Evaluating blunt abdominal trauma with sonography: a cost analysis.

Ultrasonography (US) is becoming increasingly utilized in the United States for the evaluation of blunt abdominal trauma (BAT). The objective of this study was to assess the cost impact of utilizing US in the evaluation of patients with BAT in a major trauma center. All patients sustaining BAT during a 6-month period before US was used at our institution (Jan-Jun 1993) were compared to BAT patients from a recent period in which US has been utilized (Jan-Jun 1995). The numbers of US, computed tomography (CT), and diagnostic peritoneal lavage (DPL) were tabulated for each group. Financial cost for each of these procedures as determined by our finance department were as follows: US $96, CT $494, DPL $137. These numbers are representative of actual hospital expenditures exclusive of physician fees as calculated in 1994 U.S. dollars. Cost analysis was performed with t test and chi squared test, and significance was defined as P < 0.05. There were 890 BAT admissions in the 1993 study period and 1033 admissions in the 1995 study period. During the 1993 period, 642 procedures were performed on the 890 patients to evaluate the abdomen: 0 US, 466 CT, and 176 DPL (see table) [table: see text]. This compares to 801 procedures on the 1,033 patients in 1995: 552 US, 228 CT, and 21 DPL. Total cost was $254,316 for the 1993 group and $168,501 for the 1995 group. Extrapolated to a 1-year period, a significant (P < 0.05) cost savings of $171,630 would be realized. Cost per patient evaluated was significantly reduced from $285.75 in 1993 to $163.12 in 1995 (P < 0.05). This represents a 43 per cent reduction in per patient expenditure for evaluating the abdomen. By effectively utilizing ultrasonography in the evaluation of patients with blunt abdominal trauma, a significant cost savings can be realized. This effect results chiefly from an eight-fold reduction in the use of DPL, and a two-fold reduction in the use of CT.

Measuring service-specific performance and educational value within a general surgery residency: the power of a prospective, anonymous, Web-based rotation evaluation system in the optimization of resident satisfaction.

BACKGROUND: We used a Web-based evaluation system to institute specific changes to various clinical teaching services in our integrated residency in an effort to optimize the overall quality of the educational experience and measured the resident satisfaction in these rotations. METHODS: Residents rated 8 categories of experience on a scale of 1 to 5 (maximum summation score, 40 points). Data were analyzed by t-test for equality of means. A probability value of less than.05 was considered significant. RESULTS: Compliance with completion of the evaluations was 100%. The Chronbach's alpha reliability coefficient of the tool was 0.826. Tukey's estimate of power to achieve additivity was 1.5. Six under-performing services were re-engineered with prominent effects on 7 postgraduate year (PGY) rotations. On 2 general surgery services at 1 hospital, the workload was redistributed, and a dedicated team teaching time was instituted (PGY-3 [a]: before, 22 points/after, 31 points; P =.003; PGY-3 [b]: before, 25 points/after, 31 points; P =.004; PGY-1: before, 24 points/after, 29 points; P =.07). A general surgery service at another hospital redistributed coverage of the attending surgeons to create a nonteaching service (PGY-1: before, 22 points/-after, 27 points; P =.01). The transplantation service (PGY-3) was examined, and the role of the point was redefined (before, 24 points/after, 31 points; P =.01). One vascular service (PGY-2) redistributed cases and workload (before, 27 points/after, 22 points; P =.07). The vascular PGY-2 position was eliminated and replaced by a mid-level practitioner. The cardiothoracic service (PGY-1) rotation was converted into a preceptorship (before, 23 points/after, 30 points; P =.015). CONCLUSIONS: A web-based clinical rotation evaluation provides a means for the assessment of the impact of programmatic changes while preserving resident anonymity and maintaining accountability.

Beyond requirements: residency management through the Internet.

