A 90 year old female presented to her local hospital after her family found her to be having difficulty speaking. She was a pretty healthy and active 90 year old. She did have a history of atrial fibrillation and pulmonary emboli and therefore she was on Warfarin.

Upon presentation to her local ER, the physician did find her to have expressive and probably receptive aphasia. Her INR was therapeutic at 2.0. She underwent a noncontrast CT scan of the brain (image above) showing the left subdural hematoma with subfalcine herniation. A Neurosurgical consultation was obtained and the patient was transferred to my NeuroIntensive Care Unit.

The consulting Neurosurgeon was not impressed by the presentation of aphasia and elected to observe her in the ICU. Overnight her aphasia started to improve and then worsen again. A repeat CT showed the same subdural. The patient went to the OR later that day for evacuation.

I was always taught that a subdural hematoma with neurological findings was a surgical emergency. I was confused as to why the Neurosurgeon did not think so. I think I know the answer. Aphasia is not a usual presentation of a subdural hematoma (SDH).

To briefly review, head trauma is the leading cause of SDH usually related to car accidents, falls and assaults. Diffuse cerebral atrophy and the use of anticoagulation round out the list. A seemingly spontaneous unprovoked SDH occurs only 2.6% of the time.

The clinical finding associated with acute SDH is coma in 50% of cases. Posterior fossa SDH presents with symptoms of increased intracranial pressure like headache, vomiting. ataxia. Chronic SDH hematoma usually presents with headache, lightheadedness, apathy and somnolence.

Interestingly in my review, I did not find an aphasia as presenting symptom for SDH. I did find 2 studies- one from the Annals of Neurology which had 4 patients with aphasia and SDH and one form the Journal of American Medical Directors Assocation which had 1 patient with aphasia as a presenting symptom. Having seen this literature I understood a little bit more why the Neurosurgeon was not initially impressed with the case. Next time I will be an even more educated advocate for my patient in terms of needing to go to the OR with SDH presents with aphasia.

How many times have I been asked by the trauma surgeons to see a trauma patient for respiratory failure? The reason for intubation and ventilatory support – being combative and non-cooperative.

Intubating, sedating and sometimes even paralyzing a combative patient is an established practice. Combative patients are dangerous to themselves and to the medical staff. Clinical and radiological evaluation of these patients is difficult as well. Asking “What is hurting, Sir” if the patient is kicking, screaming, biting and spitting is unlikely to yield any clinically useful information. Getting an extremely agitated patient to a CT scanner could be a great challenge.

Most of those patients end up on a ventilator only temporarily. Once the effects of alcohol and drugs that had been taken wears off the patient is taken off the ventilator. In some cases serious injuries could be found that would require extended ventilatory support.

Intubation or insertion of a breathing tube could be associated with complications. Especially when performed urgently and in the field conditions, the patient can experience hypoxemia (low oxygen level), aspiration of gastric contents into the lungs and damage to the vocal cords. Sedatives and paralytics used for intubation can interfere with the neurological exam and clinical evaluation.

A study published in the June issue of the Journal of Trauma compares outcomes between two groups of patients. The patients in the first group were intubated for combativeness. The patients in the second group were similar patients in all aspects, yet they were not intubated.

The results of this study are not surprising. When intubated for combativeness, patients had longer hospital stays, more frequent respiratory complications and poorer discharge status.

The authors proposed that combativeness in some patients could be a manifestation of a traumatic brain injury even if a CT head was negative for acute pathology. It is true – some patients with head injury could have an unremarkable CT scans.

The authors also suggested using sedating medications like Haldol and Benzodiazepines to control agitation and avoid intubation.

In my personal experience, many combative patients “fail” a less radical sedation prior to being put on a ventilator.

Interestingly, even though this is a very recently printed article, it was submitted for publication back in July of 2006. Using a newer drug Precedex might be helpful to control extreme agitation. Next time I get asked to see a patient with “respiratory failure from being obnoxious” I will suggest it to the surgeon.

When I was called to see the patient after a motorcycle accident I expected the worst. The patient sustained a thoracic spine injury with cord transsection at T5 level as well as significant chest wall injury on the right side.

Multiple ribs were broken; some with a significant displacement (see the upper image above). Managing patients with a significant chest wall trauma could be a nightmare. Pain control is only one of the challenges.

Mechanics of the respiratory mechanism is impaired. Patients often are unable to take a deep breath and fully expand their lungs. Clearance of the secretions is a concern as well. Many patients with severe chest wall injury succumb to pneumonia and respiratory failure.

To facilitate pulmonary clearance, improve pain control and pulmonary mechanics chest wall stabilization has become a practical option. The technique of realigning and stabilizing ribs with metal plates is yet to be widely adopted. I have witnessed on multiple occasions that the patients with a stabilized chest do better and recover faster then the patients treated conservatively.

I was surprised to see that the patient was, actually, doing Ok from the respiratory standpoint. He was describing that he could feel his whole right side of the chest shifting when he was being moved. Besides that, pain was not a major issue and his respiratory status, otherwise, was stable.

The explanation for this surprising “wellness” was not in any way satisfying. He also sustained a severe spine injury with cord transsection at T5 level. His sensory level was just below his nipples. The patient simply could not feel the pain from the chest injury.

In no way I can call it even a mixed blessing. Most of us would likely take severe pain over being paralyzed.

It did make me think, nevertheless, about the importance of pain control in these trauma patients. Huge doses of narcotics are often unable to control the discomfort. Epidural analgesia is frequently employed to alleviate the pain. Some centers even utilize pain control techniques like intercostal blocks to achieve analgesia.