Monthly Archives: January 2017

Cervical seatbelt sign and CTA

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Summary: No CTA for isolated cervical seatbelt sign.

Good blog post.
http://wueverydayebm.blogspot.com/2014/07/does-cervical-seatbelt-sign-mandate.html
Take Home:
CT-angiogram is not necessarily indicated based on the finding of a cervical seatbelt sign alone in the absence of significant hematoma, neurologic symptoms, or other traumatic injuries.

EAST Guideline:
https://www.east.org/education/practice-management-guidelines/blunt-cerebrovascular-injury
What patients are of high enough risk, so that diagnostic evaluation should be pursued for the screening and diagnosis of BCVI?
1. Patients presenting with any neurologic abnormality that is unexplained by a diagnosed injury should be evaluated for BCVI.
2. Blunt trauma patients presenting with epistaxis from a suspected arterial source after trauma should be evaluated for BCVI.
3. Asymptomatic patients with significant blunt head trauma as defined below are at significantly increased risk for BCVI and screening should be considered. Risk factors are as follows:
* Glasgow Coma Scale score ≤8;
* Petrous bone fracture;
* Diffuse axonal injury;
* Cervical spine fracture particularly those with (i) fracture of C1 to C3 and (ii) fracture through the foramen transversarium;
* Cervical spine fracture with subluxation or rotational component; and
* Lefort II or III facial fractures

From EAST Guideline:
An isolated cervical seat belt sign without other risk factors and normal physical examination has failed to be identified as an independent risk factor in two retrospective studies and should not be used as the sole criteria to stratify patients for screening.
References:
https://www.ncbi.nlm.nih.gov/pubmed/12013287
https://www.ncbi.nlm.nih.gov/pubmed/12013287

Alternate Screening Guidelines:

Screening Criteria for BCVI adapted from Biffl et al[10] (with permission)
Screening Criteria for BCVIInjury mechanism

  • Severe cervical hyperextension/rotation or hyperflexion, particularly if associated with
    • Displaced midface or complex mandibular fracture
    • Closed head injury consistent with diffuse axonal injury
  • Near hanging resulting in anoxic brain injury Physical signs
  • Seat belt abrasion or other soft tissue injury of the anterior neck resulting in significant swelling or altered mental status

Fracture in proximity to internal carotid or vertebral artery

  • Basilar skull fracture involving the carotid canal
  • Cervical vertebral body fracture
Denver Modification of Screening Criteria for BCVI adapted from Cothren et al[51] (with permission)
Denver Modification of Screening CriteriaSigns/symptoms of BCVI

  • Arterial hemorrhage
  • Cervical bruit
  • Expanding cervical hematoma
  • Focal neurological deficit
  • Neurologic examination incongruous with CAT scan findings
  • Ischemic stroke on secondary CAT scan

Risk factors for BCVI

  • High-energy transfer mechanism with
    • Lefort II or III fracture
    • Cervical spine fracture patterns: subluxation, fractures extending into the transverse foramen, fractures of C1-C3
    • Basilar skull fracture with carotid canal involvement
    • Diffuse axonal injury with GCS =6
    • Near hanging with anoxic brain injury

Decreased Survival with Intubation During Cardiac Arrest

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Quick Read on something I feel like comes up a lot with our cardiac arrest patients. They don’t typically need intubated, they need good CPR. Bag or put an LMA in and stop at that. While the numbers aren’t astounding, given the differences in such a large amount of patients think these make sense.

http://www.healio.com/cardiology/arrhythmia-disorders/news/online/%7B5396b1a2-0167-4a2d-885c-0e1bc527398e%7D/findings-do-not-support-early-tracheal-intubation-for-in-hospital-cardiac-arrest-in-adults

Top Ten UTI Myths

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Good 5-10 minute read on myths regarding UTI and asymptomatic bacteriuria. Hope you’ll take a look as this is a common problem in many EDs, not just ours with regards to over-diagnosis and over-treatment.
http://www.medscape.com/viewarticle/865175
Ross

Abandon the BVM?

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Excellent 1 pager from Dr Levitan in the new ACEP now newspaper.

I have been trying to get the residents to implement the nasal cannula, and to a lesser extent the LMA, for years. Pearl: nasal cannula plus mandible traction opens the nasopharynx and allows oxygen to diffuse to the alveoli (due to gradient made by hemoglobin absorbing oxygen). This is apnea oxygenation, increased safe apnea time. See the pure gold article by Levitan/Weingart, apparently 4th most read annals of EM article.

Add the cannula and mandible thrust to a properly positioned patient, ear to sternal notch or even well above sternal notch, and you will be amazed how long it takes to desat. OOPS (Oxygen On, Pull the mandible, Sit the patient up.

Read this brief article a few times and change how you practice.

Level 1 Rapid Infuser & Autotransfusion

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All,
Couple videos on what was covered today with Level 1 Infuser and Autotransfusion. They’re not bad, definitely get the overall setup at least. With the autotransfusion videos, there are a few small differences in their setup vs ours I think, but overall for your purposes is mostly the same. Hope this helps.
Ross

Level 1 Infuser
https://www.youtube.com/watch?v=9YIROsYE_Yo

Autotransfusion
https://www.youtube.com/watch?v=WmLs-43jaR4