Professor Ian Aird: Master of surgical education

Ian Aird (1905-1962) was a Scottish surgeon renowned for his textbook: "A companion in surgical studies", a uniquely single-author work of thousands of pages. It was an essential study for young surgeons aspiring to pass the FRCS (Edin) examination. He was appointed Chair of Surgery of the Royal Postgraduate Medical School at Hammersmith Hospital in London. Under his direction, his faculty developed a pump oxygenator, used it successfully for the first time in a patient and introduced cardiac surgery in Russia. They also pioneered kidney transplantation in Britain. Aird himself discovered the relationship of blood groups to cancer and peptic ulceration. He became famous for the surgical separation of conjoined twins from Nigeria, fame that created conflicts with medical authority on the issue of cooperating with the press. He became frustrated when the medical council refused to support and sponsor funding for research. Sadly, even his indomitable energy and brilliance could not see him through his depression. He committed suicide at the age of 57.

Developing congenital heart surgery in India: The travails and triumphs of a pioneer

Professor IM Rao, from All India Institute of Medical Sciences, New Delhi, was a pioneering cardiac surgeon who, against overwhelming odds, developed congenital heart surgery in India. He made many contributions to the evolution of his specialty, spanning more than four decades and three countries. This is a brief report of his professional life and accomplishments.

Endpoints of Resuscitation for the Victim of Trauma

Useful resuscitation endpoints must serve both to diagnose the need for and to ensure the ongoing adequacy of resuscitation. To this end, traditional measures of organ perfusion are now widely appreciated to be grossly inadequate. Useful endpoints or milestones range from the global, to the regional, to the cellular specific. Understanding the basic principles of perfusion-related dysoxia in trauma and hemorrhage and its potential rapid transition to involve inflammatory and immune responses on cellular oxygen utilization will aid the clinician in choosing and appropriately interpreting endpoint monitoring data. There also appears to be an optimal window of opportunity for monitoring to help mitigate the development of more complicated inflammatory states. This article reviews the underlying need for endpoint selection (both global and regional, biochemical and functional) and monitoring during resuscitation of the polytrauma patient. At this juncture it appears that early use of a blend of global markers such as lactate and base deficit coupled with an available sensitive regional monitor such as gastric tonometry may offer the best combination of current technology to guard against early perfusion-related dysoxia. Future techniques involving optical spectroscopy offer the exciting potential to assess oxygenation at the cellular level. This may aid in ultra-early detection and resolution of perfusion-related dysoxia in addition to recognizing its transition to more complex inflammatory-mediated circulatory and metabolic failure.

Trauma Registry of the Pan-American Trauma Society: One year of experience in two hospitals in southwest Colombia

BACKGROUND

Trauma information systems are needed to improve decision making and to identify potential areas of intervention.

OBJECTIVE

To describe the first year of experience with a trauma registry in two referral centers in southwest Colombia.

METHODS

The study was performed in two referral centers in Cali. Patients with traumatic injuries seen between January 1 and December 31, 2012, were included. The collected information included demographics, mechanism of trauma, injury severity score (ISS), and mortality. A descriptive analysis was carried out.

RESULTS

A total of 17,431 patients were registered, of which 67.8% were male with an average age of 30 (±20) years. Workplace injuries were the cause of emergency consultations in 28.2% of cases, and falls were the most common mechanism of trauma (37.3%). Patients with an ISS ≥15 were mostly found in the 18-35-year age range (6.4%). Most patients who suffered a gunshot wound presented an ISS ≥15. A total of 2.5% of all patients died, whereas the mortality rate was 54% among patients with an ISS ≥15 and a gunshot wound.

CONCLUSION

Once the trauma registry was successfully implemented in two institutions in Cali, the primary causes of admission were identified as falls and workplace injuries. The most severely compromised patients were in the population range between 18 and 35 years of age. The highest mortality was caused by gunshot wounds.

INTRODUCCIÓN

Los sistemas de información en trauma son requeridos para mejorar la toma de decisiones e identificar potenciales áreas de intervención.

OBJETIVO

Describir el primer año de experiencia del registro de trauma en dos centros de referencia de trauma del suroccidente Colombiano.

MÉTODOS

Estudio realizado en dos centros de referencia de Cali. Se incluyeron pacientes con trauma o lesiones externas entre el 1-Ene y el 31-Dic-2012. Se recolectó información demográfica, relacionada con mecanismos de trauma, severidad (ISS) y mortalidad. Se presenta un análisis descriptivo.

RESULTADOS

Se registraron 17,431 pacientes. El 67.8% de los pacientes eran de género masculino con edad promedio de 30 (±20) años. Las lesiones laborales fueron causa de consulta a urgencias en un 28.2%, y las caídas el mecanismo de trauma más frecuente (37.3%). Los pacientes con ISS ≥15 en su mayoría se encontraban en el rango de edad de 18-35 años (6.4%). El 28% de los pacientes que sufrieron lesión por arma de fuego presentaron un ISS ≥15. El 2.5% de los pacientes murieron y aquellos pacientes con ISS ≥15 y lesión por arma de fuego presentaron mortalidad del 54%.

CONCLUSIÓN

una vez se logró implementar el registro de trauma en dos instituciones en Cali, se identificó que la principal causa de ingreso fue secundaria a caídas y las lesiones laborales. Los pacientes más severamente comprometidos están en el rango de población entre 18 a 35 años. La mayor mortalidad se presentó secundario a lesiones de causa externa por arma de fuego.

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting

Acute left sided colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in acute setting. A World Society of Emergency Surgery (WSES) Consensus Conference on acute diverticulitis was held during the 3rd World Congress of the WSES in Jerusalem, Israel, on July 7th, 2015. During this consensus conference the guidelines for the management of acute left sided colonic diverticulitis in the emergency setting were presented and discussed. This document represents the executive summary of the final guidelines approved by the consensus conference.

