American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for postdischarge venous thromboembolism prophylaxis after trauma

ABSTRACT

Trauma patients are at an elevated risk for developing venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis. In the inpatient setting, prompt pharmacologic prophylaxis is utilized to prevent VTE. For patients with lower extremity fractures or limited mobility, VTE risk does not return to baseline levels postdischarge. Currently, there are limited data to guide postdischarge VTE prophylaxis in trauma patients. The goal of these postdischarge VTE prophylaxis guidelines are to identify patients at the highest risk of developing VTE after discharge and to offer pharmacologic prophylaxis strategies to limit this risk.

Emergencies do not shut down during a pandemic: COVID pandemic impact on Acute Care Surgery volume and mortality at a level I trauma center

BACKGROUND

The aim of this study was to evaluate the impact of the COVID-19 pandemic on volume and outcomes of Acute Care Surgery patients, and we hypothesized that inpatient mortality would increase due to COVID+ and resource constraints.

METHODS

An American College of Surgeons verified Level I Trauma Center's trauma and operative emergency general surgery (EGS) registries were queried for all patients from Jan. 2019 to Dec. 2020. April 1st, 2020, was the demarcation date for pre- and during COVID pandemic. Primary outcome was inpatient mortality.

RESULTS

There were 14,460 trauma and 3091 EGS patients, and month-over-month volumes of both remained similar (p > 0.05). Blunt trauma decreased by 7.4% and penetrating increased by 31%, with a concomitant 25% increase in initial operative management (p < 0.001). Despite this, trauma (3.7%) and EGS (2.9-3.0%) mortality rates remained stable which was confirmed on multivariate analysis; p > 0.05. COVID + mortality was 8.8% and 3.7% in trauma and EGS patients, respectively.

CONCLUSION

Acute Care Surgeons provided high quality care to trauma and EGS patients during the pandemic without allowing excess mortality despite many hardships and resource constraints.

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma

ABSTRACT

Trauma patients are at increased risk of venous thromboembolism (VTE), which includes both deep vein thrombosis and pulmonary embolism. Pharmacologic VTE prophylaxis is a critical component of optimal trauma care that significantly decreases VTE risk. Optimal VTE prophylaxis protocols must manage the risk of VTE with the competing risk of hemorrhage in patients following significant trauma. Currently, there is variability in VTE prophylaxis protocols across trauma centers. In an attempt to optimize VTE prophylaxis for the injured patient, stakeholders from the American Association for the Surgery of Trauma and the American College of Surgeons-Committee on Trauma collaborated to develop a group of consensus recommendations as a resource for trauma centers. The primary goal of these recommendations is to help standardize VTE prophylaxis strategies for adult trauma patients (age ≥15 years) across all trauma centers. This clinical protocol has been developed to (1) provide standardized medication dosing for VTE prophylaxis in the injured patient; and (2) promote evidence-based, prompt VTE prophylaxis in common, high-risk traumatic injuries.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level V.

Trauma Center Youth Violence Screening and Brief Interventions: A Multisite Pilot Feasibility Study

Every day, 16 American youths between the ages of 10 and 24 years are murdered; 84% of these fatalities involve a firearm. Nearly half of traumatic youth deaths result from violence-related injuries. In 2013, 580,250 youth suffered nonfatal, assault-related injuries, necessitating emergency department treatment. The aim of this multisite pilot study was to examine the process, feasibility, and challenges of violence brief interventions (VBIs). The participants were youth between 15 and 25 years of age, at 2 major Level 1 trauma centers (TCs; TC1, TC2) in the Southeastern United States. Eligible participants (N = 38; TC1: n = 20, TC2: n = 18) received at least 1 VBI during their hospital stay, which provided information about individual screening results and elicited patients' perspectives on violent and risky behaviors. More participants at TC2 than at TC1 completed 2 VBI sessions. Barriers to and support of implementation were identified at both sites, and factors for improving implementation were identified, including the need for staff support through clinical guidelines and coordinated prevention and outreach programs. Further research is needed to identify factors for successful implementation of VBIs in TCs.

Abdominal Wall Reconstruction After Temporary Abdominal Closure: A Ten-Year Review

Abdominal wall reconstruction (AWR) is often required for hernias created after temporary abdominal closure (TAC). Demographic and clinical data from patients undergoing TAC and AWR between January 1, 1992, and December 31, 2002, were collected and univariate analysis performed. Temporary abdominal closure and AWR were performed in 21 patients. Complications developed in 12 patients (57.1%) after TAC; associated risk factors were mesh placement ( P = .04) and skin grafting ( P = .04). Successful AWR included mesh (n = 6), component separation (n = 6), primary repair (n = 4), and 3 combination techniques. Six patients (28.6%) developed intraoperative complications, and 14 (66.7%) developed postoperative complications. Intraoperative complications were increased in patients with tissue expanders ( P = .01). Postoperative complications ( P = .04) were less likely with component separation. The complication rate with TAC and AWR is high. Tissue expanders are associated with an increased risk of intraoperative complications with AWR, whereas component separation is associated with a reduction in postoperative complications.

Trauma intensive care unit 'bouncebacks': identifying risk factors for unexpected return admission to the intensive care unit

Return transfer (RT) to the intensive care unit (ICU) negatively impacts patient outcomes, length of stay (LOS), and hospital costs. This study assesses the most common events necessitating RT in trauma patients. We performed a retrospective chart review of ICU RT from 2004 to 2008. Patient demographics, injuries and injury severity, reason for transfer, LOS, interventions, and outcomes data were collected. Overall, 158 patients required readmission to the ICU. Respiratory insufficiency/failure (48%) was the most common reason for RT followed by cardiac (16%) and neurological (13%) events. The most commonly associated injuries were traumatic brain injuries (TBIs) (32%), rib fractures (30%), and pulmonary contusions (20%). Initial ICU LOS was 6.6 ± 8 days (range, 1 to 44 days) with 4.4 ± 7.8 ventilator days. Mean floor time before ICU RT was 5.7 ± 6.3 days (range, 0 to 33 days). Forty-nine patients (31%) required intubation and mechanical ventilation on RT. ICU RT incurred an additional ICU LOS of 8 ± 8.5 days (range, 1 to 40 days) and 5.2 ± 7.5 ventilator days. Mortality after a single RT was 10 per cent (n = 16). RT to the ICU most often occurs as a result of respiratory compromise, and patients with TBI are particularly vulnerable. Trauma pulmonary hygiene practices should be evaluated to determine strategies that could decrease RT.

The Organ Donation Breakthrough Collaborative: has it made a difference?

