Scott H. Norwood

Temporary intravenous bag silo closure in severe abdominal trauma.

Several temporary abdominal wall closure techniques have been described in the literature. We present our experience with an inexpensive and efficient method of temporary abdominal closure when bowel edema and distension preclude safe primary closure. Our technique is a variation of the silon (silo) closure used in the repair of gastroschisis and omphalocele, using a pre-gas-sterilized, soft 3-L plastic cystoscopy fluid irrigation bag cut to an oval shape and stapled or sutured to the skin edges of the wound.

Incidence of Tracheal Stenosis and Other Late Complications After Percutaneous Tracheostomy

ObjectiveTo determine the incidence of tracheal stenosis, voice and breathing changes, and stomal complications after percutaneous dilatational tracheostomy (PDT). MethodsFrom December 1992 through June 1999, 420 critically ill patients underwent 422 PDTs. There were 340 (81%) long-term survivors, 100 (29%) of whom were interviewed and offered further evaluation by fiberoptic laryngotracheoscopy (FOL) and tracheal computed tomography (CT). Tracheal stenosis was defined as more than 10% tracheal narrowing on transaxial sections or coronal and sagittal reconstruction views. Forty-eight patients agreed to CT evaluation; 38 patients also underwent FOL. CT and FOL evaluations occurred at 30 ± 25 (mean ± standard deviation) months after PDT. ResultsTwenty-seven (27%) patients reported voice changes and 2 (2%) reported persistent severe hoarseness. Vocal cord abnormalities occurred in 4/38 (11%) patients, laryngeal granuloma in 1 (3%) patient, focal tracheal mucosal erythema in 2 (5%) patients, and severe tracheomalacia/stenosis in 1 (2.6%) patient. CT identified mild (11–25%) stenosis in 10 (21%) asymptomatic patients, moderate (26–50%) stenosis in 4 (8.3%) patients, 2 who were symptomatic, and severe (>50%) stenosis in 1 (2%) symptomatic patient. Ten patients (10%) reported persistent respiratory problems after tracheal decannulation, but only four agreed to be studied. Two patients had moderate stenosis, and one had severe stenosis. One patient’s CT scan was normal. No long-term stomal complications were identified or reported. ConclusionsSubjective voice changes and tracheal abnormalities are common after endotracheal intubation followed by PDT. Long-term follow-up of critically ill patients identified a 31% rate of more than 10% tracheal stenosis after PDT. Symptomatic stenosis manifested by subjective respiratory symptoms after decannulation was found in 3 of 48 (6%) patients.

A prehospital glasgow coma scale score < or = 14 accurately predicts the need for full trauma team activation and patient hospitalization after motor vehicle collisions.

BACKGROUND Trauma team activation protocols should ideally minimize the undertriage of seriously injured patients and eliminate unnecessary activations for those patients that do not require hospitalization. This study examined which physiologic parameter(s) most reliably predicted the need for hospitalization after motor vehicle collisions (MVCs). METHODS A prehospital triage tool using standard physiologic parameters was developed and prospectively analyzed for reliability in predicting subsequent patient admission at a Level II trauma center after MVCs. Data were collected on 4,014 consecutive patients, 2,880 (72%) of whom had all of the physiologic parameters reported and recorded. Patients who arrived in extremis, who were dead on arrival, or who died shortly after arrival despite appropriate trauma team activation were ineligible for the study. Multivariate stepwise logistic regression analysis was used to determine which parameters were associated with hospital admission. RESULTS The Glasgow Coma Scale (GCS) score was the only prehospital physiologic parameter providing a clinically identifiable difference between those patients admitted (13 +/- 4) and those discharged to home (15 +/- 0.5) (mean + SD) (relative risk for hospitalization, 2.24; 95% confidence interval, 1.86-2.70 for GCS score < 14). CONCLUSION The prehospital GCS score is a reliable physiologic parameter for predicting hospital admission after MVC. When obvious indicators (hypoxemia, multiple long bone fractures, focal neurologic deficits) for trauma team activation are lacking, the prehospital GCS score may be used to reduce overtriage and undertriage rates.

Blunt traumatic occult pneumothorax: is observation safe?--results of a prospective, AAST multicenter study.

BACKGROUND An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma patients. Indications for intervention remain controversial. We sought to determine which factors predicted failed observation in blunt trauma patients. METHODS A prospective, observational, multicenter study was undertaken to identify patients with OPTX. Successfully observed patients and patients who failed observation were compared. Multivariate logistic regression was used to identify predictors of failure of observation. OPTX size was calculated by measuring the largest air collection along a line perpendicular from the chest wall to the lung or mediastinum. RESULTS Sixteen trauma centers identified 588 OPTXs in 569 blunt trauma patients. One hundred twenty-one patients (21%) underwent immediate tube thoracostomy and 448 (79%) were observed. Twenty-seven patients (6%) failed observation and required tube thoracostomy for OPTX progression, respiratory distress, or subsequent hemothorax. Fourteen percent (10 of 73) failed observation during positive pressure ventilation. Hospital and intensive care unit lengths of stay, and ventilator days were longer in the failed observation group. OPTX progression and respiratory distress were significant predictors of failed observation. Most patient deaths were from traumatic brain injury. Fifteen percentage of patients in the failed observation group developed complications. No patient who failed observation developed a tension PTX, or experienced adverse events by delaying tube thoracostomy. CONCLUSION Most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy; however, OPTX progression and respiratory distress are independently associated with observation failure.