Trauma Registry of the Pan American Society of Trauma: One year of experience in two referral centers in the colombian southwestern

Background: Emergency care information systems in trauma are essential to improve the decision making and identify potential areas of intervention. Objective: To describe the first year of experience of trauma registry in two reference trauma centers of the southwestern Colombia. Methods: A study conducted in two reference trauma centers of Cali city. There were included those patients with any injury from external causes or trauma occurred between January 1st and December 31st of 2012. Information related with demographics, injury mechanism, severity injury (ISS) and mortality were collected. We presented a descriptive analysis. Results: There were registered 17,431 patients whereof 67.8% were male with a mean of 30 (±20) years old. Workplace injuries were the 28.2% cause of emergency consultation, and falls were the most prevalent trauma mechanism. Majority of patients with a ISS ≥15 were in a range age of 18-35 years (6.4%). The 28% of patients with gunshot wounds had a ISS ≥15. An overall of 2.5% of included patients died and those who had a ISS ≥15 and gunshot wounds showed a mortality of 54%. Conclusion: Upon the implementation of the trauma registry in two main hospitals of Cali city, we identify that falls and workplace injuries were the leading cause of admission to the emergency room. Severely compromised patients are in the range age of 18-35 years old. Mortality was higher for those patients who suffered gunshot wounds.

DVT surveillance program in the ICU: analysis of cost-effectiveness

BACKGROUND

Venous Thrombo-embolism (VTE--Deep venous thrombosis (DVT) and/or pulmonary embolism (PE)--in traumatized patients causes significant morbidity and mortality. The current study evaluates the effectiveness of DVT surveillance in reducing PE, and performs a cost-effectiveness analysis.

METHODS

All traumatized patients admitted to the adult ICU underwent twice weekly DVT surveillance by bilateral lower extremity venous Duplex examination (48-month surveillance period--SP). The rates of DVT and PE were recorded and compared to the rates observed in the 36-month pre-surveillance period (PSP). All patients in both periods received mechanical and pharmacologic prophylaxis unless contraindicated. Total costs--diagnostic, therapeutic and surveillance--for both periods were recorded and the incremental cost for each Quality Adjusted Life Year (QALY) gained was calculated.

RESULTS

4234 patients were eligible (PSP--1422 and SP--2812). Rate of DVT in SP (2.8%) was significantly higher than in PSP (1.3%) - p<0.05, and rate of PE in SP (0.7%) was significantly lower than that in PSP (1.5%) - p<0.05. Logistic regression demonstrated that surveillance was an independent predictor of increased DVT detection (OR: 2.53 - CI: 1.462-4.378) and decreased PE incidence (OR: 0.487 - CI: 0.262-0.904). The incremental cost was $509,091/life saved in the base case, translating to $29,102/QALY gained. A sensitivity analysis over four of the parameters used in the model indicated that the incremental cost ranged from $18,661 to $48,821/QALY gained.

CONCLUSIONS

Surveillance of traumatized ICU patients increases DVT detection and reduces PE incidence. Costs in terms of QALY gained compares favorably with other interventions accepted by society.

Trauma surgery associations and societies: which organizations match your goals?

This focused summary is a multi-institutional, multi-national, and multi-generational project designed to briefly summarize current academic trauma societies for both trainees and faculty alike. The co-authorship is composed of former and/or current presidents from most major trauma organizations. It has particular relevance to trainees and/or recent graduates attempting to navigate the multitude of available trauma organizations.

Management of open abdomen

Non-closure of abdominal fascia and the resultant open abdomen after laparotomy has become a major advance in the management of critically ill or injured patients. The benefits of open abdomen are many and include the prevention of intra-abdominal hypertension and the consequent abdominal compartment syndrome. Appropriately and exquisitely managed, it can provide all the benefits and prevent highly morbid complications of leaving the abdomen open. This review will provide some insights into such management.

Oesophageal injuries: Position paper, WSES, 2013

The oesophagus is a difficult challenge for the surgeon because of its lack of serosal covering, the tenuous, segmental blood supply and the common delay in the diagnosis of injury. Early diagnosis is the key to successful management. Recent introduction of newer, minimally invasive techniques have provided management alternatives for both the normal and the diseased organ that is injured with both early and delayed diagnosis.

Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy: results from the prospective AAST Open Abdomen registry

IMPORTANCE

Enterocutaneous fistula (ECF), enteroatmospheric fistula (EAF), and intra-abdominal sepsis/abscess (IAS) are major challenges for surgeons caring for patients undergoing damage control laparotomy after trauma.

OBJECTIVE

To determine independent predictors of ECF, EAF, or IAS in patients undergoing damage control laparotomy after trauma, using the AAST Open Abdomen Registry.

DESIGN

The AAST Open Abdomen registry of patients with an open abdomen following damage control laparotomy was used to identify patients who developed ECF, EAF, or IAS and to compare these patients with those without these complications. Univariate analyses were performed to compare these groups of patients. Variables from univariate analyses differing at P < .20 were entered into a stepwise logistic regression model to identify independent risk factors for ECF, EAF, or IAS.

SETTING

Fourteen level I trauma centers.

PARTICIPANTS

A total of 517 patients with an open abdomen following damage control laparotomy.

MAIN OUTCOMES AND MEASURES

Complication of ECF, EAF, or IAS.

RESULTS

More patients in the ECF/EAF/IAS group than in the group without these complications underwent bowel resection (63 of 111 patients [57%] vs 133 of 406 patients [33%]; P < .001). Within the first 48 hours after surgery, the ECF/EAF/IAS group received more colloids (P < .03) and total fluids (P < .03) than did the group without these complications. The ECF/EAF/IAS group underwent almost twice as many abdominal reexplorations as did the group without these complications (mean [SD] number, 4.1 [4.1] vs 2.2 [3.4]; P < .001). After multivariate analysis, the independent predictors of ECF/EAF/IAS were a large bowel resection (adjusted odds ratio [AOR], 3.56 [95% CI, 1.88-6.76]; P < .001), a total fluid intake at 48 hours of between 5 and 10 L (AOR, 2.11 [95% CI, 1.15-3.88]; P = .02) or more than 10 L (AOR, 1.93 [95% CI, 1.04-3.57]; P = .04), and an increasing number of reexplorations (AOR, 1.14 [95% CI, 1.06-1.21]; P < .001).

CONCLUSIONS AND RELEVANCE

Large bowel resection, large-volume fluid resuscitation, and an increasing number of abdominal reexplorations were statistically significant predictors of ECF, EAF, or IAS in patients with an open abdomen after damage control laparotomy.

