Biomedical subjects

G C Velmahos

Publications and source records attributed to G C Velmahos.

At least 19 recordsLinked to original sources

PubMed2004

Management of cervical aerodigestive injuries.

The management of patients with cervical injuries is highly controversial. Some authorities advocate mandatory exploration for all such injuries, while others advocate selective exploration. This paper will objectively review the evidence supporting each approach. The non-operative approach may be pursued through a variety of diagnostic modalities and this paper will also review the evidence supporting their use in cervical trauma. A clear understanding of these modalities and their relative merits is mandated by the potential severity of cervical injuries and their need for rapid intervention.

Clinical Trials as Topic↗

PubMed2002

Penetrating injuries of the chest: indications for operation.

Penetrating injuries to the chest present a frequent and challenging problem. The majority of these injuries can be managed non-operatively. The selection of patients for operation or observation can be made by clinical examination and appropriate investigations. The trauma ultrasound has become a valuable first-line tool to rule out pericardial tamponade. Spiral computed tomography of the chest is increasingly used to evaluate transmediastinal gunshot wounds and direct, if needed, further organ-specific tests, such as esophagography, aortography, or bronchoscopy. Minimally invasive techniques have found sound application in the thoracoscopic evacuation of undrained hemothorax and the laparoscopic evaluation of diaphragmatic trauma. In the operative arena, lung-sparing techniques with the use of staplers, like wedge resection and tractotomy, have allowed easier, faster, and effective control of bleeding without sacrificing unnecessarily normal pulmonary parenchyma. Knowledge of the new advancements in the field of thoracic trauma will allow surgeons to provide expert care and improved outcomes.

Emergency Medical Services↗

PubMed2002

When to operate on abdominal gunshot wounds.

Historically, penetrating abdominal trauma was managed expectantly until the late 19th century. In World War I, with the high mortality and morbidity associated with penetrating abdominal trauma, operative management replaced expectant management. It was soon realized that not all penetrating abdominal injuries required an operation. Since the 1960's, selective nonoperative management of stab wounds to the anterior abdomen has become the standard of care. However, gunshot wounds to the abdomen are still treated by mandatory exploration based on an allegedly high incidence of intra-abdominal injuries and low rate of complications, if laparotomy turns out negative. A number of series have recently surfaced, reporting successful outcomes, while decreasing morbidity and hospital length of stay, with selective non-operative management of gunshot wounds to the abdomen. This review will address the current controversies surrounding selective nonoperative management of gunshot wounds to the abdomen and will present our experience and current approaches.

Abdominal Injuries↗

PubMed2001

The role of thyroid hormone administration in potential organ donors.

HYPOTHESIS: Levothyroxine sodium therapy should be used in brain-dead potential organ donors to reverse hemodynamic instability and to prevent cardiovascular collapse, leading to more available organs for transplantation. DESIGN: Prospective, before and after clinical study. SETTING: A surgical intensive care unit of an academic county hospital. PATIENTS: During a 12-month period (September 1, 1999, through August 31, 2000), we evaluated 19 hemodynamically unstable patients with traumatic and nontraumatic intracranial lesions, who were candidates for organ donation following brain death declaration. INTERVENTIONS: All patients were resuscitated aggressively for organ preservation by fluids, inotropic agents, and vasopressors. If, despite all measures, the patients remained hemodynamically unstable, a bolus of 1 ampule of 50% dextrose, 2 g of methylprednisolone sodium succinate, 20 U of insulin, and 20 microg of levothyroxine sodium was administered, followed by a continuous levothyroxine sodium infusion at 10 microg/h. RESULTS: There was a significant reduction in the total vasopressor requirement after levothyroxine therapy (mean +/- SD, 11.1 +/- 0.9 microg/kg per minute vs 6.4 +/- 1.4 microg/kg per minute, P =.02). Ten patients (53%) had complete discontinuation of vasopressors. There were no failures to reach organ donation due to cardiopulmonary arrest. CONCLUSIONS: Levothyroxine therapy plays an important role in the management of hemodynamically unstable potential organ donors by decreasing vasopressor requirements and preventing cardiovascular collapse. This may result in an increase in the quantity and quality of organs available for transplantation.

