John F. Bilello

Routine evaluation of the cervical spine in head-injured Patients with dynamic fluoroscopy : A reappraisal

BACKGROUND The mechanism for clearing the cervical spine in patients with altered mental status remains controversial. Recommendations have ranged from removal of the cervical collar after 24 hours in patients with normal radiographs, to indefinite immobilization in a cervical collar, and recently cervical flexion-extension examinations using dynamic fluoroscopy. The purpose of this study was to evaluate the efficacy and safety of dynamic fluoroscopy flexion-extension examinations in identifying ligamentous cervical spine injury and clearing the cervical spine in patients with altered mental status after trauma. METHODS Patients with a Glasgow Coma Scale score < 13 for greater than 48 hours after admission and normal cervical spine radiographs were candidates for fluoroscopic evaluation. The protocol required visualization of the entire cervical spine, through T1, through full extension and flexion under the direct supervision of a radiologist. Oblique fluoroscopic views were obtained, as necessary, to visualize the cervicothoracic junction. Demographic data, fluoroscopy time, total time per study, true and false positives and negatives, and complications were recorded. RESULTS From July 1992 through December 1999, fluoroscopic examinations were performed on 301 patients. There were 297 true-negative examinations, 2 true-positive examinations (stable injuries), 1 false-negative examination, and 1 false-positive examination. The incidence of ligamentous injury identified by fluoroscopy in this study was 2 of 301 (0.7%). Unstable cervical spine ligamentous injuries were identified in only 0.02% of all trauma patients. One patient developed quadriplegia when fluoroscopic evaluation was performed after two protocol violations. CONCLUSION Unstable cervical spine ligamentous injury without fracture is a rare occurrence. The cervical spine may be cleared after a normal cervical spine series (plain radiograph and computed tomographic scan) as recommended in the 1998 Eastern Association for the Surgery of Trauma guidelines. If dynamic fluoroscopy is to be used, adherence to the protocol, including review of the cervical spine radiographs before fluoroscopy and visualization of the entire cervical spine, C1-T1, is mandatory to ensure patient safety.

Are automated blood pressure measurements accurate in trauma patients

BACKGROUND Automated blood pressure (BP) determinations by oscillometry are reported to be as accurate as invasive monitoring for systolic pressures as low as 80 mm Hg. Automated BP devices are widely used by prehospital providers and in hospital operating rooms, emergency departments, and intensive care units, although the accuracy of automated BP has not been demonstrated in trauma patients. We hypothesized that automated BP is less accurate than manual BP in trauma patients. The purpose of this study was to determine the accuracy of automated BP versus manual BP in trauma patients. METHODS A retrospective review of patients who met trauma activation criteria admitted to a Level I trauma center over a 30-month period was conducted. Patients were included if both manual BP and automated BP were measured within 5 minutes of admission. Additional data collected included Injury Severity Score, base deficit, and emergency department resuscitation volume. Statistical analysis was performed using paired t test, chi2, and linear regression analysis. Significance was attributed to a value of p < 0.05. RESULTS From January 2000 through June 2002, 388 patients met inclusion criteria. Patients were grouped by manual BP levels: group 1, BP < or = 90 mm Hg (n = 92); group 2, BP 91-110 mm Hg (n = 119); and group 3, BP > or = 110 mm Hg (n = 177). The mean automated BP measurements were significantly higher than the manual measurements in groups 1 and 2 (26 and 16 mm Hg, respectively; p < 0.001). Of the 92 patients with manual BP < or = 90, 45 (49%) had automated BP > or = 100. The base deficit (-5, -3, and -2 for groups 1, 2, and 3, respectively; p < 0.01), Injury Severity Score (30, 25, and 18; p < 0.01), and volume of resuscitative fluid and blood (p < 0.001) all decreased with higher BP group. CONCLUSION Injury severity, degree of acidosis, and resuscitation volume were more accurately reflected by manual BP. Automated BP determinations were consistently higher than manual BP, particularly in hypotensive patients. Automated BP devices should not be used for field or hospital triage decisions. Manual BP determinations should be used until systolic blood pressure is consistently > or = 110 mm Hg.

Percutaneous tracheostomy: to bronch or not to bronch--that is the question.

