Grace S. Rozycki

Practice Management Guidelines for the Prevention of Venous Thromboembolism in Trauma Patients: The EAST Practice Management Guidelines Work Group

These original guidelines were developed by interested trauma surgeons in 1997 for the EAST Web site (www.eas- t.org), where a brief summary of four guidelines was pub- lished. A revised, complete, and significantly edited practice management guidelines for the prevention of venous throm- boembolism in trauma patients is presented herein. The step-by-step process of practice management guide- line development, as outlined by the Agency for Health Care Policy and Research (AHCPR), has been used as the meth- odology for the development of these guidelines. 2 Briefly, the first step in guideline development is a classification of sci- entific evidence. A Class I study is a prospective, randomized controlled trial. A Class II study is a clinical study with prospectively collected data or large retrospective analyses with reliable data. A Class III study is retrospective data, expert opinion, or a case report. Once the evidence is classi- fied, it can be used to make recommendations. A Level I recommendation is convincingly justifiable on the basis of the scientific information alone. Usually, such a recommen- dation is made on the basis of a preponderance of Class I data, but some strong Class II data can be used. A Level II rec- ommendation means the recommendation is reasonably jus- tifiable, usually on the basis of a preponderance of Class II data. If there are not enough Class I data to support a Level I recommendation, they may be used to support a Level II recommendation. A Level III recommendation is generally only supported by Class III data. These practice guidelines address eight different areas of practice management as they relate to the prevention and diagnosis of venous thromboembolism in trauma patients. There are few Level I recommendations because there is a paucity of Class I data in the area of trauma literature. We believe it is important to highlight areas where future inves- tigation may bring about definitive Level I recommendations.

Prospective Evaluation Of Surgeons' Use Of Ultrasound In The Evaluation Of Trauma Patients

Ultrasound diagnostic imaging has been demonstrated to be a valuable investigative tool in the evaluation of trauma patients in Europe and Japan. In the United States, however, ultrasound has not been widely used by trauma surgeons because of its lack of availability in the trauma resuscitation area and the associated cost and lack of full-time availability of a technician. In this prospective study, four attending trauma surgeons, four trauma fellows (PGY 6 and 7), and 25 surgical residents (PGY 4) at a level I trauma center were trained in specific ultrasound techniques to identify fluid in trauma patients with thoracoabdominal injuries. Their ultrasound evaluations of 476 patients demonstrated that in 90 patients with clinically significant injuries, ultrasound imaging successfully detected injury in 71, for a 79% sensitivity. Specificity was 95.6%. We conclude that (1) surgeons can rapidly and accurately perform and interpret ultrasound examinations; and (2) ultrasound is a rapid, sensitive, specific diagnostic modality for detecting intraabdominal fluid and pericardial effusion.

A Prospective Study of Surgeon-performed Ultrasound as the Primary Adjuvant Modality for Injured Patient Assessment

Ultrasound diagnostic imaging, having been used in Germany in the trauma setting for more than 15 years, has unique qualities that give it distinct advantages over other tests (DPL, CT), and is gradually gaining acceptance by surgeons in the United States. In this prospective study, experienced surgeon sonographers successfully used ultrasound as the primary adjuvant modality to detect hemoperitoneum and pericardial effusion in injured patients. The ultrasound evaluations of 371 patients demonstrated that in 65 patients with significant injuries, ultrasound detected 53, that is, had an 81.5% sensitivity and 99.7% specificity. They conclude that ultrasound should be the primary adjuvant instrument for the evaluation of injured patients because it is rapid, accurate, and is potentially cost-effective.

Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients.

OBJECTIVE To determine the accuracy of the Focused Assessment for the Sonographic examination of the Trauma patient (FAST) when performed by trauma team members during a 3-year period, and to determine the clinical conditions in which the FAST is most accurate in the assessment of injured patients. SUMMARY BACKGROUND DATA The FAST is a rapid test that sequentially surveys the pericardial region for hemopericardium and then the right and left upper quadrants and pelvis for hemoperitoneum in patients with potential truncal injuries. The clinical conditions in which the FAST is most accurate in the assessment of injured patients have yet to be determined. METHODS FAST examinations were performed on patients with precordial or transthoracic wounds or blunt abdominal trauma. Patients with a positive ultrasound (US) examination for hemopericardium underwent immediate surgery, whereas those with a positive US for hemoperitoneum underwent a computed tomography scan (if they were hemodynamically stable) or immediate celiotomy (if they were hemodynamically unstable- blood pressure < or = 90 mmHg). RESULTS FAST examinations were performed in 1540 patients (1227 with blunt injuries, 313 with penetrating injuries). There were 1440 true-negative results, 80 true-positive results, 16 false-negative results, and 4 false-positive results; the sensitivity was 83.3%, the specificity 99.7%. US was most sensitive and specific for the evaluation of patients with precordial or transthoracic wounds (sensitivity 100%, specificity 99.3%) and hypotensive patients with blunt abdominal trauma (sensitivity 100%, specificity 100%). CONCLUSIONS US should be the initial diagnostic modality for the evaluation of patients with precordial wounds and blunt truncal injuries because it is rapid and accurate. Because of the high sensitivity and specificity of US in the evaluation of patients with precordial wounds and hypotensive patients with blunt torso trauma, immediate surgical intervention is justified when those patients have a positive US examination.

