From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Head bang, Nasal blood?
Date: 22 May 2005 10:42:04 -0500
Message-ID: <4290a805$0$16219$bb4e3ad8@newscene.com>

<fake_fake_666@yahoo.com> wrote in message
news:1116771750.938017.170630@g47g2000cwa.googlegroups.com...
> Hi
> 24hrs ago I slammed the front-top of my head into the side of the
> doorway. No loss of consciousness or amnesia, and no cut just a bump.
>
> A couple hours ago when I woke up and blew my nose there was blood
> mixed with the mucus. Is the blood just a coincidence?
>
> I did a search and read about this double ring if it is CSF when put on
> filter paper, but can't find any pictures. Mine has blood in the
> center, an off-white color surrounding it, and a thin outline of red at
> the edges. Like an egg in a frying pan or coffee stain.
>
> Probably just nasal blood and nothing to worry about right? If it was
> from the head whack will it heal on it's own?
>

Hmm...in the spectrum of traumatic brain injury, your positive double-ring
sign, and epistaxis don't fit very well with the fact that there was no LOC,
no focal defecits, no altered mental state, normal GCS.

In the event you're not trolling, I'd have to recommend that someone drive
you to the nearest ER. Sounds like you need a CT scan.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Head bang, Nasal blood?
Date: 22 May 2005 11:26:07 -0500
Message-ID: <4290b22d$0$16262$bb4e3ad8@newscene.com>

<fake_fake_666@yahoo.com> wrote in message
news:1116777394.993801.247730@g14g2000cwa.googlegroups.com...
> Is what I described really a positive double-ring? I've had blood on
> the nose tissue before in the past, as has everyone I know... does
> nasal blood absolutely not spread out as I described on the paper?
>
> It's not like I was in a car accident, just kind of fast walked into
> the side of the doorway. I was hoping to hear, "Don't worry about it."



What you described is consistent with a double-ring sign, and you reported a
nose bleed from a blow to the top front of your head (nose not injured).
Can't just shrug that off. My interpretation depends on the accuracy of your
description, since I can't see it. It's possible that it could be just
mucus, but since I can't tell from here if your drainage contains
polysaccharides, and since CSF rhinorrhea carries the very significant risk
of bacteria from the sinus infecting your brain, then yes, go to the ER.


> What could a CT scan show?

It *might* show a sinus full of blood, or it might show a fracture, or it
might show a tumor in your frontal sinus. It might show nothing.



> Is it not okay to just give it time and
> monitor for any other unusual symptoms?

You asked for advice over the internet, where a proper history is unlikely
and a physical exam is impossible. I'm giving you the same advice you'd
likely get if you called the ER doctor on the phone.....clear nasal drainage
mixed with blood after a blow to the head *might* be nothing, but it *might*
be CSF rhinorrhea. Since it's impossible to tell over the internet or over
the phone, go to the ER.

Here's the deal...you've presented a set of facts, now, readers here have to
guess what's going on. The consequences of guessing "go for examination" and
being wrong are wasted time for you. The consequences of guessing "Don't
worry about it" and being wrong might result a your death.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Head bang, Nasal blood?
Date: 22 May 2005 12:09:02 -0500
Message-ID: <4290bc52$0$16188$bb4e3ad8@newscene.com>

<fake_fake_666@yahoo.com> wrote in message
news:1116780849.552981.263680@g14g2000cwa.googlegroups.com...
>
> Yes, I appreciate your advice very much. It is always a gamble I guess.
> :) I will wait a bit and if there is more blood/discharge, or other
> signs I will go to the ER.
>

In the absence of altered mental state or other focal neurological signs, I
can't say that that's unreasonable. CSF rhinorrhea is likely to be
persistant and ongoing, not episodic.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Head bang, Nasal blood?
Date: 23 May 2005 10:11:03 -0500
Message-ID: <4291f1e8$0$51502$bb4e3ad8@newscene.com>

"Carey Gregory" <tiredofspam123@comcast.net> wrote in message
news:p9r291lrj3k8ff5ek2q2oi5jurghc8f197@4ax.com...
> "Howard McCollister" <nospam@nospam.net> wrote:
>
>>Here's the deal...you've presented a set of facts, now, readers here
>>have to guess what's going on. The consequences of guessing "go for
>>examination" and being wrong are wasted time for you. The consequences
>>of guessing "Don't worry about it" and being wrong might result a your
>>death.
>
> I'm going to go out on a limb here and pronounce his death highly
> unlikely based solely on the fact that it's been several hours and he's
> still posting messages to this newsgroup.
>
> Call me bold and rash.
>

