Screening of Acute Traumatic Stress Disorder and Posttraumatic Stress Disorder in Pediatric Trauma Patients: A Pilot Study.

BACKGROUND: Children who experience traumatic physical injuries are at risk of developing acute stress disorder and posttraumatic stress disorder (PTSD). Early identification and treatment of these high-risk children can lead to improved mental health outcomes in this population. OBJECTIVE: This study assesses the feasibility of a study protocol that compares 3 screening tools for identifying patients at a high risk of later development of acute stress disorder or PTSD among pediatric trauma patients. METHODS: This pilot study compared 3 questionnaires used as screening tools for predictors of later development of PTSD in a convenience sample of pediatric trauma patients aged 7-17 years. Patients were randomized to one of 3 screening tools. Families were contacted at 30, 60, and 90-120 days postinjury to complete the Child Report of Post-Traumatic Symptoms questionnaire. The sensitivity and negative predictive value of the screening tools were compared for the diagnosis of PTSD defined using the Child Report of Post-Traumatic Symptoms questionnaire. RESULTS: Of the 263 patients identified for possible enrollment, 52 patients met full inclusion criteria and agreed to participate. Only 29 (55.7%) patients completed at least one follow-up questionnaire. The prevalence of acute stress disorder and PTSD in our population was 41% (95% CI [24, 61]) and 31% (95% CI [15, 51]), respectively. CONCLUSIONS: In this pilot study, we sought to determine the utility of the 3 commonly used screening instruments for measuring traumatic stress symptoms in pediatric trauma patients to predict the diagnosis of acute stress disorder or PTSD. Limitations include the use of the Child Report of Post-Traumatic Symptoms screening tool as the gold standard for calculating test characteristics and lack of 24/7 enrollment capabilities. As such, a significant portion of patients were discharged prior to our teams' engagement for enrollment.

Redefining Mild Traumatic Brain Injury (mTBI) delineates cost effective triage.

OBJECTIVES: Mild traumatic brain injury (mTBI) is defined as Glasgow Coma Score (GCS) of 14 or 15. Despite good outcomes, patients are commonly transferred to trauma centers for observation and/or neurosurgical consultation. The aim of this study is to assess the value of redefining mTBI with novel radiographic criteria to determine the appropriateness of interhospital transfer for neurosurgical evaluation. METHODS: A retrospective study of patients with blunt head injury with GCS 13-15 and CT head from Jan 2014-Dec 2016 was performed. A novel criteria of head CT findings was created at our institution to classify mTBI. Outcomes included neurosurgical intervention and transfer cost. RESULTS: A total of 2120 patients were identified with 1442 (68.0%) meeting CT criteria for mTBI and 678 (32.0%) classified high risk. Two (0.14%) patients with mTBI required neurosurgical intervention compared with 143 (21.28%) high risk TBI (p < 0.0001). Mean age (55.8 years), and anticoagulation (2.6% vs 2.8%) or antiplatelet use (2.1% vs 3.0%) was similar between groups (p > 0.05). Of patients with mTBI, 689 were transferred without receiving neurosurgical intervention. Given an average EMS transfer cost of $700 for ground and $5800 for air, we estimate an unnecessary transfer cost of $733,600. CONCLUSION: Defining mTBI with the described novel criteria clearly identifies patients who can be safely managed without transfer for neurosurgical consultation. These unnecessary transfers represent a substantial financial and resource burden to the trauma system and inconvenience to patients.

Do not waste your time: straight to magnetic resonance imaging for pediatric burners and stingers.

BACKGROUND: Permanent neurologic injury in pediatric patients with burner and stinger syndrome (BSS) is unlikely. This study aims to assess the feasibility of clinical observation without extensive radiologic workup in this selective population. METHODS: A retrospective study was conducted of patients aged younger than 18 years evaluated at a level I trauma center from 2012 to 2014. Patients were grouped according to positive deficit (PD) or negative deficit (ND) upon physical examination. Demographics, clinical findings, and outcomes were analyzed. RESULTS: Thirty patients (ND, n = 14; PD, n = 16) were evaluated for BSS, most often as a result of injurious football tackle. Age and length of stay were similar between groups. Injury Severity Score was lower in the ND group than the PD group (1.6 ± 1.2 vs 3.8 ± 3.1, respectively; P< .05). Cervical computed tomography was performed on 11 patients (78.6%) in the ND group and 15 patients (93.8%) in the PD group at considerable added cost, with only 1 positive result in the ND group and none in the PD group. Magnetic resonance imaging (MRI) revealed 2 positive findings in each group, and no surgical interventions were indicated. Ten ND (71.4%) and 12 PD (75%) patients reported complete resolution of symptoms at discharge (P> .05). CONCLUSIONS: Children presenting with BSS experience temporary symptoms that resolve without surgical intervention. Magnetic resonance imaging identified more injuries than computed tomographic imaging; therefore, we suggest that management for BSS should include observation, serial neurologic examinations, and MRI evaluation as appropriate.