A multivariate logistic regression analysis of risk factors for blunt cerebrovascular injury

INTRODUCTION The diagnosis of blunt cerebrovascular injuries (BCVI) has improved with widespread adaptation of screening protocols and more accurate multi-detector computed tomography (MDCT-A) angiography. The population at risk and for whom screening is indicated is still controversial. To help determine which blunt trauma patients would best benefit from screening we performed a comprehensive analysis of risk factors associated with BCVI. METHODS All patients with BCVI from June 12, 2000 (the date at which our institution began screening for these injuries) to June 30, 2009 were identified by the primary author (JDB) and recorded in a prospective database. Associated injuries were identified retrospectively by International Classification of Diseases, Ninth Revision (ICD-9) code and compared with similar patients without BCVI. Demographic information was also compared from data obtained from the trauma registry. Univariate analyses exploring associations between individual risk factors and BCVI were performed using Fishers exact test for dichotomous variables and Students t test for continuous variables. Additionally, relative risk (RR) was calculated for dichotomous variables to describe the strength of the relationship between the categorical risk factors and BCVI. Multivariate logistic regression models for BCVI, BCAI (blunt internal carotid artery injury), and BVAI (blunt vertebral artery injury) were developed to explore the relative contributions of the various risk factors. RESULTS One hundred two patients with BCVI were identified out of 9935 blunt trauma patients admitted during this time period (1.03% incidence). Fifty-nine patients (0.59% incidence) had a BVAI and 43 patients (0.43% incidence) had a BCAI. Univariate analysis found cervical spine fracture (CSI) (RR = 10.4), basilar skull fracture (RR = 3.60), and mandible fracture (RR = 2.51) to be most predictive of the presence of BCVI (P < .005). Independent predictors of BCVI on multivariate logistic regression were CSI (OR = 7.46), mandible fracture (OR = 2.59), basilar skull fracture (OR = 1.76), injury severity score (ISS) (OR = 1.05), and emergency department Glasgow Coma Scale (ED-GCS) (OR = 0.93): all P < .05. CONCLUSIONS Blunt trauma patients with a high risk mechanism and a low GCS, high injury severity score, mandible fracture, basilar skull fracture, or cervical spine injury are at high risk for BCVI should be screened with MDCT-A.

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: A multi-center study of the american association for the surgery of trauma

BACKGROUND Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Ventilator-associated pneumonia is more common and of less consequence in trauma patients compared with other critically ill patients.

BACKGROUND Ventilator-associated pneumonia (VAP) incidence is used as a quality measure. We hypothesized that patient and provider factors accounted for the higher incidence of VAP in trauma patients compared with other critically ill patients. METHODS We conducted a 2-year study of all intubated adult patients at our Trauma Center. VAP was identified according to the Centers for Disease Control and Prevention definition. Groups were compared for the incidence of VAP and outcomes. RESULTS The cohort of 2,591 patients included 511 trauma patients and 2,080 nontrauma patients. VAP occurred in 161 patients and more frequently in trauma patients (17.8% vs. 3.4%, p < 0.001). The overall death rate (17.4% vs. 9.8%, p < 0.001) and the death rate for VAP patients (31.4% vs. 11%, p = 0.002) was higher in the nontrauma group. Bronchoalveolar lavage was performed more frequently in the trauma patient group (22.1% vs. 8.9%, p < 0.001), and gram-negative organisms were isolated more commonly in trauma patients (65.9% vs. 30%, p < 0.001), respectively. VAP occurred earlier among the trauma group (mean 8.9 days vs. 14.1 days, p < 0.001). Trauma represented an odds ratio of 3.9 (95% confidence interval 2.4-6.3, p < 0.001) for the development of VAP. CONCLUSION The incidence of VAP is greatest among trauma patients at our institution. The increased use of bronchoalveolar lavage, the earlier onset of VAP, and the higher incidence of gram-negative pneumonias suggest that both patient and provider factors may influence this phenomenon. VAP was associated with increased mortality in the nontrauma group only. These factors should be considered before VAP is applied as a quality indicator.

An evaluation of multidetector computed tomography in detecting pancreatic injury: results of a multicenter AAST study.

