Health-related quality of life among US military personnel injured in combat: findings from the Wounded Warrior Recovery Project.

PURPOSE: Little is known about the long-term, health-related quality of life (HRQOL) of those wounded in combat during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. The present study described the overall HRQOL for a large group of US service members experiencing mild-to-severe combat-related injuries, and assessed the unique contribution of demographics, service- and injury-related characteristics, and mental health factors on long-term HRQOL. METHOD: The Wounded Warrior Recovery Project examines patient-reported outcomes in a cohort of US military personnel wounded in combat. Participants were identified from the Expeditionary Medical Encounter Database, a US Navy-maintained deployment health database, and invited to complete a web-based survey. At the time of this study, 3245 service members consented and completed the survey. Hierarchical linear regression analyses were conducted to assess the unique contribution of each set of antecedents on HRQOL scores. RESULTS: HRQOL was uniquely associated with a number of demographics, and service- and injury-related characteristics. Nevertheless, screening positive for posttraumatic stress disorder (B = - .09; P < .001), depression (B = - .10; P < .001), or both as a set (B = - .19; P < .001) were the strongest predictors of lower long-term HRQOL. CONCLUSIONS: Postinjury HRQOL among service members wounded in combat was associated with service and injury experience, and demographic factors, but was most strongly linked with current mental health status. These findings underscore the significance of mental health issues long after injury. Further, findings reinforce that long-term mental health screening, services, and treatment are needed for those injured in combat.

Resource commitment to improve outcomes and increase value at a level I trauma center.

BACKGROUND: Optimal care of trauma patients requires cost-effective organization and commitment of trauma center resources. We examined the impact of creating a dedicated trauma care unit (TCU) and adding advanced practice nurses on the quality and cost of care at an adult Level I trauma center. METHODS: Patient demographic and injury data, length of stay, complications, outcomes, and total direct cost of care were evaluated for four 1-year intervals in the recent history of our trauma center: Year A, a trauma team of in-house trauma surgeons and resident physicians; Year B, the addition of nurse practitioners to the trauma team 5 days/week; Year C, the creation of a dedicated TCU for all non intensive care unit trauma patients; and Year D, the addition of a permanent clinical nurse specialist and an increase in nurse practitioner coverage to 7 days/week. For each year, value was determined by calculating the median cost of a survivor and the median cost of a survivor with no complications. Significance was attributed to p<0.05. RESULTS: Patient volume increased from 1,927 in year A to 2,546 by year D. Over the period of study, there was an increase in blunt trauma (87.1-89.9%; p<0.05), median Injury Severity Score (5-6; p<0.05), and patients aged ≥65 years (11.4-19.8%; p<0.05). However, risk-adjusted mortality was unchanged. There was a decrease in patients with a complication (20.8-14.9%; p < 0.05), median intensive care unit length of stay (39.5-23.4 hours; p < 0.05), and median cost of care ($4,306-$3,698; p<0.05). Value increased: both the median costs of a survivor and of a survivor with no complications decreased from $4,259 to $3,658 (p<0.05) and from $3,898 to $3,317 (p<0.05), respectively. The median cost of a survivor with severe injury (Injury Severity Score ≥15) decreased from $17,651 to $12,285 (p<0.05). CONCLUSION: The addition of a dedicated TCU and advanced practice nurses improved the quality and reduced the cost of care, resulting in increased value at an adult Level I trauma center.

Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulants and prescription antiplatelet agents at risk?

