John B. Fortune

Transophageal Echocardiography for the Initial Evaluation of the Widened Mediastinum in Trauma Patients

Traumatic disruption of the thoracic aorta is an injury that is rapidly fatal if not recognized and treated early. Increasingly, transesophageal echocardiography (TEE) is being used to evaluate the thoracic aorta after trauma with reported sensitivity and specificity rates of up to 100%. To confirm these results, we instituted a protocol using TEE as the initial diagnostic study for excluding a ruptured thoracic aorta in patients with widened mediastinum. All TEE studies were done by experienced cardiologists; 96% were done in the trauma receiving area. TEE studies were classified as positive, negative, or indeterminant. Indeterminant studies were those in which the diagnosis of aortic injury could not be excluded based solely on TEE findings. Because we were interested in using TEE as a definitive diagnostic modality, indeterminant studies were regarded as positive for our analysis. This protocol was used in 114 trauma patients over a 3-year period. TEE identified five thoracic aortic disruptions--three confirmed by aortography and two by thoracotomy. TEE was read as indeterminant in 17 patients and further investigation with aortography showed no aortic injury in these patients. TEE was negative in 89 patients who had no further evaluation and were subsequently discharged or who died from other injuries. TEE failed to reveal significant lesions in three patients who had aortograms that revealed disruptions requiring thoracotomy. The use of TEE for the definitive diagnosis of ruptured aorta in this series yields a sensitivity of 63% and a specificity of 84%.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of prehospital surgical cricothyrotomy in trauma patients.

OBJECTIVEnThe use of surgical cricothyrotomy (SC) in the prehospital setting is controversial, and the need to teach this procedure to paramedics and intermediate emergency medical technicians remains unclear. The purpose of this study is to define the efficacy, complication rate, and overall survival after SC performed in the prehospital setting.nnnMETHODSnIn our region, emergency medical technicians receive training in this technique using an animal model with bi-annual updates required. We retrospectively reviewed data in our regional trauma register (15,686 injured patients) for the years 1991-1995.nnnRESULTSnPrehospital emergency airway intubation was required in 376 patients, 56 of whom received SC. The primary indications for SC were facial fractures and deformities (32%) and blood in the airway (30%). In 79% of the patients requiring SC, attempted orotracheal intubation prior to SC was unsuccessful, with a mean of 1.9 attempts per patient. SC was judged to provide an adequate airway in the field in 89% of attempts. Complications at the scene included six failed attempts, one case of excessive bleeding, and one adverse patient reaction (agitation). When patients arrived at the trauma center, the SC was judged to be acceptable in 64%, whereas 16% were functioning with some question of adequacy and required airway manipulation (most commonly a mainstem bronchial intubation). Overall survival to hospital discharge was 27%; however, survival to emergency department discharge (an indicator of emergency airway adequacy) was 62%. Using TRISS methodology, there were five unexpected survivors and six unexpected deaths. Only three patients were discharged with a good neurologic recovery.nnnCONCLUSIONn(1) Prehospital SC can be performed effectively with few complications after training on animal models (2) Good neurologic outcome is rare after the use of this procedure. (3) Although it is effective, clear indications must be developed and followed for the prehospital use of SC.

Use of an Objective Structured Clinical Examination (osce) for the Assessment of Physician Performance in the Ultrasound Evaluation of Trauma

