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BACKGROUND: High-grade liver injuries with extravasation (HGLI â+ âExtrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI â+ âExtrav. Therefore, we evaluated the management of HGLI â+ âExtrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS: HGLI â+ âExtrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS: From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p â= â0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p â> â0.05). CONCLUSION: Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI â+ âExtrav patients.
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Embolização Terapêutica , Extravasamento de Materiais Terapêuticos e Diagnósticos , Fígado , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Fígado/lesões , Fígado/diagnóstico por imagem , Embolização Terapêutica/métodos , Radiologia Intervencionista , Conduta Expectante , Estudos Retrospectivos , Angiografia , Idoso , Adulto , Meios de ContrasteRESUMO
Objectives: Our understanding of blunt cerebrovascular injury (BCVI) has changed significantly in recent decades, resulting in a heterogeneous description of diagnosis, treatment, and outcomes in the literature which is not suitable for data pooling. Therefore, we endeavored to develop a core outcome set (COS) to help guide future BCVI research and overcome the challenge of heterogeneous outcomes reporting. Methods: After a review of landmark BCVI publications, content experts were invited to participate in a modified Delphi study. For round 1, participants submitted a list of proposed core outcomes. In subsequent rounds, panelists used a 9-point Likert scale to score the proposed outcomes for importance. Core outcomes consensus was defined as >70% of scores receiving 7 to 9 and <15% of scores receiving 1 to 3. Feedback and aggregate data were shared between rounds, and four rounds of deliberation were performed to re-evaluate the variables not achieving predefined consensus criteria. Results: From an initial panel of 15 experts, 12 (80%) completed all rounds. A total of 22 items were considered, with 9 items achieving consensus for inclusion as core outcomes: incidence of postadmission symptom onset, overall stroke incidence, stroke incidence stratified by type and by treatment category, stroke incidence prior to treatment initiation, time to stroke, overall mortality, bleeding complications, and injury progression on radiographic follow-up. The panel further identified four non-outcome items of high importance for reporting: time to BCVI diagnosis, use of standardized screening tool, duration of treatment, and type of therapy used. Conclusion: Through a well-accepted iterative survey consensus process, content experts have defined a COS to guide future research on BCVI. This COS will be a valuable tool for researchers seeking to perform new BCVI research and will allow future projects to generate data suitable for pooled statistical analysis with enhanced statistical power. Level of evidence: Level IV.
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Objective(s): Understanding patient goals of care is essential in any setting, and especially so in an urban, safety net trauma centers' Surgical Intensive Care Units (SICU). This underscores the need for implementation of palliative care principles and practices, such as identification of surrogate decision makers, goals-of-care discussions, and CPR directives, in the SICU. Methods: A pragmatic, quality improvement study utilizing a retrospective, pre- and post-intervention continuum analysis. Interventions included a surgeon champion, resident education, and an electronic medical record template, called the Advanced Care Planning (ACP) Note, for use on daily rounds. We reviewed the charts of all adults admitted to the SICU before, during, and after these interventions to identify the incidence of surrogate decision maker documentation by SICU residents. Results: There was an early and enthusiastic adoption in ACP note utilization by SICU residents over the study period. Rates of documenting surrogate decision makers increased throughout the study period (p < 0.0001). Having an ACP note in the chart was associated with significantly higher rates of documented surrogate decision makers (p < 0.0001). Conclusions: Through the integration of targeted education, standardization of an electronic medical record tool for palliative care documentation, and incorporation of palliative care goals into daily rounding ICU checklists, we significantly increased identification of surrogate decision makers in the SICU of our urban Level One trauma center. Chart review from one year post-intervention showed sustained commitment to the use of the ACP note and identification of surrogate decision makers.
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Planejamento Antecipado de Cuidados , Cuidados Paliativos , Adulto , Cuidados Críticos , Humanos , Unidades de Terapia Intensiva , Estudos RetrospectivosRESUMO
BACKGROUND: Subclavian and axillary artery injuries are uncommon. In addition to many open vascular repairs, endovascular techniques are used for definitive repair or vascular control of these anatomically challenging injuries. The aim of this study was to determine the relative roles of endovascular and open techniques in the management of subclavian and axillary artery injuries comparing hospital outcomes, and long-term limb viability. METHODS: A multicenter, retrospective review of patients with subclavian or axillary artery injuries from January 1, 2004, to December 31, 2014, was completed at 11 participating Western Trauma Association institutions. Statistical analysis included χ, t-tests, and Cochran-Armitage trend tests. A p value less than 0.05 was significant. RESULTS: Two hundred twenty-three patients were included; mean age was 36 years, 84% were men. An increase in computed tomography angiography and decrease in conventional angiography was observed over time (p = 0.018). There were 120 subclavian and 119 axillary artery injuries. Procedure type was associated with injury grade (p < 0.001). Open operations were performed in 135 (61%) patients, including 93% of greater than 50% circumference lacerations and 83% of vessel transections. Endovascular repairs were performed in 38 (17%) patients; most frequently for pseudoaneurysms. Fourteen (6%) patients underwent a hybrid procedure. Use of endovascular versus open procedures did not increase over the duration of the study (p = 0.248). In-hospital mortality rate was 10%. Graft or stent thrombosis occurred in 7% and graft or stent infection occurred in 3% of patients. Mean follow-up was 1.6 ± 2.4 years (n = 150). Limb salvage was achieved in 216 (97%) patients. CONCLUSION: The management of subclavian and axillary artery injuries still requires a wide variety of open exposures and procedures, especially for the control of active hemorrhage from more than 50% vessel lacerations and transections. Endovascular repairs were used most often for pseudoaneurysms. Low early complication rates and limb salvage rates of 97% were observed after open and endovascular repairs. LEVEL OF EVIDENCE: Prognostic/epidemiologic, level IV.
