Rapid Detection of Significant Traumatic Brain Injury Requiring Emergency Intervention.

Moderate and severe traumatic brain injuries (TBI) are a major cause of severe morbidity and mortality; rapid diagnosis and management allow secondary injury to be minimized. Traumatic brain injury is only one of many potential causes of altered mental status; head computed tomography (HCT) is used to definitively diagnose TBI. Despite its widespread use and obvious importance, interpretation of HCT images is rarely covered by formal didactics during general surgery or even acute care surgery training. The schema illustrated here may be applied in a rapid and reliable fashion to HCT images, expediting the diagnosis of clinically significant traumatic brain injury that warrants emergent medical and surgical therapies to reduce intracranial pressure. It consists of 7 normal anatomic structures (cerebrospinal fluid around the brain stem, open fourth ventricle, "baby's butt," "Mickey Mouse ears," absence of midline shift, sulci and gyri, and gray-white differentiation). These 7 features can be seen even as the CT scanner obtains images, allowing the trauma team to expedite medical management of intracranial hypertension and pursue neurosurgical consultation prior to radiologic interpretation if the features are abnormal.

Detecting direct oral anticoagulants in trauma patients using liquid chromatography-mass spectrometry: A novel approach to medication reconciliation.

BACKGROUND: Accurate medication reconciliation in trauma patients is essential but difficult. Currently, there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS)-based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival. METHODS: Plasma samples were collected from 356 patients who provided informed consent including 10 healthy controls, 19 known positive or negative controls, and 327 trauma patients older than 65 years who were evaluated at our large, urban level 1 trauma center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban, and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage were compared with LCMS results to determine overall accuracy, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of the assay. RESULTS: Of 356 patients, 39 (10.96%) were on DOACs: 21 were on apixaban, 14 on rivaroxaban, and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.05% (PPV, 92.50%; NPV, 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.10% (PPV, 86.36%; NPV 99.40%). There were three false-positive results and two false-negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity. CONCLUSION: This LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients. LEVEL OF EVIDENCE: Diagnostic Test, level III.

Dysphagia and soft-tissue swelling after anterior cervical surgery: a radiographic analysis.

BACKGROUND CONTEXT: Dysphagia is common in the early postoperative period after anterior cervical discectomy and fusion (ACDF). Several mechanisms, including soft-tissue swelling, have been implicated as a cause of postoperative dysphagia. PURPOSE: To determine whether anterior soft-tissue swelling is greater in patients with postoperative dysphagia. STUDY DESIGN: Prospective cohort study. PATIENT SAMPLE: Forty-three patients. OUTCOME MEASURES: Validated dysphagia questionnaire, lateral cervical spine radiographs. METHODS: Patients undergoing one- or two-level ACDF using allograft bone and anterior instrumentation were enrolled. Baseline patient demographic characteristics and history were recorded. A dysphagia questionnaire, including a dysphagia numeric rating scale (DNRS; range, 0-10), was administered preoperatively and 2 and 6 weeks postoperatively. Lateral cervical radiographs were obtained preoperatively and 2 and 6 weeks postoperatively. The anterior cervical soft-tissue shadow width was measured at each level. Patients were divided into groups based on the 2-week dysphagia questionnaire: Group 1 (no symptoms/mild dysphagia) and Group 2 (moderate/severe dysphagia). Anterior soft-tissue shadow width at each level was compared between groups. Correlation was used to assess the relationship between DNRS and anterior soft-tissue swelling. RESULTS: Forty-three patients (24 females; average age, 47.9) were enrolled. Fifteen patients had one-level and 28 patients had two-level ACDF. The anterior soft-tissue shadow width increased significantly from preoperative values at all levels except C1 at 2 and 6 weeks and C2 at 6 weeks. At 2 weeks, 18 patients had no symptoms/mild dysphagia (Group 1) and 25 patients had moderate/severe dysphagia (Group 2). The average DNRS was 1.1 for Group 1 and 5.3 for Group 2 (p<.001). This difference decreased by 6 weeks but remained significant. There were no significant differences in the soft-tissue measurements between groups at any level. There was no significant correlation between the DNRS and anterior soft-tissue swelling at any time point. CONCLUSIONS: There is a significant increase in anterior cervical soft-tissue swelling after ACDF. The width of prevertebral soft-tissue does not correlate with postoperative dysphagia.