Can routine trauma bay chest x-ray be bypassed with an extended focused assessment with sonography for trauma examination?

The objective of this study was to investigate the feasibility of using ultrasound (US) in place of portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single institution from August 2011 to May 2012 underwent an extended focused assessment with sonography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were compared with CXR and chest computed tomography (CT) scans, when obtained. The average age was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9 per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior, loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.

Ventilator-associated pneumonia: depends on your definition.

Reduction of hospital-acquired infections is a patient safety goal and regularly monitored by Performance Improvement committees. There is discordance between the ventilator-associated pneumonia (VAP) rate reported by the Infection Control Committee (ICC) and that observed by our Trauma Service. To investigate this difference, a retrospective evaluation of cases of VAP diagnosed on a single service was undertaken. A prospectively collected database was queried for VAP in intensive care unit patients between January 2010 and June 2011. This was compared with the list of mechanically ventilated patients provided by the ICC. Comparison for criteria used to diagnose pneumonia, ventilator day of the diagnosis, was recorded. The ICC identified two VAPs from 136 potential patients compared with the Trauma Service identifying 36 VAPs. A difference in diagnostic criteria between the ICC and the Trauma Service focused on use of the National Nosocomial Infection Survey (NNIS) algorithm versus quantitative microbiology from bronchoalveolar lavage specimens. Thirty-five of 36 Trauma Service VAPs were not identified as VAPs by the NNIS algorithm as a result of the chest radiographs. Application of differing definitions of VAP results in markedly different VAP rates. The difference has significant implications as infection rates are increasingly reported as a quality metric.

Screening human immunodeficiency virus-positive men for anal intraepithelial neoplasia.

Squamous cell carcinoma of the anus is rare, but more common in men with human immunodeficiency virus (HIV). We describe our findings in 50 biopsies done on 37 HIV-positive men over 5 years. The men were referred from our HIV clinic for abnormal cytology on anal pap or anal condyloma. Thirty-seven patients were referred from the HIV clinic for abnormal cytology on anal pap or the presence of anal condyloma. Biopsies were done in the operating room using acetic acid to visually localize areas of dysplasia. If no abnormalities were seen, biopsies were taken from each quadrant of the anus. A retrospective review was done for biopsy indication, pathology, recurrence, and correlation with anal pap results. On initial biopsy, anal condyloma conferred the presence of anal intraepithelial neoplasia (AIN) in 64.7 per cent (11 of 17), abnormal paps in 83.3 per cent (10 of 12), and both in 50 per cent (3 of 6). Patients with anal condyloma had AIN in an average of 2.5 quadrants whereas those with abnormal cytology had AIN in 2.3 quadrants. Thirty-four of 50 biopsies showed abnormalities (68%), with AIN present in 32 cases, one case of carcinoma in situ, and one case of invasive carcinoma. Aldara was used nine times with improvement in four cases. In HIV-positive men, the presence of condyloma warrants surgical biopsy. Performing anal cytology on patients with anal condyloma did not increase the rate of positive results. Patients with AIN often had disease in more than two quadrants, making surgical excision problematic.

MRI as an adjunct to cervical spine clearance: a utility analysis.

Cervical spine (CS) injury occurs in 1 to 3 per cent of blunt trauma patients. The goal of this study is to evaluate the use of magnetic resonance imaging (MRI) as an adjunct to CS computed tomography (CT) in the presence of persistent pain with a normal physical examination or obtundation. A retrospective chart review was performed on 389 blunt trauma patients undergoing both CS CT and MRI between 2007 and 2010. Abnormal CT findings were found in 199. The remaining 190 patients with normal CT scans underwent MRI for persistent pain (109), neurologic symptoms (57), or obtundation (24). Motor vehicle crashes predominated (50%) followed by falls (19%) and motorcycle crashes (12%). In the patients with persistent pain, CT showed no acute injury (89%) with subsequent MRI demonstrating ligamentous edema or injury not seen on CT in 12 per cent of patients. No patient required an operation for CS instability. All the obtunded patients demonstrated localizing motion of four extremities. MRI of these patients demonstrated ligamentous edema or injury not seen on CT in 20 per cent of patients. No obtunded patient had CS instability or needed operative intervention. A localizing physical examination in conjunction with normal CS CT safely precludes a CS injury requiring cervical fixation. MRI does not add substantially to this decision-making and the cervical collar can be safely removed.