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Traumatismos do Braço/complicações , Artéria Axilar/lesões , Implante de Prótese Vascular/métodos , Artéria Subclávia/lesões , Traumatismos Torácicos/complicações , Lesões do Sistema Vascular/cirurgia , Ferimentos Penetrantes/complicações , Adulto , Traumatismos do Braço/diagnóstico , Traumatismos do Braço/mortalidade , Artéria Axilar/diagnóstico por imagem , Artéria Axilar/cirurgia , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/métodos , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Incidência , Escala de Gravidade do Ferimento , Masculino , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Sociedades Médicas , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/cirurgia , Taxa de Sobrevida/tendências , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/mortalidade , Traumatologia , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/etiologia , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/mortalidadeRESUMO
BACKGROUND: The utility of urinalysis (UA) to diagnose intra-abdominal (IA) or genitourinary (GU) injury after blunt trauma remains controversial. The purpose of this study was to determine the significance of UA in the blunt trauma patient. METHODS: A retrospective review of patients admitted for blunt abdominal trauma from 2011 to 2013. RESULTS: A total of 1,795 patients sustained blunt abdominal trauma: mean age of 44 ± 21 years; mean Injury Severity Score of 13 ± 10. Overall 810 patients had a negative UA (45%). Two patients (2/810 and .2%) had a GU injury and neither required intervention. Thirty-two patients (32/810 and 4.0%) had an IA injury, and 2 (2/810 and .02%) required intervention. The sensitivity for predicting GU injury requiring intervention was 1, and IA injury requiring intervention was .96. Negative predictive values were 1 and .99. CONCLUSIONS: A negative UA correlates with a low risk for GU and IA injury after blunt abdominal trauma. A negative UA should be evaluated prospectively as part of a clinical prediction score to rule out injury and avoid unnecessary radiation exposure from computed tomography imaging.
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Traumatismos Abdominais/diagnóstico , Urinálise , Sistema Urogenital/lesões , Ferimentos não Penetrantes/diagnóstico , Traumatismos Abdominais/urina , Adulto , Idoso , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Ferimentos não Penetrantes/urina , Adulto JovemRESUMO
BACKGROUND: Previous studies of surgical stabilization of rib fractures (SSRF) have been limited by small sample sizes, retrospective methodology, and inclusion of only patients with flail chest. We performed a prospective, controlled evaluation of SSRF as compared with optimal medical management for severe rib fracture patterns among critically ill trauma patients. We hypothesized that SSRF improves acute outcomes. METHODS: We conducted a 2-year clinical evaluation of patients with any of the following rib fracture patterns: flail chest, three or more fractures with bicortical displacement, 30% or greater hemithorax volume loss, and either severe pain or respiratory failure despite optimal medical management. In the year 2013, all patients were managed nonoperatively. In the year 2014, all patients were managed operatively. Outcomes included respiratory failure, tracheostomy, pneumonia, ventilator days, tracheostomy, length of stay, daily maximum incentive spirometer volume, narcotic requirements, and mortality. Univariate and multivariable analyses were performed. RESULTS: Seventy patients were included, 35 in each group. For the operative group, time from injury to surgery was 2.4 day, operative time was 1.5 hours, and the ratio of ribs fixed to ribs fractured was 0.6. The operative group had a significantly higher RibScore (4 vs. 3, respectively, p < 0.01) and a significantly lower incidence of intracranial hemorrhage (5.7% vs. 28.6%, respectively, p = 0.01). After controlling for these differences, the operative group had a significantly lower likelihood of both respiratory failure (odds ratio, 0.24; 95% confidence interval, 0.06-0.93; p = 0.03) and tracheostomy (odds ratio, 0.18; 95% confidence interval, 0.04-0.78; p = 0.03). Duration of ventilation was significantly lower in the operative group (p < 0.01). The median daily spirometry value was 250 mL higher in the operative group (p = 0.04). Narcotic requirements were comparable between groups. There were no mortalities. CONCLUSION: In this evaluation, SSRF as compared with the best medical management improved acute outcomes among a group of critically ill trauma patients with a variety of severe fracture patterns. LEVEL OF EVIDENCE: Therapeutic study, level II.