BACKGROUND

The Organ Donation Breakthrough Collaborative (ODBC) was established in 2003 to increase the number of transplantable organs in the United States. However, recent publications have suggested that the ODBC has not impacted donation conversion rates at local organ procurement organizations (OPOs). We sought to determine the impact, if any, of our becoming part of the ODBC on organ donation rates in our OPO or in our institution (Carolinas Medical Center [CMC]), particularly among minority donors.

METHODS

This is a retrospective review of data entered concurrently into a patient referral database maintained by our local OPO. Donation approach and consent rates were calculated. They were then analyzed by race and institution, and trends were analyzed over the study period of 2002 to 2010. Statistical differences between the various patient groups were determined by the chi-square test or the Fisher exact test. Statistical differences over time were determined by the Cochran-Armitage trend test.

RESULTS

From 2002 to 2010, 10,855 patients were screened by our OPO for potential organ donation. The overall approach rate was 13.4%, and the consent rate was 57.6%. An increase in approach and consent rates was noted beginning in 2004, but this increase was not sustained. Consent rates in general were higher for white patients than for black and Hispanic patients. Consent rates for CMC did increase significantly (P = .02), but they did not increase for the non-CMC hospitals. When analyzed by race, no significant changes were noted in consent rates over time. When analyzed by race and institution, the only statistically significant increase in consent rates occurred for white patients at CMC.

CONCLUSIONS

Since joining the ODBC, we have noted an increase in consent rates at a single institution (CMC), but no other significant changes. Greater emphasis should be placed on methods to increase and sustain consent rates for all racial groups in general, with a special emphasis on increasing consent rates in minority patients.

Breakdown of the Consent Process at a Quaternary Medical Center: Our Full Disclosure

Circumstances may arise in the intensive care unit (ICU) when the physician is unable to obtain informed consent. We undertook this study to determine the variations in the consent process. An anonymous survey was distributed to all critical care nurses (RN), resident physicians (RES), advanced practitioners (AP), and attending physicians (ATT). Participants were asked to describe the risks of nine common ICU procedures (central venous line, peripherally inserted central catheter, bronchoscopy, tube thoracostomy, tracheostomy, vena cava filter, angioembolization, image-guided drainage, and percutaneous endoscopic gastrostomy tube). Participants were also asked which member of the healthcare team should obtain consent. All groups were compared with ATT responses and RN responses were compared with the remaining groups. The response rate was 134 of 610 participants (22%) with 51 per cent RN (n = 68), 17 per cent RES (n = 23), 7 per cent AP (n = 9), and 25 per cent ATT (n = 34). Compared with ATT, RN assessment of important risks varied significantly for eight of nine procedures. RES responses varied in three procedures. A minority believed that nurses should obtain consent. However, many physicians (34% ATT and 27% RES) denied having informed consent discussions with 50 per cent or more of their patients. This study has exposed a wide variation in consent practices. Future efforts to standardize consent processes are needed to protect patients and physicians.

Breakdown of the consent process at a quaternary medical center: our full disclosure

Circumstances may arise in the intensive care unit (ICU) when the physician is unable to obtain informed consent. We undertook this study to determine the variations in the consent process. An anonymous survey was distributed to all critical care nurses (RN), resident physicians (RES), advanced practitioners (AP), and attending physicians (ATT). Participants were asked to describe the risks of nine common ICU procedures (central venous line, peripherally inserted central catheter, bronchoscopy, tube thoracostomy, tracheostomy, vena cava filter, angioembolization, image-guided drainage, and percutaneous endoscopic gastrostomy tube). Participants were also asked which member of the healthcare team should obtain consent. All groups were compared with ATT responses and RN responses were compared with the remaining groups. The response rate was 134 of 610 participants (22%) with 51 per cent RN (n = 68), 17 per cent RES (n = 23), 7 per cent AP (n = 9), and 25 per cent ATT (n = 34). Compared with ATT, RN assessment of important risks varied significantly for eight of nine procedures. RES responses varied in three procedures. A minority believed that nurses should obtain consent. However, many physicians (34% ATT and 27% RES) denied having informed consent discussions with 50 per cent or more of their patients. This study has exposed a wide variation in consent practices. Future efforts to standardize consent processes are needed to protect patients and physicians.

The Reward is Worth the Wait: A Prospective Analysis of 100 Consecutive Organ Donors

Aggressive donor management protocols have evolved to maximize the number of procured organs. Our study assessed donor management time and the number and types of organs procured with the hypothesis that shorter management time yields increased organ procurement and transplant rates. We prospectively analyzed 100 donors managed by a regional organ procurement organization (OPO) during 2007 to 2008. Data included patient demographics, number and types of organs procured and transplanted, patient management time by the OPO, and achievement of donor pre-procurement goals. One hundred consecutive organ donors were managed with a mean age 41 ± 18 years and mean management time 23 ± 9 hours; 376 organs were procured and 327 successfully transplanted. Donors managed greater than 20 hours yielded significantly more heart (5 vs 26, P < 0.01) and lung (6 vs 40, P < 0.01) procurements, more organs procured per donor (3.2 ± 1.4 vs 4.2 ± 1.6, P < 0.01), and more organs transplanted per donor (2.6 ± 1.5 vs 3.7 ± 1.8, P < 0.01) than those managed 20 hours or less. No difference in the attainment of donor management goals was observed between these populations. Contrary to our initial hypothesis, donor management times greater than 20 hours yielded increased organ procurement and transplant rates, particularly for hearts and lungs, despite no differences in the achievement of donor preprocurement management goals.

The reward is worth the wait: a prospective analysis of 100 consecutive organ donors

Aggressive donor management protocols have evolved to maximize the number of procured organs. Our study assessed donor management time and the number and types of organs procured with the hypothesis that shorter management time yields increased organ procurement and transplant rates. We prospectively analyzed 100 donors managed by a regional organ procurement organization (OPO) during 2007 to 2008. Data included patient demographics, number and types of organs procured and transplanted, patient management time by the OPO, and achievement of donor preprocurement goals. One hundred consecutive organ donors were managed with a mean age 41 ± 18 years and mean management time 23 ± 9 hours; 376 organs were procured and 327 successfully transplanted. Donors managed greater than 20 hours yielded significantly more heart (5 vs 26, P < 0.01) and lung (6 vs 40, P < 0.01) procurements, more organs procured per donor (3.2 ± 1.4 vs 4.2 ± 1.6, P < 0.01), and more organs transplanted per donor (2.6 ± 1.5 vs 3.7 ± 1.8, P < 0.01) than those managed 20 hours or less. No difference in the attainment of donor management goals was observed between these populations. Contrary to our initial hypothesis, donor management times greater than 20 hours yielded increased organ procurement and transplant rates, particularly for hearts and lungs, despite no differences in the achievement of donor preprocurement management goals.