One Elevated Bladder Pressure Measurement May Not be Enough to Diagnose Abdominal Compartment Syndrome

Bladder pressure measurements (BPMs) are considered a key component in the diagnosis of abdominal compartment syndrome (ACS). The purpose of this observational review was to determine risk factors of ACS and associated mortality with particular focus on the role of BPM. A retrospective trauma registry and chart review was performed on trauma patients from January 2003 through December 2010. Comparisons were made between patients with and without ACS. There were 3172 patients included in the study of whom 46 had ACS. Patients with ACS were younger, more severely injured, with longer lengths of stay. Logistic regression determined Injury Severity Score (ISS) and urinary catheter days as independent predictors of ACS, whereas independent predictors of mortality included age, ISS, and ACS. Subset analysis demonstrated no association between BPM 20 mmHg or greater and diagnosis of ACS versus no ACS. Logistic regression indicated independent predictors of mortality were number of BPM 20 mmHg or greater and age. Patients with ACS are more severely injured with worse outcomes. An isolated BPM 20 mmHg or greater was not associated with ACS and may be inadequate to independently diagnose ACS. These findings suggest the need for repeat measurements with early intervention if they remain elevated in an effort to decrease mortality associated with ACS.

One elevated bladder pressure measurement may not be enough to diagnose abdominal compartment syndrome

Bladder pressure measurements (BPMs) are considered a key component in the diagnosis of abdominal compartment syndrome (ACS). The purpose of this observational review was to determine risk factors of ACS and associated mortality with particular focus on the role of BPM. A retrospective trauma registry and chart review was performed on trauma patients from January 2003 through December 2010. Comparisons were made between patients with and without ACS. There were 3172 patients included in the study of whom 46 had ACS. Patients with ACS were younger, more severely injured, with longer lengths of stay. Logistic regression determined Injury Severity Score (ISS) and urinary catheter days as independent predictors of ACS, whereas independent predictors of mortality included age, ISS, and ACS. Subset analysis demonstrated no association between BPM 20 mmHg or greater and diagnosis of ACS versus no ACS. Logistic regression indicated independent predictors of mortality were number of BPM 20 mmHg or greater and age. Patients with ACS are more severely injured with worse outcomes. An isolated BPM 20 mmHg or greater was not associated with ACS and may be inadequate to independently diagnose ACS. These findings suggest the need for repeat measurements with early intervention if they remain elevated in an effort to decrease mortality associated with ACS.

Thin Chest Wall is an Independent Risk Factor for the Development of Pneumothorax after Chest Tube Removal

The factors contributing to the development of pneumothorax after removal of chest tube thoracostomy are not fully understood. We hypothesized that development of post pull pneumothorax (PPP) after chest tube removal would be significantly lower in those patients with thicker chest walls, due to the “protective” layer of adipose tissue. All patients on our trauma service who underwent chest tube thoracostomy from July 2010 to February 2011 were retrospectively reviewed. Patient age, mechanism of trauma, and chest Abbreviated Injury Scale score were analyzed. Thoracic CTs were reviewed to ascertain chest wall thickness (CW). Thickness was measured at the level of the nipple at the midaxillary line, as perpendicular distance between skin and pleural cavity. Chest X-ray reports from immediately prior and after chest tube removal were reviewed for interval development of PPP. Data are presented as average ± standard deviation. Ninety-one chest tubes were inserted into 81 patients. Patients who died before chest tube removal (n = 11), or those without thoracic CT scans (n = 13) were excluded. PPP occurred in 29.9 per cent of chest tube removals (20/67). When PPP was encountered, repeat chest tube was necessary in 20 per cent of cases (4/20). After univariate analysis, younger age, penetrating mechanism, and thin chest wall were found to be significant risk factors for development of PPP. Chest Abbreviated Injury Scale score was similar in both groups. Logistic regression showed only chest wall thickness to be an independent risk factor for development of PPP.

Thin chest wall is an independent risk factor for the development of pneumothorax after chest tube removal

The factors contributing to the development of pneumothorax after removal of chest tube thoracostomy are not fully understood. We hypothesized that development of post pull pneumothorax (PPP) after chest tube removal would be significantly lower in those patients with thicker chest walls, due to the "protective" layer of adipose tissue. All patients on our trauma service who underwent chest tube thoracostomy from July 2010 to February 2011 were retrospectively reviewed. Patient age, mechanism of trauma, and chest Abbreviated Injury Scale score were analyzed. Thoracic CTs were reviewed to ascertain chest wall thickness (CW). Thickness was measured at the level of the nipple at the midaxillary line, as perpendicular distance between skin and pleural cavity. Chest X-ray reports from immediately prior and after chest tube removal were reviewed for interval development of PPP. Data are presented as average ± standard deviation. Ninety-one chest tubes were inserted into 81 patients. Patients who died before chest tube removal (n = 11), or those without thoracic CT scans (n = 13) were excluded. PPP occurred in 29.9 per cent of chest tube removals (20/67). When PPP was encountered, repeat chest tube was necessary in 20 per cent of cases (4/20). After univariate analysis, younger age, penetrating mechanism, and thin chest wall were found to be significant risk factors for development of PPP. Chest Abbreviated Injury Scale score was similar in both groups. Logistic regression showed only chest wall thickness to be an independent risk factor for development of PPP.

Bladder pressure measurements and urinary tract infection in trauma patients

BACKGROUND

The purpose of this trial was to determine if using a closed technique for bladder pressure measurements (BPMs) would eliminate them as a risk factor for urinary tract infection (UTI) in trauma patients, as was shown previously using an open technique.

METHODS

Data were collected prospectively from January 2006 until December 2009 by a dedicated epidemiology nurse and combined with trauma registry data at our Level 1 trauma center. All trauma patients admitted to the surgical trauma intensive care unit (STICU) with and without UTIs were compared for demographic and epidemiologic data. A closed system was used in which the urinary drainage catheter (UDC) remained connected to the bag and 45 mL of saline was injected through a two-way valved sideport, with subsequent measurements through the sideport.

RESULTS

There were 1,641 patients in the trial. The UTI group was sicker (Injury Severity Score [ISS] 18.7±11.9 no UTI vs. 28±10.7 UTI; p<0.0001), with longer stays (11.4±12.4 days no UTI vs. 37.9±20.3 days UTI; p<0.0001) and more UDC days (4.3±6.6 no UTI vs. 23.9±16.6 UTI; p<0.0001). The BPM group had more UDC days (15.6 days±16.0 BPM vs. 5.4 days±7.3 no BPM; p<0.0001), yet no difference in UTI rate/1,000 UDC days (5.7 no BPM vs. 8.0 BPM; p=0.5291). Logistic regression demonstrated only UDC days to be a predictor of UTI (1.125; 95% confidence interval [CI] 1.097-1.154; p<0.0001), whereas ISS (1.083, 95% CI 1.063-1.104; p<0.0001) and age (1.051, 95% CI 1.037-1.065; p<0.0001) were the only predictors of death.