Improvements in early mortality and coagulopathy are sustained better in patients with blunt trauma after institution of a massive transfusion protocol in a civilian level I trauma center.

INTRODUCTION Transfusion practices across the country are changing with aggressive use of plasma (fresh-frozen plasma [FFP]) and platelets during massive transfusion with current military recommendations to use component therapy at a 1:1:1 ratio of packed red blood cells to FFP to platelets. METHODS A massive transfusion protocol (MTP) was designed to achieve a packed red blood cell:FFP:platelet ratio of 1:1:1 We prospectively gathered demographic, transfusion, and patient outcome data during the first year of the MTP and compared this with a similar cohort of injured patients (pre-MTP) receiving > or = 10 red blood cell (RBC) in the first 24 hours of hospitalization before instituting the MTP. RESULTS One hundred sixteen MTP activations occurred. Twelve non-trauma patients and 31 who did not receive 10 RBC (15 deaths, 16 early bleeding controls) were excluded. Seventy-three MTP patients were compared with 84 patients with pre-MTP who had similar demographics and injury severity score (29 vs. 29, p = 0.99). MTP patients received an average of 23.7 RBC and 15.6 FFP transfusions compared with 22.8 RBC (p = 0.67) and 7.6 FFP (p < 0.001) transfusions in pre-MTP patients. Early crystalloid usage dropped from 9.4 L (pre-MTP) to 6.9 L (MTP) (p = 0.006). Overall patient mortality was markedly improved at 24 hours, from 36% in the pre-MTP group to 17% in the MTP group (p = 0.008) and at 30 days (34% mortality MTP group vs. 55% mortality in pre-MTP group, p = 0.04). Blunt trauma survival improvements were more marked and more sustained than victims of penetrating trauma. Early deaths from coagulopathic bleeding occurred in 4 of 13 patients in the MTP group vs. 21 of 31 patients in the pre-MTP group (p = 0.023). CONCLUSIONS In the civilian setting, aggressive use of FFP and platelets drastically reduces 24-hour mortality and early coagulopathy in patients with trauma. Reduction in 30 day mortality was only seen after blunt trauma in this small subset.

Ultrasound, what every trauma surgeon should know.

The use of ultrasonography by surgeons to detect hemoperitoneum following abdominal trauma has, in the past two decades, become an accepted practice in Europe and the Far East. Surgeons in the United States, however, have not as readily adopted ultrasound as a diagnostic modality. There appear to be

Blunt vascular trauma in the extremity: diagnosis, management, and outcome

BACKGROUND Blunt vascular trauma in an extremity is an uncommon diagnosis. Considering the complexity of these injuries, it is worthwhile to determine how select factors affect the outcome of the limb and the patient. The objectives of this study were to review the diagnosis, management, and outcomes of patients who sustained blunt vascular injuries in the extremities and relate factors in their treatment to the outcome of the injured extremity. METHODS A retrospective review of data on adult and pediatric patients who had a diagnosis of blunt vascular injury in an extremity and underwent some attempt at restoration of vascular flow was conducted. RESULTS From January 1995 to December 2002, 62 patients (80.3% male; mean age, 33.2 +/- 15.8 years) sustained blunt trauma (mean Injury Severity Score, 14.6 +/- 8.4), with 93 vascular injuries in 65 extremities (16 upper and 49 lower). Hard signs of vascular injury occurred in 41 (66%) patients. An associated fracture and/or dislocation was present in 59 patients (95%). Preoperative arteriograms were obtained in 20 patients (17 occlusions, 2 embolizations, and 1 untreated). Vessel injuries were as follows: 16 upper (brachial artery, 50%) and 63 lower (tibial/peroneal/popliteal, 84%), with ligation being the most common treatment in the latter. Intravascular shunts were used to restore blood flow in 18 vessels (13 arteries and 5 veins) in 13 patients. Delays in diagnosis or treatment occurred in six patients, mostly because of errors in management/judgment. Delayed or late fasciotomies were performed in six patients, and five developed rhabdomyolysis. Six patients died. The age (p = 0.0006), Injury Severity Score (p = 0.0007), and Mangled Extremity Severity Score (p = 0.0009) were significantly different for the survivors compared with the nonsurvivors. CONCLUSION Blunt vascular injuries in the lower extremities occur most commonly in the anteroposterior tibial arteries; injured arteries in the proximal upper and lower extremity require resection with interposition grafting, whereas those in the forearm or calf are usually ligated; the amputation rate in 65 injured extremities with blunt vascular trauma was 18.%, which is at least three times that for those who sustain penetrating injury; and delays in diagnosis and treatment are uncommon in these patients with multiple injuries.

