VA Report Pearls 7.15.15 – Maxillofacial Trauma and Falls in the Outpatient World

  • We discussed the different of syncopal vs nonsyncopal falls. Some key tidbits were the following:
    • Autonomic neuropathy can be related to both duration and severity of diabetes.
    • Tongue lacerations can be telling for seizure vs syncope. Seizures tend to be associated with lateral lacerations and the tip of the tongue is more often involved in syncope. The data is from two pooled studies: (1) Benbadis et al., Archives of Internal Medicine, 1995 and (2) Akor et al., Seizure, 2013.
      • The pooled accuracy measure of biting involving the tip of the tongue in diagnosis of syncope are sensitivity 0.11 (95% CI 0.04-0.36) and specificity 99.8%. The pooled accuracy measure of lateral tongue biting in the diagnosis of epileptic seizures is sensitivity of 11.3% and specificity of 99.8%.
    • Cognitive deficits can play a key role in nonsyncopal falls and one way this can be assessed is evaluating gait while the patient is focused on their gait only and then while they are doing another activity while assessing their gait (an example was given of a patient with intact gait who had impaired gait at the end of their visit while putting on their sweater).
  • Guidelines for Head CTs in Falls
    • Canadian CT Head Rule
      • Clinical decision aid that allows physicians to rule out the presence of intracranial injuries that would require neurosurgical intervention
      • Involves major criteria and minor criteria
        • Major criteria: GCS < 15 at 2 hours post-injury, suspected open or depressed skull fracture, any sign of basilar skull fracture, > 2 episodes of vomiting, age > 65
        • Minor criteria: retrograde amnesia to the event > 30 minutes, dangerous mechanism (ejected from motor vehicle, struck by motor vehicle, fall > 3 feet or > 5 stairs)
    • CHIP Prediction Rule
      • Calculates a score for predicted probability of intracranial traumatic findings on CT (Smits et al, Ann Intern Med, 2007)
      • Involves various components including the following:
        • Signs and symptoms: signs of skull fracture, skull contusion, vomiting, LOC, posttraumatic seizure
        • Patient characeristics: age, use of anticoagulants
        • Mechanism of injury: fall from any elevation, pedestrian/cyclist vs vehicle, ejected from vehicle
        • Neurological exam: GCS at presentation and after one hour, post-traumatic amnesia, neurological deficits
  • Adjuvant tools that we have to reduce the risk of falls
    • Referring to gait training/PT
    • Home safety evaluations
    • Vitamin D replacement is key!
      • JAMA meta-analysis by Bischoff-Ferrari et al. (2004) revealed that vitamin D supplementation reduced the risk of falls among ambulatory or institutionalized older individuals by more than 20%. The NNT was impressive! 15 patients would need to be treated with vitamin D to prevent 1 person from falling.

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