Distracting Painful Injuries Associated with Cervical Spinal Injuries in Blunt Trauma

Distracting painful injuries (DPIs) may mask symptoms of spinal injury in blunt trauma victims and form an important element in a decision instrument used to identify individuals who require cervical spine radiography. OBJECTIVE: To identify the types and frequencies of injuries that actually act as DPIs among blunt trauma patients undergoing cervical spinal radiography. METHODS: This was a prospective observational study of consecutive blunt trauma victims presenting to an urban Level 1 regional trauma center between April 1, 1998, and September 30, 1998. Prior to cervical spinal radiography, treating physicians evaluated each patient to determine whether a DPI was present or absent and, if present, what type of injury was sustained. Injuries were categorized as fractures, soft-tissue injuries and lacerations, burns, visceral injuries, crush injuries, or other injuries. RESULTS: Data were collected for 778 patients, between 1 month and 98 years old, of whom 264 (34%) were considered to have DPIs. Physicians were unable to determine the DPI status in 47 (6%) additional cases. Fractures accounted for a majority of DPIs (154, or 58%), 42 (16%) were soft-tissue injuries or lacerations, and 86 (34%) were due to a variety of other entities, including visceral, crush, burn, or other miscellaneous injuries. Among the 37 (5%) patients with an acute cervical spinal injury, 20 (54%) had a DPI, including three (8%) who had DPI as the only indication for cervical radiography. CONCLUSIONS: A significant number of blunt trauma patients are believed by clinicians to have DPIs that can possibly mask the presence of cervical spinal injury. Fractures and trauma to soft tissues are the most common types of DPI.     

Identification of Intra-abdominal Injuries in Children Hospitalized Following Blunt Torso Trauma

OBJECTIVE: To determine the utility of the ED physical examination and laboratory analysis in screening hospitalized pediatric blunt trauma patients for intra-abdominal injuries (IAIs). METHODS: The authors reviewed the records of all patients aged <15 years who sustained blunt traumatic injury and were admitted to a Level 1 trauma center over a four-year period. Patients were considered high-risk for IAI if they had any of the following at ED presentation: decreased level of consciousness (GCS < 15), abdominal pain, tenderness on abdominal examination, or gross hematuria. Patients without any of these findings were considered moderate risk for LAI. The authors compared moderate-risk patients with and without IAIs with regard to physical examination and laboratory findings obtained in the ED. RESULTS: Of 1,040 children with blunt trauma, 559 (54%) were high-risk and 481 (46%) were moderate-risk for IAI. 126 (23%) of the high-risk and 22 (4.6%) of the moderate-risk patients had IAIs. Among moderate-risk patients with and without IAIs, those with IAIs were more likely to have abdominal abrasions (5/22 vs 34/459, p = 0.008), an abnormal chest examination (11/22 vs 86/457, p = 0.01), higher mean serum concentrations of aspartate aminotransferase (AST) (604 U/L vs 77 U/L, p < 0.001) and alanine aminotransferase (ALT) (276 U/L vs 39 U/L, p = 0.002), higher mean white blood cell (WBC) counts (16.3 K/mm3 vs 12.8 K/mm3, p < 0.001), and a higher prevalence of >5 RBCs/hpf on urinalysis (7/22 vs 54/427, p = 0.02). There was no significant difference (p > 0.05) between moderate-risk patients with and without IAIs in initial serum concentrations of amylase, initial hematocrit, drop in hematocrit >5 percentage points in the ED, or initial serum bicarbonate concentrations. CONCLUSION: In children hospitalized for blunt torso trauma who are at moderate risk for IAI, ED findings of abdominal abrasions, an abnormal chest examination, and microscopic hematuria as well as elevated levels of AST and ALT, and elevated WBC count are associated with IAI.     

Vasospasm Surveillance With Transcranial Doppler Sonography in Subarachnoid Hemorrhage

The use of transcranial Doppler monitoring for the diagnosis of vasospasm in subarachnoid hemorrhage is backed by national guidelines. However, it remains poorly used across neurologic intensive care units in the United States. This current practice article uses 2 clinical vignettes to illustrate the simplicity and logic behind routine daily surveillance of vasospasm with transcranial Doppler sonography in patients with subarachnoid hemorrhage, in preference to other modalities.     

