Randy J. Woods

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.

Neurologic Outcomes with Cerebral Oxygen Monitoring in Traumatic Brain Injury

BACKGROUND Optimizing cerebral oxygenation is advocated to improve outcome in head-injured patients. The purpose of this study was to compare outcomes in brain-injured patients treated with 2 types of monitors. METHODS Patients with traumatic brain injury and a Glasgow Coma Scale score<8 were identified on admission. A polarographic cerebral oxygen/pressure monitor (Licox) or fiberoptic intracranial pressure monitor (Camino) was inserted. An evidence-based algorithm for treatment was implemented. Elements from the prehospital and emergency department records and the first 10 days of intensive care unit (ICU) care were collected. Glasgow Outcome Scores (GOS) were determined every 3 months after discharge. RESULTS Over a 3-year period, 145 patients were entered into the study; 81 patients in the Licox group and 64 patients in the Camino group. Mortality, hospital length of stay, and ICU length of stay were equivalent in the 2 groups. More patients in the Licox group achieved a moderate/recovered GOS at 3 months than in the Camino Group (79% vs 61%; P = .09). CONCLUSION Three-month GOS revealed a clinically meaningful 18% benefit in patients undergoing cerebral oxygen monitoring and optimization. Six-month outcomes were also better. Unfortunately, these important differences did not reach significance. Continued study of the benefits of cerebral oxygen monitoring is warranted.

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.

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.

Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax

BACKGROUND Thoracic needle decompression is lifesaving in tension pneumothorax. However, performance of subsequent tube thoracostomy is questioned. The needle may not enter the chest, or the diagnosis may be wrong. The aim of this study was to test the hypothesis that routine tube thoracostomy is not required. METHODS A prospective 2-year study of patients aged ≥18 years with thoracic trauma was conducted at a level 1 trauma center. RESULTS Forty-one patients with chest trauma, 12 penetrating and 29 blunt, had 47 needled hemithoraces for evaluation; 85% of hemithoraces required tube thoracostomy after needle decompression of the chest (34 of 41 patients [83%]). CONCLUSIONS Patients undergoing needle decompression who do not require placement of thoracostomy for clinical indications may be assessed using chest radiography, but thoracic computed tomography is more accurate. Air or blood on chest radiography or computed tomography of the chest is an indication for tube thoracostomy.

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.

Professionalism in the Twilight Zone: A Multicenter, Mixed-Methods Study of Shift Transition Dynamics in Surgical Residencies

Purpose Duty hours rules sparked debates about professionalism. This study explores whether and why general surgery residents delay departures at the end of a day shift in ways consistent with shift work, traditional professionalism, or a new professionalism. Method Questionnaires were administered to categorical residents in 13 general surgery programs in 2014 and 2015. The response rate was 76% (N = 291). The 18 items focused on end-of-shift behaviors and the frequency and source of delayed departures. Follow-up interviews (N = 39) examined motives for delayed departures. The results include means, percentages, and representative quotations from the interviews. Results A minority (33%) agreed that it is routine and acceptable to pass work to night teams, whereas a strong majority (81%) believed that residents exceed work hours in the name of professionalism. Delayed departures were ubiquitous: Only 2 of 291 residents were not delayed for any of 13 reasons during a typical week. The single most common source of delay involved a desire to avoid the appearance of dumping work on fellow residents. In the interviews, residents expressed a strong reluctance to pass work to an on-call resident or night team because of sparse night staffing, patient ownership, an aversion to dumping, and the fear of being seen as inefficient. Conclusions Resident behavior is shaped by organizational and cultural contexts that require attention and reform. The evidence points to the stunted development of a new professionalism, little role for shift-work mentalities, and uneven expression of traditional professionalism in resident behavior.

Outcomes and charges associated with outpatient inguinal hernia repair according to method of anesthesia and surgical approach

BACKGROUND We conducted this study to compare short-term outcomes and charges between methods of hernia repair and anesthesia in the outpatient setting. METHODS Using New Yorks state ambulatory surgery databases, we identified discharges for patients who underwent inguinal hernia repair. Patients were grouped by method of hernia repair. We compared hospital-based acute care encounters and total charges across groups. RESULTS Locoregional anesthesia (5.2%) experienced a similar frequency of hospital-based acute care encounters within 30 days of discharge when compared with patients receiving general (6.0%) or having a laparoscopic procedure (6.0%). Risk-adjusted charges increased across groups (locoregional =