Tag Archives: complications

Complications, Head

EAST 2017 #8: When Is “Mild TBI” Not So Mild?

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Traumatic brain injury (TBI) is very common, with the majority falling into the “mild” category. This is usually defined as patients with injury to the head and a GCS of 13-15. These uncomplicated patients are frequently discharged from the emergency department, or undergo only a brief evaluation if admitted for other reasons.

The group at Shock Trauma focused on a less appreciated subset of mild TBI patients, those whose condition is a little more complicated. Specifically, these are patients with GCS 13-14 with positive findings on head CT leading to a calculated abbreviated injury score (head) of > 2, and some persistence of their symptoms while in the hospital. At many hospitals (including my own), these patients receive an inpatient TBI evaluation. But if they pass this initial screening, they are not consistently referred for any outpatient TBI followup.

Are these mild, complicated TBI patients (mcTBI) unique? Do they behave the same as the uncomplicated ones? The research group performed a prospective study on patients who sustained an mcTBI over a 4 month period.  They excluded patients with mental illness, dementia, and non-English speaking and homeless patients. They tried to contact patients up to three times after discharge to administer several standard tests and determine if they had any specific residual symptoms.

Here are the factoids:

  • Of the 142 patients with mcTBI during the study period, there was substantial attrition over time, with only 25 remaining at 6 months and 10 at one year
  • 64% of patients who responded at 6 months remained symptomatic. Depression, dizziness, and a feeling of impaired health were common.
  • 80% of patients still described symptoms at one year. The same complaints were most common, and some required changes in activities of daily living or assistive devices.

Bottom line: Although small and fraught with the usual problems in long-term tracking of urban trauma patients, this study is eye-opening. We too often dismiss “mild TBI” and being almost nothing, even in patients with positive findings on head CT. This work suggests that we are underestimating the needs of those patients. The authors used this data to design longer-term care processes for this subset of patients. Other centers should follow suit to make sure these patients’ post-injury needs are better met.

Questions and comments for the authors/presenters:

  • Describe the possible biases that patient selection and attrition may have had on the study
  • What type of TBI screening do you use in the hospital?
  • Given that a number of assessments were administered over the phone, I look forward to hearing some of the other details not listed in the abstract
  • Was there any correlation between specific CT findings and later symptoms?
  • Provide details of your long-term care programs for these patients
  • I enjoyed this thought provoking abstract!

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: Mild TBI is not ‘mild’… survivors tell their complicated stories. Quick Shot #3, EAST 2017.

Procedures

Air Embolism From an Intraosseous (IO) Line

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IO lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.

But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.

This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC).

During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line is not closed properly, there could be.

Bottom line: Treat an IO line as carefully as you would a regular IV. You can give anything through it that can be given via a regular IV: crystalloid, blood, drugs. And even air, so be careful!

General

Complications of Splenic Embolization for Trauma

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Angioembolization has become a common procedure that can increase the likelihood of success for nonoperative management for splenic trauma. It does have its own set of complications to be aware of, however.

The most obvious complication is mechanical injury to the femoral artery. This occurs in 1 to 3% of patients. It is more common in the very young (small caliber artery) and the elderly (arteries of stone). Rarely, the substance or device that is used for the embolization may migrate or end up on the wrong spot, infarcting something important.

A common issue that occurs is infarction of portions of the spleen. This is actually the desired effect, as it stops the bleeding. Most of the time, we are unaware of the changes that take place in the spleen post-procedure. But every once in a while we get a repeat CT scan days or weeks down the road and see some very interesting things.

The most common finding is a splenic infarct alone. This is an area of the spleen, sometimes wedge shaped, that does not take up contrast. This is normal. In some cases, gas bubbles are seen within the spleen parenchyma, usually within the infarcted area. In others, large areas of gas are present, and an air-fluid level may also be seen. This is definitely not normal.

Note the infarcted area at the arrow, with a tiny gas bubble visible.

