S. A. Deane

Clinical examination is an inaccurate predictor of intraabdominal pressure.

This study was designed to establish if clinical examination can accurately predict intraabdominal pressure (IAP). Between August 1998 and March 2000 a prospective blinded observational study of postoperative intensive care unit patients was undertaken at a major trauma center. IAP was measured using an intravesicular technique and compared with clinical evaluation. An IAP of at least 18 mmHg was considered elevated. The sensitivity, specificity, positive predicative value (npv), negative predictive value (npv), kappa score, and reliability analysis were calculated. A total of 110 patients provided 150 estimates of IAP, which was elevated in 21%. The kappa score was 0.37; sensitivity, 60.9%; specificity, 80.5%; ppv, 45.2%; npv, 88.6%. The mean difference in IAP values between intravesicular readings and clinical estimates was −1.0±4.1. Prediction of IAP using clinical examination is not accurate enough to replace intravesicular IAP measurements.RésuméLe but de cette étude a été d’établir si l’examen clinique peut prédire avec précision la pression intra-abdominale (PIA). Entre août 1998 et mars 2000 on a entrepris une étude observationnelle prospective à l’insu des patients post-opératoires en soins intensifs (SI) hospitalisés dans un centre de traumatologie majeure. La PIA a été mesurée par la technique intravésicale et comparée à l’évaluation clinique. On a considéré qu’une PIA ≥ 18 mmHg était «élevée». On a calculé la sensibilité (Se), la spécificité (Sp), la valeur prédictive positive (VPP), la valeur prédictive négative (VPN), le score kappa, et la fiabilité. On a estimé cliniquement la PIA 150 fois chez 110 patients. La PIA était élevée dans 21% des cas. Le score Kappa a été de 0.37, la Se de 60.9%, la Sp, de 80.5%, la VPP de 45.2%, la VPN, de 88.6%. La différence moyenne en PIA entre la valeur intra-vésicale et l’estimation clinique a été de −1.0±4.1. La prédiction de la PIA par examen clinique n’est pas suffisamment précise pour remplacer la mesure par pression intravésicale.ResumenEl objetivo del estudio fue averiguar si la exploración clínica permite evaluar con exactitud la presión intraabdominal (IAP). Entre agosto de 1998 y marzo de 2000, se efectuó un estudio prospective ciego, durante el postoperatorio de pacientes ingresados en la UCI de un Centro Traumatológico de referencia. La IAP se midió mediante la técnica intravesical comparandose con los hallazgos clínicos obtenidos. Se consideró que la presión estaba elevada cuando la IAP era ≥18 mm Hg. Comprobamos: la sensibilidad, especificidad, valor predictivo positivo (ppv) y negativo (npv), la puntuación de Kappa y la fiabilidad de los análisis. La puntuación de Kappa fue de 0.37, la sensibilidad del 60.9%, especificidad 80.5%, ppv 45.2% y npv 88.6%. La diferencia media entre los valores de la IAP registrados mediante sonda intravesical y los estimados por la exploración clínica fueron de −1.0±4.1. La valoración clínica de la IAP no es lo suficientemente precisa como para reemplazar la medición intravesical.

Prospective evaluation of early missed injuries and the role of tertiary trauma survey.

BACKGROUND This study prospectively evaluated the prevalence, clinical significance, and contributing factors to early missed injuries and the role of tertiary survey in minimizing frequency of missed injuries in admitted trauma patients. Missed injury, clinically significant missed injury, tertiary survey, and contributing factors were defined. Tertiary survey was conducted within 24 hours. RESULTS Of 206 patients, 134 patients (65%) had 309 missed injuries composing 39% of all 798 injuries seen. Tertiary trauma survey detected 56% of early missed injuries and 90% of clinically significant missed injuries within 24 hours. Clinically significant missed injuries occurred in 30 patients with complications in 11 patients and death in two patients. Of 224 contributing errors, 123 errors were in clinical assessment, 83 errors were in radiology, 14 errors were patient related, and four errors were technical. The missed injury rate was significantly higher in patients with multiple injuries and in those involved in road crashes. CONCLUSIONS Secondary trauma survey is not a definitive assessment and should be supplemented by tertiary trauma survey.

