Analysis of American College of Surgeons trauma consultation program.

OBJECTIVE: To identify the criteria deficiencies found during peer consultation of hospitals and the relationship to subsequent verification. METHODS: Between September 1987 and December 1992, 52 hospitals had consultation visits using American College of Surgeons criteria. Each report was studied for deficiencies, frequency of deficiencies, and relationship to verification. RESULTS: There are 108 American College of Surgeons criteria. Thirty-five different criteria deficiencies were found. The number of deficiencies per hospital ranged from zero to 12. The more frequent deficiencies included a lack of the following: quality improvement, 35 (67%); trauma service, 20 (38%); trauma surgeon in emergency department, 20 (38%); 24-hour operating room availability, 17 (33%); trauma registry, 17 (33%); trauma continuing medical education, 16 (31%); trauma director, 15 (29%); computed tomography technician in hospital, 15 (29%); research, 14 (27%); trauma coordinator, 14 (27%); and neurosurgeon availability, 13 (25%). No hospital that lacked commitment of surgeons (n = 12) or hospital (n = 3) requested a verification visit. Twenty-four hospitals (46%) achieved verification by February 1994. Twenty-eight hospitals had six or fewer deficiencies, with 19 (68%) verified. Twenty-four hospitals had seven or more deficiencies, with only five (21%) subsequently verified. Verification visits followed consultation by 3 to 52 months. Two hospitals with nine deficiencies were verified after 30 and 48 months, although one failed its first verification visit. CONCLUSIONS: American College of Surgeons consultation assists hospitals to identify their trauma center capability and appears to improve their ability to pass subsequent trauma center verification. Most criteria deficiencies are correctable. Lack of commitment by the surgeons or hospital is difficult to correct. There is an inverse relationship between the number of deficiencies and subsequent verification.

American College of Surgeons Verification/Consultation Program: analysis of unsuccessful verification reviews.

UNLABELLED: This study was designed to document the reasons hospitals have been unsuccessfully peer reviewed as potential trauma centers. METHOD: 120 trauma center reviews were performed by a peer review program between September 1987 and December 1992 using the American College of Surgeons (ACS) criteria. Fifty-four hospitals had criteria deficiencies. These reviews were studied for criteria deficiencies for each hospital with documentation of frequency and relationship to re-review outcome. RESULTS: There are 108 ACS criteria. The 54 hospitals had various combinations of 28 different criteria deficiencies. Deficiencies ranged from 1 to 15 per hospital. Thirty-one hospitals underwent a second review. Twenty-five hospitals had corrected the deficiencies and were verified. No hospital with over 8 deficiencies was subsequently verified. The Quality Improvement program was the most common deficiency (74%) and was correctable (50%). Other frequent deficiencies were no trauma service (46%), no surgeons in ED (41%), inadequate neurosurgeon response (35%), no trauma coordinator (31%), no trauma registry (28%), lack of surgical commitment (26%), and lack of 24 hour OR availability (24%). The lack of surgeon or hospital commitment accounted for most of the 28 criteria deficiencies. Subsequent verification was notably poorer for hospitals seeking verification for the purpose of designation versus verification only (29% versus 75%). Only 1 hospital with a prior ACS consultation visit failed the first verification review. CONCLUSIONS: A limited but critical set of criteria enable a hospital to function as a trauma center. Trauma quality improvement is a poorly understood but a correctable issue. Surgical and hospital commitment are essential for verification. Prior consultation may be of benefit.

Abdominal surgical wound infection is lowered with improved perioperative enterococcus and bacteroides therapy.

Perioperative antibiotics decrease surgical wound infection (SWI) in trauma patients requiring abdominal exploration. This investigation evaluated 24 hours of cefoxitin or ampicillin/sulbactam used for early therapy in such patients. Patients were randomly assigned to one of two treatment groups. The primary endpoint evaluated was SWI, which was defined as purulent drainage or active wound treatment. Five hundred ninety-two patients were evaluated: 283 received ampicillin/sulbactam and 309 received cefoxitin. The incidence of wound infection among the ampicillin/sulbactam patients was 2% and among cefoxitin patients it was 7% (p < 0.004). The cefoxitin patients with colon injuries were analyzed (p < 0.007). The major difference between the two groups was an increased incidence of enterococcal infections in the cefoxitin-treated patients. A single broad-spectrum antibiotic given for 24 hour perioperatively effectively controls SWI. Use of ampicillin/sulbactam results in a significantly lower SWI rate than use of cefoxitin, which may be a result of improved enterococcal and Bacteroides coverage.

Computed tomography in the evaluation of children with blunt abdominal trauma.