BACKGROUNDnA reliable means of assessing physician competency in performing ultrasound (US) is critical for training and credentialing. Objective Structured Clinical Examinations (OSCE) have been used successfully to assess clinical competency in other areas of surgical education but have not been applied previously to trauma ultrasound training. The objectives of this study were to assess physician performance in the focused abdominal sonography in trauma (FAST) examination by using a specifically designed OSCE, and to determine whether the OSCE detects differences in two determinants of competency (knowledge acquisition and clinical interpretation skills).nnnMETHODSnEighty-two physicians in surgery (n = 49) and emergency medicine (n = 33) at a Level I trauma center were evaluated. All participated in a FAST course consisting of didactic sessions on US physics, indications, and technique, FAST examination videos, and a hands-on session with human models. The OSCE consisted of two parts: written examination that assessed factual knowledge, and videotape of real-time US examinations that assessed interpretation skills. The OSCE was administered before and after the FAST course.nnnRESULTSnSignificant improvements in postcourse OSCE scores were observed for factual knowledge (52.5 +/- 2.0 vs. 87.5 +/- 1.1, p < 0.001) and interpretation skills (27.2 +/- 1.4 vs. 62.9 +/- 1.3, p < 0.007). Scores for US interpretation were significantly lower than those for factual knowledge at both precourse (27.2 +/- 1.4 vs. 52.5 - 2.0, p < 0.001) and postcourse (62.9 +/- 1.3 vs. 87.5 +/- 1.1, p < 0.01). No performance differences were observed between surgeons and emergency medicine physicians and no effect of training level on test scores was observed.nnnCONCLUSIONnKnowledge acquisition and US interpretation skills can be assessed reliably with a specifically designed OSCE. Although both skills improved after participation in a FAST course, US interpretation scores were consistently lower than those for factual knowledge. This study supports the use of the objective structured clinical examination in both the design of ultrasound teaching programs and the assessment of physician competency.

Early complications of airway management in head-injured patients.

Head‐injured patients are frequently young, healthy individuals whose excellent medical condition is suddenly altered by trauma. The purpose of this study is to evaluate the early complications of airway management which occur in head‐injured patients and to determine if these are different from what has been reported in patients with chronic illnesses (i.e., diabetes, atherosclerosis, or immunosuppres‐sion).

Distal esophageal rupture after external blunt trauma: report of two cases.

Thoracic esophageal rupture secondary to blunt trauma is an extremely rare injury, with only six reported cases in the world literature. We report two cases with unique presentations of rupture of the distal thoracic esophagus after blunt trauma. Both patients were treated initially by wide mediastinal drainage and primary repair. One patient developed an anastomotic leak and required esophageal stapling and proximal end-cervical esophagostomy. Both patients survived.

Primary leiomyoma of the liver. A case report and review of the literature

SummaryThe fourth known case of primary leiomyoma of the liver is described. This diagnosis depends on the exclusion of leiomyoma at other intraabdominal sites and careful histologic review to exclude malignant change. In the presented case, multiple noninvasive imaging modalities failed to allow a tissue specific diagnosis, although magnetic resonance imaging of the liver did add useful information. For this problem, hepatic lobectomy is both diagnostic and curative.

Predictive value of the Glasgow Coma Scale for tracheotomy in head-injured patients

Patients with severe head trauma often require prolonged intubation and subsequent tracheotomy. The Glasgow Coma Scale (GCS), an indicator of the severity of head injury, may help identify that subpopulation of trauma victims who will ultimately undergo tracheotomy. This retrospective study demonstrates through discriminant analysis that the likelihood of tracheotomy is significantly greater in patients with a GCS rating ≤7 than it is in patients with a GCS rating >7 (p= .0001). Conversely, the presence of thoracoabdominal or maxillofacial injury is associated with but not predictive of eventual tracheotomy. In the hope of minimizing complications and enhancing the utilization of hospital resources, this study argues for early tracheotomy in patients with a GCS score ≤7 who do not undergo craniotomy and are otherwise stable.

Anticoagulation management around percutaneous bedside procedures: is adjustment required?

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) and percutaneous dilatational tracheostomy (PDT) are frequently performed bedside in the intensive care unit. Critically ill patients frequently require anticoagulant (AC) and antiplatelet (AP) therapies for myriad indications. There are no societal guidelines proffering strategies to manage AC/AP therapies periprocedurally for bedside PEG or PDT. The aim of this study is to evaluate the management of AC/AP therapies around PEG/PDT, assess periprocedural bleeding complications, and identify risk factors associated with bleeding. METHODS: A retrospective, observational study of all adult patients admitted from October 2004 to December 2009 receiving a bedside PEG or PDT was conducted. Patients were identified by procedure codes via an in-hospital database. A medical record review was performed for each included patient. RESULTS: Four hundred fifteen patients were included, with 187 PEGs and 352 PDTs being performed. Prophylactic anticoagulation was held for approximately one dose before and two doses or less after the procedure. There was wide variation in patterns of holding therapy in patients receiving anticoagulation via continuous infusion. There were 19 recorded minor bleeding events, 1 (0.5%) with PEG and 18 (5.1%) with PDT, with no hemorrhagic events. No association was found between international normalized ratio, prothrombin time, or activated partial thromboplastin time values and bleed risk (p = 0.853, 0.689, and 0.440, respectively). Platelet count was significantly lower in patients with a bleeding event (p = 0.006). CONCLUSIONS: We found that while practice patterns were quite consistent in regard to the management of prophylactic anticoagulation, it varied widely in patients receiving therapeutic anticoagulation. It seems that prophylactic anticoagulation use did not affect bleed risk with PEG/PDT. LEVEL OF EVIDENCE: II, therapeutic study.

