Posterior Thoracic Stab Wounds: Evaluating the Value of Commonly Used Radiologic Modalities.

This study was performed to assess our institution's experience with stab injuries to the posterior mediastinal box. We examine the value of performing CT of the chest and esophagram in conjunction with a chest X-ray (CXR) over performing CXR(s) alone in evaluating this group of patients. We performed a retrospective study covering a 10-year period consisting of patients with stab wounds to the posterior mediastinal box. Age, gender, and injury severity score as demographic data points were collected. CXR, CT, and esophagram results; identified injuries; and subsequent interventions were analyzed. Of 78 patients who met the inclusion criteria, a total of 55 patients underwent esophagram, one had a false-positive result, and zero had their course altered by the study. Sixty-six patients underwent CT imaging, and there were nine missed findings on initial CXR. Five of these were clinically insignificant and the remaining four were managed with a chest tube alone. There were no tracheobronchial, esophageal, cardiac, or great vessel injuries. Hemodynamically stable, asymptomatic patients with stab wounds to the posterior mediastinal box do not require routine CT and esophagram in the absence of CXR and cardiac ultrasonographic abnormalities.

The incidence of acute venous injury as a result of proximity penetrating trauma screened with colour flow duplex ultrasound.

INTRODUCTION: The incidence of acute deep venous thrombosis as a result of penetrating proximity extremity trauma (PPET) to the thigh has been demonstrated to be 16% in a single report. The purpose of the current study is to demonstrate the incidence and clinical significance of venous injury as a result of proximity trauma to the thigh in a large cohort screened with colour flow duplex (CFD) ultrasound and to identify factors predictive of defining a wound in proximity to a major vascular structure. PATIENTS AND METHODS: A prospective observational study was conducted from January 1st, 2010 to January 1st, 2012 on all patients presenting with penetrating extremity trauma. Data on injury location, mechanism, associated extremity and non-extremity injuries, use and results of CFD, as well as the admitting trauma surgeon were recorded and analysed. RESULTS: 220 thigh wounds with a normal physical examination were identified, of which 167 (75.9%) underwent CFD due to proximity. The incidence of acute venous injury was 4.8% (8/167). 37.5% (3/8) of these injuries resulted in morbidity. Injury mechanism and which attending physician was on call were predictive of a wound being defined as in proximity, whereas an injury with an associated fracture was a negative predictor. CONCLUSIONS: Occult venous injuries as a result of PPET occur in 4.8% of patients with thigh wounds in proximity to a major vascular structure. The designation of a wound as being in "proximity" was influenced by injury mechanism, associated fractures, and the judgement of the on-call attending. Colour flow duplex is a valuable tool with the ability to identify not only occult arterial injuries, but also venous injuries with the potential to cause significant morbidity as well.

Utilization of cardiothoracic surgeons for operative penetrating thoracic trauma and its impact on clinical outcomes.

BACKGROUND: Large series reporting outcomes for penetrating thoracic trauma have identified injury pattern and injury severity scoring as predictors of poor outcome. However, the impact of surgical expertise on patient outcomes has not been previously investigated. We sought to determine how often board-certified cardiothoracic surgeons are utilized for operative thoracic trauma and whether this has an effect on patient outcomes. METHODS: A level I trauma center registry was queried between 2003 and 2011. Records of patients undergoing surgery as a result of penetrating thoracic trauma were retrospectively reviewed. Patient demographics, injuries, injury severity, utilization of a cardiothoracic surgical operative consult and outcomes were recorded. Patients operated on by cardiothoracic surgeons were compared with patients operated on by trauma surgeons using stepwise multivariate analyses to determine the factors associated with utilization of cardiothoracic surgeons for operative thoracic trauma and survival. RESULTS: Cardiothoracic surgeons were used in 73.0% of cases (162 of 222) over the study period. The use of cardiothoracic surgeons increased incrementally both overall (38.5% to 73.9%), and for emergent/urgent cases (31.8% to 73.3%). When comparing patients undergoing operation on an emergent/urgent basis by cardiothoracic versus trauma surgeons, there was no significant difference with regard to demographics, mechanism of injury, injury severity scoring, or surgical morbidity. Stepwise logistic regression showed the presence of a cardiothoracic surgeon to be independently associated with survival (odds ratio 4.70; p = 0.019). CONCLUSIONS: Use of cardiothoracic surgeons for operative thoracic trauma increased over the study period. Outcomes for severely injured patients with elevated chest injury scores or decreased revised trauma scores may be improved with appropriate operative consultation with a board-certified cardiothoracic surgeon.

Color-flow duplex screening for upper extremity proximity injuries: a low-yield strategy for therapeutic intervention.