OBJECTIVE: This study determined the sensitivity, specificity, and accuracy of CT in pediatric patients with blunt trauma. Correlation of the CT-identified injuries and intraoperative findings with comparison to the results of DPL was performed. SUMMARY BACKGROUND DATA: Clinical evaluation frequently is unreliable in determining the presence of intra-abdominal injury in children with blunt trauma. Peritoneal lavage has been used to establish the need for operative intervention and has been found to be safe, efficient, and reliable (98%). In many institutions, abdominal CT scans are used to evaluate these children. Because most reports involve nonoperative management, operative confirmation of CT-identified injuries is available only for those children in whom nonoperative treatment is unsuccessful. METHODS: Sixty children sustaining blunt abdominal trauma were included in the study. CT scans with both oral and IV contrast were performed before open lavage, and positive results were confirmed by operation in 18 patients. RESULTS: CT had a sensitivity of 67%, however, only 60% of the actual organ injuries were identified by the scan. In contrast, DPL has a sensitivity of 94%. Both studies were equally specific (100%). DPL was also more accurate, 98% as compared with 89% for CT. CONCLUSIONS: Although the abdominal CT scan is useful in evaluating children with blunt abdominal trauma, a number of significant injuries were missed. Based on the low sensitivity of the CT, the authors suggest diagnostic peritoneal lavage may offer advantages over CT as the initial study in the evaluation of children with blunt abdominal trauma.

Inner-city trauma centers. Financial burdens or community saviors?

Trauma systems have proved effective in reducing morbidity and mortality rates. Depending on a center's geographic location and patient mix between penetrating and blunt trauma, participation in a system may be a liability or an asset. In general, inner-city hospitals tend to see more indigent patients and to have sizeable financial losses. At the same time, they provide an invaluable service to any community, and their ability to do so must be preserved. The two important issues of malpractice and uncompensated care threaten to destroy the very concept of trauma care and therefore pose a serious threat to the health care profession. Solutions are possible, but it will take a significant public awareness and education campaign to elicit the support and initiate the programs that will ensure that every injured patient has an opportunity to receive the best of trauma care. Inner-city hospitals are both a financial burden and a community savior.

Vascular proximity: is it a valid indication for arteriography in asymptomatic patients?

The role of arteriography in asymptomatic patients with penetrating extremity wounds in proximity to major vessels is controversial. This prospective study was designed to evaluate a precise definition of proximity, determine the incidence of positive arteriograms, and correlate angiographic interpretation with operative findings. Proximity was defined as any wound located within 1 cm of a major vessel. Excluded were patients with a pulse deficit, bruit, thrill, history of arterial hemorrhage, expanding hematoma, nerve deficit, fracture, or significant soft-tissue injury. One hundred sixty arteriograms were performed in 146 patients. One hundred forty-three (89.4%) were true-negatives. Seventeen (10.6%) were suggestive of injury. These included seven (4.4%) true-positive arteriograms, six (3.8%) false-positive studies, and four (2.5%) positive arteriograms in patients who were not operated upon. The angiographic report correlated with operative findings in five (38.5%) of 13 patients. These data confirm the low incidence (4.4%) of vascular injury in asymptomatic patients. The use of extremity angiography when proximity is the sole indication in an asymptomatic patient with a normal vascular examination must be questioned.

Management of colon injuries.

The evaluation and management of colon injuries have recently undergone significant changes. The time-honored philosophy of conservative management by repair and diversion is giving way to a more aggressive approach, which includes primary repair of many injuries. The role of colostomy has been challenged by the need for additional operative procedures, patient disability, and rising hospital and medical costs. Based on the current literature, the authors have come to the following conclusions: 1. Primary repair is safe in carefully selected cases. 2. Colostomy should not be abandoned because of a fear of the morbidity associated with its closure. 3. The difference between injuries on the right and the left is questionable and probably not as significant as previously thought. 4. Exteriorized repair frequently requires conversion to colostomy and probably has little indication for use. 5. Short-term perioperative single-antibiotic coverage is sufficient. 6. Use of drains cannot be supported in most instances. 7. Wounds are best left open in patients with significant contamination. Surgical judgment remains the final arbiter in the decision process. These controversies and the debate generated have sharpened the guidelines for that judgment.

Results of venous interposition grafts in arterial injuries.

Controversy continues regarding the use of PTFE versus autogenous vein grafts in the repair of arterial injuries. This study was designed to evaluate the results of a large series of autogenous interposition vein grafts used for arterial trauma. The charts of 191 patients with 192 arterial injuries repaired with an autogenous vein graft were reviewed. Specific areas of interest included graft-related complications such as thrombosis, infection, rupture, incidence of amputation, and mortality. Seventy-six per cent of the injuries were due to penetrating trauma. Forty-five per cent involved the upper and 51% the lower extremity. Shock (B. P. less than 80) occurred in one third of the patients. There were 23 (12%) graft-related complications. Sixteen (8.3%) of the grafts thrombosed. Three of these patients required an amputation and one a nephrectomy. Seven grafts (3.6%) became infected; all seven eventually ruptured. Five of these patients required an amputation. Eighteen patients (9.4%) required amputation; however, only eight (4.2%) of these cases were graft related. One patient died from non-graft-related multiple organ failure, establishing a mortality rate of 0.5%. Based on the data reported in this series, it is concluded that autogenous grafts continue to provide a safe, readily accessible, and effective means by which selected arterial injuries can be repaired.

