Snaps

The Ford Windstar minivan is being recalled to deal with a design defect in the rear axle. Here is NHTSA analysis video of what happens when the axle separates. The read of the car begins to steer in random, different directions. This makes the steering wheel nearly useless. Note how the professional driver in this video is saved from a rollover by the attached stabilizer bars.