sinaiem.org

Thank you to our speakers today — Dr. Richardson on research methods, Dr. Weingart on hypothermia, Bing with his journal club presentation (highlighted here), Abiola with trauma talk on the utility of repeat head CTs for recognizing intracranial hemorrhage, and Suzi for her M+M presentation on burn management.

Bing’s journal club presentation and discussion is summarized here — please feel free to add comments.

As for points from Abiola’s and Suzi’s talks, please see below:

Abiola constructed an evidentiary table on the usefulness of repeat CT’s in head trauma — it’s available here. After conference, another paper was unearthed that addressed the question of disposition for anticoagulated patients with head trauma — “Delayed posttraumatic acute subdural hematoma in elderly patients on anticoagulation” by Itshayek et al in Neurosurgery 58:851-856, 2006 (PMID:16639305 ) (residents, this journal article is available online).

This trial reviewed cases of four elderly anticoagulated patients with mild TBI and normal CT and neuro exam, who developed DASH (delayed posttraumatic acute subdural hemorrhage) and detiorated. The DASH happened 9 hours to 3 days post-TBI, and three out of the four needed surgical management.

Dr. Weingart had some comments on this paper and this clinical question in general, which I’ve summarized below:

These authors defined minor head trauma as differently than most other head trauma literature — they actually define minor as no LOC and no amnesia, just a bop to the head). Most folks would still say scan these patients once and then observe for 6 hours. A few would say just observe, a very few would say admit for 24 hours. Some would argue that you should be more scared in the supratherapeutic INR patients than normal level anticoagulation.

- In cases of anticoagulated patients with head trauma AND loss of consciousness, but GCS of 15 in the ED:  definitely scan, definitely observe at least 6 hours, most would say either rescan or admit for 24 hours.

- In cases of anticoagulated patients with TBI, LOC and GCS < 15, scan them, almost certainly admit for 24 hours, probably rescan prior to discharge.

Also Dr. C had some comments on Suzi’s M+M, abridged and summarized below:

1. Fluid resuscitation of burn victims begins with one of the basic formulas (Parkland, etc) but the clear intermediate and long term goal is urine output of 0.5-1cc/kg/hr.  In the setting of renal failure or other confounders, central venous pressure is probably your best alternative.

2. Critically ill patients who spend more than a few hours in the ED REQUIRE special attention particularly with regard to disposition as now several studies agree that mortality increases with ED l;ength-of-stay.

3. Haldol given IV has the same black box warning as Droperidol.  The time of onset of IM haldol is in the range of 20-30 minutes.  I think given this new development (it is almost 1 year old now), that a risk/benefit analysis needs to be done and droperidol should be more readily considered as long as the thinking is documented in the chart.

Comments, as always, are welcome.

Posted on Thursday, August 7th, 2008 at 1:56 pm by Nick. Filed under Stroke / TIA, Post-Conference Letter, Risk Stratification, Headache, Radiology, Blog.
You may post a comment.