Vena Cava Filter Insertion and the General Surgery Armamentarium: A 13-Year Experience

The prevention of pulmonary emboli has a long surgical history. Through the development of percutaneous technologies, vena cava filters (VCFs) are now commonly inserted by interventional radiologists. This study reviews our experience with VCFs inserted by general surgeons. We retrospectively reviewed data from our VCF performance improvement database, which is a prospective collection of the VCF experience of the Department of General Surgery from February 1996 to May 2009. Demographics, procedural information, and complications were recorded. Eight hundred fifty-five VCFs were inserted in 853 patients. The mean age was 42.0 years (range, 14 to 90 years). One hundred ninety-seven VCFs were placed in the operating room, and 658 were placed in the intensive care unit. Twelve VCFs were intentionally inserted in a suprarenal position, and four were placed in the superior vena cava. Two patients received both superior vena cava and inferior vena cava filters. Complications included deep vein thrombosis at the insertion site (n = 16), vena cava thrombosis (n = 9), post-VCF pulmonary embolism (n = 2), and a ventricle perforation requiring operative repair (n = 1). No deaths were attributed to the presence of a VCF. Overall insertion success was 99.8 per cent. In two patients, an inferior VCF could not be placed as a result of inferior vena cava occlusion with no safe “landing zone” for deployment. The placement of VCFs is a vital skill in the general surgery armamentarium. Our experience demonstrates that general surgeons can safely insert VCFs with minimal perioperative complications.

Vena cava filter insertion and the general surgery armamentarium: a 13-year experience

The prevention of pulmonary emboli has a long surgical history. Through the development of percutaneous technologies, vena cava filters (VCFs) are now commonly inserted by interventional radiologists. This study reviews our experience with VCFs inserted by general surgeons. We retrospectively reviewed data from our VCF performance improvement database, which is a prospective collection of the VCF experience of the Department of General Surgery from February 1996 to May 2009. Demographics, procedural information, and complications were recorded. Eight hundred fifty-five VCFs were inserted in 853 patients. The mean age was 42.0 years (range, 14 to 90 years). One hundred ninety-seven VCFs were placed in the operating room, and 658 were placed in the intensive care unit. Twelve VCFs were intentionally inserted in a suprarenal position, and four were placed in the superior vena cava. Two patients received both superior vena cava and inferior vena cava filters. Complications included deep vein thrombosis at the insertion site (n=16), vena cava thrombosis (n=9), post-VCF pulmonary embolism (n=2), and a ventricle perforation requiring operative repair (n=1). No deaths were attributed to the presence of a VCF. Overall insertion success was 99.8 per cent. In two patients, an inferior VCF could not be placed as a result of inferior vena cava occlusion with no safe "landing zone" for deployment. The placement of VCFs is a vital skill in the general surgery armamentarium. Our experience demonstrates that general surgeons can safely insert VCFs with minimal perioperative complications.

Trauma Attending Physician Continuity: Does it Make a Difference?

Continuity of care is important in achieving optimal outcomes in trauma patients, but the optimal length of the trauma attending (TA) rotation is unknown. We hypothesize that longer TA rotations provide greater continuity, and therefore improve outcomes. We did a retrospective comparison of trauma patient outcomes from two consecutive 6-month periods during which we transitioned from a 1-month TA rotation to a 1-week TA rotation. The Wilcoxon rank sum test, and the χ2 were used for statistical analysis. Over the 12-month study period 1924 patients were admitted to the Trauma Service. The two groups were similar with regard to age, gender, injury mechanism, Injury Severity Score and Glasgow Coma Scale scores, and Abbreviated Injury Scores for the chest, abdomen, and extremities. Although mortality, patient charges, and violations of the standard of care were similar between the two groups, overall morbidity was lower (18.6% vs 23.2%), and hospital length of stay higher (9.07 days vs 8.41 days) in the 1-week TA group compared with the 1-month TA group. A one-week TA rotation was associated with a longer hospital length of stay, but improved morbidity. Longer TA rotations do not necessarily provide improved continuity or improved outcomes.

Trauma attending physician continuity: does it make a difference?

Continuity of care is important in achieving optimal outcomes in trauma patients, but the optimal length of the trauma attending (TA) rotation is unknown. We hypothesize that longer TA rotations provide greater continuity, and therefore improve outcomes. We did a retrospective comparison of trauma patient outcomes from two consecutive 6-month periods during which we transitioned from a 1-month TA rotation to a 1-week TA rotation. The Wilcoxon rank sum test, and the chi2 were used for statistical analysis. Over the 12-month study period 1924 patients were admitted to the Trauma Service. The two groups were similar with regard to age, gender, injury mechanism, Injury Severity Score and Glasgow Coma Scale scores, and Abbreviated Injury Scores for the chest, abdomen, and extremities. Although mortality, patient charges, and violations of the standard of care were similar between the two groups, overall morbidity was lower (18.6% vs. 23.2%), and hospital length of stay higher (9.07 days vs. 8.41 days) in the 1-week TA group compared with the 1-month TA group. A one-week TA rotation was associated with a longer hospital length of stay, but improved morbidity. Longer TA rotations do not necessarily provide improved continuity or improved outcomes.

Wasted hospital days impair the value of length-of-stay variables in the quality assessment of trauma care

Hospital length of stay (LOS) is frequently used to evaluate the quality of trauma care but LOS may be impacted by nonmedical factors as well. We reviewed our experience with delays in patient discharge to determine its financial consequences and its impact on LOS. We performed an analysis of linked trauma registry and "delayed discharge" databases. Actual LOS (A-LOS) values were compared with calculated ideal LOS (I-LOS) values, and the per cent increase in LOS was calculated. Linear regression analysis was used to identify significant predictors of prolonged LOS. One thousand, five hundred and seventeen patients were studied, with an A-LOS of 6.54 days. Seven per cent of patients experienced discharge delays, resulting in 580 excess hospital days. Calculated I-LOS was 6.15 days, 6.34 per cent lower than A-LOS. Other I-LOS estimates were as much as 25 per cent lower than A-LOS. Estimated excess patient charges associated with delayed discharges were $4,000,000 to $15,000,000. Discharge delays are an infrequent, although costly, occurrence that has a significant impact on LOS. LOS therefore may not be an appropriate metric for assessing the quality of trauma care, and should only be used if it has been corrected for discharge delays. Concerted efforts should be directed towards identifying and correcting the factors responsible for delayed discharge in trauma patients.