HYPOTHESIS: An Internet application could collect information to satisfy documentation required by the Residency Review Committee. Beyond replacing a difficult and inefficient paper system, it would collect, process, and distribute information to administration, faculty, and residents. DESIGN: Descriptive study. SETTING: An integrated residency of 18 services at a university teaching hospital with 4 affiliated institutions. PARTICIPANTS: Residency administrators, faculty, and residents. INTERVENTIONS: The application included a procedure recorder, resident evaluation of faculty and rotations, goals and objectives (stratified by service and resident level), and matching faculty evaluation of residents with these goals as competencies. Policies, schedules, research opportunities, clinical site information, and curriculum support were created. MAIN OUTCOME MEASURES: Degree of compliance with Residency Review Committee standards, number of deficiencies corrected, and quantity and quality of information available to administration, faculty, and residents. RESULTS: The Internet system increased resident compliance for faculty and rotation evaluations from 20% and 34%, respectively, to 100%, which was maintained for 22 months. These evaluations can be displayed individually, in summary grids, and as postgraduate year-specific averages. Faculty evaluations of residents can be reviewed throughout the system. The defined category report for procedures, which had deficiencies in the preceding 6 years, had none for the last 2 years. The Internet application provides Accreditation Council for Graduate Medical Education-validated operative logs to regulatory agencies. CONCLUSIONS: A Web-based system can satisfy requirements and provide processed data that are of better quality and more complete than our paper system. We are now able to use scarce time and personnel to nurture developing surgical residents instead of shuffling paper.

Perioperative antibiotic use in high-risk penetrating hollow viscus injury: a prospective randomized, double-blind, placebo-control trial of 24 hours versus 5 days.

BACKGROUND: The purpose of this study was to compare the safety and therapeutic efficacy of a 24-hour versus 5-day course of ampicillin/sulbactam for the prevention of postoperative infections in high-risk patients sustaining hollow viscus injury from penetrating abdominal trauma. METHODS: A total of 317 patients from four Level I trauma centers with penetrating abdominal injuries and at least one hollow viscus perforation each received one preoperative and three postoperative doses of ampicillin/sulbactam 3 g intravenously. After receiving 24 hours of unblinded ampicillin/sulbactam, patients were then randomized into one of two groups. Group 1 received 4 additional days of blinded ampicillin/sulbactam (5 days total of antibiotic), and Group 2 received 4 days of placebo (24 hours of antibiotic). Patients were assessed postoperatively for occurrence of deep surgical-site infections (intra-abdominal abscess, fasciitis, and peritonitis) and superficial (wound) surgical-site infections. Development of nonsurgical-site infections (e.g., pneumonia, urinary tract infection, phlebitis, and cellulitis) was also recorded. Continuous variables were analyzed by analysis of variance and discrete variables by the Cochran-Mantel-Haenszel chi2 test. Multivariate logistic regression analyses were also performed to identify independent risk factors for postoperative infection. RESULTS: A total of 159 patients were randomized into Group 1, and 158 patients were randomized into Group 2. The Injury Severity Score and penetrating abdominal trauma index were 18+/-8 and 21+/-13, respectively, for Group 1 and 18+/-9 and 20+/-15, respectively, for Group 2. A total of 162 (51%) patients sustained one or more colon injuries (82 in Group 1 and 80 in Group 2). There were 16 (10%) surgical-site infections in Group 1 and 13 (8%) surgical-site infections in Group 2 (p = 0.74). Group 1 patients experienced 17 (11%) nonsurgical-site infections, whereas Group 2 had 32 (20%) nonsurgical-site infections. This difference, however, was not statistically significant (p = 0.16). Only the total number of blood units transfused and the presence of a PATI score greater than or equal to 25 were found to be independently associated with the development of a postoperative surgical- and nonsurgical-site infections (p = 0.001 and p = 0.003, respectively). Of note, the presence of a colon injury was not found to be an independent risk factor (p = 0.11) for either surgical or nonsurgical site postoperative infection in our study. CONCLUSION: High-risk patients with colon or other hollow viscus injuries from penetrating abdominal trauma are at no greater risk for surgical-site or nonsurgical-site infection when treated with only a 24-hour course of a broad-spectrum antibiotic.

Patterns of maxillofacial injuries in powered watercraft collisions.