The Significance of Out-of-hospital Hypotension in Blunt Trauma Patients

Objective: To determine the significance of a low out-of-hospital systolic blood pressure (SBP) reading in blunt trauma patients who have a normal SBP upon ED arrival.
Methods: A retrospective case-control study compared admitted blunt trauma patients who were hypotensive (SBP ≤90 mm Hg) in the field and normotensive in the ED (group 1) with those who were normotensive both in the field and in the ED (group 2). The groups were compared for mortality, intensive care unit (ICU) admission, injury severity scale (ISS) score, need for transfusion in the ED, incidence of intra-abdominal injury, and incidence of pelvic or femur fracture.
Results: Each group consisted of 52 patients. The groups were similar with respect to age, gender, and initial ED SBP. The group 1 patients had a higher mortality (10 vs 1, p = 0.008), a higher number of ICU admissions (28 vs 12, p = 0.001), more pelvic or femur fractures (16 vs 7, p = 0.03), and a higher ISS score (19.0 vs 10.5, p = 0.01). Although not significant, group 1 also had higher incidences of intra-abdominal injury (10 vs 3, p = 0.07) and transfusion (8 vs 2, p = 0.09).
Conclusion: The injured patients who were hypotensive in the out-of-hospital setting but normotensive upon ED arrival were more severely injured and had more potential for blood loss than were the patients who were normotensive both in the out-of-hospital setting and in the ED. Out-of-hospital hypotension may be a clinical predictor of severe injury, even in the face of normal ED SBP. Prospective studies are indicated to validate this hypothesis.     

Vascular Reactivity During Migraine Attacks: A Transcranial Doppler Study

We measured vascular reactivity--expressed i) as decrease in blood flow velocity (cm/sec) per vol% CO2 decrease due to voluntary hyperventilation and ii) as increase of blood flow velocity during the first minute after resuming normal ventilation, per vol% CO2 increase--in the middle cerebral and basilar artery of 48 migraineurs with attacks without aura, and 17 normal controls. We found no differences for both determinants of vascular reactivity between migraineurs during and outside an attack, and between migraineurs and healthy volunteers. We conclude that the vasomotor reactivity is normal during migraine attacks without aura.     

Transcranial Doppler Ultrasound Use in Pediatric Patients With Penetrating Traumatic Brain Injuries

The purpose of this article is to increase awareness of the usefulness of transcranial Doppler (TCD) ultrasound as a noninvasive neuromonitor and bedside ultrasound in pediatric patients who have experienced a penetrative traumatic brain injury (TBI) as a result of a firearm. To date, the use of TCD is not standard of care in pediatric TBI patients. TCD is a portable ultrasound that can be performed in any care environment. The use of TCD in pediatric TBI studies have demonstrated abnormalities in cerebral blood flow velocity, autoregulation, and embolic events; all of which have been associated with poor neurocognitive and functional outcomes. A penetrating brain injury as a result of a firearm is associated with ongoing vascular injury and thereby an increased risk for poor neurologic sequelae. We discuss two exemplars of TCD use in children who experienced a firearm-related penetrating TBI and their TCD findings. Both exemplars identified the unique insights provided by TCD that were unappreciated by clinical observation. This article provides early evidence for the use of TCD as a neuromonitor in pediatric penetrating TBI.     

Blunt Splenic Injuries in the Adolescent Trauma Population: The Role of Angiography and Embolization

Background: Splenic artery embolization (SAE) improves non-operative splenic salvage rates in adults, but its utility and safety in the pediatric population is less well defined. Objective: Because adolescent trauma patients are often triaged to adult trauma centers, we were interested in evaluating SAE in this particular population. We hypothesize that angiography and embolization is a safe and effective adjunct to non-operative management in the adolescent population. Methods: A retrospective review of all patients aged 13-17 years admitted to our Level I Trauma Center with blunt splenic injury from 1997-2005 was performed. We reviewed patient demographics, operative reports, admission, and follow-up abdominal computed tomography (ACT) results, angiographic reports, and patient outcomes. Results: A total of 97 patients were reviewed. Eighteen patients underwent immediate surgery, and 79 of the remaining patients had planned non-operative management. Of those participating in non-operative management, 35/79 (44%) were initially observed and 44/79 (56%) underwent initial angiography, 23/44 having embolization. Patients in the embolization group had an overall high grade of injury (American Association for the Surgery of Trauma mean grade 3.3, SD 0.6). The overall splenic salvage rate was 96% (76/79) in the non-operative management group; 100% splenic salvage was seen in the observational group; 100% salvage was also seen in patients with negative angiography, and 87% salvage (20/23) in the splenic artery embolization group. Conclusion: Splenic artery embolization may be a valuable adjunct in adolescent blunt splenic injury, especially in higher grade injuries or with evidence of splenic vascular injury on ACT.     

