What You Need To Know About Frontal Sinus Fractures

Fracture of the frontal sinus is less common than other facial injuries, but can be more complex to deal with, both in the shorter and longer terms. These are generally high energy injuries, and facial impact in car crashes is the most common mechanism. Fists generally can’t cause the injury, but blunt objects like baseball bats can.

Here’s the normal anatomy:

sinus-fracture-treatment

 

Source: www.facialtraumamd.com

There are two “tables”, the anterior and the posterior. The anterior is covered with skin and a small amount of subcutaneous tissue. The posterior table is separated from the brain by the meninges.

Here’s an image of an open fracture involving both tables. Note the underlying pneumocephalus.

frontal_sinus1

A third of injuries violate the anterior table, and two thirds violate both. Posterior table fractures are very rare. A third of all patients will develop a CSF leak, typically from their nose.

These fractures may be (rarely) identified on physical exam if deformity and flattening is noted over the forehead. Most of the time, these patients undergo imaging for brain injury and the fracture is found incidentally. Once identified, go back and specifically look for a CSF leak. Clear fluid in the nose is, by definition, CSF. Don’t waste time on a beta-2 transferring (see below).

If a laceration is clearly visible over the fracture, or if a CSF leak was identified, notify your maxillofacial specialist immediately. If more than a little pneumocephalus is present, let your neurosurgeon know. Otherwise, your consults can wait until the next morning.

In general, these patients frequently require surgery for the fracture, either to restore cosmetic contours or to avoid mucocele formation. However, these are seldom needed urgently unless the fracture is an open fracture with contamination or there is a significant CSF leak. If in doubt, though, consult your specialist.

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Source: The Trauma Professionals’s Blog

Using Your Hybrid OR For Trauma

Every hospital wants some gadget or other. First, it was a robot. Or two. Now, it’s a hybrid operating room.

lourdes-hybrid-or1

What is this, you ask? It’s a mashup of an operating room and an interventional radiology suite. It’s new. It’s big. It’s cool (literally, which is an issue for trauma surgeons).

More and more hospitals are adding hybrid rooms at the request of their vascular surgery teams. These rooms allow for both angiographic and open operative procedures, potentially at the same time. They are perfect for endovascular procedures that need some degree of hands-in work as well. They are frequently used for thoracic endovascular repair of the aorta (TEVAR), repair of abdominal aortic aneurysm (AAA), and transcatheter aortic valve replacement (TAVR).

These rooms would seem to be perfect for some trauma cases as well. Some injuries require a mix of interventional work and open surgery. Think complex pelvic fractures and extremity vascular injuries.

But before you go rushing off to the hybrid room with the next patient you think might benefit from it, consider these issues:

  • You must first secure access to the hybrid room. Just because you want it doesn’t mean you can get it. This room was probably built with other services in mind. You must work with them closely to set up rules and priorities. Consider questions like, can a trauma case bump an elective one?
  • Decide what specific cases can be done in the room. Don’t waste it on procedures that can be done in any old OR. Ideally, it is for multi-team cases and must take advantage of the radiographic capabilities of the hybrid room. If it doesn’t, it should be done in any other room of appropriate size.
  • Check your hardware. Make sure that anything you might attach to the hybrid table actually will attach to it. Frequently, the side rails are missing and the table thickness is different than a standard OR table. Check all of your retractor systems for compatibility. If your neurosurgeons use a skull clamp like a Mayfield, make sure it will attach to the table. If they do not, look for adapters to make it possible. Don’t discover this on your first trip to the room.
  • Watch for hypothermia! These are big rooms, and are difficult to heat up uniformly. In addition, the electronics in the room may be heat sensitive, so you may not be able to raise the temperature to the levels you are accustomed. Place heating systems under and around the patient as much as possible, warm everything that goes into them, and monitor their temp closely.
  • Treat the equipment with respect.  This stuff is delicate, and must be used by other surgeons for sensitive procedures. Don’t break it!

Related posts:

Source: The Trauma Professionals’s Blog

How To Remember Those “Classes of Hemorrhage”

The Advanced Trauma Life Support course lists “classes of hemorrhage”, and various other sources list a similar classification for shock. I’ve not been able to pinpoint where these concepts came from, exactly. But I am sure of one thing: you will be tested on it at some point in your lifetime.

Here’s the table used by the ATLS course:

classes_of_shock

The question you will always be asked is:

What class of hemorrhage (or what % of blood volume loss) is the first to demonstrate systolic hypotension?

This is important because prehospital providers and those in the ED typically rely on systolic blood pressure to figure out if their patient is in trouble.

