Right Heart Function in Critically Ill Patients at Risk for Acute Right Heart Failure: A Description of Right Ventricular-Pulmonary Arterial Coupling, Ejection Fraction and Pulmonary Artery Pulsatility Index.

BACKGROUND: The gold standard for right heart function is the assessment of right ventricular-pulmonary arterial coupling defined as the ratio of arterial to end-systolic elastance (Ea/Emax). This study demonstrates the use of the volumetric pulmonary artery (PA) catheter for estimation of Ea/Emax and describes trends of Ea/Emax, right ventricular ejection fraction (RVEF), and pulmonary artery pulsatility index (PAPi) during initial 48hours of resuscitation in the trauma surgical intensive care unit (ICU). METHODS: Review of prospectively collected data for 32 mechanically ventilated adult trauma and emergency general surgery patients enrolled within 6hours of admission to the ICU. Haemodynamics, recorded every 12hours for 48hours, were compared among survivors and non-survivors to hospital discharge. RESULTS: Mean age was 49±20 years, 69% were male, and 84% were trauma patients. Estimated Ea/Emax was associated with pulmonary vascular resistance and inversely related to pulmonary arterial capacitance and PA catheter derived RVEF. Seven (7) trauma patients did not survive to hospital discharge. Non-survivors had higher estimated Ea/Emax, suggesting right ventricular-pulmonary arterial uncoupling, with a statistically significant difference at 48hours (2.3±1.7 vs 1.0±0.58, p=0.018). RVEF was significantly lower in non-survivors at study initiation and at 48hours. PAPi did not show a consistent trend. CONCLUSIONS: Estimation of Ea/Emax using volumetric PA catheter is feasible. Serial assessment of RVEF and Ea/Emax may help in early identification of right heart dysfunction in critically ill mechanically ventilated patients at risk for acute right heart failure.

Evaluation of palliative care training and skills retention by medical students.

BACKGROUND: Training in palliative and end-of-life care has been introduced in medical education; however, the impact of such training and the retention of skills and knowledge have not been studied in detail. This survey study examines long-term follow-up on end-of-life communication skills training, evaluation, and skills retention in medical students. MATERIALS AND METHODS: During the surgical clerkship, all third-year medical students received communication skills training in palliative care using simulated patients. The training involved three scenarios involving diverse surgical patients with conditions commonly encountered during the surgical clerkship. The students used web-based best practice guidelines to prepare for the patient encounters. The following communication abilities were evaluated: (1) giving bad news clearly and with empathy, (2) initiating death and dying conversations with patients and/or their family members, (3) discussing do not resuscitate status and exploring preferences for end-of-life care, and (4) initiating conversations regarding religious or spiritual values and practices. All students were surveyed after 1 year (12-24 mo) to ascertain: (1) the retention of skills and/or knowledge gained during this training, (2) application of these skills during subsequent clinical rotations, and (3) overall perception of the value added by the training to their undergraduate medical education. These results were correlated with residency specialty choice. RESULTS: The survey was sent to all graduating fourth-year medical students (n = 105) in our program, of which 69 students responded to the survey (66% response rate). All respondents agreed that palliative care training is essential in medical school training. Seventy percent of the respondents agreed that the simulated encounters allowed development of crucial conversation skills needed for palliative/end-of-life care communications. The most useful part of the training was the deliberate practice of "giving bad news" (85%). Most of the respondents (80%) indicated retention of overall communication skills with regard to approach and useful phrases. Forty-five percent claimed retention of communication skills surrounding death and dying, and 44% claimed retention of end-of-life preferences/advance directives/do not resuscitate. Relatively few respondents (16%) retained skills regarding religious or spiritual values. There was no correlation between training evaluation/skill retention and the area of residency specialty the students pursued on graduation. CONCLUSIONS: Early training in palliative and end-of-life care communication is feasible and effective during the surgical clerkship. Students highly valued the simulated patient and/or family discussions and retained most of the skills and knowledge from the experiential simulated encounters. However, students felt the skills developed could be reinforced with opportunities to observe their attending physicians or residents leading such discussions and involving students in such discussions as and when appropriate.

Simulation-based end-of-life care training during surgical clerkship: assessment of skills and perceptions.