Adult↗

PubMed2001

Spiral computed tomography for the diagnosis of pulmonary embolism in critically ill surgical patients: a comparison with pulmonary angiography.

HYPOTHESIS: Spiral computed tomographic pulmonary angiography (CTPA) is sensitive and specific in diagnosing pulmonary embolism (PE) in critically ill surgical patients. DESIGN: Prospective study comparing CTPA with the criterion standard, pulmonary angiography (PA). SETTING: Surgical intensive care unit of an academic hospital. PATIENTS: Twenty-two critically ill surgical patients with clinical suspicion of PE. The CTPAs and PAs were independently read by 4 radiologists (2 for each test) blinded to each other's interpretation. Clinical suspicion was classified as high, intermediate, or low according to predetermined criteria. All but 2 patients had marked pulmonary parenchymal disease at the time of the event that triggered evaluation for PE. INTERVENTIONS: Computed tomographic pulmonary angiography and PA in 22 patients, venous duplex scan in 19. RESULTS: Eleven patients (50%) had evidence of PE on PA, 5 in central and 6 in peripheral pulmonary arteries. The sensitivity and specificity of CTPA was, respectively, 45% and 82% for all PEs, 60% and 100% for central PEs, and 33% and 82% for peripheral PEs. Duplex scanning was 40% sensitive and 100% specific in diagnosing PE. The independent reviewers disagreed only in 14% of CTPA and 14% of PA interpretations. There were no differences in risk factors or clinical characteristics between patients with and without PE. The level of clinical suspicion was identical in the 2 groups. CONCLUSIONS: Pulmonary angiography remains the gold standard for the diagnosis of PE in critically ill surgical patients. Computed tomographic pulmonary angiography needs further evaluation in this population.

Adult↗

PubMed2001

Healing of traumatic diaphragm injuries: comparison of laparoscopic versus open techniques in an animal model.

BACKGROUND: Minimally invasive surgical techniques have become routinely applied to the evaluation and treatment of patients with isolated diaphragmatic injuries due to penetrating trauma. The objective of the study was to compare the healing of diaphragm injuries as determined by macroscopic inspection, histologic appearance, and tensile strength following repair by open suturing, laparoscopic suturing, and laparoscopic stapling techniques in an animal model. METHODS: Using a pig model, three injuries were created and repaired in each hemidiaphragm of five animals, for a total of 30 lacerations. These injuries were repaired using single-layer open repair, single-layer laparoscopic repair, or laparoscopic stapling. After a 6-week healing period the animals were sacrificed. The gross integrity, histologic appearance using H+E and trichrome satins, and tensile strength of each repair were assessed. RESULTS: All injuries were grossly intact without dehiscence or herniation. Histologic examination revealed no difference in the collagen deposition between the three groups. The tensile strengths of each type of repair were similar. CONCLUSION: Laparoscopic techniques used to repair diaphragmatic injuries allow for adequate healing equivalent to open sutured repairs. Simple approximation of the peritoneum with laparoscopic staples allows full-thickness healing of these injuries.

Animals↗

PubMed2001

Penetrating trauma in patients older than 55 years: a case-control study.

BACKGROUND: Multiple studies have compared young and elderly blunt trauma patients, and concluded that, because elderly patients have outcomes similar to young patients, aggressive resuscitation should be offered regardless of age. Similar data on penetrating trauma patients are limited. STUDY DESIGN: In a retrospective review, 79 patients with penetrating injuries and age > or =55 were blindly matched for Injury Severity Score (ISS) and Abbreviated Injury Scores (AIS) with 79 penetrating trauma patients aged 15-35 years, who were admitted to the hospital over the same 4 year period (June 1994-June 1998). Mortality rates and length of stay in the intensive care unit (ICU) and the hospital were compared between the two groups. RESULTS: The average ISS for all patients was 12 (range 1-75) and identical for both groups. Both groups had similar injuries and were evaluated by an equal number and type of diagnostic studies. The mean ISS was not different between severely injured older and younger patients who required ICU admission or died. Among 32 nonsurvivors (18 older and 14 younger), older patients were more likely than younger patients to present with normal vital signs, although the comparison did not reach statistical significance (50% vs. 13%, P=0.25). There was a clinically significant trend for longer ICU (15+/-30 vs. 3+/-2 days, P=0.096) and hospital stay (10+/-18 vs. 6+/-8 days, P=0.08) among older patients, but mortality rates were similar (23% in older vs. 18% in younger, P=NS). Furthermore, these outcome parameters showed no difference when both groups were classified according to severity of injury or physiologic response. CONCLUSIONS: Following penetrating trauma, older patients arriving alive and admitted to the hospital are as likely to survive as younger patients who have injuries of similar severity, but at the expense of longer ICU and hospital stays.