The answer is Class III, or 30-40%. But how do you remember the damn percentages?

multiscore-maxi1

It’s easy! The numbers are all tennis scores. Here’s how to remember them:

Class I up to 15% Love – 15
Class II 15-30% 15 – 30
Class III 30-40 30 – 40
Class IV >40% Game (almost) over!

Bottom line: Never miss that question again!

Source: The Trauma Professionals’s Blog

Pan Scanning for Elderly Falls?

The last abstract for the Clinical Congress of the American College of Surgeons that I will review deals with doing a so-called “pan-scan” for ground level falls. Apparently, patients at this center have been pan-scanned for years, and they wanted to determine if it was appropriate.

This was a retrospective trauma registry review of 9 years worth of ground level falls. Patients were divided into young (18-54 years) and old (55+ years) groups. They were included in the study if they received a pan-scan.

Here are the factoids:

  • Hospital admission rates (95%) and ICU admission rates (48%) were the same for young and old
  • ISS was a little higher in the older group (9 vs 12)
  • Here are the incidence and type of injuries detected:
Young (n=328) Old (n=257)
TBI 35% 40%
C-spine 2% 2%
Blunt Cereb-vasc inj * 20% 31%
Pneumothorax 14% 15%
Abdominal injury 4% 2%
Mortality * 3% 11%

 * = statistically significant

Bottom line: There is an ongoing argument, still, regarding pan-scan vs selective scanning. The pan-scanners argue that the increased risk (much of which is delayed or intangible) is worth the extra information. This study shows that the authors did not find much difference in injury diagnosis in young vs elderly patients, with the exception of blunt cerebrovascular injury.

Most elderly patients who fall sustain injuries to the head, spine (all of it), extremities and hips. The torso is largely spared, with the exception of ribs. In my opinion, chest CT is only for identification of aortic injury, which just can’t happen from falling over. Or even down stairs. And solid organ injury is also rare in this group.

Although the future risk from radiation in an elderly patient is probably low, the risk from the IV contrast needed to see the aorta or solid organs is significant in this group. And keep in mind the dangers of screening for a low probability diagnosis. You may find something that prompts invasive and potentially more dangerous investigations of something that may never have caused a problem!

I recommend selective scanning of the head and cervical spine (if not clinically clearable), and selective conventional imaging of any other suspicious areas. If additional detail of the thoracic and/or lumbar spine are needed, specific spine CT imaging should be used without contrast.

Related posts:

Reference: Pan-scanning for ground level falls in the elderly: really? ACS Surgical Forum, trauma abstracts, 2016.

Source: The Trauma Professionals’s Blog

REBOA vs ED Thoracotomy: Which One Is Winning?

Many trauma centers are talking about REBOA (resuscitative endovascular balloon occlusion of the aorta), but only a few are actually doing it. And of those, only a handful are doing it regularly and closely studying how it’s working.

The RA Cowley Shock Trauma Center is one of those very few. They have integrated the preparation phase for REBOA (femoral art line insertion) into their initial resuscitation protocols. This allows them to actually perform the technique quickly in any patient who starts to go bad and meets criteria. This center has been using REBOA nearly exclusively since they began studying it  a few years ago. They have actually supplanted ED thoracotomy (EDT) with this technique, and are a leader in producing data and studies on its nuances.

They compared short term outcomes in patients suffering traumatic arrest undergoing REBOA  (2013-2015) to those in patients with EDT (2008-2013). This was a simple study, with easy to understand statistical analyses.

Here are the factoids:

  • 19 thoracotomies and 17 REBOA were performed during the study periods (this shows how uncommon these procedures are, even at a busy center)
  • Average ISS was about the same (31 vs 26). Median GCS was 3 in both groups.
  • Return of spontaneous circulation (ROSC) occurred in 7 EDT and 9 REBOA
  • 13 EDT and 9 REBOA patients survived long enough to get to the OR
  • Mean systolic BP after occlusion was higher after REBOA (80 vs 46 torr)
  • There was only one survivor of the 36, and they received REBOA. This patient actually discharged home. (!)

Bottom line: Shock Trauma is a very busy center, and as you can see, even their REBOA numbers are low. This is why it is so critically important that all REBOA patients be part of a study. We really need to know how well it works, who it works best in, and what the downsides are. In this study, ROSC and survival to OR were statistically identical, but blood pressure was higher with REBOA compared to cross-clamping. Survival was also the same (abysmal), with one excellent outcome in the REBOA group.

