Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What is this and how should we handle it? – My thoughts

In my original post,[1] I asked what this is and how we should handle it –
 

 

Nobody answered incorrectly about what it is. Battle’s sign, which is a sign of a skull fracture.[2]

There was less agreement about how to handle it.

A 46-year-old man presented to the otolaryngology clinic with hearing loss and a sensation of fullness in the left ear. The symptoms had started a few days before presentation. He had no other neurologic symptoms.[3]

This is a few days old. Is it a true emergency?

Is there a recent change in symptoms, or have the symptoms remained stable for the past few days?

IV (IntraVenous) line? Yes, No, Maybe?

Is an IV going to make any difference? Only if we need to give medications. We may only need to give medications to treat agitation brought on by aggressive handling of this patient.

Oxygen?

If there is no documentation of hypoxia, should we be giving this dangerous drug? Should BLS (Basic Life Support) personnel be giving oxygen without pulse oximetry to document a need for oxygen?

What about the magical long board and the EMS cervical collar?
 

Image credit.
 

Fracture?

What fracture?

Are we only treating mechanism of injury, because we are not supposed to think about what is best for the patient?

If there is a skull fracture, will applying pressure to the fracture site cause an increase in ICP (IntraCranial Pressure)?

Say it an’t so, Joe!

We are treating something that indicates a fracture by putting pressure on the place that we are supposed to assume is fractured, but we are ignoring the problems this may create.

This is bad, but perhaps not atypical, EMS thinking.

If immobilization is required by protocol, or by medical command (assuming we call to explain the probable harm the doctor would be causing by requiring spinal immobilization), we should only use a towel, or sheets, or something soft to avoid putting pressure on the fracture.

Here is the scan of the fracture. Arrows point to the fractures.
 

 

We know that even properly applied cervical collars apply distracting (separating) pressure between the torso and the head by pushing down on the trapezius muscles and the clavicles and pushing up on the bottom of the jaw and the head.
 


Picture credit.[4] Click on the image to make it larger.
 

If I do have a head injury, my intracranial pressure will probably be increased by application of a cervical collar.

According to a review of seven papers examining the effects of cervical collars on intracranial pressure.

In conclusion, there is evidence that rigid collars for cervical spine protection may exacerbate intracranial hypertension in patients with severe head injury. Although the clinical significance of this phenomenon has not yet been convincingly established, the detrimental effects of increased ICP in head-injured patients are well known.[5]

Does this patient have a severe head injury?

Probably not, but we might make it worse by increasing the patient’s intracranial pressure.

The best thing for this patient is probably benign neglect, but malignant intervention is the EMS way.

There is nothing so bad that we cannot make it worse by applying protocol.

We should avoid the collar, or any other treatment, especially when the treatment is likely to make an injury worse for no benefit to the patient.

Footnotes:

[1] What is this and how should we handle it?
Rogue Medic
Thu, 20 Sep 2012
Article

[2] Basilar skull fracture
Wikipedia
Article

[3] Battle’s Sign
Kenta Watanabe, M.D., Ph.D., and Wataru Kida, M.D.
N Engl J Med 2012; 367:1135September 20, 2012
Images in clinical medicine

Free Full Text from N Engl J Med

[4] Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury.
Ben-Galim P, Dreiangel N, Mattox KL, Reitman CA, Kalantar SB, Hipp JA.
J Trauma. 2010 Aug;69(2):447-50.
PMID: 20093981 [PubMed – indexed for MEDLINE]

Free Full Text PDF Download from medicalsci.de

[5] Rigid cervical collar and intracranial pressure of patients with severe head injury.
Ho AM, Fung KY, Joynt GM, Karmakar MK, Peng Z.
J Trauma. 2002 Dec;53(6):1185-8. Review. No abstract available.
PMID: 12478051 [PubMed – indexed for MEDLINE]

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