Adolescent↗

PubMed2001

"Insignificant" mechanism of injury: not to be taken lightly.

BACKGROUND: Trauma resources should be spent rationally. The mechanism of trauma is used extensively to triage patients to appropriate levels of care. We examine the hypothesis that patients with "insignificant" mechanism of trauma may have major injuries that require expert trauma care. STUDY DESIGN: Over 9 months at a high-volume Level I trauma center, a prospective study was done on patients who sustained ground-level falls (GLF), low-level falls (LLF) from less than 10 feet, or were found down (FD) with no external evidence of significant trauma, and required evaluation by the trauma team. Of 301 patients included, 110 (37%) had GLF, 95 (31%) LLF, and 96 (32%) FD. Our main outcomes measure was significant injuries, defined as visceral or intracranial injuries, long-bone, pelvic, facial, or spinal fractures. RESULTS: One hundred ten patients (37%) had significant injuries, 20 (7%) were admitted to the ICU, 14 (5%) required an operation, and 4 (1%) died. The most common injuries were intracranial and skeletal. Almost all patients were evaluated by CT (95%), but only one-quarter had abnormal findings on it. LLF, age more than 55 years, and the absence of severe intoxication (blood alcohol level of less than 200 mg/dL) were independent risk factors for significant injuries. A statistical prediction model showed that, when all risk factors are present, the probability of significant injuries is 73%; when all risk factors are absent, there is still a 16% chance for significant injuries. Patients with significant injuries had more operations, longer hospital stays, and higher hospitalization costs compared with patients without significant injuries. CONCLUSIONS: Low-energy trauma may produce significant injuries, predominantly intracranial and skeletal. Trauma care providers should be cautious about dismissing such patients based on the trivial mechanism of injury. Patients with LLF who are older than 55 years and not severely intoxicated have a high likelihood for significant injuries. Resources should be spent rationally for patients who do not have these characteristics, because the probability of significant injuries among them is low, but not zero.

Abdominal Injuries↗

PubMed2001

Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care?

OBJECTIVE: To evaluate the safety of a policy of selective nonoperative management (SNOM) in patients with abdominal gunshot wounds. SUMMARY BACKGROUND DATA: Selective nonoperative management is practiced extensively in stab wounds and blunt abdominal trauma, but routine laparotomy is still the standard of care in abdominal gunshot wounds. METHODS: The authors reviewed the medical records of 1,856 patients with abdominal gunshot wounds (1,405 anterior, 451 posterior) admitted during an 8-year period in a busy academic level 1 trauma center and managed by SNOM. According to this policy, patients who did not have peritonitis, were hemodynamically stable, and had a reliable clinical examination were observed. RESULTS: Initially, 792 (42%) patients (34% of patients with anterior and 68% with posterior abdominal gunshot wounds) were selected for nonoperative management. During observation 80 (4%) patients developed symptoms and required a delayed laparotomy, which revealed organ injuries requiring repair in 57. Five (0.3%) patients suffered complications potentially related to the delay in laparotomy, which were managed successfully. Seven hundred twelve (38%) patients were successfully managed without an operation. The rate of unnecessary laparotomy was 14% among operated patients (or 9% among all patients). If patients were managed by routine laparotomy, the unnecessary laparotomy rate would have been 47% (39% for anterior and 74% for posterior abdominal gunshot wounds). Compared with patients with unnecessary laparotomy, patients managed without surgery had significantly shorter hospital stays and lower hospital charges. By maintaining a policy of SNOM instead of routine laparotomy, a total of 3,560 hospital days and $9,555,752 in hospital charges were saved over the period of the study. CONCLUSION: Selective nonoperative management is a safe method for managing patients with abdominal gunshot wounds in a level 1 trauma center with an in-house trauma team. It reduces significantly the rate of unnecessary laparotomy and hospital charges.