BACKGROUND: Trauma centers are more frequently evaluating patients who are receiving anticoagulant or prescription antiplatelet (ACAP) therapy at the time of injury. Because there are reports of delayed intracranial hemorrhage (ICH) after blunt trauma in this patient group, we evaluated patients receiving ACAP with a head computed tomography (CT) on admission (CT1) followed by a routine repeat head CT (CT2) in 6 hours. We hypothesized that among patients with no traumatic findings on CT1 and a normal or unchanged interval neurologic examination, the incidence of clinically significant delayed ICH would be zero. METHODS: We retrospectively reviewed adult blunt trauma patients admitted to our Level I trauma center from January 2006 to August 2009 who were receiving preinjury ACAP therapy. We reviewed medications, mechanism of injury, head CT results, and outcomes. Demographic data, injury severity scores, international normalized ratio, and neurologic examinations were recorded. We determined the incidence of delayed ICH on CT2 for patients with a negative CT1. RESULTS: Five hundred patients qualified for the protocol. Of these, 424 patients (85%) had a negative CT1. Among these patients, mean age was 75 years; 210 (50%) were male. Fall from standing was the most common mechanism of injury found in 357 patients (84%). Warfarin alone was taken in 68%, clopidogrel alone in 24%, and other agents in 2%. Six percent of patients were taking two agents. Mean international normalized ratio for patients on warfarin was 2.5. Among patients with a negative CT1, CT2 was obtained in 362 patients (85%) and was negative in 358 patients (99%). Four patients (1%) with a negative CT1 had a positive (n = 3) or equivocal (n = 1) CT2. All the changes on CT2 were minor and had either resolved or stabilized on third head CT. Of the four patients with positive or equivocal CT2, none had a change in neurologic examination; however, two had symptoms that could be attributed to head injury. Three were discharged home and one died of cardiac disease unrelated to head trauma. CONCLUSIONS: The incidence of delayed ICH in our study was 1%. However, none of the delayed findings were clinically significant. Among patients on ACAP therapy with a negative CT1 and a normal or unchanged neurologic examination, a routine CT2 is unnecessary. We recommend a period of observation to recognize those patients with symptoms that could be due to delayed ICH.

Alcohol and high-risk behavior among young first-time offenders.

BACKGROUND: Underage drinking carries a high risk of injury. An important approach for reducing underage drinking is limiting youth access to alcohol. Underage drinkers obtain alcohol from multiple sources and patterns of access may vary by region. We examined patterns of access to alcohol and alcohol use among youth in a local court-ordered diversion program for first-time adolescent alcohol offenders as a basis for designing and evaluating community prevention efforts. METHODS: Youth in the program completed a survey of demographic data, type of offense, source, setting, and quantity of alcohol consumed at time of offense, and 1-year alcohol-related high-risk behaviors. Significance was attributed to p < or = 0.05. RESULTS: Completed surveys were obtained from 1,158 (84.8%) of 1,366 eligible participants during the 23-month study period. There were 71% males and 29% females with a mean age of 17.2 years (range, 12-24 years). Respondents were Caucasian (64.5%), Hispanic/Latino (19.9%), Asian (3.5%), African American (2.5%), and others (9.6%). Offenses included minor in possession (55.8%), driving under the influence (21.2%), and drunk in public (20.4%). Consumption at time of offense was one or less drinks in 36.3%, two to five drinks in 31.7%, and 32.0% reported six or more drinks. Social sources of alcohol (got it from someone else) were reported by 72.9% and commercial sources (bought it or took it from a store) were reported in 11.9%. The two most common places of consumption were someone else's home (30.7%) and the beach (14.6%). Multiple 1-year high-risk behaviors were reported and 41.0% drove after drinking or rode with someone else who had been drinking. Binge drinking (5 or more drinks for males; 4 or more drinks for females) was reported by 43.1% of males and 36.7% of females. All high-risk behaviors were more common in binge drinkers (p < 0.001). Drinking and driving or riding with a drinking driver was reported in 54.2% of those who binged. Females who binged reported a higher rate than males in 8 of 10 high-risk behaviors. CONCLUSIONS: This study revealed the predominance of social sources of alcohol among young first-time alcohol offenders. Drinking and driving or riding with a drinking driver was reported at an alarmingly high rate. Other alcohol-related high-risk behaviors were also common. Efforts to prevent alcohol-related trauma should target social access to alcohol, the resulting high-risk behaviors, and include a special focus on young females.

Small catheter tube thoracostomy: effective in managing chest trauma in stable patients.