Wasted Hospital Days Impair the Value of Length-of-Stay Variables in the Quality Assessment of Trauma Care

Hospital length of stay (LOS) is frequently used to evaluate the quality of trauma care but LOS may be impacted by nonmedical factors as well. We reviewed our experience with delays in patient discharge to determine its financial consequences and its impact on LOS. We performed an analysis of linked trauma registry and “delayed discharge” databases. Actual LOS (A-LOS) values were compared with calculated ideal LOS (I-LOS) values, and the per cent increase in LOS was calculated. Linear regression analysis was used to identify significant predictors of prolonged LOS. One thousand, five hundred and seventeen patients were studied, with an A-LOS of 6.54 days. Seven per cent of patients experienced discharge delays, resulting in 580 excess hospital days. Calculated I-LOS was 6.15 days, 6.34 per cent lower than A-LOS. Other I-LOS estimates were as much as 25 per cent lower than A-LOS. Estimated excess patient charges associated with delayed discharges were $4,000,000 to $15,000,000. Discharge delays are an infrequent, although costly, occurrence that has a significant impact on LOS. LOS therefore may not be an appropriate metric for assessing the quality of trauma care, and should only be used if it has been corrected for discharge delays. Concerted efforts should be directed towards identifying and correcting the factors responsible for delayed discharge in trauma patients.

Has the pendulum swung too far? The impact of missed abdominal injuries in the era of nonoperative management

Nonoperative management for traumatic injuries has significantly influenced trauma care during the last decade. We undertook this study to assess the impact of nontherapeutic laparotomies for suspected abdominal injuries compared with delayed laparotomies for questionable abdominal injuries for patients with abdominal trauma. The records of patients admitted to the trauma service between 2002 and 2007 who underwent laparotomies deemed nontherapeutic or delayed were retrospectively reviewed. Demographics, severity of injury, management scheme, and outcome data were analyzed. Sixteen patients underwent delayed laparotomies, whereas 26 patients incurred nontherapeutic laparotomies. Injury severity scores, Glasgow coma scale scores, abdominal abbreviated injury scale score (AIS), and age were similar for both populations. Delayed laparotomies occurred an average of 7 +/- 9 days postinjury. Intensive care unit length of stay (26 +/- 24 vs 10 +/- 6 days), hospital length of stay (40 +/- 37 vs 11 +/- 10 days), ventilator days (31 +/- 29 vs 11 +/- 10), and number of abdominal operative procedures (1.9 +/- 1.5 vs 1 +/- 0) were significantly higher in the delayed laparotomies group versus the nontherapeutic laparotomies group, respectively. Delayed diagnosis of intra-abdominal injuries yielded a significantly increased morbidity and mortality. During the evolving era of technological imaging for traumatic injuries, we must not allow the nonoperative pendulum to swing too far.

Has the Pendulum Swung Too Far? The Impact of Missed Abdominal Injuries in the Era of Nonoperative Management

Nonoperative management for traumatic injuries has significantly influenced trauma care during the last decade. We undertook this study to assess the impact of nontherapeutic laparotomies for suspected abdominal injuries compared with delayed laparotomies for questionable abdominal injuries for patients with abdominal trauma. The records of patients admitted to the trauma service between 2002 and 2007 who underwent laparotomies deemed nontherapeutic or delayed were retrospectively reviewed. Demographics, severity of injury, management scheme, and outcome data were analyzed. Sixteen patients underwent delayed laparotomies, whereas 26 patients incurred nontherapeutic laparotomies. Injury severity scores, Glasgow coma scale scores, abdominal abbreviated injury scale score (AIS), and age were similar for both populations. Delayed laparotomies occurred an average of 7 ± 9 days postinjury. Intensive care unit length of stay (26 ± 24 vs 10 ± 6 days), hospital length of stay (40 ± 37 vs 11 ± 10 days), ventilator days (31 ± 29 vs 11 ± 10), and number of abdominal operative procedures (1.9 ± 1.5 vs 1 ± 0) were significantly higher in the delayed laparotomies group versus the nontherapeutic laparotomies group, respectively. Delayed diagnosis of intra-abdominal injuries yielded a significantly increased morbidity and mortality. During the evolving era of technological imaging for traumatic injuries, we must not allow the nonoperative pendulum to swing too far.

Imaging of the vena cava in the intensive care unit prior to vena cava filter insertion: carbon dioxide as an alternative to iodinated contrast

This study evaluates the safety and effectiveness of carbon dioxide (CO2) as a contrast agent in patients in the intensive care unit undergoing vena cava filter (VCF) insertion. We prospectively evaluated patients in the intensive care unit undergoing bedside VCF insertion using CO2 cavagraphy. Blood pressure, pulse rate, mixed venous oxygen saturation, and intracranial pressure were monitored before, during, and after the CO2 injection. Fifty patients in the intensive care unit (mean age 48.2 +/- 16.5 years) were included in the study. Five patients had decreases in blood pressure, which resolved without intervention. Two patients required iodinated contrast as a result of inadequate CO2 imaging. All patients had successful insertion of VCF. The use of CO2 as a contrast agent is a safe and highly effective alternative for vena cava imaging and can be considered the first-line contrast agent for all critically ill patients requiring VCF placement.

Imaging of the Vena Cava in the Intensive Care Unit Prior to Vena Cava Filter Insertion: Carbon Dioxide as an Alternative to Iodinated Contrast

This study evaluates the safety and effectiveness of carbon dioxide (CO2) as a contrast agent in patients in the intensive care unit undergoing vena cava filter (VCF) insertion. We prospectively evaluated patients in the intensive care unit undergoing bedside VCF insertion using CO2 cavagraphy. Blood pressure, pulse rate, mixed venous oxygen saturation, and intracranial pressure were monitored before, during, and after the CO2 injection. Fifty patients in the intensive care unit (mean age 48.2 ± 16.5 years) were included in the study. Five patients had decreases in blood pressure, which resolved without intervention. Two patients required iodinated contrast as a result of inadequate CO2 imaging. All patients had successful insertion of VCF. The use of CO2 as a contrast agent is a safe and highly effective alternative for vena cava imaging and can be considered the first-line contrast agent for all critically ill patients requiring VCF placement.

Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism

BACKGROUND

Retrieval of optional vena cava filters (VCF) has been demonstrated to be safe and feasible in injured patients in 4 recent studies. However, 2 pulmonary emboli PE were reported in these studies with mean implant durations less than 19 days. In light of these occurrences, we changed our practice for VCF retrieval when patients had recovered from their injuries and at least 30 days after their discharge, or had been stable on therapeutic anticoagulation for deep venous thrombosis (DVT) or PE for at least 2 weeks. The aim of the current study was to assess the safety of this approach.

