Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma.

BACKGROUND: Blunt injury to the carotid or vertebral vessels (blunt cerebrovascular injury [BCVI]) is diagnosed in approximately 1 of 1,000 (0.1%) patients hospitalized for trauma in the United States with the majority of these injuries diagnosed after the development of symptoms secondary to central nervous system ischemia, with a resultant neurologic morbidity of up to 80% and associated mortality of up to 40%. With screening, the incidence rises to 1% of all blunt trauma patients and as high as 2.7% in patients with an Injury Severity Score of >or=16. The Eastern Association for the Surgery of Trauma organization Practice Management Guidelines committee set out to develop an EBM guideline for the screening, diagnosis, and treatment of BCVI. METHODS: A computerized search of the National Library of Medicine/National Institute of Health, Medline database was performed using citations from 1965 to 2005 inclusive. Titles and abstracts were reviewed to determine relevance, and isolated case reports, small case series, editorials, letters to the editor, and review articles were eliminated. The bibliographies of the resulting full-text articles were searched for other relevant citations, and these were obtained as needed. These papers were reviewed based on the following questions: 1. What patients are of high enough risk, so that diagnostic evaluation should be pursued for the screening and diagnosis of BCVI? 2. What is the appropriate modality for the screening and diagnosis of BCVI? 3. How should BCVI be treated? 4. If indicated, for how long should antithrombotic therapy be administered? 5. How should one monitor the response to therapy? RESULTS: One hundred seventy-nine articles were selected for review, and of these, 68 met inclusion criteria and are excerpted in the attached evidentiary table and used to make recommendations. CONCLUSIONS: The East Practice Management Guidelines Committee suggests guidelines that should be safe and efficacious for the screening, diagnosis, and treatment of BCVI. Risk factors for screening are identified (see ), screening modalities are reviewed indicating that although angiography remains the gold standard, multi-planar (>or==8 slice) CT angiography may be equivalent, and treatment algorithms are evaluated. It is noted that change in the diagnosis and management of this injury constellation is rapid due to technological advancement and the difficulties inherent in performing randomized prospective trials in this patient population.

Percutaneous endoscopic gastrostomy: the preferred method of elective feeding tube placement in trauma patients.

PURPOSE: The purpose of this study was to determine whether gastric feeding tubes placed by the percutaneous endoscopic route resulted in fewer and less severe complications than open surgical gastrostomy (SG). METHODS: Charts for all trauma patients admitted 1/94 to 12/98, which had an electively placed feeding tube, were individually reviewed. All tube-related complications were recorded. Of 8119 patients screened, 158 (1.9%) met inclusion criteria. Percutaneous endoscopic gastrostomies (PEGs) were placed in 95 (60.1%) and surgical gastrostomies in 63 (39.9%). Most patients (79.1%) had AIS 3 or greater head or spinal cord injury as the primary diagnosis leading to tube placement. RESULTS: Overall, SG patients were 5.4 times more likely than PEG patients to have a complication from their gastrostomy tube (95% CI, 2.1-13.8). They were 2.6 times more likely to have a major complication (internal leakage, dehiscence, peritonitis, and fistula), and 5.5 times more likely to have a minor complication (unplanned removal, dislodgment, external leak, skin infection, and nonfunction). The groups did not differ on ISS, ICU LOS, total LOS, or mortality (p > 0.05). Overall, a total of 39 individual complications related to tube placement were noted in 26 separate patients (PEG, 7; SG, 19). All four of the major complications requiring operative intervention were in the SG group. There were 31 minor complications, 8 in the PEG group and 27 in the SG group. Mean total charges for placement were also significantly lower in the PEG group than the SG group ($1271 vs. $2761, p < 0.001) CONCLUSION: Gastrostomy tubes placed via the percutaneous endoscopic route had a significantly lower complication rate than surgically placed tubes. In addition, the charges incurred for their placement were also significantly less. Based on the findings of this study, PEG should be considered as the method of choice for gastric feeding tube placement for trauma patients who do not have specific contraindications to the procedure.