BACKGROUND: Assessment of interpersonal and psychosocial competencies during end-of-life care training is essential. This study reports the relationship between simulation-based end-of-life care Objective Structured Clinical Examination ratings and communication skills, trust, and self-assessed empathy along with the perceptions of students regarding their training experiences. METHOD: Medical students underwent simulation-based end-of-life care OSCE training that involved standardized patients who evaluated students' communication skills and physician trust with the Kalamazoo Essential Elements Communication Checklist and the Wake Forest Physician Trust Scale. Students also completed the Jefferson Scale of Physician Empathy. Pearson correlation was used to examine the relationship between OSCE performance grades and communication, trust, and empathy scores. Student comments were analyzed using the constant comparative method of analysis to identify dominant themes. RESULTS: The 389 students (mean age 26.6 ± 2.8 y; 54.5% female) had OSCE grades that were positively correlated with physician trust scores (r = 0.325, P < 0.01) and communication skills (r = 0.383, P < 0.01). However, OSCE grades and self-reported empathy were not related (r = 0.021, P = 0.68). Time of clerkship differed for OSCE grade and physician trust scores; however, there was no trend identified. No differences were noted between the time of clerkship and communication skills or empathy. Overall, students perceived simulation-based end-of-life care training to be a valuable learning experience and appreciated its placement early in clinical training. CONCLUSIONS: We found that simulation-based OSCE training in palliative and end-of-life care can be effectively conducted during a surgery clerkship. Moreover, the standardized patient encounters combined with the formal assessment of communication skills, physician trust, and empathy provide feedback to students at an early phase of their professional life. The positive and appreciative comments of students regarding the opportunity to practice difficult patient conversations suggest that attention to these professional characteristics and skills is a valued element of clinical training and conceivably a step toward better patient outcomes and satisfaction.

Traumatic axillary artery pseudoaneurysm treated with intravascular balloon occlusion and percutaneous thrombin injection.

Axillary artery pseudoaneurysms are relatively rare, with few reported cases found in the literature. Furthermore, treatment with percutaneous thrombin injection has not yet been reported. We report the case of a 59-year-old man with a large (10 cm) post-traumatic pseudoaneurysm of the left axillary artery found five weeks after a motorcycle crash. The patient sustained multiple injuries, including fractures of the left scapula and clavicle. Edema was observed at the time of diagnosis. Arteriography with successful ultrasound-guided percutaneous thrombin injection was undertaken. The patient experienced no complications after the procedure.

Palliative and end-of-life care training during the surgical clerkship.

BACKGROUND: In 2000, the Liaison Committee on Medical Education required that all medical schools provide experiential training in end-of-life care. To adhere to this mandate and advance the professional development of medical students, experiential training in communication skills at the end-of-life was introduced into the third-year surgical clerkship curriculum at Wright State University Boonshoft School of Medicine. MATERIALS AND METHODS: In the 2007-08 academic year, 97 third-year medical students completed six standardized end-of-life care patient scenarios commonly encountered during the third-year surgical clerkship. Goals and objectives were outlined for each scenario, and attending surgeons graded student performances and provided formative feedback. RESULTS: All 97 students, 57.7% female and average age 25.6 ± 2.04 y, had passing scores on the scenarios: (1) Adult Hospice, (2) Pediatric Hospice, (3) Do Not Resuscitate, (4) Dyspnea Management/Informed Consent, (5) Treatment Goals and Prognosis, and (6) Family Conference. Scenario scores did not differ by gender or age, but students completing the clerkship in the first half of the year scored higher on total score for the six scenarios (92.8% ± 4.8% versus 90.5% ± 5.0%, P = 0.024). CONCLUSIONS: Early training in end-of-life communication is feasible during the surgical clerkship in the third-year of medical school. Of all the scenarios, "Conducting a Family Conference" proved to be the most challenging.

Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax?