METHODS

A review of prospectively collected data on optional VCF over a 16-month period. The filters were inserted prophylactically per an institutional practice guideline or for the presence of DVT or PE with a contraindication and/or complication to anticoagulation. All patients underwent duplex imaging of the lower extremities and had pre- and post- retrieval cavagrams. Demographics, duration of implantation, and complications were recorded.

RESULTS

Eighty-three patients had optional VCF inserted since the change in our clinical practice. Indications included prophylaxis for high-risk trauma patients (n = 58), DVT or PE with acute contraindication to therapeutic anticoagulation (n = 22), or complications of anticoagulation (n = 3). Two patients developed lower extremity DVT after filter insertion and 1 patient developed a vena cava thrombosis. Retrieval was successful in 47 of 54 cases (87%) attempted. Median implantation duration was 142 days (range 17-475). A filter strut fracture occurred during retrieval without further consequences. No post-insertion or post-retrieval PE occurred in this study.

CONCLUSION

Extended intervals for retrieval of VCF are safe and may maximize protection against pulmonary embolism.

Nine-year experience with insertion of vena cava filters in the intensive care unit

BACKGROUND

Vena cava filter insertion (VCF) is traditionally performed in a radiology suite or in the operating room. We reviewed our experience of bedside VCF insertion in the intensive care unit (ICU) performed by general surgeons.

METHODS

A prospective, observational study of bedside VCF insertion in the ICU was performed by general surgeons between February 1996 and June 2005. Demographic data and procedural complications were recorded.

RESULTS

Four hundred three patients underwent bedside VCF insertion. Complications included 1 groin hematoma, 2 misplacements, and a right ventricular perforation from a dilator requiring surgical repair. DVT occurred in 38 patients (8.5%); 14 occurred at the insertion site. There were 2 pulmonary embolisms (<1%) after VCF. Contrast-related renal failure occurred in 2 of the first 35 patients; carbon dioxide gas is now used for contrast in high-risk patients.

CONCLUSIONS

Bedside insertion of VCF in the ICU by surgeons is safe and effective.

Utility of Neurosurgical Consultation for Mild Traumatic Brain Injury

Trauma patients presenting with a Glasgow Coma Scale (GCS) score of 14–15 are considered to have mild traumatic brain injury (TBI) with overall good neurologic outcomes. Current practice consists of initial stabilization, followed by a head CT, and neurosurgical consultation. Aside from serial neurologic examinations, patients with a GCS of 15 rarely require neurosurgical intervention. In this study, we examined the added value of neurosurgical consultation in the care of patients after TBI with a GCS of 15. We retrospectively reviewed the medical records of patients presenting after blunt trauma with an abnormal head CT and GCS of 15 between January 2004 and January 2005. Patients with a normal head CT and <48 hours hospital stay were excluded. Data included demographics, mechanisms of injury, Injury Severity Score, the radiologists’ dictated interpretations of the head CT, and neurosurgical interventions. Fifty-six patients met the inclusion criteria. The mean age was 41 ± 2.3 years, and the mean Injury Severity Scores was 10.2 ± 0.6. Mechanisms of injury included 64 per cent motor vehicle crash, 16 per cent motorcycle crash, 13 per cent fall, and 7 per cent all-terrain vehicle crash. The initial CT scans showed 43 per cent parenchymal contusions, 38 per cent subarachnoid hemorrhage, 14 per cent subdural hematomas, and 5 per cent epidural hematomas. All patients received a routine follow-up head CT, and 16 per cent showed changes (five improved and four were worse compared with initial CT scans). None of these patients received a neurosurgical intervention, and two were transferred to a rehabilitation service. In this era of limited resources, trauma patients who present with a GCS score of 15 after mild TBI can be safely managed without neurosurgical consultation, even in the presence of an abnormal head CT scan.

Utility of neurosurgical consultation for mild traumatic brain injury

Trauma patients presenting with a Glasgow Coma Scale (GCS) score of 14-15 are considered to have mild traumatic brain injury (TBI) with overall good neurologic outcomes. Current practice consists of initial stabilization, followed by a head CT, and neurosurgical consultation. Aside from serial neurologic examinations, patients with a GCS of 15 rarely require neurosurgical intervention. In this study, we examined the added value of neurosurgical consultation in the care of patients after TBI with a GCS of 15. We retrospectively reviewed the medical records of patients presenting after blunt trauma with an abnormal head CT and GCS of 15 between January 2004 and January 2005. Patients with a normal head CT and <48 hours hospital stay were excluded. Data included demographics, mechanisms of injury, Injury Severity Score, the radiologists' dictated interpretations of the head CT, and neurosurgical interventions. Fifty-six patients met the inclusion criteria. The mean age was 41+/-2.3 years, and the mean Injury Severity Scores was 10.2 +/-0.6. Mechanisms of injury included 64 per cent motor vehicle crash, 16 per cent motorcycle crash, 13 per cent fall, and 7 per cent all-terrain vehicle crash. The initial CT scans showed 43 per cent parenchymal contusions, 38 per cent subarachnoid hemorrhage, 14 per cent subdural hematomas, and 5 per cent epidural hematomas. All patients received a routine follow-up head CT, and 16 per cent showed changes (five improved and four were worse compared with initial CT scans). None of these patients received a neurosurgical intervention, and two were transferred to a rehabilitation service. In this era of limited resources, trauma patients who present with a GCS score of 15 after mild TBI can be safely managed without neurosurgical consultation, even in the presence of an abnormal head CT scan.

Audience response system technology improves accuracy and reliability of trauma outcome judgments

BACKGROUND

Peer-review judgments are necessary for effective trauma performance improvement (PI), but may be influenced by peer pressure and the tendency to vote with the majority. Incorporation of Audience Response System (ARS) technology into trauma PI should result in improved outcome assessments.

METHODS

We compared 30 months of nonanonymous trauma care judgments with 30 months of anonymous judgments obtained with the use of a keypad-based ARS. Statistical methods included the chi2 test and the Wilcoxon rank sum test.

RESULTS

Use of the ARS resulted in a 28% reduction in deaths judged nonpreventable and a 24% reduction in trauma care judged to be appropriate (p < 0.0001). Unanimous outcome judgments were also significantly reduced (p < 0.0001).

CONCLUSIONS

Outcome judgments obtained anonymously were significantly more divergent and less positive than those obtained nonanonymously. Anonymously derived outcome judgments may provide a better opportunity to identify adverse outcomes and thereby potentially improve trauma PI and trauma care.