Femur fractures should not be considered distracting injuries for cervical spine assessment.

INTRODUCTION: The National Emergency X-Radiography Utilization Study (NEXUS) clinical decision rule is extremely sensitive for clearance of cervical spine (C-spine) injury in blunt trauma patients with distracting injuries. OBJECTIVES: We sought to determine whether the NEXUS criteria would maintain sensitivity for blunt trauma patients when femur fractures were not considered a distracting injury and an absolute indication for diagnostic imaging. METHODS: We retrospectively analyzed blunt trauma patients with at least 1 femur fracture who presented to our emergency department as trauma activations from 2009 to 2011 and underwent C-spine injury evaluation. Presence of C-spine injury requiring surgical intervention was evaluated. RESULTS: Of 566 trauma patients included, 77 (13.6%) were younger than 18 years. Cervical spine injury was diagnosed in 53 (9.4%) of 566. A total of 241 patients (42.6%) had positive NEXUS findings in addition to distracting injury; 51 (21.2%) of these had C-spine injuries. Of 325 patients (57.4%) with femur fractures who were otherwise NEXUS negative, only 2 (0.6%) had C-spine injuries (95% confidence interval [CI], 0.2%-2.2%); both were stable and required no operative intervention. Use of NEXUS criteria, excluding femur fracture as an indication for imaging, detected all significant injuries with a sensitivity for any C-spine injury of 96.2% (95% CI, 85.9%-99.3%) and negative predictive value of 99.4% (95% CI, 97.6%-99.9%). CONCLUSIONS: In our patient population, all significant C-spine injuries were identified by NEXUS criteria without considering the femur fracture a distracting injury and indication for computed tomographic imaging. Reconsidering femur fracture in this context may decrease radiation exposure and health care expenditure with little risk of missed diagnoses.

Risk-stratified thromboprophylaxis effects of aspirin versus low-molecular-weight heparin in orthopedic trauma patients: A secondary analysis of the PREVENT CLOT trial.

BACKGROUND: The PREVENT CLOT trial concluded that thromboprophylaxis with aspirin was noninferior to low-molecular-weight heparin (LMWH) in preventing death after orthopedic trauma. However, it was unclear if these results applied to patients at highest risk of thrombosis. Therefore, we assessed if the effect of aspirin versus LMWH differed based on patients' baseline risk of venous thromboembolism (VTE). METHODS: The PREVENT CLOT trial enrolled 12,211 adult patients with fractures. This secondary analysis stratified the study population into VTE risk quartiles: low (<1%) to high (>10%) using the Caprini score. We assessed stratum-specific treatment effects using the win ratio method, in which each patient assigned to aspirin was paired with each assigned to LMWH. In each pair, we compared outcomes hierarchically, starting with death, then pulmonary embolism, deep vein thrombosis, and bleeding. The secondary outcome added patients' medication satisfaction as a fifth composite component. RESULTS: In the high-risk quartile (n = 3052), 80% had femur fracture, pelvic, or acetabular fractures. Thoracic (47%) and head (37%) injuries were also common. In the low risk quartile (n = 3053), most patients had a tibia fracture (67%), 5% had a thoracic injury, and less than 1% had head or spinal injuries. Among high risk patients, thromboembolic events did not differ statistically between aspirin and LMWH (win ratio, 0.94; 95% confidence interval [CI], 0.82-1.08, p = 0.42). This result was consistent in the low (win ratio, 1.15; 95% CI, 0.90-1.47, p = 0.27), low-medium (win ratio, 1.05; 95% CI, 0.85-1.29, p = 0.68), and medium-high risk quartiles (win ratio, 0.94; 95% CI, 0.80-1.11, p = 0.48). When medication satisfaction was considered, favorable outcomes were 68% more likely with aspirin (win ratio, 1.68; 95% CI, 1.60-1.77; p < 0.001). CONCLUSION: Thromboembolic outcomes were similar with aspirin or LMWH, even among patients at highest risk of VTE. Aspirin was favored if medication satisfaction was also considered. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Emergencies do not shut down during a pandemic: COVID pandemic impact on Acute Care Surgery volume and mortality at a level I trauma center.