BACKGROUND: Image-guided small catheter tube thoracostomy (SCTT) is not currently used as a first-line procedure in the management of patients with chest trauma. We adopted a practice recommendation to use SCTT as a less invasive alternative in the treatment of chest injuries. We reviewed our trauma registry to evaluate our change in practice and the effectiveness of SCTT. METHODS: Retrospective review of all tube thoracostomies (TT) performed in patients with chest injury at a level I trauma center from September 2002 through March 2006. Data collected included age, sex, indications and timing for TT, use of antibiotics, length of stay, complications, and outcomes. Large catheter tube thoracostomy (LCTT) not performed in the operating room or trauma room and all SCTT were deemed nonemergent. RESULTS: There were 565 TT performed in 359 patients. Emergent TT was performed in 252 (70%) and nonemergent TT in 157 (44%) patients, of which 63 (40%) received LCTT and 107 (68%) received SCTT. Although SCTT was performed later after injury than nonemergent LCTT (5.5 days vs. 2.3 days, p < 0.001), average duration of SCTT was shorter (5.5 days vs. 7 days, p < 0.05). Rates of hemothoraces were similarly low for SCTT versus nonemergent LCTT (6.1% vs. 4.2%, p = NS) and rates of residual/recurrent pneumothoraces were not significantly different (8% vs. 14%, p = NS). The rate of occurrence of fibrothorax, however, was significantly lower for SCTT compared with nonemergent LCTT (0% vs. 4.2%, p < 0.05). In patients receiving a single nonemergent TT, SCTT was performed in 55 (61%) and LCTT in 35 (39%). A comparison of these groups revealed that SCTT was performed in older patients (p < 0.05), and was associated with a lower Injury Severity Score (p < 0.05) and shorter length of stay (p = 0.05). SCTT was increasingly used in younger and more seriously injured patients as our experience grew. CONCLUSION: SCTT is effective in managing chest trauma. It is comparable with LCTT in stable trauma patients. This study supports adopting image-guided small catheter techniques in the management of chest trauma in stable patients.

Early intubation in the management of trauma patients: indications and outcomes in 1,000 consecutive patients.

BACKGROUND: The Eastern Association for the Surgery of Trauma Practice Management Guidelines identify indications (EI) for early intubation. However, EI have not been clinically validated. Many intubations are performed for other discretionary indications (DI). We evaluated early intubation to assess the incidence and outcomes of those performed for both EI and DI. METHODS: One thousand consecutive intubations performed in the first 2 hours after arrival at our Level I trauma center were reviewed. Indications, outcomes, and trauma surgeon (TS) intubation rates were evaluated. RESULTS: During a 56-month period, 1,000 (9.9%) of 10,137 trauma patients were intubated within 2 hours of arrival. DI were present in 444 (44.4%) and EI in 556 (55.6%). DI were combativeness or altered mental status in 375 (84.5%), airway or respiratory problems in 21 (4.7%), and preoperative management in 48 (10.8%). Injury Severity Score was 14.6 in DI patients and 22.7 in EI patients (p < 0.001). Predicted versus observed survival was 96.6% versus 95.9% in DI patients and 75.2% versus 75.0% in EI patients (p < 0.001). Head Abbreviated Injury Scale score of >or=3 occurred in 32.7% with DI and 52.0% with EI (p < 0.001). Seven (0.7%) surgical airways were performed; two for DI (0.2%). Eleven (1.1%) patients aspirated during intubation and five (0.5%) suffered oral trauma. There were no other significant complications of intubation for either DI or EI and complication rates were similar in the two groups. Delayed intubation (early intubation after leaving the trauma bay) was required in 67 (6.7%) patients and 59 (88.1%) were for combativeness, neurologic deterioration, or respiratory distress or airway problems. Intubation rates varied among TS from 7.6% to 15.3% (p < 0.001) and rates for DI ranged from 3.3% to 7.4% (p < 0.001). There was a statistically insignificant trend among TS with higher intubation rates to perform fewer delayed intubations. CONCLUSIONS: Early intubation for EI as well as DI was safe and effective. One third of the DI patients had significant head injury. Surgical airways were rarely needed and delayed intubations were uncommon. The intubation rates for EI and DI varied significantly among TSs. The Eastern Association for the Surgery of Trauma Guidelines may not identify all patients who would benefit from early intubation after injury.

Preemptive craniectomy with craniotomy: what role in the management of severe traumatic brain injury?

