Timing of venous thromboembolism chemoprophylaxis after traumatic brain injury.

OBJECTIVES: Currently no national standard exists on optimal timing to initiate VTE chemoprophylaxis after traumatic brain injury (TBI). We designed this survey to assess current practice regarding the timing of VTE chemoprophylaxis after TBI. METHODS: All the EAST members were surveyed online. Participants reported demographics, and responses to questions regarding VTE chemoprophylaxis in TBI and timing of chemoprophylaxis in 2 hypothetical clinical scenarios of TBI. RESULTS: Three hundred and ninety-one full responses were collected (response rate 30.9%). Most respondents (75%) reported the decision to initiate VTE chemoprophylaxis with a consensus between the neurosurgery and trauma/critical care services. While 76% of respondents reported experience of seeing pulmonary embolism without chemoprophylaxis, 44% witnessed progression of TBI after VTE chemoprophylaxis. Approximately 50% considered their practice of VTE chemoprophylaxis in TBI patients to be conservative. Almost 50% reported no standardized protocol in their institutions. While 1/3 of the members believed guidelines exist, another 1/3 believed no guidelines available. Responses to two clinical scenarios showed various approaches regarding the timing of VTE chemoprophylaxis. CONCLUSIONS: Currently there is a wide variability in the practice patterns regarding the timing of VTE chemoprophylaxis in TBI patients. This survey reinforces the need for further investigation to guide clinical practice.

Revisiting endotracheal self-extubation in the surgical and trauma intensive care unit: Are they all fine?

OBJECTIVES: Endotracheal self-extubation (ESE) is a serious health care concern. We designed this study to test our hypothesis that not all patients with ESE are successful in spontaneous breathing and reintubation has negative impact on outcomes. METHODS: Data on all 39 patients of ESE in our surgical and trauma intensive care unit (ICU) in 2012 were prospectively collected and retrospectively analyzed. RESULTS: There were 42 episodes of ESE in 39 of 939 intubated patients (frequency, 4.0%), with 54% of events requiring reintubation. Pre-ESE positive end-expiratory pressure was higher and Pao2/fraction of inspired oxygen ratio was lower, and the post-ESE respiration rate was higher in the reintubated group. On univariate analysis, weaning and spontaneous breathing trial before ESE were favorable predictors for nonreintubation. Multivariate regression analysis demonstrated that agitation before ESE was an independent predictor of reintubation. The need for reintubation was associated with increased risk of pulmonary infectious complications, ventilator days, the need for tracheostomy, and ICU and hospital LOS. The financial costs for ventilator days and ICU rooms were significantly higher in patients with reintubation. CONCLUSION: Not all patients were fine after ESE. We have not decreased the frequency of ESE or improved outcomes if the patients were reintubated. The need for reintubation was not only associated with a high pulmonary complication rate but also prolonged duration on mechanical ventilation and hospital/ICU stay and increased the hospital costs.

Do we really rely on fast for decision-making in the management of blunt abdominal trauma?

INTRODUCTION: The Focused Assessment with Sonography in Trauma examination (FAST) is currently taught and recommended in the ATLS(®), often as an addendum to the primary survey for patients with blunt abdominal trauma. Although it is non-invasive and rapidly performed at bedside, the utility of FAST in blunt abdominal trauma has been questioned. We designed this study to examine our hypothesis that FAST is not an efficacious screening tool for identifying intra-abdominal injuries. METHODS: We performed a retrospective chart review of all patients with confirmatory diagnosis of blunt abdominal injuries with CT and/or laparotomy for a period of 1.5 years (from 7/2009 to 11/2010). FAST was performed by ED residents and considered positive when free intra-abdominal fluid was visualized. Abdominal CT, or exploratory laparotomy findings were used as confirmation of intra-abdominal injury. RESULTS: A total of 1671 blunt trauma patients were admitted to and evaluated in the Emergency Department during a 1½ year period and 146 patients were confirmed intra-abdominal injuries by CT and/or laparotomy. Intraoperative findings include injuries to the liver, spleen, kidneys, and bowels. In 114 hemodynamically stable patients, FAST was positive in 25 patients, with a sensitivity of 22%. In 32 hemodynamically unstable patients, FAST was positive in 9 patients, with a sensitivity of 28%. A free peritoneal fluid and splenic injury are associated with a positive FAST on univariate analysis, and are the independent predictors for a positive FAST on multiple logistic regression. CONCLUSION: FAST has a very low sensitivity in detecting blunt intraabdominal injury. In hemodynamically stable patients, a negative FAST without a CT may result in missed intra-abdominal injuries. In hemodynamically unstable blunt trauma patients, with clear physical findings on examination, the decision for exploratory laparotomy should not be distracted by a negative FAST.