BACKGROUND: The aim of this study was to evaluate the impact of the COVID-19 pandemic on volume and outcomes of Acute Care Surgery patients, and we hypothesized that inpatient mortality would increase due to COVID+ and resource constraints. METHODS: An American College of Surgeons verified Level I Trauma Center's trauma and operative emergency general surgery (EGS) registries were queried for all patients from Jan. 2019 to Dec. 2020. April 1st, 2020, was the demarcation date for pre- and during COVID pandemic. Primary outcome was inpatient mortality. RESULTS: There were 14,460 trauma and 3091 EGS patients, and month-over-month volumes of both remained similar (p > 0.05). Blunt trauma decreased by 7.4% and penetrating increased by 31%, with a concomitant 25% increase in initial operative management (p < 0.001). Despite this, trauma (3.7%) and EGS (2.9-3.0%) mortality rates remained stable which was confirmed on multivariate analysis; p > 0.05. COVID + mortality was 8.8% and 3.7% in trauma and EGS patients, respectively. CONCLUSION: Acute Care Surgeons provided high quality care to trauma and EGS patients during the pandemic without allowing excess mortality despite many hardships and resource constraints.

The Obesity Paradox in Emergency General Surgery Patients.

BACKGROUND: Operative management of emergency general surgery (EGS) diagnoses involves a range of procedures which can carry high morbidity and mortality. Little is known about the impact of obesity on patient outcomes. The aim of this study was to examine the association between body mass index (BMI) >30 kg/m2 and mortality for EGS patients. We hypothesized that obese patients would have increased mortality rates. METHODS: A regional integrated health system EGS registry derived from The American Association for the Surgery of Trauma EGS ICD-9 codes was analyzed from January 2013 to October 2015. Patients were stratified into BMI categories based on WHO classifications. The primary outcome was 30-day mortality. Longer-term mortality with linkage to the Social Security Death Index was also examined. Univariate and multivariable analyses were performed. RESULTS: A total of 60 604 encounters were identified and 7183 (11.9%) underwent operative intervention. Patient characteristics include 53% women, mean age 58.2 ± 18.7 years, 64.2% >BMI 30 kg/m2, 30.2% with chronic obstructive pulmonary disease, 19% with congestive heart failure, and 31.1% with diabetes. The most common procedure was laparoscopic cholecystectomy (36.4%). Overall, 90-day mortality was 10.9%. In multivariable analysis, all classes of obesity were protective against mortality compared to normal BMI. Underweight patients had increased risk of inpatient (OR = 1.9, CI = 1.7-2.3), 30-day (OR = 1.9, CI = 1.7-2.1), 90-day (OR = 1.8, CI 1.6-2.0), 1-year (OR = 1.8, CI = 1.7-2.0), and 3-year mortality (OR = 1.7, CI = 1.6-1.9). CONCLUSIONS: When stratified by BMI, underweight EGS patients have the highest odds of death. Paradoxically, obesity appears protective against death, even when controlling for potentially confounding factors. Increased rates of nonoperative management in the obese population may impact these findings.

MOPEDS: Motorized Objects Propelling Ethanol Drinking Subjects.

Mopeds are not subject to the same laws and jurisdiction as cars or motorcycles, including the requirement of a driver's license. We undertook this study to examine the influence of alcohol (ETOH) on moped crashes. We retrospectively reviewed adult moped injuries compared with motor vehicle crashes (MVCs) and motorcycle crashes (MCCs) from 1995 through 2006. Demographics, severity of injury, mortality, and serum ETOH levels were recorded. Data were analyzed using the Student t test for continuous data and the χ² test for proportional data. Motor vehicle crashes accounted for 7186 admissions. MCC and moped crashes numbered 973 and 113, respectively. Although not statistically significant (P = 0.064), moped crashes yielded the highest mortality (9.7%) compared with MCCs (8.5%) and MVCs (6.7%). An increased association of blood ETOH levels with moped crashes, however, was statistically significant (P = 0.004). Serum ETOH levels above 0.05 g/dL were observed in 1681 MVCs (23.4%), 241 MCCs (24.8%), and 44 moped crashes (39%). In this study, we discovered that moped crashes demonstrate a significantly higher ETOH involvement than either MVCs or MCCs representing a previously unrecognized public safety risk.