Because of the widespread popularity of water sports, plastic and reconstructive surgeons can expect to manage an increasing number of injuries associated with these activities, particularly those related to powered watercraft vehicles. Although seat belts for motorists and helmets for motorcyclists may be efficacious, such devices currently do not serve a similar role in powered watercraft sports. In this study, a retrospective chart review of 194 consecutive patients who presented to the University of Miami/Jackson Memorial Hospital (Level I trauma center) as a result of powered watercraft collisions is presented. The purpose of this investigation was to assess the incidence, cause, demographics, and available management options for head and neck injuries secondary to powered watercraft. Identified were 194 patients who presented because of watersports-related injuries during the period January 1, 1991, through December 31, 1996. From this group, 81 patients (41.8 percent) sustained injuries directly attributable to powered watercraft collisions, including 41 personal watercraft collisions (50.6 percent), 39 boat collisions (48.1 percent), and 1 airboat collision (1.2 percent). The patient population, as expected, tended to be young and male with an average age of 29 years (range, 8 to 64 years old). Interestingly, 41 of the patients (50.6 percent) who presented to this trauma center as a result of powered watercraft collisions also sustained associated head and neck trauma. Of 74 injuries 24 were facial fractures (32.4 percent), 18 were facial lacerations (24.3 percent), 14 were closed head injuries (18.9 percent), 8 were skull fractures (10.8 percent), 4 were scalp lacerations (5.4 percent), 4 were C-spine fractures (5.4 percent), 1 was an ear laceration (1.4 percent), and 1 was a fatality (1.4 percent). Le Fort fractures were the most commonly identified facial fracture in this series. The number of these injuries seen in hospital emergency rooms will most likely increase in the future as the popularity of water-related recreational activities becomes even more widespread. Based on these findings, it is strongly recommended that future efforts be directed toward the prevention of these injuries through patient education and the eventual development of efficacious and safe protective equipment.

Strategies to prevent organ failure.

The gastrointestinal tract and the generalized inflammatory response initiated by severe injury or infection have been implicated in the pathophysiology of multiple-organ system failure. Once multiple-organ system failure has occurred, treatment focuses on supporting end-organ function. Recent studies have shown, however, that it may be possible to reduce the incidence and prevalence of multiple-organ system failure by controlling the reperfusion injury cascade, normalizing gastrointestinal blood flow and preserving the integrity of the gastrointestinal immune barrier.

The role of computed tomography in selective management of gunshot wounds to the abdomen and flank.

OBJECTIVE: To determine whether computed tomography (CT) is an accurate diagnostic modality for the triage of hemodynamically stable patients with gunshot wounds of the abdomen and flank. METHODS: A chart review of 83 trauma patients for whom abdominal CT was used as initial screening. RESULTS: In 53 patients, CT revealed no evidence of peritoneal penetration, and in 15 patients, there was evidence of either peritoneal penetration or liver injury. There were no false results in these patients. Among 15 patients with questionable peritoneal penetration, cavitary endoscopy was performed in 11 and exploratory laparotomy was performed in 3, and 1 patient was initially observed and subsequently underwent exploratory surgery for a missed colonic injury. CONCLUSION: In selected centers and in hemodynamically stable patients with abdominal and flank gunshot wounds, abdominal CT can be an effective and safe initial screening modality to document the presence or absence of peritoneal penetration and to manage nonoperatively stable patients with liver injuries. If there is any question of peritoneal penetration, cavitary endoscopy should be part of the protocol of nonoperative management.

Immune responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy.