CONCLUSION

Although patients undergoing BPM have more UTIs than patients without BPM, the measurements are not an independent predictor of UTI when done by the closed technique. These findings emphasize the judicious use of BPM with a closed system and, more importantly, the need for early removal of catheters.

Lactate in Trauma: A Poor Predictor of Mortality in the Setting of Alcohol Ingestion

Resuscitation end point markers such as lactate and base deficit (BD) are used in trauma to identify and treat a state of compensated shock. Lactate and BD levels are also elevated by alcohol. In blunt trauma patients with positive blood alcohol levels, lactate may be a poor indicator of injury. Retrospective data were collected on 1083 blunt trauma patients with positive blood alcohol levels admitted a Level I trauma center between 2003 and 2006. Patients were stratified by Injury Severity Score, age, gender, and Glasgow Coma Score. Logistic regression analyses were used to assess lactate and BD as independent risk factors for mortality. Seventy-four per cent of patients had an abnormal lactate level compared with 28 per cent with abnormal BD levels. In patients with mild injury, lactate levels were abnormal in more than 70 per cent of patients compared with less than 20 per cent of patients with abnormal BD levels. Linear regression showed lactate is not a significant predictor of mortality. Regardless of Injury Severity Score, lactate appeared to be more often abnormal than BD in the setting of alcohol ingestion. Additionally, because BD, and not lactate, was shown to be an independent predictor of mortality, lactate may not be a reliable marker of end point resuscitation in this patient population.

Lactate in trauma: a poor predictor of mortality in the setting of alcohol ingestion

Resuscitation end point markers such as lactate and base deficit (BD) are used in trauma to identify and treat a state of compensated shock. Lactate and BD levels are also elevated by alcohol. In blunt trauma patients with positive blood alcohol levels, lactate may be a poor indicator of injury. Retrospective data were collected on 1083 blunt trauma patients with positive blood alcohol levels admitted a Level I trauma center between 2003 and 2006. Patients were stratified by Injury Severity Score, age, gender, and Glasgow Coma Score. Logistic regression analyses were used to assess lactate and BD as independent risk factors for mortality. Seventy-four per cent of patients had an abnormal lactate level compared with 28 per cent with abnormal BD levels. In patients with mild injury, lactate levels were abnormal in more than 70 per cent of patients compared with less than 20 per cent of patients with abnormal BD levels. Linear regression showed lactate is not a significant predictor of mortality. Regardless of Injury Severity Score, lactate appeared to be more often abnormal than BD in the setting of alcohol ingestion. Additionally, because BD, and not lactate, was shown to be an independent predictor of mortality, lactate may not be a reliable marker of end point resuscitation in this patient population.

Geriatric education for surgical residents: identifying a major need

This study evaluated a program designed to test and enhance residents' knowledge of geriatrics. A 2-year prospective interventional trial was conducted. Surgical residents underwent pretesting (pre) in three areas: polypharmacy, delirium, and end of life. They then received educational materials and completed a posttest within 1 month and a patient simulation examination graded by a physician observer and the patient on his or her satisfaction. Forty-nine residents (51% interns, 55% general surgery residents) participated. Seventy per cent had no prior geriatrics education. Test scores significantly improved from pretest to posttest (12.9 ± 3.1 vs 13.78 ± 3.12, P = 0.01). The scores were consistently better on poly topics and consistently worse on end-of-life topics: pretest per cent correct: polypharmacy 60, end of life 46, P = 0.007; posttest percent correct: polypharmacy 63, end of life 49, P = 0.0014. By Pearson correlation, the pretest and posttest scores did not correlate with either the observer (R = -0.16, P = 0.27 pre, R = -0.08, P = 0.59 post) or subscores (R = -0.27, P = 0.11 pre, R = -0.13, P = 0.45 post), although the observer and subscore correlated with each other (R = 0.35, P = 0.036). Performance was poor and did not correlate with better patient care by simulation. Other options for geriatric education need to be considered and evaluated.

Surgical management of intra-abdominal hypertension and abdominal compartment syndrome

The initial management of intra-abdominal hypertension (IAH) is medical measures to reduce intra-abdominal pressure (IAP). These, in combination with percutaneous drainage of peritoneal free fluid, may serve to reduce IAH. If these measures fail, surgical decompression of the abdomen by laparotomy is necessary to control the IAP, search for and treat inciting factors, and reduce the hypertension. The abdomen is usually left open with temporary abdominal closure techniques. Surgical decompression of IAH associated with acute pancreatitis or secondary abdominal compartment syndrome has other surgical options besides a complete celiotomy. Attention to detail in surgical technique and postoperative care is essential for optimal outcome.

Geriatric Education for Surgical Residents: Identifying a Major Need

This study evaluated a program designed to test and enhance residents’ knowledge of geriatrics. A 2-year prospective interventional trial was conducted. Surgical residents underwent pretesting (pre) in three areas: polypharmacy, delirium, and end of life. They then received educational materials and completed a posttest within 1 month and a patient simulation examination graded by a physician observer and the patient on his or her satisfaction. Forty-nine residents (51% interns, 55% general surgery residents) participated. Seventy per cent had no prior geriatrics education. Test scores significantly improved from pretest to posttest (12.9 ± 3.1 vs 13.78 ± 3.12, P = 0.01). The scores were consistently better on poly topics and consistently worse on end-of-life topics: pretest per cent correct: polypharmacy 60, end of life 46, P = 0.007; posttest percent correct: polypharmacy 63, end of life 49, P = 0.0014. By Pearson correlation, the pretest and posttest scores did not correlate with either the observer ( R = -0.16, P = 0.27 pre, R = -0.08, P = 0.59 post) or subscores ( R = -0.27, P = 0.11 pre, R = -0.13, P = 0.45 post), although the observer and subscore correlated with each other ( R = 0.35, P = 0.036). Performance was poor and did not correlate with better patient care by simulation. Other options for geriatric education need to be considered and evaluated.

Enterocutaneous fistulas: an overview

Enterocutaneous fistulas remain a difficult management problem. The basis of management centers on the prevention and treatment of sepsis, control of fistula effluent, and fluid and nutritional support. Early surgery should be limited to abscess drainage and proximal defunctioning stoma formation. Definitive procedures for a persistent fistula are indicated in the late postoperative period, with resection of the fistula segment and reanastomosis of healthy bowel. Even more complex are the enteroatmospheric fistulas in the open abdomen. These enteric fistulas require the highest level of multidisciplinary approach for optimal outcomes.

Bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia: to quantitate or not, that is the question

Quantitative bronchoalveolar lavage (BAL) is used to diagnose ventilator-associated pneumonia (VAP). We prospectively compared semiquantitative (SQ) and quantitative (Qu) culture of BAL for VAP diagnosis. Ventilated patients suspected of VAP underwent bronchoscopic BAL. BAL fluid was examined by both Qu (colony-forming units [CFUs]/mL) and SQ culture (none, sparse, moderate, or heavy) and results were compared. VAP was defined as 10⁵ CFU/mL or greater on Qu culture. Over 36 months, 319 BALs were performed. Sixty-three of 319 (20%) showed diagnostic growth by Qu culture identifying a total of 81 organisms causing VAP. All 63 specimens showed growth of some organism(s) on SQ culture with 79 of 81 causative organisms identified and two (Pseudomonas, one; Corynebacterium, one) not identified. The remaining 256 specimens did not meet the threshold for VAP by the Qu method. Among these, 79 did not show any growth on SQ culture. Among the 240 specimens showing some growth on SQ culture, a total of 384 organisms were identified. VAP rates in relation to strength of growth on SQ culture were: sparse, 10 of 140 (7%); moderate, 24 of 147 (16%); and heavy, 45 of 97 (46%). Sensitivity (Sn), specificity (Sp), positive (PPV), and negative (NPV) predictive values of SQ culture of BAL fluid for the diagnosis of VAP were 97, 21, 21, and 97 per cent, respectively. Nonquantitative culture of BAL fluid is fairly accurate in ruling out VAP (high Sn and NPV). It however has poor Sp and PPV and using this method will lead to unnecessary antimicrobial use with its attendant complications of toxicity, cost, and resistance.

Bronchoalveolar Lavage in the Diagnosis of Ventilator-Associated Pneumonia: To Quantitate or Not, That is the Question

Quantitative bronchoalveolar lavage (BAL) is used to diagnose ventilator-associated pneumonia (VAP). We prospectively compared semiquantitative (SQ) and quantitative (Qu) culture of BAL for VAP diagnosis. Ventilated patients suspected of VAP underwent bronchoscopic BAL. BAL fluid was examined by both Qu (colony-forming units [CFUs]/mL) and SQ culture (none, sparse, moderate, or heavy) and results were compared. VAP was defined as 105 CFU/mL or greater on Qu culture. Over 36 months, 319 BALs were performed. Sixty-three of 319 (20%) showed diagnostic growth by Qu culture identifying a total of 81 organisms causing VAP. All 63 specimens showed growth of some organism(s) on SQ culture with 79 of 81 causative organisms identified and two ( Pseudomonas, one; Corynebacterium, one) not identified. The remaining 256 specimens did not meet the threshold for VAP by the Qu method. Among these, 79 did not show any growth on SQ culture. Among the 240 specimens showing some growth on SQ culture, a total of 384 organisms were identified. VAP rates in relation to strength of growth on SQ culture were: sparse, 10 of 140 (7%); moderate, 24 of 147 (16%); and heavy, 45 of 97 (46%). Sensitivity (Sn), specificity (Sp), positive (PPV), and negative (NPV) predictive values of SQ culture of BAL fluid for the diagnosis of VAP were 97, 21, 21, and 97 per cent, respectively. Nonquantitative culture of BAL fluid is fairly accurate in ruling out VAP (high Sn and NPV). It however has poor Sp and PPV and using this method will lead to unnecessary antimicrobial use with its attendant complications of toxicity, cost, and resistance.

Bladder pressure measurements are an independent predictor of urinary tract infection in trauma patients

PURPOSE

To determine the risk factors for urinary tract infections (UTIs) specific to trauma patients in order to assist in the development of infection control protocols.

METHODS

Data were collected prospectively from January 2003 until December 2005 by an epidemiology nurse and combined with registry data from our Level 1 trauma center. The trauma patients admitted to the Surgery and Trauma Intensive Care Unit (STICU)(n = 938) who did and did not have UTIs were compared for demographics, Injury Severity Score (ISS), and epidemiologic data, including use of Foley catheters and bladder pressure measurements (BPMs). An open system was used for the measurements in which the catheter was disconnected from the bag to instill 50 mL of saline into the bladder, and an 18-gauge needle was inserted into the catheter to measure the pressure.

RESULTS

A total of 50 patients had no Foley catheter or UTIs. Among the 836 patients with catheters but no BPMs, there were 36 UTIs (4.31%), whereas the 52 patients with catheters and BPMs had 12 UTIs (23.08%)(p < 0.0001). Patients with UTIs were more severely injured older females (mean age 40.1 ± 18.6 years with no UTI vs. 48.5 ± 20.8 with UTIs; p = 0.0083; percent female 26.4 no UTI vs. 45.8 UTI; p = 0.007; ISS 19.3 ± 11.3 no UTI vs. 26.2 ± 11.6; p < 0.0001). Using logistic regression, BPM was an independent predictor of UTI, with infection being seven times more likely in the patients having the measurements (odds ratio [OR] 6.99; 95% confidence-interval [CI] 3.087-15.827). Along with age (OR 1.039; CI 1.024-1.054) and ISS (OR 1.081; CI 1.056-1.106), having BPMs was an independent predictor of death (OR 2.475; CI 1.191-6.328).

CONCLUSION

This is the first study that demonstrates a greater risk of UTI with BPM using the open technique independent of patient gender or degree of injury. Given these findings and a previous trial demonstrating no difference in UTI rates with a closed circuit for BPM, our institution has incorporated a closed circuit technique into its infection control protocol.

Do Flexion Extension Plain Films Facilitate Treatment after Trauma?

We hypothesized that flexion extension (FE) films do not facilitate the diagnosis or treatment of ligamentous injury of the cervical spine after blunt trauma. From January 2000 to December 2008 we reviewed all patients who underwent FE films and compared five-view plain films (5view) and cervical spine CTC with FE in the diagnosis of ligamentous injury. There were 22,929 patients with blunt trauma and of these, 271 patients underwent 303 FE films. Average age was 39.6 years, Injury Severity Score was 10.8, Glasgow Coma Score was 14.1, lactate was 2.6 mmol/L, and hospital length of stay was 6 days. Compared with FE, 5view and CTC had a sensitivity of 80 per cent (8 of 10), positive predictive value of 47.1 per cent (8 of 17), specificity of 96.55 per cent (252 of 261), and negative predictive value of 99.21 per cent (252 of 254). For purposes of analysis, incomplete and ambiguous FE films were listed as negative; however, 20.5 per cent (62 of 303) were incomplete and 9.2 per cent (28 of 303) were ambiguous. Management did not change for the 2 patients with missed ligament injuries. The 303 studies cost $162,105.00 to obtain. FEs are often incomplete and unreliable making it difficult to use them to base management decisions. They do not facilitate treatment and may lead to increased cost and prolonged cervical collars.