BACKGROUND Efforts to determine the suitability of low-grade pancreatic injuries for nonoperative management have been hindered by the inaccuracy of older computed tomography (CT) technology for detecting pancreatic injury (PI). This retrospective, multicenter American Association for the Surgery of Trauma-sponsored trial examined the sensitivity of newer 16- and 64-multidetector CT (MDCT) for detecting PI, and sensitivity/specificity for the identification of pancreatic ductal injury (PDI). METHODS Patients who received a preoperative 16- or 64-MDCT followed by laparotomy with a documented PI were enrolled. Preoperative MDCT scans were classified as indicating the presence (+) or absence (-) of PI and PDI. Operative notes were reviewed and all patients were confirmed as PI (+), and then classified as PDI (+) or (-). As all patients had PI, an analysis of PI specificity was not possible. PI patients formed the pool for further PDI analysis. As sensitivity and specificity data were available for PDI, multivariate logistic regression was performed for PDI patients using the presence or absence of agreement between CT and operative note findings as an independent variable. Covariates were age, gender, Injury Severity Score, mechanism of injury, presence of oral contrast, presence of other abdominal injuries, performance of the scan as part of a dedicated pancreas protocol, and image thickness < or =3 mm or > or =5 mm. RESULTS Twenty centers enrolled 206 PI patients, including 71 PDI (+) patients. Intravenous contrast was used in 203 studies; 69 studies used presence of oral contrast. Eight-nine percent were blunt mechanisms, and 96% were able to have their duct status operatively classified as PDI (+) or (-). The sensitivity of 16-MDCT for all PI was 60.1%, whereas 64-MDCT was 47.2%. For PDI, the sensitivities of 16- and 64-MDCT were 54.0% and 52.4%, respectively, with specificities of 94.8% for 16-MDCT scanners and 90.3% for 64-MDCT scanners. Logistic regression showed that no covariates were associated with an increased likelihood of detecting PDI for either 16- or 64-MDCT scanners. The area under the curve was 0.66 for the 16-MDCT PDI analysis and 0.77 for the 64-MDCT PDI analysis. CONCLUSION Sixteen and 64-MDCT have low sensitivity for detecting PI and PDI, while exhibiting a high specificity for PDI. Their use as decision-making tools for the nonoperative management of PI are, therefore, limited.

A randomized, double-blinded, placebo-controlled pilot trial of anticoagulation in low-risk traumatic brain injury: The Delayed Versus Early Enoxaparin Prophylaxis I (DEEP I) study.

BACKGROUND Our group has created an algorithm for venous thromboembolism prophylaxis after traumatic brain injury (TBI), which stratifies patients into low, moderate, and high risk for spontaneous injury progression and tailors a prophylaxis regimen to each arm. We present the results of the Delayed Versus Early Enoxaparin Prophylaxis I study, a double-blind, placebo-controlled, randomized pilot trial on the low-risk arm. METHODS In this two-institution study, patients presenting within 6 hours of injury with prespecified small TBI patterns and stable scans at 24 hours after injury were randomized to receive enoxaparin 30 mg bid or placebo from 24 to 96 hours after injury in a double-blind fashion. An additional computed tomography scan was obtained on all subjects 24 hours after starting treatment (and therefore 48 hours after injury). The primary end point was the radiographic worsening of TBI; secondary end points were venous thromboembolism occurrence and extracranial hemorrhagic complications. RESULTS A total of 683 consecutive patients with TBI were screened during the 28 center months. The most common exclusions were for injuries larger than the prespecified criteria (n = 199) and preinjury anticoagulant use (n = 138). Sixty-two patients were randomized to enoxaparin (n = 34) or placebo (n = 28). Subclinical, radiographic TBI progression rates on the scans performed 48 hours after injury and 24 hours after start of treatment were 5.9% (95% confidence interval [CI], 0.7–19.7%) for enoxaparin and 3.6% (95% CI, 0.1–18.3%) for placebo, a treatment effect difference of 2.3% (95% CI, −14.42–16.5%). No clinical TBI progressions occurred. One deep vein thrombosis occurred in the placebo arm. CONCLUSION TBI progression rates after starting enoxaparin in small, stable injuries 24 hours after injury are similar to those of placebo and are subclinical. The next Delayed Versus Early Enoxaparin Prophylaxis studies will assess efficacy of this practice in a powered study on the low-risk arm and a pilot trial of safety of a 72-hour time point in the moderate-risk arm. LEVEL OF EVIDENCE Therapeutic study, level II.

Infectious Disease Consultation and Microbiologic Surveillance for Intensive Care Unit Trauma Patients: A Pilot Study

Infection remains a major cause of posttrauma morbidity. We retrospectively reviewed 2 cohorts of trauma patients admitted to a regional trauma center before and after a policy change integrating prospective microbiologic surveillance and infectious disease (ID) consultation into management of trauma admissions. Primary interests were effects of this policy change on antimicrobial use and diagnostic precision (particularly differentiation of infection from colonization). Associated costs, microflora, survival, and disability were also compared. Patients were stratified for risk of infection. ID consultation was associated with a 49% increased odds that an infection diagnosis was microbiologically based (P=.006) and 57% reduction of antibiotics costs per hospitalized day (P=.0008). Costs of consultation and an 86% increase (P<10(-6)) in total cultures combined to minimally exceed that financial saving. The observed improvements in diagnostic precision and antimicrobial usage, however, suggest consideration of prospective microbiologic surveillance and multidisciplinary physician teams including ID physicians for high-risk trauma patients.