OBJECTIVES: Pneumococcal polysaccharide vaccine is given after emergency splenectomy for trauma to lessen the risk of overwhelming postsplenectomy sepsis. This study was undertaken to determine optimal timing of vaccine administration as determined by serum type-specific polysaccharide antibody concentration titer and functional activity of the resulting antibodies. METHODS: Fifty-nine consecutive patients undergoing splenectomy after trauma were randomized to receive pneumococcal vaccine postoperatively at 1, 7, or 14 days. Immunoglobulin G serum antibody concentrations against serogroup 4 and serotypes 6B, 19F, and 23F were measured before vaccination and 4 weeks postvaccination. Antibody concentrations were determined by enzyme-linked immunosorbent assay, and functional antibody by opsonophagocytosis. Results were compared with a normal adult control group (n = 12). RESULTS: Postvaccination enzyme-linked immunosorbent assay immunoglobulin G antibody concentrations for all serogroups and serotypes studied were not significantly different in splenectomized patients and control subjects. Postvaccination functional antibody activity was significantly reduced in early vaccination groups (serotype 6B excepted). However, with the exception of 19F, all titers for the 14-day group approached those of the control subjects (p > 0.05). Fold-increases of opsonophagocytic titers for serogroup 4 and serotypes 6B and 19F showed progressive increases with delay in vaccination. Except for serotype 23F, the number of postsplenectomy patients with opsonophagocytic titers <64 significantly decreased with a delay in vaccination (14 days). CONCLUSIONS: Postvaccination immunoglobulin G serum antibody concentrations were not significantly different from normal control subjects regardless of the time of vaccination (1, 7, or 14 days). Although concentrations approach normal, functional antibody activity was significantly lower. Better functional antibody responses against the serogroup and serotypes studied seemed to occur with delayed (14-day) vaccination.

Failure of splanchnic resuscitation in the acutely injured trauma patient correlates with multiple organ system failure and length of stay in the ICU.

INTRODUCTION: The purpose of our study was to evaluate the relationship between the state of splanchnic perfusion and morbidity and mortality in the hemodynamically unstable trauma patient acutely resuscitated in the ICU. METHODS: Gastric intramucosal pH (pHi) was monitored in a blinded fashion in 19 consecutive critically ill trauma patients with evidence of systemic hypoperfusion (arterial pH [pHa] <7.35, base excess >2.3 mmol/L, lactic acid >2.3 mEq/L) who received right heart catheters to guide resuscitation and subsequent hemodynamic monitoring. DESIGN: Prospective randomized consecutive series with retrospective analysis of data. SETTING: University hospital, surgical ICU. RESULTS: The mean values of APACHE II (acute physiology and chronic health evaluation) Injury Severity Score, pHa, arterial base excess, cardiac index, oxygen delivery index, and oxygen consumption index by 24 h were similar (Student's t test, p>0.1) between survivors and nonsurvivors and between those who developed at most a single (SOF) vs multiple organ system failure (MOSF). Supranormal oxygen delivery and utilization parameters were evenly distributed among survivors and nonsurvivors and patients with SOF and MOSF (chi2, p>0.5). Ten patients had a pHi <7.32 and nine patients had a pHi > or = 7.32 by 24 h. Fifty percent of patients with a pHi <7.32 died, compared with 11% of patients with a pH > or = 7.32 (chi2, p=0.07). Sixty percent of patients with a pHi <7.32 developed MOSF compared with 11% of patients with a pHi > or = 7.32 (chi2, p=0.03). The one patient who developed MOSF and died in the pHi > or = 7.32 cohort suffered from massive head trauma and had all futile medical interventions halted. No other patients who achieved a pH > or = 7.32 by hour 24 developed MOSF. Survivors with a pHi <7.32 at hour 24 had an increased ICU stay (pHi <7.32=46+/-15 days, pHi > or = 7.32=13+/-9 days; p<0.01). A pHi <7.32 carried a relative risk of 4.5 for death and 5.4 for the occurrence of MOSF. CONCLUSION: Attainment of a pHi > or = 7.32 at hour 24 carried a significantly reduced likelihood of MOSF. Being an inference of the state of regional perfusion, in a high-risk microvascular bed, gastric intraluminal tonometry should identify perfusion states of compensated or uncompensated shock during hemodynamic resuscitation of the critically ill injury patient. A low pHi appears to be a marker of postresuscitative morbidity and subsequent increased length of stay.

Personal watercraft crash injuries: an emerging problem.