Guide Wire Entrapment by Inferior Vena Cava Filters: An Experimental Study

BACKGROUND

In situ vena cava filters are at risk for complications with the use of J-tipped guide wires. The purpose of this study was to evaluate the impact of two commonly used J-tipped guide wires on the stability of the four most recently released vena cava filters in an in vitro flow model.

STUDY DESIGN

Four filters (OptEase [F1], Günther Tulip [F2], Vena Tech LP [F3], and Recovery [F4]) were inserted into an in vitro flow model. Two J-tipped guide wires (0.032-inch [GW-1], 0.035-inch [GW-2]) were passed through each filter (n = 50 passes per wire) for a distance of 10 cm. The inserter was blind as to the effects of the wire. The filters were monitored by an independent observer for adverse events occurring between the filters and the guide wires. These were defined as: migrations (>1 cm), change of position (tilt>10 degrees), and entrapment of the wire (unable to remove wire). Descriptive statistics, chi-square, and Fisher's exact test were used (p < 0.05 considered significant).

RESULTS

GW-1 resulted in a lower incidence of entrapment, migration, and tilt for all filters compared with GW-2 (F1, p = 0.003; F2, p < 0.0001; F3, p < 0.0001; F4, p = 0.0004). GW-1 resulted in entrapment in 0%, migration in 7.5%, and tilt in 10.5% of insertions. GW-2 resulted in entrapment in 1%, migration in 26.5%, and tilt in 5.5% of insertions. The incidence of adverse events for GW-1 was significantly different compared with all filters (F1, 0%; F2, 46%; F3, 4%; and F4, 22%; p < 0.0001). Similarly, the incidence of adverse events for GW-2 was significantly different when evaluating all filters (F1, 12%; F2, 48%; F3, 22%; F4 60%; p < 0.0001).

CONCLUSIONS

The smaller-diameter guide wire resulted in a decreased incidence of adverse events for all filters, but there is still risk for complications. Knowledge of potential complications associated with vena cava filters and the postinsertion use of guide wires are essential to avoid potential mishaps.

The Role of Transesophageal Echocardiography in Optimizing Resuscitation in Acutely Injured Patients

BACKGROUND

The goal of resuscitation is to correct the mismatch between oxygen delivery and that of cellular demands. The pulmonary artery catheter (PAC) is frequently used to gauge the adequacy of resuscitation and guide therapy based on ventricular filling pressures. Transesophageal echocardiography (TEE) has emerged as a potential tool in assessing adequacy of acute hemodynamic resuscitation. The purpose of this study was to evaluate the role of TEE in assessing preload during ongoing volume resuscitation in trauma patients.

METHODS

A retrospective review was conducted of acutely injured patients undergoing TEE during resuscitation from hemorrhagic shock from January 2002 to 2004 at a Level I trauma center. The indication for TEE was persistent hemodynamic instability in the absence of ongoing surgical hemorrhage. Variables included hemodynamic and PAC parameters, pre-TEE resuscitation volume, and vasopressor requirements. The impact of TEE findings on therapeutic decisions was evaluated.

RESULTS

Twenty-five patients underwent TEE, 18 (72%) had an indwelling PAC with a mean pulmonary artery occlusion pressure of 19.3 mm Hg (range, 12-29 mm Hg) and mean cardiac index of 2.9 L/min/m2 (range, 1.6-4.6 L/min/m2). Twelve patients (48%) were receiving inotropes and/or vasopressors for hypotension at the time of TEE. Resuscitation volume within 6 hours before TEE included a mean of 6.5 L of crystalloid and 12.2 units of blood products (packed red blood cells, fresh frozen plasma, and platelets). TEE revealed left ventricular hypovolemia in 13 patients (52%) and altered therapy in 16 patients (64%), including additional volume (n = 13), addition of an inotrope (n = 4), and addition of a vasodilator (n = 1) in one patient with ventricular overdistention. Comparison of the abnormal and normal TEE groups revealed that only cardiac index was significantly different (2.6 L/min/m2 in the abnormal group vs. 3.9 L/min/m2 in the normal group; p = 0.005). Significant mitral valve regurgitation leading to valve replacement was identified in one patient. No clinically relevant pericardial effusion was identified.

CONCLUSION

TEE altered resuscitation management in almost two thirds of patients. Many patients with "acceptable" pulmonary artery occlusion pressure parameters may in fact have inadequate left ventricular filling. In addition, TEE offers the advantage of direct assessment of cardiac valve competency, myocardial wall contractility, and pericardial fluid.

Age, blood transfusion, and survival after trauma

Blood transfusion affects outcomes after trauma, but whether elderly patients are disproportionately affected remains unknown. To determine the possible interaction between age, packed cell transfusion volume (PCTV), and mortality after injury, we designed a 6-year retrospective review (January 1995 through December 2000) of patients > or = 16 years of age who received blood transfusion within the first 24 hours after injury. One thousand three hundred twelve patients > or = 16 years of age admitted to our trauma center received packed red blood cells in the initial 24 hours after admission. Of the 1312 patients, 1028 (78%) were < or = 55 years and 284 (22%) were > 55 years of age, and overall mortality was 21.2 per cent. Age, Injury Severity Score (ISS) Glasbow Coma Scale (GCS), and PCTV emerged as independent predictors of mortality. PCTV for elderly survivors (4.6 units) was significantly less than that of younger survivors (6.7 units). Furthermore, mean PCTV for all survivors decreased progressively with advancing age. No patient >75 years with a PCTV > 12 units survived. Age and PCTV act independently, yet synergistically to increase mortality following injury.

Special considerations in geriatric injury

PURPOSE OF REVIEW

As the elderly population expands and adopts increasingly more active lifestyles, trauma and critical care practitioners will be faced with providing care for greater numbers of severely injured patients. However, because of their associated preexisting medical conditions and poor relative physiologic reserve, geriatric patients have higher mortality rates and poorer long-term functional outcomes than their younger counterparts. A thorough understanding of the causes for these disparate outcomes is critical if successful strategies and treatments for this unique patient population are to be developed.

RECENT FINDINGS

The currently available geriatric trauma literature is largely descriptive and retrospective, and does not provide ready explanations or solutions for the substantially worse outcomes experienced by this patient population. It does appear that outcomes are improved by providing early and aggressive care in designated trauma centers, yet undertriage remains a significant problem. Early admission to an ICU has been recommended, but its benefits remain unproved. Significant differences exist between older and younger patients in injury patterns, and in the frequency and type of complications These differences in turn demand prompt diagnostic approaches, aggressive treatment, and unique prevention strategies.