I don't disagree, but my advice to patients with potentially
life-threatening problems that I can't evaluate tends to err on the side of
caution. Going out on a limb is generally discouraged as a concept.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Head bang, Nasal blood?
Date: 24 May 2005 00:02:04 -0500
Message-ID: <4292b4ee$0$91679$bb4e3ad8@newscene.com>

<fake_fake_666@yahoo.com> wrote in message
news:1116900238.174343.252790@g43g2000cwa.googlegroups.com...
>I understand why you guys err on the side of caution, but sometimes I
> wish physicians gave two opinions; one as a professional, and the other
> in a lighter, 'off the record' tone.
>
> Once in the past I tried to get a quick appointment but everyone was
> out, and I was told to go to the ER over the phone. When I went there
> it turned out to be nothing. Here I was healthy surrounded by serious
> injuries, and I felt stupid. I wish I wasn't told to go. The doctor hid
> it, but I could tell he was laughing at me inside like, "what a waste
> of time".
>
> The other thing besides a waste of a visit is the anxiety. A
> physician's word can be intimidating and when they speak strongly,
> including the word death, it can be very scary.
>
> It's been around 60 hours since my incident, and I haven't had a repeat
> of nose discharge, it is quite dry. Last night my neck was rather
> stiff, but today it is improved and I feel mostly fine.
>
> I appreciate Howard, and now your advice Robert, but I would be lying
> if I said it didn't cause stress. Sometimes I wonder if the stress
> caused by a doctor stating the possibility of a serious issue ever
> causes one, or prevents something from what would have otherwise
> healed.
>
> I did some reading about the CSF rhinorrhea and minor head trauma. The
> stats I read said that most leaks close up within a week or two on
> their own, and only a fraction get things like meningitis, and only a
> small number of those die. It looked like if the CT scan showed such
> that the first treatment would be simply bed rest, and surgery as a
> last resort. But it doesn't sound like something that is so critical to
> the hour. I can take it easy at home for a week or two until things
> fully heal, but the odds are that it was no big deal and I would've
> wasted a bed at the ER.
>
> Anyways I do appreciate the advice... and who knows, maybe I'll still
> need a CT scan since Howard said it is persistent. But I wanted you
> guys to know that hearing these things can cause anxiety, and sometimes
> maybe you can offer some reassurance along with the advice to soothe
> the nerves. If you have to go to the ER, and might die, it would be
> nice to be relaxed in the process and have some words of hope to hold
> onto.
>

I am not unmindful of the stress and anxiety that a physician's advice can
sometimes cause, and like most physicians, my ongoing goals for my patients
include not causeing such stress unnecessarily. However, I've been doing
this long enough to be aware of the disasters that can come from not being
cautious enough. When people play the odds, it's important to for them to
know what they're betting relative to what the cost is. I advise you to go
to the ER, and the worst case scenario is that it's a wasted trip and you
get some unnecessary anxiety. So, in this, as in many other cases in my
career, I balance the risks vs the benefits -- an unnecessary trip to the ER
vs a timely discovery of a potentially lethal medical condition. What to
choose...

I'm sorry about your anxiety. I'd have been a lot sorrier if I'd advised you
to shrug it off and you had died of septic meningitis.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Head bang, Nasal blood?
Date: 26 May 2005 11:59:03 -0500
Message-ID: <42960009$0$50241$bb4e3ad8@newscene.com>

"Carey Gregory" <tiredofspam123@comcast.net> wrote in message
news:75ma91th2no3e27guhcqpesm4mj7cv7d68@4ax.com...
> fake_fake_666@yahoo.com wrote:
>
>>can you imagine being known for dying by running into a
>>doorway? :)
>
> Oh, yes.  Definitely.  Trust me, there are dumber, far more embarrassing
> ways to die.  Happens all the time.
>
>>Thanks for your first reply, "his death highly unlikely"...
>>you'd be surprised how a few simple words can help bring back focus on
>>reality.
>
> You're quite welcome, even if two highly respected individuals with far
> more training than I have both disagreed with my advice.  You got lucky
> -- I happened to be right (as they expected)... or at least so it seems.
>
> Next time just do us all a favor and don't ask here, okay?  Emergency
> questions just don't work on the internet.  Call your doctor, call 911,
> visit a walk-in clinic, or whatever works where you are.  Don't wait for
> answers here.
>
> Oh, and watch out for doors....