Vena cava filter insertion and the general surgery armamentarium: a 13-year experience.

The prevention of pulmonary emboli has a long surgical history. Through the development of percutaneous technologies, vena cava filters (VCFs) are now commonly inserted by interventional radiologists. This study reviews our experience with VCFs inserted by general surgeons. We retrospectively reviewed data from our VCF performance improvement database, which is a prospective collection of the VCF experience of the Department of General Surgery from February 1996 to May 2009. Demographics, procedural information, and complications were recorded. Eight hundred fifty-five VCFs were inserted in 853 patients. The mean age was 42.0 years (range, 14 to 90 years). One hundred ninety-seven VCFs were placed in the operating room, and 658 were placed in the intensive care unit. Twelve VCFs were intentionally inserted in a suprarenal position, and four were placed in the superior vena cava. Two patients received both superior vena cava and inferior vena cava filters. Complications included deep vein thrombosis at the insertion site (n=16), vena cava thrombosis (n=9), post-VCF pulmonary embolism (n=2), and a ventricle perforation requiring operative repair (n=1). No deaths were attributed to the presence of a VCF. Overall insertion success was 99.8 per cent. In two patients, an inferior VCF could not be placed as a result of inferior vena cava occlusion with no safe "landing zone" for deployment. The placement of VCFs is a vital skill in the general surgery armamentarium. Our experience demonstrates that general surgeons can safely insert VCFs with minimal perioperative complications.

Operative experience in the era of duty hour restrictions: is broad-based general surgery training coming to an end?

Since the institution of Accreditation Council for Graduate Medical Education (ACGME) resident work hour restrictions, conflicting evidence exists regarding the impact on resident case volume with most data from single-institution studies. We examined the effect of restrictions on national resident operative experience. After permission from the ACGME, we reviewed the publicly available national resident case log data (1999 through 2008) maintained on the ACGME web site (www.acgme.org), including total major cases with subanalysis of the ACGME-specified categories. The mean cases per resident were compared before (1999 to 2003) and after (2003 to 2008) restrictions. After the implementation of duty hour restrictions, the mean number of total cases per resident significantly decreased (949 +/- 18 vs 911 +/- 14, P = 0.004). Subanalysis showed a significant increase in alimentary tract (217 +/- 7 vs 229 +/- 3, P = 0.004), skin/soft tissue (31 +/- 3 vs 36 +/- 1, P = 0.01), and endocrine (26 +/- 2 vs 31 +/- 2, P = 0.006) cases. However, we observed a significant decrease in head and neck (21 +/- 0.3 vs 20 +/- 0.3, P = 0.01), vascular (164 +/- 29 vs 126 +/- 5, P = 0.01), pediatric (41 +/- 1 vs 37 +/- 2, P = 0.006), genitourinary (10 +/- 2 vs 7 +/- 1, P = 0.004), gynecologic surgery (5 +/- 1 vs 3 +/- 0.6, P = 0.002), plastics (16 +/- 0.3 vs 15 +/- 0.7, P = 0.03), and endoscopy (91 +/- 3 vs 82 +/- 2, P < 0.001) procedures. Analysis of the ACGME-compiled national data confirms that duty hour restrictions have significantly impacted resident operative experience. Importantly, experience in specialty areas, including vascular and endoscopy, appears to have been sacrificed for consolidation of resources into general surgery services as indicated by the increase in alimentary tract and endocrine cases. These findings raise the following question: Is the era of truly broad-based general surgery training coming to an end?

Maximizing the Calm before the Storm: Tiered Surgical Response Plan for Novel Coronavirus (COVID-19).

The novel coronavirus (COVID-19) was first diagnosed in Wuhan, China in December 2019 and has now spread throughout the world, being verified by the World Health Organization as a pandemic on March 11. This had led to the calling of a national emergency on March 13 in the US. Many hospitals, healthcare networks, and specifically, departments of surgery, are asking the same questions about how to cope and plan for surge capacity, personnel attrition, novel infrastructure utilization, and resource exhaustion. Herein, we present a tiered plan for surgical department planning based on incident command levels. This includes acute care surgeon deployment (given their critical care training and vertically integrated position in the hospital), recommended infrastructure and transfer utilization, triage principles, and faculty, resident, and advanced care practitioner deployment.

Mitigating clinical waste in the trauma intensive care unit: Limited clinical utility of cardiac troponin testing for trauma patients with atrial fibrillation.