The role of abdominal CT in the evaluation of stab wounds to the back.

Two hundred five patients with stab wounds to the back were evaluated with CT scans using both oral and IV contrast material. One hundred sixty-nine patients had a negative scan. Thirty (17.8%) of the 169 patients were operated upon because of clinical concern. Injuries were found in two of these patients: a diaphragmatic injury in one and a combined diaphragmatic and liver injury in the other. None of the 139 patients observed developed any sequelae. Twenty of the 33 patients with a positive CT were taken to the operating room where 16 were found to have a significant injury. Seven of these 16 patients had additional injuries not identified on CT. There were four false positive scans. Thirteen patients with a positive scan and two patients with an equivocal scan were observed based upon clinical judgment. Ten of these 15 patients had minor isolated renal or hepatic injuries seen on scan. None of these developed complications. It is concluded that abdominal computed tomography, with a sensitivity of 89%, specificity of 98%, and accuracy of 97% is a reliable study in the evaluation of patients with stab wounds to the back.

Evaluation of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma.

Three hundred one hemodynamically stable patients with equivocal abdominal examinations following blunt abdominal trauma had a CT scan followed by DPL. Both studies were negative in 194 patients (71.6%) and positive in 51 patients (27.1%). Seven of the 51 patients (13.7%) had an additional significant injury at operation that was not seen on the CT scan. Nineteen patients had a negative CT scan, a positive DPL, and a significant injury confirmed at celiotomy. In this group of 19 patients, the CT failed to identify seven splenic, three hepatic, and three small bowel injuries. There were two complications attributed to DPL. Three patients had a false negative DPL. Diagnostic peritoneal lavage continues to be a reliable study (sensitivity--95.9%, specificity--99%, accuracy--98.2%). The CT scan is not as sensitive (sensitivity--74.3%, p less than 0.001; specificity--99.5%, accuracy--92.6%). It is concluded that selective use of both procedures is appropriate as long as one recognizes the inherent limitations of each.

Intra-arterial digital subtraction angiography in the evaluation of peripheral vascular trauma.

The role of intra-arterial digital subtraction angiography (IADSA) in the evaluation of extremity trauma has not been clearly established. Several potential advantages would make IADSA a preferable study to conventional angiography (CA). This retrospective study analyzed 104 major peripheral arteries with suspected injury. Multiplane IADSA studies were compared with conventional angiography of the same vessel in 97 patients. The arteriograms were evaluated by a physician and a radiologist in a double-blinded fashion. IADSA correlated well with CA. Similar findings comparing both studies were noted in 101 of 104 angiograms (97%) (p less than 0.001) in review by the radiologist and in 100 of 104 (96%) (p less than 0.001) by the surgeon. Only one injury confirmed at surgery was not seen on IADSA; this study was read as equivocal by both examiners. These data confirm that IADSA is a reliable and reasonable study for the evaluation of patients with suspected peripheral arterial injury.

Wounds of the extremities in proximity to major arteries: value of angiography in the detection of arterial injury.

The place of angiography in the diagnosis of arterial injuries in cases of penetrating wounds of the extremities has been a source of controversy, especially when the injury is in proximity to the artery but there is no clinical evidence of arterial injury. The positive yield of angiography has been reported to be between 6% and 20%, but most angiographers suspect the yield to be lower. The cost of angiography continues to increase. A retrospective analysis was performed in 507 patients with 534 possible arterial injuries associated with wounds near vessels. Thirty-one arteries were considered by the radiologist to have surgically significant injury. Seven patients did not have surgery. On the basis of surgical findings in 24 patients, there was a true-positive angiographic yield of 3.6% as well as five false-positive angiograms. Angiographic sensitivity was 100%, specificity 99%, accuracy 99%, positive predictive value 85%, and negative predictive value 100%. Ten (2.0%) minor angiographic complications and two (0.4%) major complications occurred. There were three surgical complications in negative surgeries. False-positive angiograms can probably be reduced by more circumspect evaluation of minor abnormalities. However, the 3.6% true-positive yield must be balanced against the complications of surgery and angiography and the associated costs. Although delayed diagnosis and therapy of arterial injury are less satisfactory than early repair, angiography of wounds in proximity to major extremity arteries should be reserved for situations in which exclusion of injury is critical to overall management of the patient.