BACKGROUND: Patients with severe traumatic brain injury (TBI) require aggressive management to prevent secondary brain injury. "Preemptive" craniectomy (CE)--craniectomy performed as a primary procedure in conjunction with craniotomy--has been used as prophylaxis for secondary injury, but the indications and outcomes of craniectomy used for this purpose are not well defined. METHODS: To evaluate the role of CE in the management of TBI, we retrospectively reviewed 62 consecutive patients who underwent CE in a 78-month period at our level I trauma center. A cohort of patients who underwent craniotomy only (CO) during this period was compared with the CE group for TBI patterns, indications for operation, and outcomes. Multivariable logistic regression and matched propensity score analysis were used to test the association between CE and survival. The rate of CE was determined by individual neurosurgeons. RESULTS: Of 197 patients with brain injuries who underwent craniotomy, 62 (31.5%) had CE and 135 (68.5%) had CO. Mean age for CE versus CO was 41 years versus 51 years (p < 0.01). Mean admission Glasgow Coma Score was lower in CE versus CO (7.6 vs. 11.8, p < 0.001); Injury Severity Score was higher (30.2 vs. 26.3, p < 0.01). The indication for operation for CE compared with CO was subdural hematoma in 41 (66.1%) versus 87 (64.4%, p = 0.82), epidural hematoma in 2 (3.2%) versus 26 (19.3%, p < 0.01), and cerebral contusion or hematoma in 15 (24.2%) versus 8 (5.9%, p < 0.001). Postoperative intracranial pressure was monitored in 48 (77.4%) CE and 44 (32.6%) CO patients (p < 0.001). Intracranial pressure <20 was maintained in 26 (54.2%) after CE and in 31 (70.5%) after CO (p = 0.12). In the CE group, 26 (42%) died compared with 31 (26%, p < 0.01) in the CO group. When adjusted for severity of injury, however, there was no significant difference in mortality between the two groups (p = 0.134). The CE rate obtained by a neurosurgeon varied from 8.6% to 75.0% (p < 0.001). CONCLUSION: CE was used in patients with more severe injuries, and particularly in those with more severe head injuries. When adjusted for injury severity, CE was not associated with worsened survival, and therefore may reasonably be included in the armamentarium of neurotrauma care. Use of CE by our neurosurgeons, however, varied significantly. These findings underscore the need for practice guidelines based on randomized trials to fully evaluate the role of CE in the management of TBI.

Evaluation of Three Postal Invitational Strategies to Increase Survey Response Rates in a Combat-Injured U.S. Military Population: Findings From the Wounded Warrior Recovery Project.

The survival rate of those injured in combat in overseas contingency operations is higher than in previous conflicts. There is a need to assess the long-term psychosocial and quality of life outcomes of those injured in combat, yet surveying this population presents inherent challenges. As part of a large-scale, longitudinal examination of patient-reported outcomes of service members injured on deployment, the present manuscript evaluated the effectiveness of three postal strategies on response rates: (1) mailing a study prenotification postcard, (2) mailing the survey invitation in a larger envelope, and (3) including a small cash preincentive ($2). Evaluation of these strategies yielded mixed results in this population. Neither the prenotification postcard nor inclusion of a $2 cash preincentive significantly increased response rates. However, use of a larger envelope to mail the survey invitation significantly increased the response rate by 53.1%. Researchers interested in collecting patient-reported outcomes among military populations, including those with combat-related injuries, may find that increasing the visibility of recruitment materials is more effective for improving response rates than attempting to cognitively prime or offer prospective participants preincentives.

The need for immediate computed tomography scan after emergency craniotomy for head injury.