BACKGROUND: Thoracic needle decompression is lifesaving in tension pneumothorax. However, performance of subsequent tube thoracostomy is questioned. The needle may not enter the chest, or the diagnosis may be wrong. The aim of this study was to test the hypothesis that routine tube thoracostomy is not required. METHODS: A prospective 2-year study of patients aged ≥18 years with thoracic trauma was conducted at a level 1 trauma center. RESULTS: Forty-one patients with chest trauma, 12 penetrating and 29 blunt, had 47 needled hemithoraces for evaluation; 85% of hemithoraces required tube thoracostomy after needle decompression of the chest (34 of 41 patients [83%]). CONCLUSIONS: Patients undergoing needle decompression who do not require placement of thoracostomy for clinical indications may be assessed using chest radiography, but thoracic computed tomography is more accurate. Air or blood on chest radiography or computed tomography of the chest is an indication for tube thoracostomy.

Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: During the last century, the management of blunt force trauma to the liver has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma in the Practice Management Guidelines for Nonoperative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the previous Eastern Association for the Surgery of Trauma guideline. METHODS: The National Library of Medicine and the National Institutes of Health MEDLINE database were searched using PubMed (http://www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords liver injury and blunt abdominal trauma. RESULTS: One hundred seventy-six articles were reviewed, of which 94 were used to create the current practice management guideline for the selective nonoperative management of blunt hepatic injury. CONCLUSION: Most original hepatic guidelines remained valid and were incorporated into the greatly expanded current guidelines as appropriate. Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age. Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries. Repeated imaging should be guided by a patient's clinical status. Adjunctive therapies like angiography, percutaneous drainage, endoscopy/endoscopic retrograde cholangiopancreatography and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature.

Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: During the last century, the management of blunt force trauma to the spleen has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the Practice Management Guidelines for Non-operative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the current EAST guideline. METHODS: The National Library of Medicine and the National Institute of Health MEDLINE database was searched using Pub Med (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords splenic injury and blunt abdominal trauma. RESULTS: One hundred seventy-six articles were reviewed, of which 125 were used to create the current practice management guideline for the selective nonoperative management of blunt splenic injury. CONCLUSION: There has been a plethora of literature regarding nonoperative management of blunt splenic injuries published since the original EAST practice management guideline was written. Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and has an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries. Repeat imaging should be guided by a patient's clinical status. Adjunctive therapies like angiography with embolization are increasingly important adjuncts to nonoperative management of splenic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt splenic injuries remain without conclusive answers in the literature.

Comparison of hemodynamic measurements from invasive and noninvasive monitoring during early resuscitation.

BACKGROUND: Measurements obtained from the insertion of a pulmonary artery catheter (PAC) in critically ill and/or injured patients have traditionally assisted with resuscitation efforts. However, with the recent utilization of ultrasound in the intensive care unit setting, transthoracic echocardiography (TTE) has gained popularity. The purpose of this study is to compare serial PAC and TTE measurements and document levels of serum biomarkers during resuscitation. METHODS: Over a 25-month period, critically ill and/or injured patients admitted to a Level I adult trauma center were enrolled in this 48-hour intensive care unit study. Serial PAC and TTE measurements were obtained every 12 hours (total = 5 points/patient). Serial levels of lactate, Δ base, troponin-1, and B-type natriuretic peptide were obtained. Pearson correlation coefficient and intraclass correlation (ICC) assessed relationship and agreement, respectively, between PAC and TTE measures of cardiac output (CO) and stroke volume (SV). Analysis of variance with post hoc pairwise determined differences over time. RESULTS: Of the 29 patients, 69% were male, with a mean age of 47.4 years ± 19.5 years and 79.3% survival. Of these, 25 of 29 were trauma with a mean Injury Severity Score of 23.5 ± 10.7. CO from PAC and TTE was significantly related (Pearson correlations, 0.57-0.64) and agreed with moderate strength (ICC, 0.66-0.70). SV from PAC and TTE was significantly related (Pearson correlations, 0.40-0.58) and agreed at a weaker level (ICC, 0.41-0.62). Tricuspid regurgitation was noted in 80% and mitral regurgitation in 50% to 60% of patients. CONCLUSION: Measurements of CO and SV were moderately strong in correlation and agreement which may suggest PAC measurements overestimate actual values. The significance of tricuspid regurgitation and mitral regurgitation during early resuscitation is unknown.

A comparison of critical care research funding and the financial burden of critical illness in the United States.