BACKGROUND: The increased popularity of personal watercraft (PWC) has resulted in an increase in PWC-related injuries. In an effort to better understand the problem, a retrospective review of 37 victims of such injuries seen at a Level I trauma center and fatalities examined by the medical examiner were analyzed. RESULTS: Fourteen percent of the victims were passengers, two of whom were struck from behind, resulting in severe injuries. Twelve patients died of their injuries. For six victims, the cause of death was drowning; only one of these victims was wearing a personal flotation device. Two patients sustained transected aortas, 20% had brain injuries, 20% had spinal fractures, and 48% had skeletal and skull fractures. Abdominal organ injuries were present in only 13.5% of the victims, but they were significant, with liver, spleen, and kidney lacerations and aortic and renal artery injuries. CONCLUSION: In this population of victims of PWC crashes meeting preestablished trauma criteria or on-scene deaths, injuries were significant. Many of the drowning deaths may have been prevented with the use of personal flotation devices. The potential for serious intra-abdominal injury must be recognized and dealt with appropriately.

Spinal cord injuries in adolescents after gunshot wounds: an increasing phenomenon in urban North America.

While much attention is focused on firearm fatalities, the purpose of this study was to determine the expense of acute medical care and the rehabilitation experience of surviving adolescent patients in the USA with spinal cord injury secondary to gunshot wounds. We analyzed a cohort of 19 patients, 18 of whom survived 12 months after spinal cord injury. The need for primary medical care related to the injury, current work and scholastic status, and satisfaction with the quality of rehabilitation were determined. Ten were not involved in any type of academic or meaningful activity, five had returned to school, three were undergoing rehabilitation, and one patient died. Major complications were present in 14 of the 18 patients. Thus, despite a high survival rate after spinal cord injury in this USA population, considerable long-term disability persists, and survivors report a low level of satisfaction with life.

A prospective, randomized comparison of an in-line heat moisture exchange filter and heated wire humidifiers: rates of ventilator-associated early-onset (community-acquired) or late-onset (hospital-acquired) pneumonia and incidence of endotracheal tube occlusion.

PURPOSE: To compare the performance of an in-line heat moisture exchanging filter (HMEF) (Pall BB-100; Pall Corporation; East Hills, NY) to a conventional heated wire humidifier (H-wH) (Marquest Medical Products Inc., Englewood, Colo) in the mechanical ventilator circuit on the incidence of ventilator-associated pneumonia (VAP) and the rate of endotracheal tube occlusion. METHODS: This report describes a prospective, randomized trial of 280 consecutive trauma patients in a 20-bed trauma ICU (TICU). All intubated patients not ventilated elsewhere in the medical center prior to their TICU admission were randomized to either an in-line HMEF or a H-wH in the breathing circuit. Ventilator circuits were changed routinely every 7 days, and closed system suction catheters were changed every 3 days. HMEFs were changed every 24 h, or more frequently if necessary. A specific endotracheal tube suction and lavage protocol was not employed. Patients were dropped from the HMEF group if the filter was changed more than three times a day or the patient was placed on a regimen of ultra high-frequency ventilation. The Centers for Disease Control and Prevention (CDC) criteria for diagnosis of pneumonia were used; early-onset, community-acquired pneumonia was defined if CDC criteria were met in < or =3 days, and late-onset, hospital-acquired pneumonia was defined if criteria were met in >3 days. Laboratory and chest radiograph interpretation were blinded. RESULTS: The patient ages ranged from 15 to 95 years in the HMEF group and 16 to 87 years in the H-wH group (p=not significant), with a mean age of 46 years and 48 years, respectively. The male to female ratio ranged between 78 to 82%/22 to 18%, respectively, and 55% of all admissions were related to blunt trauma, 40% secondary to penetrating trauma, and 5% to major burns. There was no difference in Injury Severity Score (ISS) between the two groups. Moreover, there was no significant difference in mean ISS among those who did not develop pneumonia and those patients who developed either early-onset, community-acquired or late-onset, hospital-acquired pneumonia. The HMEF nosocomial VAP rate was 6% compared to 16% for the H-wH group (p<0.05), and total ventilator circuit costs (per group) were reduced. There were no differences in duration of ventilation (mean+/-SD) if the patient did not develop pneumonia or if the patient developed an early-onset, community-acquired or a late-onset, hospital-acquired pneumonia. Moreover, total TICU days were reduced in the HMEF group. In addition, the incidence of partial endotracheal tube occlusion was not significantly different between the H-wH and the HMEF groups. CONCLUSIONS: The HMEF used in this study reduced the incidence of late-onset, hospital-acquired VAP, but not early-onset, community-acquired VAP, compared to the conventional H-wH circuit. This was associated with a significant reduction in total ICU stay. Disposable ventilator circuit costs in the HMEF group were reduced compared to the H-wH group in whom circuit changes occurred at 7-day intervals. CLINICAL IMPLICATIONS: The use of the HMEF is a cost-effective clinical practice associated with fewer late-onset, hospital-acquired VAPs, and should result in improved resource allocation and utilization.

