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C Clay Cothren

Publications and source records attributed to C Clay Cothren.

At least 37 records · Page 2Linked to original sources
PubMed2005

Blunt cerebrovascular injuries.

Over the past decade, the recognition and subsequent management of blunt cerebrovascular injuries has undergone a marked evolution. Originally thought to be a rare occurrence, blunt cerebrovascular injuries are now diagnosed in approximately 1% of blunt trauma patients. The recognition of a clinically silent period allows for angiographic screening for injuries based upon the mechanism of trauma and the patient's constellation of injuries. Comprehensive screening of patients has resulted in the early diagnosis of blunt cerebrovascular injuries during the asymptomatic phase, thus allowing treatment that could prevent neurologic sequelae. Although the ideal regimen of antithrombotic therapy is yet to be determined, treatment with either antiplatelet or anticoagulant agents has been shown to reduce the blunt cerebrovascular injuries related stroke rate. Blunt cerebrovascular injury is a rare but potentially devastating injury; appropriate angiographic screening in high-risk patients should be performed and prompt treatment initiated to prevent ischemic neurologic events.

Anticoagulants↗
PubMed2005

Carotid artery stents for blunt cerebrovascular injury: risks exceed benefits.

BACKGROUND: Carotid stenting has been advocated in patients with grade III blunt carotid artery injuries (hereafter referred to as "blunt CAIs") because of the persistence of the pseudoaneurysm and concern for subsequent embolization or rupture. HYPOTHESIS: Carotid stenting is safe and effective for blunt CAIs. DESIGN: Analysis of a prospective database of all patients with blunt CAIs. SETTING: A state-designated, level I, urban trauma center. PATIENTS AND METHODS: In January 1, 1996, we initiated comprehensive screening for blunt CAIs with angiography based on injury patterns. Patients without contraindications receive anticoagulation therapy immediately for documented lesions. Patients with persistent pseudoaneurysms on a second angiography at 7 to 10 days after injury are candidates for stent placement. RESULTS: During the study period (January 1, 1996, to May 1, 2004), 46 patients sustained blunt carotid pseudoaneurysms; 23 (50%) underwent carotid stent placement. There were 4 complications in patients undergoing carotid stent placement: 3 strokes and 1 subclavian dissection. Follow-up angiography was performed in 38 patients (18 patients with stents who received antithrombotic agents, 20 patients who received antithrombotic agents alone); 8 patients had poststent carotid occlusion despite having received concurrent anticoagulation therapy. Carotid occlusion rates were significantly different (45% in patients with stents vs 5% in those who received antithrombotic agents alone). In the patients not undergoing stent placement, the only complication was a middle cerebral artery stroke in a patient not treated with antithrombotic therapy. CONCLUSIONS: Patients who have carotid stents placed for blunt carotid pseudoaneurysms have a 21% complication rate and a documented occlusion rate of 45%. In contrast, patients treated with antithrombotic agents alone had an occlusion rate of 5%; no asymptomatic patient treated with antithrombotic agents for their injury had a stroke. Antithrombotic therapy remains the recommended therapy for blunt CAIs, but the role of intraluminal stents remains to be defined.

Adult↗
PubMed2005

Screening for blunt cerebrovascular injuries is cost-effective.

BACKGROUND: Recent reports have argued that screening for blunt carotid injury is futile and have called for a cost analysis. Our data previously supported screening asymptomatic trauma patients for blunt cerebrovascular injury (BCVI) to prevent associated neurologic sequelae. Our hypothesis is that aggressive angiographic screening for BCVI based on a patient's injury pattern and symptoms allows for early diagnosis and treatment and is cost-effective because it prevents ischemic neurological events (INEs). METHODS: Beginning in January 1996, we began comprehensive screening using 4-vessel cerebrovascular angiography based on injury patterns; these patients have been followed-up prospectively. Patients without contraindications received antithrombotic therapy immediately for documented BCVI. RESULTS: From January 1996 through June 2004, there were 15,767 blunt-trauma patient admissions to our state-designated level I urban trauma center, of which 727 patients underwent screening angiography. Twenty-one patients presented with signs or symptoms of neurologic ischemia before diagnosis. BCVI was identified in 244 patients (34% screening yield); the majority were men (68%) with a mean age of 35 +/- 3.7 years and mean Injury Severity Score of 28 +/- 3.8. Asymptomatic patients (n = 187) were treated (heparin in 117, low molecular-weight heparin in 11, and antiplatelet in 59); 1 patient had a stroke (0.5%). Using estimated stroke rate by grade of injury, we averted neurologic events in 32 asymptomatic patients with antithrombotic treatment. Of the 48 asymptomatic patients who did not receive adequate anticoagulation, 10 (21%) had an INE. Patients with BCVI-related neurologic events had a statistically higher percentage requiring discharge to rehabilitation facilities (50% vs. 77% for carotid artery injury [CAI]), a higher percentage requiring rehabilitation for BCVI-related stroke (0% vs. 55% for CAI), and a higher stroke-related mortality rate (0% vs. 21% for CAI and 0% vs. 17% for vertebral artery injury) than those without neurologic events. CONCLUSIONS: The cost of long-term rehabilitation care and human life after BCVI-associated neurologic events is substantial. Surgeons caring for the multiply injured should screen for carotid and vertebral artery injuries in high-risk patients.