儿童颈性眩晕患者的颈椎X线片及经颅多普勒超声特征

目的分析颈性眩晕儿童的颈椎X线片及经颅多普勒超声(TCD)特征,探讨发病机理。方法对80 例颈性眩晕儿童进行颈椎X线片及TCD检查,分析其特点。结果本组患儿的颈椎X线片异常主要为寰枢椎或/和C2、C3椎关节紊乱,可并发颈椎失稳、颈曲变直甚至颈曲反弓、颈轴侧弯;异常TCD表现以单支或多支动脉血流速度增快为主,少数表现为单支或多支动脉血流速度减慢及双侧血流速度不对称。结论儿童颈性眩晕的病变部位主要在寰枢椎或/和C2、C3椎,发病机制主要为寰枢椎或/和C2、C3椎间多种形式的关节紊乱。     

Power M‐Mode Transcranial Doppler Examination of the Ophthalmic Artery in Pregnancy

Our aim was to describe the standard operating procedure for transcranial Doppler investigation of the ophthalmic artery in pregnancy, determine the interobserver and intraobserver variability using power M‐mode technology, and review the existing literature. Accordingly, 27 healthy pregnant or immediately postpartum women were enrolled and underwent transcranial Doppler investigation of the ophthalmic artery using power M‐mode technology. Good interobserver and intraobserver variability was observed for both, especially with respect to the clinically important indices. Transcranial Doppler power M‐mode examination of the ophthalmic artery is easy and reproducible and holds a great deal of potential for investigation in pregnancy.     

Clinical Sobriety Assessment by Emergency Physicians in Blunt Trauma Patients with Acute Alcohol Exposure

Background: Alcohol use increases injury risk and severity. However, few studies have evaluated the ability of emergency physicians (EPs) to accurately determine sobriety. Objectives: To determine the predictive value of clinical sobriety assessment by EPs in blunt trauma patients with acute alcohol use. Materials and Methods: Blunt trauma patients, aged 18–65 years with suspected acute alcohol use, were prospectively enrolled in the study. EPs assessed study subjects before sample collection for blood alcohol level (BAL) and urine drug screen measurement. Alcohol exposure was considered significant if BAL was ≥ 80 mg/dL. Sobriety (non-significant alcohol exposure) was defined as a BAL < 80 mg/dL. EP sobriety assessment was compared to measured BAL and predictive values were calculated. Agreement on significance of alcohol exposure occurred if EP-estimated BAL > 80 mg/dL agreed with measured BAL > 80 mg/dL, or estimated BAL < 80 mg/dL agreed with measured BAL < 80 mg/dL. Chi-squared analysis was used to compare the proportion of correct physician assessments among patients with sobriety and those with significant alcohol exposure. Results: Of 158 enrolled subjects, 153 completed clinical assessment. EP assessment had a predictive value of 83% (95% confidence interval [CI] 77–90%) for significant alcohol exposure and 69% (95% CI 60–78%) for sobriety. Agreement on the significance of alcohol exposure was 82% (125/153; 95% CI 76–88%). EPs identified 32% (11/34; 95% CI 17–48%) of sober patients, but identified 96% (114/119; 95% CI 92–99%) of patients with significant alcohol exposure. EP assessment was significantly less accurate in identifying sober patients (p < 0.01). Conclusions: Emergency physicians identified significant recent alcohol exposure in blunt trauma patients 96% of the time. However, clinical assessment by EPs in blunt trauma patients with recent alcohol use had only moderate predictive value for significant alcohol exposure. Sober patients were frequently misidentified as having significant alcohol exposure.     

Evaluation of Arteriovenous Malformations (AVMs) With Transcranial Color‐Coded Duplex Sonography

OBJECTIVE: The clinical value of transcranial color-coded duplex sonography (TCCS) in the evaluation of arteriovenous malformations (AVMs) has not yet been fully investigated. In this study, 54 intracranial AVMs confirmed by angiography were prospectively examined over 6 years. The purpose of the study was to describe their typical sonographic features and to define sensitivity for diagnosis with regard to the location of an AVM. METHODS: Transcranial color-coded duplex sonographic findings for 54 patients with intracranial AVMs are presented. The vessels of the circle of Willis were identified by location, course, and direction of flow on color flow images. RESULTS: In accordance with digital subtraction angiography, the intracranial AVMs could be visualized in 42 cases (sensitivity, 77.8%). The pathologic vessels were coded in different shades of blue and red, corresponding to varying blood flow directions in the AVM. The major feeding vessels could be easily identified. Hemodynamic parameters showing increased systolic and diastolic flow velocities and a decreased pulsatility index were better attainable with TCCS than with conventional transcranial Doppler sonography. Arteriovenus malformations located near the cortex, that is, in the parietal, frontal, occipital, and cerebellar regions of the brain, could not be visualized. In contrast, AVMs located in the basal regions were very easy to image (sensitivity, 88.9%). Additionally, TCCS proved useful for follow-up examinations postoperatively or after embolization. CONCLUSIONS: Transcranial color-coded duplex sonography is a valuable noninvasive method for the diagnosis and long-term follow-up of intracranial AVMs. Arteriovenous malformations located in the axial imaging plane can be more easily detected. Nevertheless, TCCS should not be used as a screening method.     