Abdominal Injuries↗

PubMed2001

Clinically significant blunt cardiac trauma: role of serum troponin levels combined with electrocardiographic findings.

BACKGROUND: The true importance of blunt cardiac trauma (BCT) is related to the cardiac complications arising from it. Diagnostic tests that can predict accurately if such complications will develop or not may allow early and aggressive monitoring or early discharge. We investigated the role of two simple and convenient tests, serum cardiac troponin I (cTnI) and electrocardiogram (ECG), when used to identify patients at risk of cardiac complications after BCT. METHODS: Over a 10-month period, 115 patients with evidence of significant blunt thoracic trauma were prospectively followed to identify the presence of clinically significant BCT (Sig-BCT), defined as cardiogenic shock, arrhythmias requiring treatment, or structural cardiac abnormalities directly related to the cardiac trauma. An ECG was obtained at admission and at 8 hours. Cardiac troponin I was measured at admission, at 4 hours, and at 8 hours. Transthoracic echocardiography was performed when clinically indicated. The sensitivity, specificity, and positive and negative predictive values of ECG and cTnI to identify Sig-BCT were calculated. Clinical risk factors for Sig-BCT were examined by univariate and multivariate analysis. RESULTS: Nineteen patients (16.5%) were diagnosed with Sig-BCT and, in 18 of them, symptoms presented within 24 hours of admission. Abnormal electrocardiographic findings were detected in 58 patients (50%) and elevated cTnI levels in 27 (23.5%). Electrocardiography and cTnI had positive predictive values of 28% and 48% and negative predictive values of 95% and 93%, respectively. However, when both tests were abnormal (positive) or normal (negative), the positive and negative predictive values increased to 62% and 100%, respectively. Other independent risk factors for Sig-BCT were head injury, spinal injury, history of preexisting cardiac disease, and a chest Abbreviated Injury Score greater than 2. CONCLUSION: The combination of ECG and cTnI identifies reliably the presence or absence of Sig-BCT. Patients with an abnormal ECG and cTnI need close monitoring for at least 24 hours. Patients with a normal admission ECG and cTnI can be safely discharged in the absence of other injuries.

Electrocardiography↗

PubMed2001

Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study.

BACKGROUND: The management of colon injuries that require resection is an unresolved issue because the existing practices are derived mainly from class III evidence. Because of the inability of any single trauma center to accumulate enough cases for meaningful statistical analysis, a multicenter prospective study was performed to compare primary anastomosis with diversion and identify the risk factors for colon-related abdominal complications. METHODS: This was a prospective study from 19 trauma centers and included patients with colon resection because of penetrating trauma, who survived at least 72 hours. Multivariate logistic regression analysis was used to compare outcomes in patients with primary anastomosis or diversion and identify independent risk factors for the development of abdominal complications. RESULTS: Two hundred ninety-seven patients fulfilled the criteria for inclusion and analysis. Overall, 197 patients (66.3%) were managed by primary anastomosis and 100 (33.7%) by diversion. The overall colon-related mortality was 1.3% (four deaths in the diversion group, no deaths in the primary anastomosis group, p = 0.012). Colon-related abdominal complications occurred in 24% of all patients (primary repair, 22%; diversion, 27%; p = 0.373). Multivariate analysis including all potential risk factors with p values < 0.2 identified three independent risk factors for abdominal complications: severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis. The type of colon management was not found to be a risk factor. Comparison of primary anastomosis with diversion using multivariate analysis adjusting for the above three identified risk factors or the risk factors previously described in the literature (shock at admission, delay > 6 hours to operating room, penetrating abdominal trauma index > 25, severe fecal contamination, and transfusion of > 6 units blood) showed no statistically significant difference in outcome. Similarly, multivariate analysis and comparison of the two methods of colon management in high-risk patients showed no difference in outcome. CONCLUSION: The surgical method of colon management after resection for penetrating trauma does not affect the incidence of abdominal complications, irrespective of associated risk factors. Severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis are independent risk factors for abdominal complications. In view of these findings, the reduced quality of life, and the need for a subsequent operation in colostomy patients, primary anastomosis should be considered in all such patients.