Rapid Detection of Traumatic Effusion Using Surgeon-Performed Ultrasonography

BACKGROUND In the injured patient, rapid assessment of the thorax can yield critical information for patient management and triage. OBJECTIVES The objectives of this prospective study were (1) to determine if experienced surgeon sonographers could successfully use a focused thoracic ultrasonographic examination to detect traumatic effusion, and (2) to compare the accuracy and efficiency of ultrasonography with supine portable chest radiography. METHODS Surgeon-sonographers performed thoracic ultrasonographic examinations on patients with blunt and penetrating torso injuries during the Advanced Trauma Life Support secondary survey. All patients also underwent portable chest radiography. Performance times for ultrasonography and chest radiography were recorded. Comparisons were made of the performance times and accuracy of both tests in detecting traumatic effusion. RESULTS In 360 patients, there were 40 effusions, 39 of which were detected by ultrasonography and 37 of which were detected by chest radiography. The 97.5% sensitivity and 99.7% specificity observed for thoracic ultrasonography were similar to the 92.5% sensitivity and 99.7% specificity for portable chest radiography. Performance time for ultrasonography was significantly faster than that for chest radiography (1.30 +/- 0.08 vs. 14.18 +/- 0.91 minutes, p < 0.0001). CONCLUSION Surgeons can accurately perform and interpret a focused thoracic ultrasonographic examination to detect traumatic effusion. Surgeon-performed thoracic ultrasonography is as accurate but is significantly faster than supine portable chest radiography for the detection of traumatic effusion.

The role of surgeon-performed ultrasound in patients with possible cardiac wounds.

OBJECTIVE The authors evaluate surgeon-performed ultrasound in determining the need for operation in patients with possible cardiac wounds. BACKGROUND DATA Ultrasound quickly is becoming part of the surgeons diagnostic armamentarium; however, its role for the patient with penetrating injury is less well-defined. Although accurate for the detection of hemopericardium, the lack of immediate availability of the cardiologist to perform the test may delay the diagnosis, adversely affecting patient outcome. To be an effective diagnostic test in trauma centers, ultrasound must be immediately available in the resuscitation area and performed and interpreted by surgeons. METHODS Surgeons performed pericardial ultrasound examinations on patients with penetrating truncal wounds but no immediate indication for operation. The subcostal view detected hemopericardium, and patients with positive examinations underwent immediate operation by the same surgeon. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded. RESULTS During 13 months, 247 patients had surgeon-performed ultrasound. There were 236 true-negative and 10 true-positive results, and no false-negative or false-positive results; however, the pericardial region could not be visualized in one patient. Sensitivity, specificity, and accuracy were 100%; mean examination time was 0.8 minute (246 patients). Of the ten true-positive examinations, three were hypotensive. The mean time (8 patients) from ultrasound to operation was 12.1 minutes; all survived. Operative findings (site of cardiac wounds) were: left ventricle (4), right ventricle (3), right atrium (2), right atrium/superior vena cava (1), and right atrium/inferior vena cava (1). CONCLUSIONS Surgeon-performed ultrasound is a rapid and accurate technique for diagnosing hemopericardium. Delay times from admission to operating room are minimized when the surgeon performs the ultrasound examination.

PROSPECTIVE EVALUATION OF THORACOSCOPY FOR DIAGNOSING DIAPHRAGMATIC INJURY IN THORACOABDOMINAL TRAUMA: A PRELIMINARY REPORT

Diagnosis of diaphragmatic injury (DI) can be difficult in patients with penetrating trauma because physical examination, computed tomographic scan, chest x-ray films, and diagnostic peritoneal lavage may miss these injuries. Mandatory exploration has been recommended because of the increased mortality associated with missed DI. Thoracoscopy was prospectively evaluated as a less invasive method for diagnosing DI in patients with penetrating trauma. Over a 14-month period, 14 patients were evaluated by thoracoscopy; video thoracoscopy was used in the last 9. Findings of thoracoscopy were confirmed by laparotomy or laparoscopy. Thoracoscopy correctly identified the presence or absence of DI in nine and five patients, respectively (all patients). Video thoracoscopy was easier and faster to perform than non-video thoracoscopy. This is the first reported series in which video thoracoscopy has been used for trauma. We found this procedure to be safe, accurate, and less invasive than laparotomy for diagnosing DI.