Adult↗
PubMed2005

Can we afford to do laparoscopic appendectomy in an academic hospital?

BACKGROUND: Multiple studies have shown laparoscopic appendectomy to be safe for both acute and perforated appendicitis, but there have been conflicting reports as to whether it is superior from a cost perspective. Our academic surgical group, who perform all operative cases with resident physicians, has been challenged to reduce expenses in this era of cost containment. We recognize resident training is an expensive commodity that is poorly reimbursed, and hypothesized laparoscopic appendectomy was too expensive to justify resident teaching of this procedure. The purpose of this study was to determine if laparoscopic appendectomy is more expensive than open appendectomy. METHODS: From April 2003 to April 2004, all patients undergoing appendectomy for presumed acute appendicitis at our university-affiliated teaching hospital were reviewed; demographic data, equipment charge, minutes in the operating room (OR), hospital length of stay, and total hospital charge were analyzed. OR minute charges were gradated based on equipment use and level of skilled nursing care. Conversions to open appendectomy were included in the laparoscopic group for analysis. RESULTS: During the study period, 247 patients underwent appendectomy for preoperative diagnosis of acute appendicitis, with 152 open (113 inflamed, 37 perforated, 2 normal), 88 laparoscopic (69 inflamed, 12 perforated, 7 normal), and 7 converted (2 inflamed, 4 perforated, 1 normal) operations performed. The majority were men (67%) with a mean age of 31.4 +/- 2.2 years. Overall, there was significant difference (P < .05) in intraoperative equipment charge (125.32 dollars +/- 3.99 dollars open versus 1,078.70 dollars +/- 24.06 dollars lap), operative time charge (3,022.16 dollars +/- 57.51 dollars versus 4,065.24 dollars +/- 122.64 dollars), and total hospital charge (12,310 dollars +/- 772 dollars versus 16,773 dollars +/- 1,319 dollars) but no significant difference in operative minutes (56.3 +/- 1.3 versus 57.4 +/- 2.3), operating room minutes (90.5 +/- 1.7 versus 95.7 +/- 2.5), or hospital days (2.6 versus 2.2). In subgroup analysis of patients with uncomplicated appendicitis, open and laparoscopic groups had equivalent hospital days (1.47 versus 1.49) but significantly different hospital charges (9,632.44 dollars versus 14,251.07 dollars). CONCLUSIONS: Although operative time was similar between the 2 groups, operative and total hospital charges were significantly higher in the laparoscopic group. Unless patient factors warrant a laparoscopic approach (questionable diagnosis, obesity), we submit open appendectomy remains the most cost-effective procedure in a teaching environment.

Academic Medical Centers↗
PubMed2005

Complications of nonoperative management of high-grade blunt hepatic injuries.

