POTD: Trauma Tuesdays. Le Forte Fractures

Allison Kornblatt · March 5, 2019 · Trauma

Inservice is over but let’s keep the review of Le Forte Fractures going strong!

Interesting historical fact: Named after French Surgeon Rene Le Forte. He described fracture classifications are based on experiments conducted in 1900 by dropping bricks on cadavers and observing the pattern of fractures.

I included the words for description of the fractures but pictures are truly best.

· Le Fort I: the gist: palate. across both maxillae above the dentition.

o More wordy: The fracture extends through the piriform aperture superior to the maxillary alveolar ridge, then propagating through the anterior, medial, and posterolateral maxillary sinus walls.

· Le Fort II: the gist: nose + palate. starts in the maxilla laterally but extends more superiorly into the orbital floor.

o More wordy: The fracture involves the posterolateral maxillary sinus wall and anterior maxillary wall, extending through the inferior orbital rim into the orbital floor, medial orbital wall, and the region of the nasofrontal suture.

· Le Fort III: The gist: craniofacial separation. completely separates the facial bones from the skull. Transverses zygomatic arches laterally. Buzz word: CSF rhinorrhea.

o More wordy: The fractures extend through the nasal bridge, medial orbital wall, posterior orbital floor, and lateral orbital wall near the frontozygomatic suture. The zygomatic arch is always fractured as well.

In general: All of these patients are going to have severe swelling, possible airway obstruction. All will need OMFS consult, IV abx, surgical management and admission.

Sources:

LIFL: https://litfl.com/le-fort-facial-fractures-eponymictionary/

ENT trauma handbook published 2017 written by the American Academy of Otolyngology- Head and Neck surgery

Photo: https://emedicine.medscape.com/article/434875-overview

POTD: Trauma Tuesdays - Concussions

Cecily Sotomayor · February 19, 2019 · Trauma, Neurology

Clinical scenario:

A 16-year-old boy presents after hitting his head in a collision with another player during a soccer game. He denies loss of consciousness but complains of a moderate headache, nausea, and difficulty concentrating.

Which of the following represents appropriate next steps in management?

A. Admit the patient to the hospital for overnight observation

B. Clear the patient to play after 48 hours if his symptoms resolve

C. Discharge with instructions to get follow-up care and not return to play

D. Order a head CT to rule out the presence of an intracranial bleed or swelling

The correct answer is C.

Concussions

What is a concussion?

The term "concussion" is often used in the medical literature as a synonym for mild TBI but more specifically describes a pathophysiological state that results in the characteristic symptoms and signs that individuals may experience after a mild TBI.

Symptoms

Rapid-onset short-lived neurologic function impairment that resolves on its own. These symptoms reflect functional disturbance rather than structural injury.

Diagnosis

If one or more of the following:

Symptoms, including somatic (headache, nausea, off balance), cognitive (“ in a fog,” slow), or emotional (rapidly changing)
Physical signs, such as loss of consciousness, amnesia, although LOC is not required
Behavior changes, such as irritability
Cognitive impairment, such as slowed reaction times
Sleep disturbance, such as insomnia

Evaluation

Concussion is a clinical diagnosis, and there are a variety of sideline assessment tools (that are outside the scope of the ED) that include measurements of orientation, symptoms, gross cognition, and physical examination findings (e.g. Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), computerized neurocognitive testing, and the Sport Concussion Assessment Tool version 5 (SCAT5 or Child-SCAT5)).
Physical exam should include:
- assessment of the cervical spine (+/- immobilization with c-collar if cervical spine injury suspected)
- detailed neurologic assessment (including mental status, cognitive functioning, and gait/balance)
- structural brain imaging (i.e. CT scan or MRI) if concern for structural injury (e.g. acute brain bleed)

Discharge Precautions

This is arguably the most important part of your role in the concussed patient. Thankfully, the CDC has a ton of great literature on the subject.

Pediatric Care Packets:

Adult Care Packets:

References:

PEER IX

http://www.emdocs.net/concussion-update/?fbclid=IwAR3KSyGMyb-55DTXUWRkTXRLBurnrvULl2zPhZb4xIyiJH8_idVktsaDTJA

https://www.uptodate.com/contents/acute-mild-traumatic-brain-injury-concussion-in-adults?search=concussion&sectionRank=3&usage_type=default&anchor=H25&source=machineLearning&selectedTitle=1~79&display_rank=1#H25

https://www.cdc.gov/HeadsUp/

Blunt Cardiac Injury Guidelines

Anya Karpov · December 19, 2018 · Trauma

To trop or not to trop? Here's a brief review of the 2012 EAST trauma guidelines for BCI.

What is BCI, anyway?

Describes a range of injuries due to blunt thoracic trauma: wall motion abnormalities, myocardial contusion, valve injuries, focal wall dilation, coronary injury, pericardial rupture, wall rupture

Right heart most commonly affected as it is most anterior.

Who to work up?

According to 2012 East guidelines: “patients with any significant blunt trauma toanterior chest should be screened.”

Also consider BCI in patients with persistent unexplained tachycardia, cardiogenic shock, or hypotension not explained by other injuries.

Now that I suspect BCI, what should I do?

Screening:

Screening consists of an EKG (Level 1 evidence) and a troponin (Level 3 evidence). Early studies suggested that EKG alone is sufficient to diagnose BCI, however multiple studies since then show that such an approach does not capture the small percentage of BCI patients that present with normal initial EKG and positive troponin.

A normal EKG and troponin rules out BCI (even in the setting of a sternal fracture, which is not predictive of BCI). Several studies show that the addition of troponin raises the NPV to 100%. Same screening approach is supported for pediatric pts.

Management & Disposition:

Management is supportive; severe trauma may require surgical repair.

Patients who have a new abnormality on EKG (arrhythmias, ST changes, heart block, PACs or PVCs, ischemic changes, etc) must be admitted to a telemetry floor for continuous monitoring.

A new dysrhythmia or hemodynamic instability warrants an echo, preferably TEE over TTE.

Note that degree or persistence of elevation of troponin does not correlate with prognosis.

The chicken or the egg…did an MI precede the MVA or is it BCI?

It is important to differentiate which patients need cath with anticoagulation and which patients would be harmed from it. Can be differentiated via ekg-gated CT angiocoronaries.