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:

• Tips for managing CSF otorrhea/rhinorrhea
• Worst complication of basilar skull fracture – the N-C tube!

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.

I’ve spent the last week writing about the nuances of field amputation. I’ve heard from a number of readers about who does it at their facility. Keep in mind that this is a very rarely performed procedure. The few times I’ve been called out in the field, the prehospital providers have conveniently managed to extricate the patient just prior to my arrival. Whew!

Various providers (prehospital, emergency physician, surgeon) may provide this “service” at various places around the world. In the US, it is usually a physician, and typically a surgeon. In my opinion, anyone can be trained to do a basic field amputation.

Much depends on local policies and procedures, training, and availability. Prehospital providers are on scene in most cases, so it makes sense that they could do a field amputation with appropriate training. Emergency physicians have more experience with airway management, sedation, and anesthesia, and can thus add value to the process. 

But again, in my opinion, a trauma surgeon is the best choice for performing this procedure. They have the technical skills, and are usually facile with anesthesia and sedation. But they also have a deep understanding of the anatomy involved, and the eventual reconstruction process. This allows them to tailor the amputation to optimize the eventual recovery from this operation. The surgeon does not necessarily have to resort to a guillotine type amputation. And they are better versed in performing amputations that involve the upper extremity, as well as more proximal amputations (shoulder, upper thigh). And if unexpected bleeding occurs that cannot be controlled by a tourniquet, they know what to do.

The only downside to using a physician is availability. There will always be extra time involved in getting them to the scene since they are typically hospital-based, whereas the prehospital providers are already present and are used to working in an austere environment. 

Bottom line: There is no cookbook for developing a field amputation policy and procedure. Look at your local resources, and the logistics imposed by environment, traffic, your hospital, and other factorss. Then look at my previous posts and figure out what works for you. And finally, make the process as simple as possible. Due to the very rare need for field amputation, you will need to periodically review the process and location of your packs so people don’t forget.