BACKGROUND Percutaneous tracheostomy is a routine procedure in the intensive care unit (ICU). Some surgeons perform percutaneous tracheostomies using bronchoscopy believing that it increases safety. The purpose of this study was to evaluate percutaneous tracheostomy in the trauma population and to determine whether the use of a bronchoscope decreases the complication rate and improves safety. METHODS A retrospective review was completed from January 2007 to November 2010. Inclusion criteria were trauma patients undergoing percutaneous tracheostomy. Data collected included age, Abbreviated Injury Score by region, Injury Severity Score, ventilator days, and outcomes. Complications were classified as early (occurring within <24 hours) or late (>24 hours after the procedure). RESULTS During the study period, 9,663 trauma patients were admitted, with 1,587 undergoing intubation and admission to the ICU. Tracheostomies were performed in 266 patients and 243 of these were percutaneous; 78 (32%) were performed with the bronchoscope (Bronch) and 168 (68%) without bronchoscope (No Bronch). There were no differences between the groups in Abbreviated Injury Score by region, Injury Severity Score, probability of survival, ventilator days, and length of ICU or overall hospital stay. There were 16 complications, 5 (Bronch) and 11 (No Bronch). Early complications were primarily bleeding (Bronch 3% vs. No Bronch 4%, not statistically significant). Late complications included tracheomalacia, tracheal granulation tissue, bleeding, and stenosis; Bronch 4% versus No Bronch 3%, (not statistically significant). One major complication occurred, with loss of airway and cardiac arrest, in the bronchoscopy group. CONCLUSION Percutaneous tracheostomy was safely and effectively performed by an experienced surgical team both with and without bronchoscopic guidance with no difference in the complication rates. This study suggests that the use of bronchoscopic guidance during tracheostomy is not routinely required but may be used as an important adjunct in selected patients, such as those with HALO cervical fixation, obesity, or difficult anatomy.

Immune reconstitution inflammatory syndrome presenting as superior vena cava syndrome secondary to Coccidioides lymphadenopathy in an HIV-infected patient.

A 39-year-old man living with AIDS presented with a swollen face. He was found to be HIV infected after presenting with Coccidioides pneumonia 2 years previously and was placed on daily fluconazole and then on highly active antiretroviral therapy. Computed tomography confirmed superior vena cava obstruction secondary to lymphadenopathy. Biopsy confirmed coccidioidomycosis with no evidence of malignancy. To our knowledge, this is the first description of superior vena cave syndrome secondary to coccidioidomycosis and the first description of immune reconstitution inflammatory syndrome involving Coccidioides.

Predicting extubation failure in blunt trauma patients with pulmonary contusion.

BACKGROUND The need for reintubation after weaning from mechanical ventilation (extubation failure) is associated with increased morbidity and mortality. In blunt trauma patients with pulmonary contusion, factors predicting successful weaning have not been reliably defined. The purpose of this study was to identify criteria predicting successful extubation in these patients. METHODS Retrospective review during a 10-year period at a Level 1 trauma center was performed. A total of 173 extubations in 163 blunt trauma patients with pulmonary contusion requiring mechanical ventilation. Exclusion criteria include Glasgow Coma Scale (GCS) score of less than 9T before extubation, successful use of noninvasive positive-pressure ventilation after extubation, quadriplegia, and preextubation FIO2 of greater than 0.5. Data included age, Injury Severity Score (ISS), ventilator days, as well as GCS score, FIO2, the ratio of arterial oxygen tension to FIO2 (P/F ratio), and alveolar-arterial oxygen (A-a) difference at the time of extubation. Failure was defined as reintubation within 72 hours (excluding stridor or acute decline in GCS score). Mann-Whitney U-test, &khgr;2 analysis, and logistic regression analysis determined variables associated with extubation failure. Odds ratios were used to compare P/F and A-a values associated with failed extubation. RESULTS A total of 147 extubations (85%) were successful; 26 required reintubation. Patients did not differ by ISS, chest Abbreviated Injury Scale (AIS) score, presence of sternal or rib fractures, and admission pneumothorax or hemothorax. Increased age, A-a difference (≥120 mm Hg), and decreased P/F (<280) were associated with reintubation (p < 0.0001). By logistic regression analysis, P/F and A-a were independent variables for failed extubation; both remained independent risk factors when adjusted for age, ventilator days, GCS score, and preextubation FIO2. Using receiver operating characteristic curve inflection points for both P/F and A-a difference (area under the curve of 0.8 for both), patients with a P/F ratio less than 290 and an A-a difference of 100 mm Hg or greater were more likely to fail extubation (odds ratio, 9.2 and 8.7, respectively, p < 0.001). CONCLUSION Blunt trauma patients with pulmonary contusion who are likely to fail extubation can be reliably identified using the readily available criteria of P/F ratio less than 290 and A-a difference of 100 mm Hg or greater. LEVEL OF EVIDENCE Prognostic study, level III.

Retrograde jejunojejunal intussusception secondary to metastatic melanoma

A 59-year-old fair-skinned man presented to the emergency department with a several-day history of increasing abdominal pain and distention. The patient had lost 13.5 kg during the preceding several months. He had a large fungating mass on the left upper portion of his back, which he had allowed to grow unchecked for more than 2 years because of religious reasons. He had not passed gas for 24 hours and had tenderness without guarding in the mid abdomen. Computed tomography (with contrast) of the abdomen showed a small bowel intussusception. The patient agreed to laparotomy and wide local excision of the back mass. Laparotomy revealed a reverse jejunojejunal intussusception with a large pigmented nodule, a pigmented wall nodule nearly obstructing the ileum, and a nodule in the omentum. Both the intussusception and the ileum were resected, and stapled side-to-side anastomoses were constructed. The omental nodule was also resected. After abdominal closure, the patient was repositioned and the back lesion was widely excised. Pathological examination identified the back mass as a nodular malignant melanoma more than 15 mm deep and confirmed abdominal metastases. Computed tomography of the head, performed because the patient exhibited subtle mental status changes, revealed brain metastases. The patient was discharged to home hospice on postoperative day 4. He and his wife refused additional adjuvant therapy.

