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New TraumaMedEd Newsletter Coming Tomorrow!
The newest TraumaMedEd newsletter will be released here tomorrow. The topic for this issue is “Philosophy”, some things learned the hard way in 30 years of taking trauma patients.
Click the link to get a copy today, and subscribe if you feel so inclined so you can get every issue as soon as it’s available.
The management of CSF leaks after trauma remains somewhat controversial. The literature is sparse, and generally consists of observational studies. However, some general guidelines are supported by large numbers of retrospectively reviewed patients.
- Ensure that the patient actually has a CSF leak. In most patients, this is obvious because they have clear fluid leaking from ear or nose that was not present preinjury. Here are the options when the diagnosis is less obvious (i.e. serosanguinous drainage):
- The “halo” or “double ring sign" is a form of pillow chromatography. The blood components separate from the CSF as they move through the pillow fabric, creating a clear ring or halo surrounding a bloody spot. This is the cheapest, fastest test and is actually fairly reliable.
- High resolution images of the temporal bones and skull base. If an obvious breach is noted, especially if fluid is seen in the adjacent sinuses, then a CSF leak is extremely likely. This test does not usually change management.
- Glucose testing. CSF glucose is low compared to serum glucose. Cheap but hard to obtain a decent specimen.
- Beta 2 transferrin assay. This marker is very specific to CSF. However, the test is expensive and results may take several days to a few weeks. Pricey, and most leaks will have closed before the results are available, making this a poor test.
- Place the patient at bed rest with the head elevated. The basic concept is to decrease intracranial pressure, which in turn should decrease the rate of leakage. This same technique is used for management of mild ICP increases after head injury.
- Consider prophylactic antibiotics carefully. The clinician must balance the likelihood of meningitis with the possibility of selecting resistant bacteria. If the likelihood of contamination is low and the patient is immunocompetent, antibiotics may not be needed.
- Ear drops are probably not necessary. They may confuse the picture when gauging resolution of the CSF leak.
- Wait. Most tramatic leaks will close spontaneously within 7-10 days. If it does not, a neurosurgeon or ENT surgeon should be consulted to consider surgical closure.
- Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol, 1997;18:188-197.
- Brodie HA. Prophylactic antibiotics for posttraumatic cerebrospinal fluid fistulas. Arch Otolaryngol Head, Neck Surg. 123:749-752.
It’s always nice to find an article that supports your biases. I’ve been doing percutaneous tracheostomy since the 1990’s, and have used a variety of kits and equipment. Some of these turned out to be rather barbaric, but the technique is now quite refined.
A routine part of the procedure involved passing a bronchoscope during the procedure to ensure that the initial needle was placed at the proper level and in the tracheal midline. It was also rather frightening to watch the trachea collapse when the dilators were inserted.
I abandoned using the bronchoscope in this procedure about 10 years ago. It was an annoyance to get the bronchoscope cart and a respiratory therapist to help run it. And to find someone available to pass the scope while I did the trach. So I added a little extra dissection to the technique, directly visualizing the trachea at the desired location. From then on, I had no need to see the puncture from the inside because I could see it quite well from the outside!
An article in the Journal of Trauma shows that this technique works just as well without the scope. The authors looked at their own series of 243 procedures; 32% were done with the bronchoscope, 68% without. There were 16 complications overall, and the distribution between the bronch and no-bronch groups was equal.
Bottom line: In general, the bronchoscope is not needed in most percutaneous tracheostomy procedures. It adds complexity and expense. However, there are select cases where it can be helpful. Consider using it in patients in a Halo cervical immobilizer, the obese, or in patients with known difficult airway anatomy. And always do the more difficult ones in the OR, not the ICU.
Reference: Percutaneous tracheostomy: to bronch or not to bronch – that is the question. J Trauma 71(6):1553-1556, 2011.
The fifth highest priority taught in the ATLS course is exposure. This generally means getting the patient’s clothes off so any hidden injuries can be identified. Early in my career, I was called to see a patient who had a gunshot to the chest that had been missed because the consulting physician had neglected to cut off her bra. A small caliber wound was found under the elastic strap in her left anterior axillary line after a chest xray showed a bullet in mid-thorax.
The usual trauma activation routine is to cut off the clothes. There are several tips and tricks we use to do this quickly. And a number of commercial products are out there to make it even easier.
But do we really need to cut everyone’s clothes off? I’m not disputing the fact that it’s important to be able to examine every square inch. But do we need to destroy everything our patient is wearing? I once saw a sequined wedding dress cut off (it’s almost as bad as cutting off a down jacket).
The answer is no. The key concept here is patient safety. Can you safely remove the clothing in a less destructive way? For most victims of major blunt trauma, we worry a lot about the spine. Unfortunately, it’s just not possible to allow the patient to wriggle out of their clothes and protect their spine. The same goes for fractures; it may be too uncomfortable to remove clothing because of fracture movement so scissors are required.
Penetrating trauma is a bit different, and in many cases it’s a good idea to try to get the clothing off intact. Once again, if spinal injury is a consideration (gunshots only), the involved clothes should be cut off. A patient with a gunshot to the chest can probably have their pants safely and gently pulled off, but their shirt and coat must be cut.
The police forensic investigators like to have intact clothing, if possible. This is another good reason to try to remove clothing from penetrating injury victims without cutting.
Bottom line: Think before you cut clothes! Major blunt trauma and bad injuries require scissors. Lesser energy blunt injury may allow some pieces of clothing to be removed in the usual method. Most penetrating injury does not require cutting. But if you must (for patient safety), avoid any holes in the fabric so forensics experts can do their job.