Let me put it this way, Carey...if it had been ME that had the OP's symptoms
after such an accident, I would NOT  have gone to the hospital ER or had a
CT scan. But I don't figure that I can take that kind of liberty with other
people's lives.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Nasal Glucose
Date: 16 Jun 2005 10:12:02 -0500
Message-ID: <42b19653$0$91609$bb4e3ad8@newscene.com>

<fake_fake_666@yahoo.com> wrote in message
news:1118929644.968843.307170@g49g2000cwa.googlegroups.com...
> Hi,
>
> A few weeks ago I made a post about hitting my head. I've been using a
> glucometer to test the clear drop of fluid that comes from the nose
> sometimes. It is usually around 25-50mg/dL. Is there any other reason
> why there would be glucose in nasal fluid besides CSF leak?
>
> The top of my neck at the base of the skull is sore sometimes, but I'm
> not sure if it is just from stress. I haven't made an appointment with
> a doctor because the waits are usually a long time and I'm not sure
> what to tell them or what they can do anyways.
>

I can't think of any. Glucose level in CSF is usually about 2/3 that blood.
Usually, glucose in nasal mucus isn't measurable.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Nasal Glucose
Date: 16 Jun 2005 17:14:02 -0500
Message-ID: <42b1f95a$0$50319$bb4e3ad8@newscene.com>

<fake_fake_666@yahoo.com> wrote in message
news:1118954793.615154.208840@o13g2000cwo.googlegroups.com...
>I saw a doctor. He said he doesn't think it's anything, but I have Head
> and Sinus CT Scans scheduled for tomorrow, "just in case". :( I don't
> have the money for unnecessary CT Scans... but they give you the
> alternative of possibly dying if you don't. Talk about a perfect
> business model. "You don't really need this fully equipped car you
> can't afford... but if you don't buy it you might die." Oh well.
>

The difference between buying a car, and dealing with your health, I
suppose. The other difference is that you can't sue the car dealer that
sells you more car than you need.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Nasal Glucose
Date: 17 Jun 2005 16:31:02 -0500
Message-ID: <42b3407b$0$667$bb4e3ad8@newscene.com>

<fake_fake_666@yahoo.com> wrote in message
news:1118929644.968843.307170@g49g2000cwa.googlegroups.com...
> Hi,
>
> A few weeks ago I made a post about hitting my head. I've been using a
> glucometer to test the clear drop of fluid that comes from the nose
> sometimes. It is usually around 25-50mg/dL. Is there any other reason
> why there would be glucose in nasal fluid besides CSF leak?
>
> The top of my neck at the base of the skull is sore sometimes, but I'm
> not sure if it is just from stress. I haven't made an appointment with
> a doctor because the waits are usually a long time and I'm not sure
> what to tell them or what they can do anyways.
>


I looked into this. The test of choice to rule out  CSF rhinorrhea is to
determine the presence of beta2 transferrin in the drainage. It is always
present in CSF, never present in other secretions. Your local lab would need
at least 0.5 cc of nasal fluid as well as a couple of CCs of blood. It would
be cheaper than a CT scan or MRI, and probably more specific.

HMc

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Nasal Glucose
Date: 17 Jun 2005 15:54:33 -0700
Message-ID: <1119048873.485027.50740@z14g2000cwz.googlegroups.com>

>> looked into this. The test of choice to rule out CSF rhinorrhea is to
determine the presence of beta2 transferrin in the drainage. It is always
present in CSF, never present in other secretions. Your local lab would
need at least 0.5 cc of nasal fluid as well as a couple of CCs of blood.
It would be cheaper than a CT scan or MRI, and probably more specific. <<

COMMENT:


Agree!  There are all kinds of ways you can have a small crack enough
to leak CSF, and never even be able to see it on CT. So they'll end up
doing chemistries on the fluid even if the CT is negative. Duh.  Which
means why not do the chemistry first to save the money of a CT (if it
IS negative)?  Answer: because nobody advising about the CT decision is
PAYING FOR THE THING.  If it was the *doctor's* money he had to pay out
of pocket, he'd have done the same 5 min medline search Dr. McCollister
just did, methinks. But it's not.

Advice to patient: if you really are going to pay out of pocket for the
radiology, demand the definitive chemistry first. That being said, I
can't think of any way you're going to have glucose that high if it's
not CSF. But who knows? These test strips aren't perfect, and aren't
made to measure glucoses at levels this low.

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Nasal Glucose
Date: 17 Jun 2005 19:52:12 -0700
Message-ID: <1119063132.208066.87700@g44g2000cwa.googlegroups.com>

>>Anyways, part of my reason for doing the CT Scan was to see that I had
a brain. It turns out, while the images show a brain, I have none since
I went through with the test rather than being smart about it.
The physician didn't even know that nasal secretions don't have glucose
or what the normal CSF levels are. <<


COMMENT:

LOL. Don't feel bad about it. Why, anybody can have a brain. That's a
very mediocre commodity. Every pusillanimous creature that crawls on
the Earth or slinks through slimy seas has a brain. Back where I come
from, we have universities, seats of great learning, where men go to
become great thinkers. And when they come out, they think deep thoughts
and with no more brains than you have. But they have one thing you
haven't got: a diploma.

-- The Man Behind the Curtain