The authors believe that REBOA and EDT are equivalent in terms of the variables they looked at. But remember, there are many other factors we need to look at, including things like resource utilization and healthcare worker safety. I strongly urge every center that is performing or considering REBOA to join a multi-center trial and/or report the the REBOA registry to hasten our understanding of this procedure.

Related posts:

Reference: Paradigm shift in hemorrhagic traumaic arrest: REBOA is at least as effective as resuscitative thoracotomy with aortic crossclamping. ACS Scientific Forum, trauma abstracts, 2016.

Source: The Trauma Professionals’s Blog

CT Crystal Ball – Part 3

And yet another one of these crystal ball abstracts, all presented at the same meeting of the American College of Surgeons Clinical Congress!

This one postulates that more injuries seen on CT scan might predict mortality in “older” trauma patients. Hmmm. The authors pulled info  on head CT findings, GCS, AIS Head, lengths of stay, death, functional scores, and discharge disposition. And the age had to be >45 years. Older? Hmmm.

A scoring tool was designed that gave 1 point each for subdural, epidural, subarachnoid, or intraparenchymal blood, cerebral contusion, skull fracture, brain edema/herniation, midline shift, and external trauma to the head/face. The score range was 0-8, even though there were 10 factors.

Lets look at the factoids:

  • Nearly 10 years of data were analyzed
  • 620 patients meeting criteria were identified
  • The scoring system positively correlated with all of the outcome measures
  • Independent predictors of mortality included GCS, AIS Head, and the CT score (odds ratio 1.3)
  • The CT test also “predicted” (author’s word) neursurgical intervention (odds ratio 1.2)

Bottom line: Oh boy, here we go again. Another correlation study, and a weak one at that. So if someone told you that an “older” patient (beginning after age 45) would do worse clinically the more injuries were seen in and around their head, what would you say? And why did it take 10 years of data to accumulate data on 620 patients in this age range (62 per year)? And why not test your scoring system prospectively? And run some really good statistics on the new data?  Sadly, I feel this is another run to submit an abstract and present at a meeting. But thankfully, I don’t think it will ever see the light of print.

Related posts:

Reference: Prognostication of traumatic brain injury outcomes in older trauma patients: a novel risk assessment tool based on initial cranial CT findings. ACS Scientific Forum, trauma abstracts, 2016.

captain-obvious1

Source: The Trauma Professionals’s Blog

The CT Crystal Ball – Part 2

Yesterday, I wrote about a study that looked at a CT scan-derived index that promised to predict complications and mortality based on the waist-hip ratio. It was actually a very good one. But there is another abstract being presented at the American College of Surgeons Clinical Congress this week that promises miracles from the CT scanner as well.

This next abstract looks at muscle mass in trauma patients, as measured by CT scan. Specifically, the authors measured the density of the psoas muscle by determining its cross-sectional area and its density in Hounsfeld units. They then looked at the relationship between this and 90 day mortality, complications, and disposition location.

Really? Well, here are the factoids:

  • The study involved only 152 patients age 45+ from the year 2008
  • Median ISS was only 9
  • Patients with the lowest psoas cross-sectional area had an associated significantly higher death rate
  • Those with lowest psoas density had an associated increase in complications, dependency on discharge, and mortality
  • The authors suggest that these measurements could aid in patients who would benefit from aggressive nutritional support and physical therapy, and could aid in discharge planning

Bottom line: Very different from yesterday’s abstract. This one has no grounding in prior research. It appears to be one that was just dreamed up from nowhere. And it is truly an association study. No causality can or should be inferred.

There were only 152 patients studied. From 2008. Why? Why didn’t the authors use a more contemporary dataset? There is something weird going on behind the scenes. Is this an old study that was forgotten, and is just now being conveniently dusted off for analysis and submission? A power analysis to find out how many patients should be reviewed is not possible, so it is important to err on the high side. Not just 152 patients.

If you were to just read the abstract and especially the conclusions, you really might get the wrong idea. This is a study that will not see it’s day in any journal. Read and learn from it. But don’t duplicate it!

Related post:

Reference: Computed tomography-measured psoas density predicts complications, discharge location, and mortality in trauma patients. ACS Scientific Forum, trauma abstracts, 2016.

 

 

Source: The Trauma Professionals’s Blog

Using The CT Scan As A Crystal Ball For Trauma?

Two abstracts that are being presented at the American College of Surgeons Clinical Congress this week use CT scans to predict interesting things. They are things that you would not think a CT scanner should be able to do.