Tiny bubbles are normal after this procedure, and can be ignored if the patient does not appear ill and does not have any systemic evidence of inflammation or sepsis. On the other hand, big bubbles or air-fluid levels probably indicate a developing splenic abscess, and the patient will usually appear ill and have a high WBC count. Unfortunately, the only treatment for this is splenectomy. Insertion of drainage catheters does not work and the patient will only become sicker if it is attempted.

General

Best Of: VIP Syndrome In Healthcare (Very Important Person)

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The VIP syndrome occurs in healthcare when a celebrity or other well-connected “important” person receives a level of care that the average person does not. This situation was first documented in a paper published in the 1960s which noted that VIP patients have worse outcomes.

VIPs have the expectation that they can get special access to care and that the care will be of higher quality than that provided to others. Healthcare providers often grant this extra access, in the form of returned phone calls and preferential access to their clinic or office. The provider tries to provide a higher quality of care by ordering additional tests and involving more consultants. This idea ignores the fact that we already provide the best care we know how, and money or fame can’t buy any better.

Unfortunately, trying to provide better care sets up the VIP for a higher complication rate and a greater chance of death. Healthcare consists of a number of intertwined systems that, in general, have found their most efficient processes and lowest complication rates. Any disturbance in this equilibrium of tests, consultants, or nursing care moves this equilibrium away from its safety point.

Every test has its own set of possible complications. Each consultant feels compelled to add something to the evaluation, which usually means even more tests, and more possible complications. And once too many consultants are involved, there is no “captain of the ship” and care can become fragmented and even more inefficient and dangerous.

How do we avoid the VIP Syndrome? First, explain these facts to the VIP, making sure to impress upon them that requesting or receiving care that is “different” may be dangerous to their health. Explain the same things to allproviders who will be involved in their care. Finally, do not stray from the way you “normally” do things. Order the same tests you usually would, use the same consultants, and take control of all of their recommendations, trying to do things in your usual way. This will provide the VIP with the best care possible, which is actually the same as what everybody else gets.

Reference: “The VIP Syndrome”: A Clinical Study in Hospital Psychiatry. Weintraub, Journal of Mental and Nervious Disease, 138(2): 181-193, 1964.

General

Delayed Diagnosis of Blunt Intestinal Injury in Children

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Yesterday, I wrote about using ultrasound in place of CT for initial diagnosis of blunt abdominal injury in children. Although it looks good for identification of solid organ injury and free fluid, it may miss injury to the intestine. Is that bad?

Lets look at a recent study that examined the consequences of delayed laparotomy for blunt intestinal injury. The American Pediatric Surgical Association conducted an 18-center study of the management of intestinal injuries in children less than 16 years of age. They were stratified by time to treatment. There were 214 patients with complete data records for review. 

The majority of the patients were involved in a motor vehicle crash or a bicycle accident. Demographics were similar in all time to treatment groups. Half were resuscitated at a referring hospital and then transferred to a pediatric trauma center, on average after 6 hours.

Key points:

  • The only deaths occurred in the 0-6hr and 6-12hr groups. The average Injury Severity Score of the children who died was significantly higher than survivors.
  • Children operated on in the 0-6hr group had significantly higher ISS as well.
  • There was no difference in early or late complications across all groups.
  • Time to beginning oral intake and time in hospital were the same in all groups.

The authors concluded that observation and serial exam rather than urgent exploration or repeated CT scans is appropriate.

Bottom line: If you combine this study with the ultrasound study I reviewed yesterday, it seems appropriate to modify the usual (read: adult) way of evaluating blunt trauma to the abdomen. In place of automatically getting a CT scan of the abdomen in children, obtain a complete abdominal ultrasound to detect solid organ injury or free fluid. This will determine the degree of monitoring needed (e.g. ICU for higher grade liver or spleen injuries). Follow this with serial abdominal exam. If the child becomes symptomatic, it’s probably time to proceed to the OR. Note: I generally do not make children npo during the observation phase. They need to eat, and if they don’t want to, that tells you something.

Related post: Sonography in pediatric abdominal trauma

Reference: Delay in diagnosis and treatment of blunt intestinal injury does not adversely affect prognosis in the pediatric patient. J Pediatric Surg 45(1):161-166, 2010.