Delayed pulmonary hemorrhage 17 years after gunshot wound to the chest.

A 45-year-old male returned 17 years after a gunshot wound to the chest with intermittent hemoptysis that progressed to frank pulmonary hemorrhage. The complications of retained intrathoracic foreign bodies are briefly reviewed.

Isolated Free Fluid on Abdominal Computed Tomography in Blunt Trauma: Watch and Wait or Operate?

BACKGROUND Isolated free fluid (FF) on abdominal CT in stable blunt trauma patients can indicate the presence of hollow viscus injury. No criteria exist to differentiate treatment by operative exploration vs observation. The goals of this study were to determine the incidence of isolated FF and to identify factors that discriminate between patients who should undergo operative exploration vs observation. STUDY DESIGN A review of blunt trauma patients at a Level I trauma center from July 2009 to March 2012 was performed. Patients with a CT showing isolated FF after blunt trauma were included. Data collected included demographics, injury severity, physical examination, CT, and operative findings. RESULTS Two thousand eight hundred and ninety-nine patients had CT scans, 156 (5.4%) of whom had isolated FF. The therapeutic operative group included 13 patients; 9 had immediate operation and 4 failed nonoperative management. The nonoperative/nontherapeutic operation group consisted of 142 patients with successful nonoperative management and 1 patient with a nontherapeutic operation. Abdominal tenderness was documented in 69% of the therapeutic operative group and 23% of the nonoperative/nontherapeutic group (odds ratio = 7.5; p < 0.001). The presence of a moderate to large amount of FF was increased in the therapeutic operative group (85% vs 8%; odds ratio = 66; p < 0.001). CONCLUSIONS Isolated FF was noted in 5.4% of stable blunt trauma patients. Blunt trauma patients with moderate to large amounts of FF without solid organ injury on CT and abdominal tenderness should undergo immediate operative exploration. Patients with neither of these findings can be safely observed.

Endovascular repair of blunt aortic injury in a patient with situs inversus and dextrocardia

A 24-year-old male pedestrian with situs inversus and dextrocardia was struck by a car and sustained multiple injuries, including a pseudoaneurysm of the proximal descending thoracic aorta. A thoracic endograft was deployed to exclude the blunt aortic injury. We are not aware of any report of endovascular repair of blunt aortic injury in a patient with this congenital finding. A brief review of the literature is also included.

After the embo: predicting non-hemorrhagic indications for splenectomy after angioembolization in patients with blunt trauma

Background Successful non-operative management (NOM) of blunt splenic trauma is enhanced with splenic angioembolization (SAE). Patients may still require splenectomy post-SAE for splenic infarction/necrosis. Prior studies have used white blood cell count (WBC), platelet count (PLT), and PLT:WBC ratio after splenectomy to predict complications, but none have evaluated these findings prior to splenectomy in patients who have undergone SAE. Changes in these values may indicate clinically significant splenic infarction, facilitating management of these patients. Methods Patients admitted to an American College of Surgeons verified level 1 trauma center from January 2007 to August 2017 who underwent SAE were identified. Patients with successful NOM after SAE (SAE/NOM) were compared with those requiring splenectomy (SAE/SPLEN). Data included demographics, splenic injury grade, Injury Severity Score (ISS), time to SAE and splenectomy, intensive care unit and hospital length of stay (LOS), and complete blood count. Lab values were analyzed immediately post-SAE (time 1) and day 5 post-SAE (or day of discharge) for SAE/NOM patients and day of SPLEN for SAE/SPLEN patients (time 2). Data were analyzed using Mann-Whitney U, χ2 tests, and receiver operating characteristic (ROC) curves with significance attributed to P<0.05. Results Of 124 patients undergoing SAE, 16 (13%) later required SPLEN for infarction/necrosis at a median of 5 days post-SAE (IQR: 3–10 days). SAE/SPLEN and SAE/NOM patients did not differ by age, gender, ISS, or grade of splenic injury. SAE/SPLEN patients had longer hospital LOS (23 vs. 10 days, P<0.001). WBC, PLT, and PLT:WBC ratio did not differ between the groups at time 1. At time 2, WBC was higher and PLT:WBC ratio was lower in SAE/SPLEN patients. Using ROC curves at time 2, the area under the curve was 0.90 (P<0.001) for WBC and 0.71 (P<0.007) for PLT:WBC ratio. Discussion Patients requiring splenectomy for clinically significant infarction/necrosis after SAE develop leukocytosis and decreased PLT:WBC ratio when compared with SAE/NOM patients. Monitoring these parameters allows more prompt diagnosis and operative intervention. Level of evidence Therapeutic/care management, level III.