SUMMARY

Ironically, the field of geriatric trauma is still in its infancy. Given the relation between advanced age, associated preexisting medical conditions, and poor physiologic reserve, a poor outcome may be inevitable by the time the geriatric patient presents for medical attention. Greater emphasis should therefore be placed on injury prevention efforts in this patient population. There is a dire need for well-designed prospective studies in geriatric trauma.

The role of vena caval filters in the management of venous thromboembolism

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are important, and not infrequent, causes of morbidity and mortality in critically ill patients. Anticoagulation remains the treatment of choice for DVT and PE, but contraindications to, and complications from, anticoagulant therapy mandate the availability of alternate therapeutic and prophylactic strategies. The recent availability of safe and effective vena caval filters that can be inserted via a minimally invasive percutaneous approach has expanded the indications for, and acceptance of, these devices in selected patients at high risk for the development of PE. This article reviews both the established and the evolving indications for vena caval filters and discusses how improvements in filter design may impact future use.

The Role of Vena Caval Filters in the Management of Venous Thromboembolism

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are important, and not infrequent, causes of morbidity and mortality in critically ill patients. Anticoagulation remains the treatment of choice for DVT and PE, but contraindications to, and complications from, anticoagulant therapy mandate the availability of alternate therapeutic and prophylactic strategies. The recent availability of safe and effective vena caval filters that can be inserted via a minimally invasive percutaneous approach has expanded the indications for, and acceptance of, these devices in selected patients at high risk for the development of PE. This article reviews both the established and the evolving indications for vena caval filters and discusses how improvements in filter design may impact future use.

Positive end-expiratory pressure alters intracranial and cerebral perfusion pressure in severe traumatic brain injury

BACKGROUND

Optimizing intracranial pressure (ICP) and cerebral perfusion pressure (CPP) is important in the management of severe traumatic brain injury (TBI). In trauma patients with TBI and respiratory dysfunction, positive end-expiratory pressure (PEEP) is often required to support oxygenation. Increases in PEEP may lead to reduced CPP. We hypothesized that increases in PEEP are associated with compromised hemodynamics and altered cerebral perfusion.

METHODS

Twenty patients (mean Injury Severity Score of 28) with TBI (Glasgow Coma Scale score < 8) were examined. All required simultaneous ICP and hemodynamic monitoring. Data were categorized on the basis of PEEP levels. Variables included central venous pressure, pulmonary artery occlusion pressure, cardiac index, oxygen delivery, and oxygen consumption indices. Differences were assessed using Kruskal-Wallis analysis of variance.

RESULTS

Data were expressed as mean +/- SE. As PEEP increased from 0 to 5, to 6 to 10 and 11 to 15 cm H O, ICP decreased from 14.7 +/- 0.2 to 13.6 +/- 0.2 and 13.1 +/- 0.3 mm Hg, respectively. Concurrently, CPP improved from 77.5 +/- 0.3 to 80.1 +/- 0.5 and 78.9 +/- 0.7 mm Hg. As central venous pressure (5.9 +/- 0.1, 8.3 +/- 0.2, and 12.0 +/- 0.3 mm Hg) and pulmonary artery occlusion pressure (8.3 +/- 0.2, 11.6 +/- 0.4, and 15.6 +/- 0.4 mm Hg) increased with rising levels of PEEP, cardiac index, oxygen delivery, and oxygen consumption indices remained unaffected. Overall mortality was 30%.

CONCLUSION

In trauma patients with severe TBI, the strategy of increasing PEEP to optimize oxygenation is not associated with reduced cerebral perfusion or compromised oxygen transport.

A thoracostomy tube guideline improves management efficiency in trauma patients

BACKGROUND

Thoracostomy tube (TT) placement constitutes primary treatment for traumatic hemopneumothorax. Practice patterns vary widely, and criteria for management and removal remain poorly defined. In this cohort study, we examined the impact of implementation of a practice guideline (PG) on improving management efficiency of thoracostomy tube.

METHODS

We developed a PG aimed at standardizing the management of TTs in critically ill patients admitted to a Level I trauma center. During the 9-month period before (Pre-PG) and 3 months after (Post-PG) implementation, practice parameters including prophylactic antibiotics, duration of TT therapy, preremoval chest radiographs with associated charges, and complications were evaluated. Differences between groups were assessed by Mann-Whitney rank sum and chi(2) with Yates correction.

RESULTS

There were 61 patients, 14 in the Pre-PG group and 47 in the Post-PG group. The groups were matched in age and Injury Severity Scores. The Post-PG cohort averaged 3 fewer days of TT therapy. After implementation of the PG, 21 patients did not have preremoval chest radiography, representing a $3000 reduction in radiology fees. Complication rates (retained pneumothorax, hemothorax, and empyema) were not different between the two groups.

CONCLUSION

Implementation of a thoracostomy tube practice guideline was associated with improved management efficiency in trauma patients.

Blunt traumatic rupture of the thoracic aorta: a report of an unusual mechanism of injury

Classic teaching suggests that blunt thoracic aortic rupture (BTAR) results from high-speed deceleration injury mechanisms. Our recent experience with a patient who sustained fatal aortic rupture resulting from a low-speed crushing injury emphasizes the importance of maintaining a high index of suspicion for BTAR, even in patients with "low-risk" injury mechanisms. Several potential pathophysiologic mechanisms of BTAR are discussed.

Suicide, depression, and isotretinoin: is there a causal link?

This paper examines the existing literature and MedWatch reports concerning a proposed relationship between isotretinoin and depression and suicide. The authors provide a brief overview of the biology of isotretinoin and depressive disorder and find no basis for a putative molecular mechanism linking the two. They also address the complexities of Substance-Induced Mood Disorder (SIMD) as a psychiatric diagnosis and its relevance to isotretinoin. Based on this review, the authors conclude that there is no evidence to support a causal connection between isotretinoin and major depression or suicide, because reported cases do not meet the established criteria for causality. The authors also conclude, however, that it is important for dermatologists to be aware of the risk factors for suicide and to monitor patients who exhibit depressive symptoms.

Bedside insertion of inferior vena cava filters in the intensive care unit

BACKGROUND

Several authors have showed that bedside insertion of inferior vena cava filters (IVCF) is feasible and cost effective, with the additional benefit of not having to transport a critically ill patient to the operating room or radiology department. The objective of this study was to examine our experience of 158 IVCF insertions at the bedside in the intensive care unit.

STUDY DESIGN

A prospective, observational study of bedside IVCF insertion performed by the authors from February 1996 through August 2000 was undertaken.