Cervical spinal cord injury associated with near-drowning does not increase pneumonia risk or mortality.

Body surfing accidents (BSA) can cause cervical spinal cord injuries (CSCIs) that are associated with near-drowning (ND). The submersion injury from a ND can result in aspiration and predispose to pulmonary complications. We predicted a worse outcome (particularly the development of pneumonia) in patients with CSCIs associated with ND. A retrospective review was performed of patients who were treated at Eastern Virginia Medical School for a CSCI resulting from a blunt mechanism. Data collected included basic demographic data, data regarding injury and in-hospital outcomes, and discharge data, including discharge disposition. Statistics were performed using χ(2) and Student t test. In 2003 to 2008, 141 patients were treated for CSCIs with inclusion criteria. Thirty patients (21%) had an associated ND (BSA) and 111 patients (79%) did not (BLT). The cohorts were similar in mean age (BSA, 45 years; BLT, 50 years; P = 0.16) and male gender distribution (BSA, 93%; BLT, 79%; P = 0.13). The cohorts were similar in injury severity using Injury Severity Score (BSA, 22; BLT, 24; P = 0.65). The cohorts were similar in rates of developing pneumonia (BSA, 3%; BLT, 12%; P = 0.31). The rate of infection was significantly higher in the cohort without an associated near-drowning (BSA, 10%; BLT, 32%; P = 0.033). The mean intensive care unit stay (BSA, 3.5 days; BLT, 11.3 days; P = 0.057) and the rate of mortality were similar (BSA, 10%; BLT, 10% P = 0.99). Those patients with an associated ND had a shorter hospital stay (BSA, 5.7 days; BLT, 22.2 days; P = 0.007) and a better chance of being discharged home (BSA, 57%; BLT, 27%; P = 0.004). CSCIs after a BSA do better than their counterparts without an associated ND. CSCIs associated with ND appear to be isolated injuries with minimal pulmonary involvement despite submersion injuries.

The incidence of benign and malignant neoplasia presenting as acute appendicitis.

Acute appendicitis remains the most common surgical emergency encountered by the general surgeon. It is most often secondary to lymphoid hyperplasia, however it can also result from obstruction of the appendiceal lumen by a mass. We sought to review our experience with neoplasia presenting as appendicitis. We retrospectively reviewed all patients admitted with the diagnosis of appendicitis to our Acute Care Surgery Service from July 1, 2007 to June 30, 2009. Patient demographics, duration of symptoms, lab findings, computed tomography findings, and pathology were all analyzed. Over the 2-year period, 141 patients underwent urgent appendectomy. Ten patients (7.1%) were diagnosed with neoplasia on final pathology, including four women and six men with a mean age of 46.9 years and mean duration of symptoms of 12.6 days. Final pathology revealed four colonic adenocarcinoma; three mucinous tumors; one carcinoid; one endometrioma; and one patient had a combination of a mucinous cystadenoma, a carcinoid tumor, and endometriosis of the appendix. Six patients had concurrent appendicitis. Colonic and appendiceal neoplasia are not unusual etiologies of appendicitis. These patients tend to present at an older age and with longer duration of symptoms.

Impact of a monitored program of care on incidence of ventilator-associated pneumonia: results of a longterm performance-improvement project.