Head injury and facial injury: is there an increased risk of cervical spine injury?

A series of 8285 blunt trauma victims from one hospital were analyzed to establish the possible association of cervical spine injuries with craniocerebral and facial injuries. Patients with clinically significant head injuries were at greater risk of cervical spine injuries than those without head trauma (4.5% vs. 1.1%, significant by Chi-squared analysis). Patients with Glasgow Coma Scale scores of 8 or less were at even greater risk of cervical spine injuries (7.8%). Facial injuries were not associated with cervical spine injuries. Procedures to achieve airway control in patients with serious head injuries must reflect these findings so that protection is afforded to the cervical spine during trauma resuscitation.

Intraabdominal Pressure and Gastric Intramucosal pH: Is There an Association?

Abstract. This study evaluated the potential association between increased intraabdominal pressure (IAP) and abnormally low gastric intramucosal pH (pHi) (≤ 7.32) in postoperative patients and assessed its effect on patient outcome. Altogether 73 patients undergoing major abdominal surgery over a 9-month period were studied prospectively. All underwent gastric tonometry and intravesical IAP measurements three time daily. An IAP of ≥ 20 mmHg and a pHi of ≤ 7.32 were considered abnormal. The development of the following complications were also documented: hypotension [mean aortic pressure (MAP) < 80 mmHg], abdominal sepsis, renal impairment, and death. The median APACHE II score was 16 (range 5–34). Twenty-two patients had upper gastrointestinal (GI) surgery, 27 lower GI surgery, and 24 aortic surgery; 44 of these patients underwent emergency surgery. Abnormal pHi (≤ 7.32) occurred in 36 patients while on the intensive care unit. Compared to patients with normal pHi, abnormal pHi patients were 11.3 times (3.2–43.5) [odds ratio ± 95% CI] more likely to have an increased IAP. Abnormal pHi was significantly associated with hypotension (χ 2 = 6.8;p = 0.009), sepsis (χ2 = 3.7;p = 0.06), renal impairment (χ2 = 28.3;p = 0.0000001), relaparotomy (χ2 = 4.1;p = 0.04), and death (χ2 = 9.7;p = 0.002). This study demonstrated a significant clinical association between increased IAP and abnormal pHi. An abnormally low pHi was associated with poor outcome.

Thyroglossal and Branchial Cleft Cysts and Sinuses

Cysts of the neck are usually congenital, with either thyroglossal or branchial cleft origin. The diagnosis is made on the basis of the physical findings. In both of these entities, total excision of the tracts is essential to minimize the likelihood of recurrence.

Sternal fractures : associated injuries and management

Prospective data from blunt trauma victims admitted to one hospital were analyzed to determine the significance of sternal fractures and possible associated injuries. A total of 12,618 patients were admitted over a 6 1/2 year period, of whom 2226 (17.6%) were injured while in a motor vehicle. One hundred seventy-two sternal fractures were recorded with 152 (89%) occurring in motor vehicle occupants. Vehicle occupants with sternal fractures included a greater proportion of patients over 50 years (56% vs. 11%), more females (55% vs. 34%) and more seat belt wearers (70% vs. 40%). There was no association with serious visceral chest injury (including cardiac contusion). There was an association with thoracic spine fractures (Chi-squared 5.871, df = 1, p < 0.05). Sternal fractures in motor vehicle occupants were associated with less injury overall (median ISS = 5.5) compared with those without sternal fractures (median ISS = 13). Assessment of such patients should include age and injury mechanism to reduce the rate of admission and investigation of patients whose sole injury is a sternal fracture without significant pain.