RESULTS

One hundred fifty-eight patients underwent bedside IVCF insertion in the intensive care unit. The mean age was 42.2 years (SD 17.5 years). The mean Injury Severity Score of the trauma patients was 27.3 (SD 14.5). The majority of patients (90%) had a prophylactic indication for IVCF insertion using our institutional guidelines for venous thromboembolic prophylaxis for trauma patients. All IVCF insertions were successfully performed at the bedside after iodinated contrast or carbon dioxide cavography. The mortality was 11% (n = 18), none attributable to the IVCF insertion or cavagram. There was one asymptomatic cava occlusion and one postinsertion pulmonary embolus in a patients with a subclavian vein thrombosis.

CONCLUSIONS

Our results demonstrate the safety and efficacy of IVCF insertion at the bedside in the ICU. This method offers less resource use and more safety for critically ill patients, avoiding the hazards of intrahospital transport.

Safety and accuracy of bedside carbon dioxide cavography for insertion of inferior vena cava filters in the intensive care unit

BACKGROUND

Bedside insertion of inferior vena caval filters (IVCFs) avoids risks associated with transporting these critically ill patients to the operating room or to the radiology suite. But because IVCF insertion requires preinsertion caval imaging, the risk of contrast-induced renal failure remains a concern. Carbon dioxide (CO2) as a contrast agent does not cause renal failure, but its accuracy in determining vena caval diameter (a critical factor in filter selection) and its safety in the critical care population are unknown. This study is designed to assess the safety of using CO2 as a contrast agent in this patient population and to evaluate its accuracy in determining the diameter of the inferior vena cava when used at the bedside.

STUDY DESIGN

A prospective study comparing CO2 with iodinated contrast (IC) material was performed in critically ill patients undergoing vena cavography before bedside IVCF placement. CO2 cavagrams were performed with one or more hand injections of 60 mL of CO2; a single injection of 40 mL of IC material was used. Digital subtraction techniques were used for all of the studies. Blood pressure, pulse rate, and arterial oxygen saturation, end-tidal CO2, and intracranial pressure (when available) were recorded before, during, and after contrast injection. Statistical analysis was performed using the paired t-test, with p < 0.05 being considered significant. Data are expressed as mean +/- SD.

RESULTS

Twenty-three patients were studied. Mean transverse inferior vena cava (IVC) diameters measured 20.4 +/- 0.7mm (IC) and 20.0 +/- 0.7mm (CO2); p = 0.003. The difference in the measurements was 0.4 +/- 0.1 mm, with the largest difference being 1.7mm. In the remaining 10 patients, CO2 differed from IC in determining IVC diameter by only 0.4mm, a statistically significant (p < 0.05) but clinically insignificant difference. No adverse effects on blood pressure, pulse, arterial oxygen saturation, end-tidal CO2, or intracranial pressure were noted with the use of CO2.

CONCLUSIONS

Carbon dioxide as a contrast agent is safe and provides accurate determination of vena caval diameter and anatomy. Carbon dioxide should be considered the contrast agent of choice in critically ill patients.

Treatment for depression following the 1996 National Depression Screening Day

OBJECTIVE

Characteristics of the subsequent treatment received by people who screened positive for depression in the 1996 National Depression Screening Day were investigated.

METHOD

A follow-up telephone survey was completed by 1,502 randomly selected participants from 2,800 sites.

RESULTS

Of 927 people for whom additional evaluation was recommended, 602 (64.9%) obtained evaluations and 503 (83.6%) received treatment. Of these 503, 260 (51.7%) received psychotherapy and medication, 130 (25.8%) received medication only, and 93 (18.5%) received psychotherapy only. Compared with people without health or mental health insurance, individuals with health insurance (66.7% versus 57.5%) and mental health insurance (74.6% versus 55.3%) were more likely to comply with the recommendation to obtain follow-up evaluation.

CONCLUSIONS

One-half of the people treated for depression received a combination of psychotherapy and medication. Lack of insurance was associated with not following the recommendation to obtain further evaluation and treatment.

Value of point-of-care blood testing in emergent trauma management

BACKGROUND

No prospective study demonstrates the value of point-of-care laboratory testing (POCT) in the management of major trauma.

METHODS

In a prospective, noninterventional, study of 200 major trauma patients, we evaluated the influence of a blood POCT profile (hemoglobin, Na+, K+, Cl-, blood urea nitrogen, glucose, pH, PCO2, PO2, HCO3-, base deficit, and lactate) on emergent diagnostic and therapeutic interventions. Physicians responded to a standardized set of questions on their diagnostic and therapeutic plans before and after the availability of POCT results. Management plan changes were deemed emergently appropriate, if they were influenced by the POCT results and, within the ensuing 30 minutes, the change in management was likely to reduce morbidity or conserve resources.

RESULTS

For emergently appropriate plan changes, Na+, Cl-, K+, and blood urea nitrogen were never influential, whereas in each of 6.0% of cases (95% confidence interval [CI], 3.5%-10.2%) at least one of the remaining POCT parameters was influential. An emergently appropriate change was based on hemoglobin in 3.5% of cases (95% CI, 1.0%-6.1%), blood gas parameters in 3.0% of cases (95% CI, 0.64%-5.7%), lactate in 2.5% of cases (95% CI, 1.1%-5.7%), and glucose in 0.5% of cases (95% CI, 0.1%-2.8%). All of these cases involved blunt injury.

CONCLUSION

Na+, Cl-, K+, and blood urea nitrogen levels do not influence the initial management of major trauma patients. In patients with severe blunt injury, hemoglobin, glucose, blood gas, and lactate measurements occasionally result in morbidity-reducing or resource-conserving management changes.

Abdominal CT scanning for trauma: how low can we go?

PURPOSE

computed tomography (CT) of the abdomen is an established, albeit expensive and perhaps overused, diagnostic modality for the evaluation of the injured patient. We developed a practice management guideline for blunt abdominal trauma intended to reduce the percentage of negative CT scans, yet minimize delayed recognition of injury and non-therapeutic laparotomy.

PROCEDURES

between April 1996 and March 1997, 1147 adult patients at risk for blunt abdominal injury were admitted to our Level I trauma centre and underwent abdominal evaluation according to the practice management guideline.

MAIN FINDINGS

abdominal CT was performed in 522 patients (45%), and 441 scans were negative (85%). Delayed recognition of injury and non-therapeutic laparotomy rates were low, 4% and 1.6%, respectively.

PRINCIPAL CONCLUSION

abdominal CT scanning in trauma patients can achieve low non-therapeutic laparotomy and delayed recognition of injury rates but at the expense of high negative CT scan rates. Greater reliance on the physical examination and perhaps abdominal ultrasound may reduce negative CT scan rates and yet preserve low non-therapeutic laparotomy and delayed recognition of injury rates.