Incomplete caval protection following suprarenal caval filter placement--a case report.

Inferior vena cava filters are increasingly utilized to prevent pulmonary emboli originating from lower extremity, pelvis, or caval thromboses. Unique indications exist for filter placement in the suprarenal portion of the vena cava. The largest reported experience in suprarenal position has involved the use of the Greenfield filter. Although unique in design, little differences have been described between the stainless steel and titanium version of this device. The authors present a case report of incomplete caval protection after successful placement of a stainless steel Greenfield filter in the suprarenal cava. Subtle differences between the titanium and the stainless steel Greenfield filter may exist and should be taken into consideration for placement in the suprarenal cava. Physiologic conditions supporting this premise are described. Further investigation between the two filter types appears justified.

Pressure control inverse ratio ventilation in the treatment of adult respiratory distress syndrome in patients with blunt chest trauma.

The objective of this study was to evaluate the efficacy of pressure control inverse ratio ventilation (PCIRV) in improving oxygenation in trauma patients with adult respiratory distress syndrome (ARDS) and to assess the potential risks associated with this form of treatment. This was a cohort study assessing the trends in hemodynamic and ventilatory parameters after the initiation of PCIRV, conducted at a community Level I trauma center intensive care unit. The study comprised 15 trauma patients developing severe, progressive ARDS [two or more of the following criteria: positive end-expiratory pressure (PEEP) >10 cm H2O; arterial partial pressure of oxygen divided by fraction of inspired oxygen (PaO2:FiO2) ratio <150; and peak inspiratory pressure (PIP) >45 cm H2O]: ten due to blunt chest injuries, three due to sepsis, and two due to fat emboli syndrome. PCIRV was initiated. Main outcome measures were PIP, PEEP (total, auto), oxygen saturation, cardiac index, oxygen delivery, PaO2:FiO2 ratio, compliance, evidence of complications of PCIRV, and mortality. Within 24 hours of conversion to PCIRV, the patients stabilized and the mean PaO2:FiO2 ratio rose from 96.3+/-57.8 to 146.8+/-91.1 (P<0.05) and PIP fell from 47.9+/-13.8 to 38.8+/-8.4 cm H2O; auto-PEEP increased from 0.5+/-1.9 to 7.5+/-5.6 cm H2O (P<0.05); oxygen delivery index remained stable (563+/-152 to 497+/-175 mL/min/m2); three patients developed evidence of barotrauma, one patient developed critical illness polyneuropathy, and two patients died (13%). PCIRV is an effective salvage mode of ventilation in patients with severe ARDS, but it is not without complications. Auto-PEEP levels and cardiac index should be monitored to ensure tissue oxygen delivery is maintained.

Traditional criteria for observation of splenic trauma should be challenged.

Age less than 55 years, normal Glasgow Coma Score (GCS), and absence of hypotension are traditional criteria for the selection of adult patients with blunt splenic trauma for observation. The objective of this study is to challenge these criteria. Two hundred twelve patients who presented with blunt splenic injury between 1992 and 1997 were identified from the Trauma Registry at our Level I trauma center. The patients were divided into three groups: 100 patients (47%) were observed, 108 (51%) underwent immediate splenorrhaphy or splenectomy, and 4 (2%) failed observation. The three groups were compared by participants' ages, GCSs, and histories of hypotension. No statistical differences were noted between the successfully observed patients and those requiring immediate surgery with respect to these criteria. Of the 4 patients who failed observation, all were younger than 55 years, all had a GCS >12, and all were normotensive. Our findings suggest that traditional criteria used to select patients for splenic trauma observation are not absolute indicators and should be liberalized: patients can be successfully observed despite having criteria that, in the past, would have led to immediate operative intervention.

Improved selection criteria for ordering stat venous ultrasounds from the emergency department.

