All posts by TheTraumaPro

Controlling Fever In Head Injury

Fever is a well recognized side effect of head injury. Management of fever is inconsistent among physicians taking care of these patients. There is a lot of debate on the best course of action, but not so much data. Current enthusiasm for applications of hypothermia has created some reluctance to tolerate much in the way of hyperthermia. Here is my take on the currently available literature.

First, understand that there is a fundamental difference between studies that study induced hyperthermia vs those that look at spontaneous fever. This lies in the fact that the set point for temperature regulation is changed in fever, but not in hyperthermia. Therefore, it is not clear whether hyperthermia studies can truly be used to answer these questions.

Animal studies originally focused on stroke models, which showed deleterious effects from hyperthermia. TBI is very different than stroke, but some hyperthermia models did tend to show cellular damage and blood brain barrier breakdown at temperatures of 39C. However, a fever model in rats showed no outcome difference (in rats) in febrile vs normothermic animals with TBI.

A Medline search (ref 4) yielded no randomized controlled trials that could be used to guide us with regard to fever management. The lesser quality papers involved a very heterogeneous group of subjects that made it difficult to draw good conclusions. As a generalization, they found that extremes of temperature, both high and low, were probably associated with worse outcomes. One randomized prospective study showed that aggressive fever control for temperatures > 38.5C had higher mortality and more infections.

A recent meta-analysis (ref 3) found that TBI patients with fever stayed in the hospital and ICU longer. This translated into an extra $14,000 per patient. Precise reasons for the longer stay cannot be accurately determined, but it might be expected that patients with fever would undergo time-consuming searches for possible infectious sources.

Finally, a very recent prospective study (ref 1) at a single institution that did not try to alter temperature found that the optimum survival occurred in a group of patients whose temperatures remained between 36.5 and 38C.

Bottom line: Literature support for aggressive management of fever is poor. If there were a clear correlation with temperature maintained at or slightly below normal, we’d probably have figured it by now. Fever up to 38 degrees C probably does not need to be treated in head injured patients. However, this does not eliminate the need to continue surveillance for infectious complications.

References:

  1. The effect of spontaneuous alterations in brain temperature on outcome: a prospective observational cohort study in patients with severe traumatic brain injury. J Neurotrauma 27(12):2157-2164, 2010.
  2. Induced normothermia attenuates intracranial hypertension and reduces fever burden after severe traumatic brain injury. Neurocrit Care 11(1):82-87, 2009.
  3. Brain injury and fever: hospital length of stay and cost outcomes. J Intensive Care Med 24(2):131-139, 2009.
  4. The significance of altered temperature after traumatic brain injury: an analysis of investigations in experimental and human studies: part 2. Br J Neurosurg 22(4):497-507, 2008.

Is It A Trauma Center Or A Coffee Shop?

Tim Horton’s is a large franchise operation that runs about 3,750 coffee shops / restaurants in the US and Canada. Some of these franchises are located inside other establishments, such as hospitals. The outlet in the Royal Columbian Hospital in New Westminster, British Columbia, Canada is one such location, and it did double duty last month. Royal Columbian is the region’s trauma centre.

Due to a large number of patients being treated in the ED and some fly-ins from earlier in the day, the coffee shop was cleaned and converted to overflow for patient care. Six stretchers with privacy screens were set up and four patients were treated in the area. This situation lasted for about 90 minutes until the overcrowding eased. The shop was cleaned once again and ready to open normally the next morning, serving coffee, not patients.

Reference: BC Local News (www.bclocalnews.com)

Myth: Motorcycle Helmets and Cervical Spine Injury

The number of motorcyclists has been increasing over the past decade. At the same time, the number of states repealing their helmet laws is increasing. The evidence is convincing that the number and severity of brain injuries is decreased with helmet use. But what about spine injury?

Many arguments against wearing helmets given by riders are derived from a report in 1986 by Goldstein*. One of the issues cited in this paper is the potential increase in cervical spine injuries due to the weight of the helmet. A recently published study using the National Trauma Data Bank (NTDB) corroborates several smaller studies which show that this just isn’t so.

All motorcycle collisions in the NTDB involving adults were analyzed by logistic regression. Missing data was compensated for using standard statistical techniques. Nearly 41,000 cases had complete records for analysis. About 77% of riders were wearing helmets, and the overall mortality was 4%. 

Nonhelmeted riders suffered the following statistically significant differences:

  • A higher proportion of severe head injury (19% vs 9% with helmets)
  • Higher incidence of shock on admission (6% vs 5% with helmets)
  • Higher injury severity score (ISS) (14.7 vs 13.4 with helmets)
  • Higher crude mortality (6.2% vs 3.5% with helmets)
  • Higher incidence of cervical spine injury (5.4% vs 3.5% with helmets)

Bottom line: Motorcyclists wearing helmets had a 22% reduction in the likelihood they would sustain a cervical spine injury in a crash. This is in addition to decreases in shock, injury severity and death. These data need to be considered when the future of helmet laws is considered in any state looking at repealing them.

References:

  • Motorcycle helmets associated with lower risk of cervical spine injury: debunking the myth. J Amer Col Surgeons 212(3):295-300, 2011.
  • *The effect of motorcycle helmet use on the probability of fatality and the severity of head and neck injury. Evaluation Rev 10:355-375, 1986.

What Is The Cribari Grid?

What Is The Cribari Grid?

I’ve spent some time discussing undertriage and overtriage. I frequently get questions on the “Cribari grid” or “Cribari method” for calculating these numbers. Dr. Cribari is currently the chair of the Verification Review Subcommittee of the ACS Committee on Trauma. He developed a table-format grid that simplifies calculation of these numbers.

I’ve simplified the process even more and provided a Word document that automates the task for you. Just fill in four numbers in the table, update the formulas and voila, you’ve got your numbers! Instructions for manual calculation are also included.

Click this link or the image above to download the file.

Trauma 20 Years Ago: ED Intubation For Head Injury Is Safe

How far we have come! It’s now commonplace to intubate trauma patients in the ED using rapid sequence induction followed by orotracheal tube placement. However, 20 years ago we were still gnashing our teeth about safety.

In 1991, the group at UMDNJ Newark looked at 100 consecutive trauma patients with suspected head injury who were paralyzed and intubated in the ED. Half of the intubations were performed by a surgeon, the other half by an anesthesiologist. Fifty seven patients were intubated orally and 40 nasally(!). Three required cricothyroidotomy after failure to intubate due to facial fractures.

The majority of these patients had head scans performed; 59% were positive and 15 required emergent neurosurgical procedures. No patients were found to have a neurologic deficit from the intubation even though seven were eventually found to have cervical spine injuries. Only one patient developed an aspiration pneumonia.

The authors concluded that paralysis and intubation in the ED was safe. It helped facilitate the diagnostic workup because they could control combative patients. Up to that time, the only alternative was heavy sedation, which carried its own risks. 

Interesting points on how far we have advanced:

  • Intubation in the ED did not used to be routine. There was a great deal of anxiety before this procedure
  • Nasal intubation was still fairly commonplace
  • The cricothyroidotomy rate was high
  • Intubation was usually performed by a surgeon or anesthesiologist