Do flexion extension plain films facilitate treatment after trauma?

We hypothesized that flexion extension (FE) films do not facilitate the diagnosis or treatment of ligamentous injury of the cervical spine after blunt trauma. From January 2000 to December 2008 we reviewed all patients who underwent FE films and compared five-view plain films (5 view) and cervical spine CTC with FE in the diagnosis of ligamentous injury. There were 22,929 patients with blunt trauma and of these, 271 patients underwent 303 FE films. Average age was 39.6 years, Injury Severity Score was 10.8, Glasgow Coma Score was 14.1, lactate was 2.6 mmol/L, and hospital length of stay was 6 days. Compared with FE, 5 view and CTC had a sensitivity of 80 per cent (8 of 10), positive predictive value of 47.1 per cent (8 of 17), specificity of 96.55 per cent (252 of 261), and negative predictive value of 99.21 per cent (252 of 254). For purposes of analysis, incomplete and ambiguous FE films were listed as negative; however, 20.5 per cent (62 of 303) were incomplete and 9.2 per cent (28 of 303) were ambiguous. Management did not change for the 2 patients with missed ligament injuries. The 303 studies cost $162,105.00 to obtain. FEs are often incomplete and unreliable making it difficult to use them to base management decisions. They do not facilitate treatment and may lead to increased cost and prolonged cervical collars.

Flexion-extension cervical spine plain films compared with MRI in the diagnosis of ligamentous injury

The purpose of this study was to compare flexion-extension (FE) plain films with MRI as the gold standard in the diagnosis of ligamentous injury (LI) of the cervical spine after trauma. A retrospective review of patients sustaining blunt trauma from January 2000 to December 2008 (n = 22929) who had both FE and MRI of the cervical spine was performed. Two hundred seventy-one patients had 303 FE films. Forty-nine also had MRI. The average Injury Severity Score was 15.6 +/- 10.2, Glasgow Coma Scale was 13.8 +/- 3.5, lactate 2.2 +/- 1.7 mmol/L, and hospital stay of 8 +/- 11.2 days. FE failed to identify all eight LIs seen on MRI. FE film sensitivity was 0 per cent (zero of eight), specificity 98 per cent (40 of 41), positive predictive value 0 per cent (zero of one), and negative predictive value 83 per cent (40 of 48). Although classified as negative for purposes of analysis, FE was incomplete 20.5 per cent (62 of 303) and ambiguous 9.2 per cent (28 of 303) of the time. The charge of FE is $535 so $48150 (90 incomplete/ambiguous films) could have been saved by eliminating these films. FE should no longer be used to diagnose LI. Given the rare incidence of these injuries, MRI should be used when there is high clinical suspicion of injury.

Flexion-Extension Cervical Spine Plain Films Compared with MRI in the Diagnosis of Ligamentous Injury

The purpose of this study was to compare flexion-extension (FE) plain films with MRI as the gold standard in the diagnosis of ligamentous injury (LI) of the cervical spine after trauma. A retrospective review of patients sustaining blunt trauma from January 2000 to December 2008 (n = 22929) who had both FE and MRI of the cervical spine was performed. Two hundred seventy-one patients had 303 FE films. Forty-nine also had MRI. The average Injury Severity Score was 15.6 ± 10.2, Glasgow Coma Scale was 13.8 ± 3.5, lactate 2.2 ± 1.7 mmol/L, and hospital stay of 8 ± 11.2 days. FE failed to identify all eight LIs seen on MRI. FE film sensitivity was 0 per cent (zero of eight), specificity 98 per cent (40 of 41), positive predictive value 0 per cent (zero of one), and negative predictive value 83 per cent (40 of 48). Although classified as negative for purposes of analysis, FE was incomplete 20.5 per cent (62 of 303) and ambiguous 9.2 per cent (28 of 303) of the time. The charge of FE is $535 so $48150 (90 incomplete/ambiguous films) could have been saved by eliminating these films. FE should no longer be used to diagnose LI. Given the rare incidence of these injuries, MRI should be used when there is high clinical suspicion of injury.

Thoracoscopy for Trauma

Thoracoscopy has numerous applications for both diagnosis and treatment in thoracic trauma. It is excellent for the diagnosis of diaphragmatic injuries, mediastinal evaluation, and the assessment of persistent air-leak. It offers therapeutic intervention for diaphragmatic lacerations, thoracic bleeding in stable patients, evacuation of residual hemothorax, air-leaks, and the prevention and treatment of empyema. Judiciously applied, it is a powerful tool in the armamentarium of the trauma surgeon.

A Central Venous Line Protocol Decreases Bloodstream Infections and Length of Stay in a Trauma Intensive Care Unit Population

We evaluated the benefit of a central venous line (CVL) protocol on bloodstream infections (BSIs) and outcome in a trauma intensive care unit (ICU) population. We prospectively compared three groups: Group 1 (January 2003 to June 2004) preprotocol; Group 2 (July 2004 to June 2005) after the start of the protocol that included minimizing CVL use and strict universal precautions; and Group 3 (July 2005 to December 2006) after the addition of a line supply cart and nursing checklist. There were 1622 trauma patients admitted to the trauma ICU during the study period of whom 542 had a CVL. Group 3 had a higher Injury Severity Score (ISS) compared with both Groups 2 and 1 (28.3 ± 13.0 vs 23.5 ± 11.7 vs 22.8 ± 12.0, P = 0.0002) but had a lower BSI rate/1000 line days (Group 1:16.5; Group 2:15.0; Group 3: 7.7). Adjusting for ISS group, three had shorter ICU length of stay (LOS) compared with Group 1 (12.11 ± 1.46 vs 18.16 ± 1.51, P = 0.01). Logistic regression showed ISS ( P = 0.04; OR, 1.025; CI, 1.001-1.050) and a lack of CVL protocol ( P = 0.01; OR, 0.31; CI, 0.13-0.76) to be independent predictors of BSI. CVL protocols decrease both BSI and LOS in trauma patients. Strict enforcement by a nurse preserves the integrity of the protocol.

