Variability in CT imaging of blunt trauma among ED physicians, surgical residents, and trauma surgeons.

BACKGROUND: Trauma triage decisions can be influenced by both knowledge and experience. Consequently, there may be substantial variability in computed tomography (CT) scans desired by emergency medicine physicians, surgical chief residents, and attending trauma surgeons. We quantified this difference and studied the effects of each group's decisions on missed injuries, cost, and radiation exposure. METHODS: All blunt trauma activations at an urban level 1 trauma center were studied over a 6-mo period. Three months into the study, a pan-scan protocol was introduced. Prior to CT imaging, providers separately completed a survey that asked which CT scans were desired for each patient. Based on the completed surveys, hypothetical missed injuries, radiation exposure, and cost were determined. RESULTS: The variability in the number of CT scans desired by each of the three providers and the resulting cost and radiation exposure were not statistically significant. Substantial variability was predominantly seen in the indications for the desired scans, with the difference between proportions ranging from 3.1%-68.7%. Agreement among the three providers was highest for head and c-spine scans (80%-100%) and lowest for maxillary face (57%-80%) and chest scans (52%-74%). Overall, the missed injury rate was similar for all the providers; chief residents missed significantly more major injuries than trauma attendings during the pan-scan period (P = 0.03). CONCLUSIONS: Trauma training and level of training did not have a substantial effect on radiological decisions during the initial trauma assessment. This study sheds light on the growing uniformity among providers with regard to medical decision-making in the initial work-up of trauma.

Low Abdominal Wall Thickness May Predict Percutaneous Endoscopic Gastrostomy Complications.

Although percutaneous endoscopic gastrostomy (PEG) tube placement is a common and safe procedure to provide enteral feeding, some patients develop complications. The aim of this study was to identify risk factors for the development of post-PEG complications. We hypothesized that patients with low albumin, diabetes, higher body mass index (BMI), thicker abdominal walls, or psychomotor agitation would have more complications. A 2-year retrospective review was performed on patients who received a PEG tube at a single institution. Variables collected included age, preoperative albumin, BMI, abdominal wall thickness (AWT), psychomotor agitation, preoperative diabetes mellitus, and mortality. A total of 91 patients (70.3% male) were identified (mean age 58.7 years, SD 18.6). Seventeen patients (18.7%) had post-PEG complications and the 30-day mortality rate was 14.3 per cent. Mortality was not attributable to tube placement. Patients with complications weighed less (P = 0.005) and had a lower BMI (P = 0.010) than patients without complications. Additionally, patients with complications had significantly lower AWT (P = 0.02), mean AWT was 21.6 mm (SD 7.6) versus 27.6 mm (SD 8.1) in the noncomplication patients. AWT was the only factor independently associated with post-PEG complications (P = 0.047). There was no significant association between complications and mortality. Continued investigation on how to limit post-PEG complications remains imperative. In our population, lower AWT was independently associated with complications. Preoperative measurement of AWT by preprocedural imaging can potentially be used to predict the risk of post-PEG complications.

Cervical spine immobilization may be of value following firearm injury to the head and neck.

BACKGROUND: Penetrating injuries to the head and neck may not be able to cause unstable fractures without concomitant spinal cord injury, rendering prehospital spinal immobilization (PHSI) ineffectual, and possibly harmful. However, this premise is based on reports including predominantly chest and abdominal injuries, which are unlikely to cause cervical spine (CS) injuries. METHODS: We performed a retrospective review of all patients presenting with a penetrating wound to the head or neck over a 4-year period at an urban, level 1 trauma center to determine if there was a benefit of PHSI. RESULTS: One hundred seventy-two patients were identified, of which 16 (9.3%) died prior to CS evaluation. Of 156 surviving patients, mechanism was gunshot wound (GSW) in 36 (28%) and stab wound (SW) in 120 (72%). Fifty-eight patients had PHSI placed (37%), and GSW patients' odds of having PHSI were greater than SW patients (OR 2.3; CI 1.08-4.9). Eight of 156 surviving patients eventually died (5.1%), and the odds of mortality were greater among those that had PHSI than those without (OR 5.54; CI 1.08-28.4). Six (3.8%; 5 GSW, 1 SW) patients had a CS fracture. Two GSW patients (5.6%) had unstable CS fractures with a normal neurological exam at initial evaluation. CONCLUSIONS: Of patients with a GSW to the head or neck that survived to be evaluated, 5.6% had unstable fractures without an initial neurologic deficit. PHSI may be appropriate in this population. Further studies are warranted prior to a determination that PHSI is unnecessary in penetrating head and neck injuries.