BACKGROUND: The clinical significance of obtaining cardiac troponin (cTn) levels among trauma patients with new onset arrhythmias is unknown. We aimed to assess whether cTn levels actually influence clinical decision making or represent an inappropriate use of resources. METHODS: Trauma patients admitted from 2013 to 2014 diagnosed with atrial fibrillation (AF) were retrospectively reviewed using the institutional trauma database. Demographics, cTn levels, and myocardial infarction (MI) diagnosis data were recorded. Standard univariate tests were used to compare data between patients with and without cTn. RESULTS: There were 258 patients included of which 126 patients had cTn levels obtained (48.8%, TEST group). The remaining 132 patients (51.2%) were untested (noTEST group). Among TEST patients, use of echocardiography nearly doubled and cardiology consultations increased (all p < 0.05). No TEST patients suffered MI or PE. CONCLUSIONS: Obtaining cTn values in trauma patients with new-onset AF resulted in increased resource utilization without clinical utility.

PATHway to success: Implementation of a multiprofessional acute trauma health care team decreased length of stay and cost in patients with neurological injury requiring tracheostomy.

BACKGROUND: The aim of this study was to determine whether the implementation of a dedicated multiprofessional acute trauma health care (mPATH) team would decrease length of stay without adversely impacting outcomes of patients with severe traumatic brain and spinal cord injuries. The mPATH team was comprised of a physical, occupational, speech, and respiratory therapist, nurse navigator, social worker, advanced care provider, and physician who performed rounds on the subset of trauma patients with these injuries from the intensive care unit to discharge. METHODS: Following the formation and implementation of the mPATH team at our Level I trauma center, a retrospective cohort study was performed comparing patients in the year immediately prior to the introduction of the mPATH team (n = 60) to those in the first full year following implementation (n = 70). Demographics were collected for both groups. Inclusion criteria were Glasgow Coma Scale score less than 8 on postinjury Day 2, all paraplegic and quadriplegic patients, and patients older than 55 years with central cord syndrome who underwent tracheostomy. The primary endpoint was length of stay; secondary endpoints were time to tracheostomy, days to evaluation by occupational, physical, and speech therapy, 30-day readmission, and 30-day mortality. RESULTS: The median time to evaluation by occupational, physical, and speech therapy was universally decreased. Injury Severity Score was 27 in both cohorts. Time to tracheostomy and length of stay were both decreased. Thirty-day readmission and mortality rates remained unchanged. A cost savings of US $11,238 per index hospitalization was observed. CONCLUSION: In the year following the initiation of the mPATH team, we observed earlier time to occupational, physical, and speech therapist evaluation, decreased length of stay, and cost savings in severe traumatic brain and spinal cord injury patients requiring tracheostomy compared with our historical control. These benefits were observed without adversely impacting 30-day readmission or mortality. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.

Has the pendulum swung too far? The impact of missed abdominal injuries in the era of nonoperative management.

Nonoperative management for traumatic injuries has significantly influenced trauma care during the last decade. We undertook this study to assess the impact of nontherapeutic laparotomies for suspected abdominal injuries compared with delayed laparotomies for questionable abdominal injuries for patients with abdominal trauma. The records of patients admitted to the trauma service between 2002 and 2007 who underwent laparotomies deemed nontherapeutic or delayed were retrospectively reviewed. Demographics, severity of injury, management scheme, and outcome data were analyzed. Sixteen patients underwent delayed laparotomies, whereas 26 patients incurred nontherapeutic laparotomies. Injury severity scores, Glasgow coma scale scores, abdominal abbreviated injury scale score (AIS), and age were similar for both populations. Delayed laparotomies occurred an average of 7 +/- 9 days postinjury. Intensive care unit length of stay (26 +/- 24 vs 10 +/- 6 days), hospital length of stay (40 +/- 37 vs 11 +/- 10 days), ventilator days (31 +/- 29 vs 11 +/- 10), and number of abdominal operative procedures (1.9 +/- 1.5 vs 1 +/- 0) were significantly higher in the delayed laparotomies group versus the nontherapeutic laparotomies group, respectively. Delayed diagnosis of intra-abdominal injuries yielded a significantly increased morbidity and mortality. During the evolving era of technological imaging for traumatic injuries, we must not allow the nonoperative pendulum to swing too far.

Resident work hour restrictions impact chief resident operative experience.

