Category Archives: General

Evaluation After Head Injury in Adolescents

Traumatic brain injury (TBI) is the most common cause of death in children. Even mild concussions can cause some degree of functional impairment. Many clinicians believe that the degree of impairment correlates with the initial Glasgow Coma Scale score (GCS), although this has only been shown in adults. This has led many hospitals to perform cognitive screening selectively, usually on adolescents with lower GCS scores.

A recent study by Goold and Vane at the Cardinal Glennon Children’s Medical Center in St. Louis, and the University of Vermont College of Medicine in Burlington looked at the correlation between GCS and level of impairment, and ways to determine which groups of adolescents need more sophisticated cognitive testing to evaluate deficits.

A total of 609 young adults age 13-21 with brain injuries were identified, and a cognitive screening test was performed (Occupational Therapy Head Injury Mini Screen [OT HIMS]). There was no correlation between GCS and the components of the OT HIMS. Interestingly, the GCS did not predict which patients were discharged to rehab centers either.

The Bottom Line: Adolescents can develop significant cognitive deficits or behavior issues after any degree of head injury. Because of this, it is not possible to selectively screen for cognitive deficits. All adolescents age 13-21 should undergo screening with an instrument like the OT HIMS after head injury.

At our Level I Pediatric Trauma Center, we consider a child to have a TBI if:

  • the mechanism involves head impact and
  • any of the following apply:
    • known or suspected loss of consciousness
    • cannot remember the event
    • parents detect any change in behavior

All of these children undergo a TBI screen performed by Gillette Children’s Specialty Hospital physiatry, occupational and physical therapy services. If needed, they receive followup in the Gillette Minor Neurotrauma Clinic.

Reference: Goold D, Vane DW. Evaluation of Functionality After Head Injury in Adolescents. Journal of Trauma 2009;67:71-74.

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Forensic Nursing

Forensic Nursing combines nursing science with the investigation of injuries or deaths that involve accidents, abuse, violence or criminal activity. Sexual Assault Nurse Examiners (SANE nurses) are one of the most recognized types of forensic nurses, but they have special training in one type of injury. Forensic nursing programs typically involve a broader set of skills, encompassing some or all of the following:

  • Interpersonal violence, including domestic violence, child and elder abuse/neglect, psychological abuse
  • Forensic mental health
  • Correctional nursing
  • Legal nurse consulting
  • Emergency/trauma services, including auto and pedestrian accidents, traumatic injuries, suicide attempts, work-related injuries, disasters
  • Patient care facility issues, including accidents/injuries/neglect, inappropriate treatments & meds
  • Public health and safety, including environmental hazards, alcohol and drug abuse, food and drug tampering, illegal abortion practices, epidemiology, and organ donation
  • Death investigation, including homicides, suicides, suspicious or accidental deaths, and mass disasters

Forensic nurses find that their additional training improves their basic nursing skills, and allows them to derive greater career satisfaction from helping patient in another rather unique way.

Approximately 37 training programs exist, ranging from certificate programs that require a specific number of hours of training, to degree programs (typically Masters level programs). Many of the certificate programs are available as online training. 

Source: International Association of Forensic Nurses (http://www.iafn.org/)

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High Inspired O2 Is Not An Effective Pneumothorax Treatment

The use of high concentrations of inspired oxygen seems to be a time-honored technique for trying to avoid chest tube insertion for pneumothorax. But does it stand up to scrutiny, or is this just an urban legend?

This recommendation is based upon a single case report involving 8 patients in 1983! Six patients with a pneumothorax of less than 30% showed a decrease in size of 4.2% per day on average. The two patients with pneumothoraces larger than 30% did not respond. A response was only seen with oxygen administered by a partial nonrebreather mask, not by nasal cannula.

What’s the problem? First, this is a very small case report. There were no controls, so it is entirely possible that the resolution rate without treatment was the same as that seen in this report. Furthermore, this study was performed prior to the availability of chest CT. Therefore, the true size of the pneumothoraces is only a guess since volumetric calculations could not be performed. It is not possible to distinguish a 4% change in the size of a pneumothorax by regular chest xray (click here for more details).

The bottom line: If the patient needs supplemental oxygen for management of other pulmonary conditions, then administer it. It is not indicated as an independent treatment for pneumothorax, and its use for this condition should be abandoned!

Related posts:

Reference: Noninvasive treatment of pneumothorax with oxygen inhalation. Chadha TS. Respiration 44(2):147-52, 1983

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Lack of EMS Documentation is Associated With Increased Mortality

EMS policy and the trauma center verification process requires that all trauma patients delivered to a trauma center must have a copy of the EMS run sheet. Two parameters that are commonly used to monitor performance improvement (PI) in EMS are:

  • accurate record of scene physiology (SBP, HR, RR, GCS)
  • request by on-scene BLS for ALS assistance

The study looked at the impact of those criteria on patient survival. A total of 4744 patients from the National Trauma Data Bank were analyzed.

Physiologic data: About 28% had at least one missing physiologic data point, with respiratory rate being most commonly missed. They found that the mortality in the group with missing data was over twice as high (10.3%) as it was in the group with complete date (4.5%).

BLS call for ALS assistance: This assist was called for in 17% of cases. These cases were less likely to involve penetrating injuries and more likely to involve car or motorcycle crashes. Injury Severity Score was the same. Eventual patient mortality was the same for BLS calling ALS and ALS response alone.

So why does failure to record physiologic data translate into higher mortality? The initial response may be that the patient was sicker, and so they needed more intense care during transport with less time to record vitals. However, the researchers controlled for this and found it was not a factor. Other issues that may be a factor are EMS training and proficiency, leadership at the scene and enroute, and available staff and resources, among other things.

The researchers speculate that documentation might be a good global measure of appropriate or inappropriate prehospital care that rolls all of these possible factors into one easily identifiable audit filter. They recommend that this be used to focus performance improvement efforts and hopefully improve survival.

I recommend that the results of this study be taken to heart and used to help persuade EMS programs to get religious about recording complete vital signs and leaving the run sheet at the trauma center every time a patient is delivered. Documentation should be evaluated regularly, and all cases with any missing vital signs should be reviewed closely. Trauma Center PI programs should work with EMS to analyze this data and look for the patterns that increase mortality.

Reference: Lack of Emergency Medical Services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. Journal of the American College of Surgeons, 210(2):220-227, 2010.

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