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Head, Imaging

EAST 2017 #5: Subarachnoid Hemorrhage, Neurosurgical Consults, and Repeat Head CT

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Neurosurgical involvement in the management of simple traumatic brain injury (TBI) has been slowly dwindling over the past several years. This is the result of the general consensus that very few of these patients progress to need neurosurgical procedures.

A group at Wright State University in Dayton sought to define the progression of one specific finding in TBI, the subarachnoid hemorrhage (SAH). Secondarily, the wanted to determine if a neurosurgery consultation was warranted in these patients.

They performed a five year retrospective review of their registry data, identifying patients with both mild TBI (GCS 13-15) and SAH. They excluded patients with any other brain lesion on CT.

Here are the factoids:

  • 301 patients were enrolled during the 5 year period
  • All had a neurosurgical consultation
  • Time between the initial CT and a followup scan was about 11 hours
  • 91% showed stable or resolving SAH on the followup scan
  • 9% showed a worsening SAH or additional lesions on the repeat scan

Bottom line: The authors conclude that initial neurosurgical consultation is not needed, since only 9% of patients have worrisome findings on repeat CT. They do, however, recommend that the practice of repeat scanning be continued because of this same number.

Our trauma service looked at this issue a year ago, and determined that most of these lesions either do not progress, or never require any intervention if they do, with a few notable exceptions. For that reason, we abandoned both neurosurgical consultation and repeat CT scans for patients with non-aneurysmal SAH, a single parenchymal hemorrhage, or linear skull fractures. We continue to do both for patients with epidural and/or subdural hemorrhage. You can download a copy of this protocol here.

Questions and comments for the authors/presenters:

  • Did you look at platelet count or INR in the study. Were patients excluded based on abnormal values?
  • Did every patient get a repeat scan?
  • Break down the lesions in the 9% of patients who had some sort of progression or new finding. Did you see any common themes (age, chronic alcohol use, etc.)?
  • Did you encounter any patients with “non-central SAH”, that might indicate an aneurysm? How were they dealt with?
  • How has or will your trauma service change its practice based on your findings.

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference:   Management of subarachnoid hemorrhage (SAH) by the trauma service: are repeat CT scanning & routine neurosurgical consultation necessary? Poster #16, EAST 2017.

Abstracts, Critical care

EAST 2017 #4: A More Restrictive Transfusion Trigger?

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For many years, patients were automatically given not one, but two units of blood anytime they got “anemic” while in the hospital. And anemia was defined as a hemoglobin (Hgb) value < 10. Wow! Then we recognized that blood was a dangerous drug, with many potential complications.

We’ve come a long way, with our transfusion trigger slowly dropping and giving just one unit of blood at a time when needed. Many trauma centers use a transfusion trigger Hgb of 7 in younger, healthier patients. The question is, how low can you (safely) go?

The trauma program at Wake Forest University analyzed their data, and found that there was no “physiologic advantage” to transfusions in patients with Hgb of 6.5 to 7. Therefore, they lowered their transfusion trigger from 7 to 6.5 and retrospectively studied the results for the six months before and six months after the switch. Patients with hemorrhage, anticipated surgical procedures, or unreconstructed coronary artery disease were excluded.

Here are the factoids:

  • Of 852 patients admitted to the ICU, 131 met criteria and had a Hgb < 7
  • 72 patients were transfused with a trigger of 7, and 59 with a trigger of 6.5
  • There was no difference in ventilator, ICU, or hospital days, or mortality
  • The transfusion rate dropped by 27%, saving 72 units of blood

Bottom line: We continue to determine how low we can go with this. In healthy patients, the magic number is probably even lower. But we are increasingly seeing older, less healthy trauma patients. The next step is to start looking at subsets to determine what is safe for each group.

Questions and comments for the authors/presenter

  • Tell us the nature of the “preliminary work” that led to this paper. Was it animal data, or some kind of analysis of your patient data?
  • Since coronary artery disease was an exclusion criterion, how did you know a patient had it? By history alone?
  • Please show an age histogram of all units given at each threshold. This will let us see if there is any age bias present.
  • How low did the Hgb actually get in both groups? A histogram would be nice on this one, too.
  • Do you have any recommendations regarding selection based on age, frailty, or other parameters? What is your practice now?
  • Your outcome measures are somewhat crude, meaning that one would not really expect much of a change in those variables due to an extra unit or two of blood. What about adverse reactions that necessitated a fever workup or other intervention? Any differences between the groups there?

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference:   Effects of a more restrictive transfusion trigger in trauma patients. Poster #38, EAST 2017.