BACKGROUND: Although the incidence of injury to the upper extremity screened with angiography as a result of proximity penetrating trauma is similar to that of the lower extremity, intervention rates seem to be higher. However, studies evaluating the incidence of injury as a result of proximity penetrating trauma have primarily focused on the lower extremity. This study shows the incidence and clinical significance of vascular injury as a result of proximity trauma to the upper extremity in a large cohort of patients screened with color-flow duplex. MATERIALS AND METHODS: A retrospective study was conducted from January 1, 2005 to January 1, 2012 on all patients undergoing color-flow duplex as a result of proximity penetrating trauma to the upper extremity. Data on injury location, mechanism, associated extremity and nonextremity injuries, and use and results of color-flow duplex were recorded and analyzed. RESULTS: A total of 341 patients were identified who underwent color-flow duplex because of proximity penetrating trauma to the upper extremity. Injuries occurred in 370 extremities, with 253 located in the upper arm and 117 in the forearm. Overall, 18 (4.9%) injuries were identified on screening duplex ultrasound, of which 12 (3.2%) were arterial and 5 (1.4%) were venous. The therapeutic intervention rate for detected injuries to the upper arm was 1.6% (4/253), whereas no injuries of the forearm were identified that necessitated intervention. CONCLUSIONS: Although color-flow duplex is an inexpensive and noninvasive means of detecting injuries as a result of proximity penetrating trauma, screening upper extremity wounds is unlikely to detect clinically significant arterial injuries in need of therapeutic intervention. Venous injuries in the form of deep venous thromboses were detected in only 1.4% of patients. These findings suggest that screening for proximity penetrating trauma of the upper extremity is unlikely to detect injuries at a rate that would prove cost-effective on formal decision analysis.

The consequences of noncompliance with guidelines for withholding or terminating resuscitation in traumatic cardiac arrest patients.

BACKGROUND: The validity of current guidelines regarding resuscitation of patients in traumatic cardiopulmonary arrest (TCPA) and the ability of emergency medical services (EMS) to appropriately apply them have been called into question. The purpose of this study is to demonstrate the consequences of violating the current published guidelines and whether EMS personnel were able to accurately identify patients in TCPA. METHODS: We conducted a retrospective review of our Level I trauma center's database that identified 294 patients over an 8-year period (January 1, 2003, to December 31, 2010) who suffered prehospital TCPA and met criteria for the withholding or termination of resuscitation based on current guidelines. Patient demographics, prehospital/emergency department physiology, survival, neurologic outcome, and hospital charges were analyzed. RESULTS: One of 294 patients (0.3%) survived to reach hospital discharge with a Glasgow Coma Scale score of 6. The total costs incurred for these 294 patients meeting criteria for withholding or termination of resuscitation were $3,852,446.65. One hundred seventeen (39.8%) patients were evaluated by more than one EMS team. There was 100% agreement on the presence (15 of 15) or absence (102 of 102) of a pulse between the EMS teams. CONCLUSIONS: Our data support the current guidelines regarding the withholding or termination of resuscitation of patients in prehospital TCPA and represent the largest series to date on this topic. EMS personnel were able to accurately determine traumatic cardiac arrest in the field in this series. Violation of the current guidelines resulted in six patients being resuscitated to a neurologically devastated state. No loss of neurologically intact survivors would have resulted had strict adherence to the guidelines been maintained.

Appropriate use of emergency department thoracotomy: implications for the thoracic surgeon.

BACKGROUND: Practice guidelines for the appropriate use of emergency department thoracotomy (EDT) according to current national resuscitative guidelines have been developed by the American College of Surgeons Committee on Trauma (ACS-COT) and published. At an urban level I trauma center we analyzed how closely these guidelines were followed and their ability to predict mortality. METHODS: Between January 2003 and July 2010, 120 patients with penetrating thoracic trauma underwent EDT at Mount Sinai Hospital (MSH). Patients were separated based on adherence (group 1, n=70) and nonadherence (group 2, n=50) to current resuscitative guidelines, and group survival rates were determined. These 2 groups were analyzed based on outcome to determine the effect of a strict policy of adherence on survival. RESULTS: Of EDTs performed during the study period, 41.7% (50/120) were considered outside current guidelines. Patients in group 2 were less likely to have traditional predictors of survival. There were 6 survivors in group 1 (8.7%), all of whom were neurologically intact; there were no neurologically intact survivors in group 2 (p=0.04). The presence of a thoracic surgeon in the operating room (OR) was associated with increased survival (p=0.039). CONCLUSIONS: A policy of strict adherence to EDT guidelines based on current national guidelines would have accounted for all potential survivors while avoiding the harmful exposure of health care personnel to blood-borne pathogens and the futile use of resources for trauma victims unable to benefit from them. Cardiothoracic surgeons should be familiar with current EDT guidelines because they are often asked to contribute their operative skills for those patients who survive to reach the OR.

Noninvasive Doppler ultrasonography for assessing cardiac function: can it replace the Swan-Ganz catheter?

BACKGROUND: Cardiac function, including cardiac index (CI), traditionally has been measured by a pulmonary artery catheter (PAC). A noninvasive alternative for measuring cardiac function would offer obvious advantages. METHODS: A prospective study of trauma and nontrauma patients was performed in a surgical intensive care unit over a 3-month period. CI was determined using both a standard PAC and a continuous-wave Doppler ultrasound (UTS). The study had 2 phases: phase I was nonblinded and phase II was blinded; the correlation between UTS- and PAC-derived CI was assessed. RESULTS: A total of 120 paired measurements of CI were observed in 31 patients. The UTS-derived CI measurements showed agreement with PAC measurements in both phase I and phase II of the study with a bias of .06 L/min/m(2) +/- .4 L/min/m(2). Paired measurements correlated well in both phase I (r = .97, R2 = .95, P < .0001) and phase II (r = .93, R2 = .86, P < .0001) of the study. CONCLUSIONS: Doppler UTS correlates well with PAC measurements of CI. This noninvasive modality is an accurate and safe alternative to PAC.