BACKGROUND: Ventilator-associated pneumonia (VAP) remains a major source of morbidity, mortality, and expense in the ICU despite therapies directed against it. STUDY DESIGN: A retrospective review of a prospectively developed performance-improvement project monitoring the incidence of VAP in two adjacent ICUs was conducted. In response to an excessive VAP rate, weekly multidisciplinary team meetings were instituted to review data, develop care protocols, and modify care routines. Protocol compliance was monitored daily and feedback provided weekly to the care teams. VAP rates were determined by the institutional Infection Control Committee and reviewed monthly with the ICU multidisciplinary team. Duration of the investigational period was 10 years. RESULTS: A standardized ventilator-weaning protocol was instituted with confirmed 95% use. Additional modifications of care, such as patient positioning, use of specific endotracheal tubes to minimize aspiration of supraglottic secretions, an oral-care regimen, and aggressive antibiotic stewardship were standardized, with a compliance rate >90%. VAP rates dropped from 12.8 per 1,000 patient-days in 1998 to 1.1 in 2007 in the burn trauma ICU and from 21.2 to <1 in the neurotrauma ICU in the same time frame. Also, mean ventilator length of stay decreased from 6 days to 4.2 and from 5.8 days to 4.75 simultaneously in the respective ICUs. Such performance improvement has been sustained since implementation of the program. CONCLUSION: A systematic, monitored program of standardized care protocols can markedly reduce VAP rate in the ICU.

Insulin requirements in the intensive care unit in response to infection.

Infectious complications in the intensive care unit (ICU) are classically identified when an elevated temperature triggers obtaining cultures. Elevated temperature, however, is a nonspecific marker of infection and may occur well into the course of the infection. The goal of this study was to evaluate whether escalating insulin demands may serve as an earlier marker for infection. A retrospective review of a prospective database from a trauma ICU over a 6-month period was done for all patients who developed infection while in the ICU. All patients in the ICU are placed at admission on an intensive insulin protocol with target blood glucose levels between 80 and 110 mg/dL. Data were collected on infection, insulin needs, blood glucose levels, temperature, white blood cell count, and antibiotic use. Twenty-four infections were identified, with 16 pneumonias, four bloodstream infections, and four urinary tract infections. Twelve of the 24 patients had increasing insulin needs in the 3 days preceding their infection diagnosis, with nine of the 12 requiring continued escalation of insulin needs from preinfection Day 3 to 2 to 1 (D3, D2, D1). In five of the 12 patients, the escalation of insulin dose preceded the elevated temperature, and in three of the 12 patients, the escalation preceded elevation of the white blood cell count above 12. For all 24 patients, the average insulin dose increased steadily, from 1.8 U/hr on D3 preinfection to 2.5 U/hr D2 and 3.1 U/hr D1. Infection does seem to be preceded by escalating insulin demands in many patients. A prospective study to evaluate the value of increased insulin demand as a marker for developing infection is warranted.

Early glucose normalization does not improve outcome in the critically ill trauma population.

Strict control of serum glucose in critically ill patients decreases morbidity and mortality. The objective of this study was to evaluate the effect of early normalization of glucose in our burn and trauma intensive care unit. From January 2002 to June 2005, 290 patients were admitted with serum glucose 150 mg/dL or greater and 319 patients with serum glucose less than 150 mg/dL. The patients with hyperglycemia were more severely injured and more often required operative intervention within the first 48 hours. The patients with hyperglycemia were at increased risk for infection and mortality. Of those 290 patients in the hyperglycemic cohort, 125 patients had early normalization of serum glucose, whereas 165 patients required more than 24 hours to normalize. The early normalization cohort was younger in mean age than the late group, but these 2 groups were similar in injury severity. Correspondingly, there was no difference in the rate of infection. Although hyperglycemia on admission appears to correlate with a worse outcome, early glucose normalization did not affect morbidity and mortality in our critically ill population.

Central line simulation: a new training algorithm.