OBJECTIVES: To estimate federal dollars spent on critical care research, the cost of providing critical care, and to determine whether the percentage of federal research dollars spent on critical care research is commensurate with the financial burden of critical care. DESIGN AND DATA SOURCES: The National Institutes of Health Computer Retrieval of Information on Scientific Projects database was queried to identify funded grants whose title or abstract contained a key word potentially related to critical care. Each grant identified was analyzed by two reviewers (three if the analysis was discordant) to subjectively determine whether it was definitely, possibly, or definitely not related to critical care. Hospital and total costs of critical care were estimated from the Premier Database, state discharge data, and Medicare data. To estimate healthcare expenditures associated with caring for critically ill patients, total costs were calculated as the combination of hospitalization costs that included critical illness as well as additional costs in the year after hospital discharge. MEASUREMENTS AND MAIN RESULTS: Of 19,257 grants funded by the National Institutes of Health, 332 (1.7%) were definitely related to critical care and a maximum of 1212 (6.3%) grants were possibly related to critical care. Between 17.4% and 39.0% of total hospital costs were spent on critical care, and a total of between $121 and $263 billion was estimated to be spent on patients who required intensive care. This represents 5.2% to 11.2%, respectively, of total U.S. healthcare spending. CONCLUSIONS: The proportion of research dollars spent on critical care is lower than the percentage of healthcare expenditures related to critical illness.

Neurologic outcomes with cerebral oxygen monitoring in traumatic brain injury.

BACKGROUND: Optimizing cerebral oxygenation is advocated to improve outcome in head-injured patients. The purpose of this study was to compare outcomes in brain-injured patients treated with 2 types of monitors. METHODS: Patients with traumatic brain injury and a Glasgow Coma Scale score<8 were identified on admission. A polarographic cerebral oxygen/pressure monitor (Licox) or fiberoptic intracranial pressure monitor (Camino) was inserted. An evidence-based algorithm for treatment was implemented. Elements from the prehospital and emergency department records and the first 10 days of intensive care unit (ICU) care were collected. Glasgow Outcome Scores (GOS) were determined every 3 months after discharge. RESULTS: Over a 3-year period, 145 patients were entered into the study; 81 patients in the Licox group and 64 patients in the Camino group. Mortality, hospital length of stay, and ICU length of stay were equivalent in the 2 groups. More patients in the Licox group achieved a moderate/recovered GOS at 3 months than in the Camino Group (79% vs 61%; P = .09). CONCLUSION: Three-month GOS revealed a clinically meaningful 18% benefit in patients undergoing cerebral oxygen monitoring and optimization. Six-month outcomes were also better. Unfortunately, these important differences did not reach significance. Continued study of the benefits of cerebral oxygen monitoring is warranted.

Diagnosis of blunt intestinal and mesenteric injury in the era of multidetector CT technology--are results better?

BACKGROUND: Blunt Bowel and Mesenteric injuries (BBMI) can present diagnostic difficulties and are occasionally recognized in a delayed fashion. Most studies evaluating these injuries predate multidetector Computerized Tomography (CT) scan technology. We set out to analyze whether the current era of multislice CT scanning has led to changes in the incidence of missed injuries in BBMI or altered the patterns of diagnosis. METHODS: All patients with blunt small and large intestinal injury as well as mesenteric lacerations, recognized in the operating room (OR) between November 2000 and December 2006 were identified from the trauma registry. A 4 slice helical multidetector CT scanner was in use for abdominal CT scans during the first portion of the study (November 2000-July 2005) whereas a 16 slice scanner was in use in the second portion (July 2005-December 2006). Rectal injuries and serosal tears were excluded. RESULTS: Eighty-two patients were identified with BBMI. Twenty-five patients went directly to the OR for laparotomy after a positive Diagnostic Peritoneal Lavage, a positive Focused Abdominal Sonogram or other injury. Of the 57 patients who underwent CT, findings indicating possible BBMI were present in 46 patients (80.7%). These included free fluid without solid organ injury (50.9%), free air (10.5%), active mesenteric bleeding (10.5%), and bowel swelling (5.3%). Eleven patients (19.3%) had delayed bowel or mesenteric injury recognition with the diagnosis ultimately made by repeat CT or in the OR (range, 1-10 days). CONCLUSION: Missed injuries remain common in BBMI even in the current era of multislice CT scanners. Free fluid w/o solid organ injury, though not specific, continues to be an important finding. Adjuncts to CT continue to be necessary for the optimal diagnosis of bowel injuries.