Complications

EAST 2017 #3: My Neck Is Broken And It Doesn’t Hurt?

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Clinical clearance of the cervical spine is a standard of care. It is usually the first method to determine if there might be an injury in patients who are awake, cooperative, and don’t have other painful distracting injuries. But appreciation of pain may be different in elderly patients, and they will frequently not notice pain from some injuries. Could this possibly impact clearance of the cervical spine?

A group at Iowa Methodist performed a retrospective review of patients > 55 with diagnosed cervical spine fractures over a four year period. They were considered to have an asymptomatic injury if they did not complain of pain, or of tenderness to palpation.

Here are the factoids:

  • A total of 173 elderly patients presented with a cervical spine injury during the study period
  • 38 of them (22%) were asymptomatic
  • The asymptomatic patients tended to have higher injury severity (ISS 15 vs 10), have a significant injury in another body region (71% vs 47%), and stayed in the hospital longer (7 days vs 5)
  • A third of patients had multiple cervical fractures (symptomatic or asymptomatic?)
  • C2 was the most common fracture level

Bottom line: I have witnessed this phenomenon myself. Not all of our elders perceive pain the same way younger patients do. This study shows that it is a very significant problem. Most of the previous papers and the only review I could find do not separate out the elderly when making cervical clearance recommendations. We will probably have to develop some specific criteria to determine when a CT scan is necessary in the asymptomatic elderly patient. In the algorithm used at my hospital, age > 65 is already used to bypass clinical clearance. Looks like I’ll have to drop that to 55!

Questions and comments for the authors/presenters:

  • Since they were asymptomatic, how do you know that you didn’t miss any patients?
  • Do you have a practice guideline for cervical spine evaluation? Has it changed based on your study?
  • Be sure to break your data down by mechanism of injury for the presentation. Were there more asymptomatic patients from falls rather than car crashes? Associated fracture patterns for each mechanism?
  • What do you now recommend for clearance?
  • Suggestion: change your title to “cervical spine fractures”, not “neck fracture”.

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference:   Asymptomatic neck fractures: current guidelines can fail older patients. Paper #8, EAST 2017.

General, Imaging

EAST 2017 #2: CT Scan After Recent Operative Exploration for Penetrating Trauma

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The general rule for penetrating trauma, especially gunshots to the abdomen, is that you don’t need to obtain a CT scan to help you decide to go to the OR. (Of course, there are a few exceptions.) And the corollary has always been that you don’t need to get a CT scan after you operate for penetrating trauma.

But the group at UCSF is questioning this. They retrospectively looked at 5 years of data on patients who underwent trauma laparotomy without preoperative imaging. They focused on new findings on CT that were not reported during the initial operation.

Here are the factoids:

  • 230 of 328 patients undergoing a trauma lap did not have preop imaging
  • 85 of the 230 patients (37%) underwent immediate postop CT scan. These patients tended to have a gunshot mechanism and higher injury severity score.
  • Unreported injuries were found in 45% (!) and tended to be GU and orthopedic in nature
  • 47% of those with unreported injuries found required some sort of intervention

Bottom line: This is a very interesting and potentially practice changing study. However, there is some opportunity for bias since only select patients underwent postop scanning. Nevertheless, one in five patients who did get a postop scan had an injury that required some sort of intervention. This study begs to be reworked to further support it, and to develop specific criteria for postop scanning.

Questions/comments for the authors/presenters:

  • Be sure to break down your results by gunshot vs stab. This will help formulate those criteria I mentioned above.
  • Specifically list the occult injuries and interventions required. In some studies, those “required interventions” are pretty weak (urology consult vs an actual procedure).
  • How exactly did the operating surgeons determine who to send to CT? Was it surgeon-specific (i.e. one surgeon always did, another never did)? Was it due to operative findings (hole near the kidney)? This is also needed when developing specific criteria for postop imaging.
  • Nice poster!

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: Routine tomography after recent operative exploration for penetrating trauma: what injuries do we miss?  Poster #14, EAST 2017.

General

EAST 2017 Page on The Trauma Pro Blog

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Hello all! I’ve created a separate page for posts regarding the upcoming meeting of the Eastern Association for the Surgery of Trauma.

I will be reviewing a baker’s dozen abstracts over the next 2 weeks, giving my own analysis and commentary. I’ll also provide some suggestions and questions to anticipate for the authors to refer to.

Click here to visit the EAST 2017 page!

And if you are a presenter and would like me to look at your paper, just email, tweet, or connect via your method of choice.