Category Archives: General

Pop Quiz: Jet Ski Injury

This post is for my readers located near large bodies of water!

Personal watercraft use exploded a decade ago, and they are still heavily used for recreation and vacation fun. However, speed and people don’t always mix well. Here’s an interesting case to ponder.

An 18 year old woman was the rear passenger on a jet ski traveling at a high rate of speed (of course). She fell off and was plucked out of the water by the driver. After riding for another 30 minutes, they headed to shore. A short while later, she began experiencing vague lower abdominal discomfort. This slowly progressed throughout the afternoon, becoming more severe.

She presents to your ED, looking uncomfortable and slightly ill. Here are some questions to ponder:

  • What injuries are you concerned about?
  • What diagnostics are appropriate?
  • If surgery is required, what are the appropriate approaches and procedures?

Please comment below, or tweet your thoughts. Answers tomorrow!

Print Friendly, PDF & Email

The First Law Of Trauma

Time for some more philosophy! After doing anything for an extended period, one begins to see the common threads and underlying principles of their area of expertise. I’ve been trying to crystallize these for years, and today I’m going to share one of the most basic laws of trauma care.

The First Law of Trauma: Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

Some examples:

  • An elderly patient who crashes his car and presents with arrhythmias and chest pain is not having a heart attack. Nor does he need a cardiologist or a trip to the cath lab.
  • A spot in the liver after blunt trauma is not a cyst or hemangioma; it is a laceration until proven otherwise.
  • A patient found at the bottom of a flight of stairs with blood in their head did not have a stroke and then fall down. 

Bottom line: The possibility of trauma always comes first! It is your job to rule it out. Only consider non-traumatic problems as a last resort. Don’t let your non-trauma colleagues try to steer you down the wrong path, only to have your patient suffer.

Related posts:

Print Friendly, PDF & Email

Blunt Vertebral Artery Injury

Following up on yesterday’s post, I’ll deal with vertebral artery injuries today. These injuries are uncommon, making them hard to study and develop management recommendations. The literature suggests that about 1% of blunt trauma patients may sustain one of these. Most commonly, the method is motor vehicle crash, and just about any mechanism (hyperflexion, hyperextension, distraction injury, and facet fractures). Fracture of C1-3 has a higher association with the injury.

What is the natural history of this injury? If treated, 67% of occluded vessels recanalize, and 90% of stenotic arteries return to normal caliber. About 15% of untreated injuries will suffer a stroke. As seen in the paper cited yesterday, a good number of these are present on patient arrival and are nonpreventable. But the key issues are identifying an injury in the first place, and treating appropriately. Unfortunately, these are not straightforward.

Although the gold standard for detecting this lesion is digital subtraction angiography, no one does this in acute trauma patients anymore. CT angiography is well established, and the sensitivity rate approaches 99%. The main question is when to get it. To see my hospital’s interpretation of the literature, download our blunt imaging protocol below.

Treatment options include anticoagulation / antiplatelet therapy and endovascular therapy. There is much more experience with the former, but it can’t be used in patients at risk for bleeding (e.g. severe TBI). Unfractionated heparin is good for in-hospital use because it easily reversed. Longer term, anti-platelet agents are preferred. Aspirin is cheaper than clopidagrel, and no study has shown convincing superiority of one over the other. Determining whether endovascular stenting or embolization is necessary requires consultation with a neurosurgeon and interventional radiologist. The decision making is complex and not laid out in the literature. It’s flying by the seat of one’s pants, at best but can be a valuable adjunct.

Followup imaging is suggested to help determine when and if anti-platelet therapy can be discontinued. The best timing for these studies has not been worked out, but since these lesions tend to evolve over 7-10 days, any time after 2 weeks should be appropriate.

Bottom line: This is a tough topic because of the scarcity of good data, which in turn is due to the rarity of the injury. I believe that finding the lesions with good screening criteria offers the best chance of preventing complications such as stroke. Choice of management is best done in collaboration with your neurosurgical and radiologist colleagues.

Related posts:

Print Friendly, PDF & Email

Outcome After Blunt Cerebrovascular Injury (BCVI)

Blunt injuries to the carotid and vertebral arteries are not as uncommon as we used to think. Unfortunately, there’s a lot of controversy surrounding everything about them: screening, management, and outcome. A paper just out detailed outcomes in a (relatively) large series of these patients. 

As expected with this rare injury, it’s a retrospective study. A busy Level I center identified 222 patients with 263 BCVIs over a 4 ½ year period. Twenty four died before discharge and 11 afterwards. Of the remaining patients, only 74 could be located and only 68 could be persuaded to complete an interview and evaluation of their functional status. Functional Independence and Functional Activity Measurements were assessed (FIM/FAM).

Pertinent findings were:

  • 8 patients suffered a stroke during their initial hospital stay (5 were present on arrival in the ED)
  • 5 additional patients had a stroke after discharge
  • Only 20% reached the maximum FIM/FAM scores, even including patients who did not have a stroke
  • Patients with stroke had a significantly lower FIM/FAM
  • There was no difference in FIM/FAM in patients with carotid vs vertebral injury

Bottom Line: Even though it is limited, this is one of the best studies we will see on BCVI because it’s an uncommon problem at most centers. The most important fact here is that the stroke rate was 19% despite discharge on antiplatelet or anticoagulant medications. And if stroke occurs, it causes significant functional problems, as expected. It’s critically important that this injury be screened and identified appropriately, then given appropriate prophylaxis. More on this tomorrow.

Related posts:

Reference: Functional outcomes following blunt cerebrovascular injury. J Trauma 74(4):955-960, 2013.

Print Friendly, PDF & Email