A central venous line protocol decreases bloodstream infections and length of stay in a trauma intensive care unit population

We evaluated the benefit of a central venous line (CVL) protocol on bloodstream infections (BSIs) and outcome in a trauma intensive care unit (ICU) population. We prospectively compared three groups: Group 1 (January 2003 to June 2004) preprotocol; Group 2 (July 2004 to June 2005) after the start of the protocol that included minimizing CVL use and strict universal precautions; and Group 3 (July 2005 to December 2006) after the addition of a line supply cart and nursing checklist. There were 1622 trauma patients admitted to the trauma ICU during the study period of whom 542 had a CVL. Group 3 had a higher Injury Severity Score (ISS) compared with both Groups 2 and 1 (28.3 +/- 13.0 vs 23.5 +/- 11.7 vs 22.8 +/- 12.0, P = 0.0002) but had a lower BSI rate/1000 line days (Group 1: 16.5; Group 2: 15.0; Group 3: 7.7). Adjusting for ISS group, three had shorter ICU length of stay (LOS) compared with Group 1 (12.11 +/- 1.46 vs 18.16 +/- 1.51, P = 0.01). Logistic regression showed ISS (P = 0.04; OR, 1.025; CI, 1.001-1.050) and a lack of CVL protocol (P = 0.01; OR, 0.31; CI, 0.13-0.76) to be independent predictors of BSI. CVL protocols decrease both BSI and LOS in trauma patients. Strict enforcement by a nurse preserves the integrity of the protocol.

Elderly Patients with Pelvic Fracture: Interventions and Outcomes

We examined the outcome of elderly trauma patients with pelvic fractures. Patients 65 years of age and older (elderly) with pelvic fractures were retrospectively compared with patients younger than 65 years with pelvic fractures and also with elderly patients without fracture. Over the study period, 1223 patients sustained a pelvic fracture (younger than 65 years, n = 1066, 87.2%; elderly, n = 157,12.8%). These patients were also compared with 1770 elderly patients with blunt trauma without fracture. Although the pelvic fracture patients were equally matched for Injury Severity Score (21.2 ± 13.4 nonelderly vs 20.5 ± 13.6 elderly), hospital length of stay was increased in the elderly (12.5 ± 13.1 days vs 11.5 ± 14.1 days) and they had a higher mortality rate (20.4% [32 of 157] vs 8.3% 88 of 1066]). The elderly without fracture also had a higher mortality rate when compared with the younger patients (10.9% [191 of 1760]; P < 0.03). The elderly were more likely to die from multisystem organ failure (25.0% [eight of 32] vs 10.2% [nine of 88]), whereas the nonelderly group was more likely to die from exsanguination (45.5% [40 of 88] younger than 65 years vs 21.9% [seven of 32] 65 years or older; P < 0.05). Elderly patients with pelvic fracture have worse outcomes than their younger counterparts despite aggressive management at a Level I trauma center.

Alcohol's Role on the Reliability of Clinical Examination to Rule Out Pelvic Fractures

The objective of this study was to determine if clinical examination accurately ruled out pelvic fractures in intoxicated patients sustaining blunt trauma A prospective comparison of intoxicated (blood alcohol level [BAL] greater than 0.08 g/dL) to nonintoxicated (BAL less than 0.08 g/dL) patients sustaining blunt trauma was performed between February 2004 and March 2007. Clinical factors were compared and subset analysis performed in which patients with factors known to compromise the clinical examination were excluded. Two hundred ninety-six intoxicated patients were compared with 1071 nonintoxicated patients. Intoxicated patients were younger and more often male. Intoxicated patients had a higher heart rate (97.1 beats/min ± 17.9 vs 91.4 beats/min ± 18.7, P < 0.0001) and lower systolic blood pressure (136.2 mmHg ± 21.2 vs 141.9 mmHg ± 26.6, P = 0.0005) than nonintoxicated patients. Intoxicated patients had a lower incidence of pelvic fracture (6.1 vs 10.6%). In subset analysis, the majority of the intoxicated patients did not have exclusion factors on examination and could be evaluated (66.6%). There were eight pelvic fractures diagnosed in this group and no missed injuries on clinical examination (sensitivity 100%). Clinical examination was not compromised by intoxication. Routine pelvic x-rays are not needed in the alert, intoxicated patient sustaining blunt trauma.

Alcohol's role on the reliability of clinical examination to rule out pelvic fractures

The objective of this study was to determine if clinical examination accurately ruled out pelvic fractures in intoxicated patients sustaining blunt trauma A prospective comparison of intoxicated (blood alcohol level [BAL] greater than 0.08 g/dL) to nonintoxicated (BAL less than 0.08 g/dL) patients sustaining blunt trauma was performed between February 2004 and March 2007. Clinical factors were compared and subset analysis performed in which patients with factors known to compromise the clinical examination were excluded. Two hundred ninety-six intoxicated patients were compared with 1071 nonintoxicated patients. Intoxicated patients were younger and more often male. Intoxicated patients had a higher heart rate (97.1 beats/min +/- 17.9 vs 91.4 beats/min +/- 18.7, P < 0.0001) and lower systolic blood pressure (136.2 mmHg +/- 21.2 vs 141.9 mmHg +/- 26.6, P = 0.0005) than nonintoxicated patients. Intoxicated patients had a lower incidence of pelvic fracture (6.1 vs 10.6%). In subset analysis, the majority of the intoxicated patients did not have exclusion factors on examination and could be evaluated (66.6%). There were eight pelvic fractures diagnosed in this group and no missed injuries on clinical examination (sensitivity 100%). Clinical examination was not compromised by intoxication. Routine pelvic x-rays are not needed in the alert, intoxicated patient sustaining blunt trauma.

Anticoagulation and the elderly head trauma patient

We sought to determine the effect of anticoagulation therapy on outcomes in elderly patients with closed head injury. We retrospectively reviewed elderly closed head injury patients (> or = 65 years) comparing 52 patients on warfarin (AC) with 439 patients not on warfarin (NAC) with subsequent 1:3 propensity matching used to analyze comparable groups. The overall AC group had a higher head abbreviated injury score (AIS) (4.0 +/- 0.7 vs 3.8 +/- 0.7, P = 0.04) compared with the NAC group. After propensity matching, 49 AC patients were compared with 147 NAC patients who were similar for age, gender, injury severity score, and head AIS. Admission INR was higher in the AC group compared to the NAC group (2.5 +/- 1.3 vs 1.1 +/- 0.3, P < 0.0001) and the AC group had a higher mortality rate (38.8% AC (19/49) vs 23.1% NAC (34/147), P = 0.04). In the AC group, survivors and nonsurvivors had similar repeat International Normalized Ratio (INR) values (1.57 +/- 0.65 survivors vs 1.8 +/- 0.72 nonsurvivors, P = 0.31). The AC group experienced greater morbidity after trauma and had higher mortality rates than their NAC counterparts. Prevention of injury and more selective use of warfarin in this patient population are essential to decrease mortality.