Maximizing Reimbursement From Trauma Response Fees (UB-92: 68X) ??? Lessons Learned from a Hospital Comparison J Trauma. 2005;58:482???486.

BACKGROUNDnThe trauma response fee (UB-92:68x) recently has been approved, to be used by hospitals to cover expenses resulting from continuous trauma team availability. These charges may be made by designated trauma centers for all defined trauma patients when notification has been received before arrival (eligible pt). This study compares two trauma centers performance in collecting this fee help define methodologies that can enhance reimbursement.nnnMETHODSnOur trauma system uses two hospitals (A and B) that are designated as the Level I trauma center for the region on alternate years. This allows hospital performance comparisons with relatively consistent patient demographics, injury severity, and payer mix. Data were collected for a one-year period beginning on January 1, 2003 and included charges, collections, and payer source for the trauma response fee. This time frame allowed the comparison of two six-month sequential periods at each trauma center.nnnRESULTSnOut of a total of 871 trauma patients, 625 were eligible for the trauma response fee (72%): hospital A = 65% and hospital B = 77%. Total trauma response fee charges for both centers were 1,111,882 dollars with collections of 319,684 dollars (28.8%). The following payer sources contributed to the collections: Indemnity insurance (77.4%), Managed Care (22.1%), Medicare (0.3%), and Medicaid (0.2%). No collections were obtained from any self-pay patient. Eligible patients were charged a trauma response fee much less frequently in Hospital A than B (29.35% versus 95.2%) but revenue / charge ratios were equivalent at both hospitals (0.32 versus 0.28). These differences resulted in markedly enhanced revenue for each eligible patient in Hospital B compared with A (735 dollars versus 174 dollars)nnnCONCLUSIONSnEnhanced collection by hospital B was a result of a higher charge, compulsive billing of all eligible patients, and emphasis on pre-admission designation of trauma patients. Effective billing and collection process related to trauma response fees results in substantial additional revenue for the trauma center without additional expense.

753-4 Transesophageal Echocardiography in Patients with Blunt Chest Trauma

Rupture of the aorta resulting from blunt chest trauma (BCT) is often fatal. Early diagnosis and surgical treatment improves the chances of survival. Transesophageal echocardiography (TEE) permits accurate and rapid visualization of the thoracic aorta and is ideal in evaluating such patients. We performed TEE as the initial diagnostic procedure in 141 patients (pts) with BCT. 90% had a widened mediastinum on chest x-ray (CXR) as an indication of possible aortic damage. 92% of studies were performed in the emergency room. Sixty pts were on mechanical ventilatory support. Passage of the scope was difficult in 2 pts. Nine developed transient hypoxemia, one requiring mechanical ventilation. Findings 116 pts (82%) had no evidence of aortic trauma on TEE. Aortic disruption was noted in 6 pts (4%). 5 of whom underwent surgery and survived. In 15 pts the findings were indeterminate. Aortogram in these pts were negative for trauma. Disruption involving the distal arch was missed in 2 pts. Both died. Conclusions (1) TEE may be safely and rapidly performed in pts with BCT despite a high proportion being critically ill. (2) Alow yield of aortic disruption is obtained when the pre-test probability is low. (3) Early identification of aortic disruption by TEE and prompt surgical management improves survival. (4) Correct identification of disruption may be difficult in some cases where there is inadequate visualization of the aorta. (5) The diagnostic accuracy in identifying aortic disruption may be improved by the newer multiplanar TEE imaging modalities and by increasing operator experience with TEE in BCT pts, making this the procedure of choice in cases of suspected aortic disruption.