BACKGROUND: Patients who undergo emergency craniotomy for head injury require vigilant postoperative (postop) care to obtain the best possible outcome. Although repeat head computed tomography (CT) scans are a key component of the management of these patients, there is no consensus on the optimal timing of the initial postop CT. METHODS: We conducted a retrospective registry-based review of the care of 199 consecutive trauma patients who underwent craniotomy for head injury at a Level I trauma center to evaluate the role of postop CT in their management. RESULTS: One hundred and ninety-nine patients underwent 218 craniotomies for head injury during the 78-month study period. Mean age was 48 years and 73.9% were men. Overall survival was 71.4%. The primary indication for operation included subdural hematoma (SDH) in 136 (62.4%), epidural hematoma (EDH) in 32 (14.7%), intraparenchymal hemorrhage or contusion in 21 (9.6%), depressed skull fracture in 17 (7.8%), and other indications in 12 (5.5%). Postop CTs were obtained after 197 (90.4%) of the operations at a mean of 19.2 hours and revealed a variety of unexpected findings with clinical implications. The only variable statistically associated with unexpected findings was SDH as an indication for operation (p < 0.01). Fourteen (7.0%) patients required a second craniotomy in the 2 days after their initial operation. In six (3.0%) patients, postop CTs were obtained between 4.2 hours and 21.1 hours after initial craniotomy and an earlier postop CT would most likely have prevented a significant delay in operation. Findings in these six patients included recurrent SDH or EDH in two, new SDH or EDH in two, and intraparenchymal hemorrhage in two. Neither neurologic examination nor postop intracranial pressure monitoring reliably predicted the presence of new or recurrent hemorrhage or other significant findings. CONCLUSION: Early, if not immediate, postop CT after emergency craniotomy for head trauma appears to be warranted. We found a significant incidence of unexpected findings on postop CT and encountered avoidable delays in treatment of new or recurrent findings.

The scourge of methamphetamine: impact on a level I trauma center.

BACKGROUND: Methamphetamine (METH) use is associated with high-risk behavior and serious injury. The aim of this study was to assess the impact of METH use in trauma patients on a Level I trauma center to guide prevention efforts. METHODS: A retrospective registry-based review of 4,932 consecutive trauma patients who underwent toxicology screening at our center during a 3-year period (2003-2005). This sample represented 76% of all trauma patients seen during this interval. RESULTS: From the first half of 2003 to the second half of 2005, overall use of METH increased 70% (p < 0.001), surpassing marijuana as the most common illicit drug used by the trauma population. Other illicit drug use did not significantly change during this interval. METH-positive patients were more likely to have a violent mechanism of injury (47.3% vs. 26.3%, p < 0.001), with 33% more assaults (p < 0.01), 96% more gunshot wounds (p < 0.001), and 158% more stab wounds (p < 0.001). They were more likely to have attempted suicide (4.8% vs. 2.6%, p < 0.01), to have had an altercation with law enforcement (1.8% vs. 0.3%, p < 0.001), or been the victim of domestic violence (4.4% vs. 2.1%, p < 0.001). METH users had a higher mean Injury Severity Score (11.2 vs. 10.0, p < 0.01), were 62% more likely to receive mechanical ventilation (p < 0.001), and 53% more likely to undergo an operation (p < 0.001). They were more prone to leave against medical advice (4.9% vs. 2.1%, p < 0.001) and 113% more likely to die from their injuries (6.4% vs. 3.0%, p < 0.001). The average cost of care per METH user was 9% higher than that for nonusers, and METH users were more likely to be unfunded than nonusers (47.6% vs. 23.1%, p < 0.001). The annual uncompensated cost of care of METH users increased 70% during the study period to $1,477,108 in 2005. CONCLUSION: METH use in trauma patients increased significantly and was associated with adverse outcomes and a significant financial burden on our trauma center. Evidence-based prevention efforts must be a priority for trauma centers to help stop the scourge of METH.

Combat amputees' health-related quality of life and psychological outcomes: A brief report from the wounded warrior recovery project.

BACKGROUND: This study extends what is known about long-term health-related quality of life (HrQoL) and other psychosocial outcomes (i.e., depression, posttraumatic stress disorder [PTSD]) among US military combat amputees serving in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. METHODS: A total of 63 combat amputees were identified from the Wounded Warrior Recovery Project, a study assessing long-term self-reported HrQoL and psychological outcomes among those wounded during military service. Another 477 service members from the Wounded Warrior Recovery Project were identified as a comparison group (i.e., nonamputees with moderate to severe extremity injuries). RESULTS: After adjusting for age, time since injury, overall injury severity, and traumatic brain injury, amputees had poorer functional HrQoL than those in the nonamputee comparison group overall and in the specific area related to performance of usual activities, and, to some degree, chronic and acute symptoms, and mobility/self-care. On the other hand, depression and PTSD symptoms were not different for the two groups. CONCLUSION: Results suggest that when assessed over 5 years postinjury, on average, amputees have unique physical and functional limitations, yet do not report greater depression or PTSD symptoms than others seriously injured in combat. It may be that state-of-the-art integrated amputee care that includes support networks and emphasis on adjustment and psychological health may increase successful coping and adjustment, at least to a level that is on par with other types of serious combat injury. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Surgeons' attitudes about communicating with patients and their families.