Do pulmonary artery catheters alter outcome in trauma patients?

OBJECTIVE: To review the literature addressing the use of the pulmonary artery catheter (PAC) in victims of blunt and penetrating trauma and examine the available evidence that supports or refutes the claim that PAC use alters outcome in this patient population. Furthermore, to determine what additional research should be done in this area. DATA SOURCE: All pertinent English language articles dealing with pulmonary artery catheterization in trauma patients were retrieved from 1979 through 1996. STUDY SELECTION: Clinical studies were considered if PACs were used to establish a cardiopulmonary diagnosis, optimize or achieve endpoints of oxygen transport and utilization indices, or guide and/or determine response to therapy. Emphasis was placed on prospective, randomized, controlled trials. However, descriptive case series and retrospectively-analyzed, uncontrolled reviews comprise the majority of available literature. DATA EXTRACTION: From these selective studies, information was obtained regarding patient demographics, therapeutic endpoints, and achieved outcome. DATA SYNTHESIS: Insufficient evidence exists to support a true survival benefit. However, recommendations for indications can be proposed where a reduction in morbidity or improvement in functional outcome is suggested. CONCLUSION: Hemodynamic data obtained from the PAC appear to be beneficial for the following indications: a) to ascertain the status of underlying cardiovascular performance and/or the need for improvement; b) to direct therapy when noninvasive monitoring may be inadequate, misleading, or the endpoints of resuscitation difficult to define; c) to assess response to resuscitation; d) to potentially decrease secondary injury when severe closed-head or acute spinal cord injuries are components of multisystem trauma; e) to augment clinical decision-making when major trauma is complicated by severe adult respiratory distress syndrome, progressive oliguria/anuria, myocardial ischemia, congestive heart failure, or major thermal injury; and f) to establish futility of care.

Management of paroxysmal atrioventricular nodal reentrant tachycardia in the critically ill surgical patient.