Adult↗

PubMed2001

Old age as a criterion for trauma team activation.

BACKGROUND: Elderly trauma patients have been shown to have a worse prognosis than young patients. Age alone is not a criterion for trauma team activation (TTA). In the present study, we evaluated the role of age > or = 70 years as a criterion for TTA. METHODS: The present study was a trauma registry study that included injured patients 70 years of age or older. Patients who died in hospital, were admitted to the intensive care unit (ICU) within 24 hours, or had a non-orthopedic operation were assumed to benefit from TTA. RESULTS: During a 7.5-year period, 883 elderly (> or = 70 years) trauma patients meeting trauma center criteria were admitted to our center. Overall, 223 patients (25%) met at least one of the standard TTA criteria. The mortality in this group was 50%, the ICU admission rate was 39%, and a non-orthopedic operation was required in 35%. The remaining 660 patients (75%) did not meet standard TTA criteria. The mortality was 16%, the need for ICU admission was 24%, and non-orthopedic operations were required in 19%. Sixty-three percent of patients with severe injuries (Injury Severity Score > 15) and 25% of patients with critical injuries (Injury Severity Score > 30) did not have any of the standard hemodynamic criteria for TTA. CONCLUSION: Elderly trauma patients have a high mortality, even with fairly minor or moderately severe injuries. A significant number of elderly patients with severe injuries do not meet the standard criteria for TTA. It is suggested that age > or = 70 years alone should be a criterion for TTA.

Age Factors↗

PubMed2001

Outcome prediction of emergency patients by noninvasive hemodynamic monitoring.

OBJECTIVES: We used noninvasive hemodynamic monitoring in the initial resuscitation beginning in the emergency department (ED) for the following reasons: (1) to describe early survivor and nonsurvivor patterns of emergency patients in terms of cardiac, pulmonary, and tissue perfusion deficiencies; (2) to measure quantitatively the net cumulative amount of deficit or excess of the monitored functions that correlate with survival or death; and (3) to explore the use of discriminant analysis to predict outcome and evaluate the biological significance of monitored deficits. METHODS: This is a descriptive study of the feasibility of noninvasive monitoring of patients with acute emergency conditions in the ED to evaluate and quantify hemodynamic deficits as early as possible. The noninvasive monitoring systems consisted of a bioimpedance method for estimating cardiac output together with pulse oximetry to reflect pulmonary function, transcutaneous oxygen tension to reflect tissue perfusion, and BP to reflect the overall circulatory status. These continuously monitored noninvasive measurements were used to prospectively evaluate circulatory patterns in 151 consecutively monitored severely injured patients beginning with admission to the ED in a university-run county hospital. The net cumulative deficit or excess of each monitored parameter was calculated as the cumulative difference from the normal value vs the time-integrated monitored curve for each patient. The deficits of cardiac, pulmonary, and tissue perfusion functions were analyzed in relation to outcome by discriminant analysis and were cross-validated. RESULTS: The mean (+/- SEM) net cumulative excesses (+) or deficits (-) from normal in surviving vs nonsurviving patients, respectively, were as follows: cardiac index (CI), +81 +/- 52 vs -232 +/- 138 L/m(2) (p = 0.037); arterial hemoglobin saturation, -1 +/- 0.3 vs -8 +/- 2.6%/h (p = 0.006); and tissue perfusion, +313 +/- 88 vs -793 +/- 175, mm Hg/h (p = 0.001). The cumulative mean arterial BP deficit for survivors was -10 +/- 13 mm Hg/h, and for nonsurvivors it was -57 +/- 24 mm Hg/h (p = 0.078). CONCLUSIONS: Noninvasive monitoring systems provided continuously monitored on-line displays of data in the early postadmission period from the ED to the operating room and to the ICU for early recognition of circulatory dysfunction in short-term emergency conditions. Survival was predicted by discriminant analysis models based on the quantitative assessment of the net cumulative deficits of CI, arterial hypoxemia, and tissue perfusion, which were significantly greater in the nonsurvivors.

Adult↗

PubMed2001

Timing, safety, and efficacy of thoracoscopic evacuation of undrained post-traumatic hemothorax.