Recent development of a partial task simulator for central line placement has altered the training algorithm from one of supervised learning on patients to mannequin-based practice to proficiency before patient interaction. There are little data published on the efficacy of this type of simulator. We reviewed our initial resident experience with central line simulation. Education to proficiency using the CentralLine Man simulator is completed by all interns during orientation. At the completion of training, te residents were asked to complete a voluntary, anonymous questionnaire with a 5-point Likert scale as well as open-ended questions. Additionally, the residents were asked to maintain a log of the initial 10 central lines placed. Retrospective review of the questionnaire and logs were done with analysis of simulator experience as well as initial line experience. Seventeen trainees completed the central line simulation course and returned the initial survey. Before the course, the trainees had placed an average of 0.4 internal jugular (IJ) and 1 subclavian (SC) line. On the simulator, an average of 3 SC attempts and 2.5 IJ attempts led to resident comfort with the procedure. On the first attempt, the vessel was accessed after an average of 1.5 SC and 1.9 IJ needlesticks, which improved to 1 SC and 1.3 IJ by the fifth simulated attempt. A total of 4 pneumothorax and 5 carotid sticks were done. Overall, the residents were highly satisfied with the course with an average score of 4.8 for didactics, 4.8 for equipment, 4.5 for the mannequin, and 4.8 for practice opportunity. Nine of the 11 residents who completed logs felt the simulation improved performance on the patient. On the first patient attempt, an average of 1.8 needlesticks was done with an average of 1.3 by the tenth line. For the first patient line documented in the logs, comfort with the anatomy was rated 3.8 with comfort with the procedure rated 2.8. Central line simulation before actual performance on patients is useful and well regarded by the trainees, suggestive of a transference effect. Prospective evaluation is needed to further determine the impact of simulation on resident performance as well as patient outcomes.

Aggressive surveillance and early catheter-directed therapy in the management of intra-abdominal hypertension.

INTRODUCTION: Trauma patients represent a heterogeneous group at risk for the development of both primary and secondary abdominal compartment syndrome (ACS). Our study aims at identifying these individuals early in their course and placing an intra-abdominal catheter to reduce intra-abdominal pressure before the serious hemodynamic consequences of ACS occur. METHODS: During a 10-month period, 12 patients were identified who developed intra-abdominal hypertension. Patients who received 12 L or more of intravenous fluids in the first 24 hours of their resuscitation or received 500 mL/hr of intravenous fluids for more than 4 consecutive hours were considered at risk and had intra-abdominal pressure readings via bladder catheters every 4 hours. After resuscitation, patients were given a physical examination and intra-abdominal pressures were taken every 4 hours or when clinically necessary. When abdominal compartment pressures (ACPs) exceeded 20 mm Hg or the abdominal perfusion pressure (APP = mean arterial pressure-ACP) fell below 50 mm Hg, a diagnostic peritoneal lavage catheter was placed. Fluid volume and type drained, abdominal pressures, heart rate, mean arterial pressure, and pulmonary compliance were recorded. If adequate control of abdominal compartment pressures was not achieved, the patients were managed with a traditional decompressive laparotomy. RESULTS: Readings taken 30 minutes after placement of the peritoneal catheter showed an average decrease in ACP of 8.0 mm Hg (p = 0.01); an increase in APP of 13.8 mm Hg (p = 0.14); an increase in static pulmonary compliance of 8.1 mL/cmH2O (p = 0.16); and an increase in mean arterial pressure of 5.8 mm Hg (p = 0.52). Ten of the twelve patients were managed nonoperatively. Four patients failed to have their APP improve to >50 mm Hg with the catheter. Two of these patients underwent laparotomy, with one survivor and one mortality secondary to infarcted small bowel. Two did not undergo laparotomy, with one dying of cerebral herniation and the other having care withdrawn. Eight of the twelve patients required intra-abdominal catheters early in their admission (in the first 32 hours), with 7 of 8 surviving. Four patients received intra-abdominal catheters later than day 4 in their admission. All of those four patients died, three within 24 hours. Overall, 5 of the 12 patients died. CONCLUSIONS: Intra-abdominal catheter placement is a reasonable first step in the early management of ACS. It may prevent a portion of patients from progressing to hemodynamically significant ACS and prevent the complications of managing an open abdominal wound. Also, the late intra-abdominal hypertension may be a prognostic indicator of an impending rapid clinical deterioration. Further prospective investigation is warranted to determine whether this method reduces overall morbidity and mortality in critically ill patients.