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Tórax Fundido/cirurgia , Fixação Interna de Fraturas , Fraturas das Costelas/cirurgia , Adulto , Idoso , Manuseio das Vias Aéreas , Feminino , Tórax Fundido/complicações , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pneumonia/etiologia , Pneumonia/terapia , Estudos Prospectivos , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , Fraturas das Costelas/complicações , Resultado do TratamentoRESUMO
BACKGROUND: The liberal use of computed tomographic (CT) scanning during the evaluation of injured children has increased their exposure to the risks of ionizing radiation. We hypothesized that CT imaging performed for mechanism of injury alone is unnecessary and that serious or life-threatening injury is rarely identified. METHODS: All pediatric blunt trauma team evaluations (age < 15 years) at a pediatric Level 2 trauma center over 72 months were reviewed. CT findings in patients with normal Glasgow Coma Scale (GCS) score, vital signs (VS), and physical examination (PE) (Group I) were compared with Group II (GCS score < 15), Group III (abnormal VS/PE), and Group IV (abnormal GCS score, VS/PE). Variables associated with any positive finding were entered into a multiple logistic regression model to assess for independent contributions. Each patient's total effective radiation dose from CT scans in millisieverts was calculated using an age-adjusted scale. RESULTS: A total 174 children met trauma team activation criteria (mean [SD] age, 7 [5] years; 63% male; mean [SD] Injury Severity Score [ISS], 10 [10]). A total of 153 (88%) were imaged by CT (I, 54 of 66; II, 25 of 25; III, 49 of 57; IV, 25 of 26). No patient in Group I had a serious finding on CT compared with Group II (17 of 77), III (25 of 111), and IV (18 of 72). Mortality was 4%. Radiation dose (mSv) from CT was not different among the groups (I, 17 [14]; II, 29 [13]; III, 21 [16]; IV, 27 [17]). By univariate analysis, GCS score of less than 15 (p < 0.01) and respiratory rate of greater than 30 (p = 0.09) were associated with a positive CT finding. By logistic regression analysis, GCS score of less than 15 remained the only variable associated significantly with a positive finding (odds ratio, 6.7; 95% confidence interval, 3-14; p < 0.01). CONCLUSION: In children imaged based only on mechanism, no patient had a serious positive finding but was subjected to radiation doses associated with an increased risk of future malignancy. The use of CT imaging in injured children in the absence of a physiologic or anatomic abnormality does not seem to be justified. LEVEL OF EVIDENCE: Care management study, level IV.
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Tomografia Computadorizada por Raios X/métodos , Centros de Traumatologia , Ferimentos não Penetrantes/diagnóstico por imagem , Criança , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Masculino , Reprodutibilidade dos Testes , Estudos RetrospectivosRESUMO
INTRODUCTION: A child's risk of developing cancer from radiation exposure associated with computed tomography (CT) imaging is estimated to be as high as 1/500. Chest CT (CCT), often as part of a "pan-scan," is increasingly performed after blunt trauma in children. We hypothesized that routine CCT for the initial evaluation of blunt injured children does not add clinically useful information beyond chest radiograph (CXR) and rarely changes management. METHODS: Pediatric (<15 y) trauma team evaluations over 6 y at an academic Level I trauma center were reviewed. Demographic data, injuries, imaging, and management were identified for all patients undergoing CT. Effective radiation dose in milliSieverts (mSv) was calculated using age-adjusted scales. RESULTS: Fifty-seven of 174 children (33%) undergoing CT imaging had a CCT; 55 (97%) of these had a CXR. Pathology was identified in significantly fewer CXRs compared with CCTs (51% versus 83%, P < 0.001). All 7/57 (12%) emergent or urgent chest interventions were based on information from CXR. In 53 children (93%), the CCT was ordered as part of a pan-scan, resulting in a radiation dose of 37.69 ± 7.80 mSv from initial CT scans. Radiation dose was significantly greater from CCT than from CXR (8.7 ± 1.1 mSv versus 0.017 ± 0.002 mSv, P < 0.001). CONCLUSIONS: Clinically useful information found on CCT had good correlation to information obtained from CXR and did not change patient management, however, did add significantly to the radiation exposure of initial imaging. We recommend selective use of CCT, particularly in the presence of an abnormal mediastinal silhouette on CXR after a significant deceleration injury.