Residual post-traumatic hemothorax (RPTH) occurs in 3 to 8 per cent of patients with tube thoracostomy and may cause serious infectious complications. Surgical evacuation is recommended, and thoracoscopic evacuation (THEVA) tends to replace open thoracotomy for this purpose. The objective of this study is to evaluate the optimal timing, safety, and efficacy of THEVA. Over 5 years patients with tube thoracostomy for trauma who had unresolved opacities on plain chest radiograph were evaluated by CT. If the residual fluid volume was estimated to be more than 500 mL3 on CT the patients were offered THEVA. Unstable patients were excluded. A score ranging from one (easy) to three (difficult) was used to grade the difficulty of the operation according to the attending surgeon's perception. Of 1728 chest trauma patients 143 (8%) were evaluated by CT for persistent opacity on plain film, 31 (1.8%) were found to have RPTH, and 24 (1.4%) were eventually taken for THEVA at 3.5+/-2 days after admission. Low oxygen saturation (less than 94%) was found in 58 per cent of patients before THEVA but in only 25 per cent after THEVA (P = 0.02). The majority of chest tubes (75%) were removed within 4 days of the operation. Two patients required conversion to thoracotomy. THEVA done within 3 days of admission was associated with a lower operative difficulty score, shorter hospital stay, and a trend toward shorter intraoperative time compared with THEVA done after 3 days of admission. All patients had effective resolution of their radiographic opacities after THEVA. Three patients developed a complication (urinary tract infection, pneumonia, and persistent air leak). We conclude that patients with significant RPTH and without major physiologic compromise are appropriate candidates for THEVA. The procedure is safe, evacuates PRTH effectively, and improves the respiratory function of affected patients. Ideally it should be performed within 3 days of admission.

Adult↗

PubMed2001

Around-the-clock attending radiology coverage is essential to avoid mistakes in the care of trauma patients.

Financial constraints due to increasing operating cost and decreased reimbursement do not allow many hospitals to maintain coverage by attending radiologists around the clock (CARAC). Preliminary film readings by radiology trainees may be inaccurate. In trauma, decisions are made fast and are often based on these preliminary readings. To examine whether there are significant discrepancies between preliminary readings (PRs) and final readings (FRs) of CT scans of trauma patients we prospectively recorded PRs (done immediately by radiology residents) and FRs (done the following working day by radiology attendings) over a period of 6 months for trauma CT scans done between 5 PM and 7 AM on weekdays or weekends. A discrepancy was classified as significant if a change in management was instituted after FR. In 42 of 383 (11%) trauma patients there was a discrepancy between PR and FR. Patients with discrepancies had a higher Injury Severity Score, higher incidence of penetrating trauma, longer hospital stay, higher hospital charges, and higher mortality than patients without any discrepancy. Most of the discrepancies were found on abdominal CT scans. The lower the level of radiology resident doing the PR the higher the likelihood of a discrepancy. In 20 patients (5%) a significant discrepancy was found. We conclude that the absence of CARAC results in inaccurate FRs risking optimal trauma patient care. The institutional savings realized by avoiding CARAC may be offset by the cost of additional care provided to patients who have delayed diagnosis and treatment due to the lack of it.

Adult↗

PubMed2000

Emergency medical services (EMS) vs non-EMS transport of critically injured patients: a prospective evaluation.

BACKGROUND: A previous report of 5,782 trauma patients demonstrated higher mortality among those transported by emergency medical services (EMS) than among their non-EMS-transported counterparts. HYPOTHESIS: Trauma patients who are transported by EMS and those who are not differ in the injury-to-hospital arrival time interval. DESIGN: Prospective cohort-matched observation study. SETTING: Level I trauma center, multidisciplinary study group. PATIENTS: All non-EMS patients were matched with the next appropriate EMS patient by an investigator who was unaware of the outcome and mode of transport. Every 10th EMS patient with an Injury Severity Score (ISS) of 13 or greater was also randomly enrolled. Matching characteristics included age, ISS, mechanism of injury, head Abbreviated Injury Score, and presence of hypotension. An interview protocol was developed to determine the time of injury. Interview responses from patients, witnesses, and friends were combined with data obtained from police, sheriff, and medical examiner reports. MAIN OUTCOME MEASURES: Time to the hospital, mortality, morbidity, and length of stay. RESULTS: A total of 103 patients were enrolled (38 non-EMS, 38 EMS matched, 27 random EMS). Injury time was estimated using all available data made on 100 patients (97%). Independent raters agreed in 81% of cases. Deaths, complications, and length of hospital stay were similar between the EMS- and non-EMS-transported groups. Although time intervals were similar among the groups overall, more critically injured non-EMS patients (ISS > or = 13) got themselves to the trauma center in less time than their EMS counterparts (15 minutes vs 28 minutes; P<.05). CONCLUSIONS: A multidisciplinary approach can be utilized, and an interview protocol created to determine actual time of injury. Critically injured non-EMS-transported patients (ISS > or =13) arrived at the hospital earlier after their injuries.