A massive transfusion protocol to decrease blood component use and costs.

HYPOTHESIS: A massive transfusion protocol (MTP) decreases the use of blood components, as well as turnaround times, costs, and mortality. DESIGN: Retrospective before-and-after cohort study. SETTING: Academic level I urban trauma center. PATIENTS AND METHODS: Blood component use was compared in 132 patients during a 2-year period following the implementation of an MTP; 46 patients who were treated the previous year served as historical control subjects. INTERVENTION: Introduction of an MTP that included recombinant factor VIIa for patients with exsanguinating hemorrhage. MAIN OUTCOME MEASURES: The amount of each blood component transfused, turnaround times, blood bank and hospital charges, and mortality rates. RESULTS: After introduction of the MTP, there was a significant decrease in packed red blood cells, plasma, and platelet use. The turnaround time for the first shipment was less than 10 minutes, and the time between the first and second shipments was reduced from 42 to 18 minutes, compared with historical controls. The decreased use of blood products represented a savings of $2270 per patient or an annual savings of $200, 000, despite increased costs for recombinant factor VIIa. There was no difference in mortality in either group; it remained around 50%. Thromboembolic complications did not increase, despite a significant increase in the use of recombinant factor VIIa. CONCLUSIONS: The MTP resulted in a reduction in the use of blood components with improved turnaround times and significant savings. Mortality was unaffected. The use of recombinant factor VIIa did not increase thromboembolic complications in these patients.

Teaching trauma care in India: an educational pilot study from Bangalore.

BACKGROUND: Trauma has become a major cause of death and disability in developing countries. In India, most trauma patients receive initial care at general practitioner-staffed hospitals. We hypothesize that general practitioners (GPs) could improve their knowledge of trauma care after attending an educational course. METHODS: A 2-day trauma course was conducted at a teaching hospital (170 bed) in Bangalore, India. Referral GPs, local surgeons and residents in training attended. A pre-course test was given to assess baseline trauma knowledge. The core didactic sessions included: resuscitation/recognition of shock states, airway prioritization, and evaluation/initial management of head, cardiothoracic, abdominal, pelvic/genitourinary, and thermal injuries. A post-course test was used to assess trauma knowledge obtained from the course. Paired t tests were performed on the test scores and demographic data were stratified by specialty and training status. RESULTS: Of the 44 participants, 32 (72%) met study inclusion criteria: MBBS degree and course completion. The study population was 62.5% male with 47% surgeons and 53% GPs. Residents were 71.8% of the entire group. Overall, the pre- and post- course scores improved from 70.7% +/-11.2 to 87.5% +/-8.9, P = 0.000 (95%CI 12.1, 21.2). There was an increase of mean scores: 21.4% (SD +/-13.7) for GPs and 11.3% (SD +/-8.5) for surgeons (P = 0.02). CONCLUSION: Although GPs had significantly lower pre-course scores than surgeons, at the end of the course, GPs performed as well as surgeons. These findings suggest allocation of limited educational resources for trauma care in India may be best used by GPs.

A case report of phaeohyphomycosis caused by Cladophialophora bantiana treated in a burn unit.

Black molds are a heterogeneous group of fungi that are distributed widely in the environment and that occasionally cause human infection. The spectrum of disease includes mycetomas, chromoblastomycosis, sinusitis, and superficial, cutaneous, subcutaneous, and systemic phaeohyphomycosis. Cladophialophora bantiana, an agent of phaeohyphomycosis, causes rare infections mainly of the central nervous system. Extracerebral involvement is uncommon, and only a few cases have been reported. We present the case of a 32-year-old immunosuppressed female who developed a cutaneous phaeohyphomycosis from C. bantiana. The patient was treated in a burn unit with wound care, surgical excision, grafting, and itraconazole. Patients with complex fungal infections represent yet another population with specialized needs that are adequately met in a verified burn center.