OBJECTIVES: Paroxysmal atrioventricular nodal reentrant tachycardia is an infrequently encountered supraventricular arrhythmia that continues to present difficult management problems in the critically ill surgical patient. The purpose of this study was to evaluate the efficacy of a new treatment algorithm involving the sequential administration of different classes of antiarrhythmic agents until conversion to sinus rhythm was achieved. DESIGN: Nonrandomized, consecutive, protocol-driven descriptive cohort. SETTING: University hospital surgical and trauma intensive care unit (ICU). PATIENTS: During an 11-month period, we prospectively evaluated all hemodynamically stable patients who sustained new-onset atrioventricular nodal reentrant tachycardia. INTERVENTIONS: Vagal maneuver, followed by the rapid, sequential infusion of antiarrhythmic agents (i.e., adenosine, verapamil, and esmolol, respectively) until the arrhythmia was terminated. MEASUREMENTS AND MAIN RESULTS: Twenty-seven patients (4% of all admissions) were evaluated, including 16 trauma patients (injury Severity Score of 20 +/- 8) and 11 general surgical patients (Acute Physiology and Chronic Health Evaluation II score of 17 +/- 7). Time from ICU admission to onset of atrioventricular nodal reentrant tachycardia was 4.5 +/- 5 days (median 2.5). Arrhythmia termination was achieved in all patients within minutes (mean 13 +/- 10 [SD]). Incremental sequential adenosine administration alone, however, was successful in affecting conversion to sinus rhythm in only 44% of initial episodes of atrioventricular nodal reentrant tachycardia (95% confidence interval 21% to 67%). A total of 14 (52%) patients developed 38 relapses of paroxysmal supraventricular tachycardia in the ICU after initial conversion to sinus rhythm. These relapses required additional antiarrhythmic therapy. Adenosine was only effective in 34% of the relapses (95% confidence interval 17% to 53%). Seven (50%) of these 14 patients developed multiple relapses. However, only two patients were receiving suppressive calcium-channel or beta-adrenergic receptor blockade at the time of relapse. CONCLUSIONS: The use of a multiagent algorithm was effective for the initial conversion of new-onset atrioventricular nodal reentrant tachycardia to sinus rhythm in critically ill surgical and trauma patients. This preliminary report suggests that adenosine has marginal efficacy in the critically ill surgical or trauma patient. Given the high frequency of relapses, regardless of the agents used to achieve initial control, suppression therapy for the arrhythmia during the period of maximal cardiovascular stress is essential.

Stab wounds to the back and flank in the hemodynamically stable patient: a decision algorithm based on contrast-enhanced computed tomography with colonic opacification.

PURPOSE: The authors wanted to determine whether contrast-enhanced computed tomography (CE-CT) with colonic opacification is an accurate tool to triage hemodynamically stable victims of stab wounds to the flank and back. PATIENTS AND METHODS: One hundred forty-five consecutive patients were categorized as low-risk ( penetration superficial to the deep fascia) or high-risk (penetration beyond the deep fascia) based on CE-CT findings. RESULTS: There were no significant differences in admission vital signs, Glasgow Coma Scale, or complete blood counts between low- and high-risk groups. None of the 92 low-risk patients required surgery or had sequelae. Six of the 53 high-risk patients underwent surgery, 2 based on initial CE-CT, 4 due to evolving clinical signs. The CE-CT correctly predicted surgical findings in all cases. CONCLUSIONS: Hemodynamically stable patients with stab wounds to the back and/or flank can be successfully triaged based on CE-CT findings. Low-risk patients may be discharged immediately. High-risk patients may have a discharge decision implemented at 24 hours.

Follow-up computerized tomography (CT) scans in moderate and severe head injuries: correlation with Glasgow Coma Scores (GCS), and complication rate.

BACKGROUND: The wide availability of computerized tomography (CT) scan has popularized its use in initial and follow-up evaluations of head trauma patients. Follow-up CT scans of clinically stable patients, however, may not provide additional information, but could potentially subject the patients to secondary injuries. The authors investigated the correlation between CT scans and Glasgow coma score (GCS), and complication rate during follow-up CT scans in an attempt to dissuade clinicians from obtaining unnecessary follow-up CT scans. METHODS: The medical records of 180 patients with blunt head trauma were retrospectively reviewed. Only patients (117) with moderate and severe head injuries were included in the study. A total of 319 follow-up brain CT's for 94 patients were obtained. RESULTS: The change in CT scans was compared to the GCS the day of the scan. These two variables were found to be positively correlated by Chi-square analysis (chi 2 = 81.2; alpha < 0.001). CPP trend was found also be correlated with CT scan evolution by the Chi-square analysis (alpha < 0.001). When patients had unchanged or improved GCS, 73.1% had improved or the same CT appearance. When patients had a worse GCS, the CT was worse in 77.9%. A 16.9% (54/319) complication rate was documented during the follow-up scans (hemodynamic instability, increased intracranial pressure, desaturation, and agitation). This rate was higher in severe head trauma (GCS 3-8) patients than in moderate head injury (GCS 9-12) patients. Hemodynamic instability was the most common complication, which comprises 42.6% (23/54) of all complications. CONCLUSION: Because of the correlation between the CT scan appearance and the clinical status, as well as the detrimental effect of mobilizing critically ill patients, the authors urge the use of follow-up CT scans only in patients with clinical deterioration unexplained by ICP changes alone.