Since the institution of the Accreditation Council for Graduate Medical Education resident work restrictions, much discussion has arisen regarding the potential effect on surgical resident training. We undertook this study to examine the effects on resident operative experience. We retrospectively analyzed chief residents' Accreditation Council for Graduate Medical Education case logs before (PRE) and after (POST) the 80-hour work restriction. Overall, 22 resident logs were evaluated, six PRE and 16 POST. Four case categories were examined: total major cases, total trauma operative cases, total chief cases, and total teaching assistant cases. Significance was defined as P < 0.05. Comparing the PRE and POST groups demonstrated a trend toward fewer total major cases (1061 vs 964, P = 0.38) and fewer total trauma operative cases (55 vs 47, P = 0.37). Teaching assistant cases increased from 67 to 91 but also failed to reach significance (P = 0.37). However, further comparison between the PRE and POST groups yielded a statistically significant decrease in the number of total chief cases (494 vs 333, P = 0.0092). The significant decrease in the number of total chief cases demonstrates that the work hour restriction most affected the chief year operative experience. Further evaluation of resident participation in nonoperative facets may reveal additional deficiencies of surgical training under work hour restrictions.

Filled to the brim: The characteristics of over-triage at a level I trauma center.

BACKGROUND: Interfacility transfers are necessary and valuable for the trauma system, but despite regional guidelines, many patients are inappropriately transferred. We evaluated over-triage at our Level I center and identified risk factors for over-triage. METHODS: Retrospective analysis at our Level I urban trauma center assessed patients transferred from regional facilities during 2017. Over-triage was defined as patients discharged <48 h without procedures. Exclusion criteria were leaving against medical advice or no outside records. RESULTS: Overall, 2352 patients met criteria. Nine hundred thirty (39.5%) with complete hospital records were discharged in <48 h; 498 (53.5%) received no procedural intervention and 909 (97.7%) were ultimately discharged home. CONCLUSION: Many patients are inappropriately transferred to tertiary care centers without a definitive need for advanced services. Studies are needed to improve triage criteria without increasing under-triage.

Not a Routine Case, Why Expect the Routine Outcome? Quantifying the Infectious Burden of Emergency General Surgery Using the NSQIP.

Emergent surgeries have different causes and physiologic patient responses than the same elective surgery, many of which are due to infectious etiologies. Therefore, we hypothesized that emergency cases have a higher risk of postoperative SSI than their elective counterparts. The ACS NSQIP database was queried from 2005 to 2016 for all cholecystectomies, ventral hernia repairs, and partial colectomies to examine common emergency and elective general surgery operations. Thirty-day outcomes were compared by emergent status. Any SSI was the primary outcome. There were 863,164 surgeries: 416,497 cholecystectomies, 220,815 ventral hernia repairs, and 225,852 partial colectomies. SSIs developed in 38,865 (4.5%) patients. SSIs increased with emergencies (5.3% vs 3.6% for any SSI). Postoperative sepsis (5.8% vs 1.5%), septic shock (4.7% vs 0.6%), length of stay (8.1 vs 2.9 days), and mortality (3.6% vs 0.4%) were increased in emergent surgery; P < 0.001 for all. When controlling for age, gender, BMI, diabetes, smoking, wound classification, comorbidities, functional status, and procedure on multivariate analysis, emergency surgery (odds ratio 1.15, 95% confidence interval 1.11-1.19) was independently associated with the development of SSI. Patients undergoing emergency general surgery experience increased rates of SSI. Patients and their families should be appropriately counseled regarding these elevated risks when consenting for emergency surgery.

"Death Knell" for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline.

The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group (P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.

Imaging of the vena cava in the intensive care unit prior to vena cava filter insertion: carbon dioxide as an alternative to iodinated contrast.

This study evaluates the safety and effectiveness of carbon dioxide (CO2) as a contrast agent in patients in the intensive care unit undergoing vena cava filter (VCF) insertion. We prospectively evaluated patients in the intensive care unit undergoing bedside VCF insertion using CO2 cavagraphy. Blood pressure, pulse rate, mixed venous oxygen saturation, and intracranial pressure were monitored before, during, and after the CO2 injection. Fifty patients in the intensive care unit (mean age 48.2 +/- 16.5 years) were included in the study. Five patients had decreases in blood pressure, which resolved without intervention. Two patients required iodinated contrast as a result of inadequate CO2 imaging. All patients had successful insertion of VCF. The use of CO2 as a contrast agent is a safe and highly effective alternative for vena cava imaging and can be considered the first-line contrast agent for all critically ill patients requiring VCF placement.