BACKGROUND: Nonoperative management of blunt hepatic injuries is highly successful. Complications associated with high-grade injuries, however, have not been well characterized. The purpose of the present study was therefore to define hepatic-related complications and associated treatment modalities in patients undergoing nonoperative management of high-grade blunt hepatic injuries. METHODS: Three hundred thirty-seven patients from two regional Level I trauma centers with grade 3 to 5 blunt hepatic injuries during a 40-month period were reviewed. Complications and treatment of hepatic-related complications in patients not requiring laparotomy in the first 24 hours were identified. RESULTS: Of 337 patients with a grade 3 to 5 injury, 230 (68%) were managed nonoperatively. There were 37 hepatic-related complications in 25 patients (11%); 63% (5 of 8) of patients with grade 5 injuries developed complications, 21% (19 of 92) of patients with grade 4 injuries, but only 1% (1 of 130) of patients with grade 3 injuries. Complications included bleeding in 13 patients managed by angioembolization (n = 12) and laparotomy (n = 1), liver abscesses in 2 patients managed with computed tomography-guided drainage (n = 2) and subsequent laparotomy (n = 1). In one patient with bleeding, hepatic necrosis followed surgical ligation of the right hepatic artery and required delayed hepatic lobectomy. Sixteen biliary complications were managed with endoscopic retrograde cholangiopancreatography and stenting (n = 7), drainage (n = 5), and laparoscopy (n = 4). Three patients had suspected abdominal sepsis and underwent a negative laparotomy, whereas an additional three patients underwent laparotomy for abdominal compartment syndrome. CONCLUSION: Nonoperative management of high-grade liver injuries can be safely accomplished. Mortality is low; however, complications in grade 4 and 5 injuries should be anticipated and may require a combination of operative and nonoperative management strategies.

Adult↗
PubMed2004

Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate.

HYPOTHESIS: Aggressive screening, early angiographic diagnosis, and prompt anticoagulation for blunt carotid artery injuries (CAIs) improves neurologic outcome. DESIGN: From January 1, 1996, through December 31, 2002, there were 13 280 blunt trauma admissions to our level I center, of which 643 underwent screening angiography for blunt CAI on the basis of a protocol including injury patterns and symptoms. Patients without contraindications underwent anticoagulation immediately for documented lesions. SETTING: A state-designated, level I urban trauma center. PATIENTS: Of the 643 patients undergoing screening angiography, 114 (18%) had confirmed CAI. INTERVENTION: Early angiographic diagnosis and prompt anticoagulation. MAIN OUTCOME MEASURES: Diagnosis, stroke rate, and complications stratified by method of intervention. RESULTS: A CAI was identified in 114 patients during the 7-year study period; the majority were men (71%), with a mean +/- SD age of 34 +/- 1.3 years and a mean +/- SD Injury Severity Score of 29 +/- 1.5. Seventy-three patients underwent anticoagulation after diagnosis (heparin in 54, low-molecular-weight heparin in 2, antiplatelet agents in 17); none had a stroke. Of the 41 patients who did not receive anticoagulation (because of a contraindication in 27, symptoms before diagnosis in 9, and carotid coil or stent in 5), 19 patients (46%) developed neurologic ischemia. Ischemic neurologic events occurred in 100% of patients who presented with symptoms before angiographic diagnosis and those receiving a carotid coil or stent without anticoagulation. CONCLUSIONS: Our prospective evaluation of blunt CAIs suggests that early diagnosis and prompt anticoagulation reduce ischemic neurologic events and their disability. The optimal anticoagulation regimen, however, remains to be established.

Accidents, Traffic↗
PubMed2004

Management of low-output pancreatic fistulas with fibrin glue.

BACKGROUND: Despite advances in surgical, endoscopic, and percutaneous therapeutic techniques, pancreatic fistulas remain a source of significant morbidity and long-term patient discomfort. The intraoperative use of fibrin sealant has been used prophylactically to prevent formation of fistula. We recognized the potential use of fibrin glue as a therapeutic modality for successful resolution of low-output pancreatic fistulas. METHODS: Three patients with low (<20 ml per day) output pancreatic fistulas underwent fluoroscopically directed injection of fibrin glue along their fistula tract. RESULTS: All 3 patients underwent successful fibrin glue injection without procedural complication. All fistula output stopped, and the 3 patients remained asymptomatic at 1 year. CONCLUSIONS: Fibrin glue inserted with image-guided catheter delivery systems may be a useful option in selected patients with low-output pancreatic fistulas.

Female↗
PubMed2004

Postinjury abdominal compartment syndrome does not preclude early enteral feeding after definitive closure.

