A retrospective observational study examining the admission arterial to end-tidal carbon dioxide gradient in intubated major trauma patients.

Major trauma patients who are intubated and ventilated are exposed to the potential risk of iatrogenic hypercapnic and hypocapnic physiological stress. In the pre-hospital setting, end-tidal capnography is used as a practical means of estimating arterial carbon dioxide concentrations and to guide the adequacy of ventilation. In our study, potentially deleterious hypercapnia (mean 47 mmHg, range 26 to 83 mmHg) due to hypoventilation was demonstrated in 49% of 100 intubated major trauma patients arriving at a major Australian trauma centre. A mean gradient of 15 mmHg arterial to end-tidal carbon dioxide concentration difference was found, highlighting the limitations of capnography in this setting. Moreover, 80% of the patients in the study had a head injury. Physiological deadspace due to hypovolaemia in these patients is commonly thought to contribute to the increased arterial to end-tidal carbon dioxide gradient in trauma patients. However in this study, scene and arrival patient hypoxia was more predictive of hypoventilation and an increased arterial to end-tidal carbon dioxide gradient than physiological markers of shock. Greater vigilance for hypercapnia in intubated trauma patients is required. Additionally, a larger study may confirm that lower end-tidal carbon dioxide levels could be safely targeted in the pre-hospital and emergency department ventilation strategies of the subgroup of major trauma patients with scene hypoxia.

Traumatic adrenal gland injury: epidemiology and outcomes in a major Australian trauma center.

INTRODUCTION: Adrenal gland injury (ADGI) is quite rare and mostly associated with other organ injuries secondary to blunt thoracoabdominal trauma. Bilateral ADGI has severe consequences if not discovered in the treatment course of trauma victims. PURPOSE: To review our experience of management of ADGI, epidemiology, and outcomes in a major Australian trauma institute. METHODS: A retrospective analysis of all patients presenting with thoracoabdominal trauma to the Alfred Hospital who had been diagnosed with adrenal gland injury between July 2001 and July 2007. RESULTS: Of 3,921 patients with blunt thoracoabdominal injuries, 2.4% were identified with blunt ADGI (70 males and 26 women, age range 15-85 years). Right adrenal injuries occurred in 72.9%, left adrenal injuries in 22.9%, and bilateral ADGI in 4.2%. Computed tomography (CT) scan findings revealed 82.2% of acute injuries to be hyperdense hematoma expanding and distorting the adrenal gland. Periadrenal stranding and hemorrhagic changes around the adrenal limbs were seen in 12.5%. Oval or round lesions were seen in 3.1%. Surgery was performed in 25% of the study group for associated thoracoabdominal injuries. Patients with left adrenal gland injury had higher rates of mortality and morbidity, and length of stay. CONCLUSION: ADGI is being increasingly recognized with the widespread use of CT scan in the evaluation of multitrauma patients. ADGI is usually self-limiting and typically managed nonoperatively. Acute adrenal insufficiency should be considered and investigated in case of unexplained hypotension in uni- or bilateral ADGI.

Retrievable Gunther Tulip inferior vena cava filter: experience in 317 patients.

The aim of our study was to assess our experience with the retrievable Gunther Tulip (GT) inferior vena cava (IVC) filter, with regard to its insertion, efficacy, ease of placement and retrieval, and associated complications. Between November 2001 and October 2005, 322 GT filters were placed in 317 patients. Insertion indications included the following: pulmonary embolus (PE) prophylaxis in trauma patients (n = 232), PE prophylaxis in perioperative patients (n = 27), PE prophylaxis in moribund intensive care unit patients (n = 22), recent PE (n = 48), extensive deep venous thrombosis (n = 66), contraindication to anticoagulation (n = 63), anticoagulation complication (n = 8) and deep venous thrombosis with failed anticoagulation (n = 8). Some patients had more than one indication for caval filter placement. Two hundred and five attempted retrievals have been carried out, with 15 failures. Our successful retrieval rate is 92%. Nineteen filters were originally inserted permanently. There have been three minor complications associated with insertion and five with retrieval. The mean time from filter insertion to attempted retrieval was 76.95 days. The ideal filter implantation time gives the patient the benefit of PE protection, while avoiding the long-term risks associated with caval filters. Although GT retrieval times have lengthened considerably, our data suggest that this is at the expense of successful retrieval rates.