Clinical examination is superior to plain films to diagnose pelvic fractures compared to CT

We prospectively compared clinical examination (CE) with plain films (PXR) and both tools with CT in patients sustaining blunt trauma. There were 1388 patients who had both PXR and CT of whom 168 (12.1%) were diagnosed with a fracture by CT. CE findings most predictive of fracture included age (OR, 1.025; CI, 1.011-1.039), hip pain (OR, 4.971; CI, 2.508-9.854), internal rotation of the leg (OR, 4.880; CI, 1.980-12.027), or tenderness to palpation over the sacrum (OR, 2.297; CI, 1.144-4.612), over the right or left hip (OR, 3.626; CI, 1.823-7.214), or diffusely throughout the pelvis (OR, 16.445; CI, 4.277-63.237). These factors were still predictive of pelvic fractures even in patients with a Glasgow Coma Scale score less than 13. There were 136 fractures identified by PXR all of which were identified by CE (sensitivity 100% [136 of 136], negative predictive value 100% [619 of 619]). There were six patients with negative clinical examinations and positive CTs (sensitivity 96.4% [162 of 168], negative predictive value 99.03% [613 of 619]), none of which were hemodynamically significant. The sensitivity for PXR compared with CT was 79.17 per cent (133 of 168) and the NPV was 97.2 per cent (1217 of 1252). CE is a reliable way to diagnose pelvic fractures and PXR is a poor screening tool for these injuries compared with CT. Because the majority of patients undergo CT after blunt trauma, routine screening radiographs should be eliminated.

The effect of anemia and blood transfusions on mortality in closed head injury patients

BACKGROUND

The purpose of this study was to determine if anemia in isolated head trauma patients results in a higher mortality rate that would justify a more liberal use of blood transfusions.

METHODS

A retrospective review of isolated blunt head trauma patients was performed between January 2001 and December 2006. Comparisons were made between survivors and nonsurvivors regarding demographics, laboratory values, transfusions received, and lengths of stay.

RESULTS

There were 788 patients with 735 survivors who were significantly younger (46.3 y +/- 21.5 survivors versus 68.9 y +/- 18.8 nonsurvivors, P < 0.0001) and less injured [(ISS: 14.7 +/- 5.2 survivors versus 23.2 +/- 4.7 nonsurvivors, P < 0.0001), (head abbreviated injury severity: 3.7 +/- 0.7 survivors versus 4.7 +/- 0.5 nonsurvivors, P < 0.0001)] than those who died (n = 53). The survivors also had shorter lengths of stay (days) [(ICU: 2.4 +/- 4.2 versus 5.6 +/- 11.7, P = 0.03), (hospital: 6.3 +/- 9.8 versus 7.8 +/- 14.8, P = 0.02)]. Multivariate logistic regression showed age (OR 1.063, CI 1.042-1.084), ISS (OR 1.376, CI 1.270-1.491), minimum hemoglobin (OR 0.855, CI 0.732-1.000), and total blood products transfused (OR 1.073, CI 1.008-1.142) to be independent predictors of mortality with an ROC of 0.942. Outcome was independent of the operative procedures, hematocrit and packed red blood cells transfused at 24, 48, and 72 h. Hemoglobin levels of <8 mg/dL were more predictive of death than >8 mg/dL (P = 0.01).

CONCLUSIONS

This study supports the need to balance mild anemia with judicious blood product use in the head trauma patient. Given the risk with blood product use, each transfusion should be carefully considered and the patient re-evaluated regularly to determine the need for further intervention.

Computed Tomographic Angiography for the Diagnosis of Blunt Carotid/Vertebral Artery Injury

OBJECTIVE

Computed tomographic angiography (CTA) by 16-channel multidetector scanner is increasingly replacing conventional digital subtraction angiography (DSA) for diagnosing or excluding blunt carotid/vertebral injuries (BCVI). To date there has been only 1 study in which all patients received both examinations. That study reported a high accuracy for 16-detector CTA. The current prospective parallel comparative study aims at validating this high accuracy and examining the rates of evaluability of CTA performed with a 16-detector scanner with image reconstruction by modern imaging software.

METHODS

Patients at risk for BCVI (facial/cervical-spinal fractures; unexplained neurologic deficit; anisocoria; lateral neck soft tissue injury; clinical suspicion) underwent both CTA (16-channel multidetector scanner) and DSA. Results of the 2 studies and the clinical course were prospectively recorded.

RESULTS

During the 40-month study period ending March 2007, approximately 7000 blunt trauma patients were evaluated and of these 119 (1.7%) consecutive patients meeting inclusion criteria were screened by CTA. Ninety-two patients underwent confirmatory DSA. Twenty-three (22%) DSA identified 26 BCVI (vertebral, 13; carotid, 13). Among these 23 CTAs, 17 identified 19 BCVIs (vertebral, 10; carotid, 9) (true positives), and 6 failed to identify 7 BCVIs (vertebral, 3; carotid, 4) (false negatives). Sixty-nine of the 92 DSA were normal. Of these 69 CTAs, 10 were falsely suspicious for 11 BCVIs (vertebral, 7; carotid, 4) (false positives), and 56 were normal (true negatives). The remaining 3 CTAs were nonevaluable (mistimed contrast, 1; streak artifact, 2). Sixteen of 89 (18%) evaluable CTAs, were suboptimal (mistimed contrast, 9; streak artifacts, 4; motion artifact, 2; body habitus, 1). Excluding the 3 nonevaluable CTAs, the sensitivity, specificity, positive and negative predictive values of CTA for diagnosing or excluding BCVI were 74%, 86%, 65%, and 90% respectively. One patient with grade II carotid artery injuries (by CTA and DSA) on antiplatelet agent developed stroke related to carotid artery injuries.

CONCLUSIONS

Current CTA technology cannot reliably diagnose or exclude BCVI. Twenty percent of CTAs are either nonevaluable or suboptimal. Until more data are available and the technique is standardized, the current trend towards using CTA to screen for and/or diagnose these rare but potentially devastating injuries is dangerous.