August 16, 2018

Background: Alcohol and drug intoxication is common in trauma patients and a significant proportion of cervical spine (c-spine) injuries occur in patients with intoxication. A standard approach to both intoxicated and sober patients with suspected c-spine injury in many trauma centers includes the placement of a rigid cervical collar for spinal immobilization until the c-spine can be “cleared.”  Even after a negative CT, intoxicated patients often are immobilized for prolonged periods of time until a reliable exam can be performed due to concern for missed findings on CT scan, specifically unstable ligamentous injuries.  This practice is less than ideal, as prolonged c-spine immobilization is associated with DVT, atelectasis, aspiration pneumonia, and elevated intracranial pressures.  In 2015, the Eastern Association for the Surgery of Trauma (EAST) demonstrated that CT imaging of obtunded patients due to any cause would miss approximately 9% of cervical spine injuries, most of which are clinically insignificant. They additionally found no benefit to prolonged immobilization.

REBEL Review 88: Sub-Dissociative Ketamine for Acute Pain

Created July 23, 2018 | Trauma | DOWNLOAD

June 13, 2018

Background: The provision of safe and judicious analgesia is an important task for the emergency physician. Recent literature has demonstrated the effectiveness of sub-dissociative ketamine (SDK) in the emergency department (ED) setting (Motov 2015), however concerns regarding increased rates of hemodynamic and psychoperceptual adverse effects have limited application of this analgesic strategy in older populations. As awareness of geriatric oligo-analgesia has risen along with efforts to limit opioid utilization, interest in identifying a data set specific to this population has grown. The authors of this study sought to distinguish the performance and shortcomings of SDK in this unique patient group.

June 5, 2018

Background: I received a text message from one of my colleagues inquiring about discharging a patient home with isolated traumatic subarachnoid hemorrhage and to be honest I had heard about this practice, but was not completely aware of the literature around it.  Turns out from a PubMed search there was a meta-analysis published just this past year trying to answer this very question.  When I was a resident, which is not that long ago, the standard practice was for patients to be assessed by neurosurgery for management which usually involved ICU admission or a trip to the OR with ICU admission. Isolated traumatic subarachnoid hemorrhage (itSAH) is typically defined as the presence of a SAH in the absence of any other traumatic radiographic intracranial pathology.  So the question is, is it safe to discharge patients home with itSAH?

May 28, 2018

Background: Patients with penetrating neck trauma can present with a variety of injury patterns including hemorrhagic shock, airway obstruction and neurologic injury. Serious injuries may not be clinically obvious making diagnosis and prompt treatment challenging. Due to the large number of critical structures in the neck, a clear knowledge of the anatomy is necessary for proper evaluation and management.

Epidemiology (Evans 2018)

  • Represent 1% of all trauma admissions in the US and have a 5% mortality rate
  • 80% of morality secondary to cerebral infarction
  • ~ 20% of mortality secondary to uncontrolled hemorrhage