Temporary abdominal closure : A prospective evaluation of its effects on renal and respiratory Physiology

This study prospectively analyzed outcomes in 49 consecutive patients undergoing temporary abdominal closure (TAC) between 1993 and 1996 at a single university hospital. There were 37 males and 12 females, mean age was 57 years (range, 25-79 years), mean Acute Physiology and Chronic Health Evaluation score was 27 (+7.8 SD), and mean Simplified Acute Physiology II score was 53.0 (+/-15.4). The reason for TAC was decompression in 22 patients, inability to close the abdomen in 10 patients, to facilitate reexploration for sepsis in 8 patients, and multifactorial in 9 patients. After TAC, there was a significant reduction in intra-abdominal pressure from 24.2+/-9.3 to 14.1+/-5.5 mm Hg and improvement in lung dynamic compliance from 24.1+/-7.9 to 27.6+/-9.4 mL/cm H2O (p < 0.05). Although 10 patients experienced brisk diuresis, there was no significant improvement in renal function; in fact, serum creatinine increased. The median length of stay was 35 days (range, 1-232 days). The mean number of abdominal operations after mesh insertion was 2.6+/-2.4. There were 21 deaths, for a standardized mortality rate of 0.80. Although it achieved significant reductions in abdominal pressures and improved lung dynamic compliance, TAC did not result in improved renal function or patient oxygenation.

A prospective study of the performance of the trauma team leader.

This study assessed the performance of the trauma team leader in 50 consecutive trauma resuscitations at Liverpool Hospital over a two-month period. The trauma team consists of intensive care (ICU), emergency, and surgical registrars, three nurses, a wardsman, a radiographer, and a social worker. The team leader position alternates between the ICU and emergency registrar on a fortnightly roster. A panel of specialists experienced in trauma management evaluated 38 aspects of the initial resuscitation. Individual variables received different weightings. The maximum possible score for team leader performance was 80. The mean team leader score was 70.4 +/- 8 (SD). The main deficiencies in the team leaders performances were in their interpersonal communications and in the adequacy of documentation of the history of the injury. In 20% of resuscitations there were failures to completely expose the patient. Medical skills were uniformly well performed. Poor communication with other team members were the main pitfall of the team leader in this study. The team leader score may prove a useful tool in improving the quality of the trauma team.

The hospital trauma team: a model for trauma management.

A triage system was established as the initiating mechanism for a trauma team response to assist the assessment and early management of patients presenting to an accident and emergency department. A checklist of triage criteria was used. During a 6-month period, 342 patients (29.7% of trauma admissions) satisfied the triage criteria, which should have resulted in an average of 1.9 trauma team calls per day. Staff compliance with the triage tool was 75.4%. The overtriage rate for the checklist criteria was 52.7%. The triage tool identified patients with severe injuries who were not initially considered sufficiently injured to justify initiation of the trauma team response. The sensitivity of the triage tool in identifying patients with serious injury was 95.0%. Comparison of the review with a similar review performed 12 months earlier demonstrated that staff compliance with initiating the trauma team response had improved. Using data from 564 patients from both series, logistic regression analysis of the power of the triage criteria to predict serious injury contributed to a revision of the triage criteria. This trauma triage tool and trauma team response constitute a valid approach to the early hospital management of trauma patients. This system may be more appropriate or achievable in many hospitals than the construction of dedicated trauma reception units or permanent surgical staffing of general Accident and Emergency departments.

Trauma outcomes: a death analysis study.

Survival and mortality outcomes for trauma patients admitted to Liverpool Hospital, Sydney were analysed to determine the adequacy of trauma care. TRISS and ASCOT survival probabilities and peer review were utilised to determine if deaths were avoidable. Evaluation methods were compared for assessment of care. During the study period 2205 trauma patients were admitted, 518 of which fulfilled the study entry criteria. There were 38 deaths. The age and Injury Severity Score (ISS) of survivors was 34 ±18 years, 9.8 ±9 (mean±sd) compared to age and ISS for nonsurvivors 37 ± 22 years and 45 ± 22*, *p<0.001. Peer review suggested that 32 deaths were non avoidable, 4 potentially avoidable and 2 were probably avoidable. TRISS and ASCOT survival probabilities were > 0.5 in 16 and 18 patients respectively. TRISS and ASCOT had low positive predictive value (25%) in identifying avoidable deaths. The Z Score was 1.79. The standardised mortality ratio (SMR) was 1.16. The Effectiveness (E) value for outcome was 0.91. Poor communication within the Area Trauma System was the greatest contributor to avoidable deaths. All trauma deaths need peer review rather than solely relying upon ASCOT and TRISS probabilities to identify “unexpected” deaths for detailed review.