Assessment of proximity of a wound to major vascular structures as an indication for arteriography.

The use of angiography to evaluate penetrating extremity wounds with proximity to major vascular structures remains controversial. Arteriography in the asymptomatic patient with a penetrating extremity wound is reported to identify arterial injuries in 6% to 21% of patients; however, some injuries may have little clinical importance. This study attempted to determine the value of proximity as an indication for angiography. Five hundred seven asymptomatic patients with 534 penetrating extremity injuries underwent arteriography due to proximity to major vascular structures. Thirty-six arteriograms (6.7%) were positive. Seven patients did not undergo operative exploration, 19 patients (3.6%) had arteriograms, and ten (1.9%) had false-positive arteriograms. The remaining 498 patients had true-negative examination results. Arteriography was associated with 13 complications (2.6%). Proved vascular injury in the clinically asymptomatic patients in our series was extremely low (3.6%). These data make it difficult to justify arteriography due to proximity of injury to major vascular structures. However, it is difficult to abandon exclusion arteriography based on these retrospective data. These observations do suggest that better criteria to define proximity need to be identified.

Perforated gastric ulcers. A plea for management by simple closures.

One hundred seven patients with perforated gastric ulcers were treated by either simple closures (omental patches, 81 patients; primary suture without patches, 13 patients; or ulcer excisions with closures, two patients) or primary gastric resections (11 patients). The latter were performed when ulcers were too large to be treated by simple closures. The mortality rate after omental patches or ulcer excisions with closures was 12%, while that following primary gastric resections was 45%. Patients who underwent closures with suturing only had a mortality rate of 62%, which was significantly higher than the mortality rate following patch closures. Gastric outlet obstructions developed following 15% of simple closures of prepyloric ulcers. Closures of perforated gastric ulcers with omental patches or ulcer excisions can be undertaken with low mortality and morbidity rates. Primary gastric resections are reserved for patients with ulcers that are large or located in the prepyloric area.

Community planning for medical support of a national political convention.

A large political gathering such as the 1984 Republican National Convention provided the ingredients necessary to challenge a community's medical system. A committee consisting of representatives from the city, the county hospital district, the Dallas County Medical Society, and the American Red Cross coordinated their efforts toward developing a comprehensive plan to provide medical support for all aspects of the convention. Provisions to deal with the following potential problems included: 1) the extreme heat; 2) security; 3) massive crowds on the convention floor; 4) the area in which the demonstrators were staying as well as the area in which the demonstrations were to occur; 5) special requirements for visiting dignitaries; and 6) terrorism. Eighty patients were seen in the protest area. Thirty-nine patients were treated by the Red Cross, and 518 patients were seen in the convention center. Ten patients required transportation to the hospital. Organization, coordination, and cooperation of all personnel and appropriate agencies helped ensure a smooth operation.

Urine dipstick vs. microscopic urinalysis in the evaluation of abdominal trauma.

This study was designed to assess the accuracy of the urine dipstick and its ability to predict injury to the urinary tract when compared to routine urinalysis: 1,485 patients had dipstick and microscopic urinalysis performed as part of their evaluation for blunt and penetrating trauma. Dipstick analysis was recorded as either positive or negative. Microhematuria was defined as greater than 0-1 RBC/HPF on microscopic analysis. Blunt trauma accounted for 1,347 (91%) of the patients and penetrating injuries accounted for 138 cases (9%): 1,209 (81.4%) of the specimens were dipstick negative, and 276 (18.6%) were dipstick positive. False negative results, consisting of a negative dipstick reading and greater than 1 RBC/HPF on microscopic analysis occurred in 100 (6.9%) of the cases. False positive dipstick readings occurred in 64 (4.3%) of the patients. There were no cases of a missed injury in the group of 100 false negatives. Cost savings by conversion to the use of dipsticks would have saved our institution about $63,000 per year. It is concluded that the urinary dipstick is a safe, accurate, and reliable screening test for the presence or absence of hematuria in patients sustaining either blunt or penetrating abdominal trauma.

Diagnosis of penetrating cervical esophageal injuries.

Arterial injuries pose the greatest early threat to the patient with penetrating neck trauma and esophageal injuries, the greatest late threat. Clinical evaluation reliably identifies 80 percent of esophageal injuries, which, in our opinion, is not adequate. In 118 minimally symptomatic or asymptomatic patients with penetrating neck trauma, the combination of esophagography with esophagoscopy identified all 10 esophageal injuries in 118 patients with penetrating neck trauma. These data suggest that patients with penetrating neck trauma and minimal clinical findings should be initially evaluated with arteriography and esophagography. If the results of arteriography or esophagography are positive, then neck exploration should be performed. If the results of esophagography are equivocal, then rigid esophagoscopy should be performed. If all test results are negative, then observation is justified.