So can we use arcane measurements of things found on CT scan to make accurate predictions about our patients? Sure, if we see very low density bubbles (free air) in the abdomen, it’s pretty likely that some kind of abdominal catastrophe has occurred. Or if their is a large amount of high density fluid (blood) in the left chest after a stab wound, the patient will probably require a chest tube.

But what about other measurements that wouldn’t seem to be related to anything? Could we have found a magic crystal ball here, or is it just wishful thinking?

The first abstract evaluated the ability of the waist to hip ratio (WHR) to predict outcomes after trauma. Obviously, this is the width of the waist divided by the width of the body at the hips.

waist-hips-ratio1

Here are the factoids for this study:

  • 555 patients were analyzed retrospectively over 1 year at a Level I trauma center.
  • In-hospital complications and death were specifically analyzed
  • Using a receiver operating characteristic curve, the authors determined that a magic ratio of 1 was the best predictor
  • Complications were significantly higher in the group with WHR>1 (50% vs 19%) as was mortality (17% vs 7%)
  • Regression analysis showed that patients with WHR>1 were 4x more likely to have a complication and 3x more likely to die
  • WHR was only weakly correlated with BMI

Bottom line: WTF? How can this be, you ask? Just because your patient is a bit “fusiform” in shape, they have a rougher time after trauma? Well, in this case there may actually be some basis for the findings. There are thousands of articles in the literature that have identified that this shape actually is associated with higher complications and mortality in general. And there are already some published trauma papers that have confirmed this association. Interestingly, the BMI was less predictive that the WHR in this study, so this may be a better surrogate measure for obesity.

The number of patients enrolled is reasonable, and the statistics look sound (for just being an abstract). So there may be something here. However, before you start using the “measure tool” on your CT console on every trauma patient, wait for the confirmatory prospective studies to come along. 

Tomorrow, a look at a not-so-good study of this type, looking at an even more arcane metric on the CT scan.

Reference: Computed tomorgraphy-measured waist to hip ratio: a reliable predictor of outcomes after trauma. ACS Scientific Forum, trauma abstracts, 2016.

Source: The Trauma Professionals’s Blog

The Chance Fracture

Centers that take care of blunt trauma are familiar with the spectrum of injury that is directly attributable to seat belt use. Although proper restraint significantly decreases mortality and serious head injury, seat belts can cause visceral injury, especially to small bowel.

Lap belt use has been associated with Chance fracture (flexion distraction injury to the lumbar spine) since 1982. The association between seat belts and intra-abdominal injury, especially with an obvious “seat belt sign” was first described in 1987.

chance-fracture-21

Chance fracture. The vertebra appears to split in half from posterior to anterior.

Twenty years ago, orthopedic surgeons in Manitoba finally put two and two together and reported a series of 7 cases of Chance fractures. They noted that 6 of the fractures were associated with restraint use. Seat belt sign was also present in 5 of the 6 patients with fractures and three of the six had bowel injuries.

The authors noted that many provinces were mandating seatbelt use at the time, and they predicted that the number of Chance fractures, seat belt signs and hollow viscus injuries would increase. On the positive side, the number of deaths and serious head injuries would be expected to decline.

Although this was a small series, it finally cemented the unusual Chance fracture, seat belt sign, and bowel injury after motor vehicle trauma.

Thankfully, three point restraints (lap belt + shoulder harness) has been required in the seats next to doors for a long time. And since 2007, they have been mandated in the middle seat as well. Thus, these injuries seldom occur in any but the oldest (beater) cars on the road. They are seen more frequently now with sports and extreme sports injuries.

Chance fractures are frequently unstable, involving all three columns of the spine. The anterior column fails under compression, and the middle and posterior columns fail from the distraction mechanism. Usually, this fracture pattern requires operative fixation. However, if the posterior column is intact, a TLSO brace can be tried. This fracture is at risk for non-union and development of kyphosis or a flat back, which can lead to chronic pain and an abnormal posture.

Reference: Pediatric Chance Fractures: Association with Intra-abdominal Injuries and Seatbelt Use. Reid et al. J Trauma 30(4) 384-91, 1990.

 

Source: The Trauma Professionals’s Blog

Submental Intubation – The Video!

Yesterday, I described a technique for providing a secure yet short-term airway tailored to patients who can’t have a tube in their mouth or nose. Patients undergoing multiple facial fracture repair are probably the best candidates for this procedure.

A picture may be worth a thousand words, but a video is even better. Please note that it is explicit and shows the blow by blow surgical procedure. Of note, it is a quick and relatively simple advanced airway technique.

Related post:

Source: The Trauma Professionals’s Blog

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