Lawrence P. Sue

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.

Post-extubation dysphagia in trauma patients: it's hard to swallow

BACKGROUND There is a significant incidence of unrecognized postextubation dysphagia in trauma patients. The purpose of this study was to evaluate the incidence, ascertain the risk factors, and identify patients with postextubation dysphagia who will require clinical swallow evaluation. METHODS A prospective observational study was performed on 270 trauma patients. Bedside clinical swallow evaluation was done within 24 hours of extubation. Logistic regression analysis was used to adjust for confounding variables. RESULTS The incidence of oropharyngeal dysphagia (OD) in our study was 42%. Ventilator days was the strongest independent risk factor for OD (3.6 vs 8.0, P < .001). The odds ratio showed a 25% risk for OD for each additional ventilator day. Silent aspiration was found in 37% of patients with OD. CONCLUSIONS Trauma patients requiring mechanical ventilation for ≥2 days are at increased risk for dysphagia and should undergo routine swallow evaluations after extubation.

Iliofemoral venous injuries: an indication for prophylactic caval filter placement.

Prophylactic placement of vena caval filters is recommended in trauma patients at high risk for pulmonary embolism (PE). We present a group of patients with iliofemoral venous trauma, and subsequent complications of deep venous thrombosis (DVT) and PE. Of twelve patients with iliac or common femoral venous injuries, seven underwent primary repair. All received DVT/ PE prophylaxis with mini-dose heparin and/or sequential compression hose. In spite of this, two patients suffered DVT, one patient had DVT and PE and one patient had clinical evidence of PE but did not undergo confirmatory testing. Three patients underwent prophylactic caval filter placement without complication. The DVT/PE complication rate in this small group was at least 43% (3 of 7). Patients with repaired iliofemoral venous injuries represent a high risk subset for DVT/PE and prophylactic caval filter placement is recommended.

An acute care surgery fellowship benefits a general surgical residency.

BACKGROUND There has been a trend toward subspecialization among general surgery graduates, and many subspecialists are reticent to participate in trauma care. This has resulted in a gap in the provision of emergency surgical care. The Acute Care Surgery (ACS) fellowship, incorporating trauma, critical care, and emergency general surgery, was developed to address this need. One of the most important aspects in establishing these ACS fellowships is that they do not detract from the existing general surgery residents’ experience. METHODS The operative case logs for residents and fellows were compared for the number of resident cases during the 3 years before the ACS fellowship and during the 3 years after the fellowship was established. Surveys were distributed to the general surgery residents addressing the impact of the fellows from the resident’s perspective at the end of the 2011 to 2012 academic year. RESULTS There was no significant change in the number of total cases; total chief resident cases; and trauma, thoracic, or vascular procedures done per graduate. A decrease in the number of liver cases performed by the residents was noted but includes the increase in resident complement as well as the fellowship. ACS fellow cases increased from 172 cases in the first year to 221 cases in the second year and 295 in the third year. The survey showed that the residents had a very positive response to having the fellow as a teacher and did not feel like their operative experience was compromised with the addition of the ACS fellowship. CONCLUSION The ACS fellow did not compromise general surgery resident experience and was regarded as an asset to the resident’s education. An ACS fellowship can be beneficial to residents and fellows. LEVEL OF EVIDENCE Care management study, level IV.

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.

Attempting to validate the overtriage/undertriage matrix at a Level I trauma center

BACKGROUND The Optimal Resources Document mandates trauma activation based on injury mechanism, physiologic and anatomic criteria and recommends using the overtriage/undertriage matrix (Matrix) to evaluate the appropriateness of trauma team activation. The purpose of this study was to assess the effectiveness of the Matrix method by comparing patients appropriately triaged with those undertriaged. We hypothesized that these two groups are different, and Matrix does not discriminate the needs or outcomes of these different groups of patients. METHODS Trauma registry data, from January 2013 to December 2015, at a Level I trauma center, were reviewed. Overtriage and undertriage rates were calculated by Matrix. Patients with Injury Severity Score (ISS) of 16 or greater were classified by activation level (full, limited, consultation), and triage category by Matrix. Patients in the limited activation and consultation groups were compared with patients with full activation by demographics, injuries, initial vital signs, procedures, delays to procedure, intensive care unit admission, length of stay, and mortality. RESULTS Seven thousand thirty-one patients met activation criteria. Compliance with American College of Surgeons tiered activation criteria was 99%. The Matrix overtriage rate was 45% and undertriage was 24%. Of 2,282 patients with an ISS of 16 or greater, 1,026 were appropriately triaged (full activation), and 1,256 were undertriaged. Undertriaged patients had better Glasgow Coma Scale score, blood pressure, and base deficit than patients with full activation. Intensive care unit admission, hospital stays, and mortality were lower in the undertriaged group. The undertriaged group required fewer operative interventions with fewer delays to procedure. CONCLUSION Despite having an ISS of 16 or greater, patients with limited activations were dissimilar to patients with full activation. Level of activation and triage are not equivalent. The American College of Surgeons Committee on Trauma full and tiered activation criteria are a robust means to have the appropriate personnel present based on the available prehospital information. Evaluation of the process of care, regardless of level of activation, should be used to evaluate trauma center performance. LEVEL OF EVIDENCE Therapeutic and care management, level III.