BACKGROUND: Critically injured patients are susceptible to the abdominal compartment syndrome (ACS), which requires decompressive laparotomy with delayed abdominal closure. Previous work by the University of Texas Houston group showed impaired gut function after resuscitation-associated gut edema. The purpose of this study was to determine if enteral nutrition was precluded by the intra-abdominal hypertension and bowel edema of the ACS. METHODS: Patients developing postinjury ACS from January 1996 to August 2003 at our level-I trauma center were reviewed. Patient demographics, time to definitive abdominal closure, and institution and tolerance of enteral nutrition were evaluated. RESULTS: Thirty-seven patients developed postinjury ACS during the study period; 26 men and 11 women with a mean age of 36 +/- 4 and injury severity score of 33 +/- 4. Mean intra-abdominal pressure before decompression was 32 +/- 3 mm Hg, and concurrent mean peak airway pressure was 50 +/- 4 cm oxygen. Enteral feeding was never started in 12 patients; 4 died within 48 hours of admission, 7 required vasoactive agents until their death, and 1 developed an enterocutaneous fistula requiring parenteral nutrition. Enteral feeding was initiated in the remaining 25 patients: 13 had feeds started within 24 hours of abdominal closure; 5 were fed with open abdomens; and 7 had a delay because of vasopressors (n = 2), multiple trips to the operating room (n = 2), paralytics (n = 2), and increased intra-abdominal pressures (n = 1). Once advanced, enteral feeding was tolerated in 23 (92%) of the 25 patients with attainment of goal feeds in a mean of 3.1 +/- 1 days. CONCLUSIONS: Despite the bowel edema and intra-abdominal hypertension related to the ACS, early enteral feeding is feasible after definitive abdominal closure.

Abdomen↗
PubMed2004

Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation?

BACKGROUND: Documented prehospital asystole justifies termination of resuscitation, but recently it has been proposed to extend this policy to patients in the field with pulseless electrical activity. Consequently, we questioned whether resuscitative thoracotomy is warranted in the critically injured patient who fails to respond to prehospital CPR. STUDY DESIGN: A prospective database of all emergency department resuscitative thoracotomies (EDT) performed at our Level I trauma center has been maintained since January 1977. These registry data were augmented by a review of prehospital paramedic records for all survivors of EDT to verify length of CPR. RESULTS: During the 26-year study period, 959 patients underwent EDT. Of the 62 patients who survived to leave the hospital, 26 (42%) required prehospital CPR. The injury mechanism in these 26 patients was stab wounds in 18 (69%), gunshot wounds in 4 (15%), and blunt trauma in 4 (15%). The duration of prehospital CPR ranged from 3 to 15 minutes and in 7 patients CPR exceeded 10 minutes. Five survivors had asystole documented at the time of EDT; four of these patients had good functional outcomes at discharge. Each of these patients had pericardial tamponade from ventricular stab wounds. Patients with blunt trauma had uniformly dismal neurologic outcomes. CONCLUSIONS: EDT after prehospital CPR can be used to salvage select critically injured patients. Based on these data, we propose that resuscitative thoracotomy is futile care in patients with blunt trauma requiring prehospital CPR longer than 5 minutes, and in patients with penetrating trauma with more than 15 minutes of prehospital CPR. EDT is warranted in those patients with penetrating trauma with less than 15 minutes of prehospital CPR, and should be performed despite documented asystole on arrival if pericardial tamponade is the proximate event.

Adolescent↗
PubMed2004

Radiographic characteristics of postinjury splenic autotransplantation: avoiding a diagnostic dilemma.

BACKGROUND: Splenic autotransplantation after postinjury splenectomy has been advocated to augment the immune response to infection and prevent overwhelming postsplenectomy sepsis. Postoperative computed tomographic (CT) scans in patients undergoing splenic autotransplantation reveal multiple intra-abdominal fluid collections that may appear similar to abscesses. This presents a diagnostic dilemma. In the past, one of our patients underwent percutaneous drainage of such collections that were sterile, and one patient required operative evacuation of infected implants. The purpose of this study was to determine whether there is a characteristic radiographic appearance of splenic implants, whether this appearance changes with time, and whether implants can be differentiated from abdominal abscesses. STUDY DESIGN: Patients at our Level I trauma center who underwent operative therapy for splenic injury from January 1995 to May 2002 were identified using our trauma registry. Charts were reviewed and CT scans read in a blinded fashion by a radiologist. RESULTS: During the study period, 505 patients were admitted for splenic trauma. One hundred forty-five patients (29%) required operative intervention for splenic injuries. Splenorrhaphy was performed in 27 patients and splenectomy was required in 118 patients. Twenty-three patients had splenic autotransplantation into the omentum, of whom 11 underwent postoperative CT scanning for clinical suspicion of intra-abdominal abscess. On average, 2.7 scans were obtained per patient, ranging from 4 to 113 days postoperatively. Imaging revealed low-density fluid collections in the anterior abdomen in 10 of 11 patients. Time-related radiographic changes (early rim enhancement and late shrinkage) of the implants were noted, but splenic implants lacked surrounding omental fat stranding or other inflammatory changes typical of an abscess. The patient with infected splenic implants had air bubbles within the fluid collections, a characteristic finding of an abscess. CONCLUSION: Autotransplanted splenic tissue may resemble an abscess on CT scanning, but splenic implants have distinct and time-related characteristic findings. Recognition of these unique features may allow differentiation of a splenic implant from an abscess, thus avoiding unwarranted intervention.

Adolescent↗
PubMed2003

Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access?

PURPOSE: The aim of this study was to determine in a pediatric population whether a routine chest x-ray after central venous access is necessary when the central venous catheter is placed with intraoperative fluoroscopy. METHODS: This was a retrospective review of the charts of all patients at Children's Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, sex, primary reason for access, access site, number of venipuncture attempts, type of catheter, intraoperative fluoroscopy results, chest x-ray results, location of the tip of the catheter, and complications were analyzed. RESULTS: There were 1,039 central venous catheters placed in 824 patients, 92.6% in the subclavian vein and 7.4% in the internal jugular vein. There were 604 (58.1%) children who had both fluoroscopy and a postprocedure chest x-ray, there were 308 (29.6%) who had only fluoroscopy, there were 117 (11.3%) who had only a postprocedure chest x-ray, and there were 10 (1.0%) who had neither fluoroscopy nor chest x-ray. On completion of the procedure, there were 12 (1.1%) children with misplaced central venous catheters, only 1 (0.1%) when intraoperative fluoroscopy was used. There were 17 (1.6%) complications; 9 (0.9%) were pulmonary (pneumothorax, hemothorax, or an effusion). All children with pulmonary complications experienced clinical signs and symptoms suggestive of the complication after their central venous catheter insertion but before their postprocedure chest x-ray. CONCLUSIONS: The number of complications encountered in children who had central venous access of the subclavian vein or internal jugular central vein with intraoperative fluoroscopy was infrequent, the number of misplaced catheters was minimized with intraoperative fluoroscopy, and all children with pulmonary complications showed clinical signs suggestive of pulmonary complications before postoperative chest x-ray. Therefore, children who have had central venous access of the subclavian and internal jugular vein with intraoperative fluoroscopy do not appear to require a routine chest x-ray after catheter placement unless clinical suspicion of a complication exists.

Adolescent↗
PubMed2003

Cervical spine fracture patterns predictive of blunt vertebral artery injury.

BACKGROUND: Aggressive screening for blunt cerebrovascular injury (BCVI) has uncovered an astonishing incidence of vertebral artery injuries (VAIs) and associated stroke rate. Stroke incidence is reduced with early recognition and prompt anticoagulation. Because of the proximity of the cervical spine and vertebral arteries, we queried whether all patients with cervical spine fractures required arteriography to rule out VAI. METHODS: Four-vessel cerebrovascular angiography remains the standard screening test for patients at risk for BCVI. Patients undergoing angiographic screening for blunt cerebrovascular injuries have been prospectively followed at our regional trauma center since January 1990; however, in January 1996, we began aggressive screening based on injury patterns. RESULTS: Ninety-two patients with vertebral artery injuries were identified during the study period from January 1996 to June 2002. Two patients with vertebral injuries had minor cervical fractures, a C6 body fracture and a C7 spinous process/laminar fracture; both underwent diagnostic angiography for injury mechanism. Of the 21 patients without cervical spine fracture, angiographic screening for BCVI was performed for neurologic symptoms (11 patients), basilar skull fracture (6 patients), or severe facial fractures (4 patients). Cervical spine fracture was the sole indication for VAI in 69 patients. The fracture patterns were subluxations in 38 patients (55%) or extension of the fracture through the foramen transversarium in 18 patients (26%). The remaining injuries (18%) were located in the upper cervical spine: isolated C1 arch in eight patients and C2/3 body fractures in five patients. CONCLUSION: Blunt vertebral artery injury is associated with complex cervical spine fractures involving subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures. Routine screening should incorporate these findings to maximize yield while limiting the use of invasive procedures.

Adult↗