Interhemispheric Comparisons of Cerebral Blood Flow Velocity Changes During Mental Tasks With Transcranial Doppler Sonography

Objective. The purpose of this study was to evaluate hemispheric asymmetry of cerebral blood flow changes during various mental tests by applying transcranial Doppler sonography (TCD) to simultaneously monitor bilateral cerebral blood flow velocity changes. Methods. Twenty‐one participants without cerebrovascular disease performed 3 left hemispheric tasks (reading, calculation, and color scaling) and 3 right hemispheric tasks (face recognition, space imagination, and line orientation). Results. Mean velocities of the rest and performing periods did not differ significantly between the left and right hemispheric tasks. Although greater acceleration of blood flow velocity was observed on the left than on the right in most of the 6 tasks except line orientation (mean left – right ratio difference [D_l–r] ranged from ?0.018 to 0.071), this difference was larger for left hemispheric tasks (mean D_l–r ranged from 0.050 to 0.071) than right hemispheric tasks (mean D_l–r ranged from ?0.018 to 0.034; P < .001). Further comparisons of each pair of (ie, left and right) hemispheric tasks revealed that the most suitable left and right hemispheric tasks to show hemispheric asymmetry were reading and line orientation, respectively (P < .001). Conclusions. Hemispheric asymmetry of cerebral blood flow changes during mental tests is demonstrable with TCD only when comparing the D_l–r in response to suitable paired left and right hemispheric tasks.     

Transcranial Doppler Sonography in Pediatric Neurocritical Care

Transcranial Doppler sonography is a noninvasive, real‐time physiologic monitor that can detect altered cerebral hemodynamics during catastrophic brain injury. Recent data suggest that transcranial Doppler sonography may provide important information about cerebrovascular hemodynamics in children with traumatic brain injury, intracranial hypertension, vasospasm, stroke, cerebrovascular disorders, central nervous system infections, and brain death. Information derived from transcranial Doppler sonography in these disorders may elucidate underlying pathophysiologic characteristics, predict outcomes, monitor responses to treatment, and prompt a change in management. We review emerging applications for transcranial Doppler sonography in the pediatric intensive care unit with case illustrations from our own experience.     

Clinical Clearance of Cervical Spinal Injuries by Emergency Nurses

OBJECTIVES: To determine the interrater reliability between emergency nurses and emergency physicians on defined criteria for clinically clearing the cervical spine in blunt trauma patients. METHODS: Blunt trauma patients, 12 years or older, arriving with cervical spinal precautions were prospectively enrolled as a convenience sample. Each member of the emergency physician-nurse pair completed a questionnaire with regard to five criteria for clinically clearing the cervical spine for each patient. Interrater reliability was determined by calculating the kappa statistics for the individual and combined criteria. RESULTS: Physicians and nurses agreed on the presence or absence of the combined criteria in 175 of 211 patients (82.9%; kappa, 0.65). Agreements on individual criteria were as follows: 1) intoxication--203 patients (96.2%; kappa, 0.82); 2) altered consciousness--197 patients (93.4%; kappa, 0.60); 3) neck pain--185 patients (87.7%; kappa, 0.75); 4) distracting injury--160 patients (75.8%; kappa, 0.36); and 5) neurologic deficit--198 patients (93.8%; kappa, 0.45). If disagreements in which the physician would clinically clear the patient but the nurse would not were considered as agreements, then overall agreement would be 198 of 211 patients (93.8%; kappa, 0.88). On the assumption that nurses would assess patients prior to physicians, they would have cleared 35% of the patients before the physicians. However, they would have ordered 12% more radiographs and unsafely clinically cleared 5% of the patients. CONCLUSIONS: The interrater reliability for the combined cervical spinal injury criteria between emergency nurses and physicians was good to excellent. However, with the training given in this study, nurses would order more radiographs than physicians and would unsafely clinically clear cervical spines in some patients.