CONTEXT: Surgeons face difficult communication challenges with patients and their families. There is a need for improved education in communication skills, especially in giving bad news. Understanding surgeons' attitudes is the first step in designing effective education programs. OBJECTIVE: To determine surgeons' self-assessment of competence, rating of importance, and perceived need for training in communication skills relevant to patient care. DESIGN: Anonymous self-report mail survey of demographic information and attitudes toward 12 patient care-related communication skills. SETTING: San Diego County, California, a geographically distinct area of close to 3 million inhabitants receiving health care from over 6000 physicians. PARTICIPANTS: A total of 351 (43.4%) respondents from the 833 surgical specialists in the San Diego County Medical Society list of member and nonmember physicians. MAIN OUTCOME MEASURES: Measurement of surgeons' attitudes toward self-perceived competence, importance, need for training in the communication skills, and the influence of age, duration of practice, and surgical-specialty on attitudes. RESULTS: Most respondents rated their competence high except in 3 skills relating to a patient's death. They found all skills important and indicated a need for training in them. Younger surgeons rated their competence and the importance significantly lower in the 3 skills relating to a patient's death (p < 0.05). Critical care surgical specialists rated their competence and the importance higher in skills relating to breaking bad news and a patient's death than did the non-critical care group (p < 0.05). Older surgeons and critical care specialists also indicated a higher level of support for training in these skills. CONCLUSION: These results suggest that surgical specialists rate themselves as competent in effective communication, believe in its importance, and agree with the need for training. An organized approach to training in interaction skills, especially in giving bad news, is warranted.

Damage control in the management of ruptured abdominal aortic aneurysm: preliminary results.

BACKGROUND: This study compared damage control measures (DCM), including operative techniques (DCO) and resuscitative measures (DCR), with standard treatment (ST) for ruptured abdominal aortic aneurysm (rAAA). METHODS: Historical cohort study methodology was used to evaluate outcomes for rAAA repairs related to DCM or ST over a 74-month period at a level I trauma center. RESULTS: Of 28 repairs, 13 (46.4%) were DCM. Compared to ST patients, DCM patients had a lower mean preoperative BP (64.6 vs. 83.2 mm Hg, P = .03) and greater intraoperative blood loss (4.6 vs. 2.1 liters, P = .033). Patients who had both DCR and DCO (DCO & DCR) received more plasma (6.8 vs 2.6 units, P = .039) and less crystalloid (2.8 vs 10.5 liters, P = .005) than those receiving DCO only. A modest decrease in mortality was seen in the DCO & DCR group compared to DCO only. No DCO-related graft infections were observed. CONCLUSION: DCR use may prove beneficial in the management of rAAA.

Incidental CT findings in trauma patients: incidence and implications for care of the injured.