BACKGROUND: The accuracy and convenience of venous ultrasound (VU) to exclude deep vein thrombosis (DVT) has led to indiscriminate use and low positive yield rates. METHODS: A total of 256 patients were referred from our emergency department (ED) for stat VU during a 2-year period (1995 to 1996). The VUs were interpreted as normal in 198 (77%). Positive findings were discovered in 58 (23%), with DVT accounting for 43 (17%). Retrospective multivariant analysis was used to identify predictive indicators. RESULTS: Unilateral leg swelling/edema identified 36 of 40 (90%) patients with DVT and 8 of 10 (80%) with other thrombotic disorders (saphenous and/or chronic venous thrombosis). A history of leg pain with prior DVT or recent trauma < or =3 days' duration increased DVT duration to 98% (39 of 40). Using these criteria, a 47% charge reduction would have been recognized. CONCLUSIONS: Improving ED screening criteria can safely increase yield rate and reduce charges with minimal loss of VU sensitivity.

Traumatic lumbar hernia: a seat belt injury.

A motor vehicle passenger sustained an acute traumatic lumbar hernia caused by an improperly positioned seat belt. Diagnosis was confirmed on computed tomographic scan, and the defect repaired primarily.

Determination of brain death with use of color duplex scanning in the intensive care unit setting.

OBJECTIVE: To determine if color flow duplex scanning (CFDS) can be used for rapid confirmation of presumed brain death. DESIGN: Pilot cohort study comparison of CFDS with radionuclide cerebral scanning (RCS) as the criterion standard. SETTING: Community-based level I trauma center intensive care unit. PATIENTS: Twenty-four patients who satisfied criteria for presumed brain death. MAIN OUTCOME MEASURE: Confirmation of presumed brain death. RESULTS: CFDS correctly identified 16 of 24 patients as brain dead, confirmed by RCS. Eight patients with brain flow on RCS were also correctly identified by CFDS. Only two of 24 patients survived their severe injuries. CONCLUSIONS: CFDS provides a uniform, cost-effective diagnostic tool for rapid confirmation of clinical brain death with 100% accuracy. Its use should complement RCS, given its rapid interpretation, portability, and economical assessment of presumed brain death.

Risk of pulmonary emboli in patients with pelvic fractures.

Multiply-injured patients with pelvic fractures are recognized to have an increased risk of deep venous thrombosis. The incidence of pulmonary emboli in patients with this injury has been reported to range from 0.5 to 8.3 per cent in several recent reviews. One hundred ninety-eight patients with pelvic fractures treated at a regional trauma center over a 3-year period were reviewed to evaluate the factors associated with an increased risk of clinically evident pulmonary embolism. The mean age SD was 44 24 years; 51 per cent were male, and mean Injury Severity Score (ISS) was 19 15. Eighteen patients (9%) died. Mortality was significantly correlated with ISS (P < 0.05), male sex, and type and severity of fracture but not with age, mechanism of injury, or operative fixation. Four patients (2.0%) had pulmonary emboli. The occurrence of clinically apparent pulmonary emboli correlated only with ISS (ISS < 15 = 0% vs ISS > 15 = 4%, P < 0.05). During the same time period, there were eight (0.2%) pulmonary emboli in 3337 trauma patients without pelvic fracture. This difference is highly significant (P < 0.0001). Pelvic fracture is indicative of severe injury and denotes a population at higher risk for pulmonary emboli than other trauma patients. Intensive screening and prophylactic measures to prevent deep venous thrombosis and subsequent pulmonary emboli should be intensively directed at this population.

Prophylactic placement of vena caval filters: a cautionary note.

Greenfield filter placement in patients without deep venous thrombosis has been performed when such patients were felt to be at high risk for asymptomatic deep venous thrombosis and subsequent embolus. In this group placement is termed "truly prophylactic" to differentiate from placement in a patient with documented deep venous thrombosis which has not yet embolized. A retrospective review of Greenfield filter placement at five Dayton, Ohio, community hospitals over three years revealed 59 filters placed in 58 patients. Of these 90% were placed surgically and 10% percutaneously at an average cost of $4,141.00 per surgical procedure. Indications included traditional as well as true prophylaxis. A low morbidity and no mortality related to filter placement was observed. The high efficacy and safety of filter placement seen at large institutions is also found in our community hospital experience despite placement by physicians who perform the procedure infrequently. Although filter placement in patients at a high risk for silent fatal pulmonary emboli may prevent a rare mortality, widespread use of this modality for pulmonary embolus prophylaxis is costly and not without patient risk. We caution against the use of Greenfield filters for pulmonary embolus prophylaxis in patients without deep venous thrombosis until evidence of superior efficacy compared to other forms of prophylaxis can be demonstrated.