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.”
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!
By popular demand, here’s our short (8 minute) humorous video on the basics of the extended FAST exam. Courtesy of Michael Zwank MD from Regions Hospital. From Trauma Education: The Next Generation 2014.
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.
They are the cliches of the courtroom. The defendant appears before the jury with a cane, a cast, and a soft cervical collar. Looks good, but are they of any use? There are really two questions to answer: does a soft collar limit mobility and does it reduce pain? Amazingly, there’s very little literature on this ubiquitous neck appliance.
First, the mobility question. It’s a soft collar. It’s made of sponge. So it should be no surprise that it doesn’t reduce motion by much, about 17%. But it is better than no collar at all.
What about pain control? One small retrospective review looked at the effect of a soft collar vs no collar at all on pain after whiplash injury. Keep in mind that the definition of “whiplash” is all over the place, so you have to take it with a big grain of salt. But the authors found that there was no difference in subjective pain scoring with or without the collar.
Another much older study (1986) compared a soft collar with active motion after whiplash. Subjects who actively moved their neck around had less subjective pain after 8 weeks.
Bottom line: The soft cervical collar keeps your neck warm. Not much else. And in my experience, prolonged use (more than a few days) tends to increase uncomfortable neck spasms. So use them as an article of clothing in Minnesota winters, but not as a medical appliance.
A comparison of neck movement in the soft cervical collar and rigid cervical brace in healthy subjects. J Manipulative Physiol Ther. 34(2):119-22, 2011.
The effect of soft cervical collars on persistent neck pain in patients with whiplash injury. Acad Emerg Med. 3(6):568-73, 1996.
Early mobilization of acute whiplash injuries. Br Med J (Clin Res Ed). 292(6521):656-7, Mar 8 1986.
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