BACKGROUND: The evaluation of patients with head, neck, and torso trauma frequently includes high-definition spiral computed tomography (SCT) scanning, which can reveal non-injury-related lesions. These incidental findings vary in their importance, from trivial lesions to findings that may have a greater impact on the health of the trauma patient than the injuries that led to the SCT. We evaluated the incidence and clinical importance of incidental findings found on SCT, and the effectiveness of a trauma practice guideline calling for appropriate management and follow-up. METHODS: The trauma registry was accessed to identify patients evaluated at an urban Level I trauma center from January to November, 2002. Trauma registry data, inpatient chart records, and the digital record of the filmless radiology archives were reviewed. Demographic data, including age, sex, type and mechanism of injury, and outcome, were recorded. All CT studies were reviewed for incidental findings. Mucus retention cysts, sinusitis (except mastoiditis), degenerative joint disease, evidence of previous operation, and age-related cerebral atrophy were excluded. Incidental findings were divided into three categories based on clinical importance. Category 1 required attention before discharge. Category 2 required follow-up with primary doctor within 1 or 2 weeks, and Category 3 required no specific follow-up. Categories 1 and 2 were considered clinically significant findings. RESULTS: Complete data were available for 991 patients (677 men, 314 women). Eight hundred and forty-eight (85.6%) patients received at least one CT scan. A total of 289 incidental findings were discovered. Thirty-one patients (3.1%) had 36 Category 1 findings. There were 108 Category 2 and 145 Category 3 findings. When comparing those patients with at least one incidental finding, the incidence of incidental findings was higher in women than in men (34.1% versus 27.6%; p < 0.05). Older patients also had a higher incidence of all categories of findings (over 40 versus 40 and younger: 46.1% versus 19.9%; p < 0.001). SCT yielded 90 (62.5%) of the clinically significant incidental findings in the abdomen/pelvis, 29 (20.1%) in the chest, and 25 (17.4%) in the head and neck. The charts of only 15 (48.4%) of the patients with Category 1 findings adequately documented the management of the incidental finding. CONCLUSIONS: SCT for the evaluation of trauma patients reveals a significant number of incidental findings. These lesions are common in the abdomen and pelvis and show an increased incidence in women and among older patients. Although many require early follow-up and specialty physician referral, there was insufficient documentation of the management of these injuries. Incidental findings in the injured remain a significant challenge for trauma centers. An organized approach is required for successful follow-up and management.

What is the role of chest X-ray in the initial assessment of stable trauma patients?

BACKGROUND: The Advanced Trauma Life Support course advocates the liberal use of chest X-ray (CXR) during the initial evaluation of trauma patients. We reviewed CXR performed in the trauma resuscitation room (TR) to determine its usefulness. METHODS: A retrospective, registry-based review was conducted and included 1,000 consecutive trauma patients who underwent CXR in the TR at a Level I trauma center during a 7-month period. RESULTS: Patients receiving CXR comprised 91.5% of all patients evaluated in the TR during the study period. CXR followed by chest computed tomography (CCT) was performed in 820 (82.0%) patients. Subsequent CCT identified missed findings in 235 (35.6%) of the 660 patients with an initial negative CXR who went on to receive CCT. CXR alone was performed in 127 (26.1%) of the 487 patients who were stable, not intubated, and had a normal chest physical examination (CPE). Seven patients (5.5%) in this group had potentially significant findings but none required intervention beyond physiotherapy or antibiotics. Three hundred and sixty (73.9%) of the 487 patients who were hemodynamically stable with a normal CPE underwent both CXR and CCT. Fifty-four patients (15%) in this group had findings of significance, and two (0.6%) required intervention. One patient received bilateral chest tubes for large pre-existing pleural effusions found on CXR and CCT; another patient undergoing general anesthesia required a chest tube for a pneumothorax found only on CCT. CONCLUSION: In stable trauma patients with a normal CPE, CXR appears to be unnecessary in their initial evaluation. CXR should be relegated to a role similar to cervical spine and pelvis radiographs in the initial evaluation of hemodynamically stable trauma patients with a normal physical examination, and should be limited to use only for clear clinical indications.

Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care?

BACKGROUND: Although spiral computed tomographic scanning (SCT) is frequently used for spinal imaging in injured patients, many trauma centers continue to rely on plain film radiography (PFR). The purpose of this study was to determine the effects of a trauma center's transition from PFR to SCT for initial spine evaluation in trauma patients by comparing diagnostic sensitivity, time required for radiographic imaging, costs, charges, and radiation exposure. METHODS: Registry-based review of all trauma patients evaluated for spinal trauma during two three-month intervals, one before (1999, "X-ray Group"), and one after (2002, "CT Group") adopting SCT as the initial spinal imaging method. Demographic data, mechanism of injury, Injury Severity Score (ISS), the presence and location of spine fractures, and the results of all spine imaging were recorded. The dates and diagnostic sensitivity for spine fractures, time for initial imaging, costs, and charges were compared between groups. Radiation exposure associated with both SCT and PFR of the spine was measured. RESULTS: There were 254 patients in the X-ray Group and 319 in the CT Group, with similar demographic data, ISS, mechanism of injury, and incidence of spine fractures. Sensitivity in the detection of spine fractures was 70% (14 out of 20) in the X-ray Group compared with 100% (34 out of 34) for the CT Group (p < 0.001). Mean time in the radiology department during initial evaluation decreased significantly in the CT Group compared with the X-ray Group (1.0 hours vs. 1.9 hours; p < 0.001). SCT of the spine was associated with higher mean overall spinal imaging charges than PFR (4,386 dollars vs. 513 dollars, p < 0.001), but a similar mean overall spinal imaging cost per patient (172 dollars vs. 164 dollars). Radiation exposure was higher with SCT versus PFR for cervical spine imaging (26 mSv vs. 4 mSv) but SCT involved lower levels of exposure than PFR for thoracolumbar imaging (13 mSv vs. 26 mSv). CONCLUSIONS: SCT is a more rapid and sensitive modality for evaluating the spine compared with PFR and is obtained at a similar cost. The advantages of SCT suggest that this readily available diagnostic modality may replace PFR as the standard of care for the initial evaluation of the spine in trauma patients.

Retrievable vena cava filters for preventing pulmonary embolism in trauma patients: a cautionary tale.

BACKGROUND: Retrievable vena cava filters (RFs) offer the appeal of short-term prophylaxis for trauma patients temporarily at risk for pulmonary embolism (PE) without the long-term risks of permanent vena cava filters (PFs). However, the evidence that RFs and PFs reduce the risks of PE and death in trauma patients is not conclusive. RFs were introduced at our trauma center in August 2002. The purpose of this study was to evaluate the effects of RFs on our strategy to prevent PE in trauma patients. METHODS: We reviewed our trauma registry to compare rates of filter placement, filter-related complications (FRCs), and PE before (Group I: January 2000 to August 15, 2002) and after (Group II: August 16, 2002 through December 2004) RF introduction. Indication for filter placement, filter retrieval, FRCs, and incidence of PE were compared. RESULTS: There were 5,042 patients in Group I and 5,038 patients in Group II. There was a threefold increase in filter placement in Group II compared with Group I (55 [1.1%] versus 161 [3.2%]; p < 0.001). There were no significant differences between the rates of PE (0.2% versus 0.2%, p = 0.636) or major FRCs (1.8% versus 2.5%, p = 0.777). Major FRCs included two filter infections with sepsis, one vena cava thrombotic occlusion, one filter lodged in the jugular vein during retrieval, and one PE after filter placement. RF removal was attempted in 43 (27%) patients and successful in 33 (21%). CONCLUSION: The advent of RFs was associated with a threefold increase in vena cava filter placement in our trauma center. Major FRCs were encountered and a very low incidence of PE was not altered by their use. Successful removal could be verified in only 21% of RFs. The results of this study lead us to question the rationale for a more liberal use of vena cava filters in trauma patients.

Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come.

BACKGROUND: Although the traditional method of diagnosing spine fractures (SF) has been plain radiography, Spiral Computed Tomography (SCT) is being used with increasing frequency. Our institution adopted SCT as the primary modality for the diagnosis of SF. The purpose of this study was to determine whether SCT scan can be used as a stand-alone diagnostic modality in the evaluation of SF. METHODS: Retrospective review of all blunt trauma patients over a two year period (1/01-12/02). Patients with neck pain, back pain, or spine tenderness underwent SCT of the symptomatic region. Patients who were unconscious or intoxicated underwent screening SCT of the entire spine. SCT was performed using 5 mm axial cuts with three-dimensional reconstructions in sagittal and coronal planes. Patients with a discharge diagnosis of cervical, thoracic, or lumbar SF were identified from the trauma registry by ICD-9 codes. RESULTS: There were 3,537 blunt trauma patients evaluated, with 236 (7%) sustaining a cervical, thoracic, or lumbar SF. Forty-five patients (19%) sustained a SF in more than one anatomic region. SCT missed SF in two patients. The cervical SF missed by SCT was a compression fracture identified by magnetic resonance imaging and was treated with a rigid collar. The thoracic SF missed by SCT was also a compression fracture identified on plain radiographs and required no treatment. CONCLUSIONS: SCT of the spine identified 99.3% of all fractures of the cervical, thoracic, and lumbar spine, and those missed by SCT required minimal or no treatment. SCT is a sensitive diagnostic test for the identification of SF. Routine plain radiographs of the spine are not necessary in the evaluation of blunt trauma patients.