A 21 y/o male presents after a dirt bike accident (he went head over heels with the bike then landed on his left side). He had a transient loss of consciousness at the scene (about 30 sec to 1 min) and doesn’t recall his trip to the hospital. He has pain and deformity of his left distil radius and left mid clavicle. He has a normal neurologic exam. Abdomen/chest exams are unremarkable. Mild flank pain and thoracic spine tenderness are noted. After a complete trauma evaluation, (CT head/neck/abd-pelvis) CXR, arm, thoracic spine radiographs, and trauma labs, he has the diagnosis of:
1. Clavicle fracture (left, comminuted)
2. Left mid and distil radius fracture.
3. Concussion (CT head was negative)
1. Is it odd that the radius is broken both at the mid-shaft and distally?
There are 3 ‘ring’ structures in the skeleton: The pelvis (which actually has several rings), the tibia and fibula, and the radius and the ulna. Since these bones essentially make a ring (the ligaments holding the tibia and fibula together and the radius and the ulna together are part of this ring) structure, it’s difficult to break only one part of the ring structure. Usually, there are two ‘breaks’ in the ring. One break is sometimes a ligamentous injury, but in general, always look for a second break in the ring…usually you’ll find it.
2. What are the different grades of concussions, and what discharge instructions are important for the patient? What is the difference between antegrade and retrograde amnesia?
Antegrade amnesia is amnesia for the post traumatic period (what this patient had). Retrograde amnesia is amnesia for events before (pre-traumatic) the injury. The easy way to remember this is: Antegrade is After (both start with A), Retrograde is Before (R is like a B without the bottom part of the letter).
There are actually numerous methods to grade concussions. The American Academy of Neurology has an easy one that I use: (2)
1. Transient confusion
2. No loss of consciousness
3. Concussion symptoms or mental status abnormalities on examination resolve in less than 15 minutes.
1. Transient confusion
2. No loss of consciousness
3. Concussion symptoms or mental status abnormalities on examination last more than 15 minutes
1. Any loss of consciousness, either brief (seconds) or prolonged (minutes)
So it’s easy to remember: Any loss of consciousness is a grade 3, and grades 1 and 2 are separated by symptoms, either greater or less than 15 minutes.
For discharge instructions, for grade 3, no sports (or other potential activities that could result in another injury) till cleared by a neurologist (the AAN recommendation) or their primary care physician (my personal discharge instructions as basically a good neurologic exam is needed) AND no sports for at least two weeks. For grade 2, no sports or other aggressive play for at least 1 week and a neurologic examination, and for grade 1, they can potentially return to play the same day if patient has a normal sideline neurologic assessment (both at rest and with exertion). (1)
3. Conscious sedation is necessary to reduce the radius fracture. What are the differences between Propofol (Diprivan) and Etomidate (Amidate)? How do you interpret nasal cannula end-tidal CO2?
Both Etomidate and Propofol are great agents for conscious sedation as they are both very short acting. (2) Etomidate only lasts 3-5 minutes, and Propofol lasts 3-10 minutes. Both have onset of action in less than 1 minute, which allows you to quickly titrate the dose. The dose is different, with Etomidate 0.1-0.2 (I use 0.15) mg/kg, and Propofol is .5-1 mg/kg IV. There are side effects to both drugs, with Etomodate causing myocolnus, pain at injection, nausea and vomiting. Etomodate also lowers the seizure threshold. Etomodate is great for trauma patients as it does NOT affect hemodynamics. Propofol actually has anticonvulsant properties (the opposite of Etomidate) and can cause cardiovascular depression and hypotension (again, opposite of Etomidate). (2) In one randomized but non-blinded study of 220 patients comparing these two medications found that both were equally safe, but Etomidate had a lower rate of procedural success and induced myoclonus in 20% of patients. (3)
End tidal carbon dioxide monitoring can identify respiratory events prior to any drop in oxygen saturation. (4) Typically, consider a rise of CO2 of 10 mmHg from pre-sedation levels, a drop below 30 or a rise above 50 as abnormal. (4)
Using Etomidate, the forearm fracture was reduced by the orthopedic resident, but unfortunately, inadequate reduction occurred necessitating operative repair. Patient was admitted to the trauma service, and discharged a few days later after operative repair of his forearm.
1. American Academy of Neurology, Practice Parameter: The Management of Concussion in Sports, 1997, accessed at:
2. Windle ML. Procedural Sedation. Emedicine Nov 17, 2010. Accessed at: http://emedicine.medscape.com/article/109695-overview
3. Miner JR, Danahy M, Moch A, Biros M. Randomized Clinical Trial of Etomidate Versus Propofol for Procedural Sedation in the Emergency Department. Ann Emerg Med Jan 2007 49(1) :5-22. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed
4. Burton JH, Harrah JD, Germann CA, Dillon DC. Does End-Tidal Carbon Dioxide Monitoring Detect Respiratory Events Prior to Current Sedation Monitoring Practices? Acad EMerg Med 2006 May; 13(5):500-4. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed