Akpofure Peter Ekeh

The prevalence of incidental findings on abdominal computed tomography scans of trauma patients.

BACKGROUND Abdominal computed tomography scanning (AbdCTS) is the standard of care in the evaluation of blunt trauma patients. The liberal use of AbdCTS coupled with advancing imaging technology often results in the detection of incidental findings. OBJECTIVES We sought to characterize the incidence and prevalence of such findings, describe the lesions most frequently seen on AbdCTS performed on patients admitted to a Level I trauma center, and develop a plan for follow-up through our performance improvement process. METHODS AbdCTS reports of all admissions to a Level I trauma center between January 2000 and December 2002 were reviewed. Incidental findings identified were classified into benign anatomic variants, benign pathologic lesions, and pathologic lesions requiring further work-up. RESULTS A total of 3,113 patients were evaluated by AbdCTS during this time period. There were 1474 incidental findings in 1,103 patients. Seventy-five percent of patients with incidental lesions had no traumatic findings. Benign anatomic variants were present in 1.8%, benign pathologic findings in 27.5%, and pathologic findings requiring work-up in 6.1%. Congenital renal anomalies and duplicate inferior vena cava were the most common benign anatomical findings. Renal and hepatic cysts were the most frequent benign lesions and non-calcified pulmonary nodules and adrenal masses were the pathologic lesions most commonly seen. CONCLUSIONS Incidental findings are seen in up to 35% of trauma AbdCTS. No concomitant traumatic injuries are present in up to 75% of these patients. Protocols for appropriate intervention or arrangements for follow-up care need to be incorporated into the care of the trauma patients.

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.

Incidence and Risk Factors for Deep Venous Thrombosis After Moderate and Severe Brain Injury

BACKGROUND Patients with traumatic injuries possess a high risk of developing deep venous thrombosis (DVT), thus the need for appropriate prophylaxis. Patients with head injuries pose a unique challenge due to contraindication to the use of anticoagulation. We sought to determine the incidence of DVT and identify specific risk factors for its development in patients with head injuries. METHODS All head injury admissions between January 1, 2000, and July 31, 2006, with a length of stay >or=7 days were identified. Patient data including age, sex, injuries, Glasgow Coma Scale, Injury Severity Score (ISS), and venous duplex scan results were collected. Mechanical methods were routinely used for prophylaxis; heparin was not used in this population. Weekly duplex screening was commenced at 7 days to 10 days after admission. RESULTS There were 939 patients who met criteria for review, however, duplex scans were performed in only 677, which was the population studied. Overall, DVT was present in 31.6%. There were fewer DVTs in patients with isolated head injuries (25.8%) compared with patients with those with head and extracranial injuries (34.3%)--p = 0.026. Independent predictors for DVT identified included male gender (p = 0.04), age >or=55 (p < 0.001), ISS >or=15 (p = 0.014), subarachnoid hemorrhage (p = 0.006), and lower extremity injury (p = 0.001). CONCLUSIONS DVT occurs in one third of moderately to severely brain injured patients. Isolated head injuries have a lower incidence. Older age, male gender, higher ISS, and the presence of a lower extremity injury are strong predictors for developing DVT. Regular screening and the use of prophylactic inferior vena cava filters in patients with risk factors should be strongly considered.

Complications arising from splenic artery embolization: a review of an 11-year experience

BACKGROUND Splenic artery embolization (SAE) is a staple adjunct in the management of blunt splenic trauma. We examined complications of SAE over an 11-year period. METHODS Patients who underwent SAE were identified. Demographic data and the location of the SAE-proximal, distal, or combined-were noted. Major and minor complications were identified. RESULTS Of 1,383 patients with blunt splenic trauma, 298 (21.5%) underwent operative management, and 1,085 (78.5%) underwent nonoperative management (NOM). SAE was performed in 8.1% of the NOM group. Major complications which occurred in 14% of patients, included splenic abscesses, infarction, cysts, and contrast-induced renal insufficiency. Three-fourths of patients with major complications underwent distal embolization. There were more complications in patients who underwent distal embolization (24% distal vs 6% proximal alone; P = .02). Minor complications, which occurred in 34% of patients, included left-sided pleural effusions, coil migration, and fever. CONCLUSIONS SAE is a useful tool for managing splenic injuries. Major and minor complications can occur. Distal embolization is associated with more major complications.

Is Chest X-Ray an Adequate Screening Tool for the Diagnosis of Blunt Thoracic Aortic Injury?

BACKGROUND Blunt thoracic aortic injuries (BTAI) have a high mortality rate. For survivors, chest X-ray (CXR) findings are used to determine the need for further diagnostic testing with chest computerized tomography with angiography (CTA) or conventional angiography. We set to determine the adequacy of utilizing CXR alone as a screening tool for BTAI. METHODS All patients diagnosed with BTAI at a level I trauma-center during a 7-year-period were identified. CXRs of these patients and those of a control group of blunt trauma patients with an injury severity score >15 were reviewed by four trauma surgeons blinded to the diagnosis. Based on each CXR viewed, the surgeons decided if they would have proceeded to chest CTA, angiography, or required no further studies to rule out BTAI. RESULTS In the 7-year-period, 83 patients had BTAI. CXRs were available in 45 patients. The four surgeons viewed 96 CXRs including those of 51 controls. Based on the CXR appearance in patients with BTAI, the surgeons chose to proceed to chest CTA in 38 patients (84.4%), conventional aortography in two patients (4.4%), and no further testing in five patients (11.2%). A widened mediastinum (75%) and loss of the aorto-pulmonary window (40%) were the most frequent CXR abnormalities. Patients with BTAI were more likely to have an abnormal CXR-40 of 45 (88.8%) patients when compared with the controls-25 of 51 (49%)patients-p < 0.001. CONCLUSIONS Although CXR is a sensitive screening modality, it failed to identify the possibility of BTAI in 11% of patients. The liberal use of chest CTA after high speed motor vehicle crashes is recommended to minimize the incidence of missed BTAI.

The impact of splenic artery embolization on the management of splenic trauma: an 8-year review

BACKGROUND Splenic artery embolization (SAE) is an adjunct to nonoperative management (NOM) of splenic injuries. We reviewed our experience with SAE to identify its impact on splenic operations. METHODS Patients admitted with splenic injuries over an 8-year period were identified and the initial method of management noted (simple observation, SAE, or splenic surgery). The first 4 years (period 1) during which SAE was introduced was compared with the latter 4 years (period 2) when it was used frequently. RESULTS There were 304 patients in period 1 and 416 in period 2. NOM was initial management in 59.9% in period 1% and 60.1% in period 2 (P = 1.0) and failure rates were 5.3% versus 2.9%, respectively (P = .12). More SAE procedures were performed in period 2 -- 13.7% versus 4.9% (P < or = .001) -- and there was a reduction in the proportion of splenic operations -- 35.2% versus 26.2% (P <.01). CONCLUSIONS SAE is associated with a reduction in splenic operations, although it did not alter the failure rate of NOM.

Outcome of cervical near-hanging injuries

BACKGROUND Cervical near-hangings are not rare, but have received little attention in the trauma literature. Increasing numbers of patients received from our local jail and detention centers prompted this study. METHODS Seventeen-year review of a level I Trauma Center Registry identified 67 patients with cervical strangulation for study. Data were analyzed using the Mann-Whitney test to evaluate continuous predictors, and Fishers exact test for categorical predictors. RESULTS Ten of 67 patients died (14.9% mortality). Patients having a lower Glasgow Coma Score (GCS) at the scene (3.5 +/- 1.3 vs. 8.3 +/- 5.0; p = 0.001) and lower GCS in the emergency department (ED) (3.0 +/- 0.0 vs. 9.0 +/- 5.3; p < 0.001) were more likely to die. Injuries consisted predominantly of neck abrasions and anoxic brain injuries (83% mortality). Laryngeal fractures and carotid arterial injuries were detected. No cervical spine fractures were seen, but subluxations were identified. Forty-two percent of the patients were in detention centers when the near-hanging incident occurred. CONCLUSIONS Cervical near-hangings are referred to the Trauma Service for evaluation. Scene or ED GCS of 3 does not preclude neurologically intact survival, although mortality is high. In our study, the most useful prognostic factors were the need for airway control by intubation or cricothyrotomy, cardiopulmonary resuscitation, lower scene and ED GCS, and cerebral edema on CT Scan. Optimal evaluation includes head and neck CT and CT angiography of the neck. We plan to share these results with local authorities and encourage improvement in risk identification, with earlier involvement of mental health personnel.

Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan

BACKGROUND There are variations in cervical spine (CS) clearance protocols in neurologically intact blunt trauma patients with negative radiological imaging but persistent neck pain. Current guidelines from the current Eastern Association for the Surgery of Trauma include options of maintaining the cervical collar or obtaining either magnetic resonance imaging (MRI) or flexion-extension films (FEF). We evaluated the utility of FEF in the current era of routine computerized tomography (CT) for imaging the CS in trauma. MATERIALS AND METHODS All neurologically intact, awake, nonintoxicated patients who underwent FEF for persistent neck pain after negative CT scan of the CS at our level I trauma center over a 13-mo period were identified. Their charts were reviewed and demographic data obtained. RESULTS There were 354 patients (58.5% male) with negative cervical CS CT scans who had FEF for residual neck pain. Incidental degenerative changes were seen in 37%--which did not affect their acute management. FEF were positive for possible ligamentous injury in 5 patients (1.4%). Two of these patients had negative magnetic resonance images and the other three had collars removed within 3 wk as the findings were ultimately determined to be degenerative. CONCLUSIONS In the current era, where cervical CT has universally supplanted initial plain films, FEF appear to be of little value in the evaluation of persistent neck pain. Their use should be excluded from cervical spine clearance protocols in neurologically intact, awake patients.

The Prevalence of Positive Drug and Alcohol Screens in Elderly Trauma Patients

BACKGROUND Alcohol and drug abuse are recognized to be significantly prevalent in trauma patients, and are frequent harbingers of injury. The incidence of substance abuse in elderly trauma patients has, however, been limitedly examined. The authors sought to identify the spectrum of positive alcohol and drug toxicology screens in patients ≥65 years admitted to a Level I trauma center. METHODS Patients ≥65 years old admitted to an American College of Surgeons (ACS) Level I trauma center over a 60--month period were identified from the trauma registry. Demographic data, blood alcohol content (BAC), and urine drug screen (UDS) results at admission were obtained and analyzed. The positive results were compared with individuals below 65 years in different substance categories using Fishers exact test. RESULTS In the 5-year period studied, of the 4139 patients ≥65 years, 1302 (31.5%) underwent toxicological substance screening. A positive BAC was present in 11.1% of these patients and a positive UDS in 48.3%. The mean BAC level in those tested was 163 mg/dL and 69% of patients had a level >80 mg/dL. CONCLUSIONS These data show that alcohol and drug abuse are an issue in patients ≥65 years in our institution, though not as pervasive a problem as in younger populations. Admission toxicology screens, however, are important as an aid to identify geriatric individuals who may require intervention.

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, &Dgr; 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. LEVEL OF EVIDENCE: II.