Pneumomediastinum in blunt trauma: If aerodigestive injury is not seen on CT, invasive workup is not indicated.

BACKGROUND: Pneumomediastinum following blunt trauma is often observed on CT imaging, and concern for associated aerodigestive injury often prompts endoscopy and/or fluoroscopy. In recent years, adoption of multi-detector CT technology has resulted in high resolution images that may clearly identify aerodigestive injuries. The purpose of this study was to evaluate the utility of multi-detector CT in the identification of blunt aerodigestive injuries. METHODS: Over five years, patients with pneumomediastinum following blunt trauma were identified from the registry of a level 1 trauma center. All CT imaging of trauma patients during this time period was accomplished with 64-slice scanners. RESULTS: 127 patients with blunt traumatic pneumomediastinum were identified. Five airway injuries were identified, and all injuries were evident on CT imaging. No patient was found to have airway injury by endoscopy that was not evident on CT. No patient had an esophageal injury. CONCLUSION: Multi-detector CT imaging identifies aerodigestive injuries associated with pneumomediastinum following blunt trauma. The absence of a recognizable aerodigestive injury by CT effectively rules out the presence of such injury.

Saccadic eye movement metrics reflect surgical residents' fatigue.

OBJECTIVE: Little is known about the effects of surgical residents' fatigue on patient safety. We monitored surgical residents' fatigue levels during their call day using (1) eye movement metrics, (2) objective measures of laparoscopic surgical performance, and (3) subjective reports based on standardized questionnaires. BACKGROUND: Prior attempts to investigate the effects of fatigue on surgical performance have suffered from methodological limitations, including inconsistent definitions and lack of objective measures of fatigue, and nonstandardized measures of surgical performance. Recent research has shown that fatigue can affect the characteristics of saccadic (fast ballistic) eye movements in nonsurgical scenarios. Here we asked whether fatigue induced by time-on-duty (~24 hours) might affect saccadic metrics in surgical residents. Because saccadic velocity is not under voluntary control, a fatigue index based on saccadic velocity has the potential to provide an accurate and unbiased measure of the resident's fatigue level. METHODS: We measured the eye movements of members of the general surgery resident team at St. Joseph's Hospital and Medical Center (Phoenix, AZ) (6 males and 6 females), using a head-mounted video eye tracker (similar configuration to a surgical headlight), during the performance of 3 tasks: 2 simulated laparoscopic surgery tasks (peg transfer and precision cutting) and a guided saccade task, before and after their call day. Residents rated their perceived fatigue level every 3 hours throughout their 24-hour shift, using a standardized scale. RESULTS: Time-on-duty decreased saccadic velocity and increased subjective fatigue but did not affect laparoscopic performance. These results support the hypothesis that saccadic indices reflect graded changes in fatigue. They also indicate that fatigue due to prolonged time-on-duty does not result necessarily in medical error, highlighting the complicated relationship among continuity of care, patient safety, and fatigued providers. CONCLUSIONS: Our data show, for the first time, that saccadic velocity is a reliable indicator of the subjective fatigue of health care professionals during prolonged time-on-duty. These findings have potential impacts for the development of neuroergonomic tools to detect fatigue among health professionals and in the specifications of future guidelines regarding residents' duty hours.