A prospective study of a focused, surgeon-performed ultrasound examination for the detection of occult common femoral vein thrombosis in critically ill patients.

HYPOTHESIS: A focused, surgeon-performed ultrasound examination of the common femoral veins is an accurate screening tool for the detection of common femoral vein thrombosis in high-risk, critically ill patients. DESIGN: A prospective study using a focused ultrasound examination for findings consistent with deep vein thrombosis of the common femoral veins. The results of these examinations were compared with those of duplex imaging or computed tomographic venography studies. SETTING: Surgical intensive care unit. PATIENTS: All critically ill patients who were admitted to the surgical intensive care unit and considered to be at high risk for the development of deep vein thrombosis. MAIN OUTCOME MEASURE: Presence of deep vein thrombosis in the common femoral veins. RESULTS: During a 16-month period, surgeons performed 306 ultrasound examinations on 220 critically ill surgical patients. The results included 295 true negative, 9 true positive, 1 false negative, and 1 false positive, yielding a 90.0% sensitivity, 99.6% specificity, and 99.3% accuracy. CONCLUSION: A focused, surgeon-performed ultrasound examination is a rapid and accurate screening method to detect common femoral vein thrombosis in critically ill patients as well as to examine those patients in whom pulmonary embolism is strongly suspected.

A two institution experience with 226 endoscopically placed jejunal feeding tubes in critically ill surgical patients.

BACKGROUND: Early jejunal feeding after surgery or trauma reduces infectious complications. Although not ideal gastric and postpyloric feedings are often used, however, because of difficulty in placing feeding tubes distal to the ligament of Treitz (LOT). Our hypothesis was that feeding tube placement distal to the LOT can be accomplished using a bedside transendoscopic technique. METHODS: Transendoscopic jejunal (TEJ) tube placement and TEJ tubes inserted simultaneously through percutaneous gastrostomy (PEG) tubes (PEG/TEJ) were attempted to be placed distal to the LOT. RESULTS: In all, 226 feeding tubes (185 TEJ, 41 PEG/TEJ) were placed in 179 trauma and 47 nontrauma patients over 3 years (August 20, 1998 to July 15, 2001). Tube location was jejunal in 93.8% of trauma patients, 76.6% of nontrauma patients, and 90.3% of all patients. (Confidence intervals were 89.3% to 96.5%, 62.8% to 86.4%, and 85.7% to 93.5%). Days of total parenteral nutrition were reduced 71.3% in trauma patients, 22.8% in nontrauma patients, and 45% overall at one institution. CONCLUSIONS: Bedside TEJ and PEG/TEJ placement is safe and successful in placing feeding tubes distal to the LOT in more than 90% of critically ill surgical patients.

A prospective study for the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs.

BACKGROUND: A delayed diagnosis of injury to cervicothoracic vessels from blunt trauma may cause significant adverse sequelae. The association of a cervicothoracic seat belt sign with such an injury is unknown. METHODS: Algorithms were prospectively studied for the detection of occult vascular injury in patients with cervicothoracic seat belt signs. Patients with neck seat belt signs underwent arteriography or computed tomographic angiography (CTA). Those with thoracic seat belt signs underwent aortography/arteriography if a ruptured thoracic aorta or injury to a great vessel was suspected or a neurovascular abnormality was present. RESULTS: During a 17-month period, 797 patients were admitted to the trauma service secondary to motor vehicle crashes. One hundred thirty-one (16.4%) had cervical or thoracic seat belt signs. Four (3%) of the patients had carotid artery injuries, the presence of which was strongly associated with a Glasgow Coma Scale score < 14, an Injury Severity Score > 16 (p < 0.0001), and the presence of a clavicle and/or first rib fracture (p < 0.0037). Of the remaining patients, 17 had thoracic trauma. There were no vascular injuries in the children and only one had thoracic trauma. CONCLUSION: The algorithms are safe and accurate for the detection of cervicothoracic vascular injury in adult and pediatric patients with seat belt signs. The cervicothoracic seat belt mark and an abnormal physical examination are an effective combination in screening for cervicothoracic vascular injury.