Category Archives: General

Pop Quiz: What I See…

Yesterday, I showed you an x-ray of a trauma patient and asked you to tell me all the pertinent things that you saw. Here’s the x-ray again:

image

And here’s the list of all the things that struck me about it. Tomorrow, I’ll explain how I figured them all out from just this x-ray.

  • The patient is a female
  • She is still on a backboard
  • She was stabbed with a long, professional cooking knife
  • The assailant was right handed
  • The course of the knife is left to right, superior to inferior, and anterior to posterior
  • She was unstable, either blood pressure or respirations
  • The patient was intubated, most likely due to hypotension and unresponsiveness (BTW, the tube is deep and needs to be pulled back)
  • There is a moderate left hemothorax
  • The mediastinum is shifted to the right
  • A deep sulcus sign is present, either from a pneumothorax that is not easily visible, or from a large hemothorax (more likely the first one)
  • Intra-abdominal and diaphragmatic injury is almost certain
  • A pulmonary contusion is present on the left
  • The stab enters the antero-lateral chest
  • It does not involve the arm or axilla
  • The patient needs a chest tube now
  • She must be taken to the OR immediately after the tube

Some of these are easy, some are not. Let me know if you found anything else by tweeting or commenting below.

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Pop Quiz: What Do You See?

Sometimes we are way too focused. Commonly, trauma professionals will look at a lab result / image / patient / etc and only see what they are looking for.

Here’s an exercise to help you break out of that trap. I want you to look at this image and make a list of all the non-trivial things you see and think about that are pertinent to the case. Like “there is a knife in, on, or under the patient” and not like “the patient has ribs.”

image

Tomorrow, I’ll go over my list of 16 items. See if you can find them all, or more! On Thursday, I’ll explain how I figured out each item. Good luck!

Hit me with your key findings via Twitter, or comment below!

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May Newsletter Released To Subscribers Tonight!

The May Trauma MedEd Newsletter will be released to subscribers tonight. I’ll be covering Nursing & Midlevels. Articles include:

  • What to do when the doc won’t listen!
  • NPs, PAs and trauma care
  • Forensic nursing
  • Nursing tips for managing pediatric orthopedic trauma
  • And more…

Anyone on the subscriber list as of 8PM tonight (CST) will receive it later this evening. I’ll release it to everyone else this Friday via the blog. So sign up for early delivery now by clicking here!

Pick up back issues here!

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More On CSF Rhinorrhea/Otorrhea

Trauma professionals worry about stuff. Like just about everything, really. Sometimes we have good guidance (research) to help us decide what to do. Many times, we don’t. Management of rhinorrhea and otorrhea from CSF leak after trauma is definitely one of those things.

I’ve seen a variety of treatments used in these patients over the years. Is it really a CSF leak? Let’s get a beta-2 transferrin test (see below). Can’t the patient get meningitis? Their may be concomitant sinus fracture and bacterial contamination, so why not give antibiotics? Or vaccinate them?

The Cochrane library contains a vast number of reviews of common clinical questions. One of those questions just happens to be the utility of giving prophylactic antibiotics in patients with basilar skull fracture. Interestingly, they’ve been reviewing and re-reviewing this question about every 5 years, since 2006. During the three reviews done, there have been no additional research papers published on the topic.

Here are the factoids:

  • Studies that specifically examined the use of prophylactic antibiotics in patients with basilar skull fracture were reviewed. All included meningitis as one of the outcome parameters.
  • There were only 5 high quality (randomized, controlled) trials, with a total of 208 participants
  • There were an additional 17 lower quality trials published, but no conclusions could be reached from them due to methodology problems
  • In the high quality trials, there were no differences in the incidence of meningitis, mortality, or meningitis-related mortality
  • There were no specific adverse effects related to antibiotic administration. But one of the high quality studies did note a shift to higher counts of pathologic bacteria in the posterior nasopharynx in the antibiotic group.
  • No studies on the use of meningitis vaccinations exist. A survey of UK physicians showed that 35% recommend at least one vaccine, typically for Strep Pneumo.

Bottom line: There is still no good evidence to support the use of prophylactic antibiotics or meningitis vaccination in patients with CSF leak from uncomplicated basilar skull fracture. When you see surveys that show some physicians promoting a treatment and others doing nothing, it means there is most likely no significant benefit. If there were a big difference, we would have seen it by now! And giving drugs (antibiotics, vaccines) that have no proven use is expensive and can always lead to unexpected complications. 

Related posts:

References:

  • Immunisations and antibiotics in patients with anterior skull base cerebrospinal fluid leaks. J Laryngol Otol 128(7):626-629, 2014.
  • Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev April 28, 2015.
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