NEW: Indexed Archive for the Trauma Professional’s Blog!

Over the past several months, I’ve wanted to refer to older blog entries while teaching our surgical and emergency medicine residents. However, I’m not completely satisfied with the search system available here on Tumblr, my blog host. And although the Archive View feature is fun (you can see a snapshot of entries by month), it’s still tough to drill down to a specific post.

I’m excited to announce an indexed version of the archive, which is now available at www.regionstrauma.org/blogs. This link opens a list of posts that are indexed by topic area. It’s now much easier to find something you are looking for, and it helps me avoid duplicating posts.

I have received occasional requests for a post on a specific topic, and I really enjoy responding to them. If you have a question about some trauma-related topic that you are “dying” to know the answer to, please email me or use the ask link to the right. 

Probiotics in Trauma Care

Probiotics are live micro-organisms that can be taken orally that can restore balance to the intestinal microflora. These bacteria or yeasts can also produce nutrients and anti-oxidants that fight bacterial endotoxin and activate the lymphoid tissue found in the intestine.

Probiotics come in a variety of forms and can cost very little or quite a lot. The simplest and cheapest forms are live culture yogurts found in the grocery store. Oral supplements are also available that are just a little more expensive. A few specialty products are available for critically ill patients that cost quite a lot.

Going along with probiotics are so-called prebiotics, which are dietary fibers that can help with fluid absorption and diarrhea, and with keeping bowel movements regular and of reasonable consistency. Use of prebiotics has been shown to decrease catheter related sepsis in ICU patients.

A newer concept is the use of probiotics when antibiotics are given for the treatment of infection. Any antibiotic can wipe out portions of the normal gut flora, leaving room for pathogenic bacteria (such as C. Diff.) to go wild. The thought is that the probiotics help recolonize the colon with “good bacteria” and avoid the development of an infectious diarrhea.

The last time I reviewed the literature on this topic, there was no clear data that probiotics reduce antibiotic associated diarrhea. There was evidence that it helped some other infectious and inflammatory conditions. Well, things have changed and new meta-analyses have been released in the last 6 months that do show a benefit. Both lactobacillus strains (found in yogurt and the usual supplements) and Saccharomyces boulardii (a yeast found only in certain supplements in this country) show statistically significant reduction in antibiotic associated diarrhea. 

Bottom line: Given the fact that these supplements are cheap and have few side effects, it is probably beneficial to administer a probiotic during and for a few days after discontinuation of antibiotics. Use should be limited to reasonably healthy, non-immunocompromised patients, since high dose Saccharomyces can cause fungemia in the critically ill. The use of prebiotics (fiber) is probably also beneficial, especially for patients on narcotic pain medications.

References:

  1. Role of Lactobacillus in the prevention of antibiotic-associated diarrhea: a meta-analysis. Kale-Pradhan PB, Jassal HK, Wilhelm SM. Pharmacotherapy. 2010 Feb;30(2):119-26.
  2. Systematic review and meta-analysis of Saccharomyces boulardii in adult patients. McFarland LV.World J Gastroenterol. 2010 May 14;16(18):2202-22.

PulseCheck: Hot Topics In EMS Handout

PulseCheck EMS logo

PulseCheck: Hot Topics in EMS is going on today at the Holiday Inn Select in Bloomington! The program includes TV anchor Don Shelby speaking on the evolution of Primary Service Areas in Minnesota.

I will be giving a presentation on pediatric trauma. This talk was added to the program on short notice, so no handout was available to participants. 

To download a copy of the slides I presented, click here.

How To: Flexion / Extension Views of the Cervical Spine

Clearance of the cervical spine can often be done using clinical criteria alone (see this video at http://youtu.be/NhjF9kDOcjE). If this is not possible, a combination of radiologic and clinical evaluation is usually carried out. 

In some cases, radiographic studies (usually CT) are normal, but there is pain on clinical exam. Our next step is to send the patient to xray for flexion and extension views. This exam is performed by removing the collar while the patient is sitting, so the thoracic and lumbar spines must be clear before ordering this. The patient then gently flexes and extends the neck to their limits of comfort. Images are then obtained at the limits of flexion and extension. The premise is that a normal, awake patient cannot and will not move their neck beyond their comfort level to the point where they could cause themselves neurologic injury. 

It is very important that you look at the images yourself. The radiologist may review the images and will report that “there is no evidence of subluxation at the limits of flexion and extension.” But the patient may have barely moved their neck!

The question is: how much flexion and extension do you need to have to clear the spine?

The answer is not easy to find, and is buried in literature from the 1980s and 90s. According to the EAST guidelines, the ideal amount is 30 degrees from neutral for both flexion and extension. This is not always achievable in elderly patients, so in those cases you must use your judgment. Talk to the patient to find out if they stopped moving their neck forward or backward due to pain, or because they just can’t move it that far.

Trouble signs to look for are:

  • Subluxation of more that 2mm at any level
  • Angulation of more than 11 degrees

Any abnormality should prompt a spine consult.

If the study is not abnormal but the amount of flexion and/or extension is not adequate, there are two options. First, just leave the collar in place and try again in a week or so and try again. This will allow any soft tissue injuries to get better and may allow a successful repeat study. The alternative is a more costly and less well-tolerated MRI.

References:

  1. EAST Practice Guidelines, Identifying Cervical Spine Injuries Following Trauma – Update (2000).
  2. Defining radiographic criteria for flexion-extension studies of the cervical spine. Robert Knopp et al. Ann Emerg Med. 2001 Jul;38(1):31-5.

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