Re-engineering ventilatory support to decrease days and improve resource utilization.

OBJECTIVE: The objective of this study was to describe the development of a cost-effective ventilatory strategy using a portable microprocessor-controlled respiratory monitor (Bicore CP-100; Allied Healthcare Products, Riverside, CA.) SUMMARY BACKGROUND DATA: Until recently, clinicians have had to accept the uncertainties of clinical judgment, which unfortunately, often biased the patient to a prolonged ventilatory course to avoid extubation failures, necessitating reintubation. METHODS: Over a 4-year period, the authors attempted to re-engineer the process of ventilatory support based on measured work of breathing (WOB), including physiologic (WOBPhys), imposed (WOBImp) and total (WOBTot). RESULTS: The authors made 90 determinations of WOB in 31 patients. The coefficient of determination (i2) of WOBTot, with the breathing frequency was 0.35, with tidal volume was 0.10, and with the rapid shallow breathing index (f/V(tau)) was 0.23; therefore, the authors discarded them as reliable inferences. Of 27 patients ventilated for > 2 days with satisfactory blood gases, but with breathing frequency > 30 breaths/minute, 6 had WOBTot < 0.8 J/L and were extubated successfully. In 21 patients, WOBTot was elevated to 1.6 +/- 0.83 J/L, WOBImp was 1.1 +/- 0.64 J/L, approximately twice the WOBPhys (0.5 +/- 0.26 J/L), a normal value. Extubation was successful in 20 of those 21 patients. This approach was extended to the spontaneous breathing pre-extubation trial. In addition, the ventilator was adjusted so that the patient sustained a WOBTot of 0.6 to 1 J/L during the ventilatory support. This evolution was tracked for 18 months in a series of 838 trauma intensive care unit patients. Average duration of ventilation decreased from 8.2 to 4.2 days (49%; p < 0.01). This translated into approximately 2400 decreased ventilator days per year. CONCLUSION: Objective measurement to guide the adequacy of ventilatory support and interpret apparent clinical weaning failures decreased total ventilatory time by 50%, permitting extubation in nearly 20% of patients previously considered failures.

Pseudoaneurysm of the superficial temporal artery.

Ours is the first report of pseudoaneurysm of the superficial temporal in a 90-year-old woman. Although falls with associated head and scalp injuries in the geriatric population are common, pseudoaneurysm of the superficial temporal artery is rarely reported, probably due to the generally protected course of the superficial temporal artery across the skull. Clinicians' familiarity with this entity is important for early diagnosis and intervention.

Lung microvessel injury from peritoneal abscesses and gram-negative bacteremia.

To analyze the effect of an extrathoracic focus of infection on lung vessel wall structure, we produced peritoneal abscesses in the rat, over a period of 3 to 7 weeks, by implanting capsules containing live gram-negative bacteria (3.0 x 10(7) Escherichia coli and 5.0 x 10(7) Bactercides fragilis) with an adjutant. We document here by arteriography, morphometric analysis, and high resolution microscopy, microvessel cell injury, and wall remodeling. In the sepsis-injured lung, both dilated and thick-walled microvessels are present. The walls of dilated vessels are disrupted by extensive endothelial and precursor smooth muscle cell injury. In thick-walled vessels these cells are hypertrophied, and the precursor smooth muscle cells express filaments, demonstrating a shift toward a contractile phenotype. Infiltrating monocytic cells focally consolidate alveolar regions. In the residual nonconsolidated regions, alveolar-capillary membrane cells are attenuated and the capillaries dilated. Vessel changes after 7 weeks are similar to those after 3 weeks but alveolar-capillary membrane injury is more extensive. These structural changes, including the development of precursor smooth muscle cells, may contribute to the known increase in reactivity of these lung vessels to challenge by vasoactive agents.