Adolescent↗

PubMed2000

Nonoperative management of splenic injuries: have we gone too far?

HYPOTHESIS: Patients with severe blunt injuries to the spleen have a high likelihood of failing nonoperative management of splenic injuries (NOMSI). DESIGN: Review of medical records, helical computed tomographic imaging data, and trauma registry data. SETTING: Academic level I trauma center at a large county hospital. PATIENTS: A total of 105 patients with blunt trauma to the spleen, admitted between January 1995 and December 1998, who survived more than 48 hours and had complete records. Of these patients, 53 (56%) were selected for NOMSI. The splenic injury was graded by the Organ Injury Scale of the American Association for the Surgery of Trauma (grades I to V, with grade V being the worst possible injury). MAIN OUTCOME MEASURES: Failure of NOMSI, defined as the need for operation to the spleen after a period of nonoperative management. RESULTS: Compared with patients who had successful NOMSI, the 29 patients (52%) in whom NOMSI failed were older and more severely injured. They also required extra-abdominal operations more frequently, underwent transfusion with more units of blood while being managed nonoperatively, and had higher grades of splenic injury. Splenic injury grade III or higher and transfusion of more than 1 U of blood were identified as independent risk factors for failure of NOMSI. The existence of both risk factors predicted failure in 97% of cases. The grading by computed tomography correlated well with the actual injury to the spleen as seen at operation. CONCLUSIONS: In patients with high-grade splenic injuries who require a transfusion of more than 1 U of blood, NOMSI is very likely to fail. Decreasing the threshold for operation or intensifying the monitoring is highly recommended for such patients.

Adult↗

PubMed2000

Bedside percutaneous tracheostomy: prospective evaluation of a modification of the current technique in 100 patients.

Percutaneous dilatational tracheostomy (PDT) is being increasingly used. Concerns have been raised as to its safety, especially when it is done at the bedside. A prospective evaluation was conducted of 100 consecutive, unselected critically ill patients with PDT. The mean intensive care unit (ICU) stay before PDT was 12 days. One surgeon performed PDT alone (5 cases) or assisted residents (95 cases) in all operations; 84 were performed at the ICU bedside. Only the first six patients were taken to the operating room solely for tracheostomy. A modified technique was used: (1) the endotracheal tube was left in place during sequential dilations; (2) dilators were inserted in a 60-degree cephalad orientation to the skin and directed caudally after penetration of the anterior tracheal wall; (3) a digit was inserted through the tracheal opening to guide withdrawal of the endotracheal tube to the level of the vocal cords; and (4) size 8 tracheostomy cannulas were inserted over 28F dilators. The average time from skin incision to insertion of the tracheostomy tube was 12 minutes (< 10 minutes, 41 patients; 10 to 15 minutes, 37 patients; > 15 minutes, 22 patients). Sixty-five percent had unfavorable anatomic conditions due to spinal precautions or diffuse neck edema. Postoperative complications occurred in four patients; surgical emphysema after tracheal lacerations in three, cannula dislodgment in one. All complications were successfully managed without an operation by tube exchange (n = 3) or observation (n = 1); there was no procedure-related mortality. Forty patients were available for long-term follow-up (6-18 months after tracheostomy) by telephone; one had persistent hoarseness without respiratory difficulty. We concluded that bedside PDT is safe and easy to teach when performed with a technique that ensures correct instrumentation.

Adult↗