Biomedical subjects

James F Holmes

Publications and source records attributed to James F Holmes.

28 records · Page 2Linked to original sources

PubMed2004

Do children require hospitalization after immediate posttraumatic seizures?

STUDY OBJECTIVE: We determine whether children with immediate posttraumatic seizures require hospitalization for observation of possible neurologic complications. METHODS: This was a prospective observational cohort study of children younger than 18 years with blunt head trauma resulting in immediate posttraumatic seizures. Patients were examined by faculty emergency physicians and underwent cranial computed tomography (CT) scanning. Children were divided into 2 cohorts according to the presence or absence of traumatic brain injury on cranial CT scan, with the a priori assumption that children with posttraumatic seizures who have abnormal cranial CT scan results require hospitalization. The outcomes of interest were neurologic complications (including further seizure activity or neurologic deficits) or the necessity for neurosurgical intervention. Medical records of hospitalized patients were reviewed, and patients discharged from the emergency department (ED) were contacted by telephone approximately 1 week after hospital discharge to identify those who developed short-term neurologic complications. RESULTS: Sixty-three children with a median age of 7 years (interquartile range 3 to 14 years) had posttraumatic seizures, and all but 1 child underwent cranial CT imaging. Ten (16%; 95% confidence interval [CI] 8% to 27%) patients had traumatic brain injuries on CT scan, and all were hospitalized. Three of these 10 patients underwent craniotomy, and 2 patients had further seizure activity. Fifty-two patients had normal cranial CT scan results, and 20 patients were hospitalized for observation. Telephone follow-up was obtained in 31 of the 32 patients with normal CT scan results who were discharged from the ED. None of the 52 patients (0%; 95% CI 0% to 5.6%) with normal cranial CT scan results had further seizure activity or required neurosurgical interventions. CONCLUSION: Children with normal neurologic examination results and normal cranial CT scan results after immediate posttraumatic seizures are at low risk for further short-term complications that require immediate hospitalization. These children may be considered for discharge home from the ED.

Adolescent↗

PubMed2004

Does an isolated history of loss of consciousness or amnesia predict brain injuries in children after blunt head trauma?

BACKGROUND: A history of loss of consciousness (LOC) is frequently used as an indication for cranial computed tomography (CT) in the emergency department (ED) evaluation of children with blunt head trauma. OBJECTIVE: We sought to determine whether an isolated LOC and/or amnesia is predictive of traumatic brain injury (TBI) in children with blunt head trauma. METHODS: We prospectively enrolled children <18 years old presenting to a level I trauma center ED between July 1998 and September 2001 with blunt head trauma. We evaluated the association of LOC and/or amnesia with 1) TBI identified on CT and 2) TBI requiring acute intervention. We defined the latter by a neurosurgical procedure, antiepileptic medication for >1 week, persistent neurologic deficits, or hospitalization for > or =2 nights. We then investigated the association of LOC and/or amnesia with TBI in those patients without other symptoms or signs of TBI ("isolated" LOC and/or amnesia). RESULTS: Of eligible children, 2043 (77%) were enrolled, 1271 (62%) of whom underwent CT; 1159 (91%) of these 1271 had their LOC and/or amnesia status known. A total of 801 (39%) of the 2043 enrolled children had a documented history of LOC and/or amnesia. Of the 745 with documented LOC and/or amnesia who underwent CT, 70 (9.4%; 95% confidence interval [CI]: 7.4%, 11.7%) had TBI identified on CT versus 11 of 414 (2.7%; 95% CI: 1.3%, 4.7%) without LOC and/or amnesia (difference: 6.7%; 95% CI: 4.1%, 9.3%). Of the 801 children known to have had LOC and/or amnesia (regardless of whether they underwent CT), 77 (9.6%; 95% CI: 7.7%, 11.9%) had TBI requiring acute intervention versus 11 of 1115 (1%; 95% CI: 0.5%, 1.8%) of those without LOC and/or amnesia (difference: 8.6%; 95% CI: 6.5%, 10.7%). For those with an isolated LOC and/or amnesia without other signs or symptoms of TBI, however, 0 of 142 (95% CI: 0%, 2.1%) had TBI identified on CT, and 0 of 164 (95% CI: 0%,1.8%) had TBI requiring acute intervention. CONCLUSIONS: Isolated LOC and/or amnesia, defined by the absence of other clinical findings suggestive of TBI, are not predictive of either TBI on CT or TBI requiring acute intervention. Elimination of an isolated LOC and/or amnesia as an indication for CT may decrease unnecessary CT use in those patients without an appreciable risk of TBI.

Adolescent↗

PubMed2003

Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients.

This study examined if use of clinical screening criteria for selective radiography of blunt trauma patients can identify all patients with thoracolumbar (TL) spine injuries. The study was a prospective cohort of patients undergoing TL spine radiographs following blunt trauma. Patients were considered at risk for TL spine injury if they had any of the following clinical criteria: 1) complaints of TL spine pain, 2) TL spine tenderness, 3) a decreased level of consciousness, 4) intoxication with ethanol or drugs, 5) a neurologic deficit, or 6) a painful distracting injury. Patients without any of these findings were considered at low risk for TL spine injury. Severity of mechanism of injury was also recorded. Data sheets were completed prior to TL radiography. Injury status was determined by the final faculty radiologist interpretation of all radiographic studies. A total of 2404 patients were enrolled. TL spine injuries were identified in 152 patients. Of these 152 patients with spine injuries, all 152 (100%, 95% confidence interval 98-100%) were considered high risk by having at least one of the high-risk criteria. These criteria have a specificity of 3.9%, a positive predictive value of 6.6%, and a negative predictive value of 100%. All of the high-risk criteria but intoxication with ethanol or drugs were important as sole predictors of TL spine injury. The use of high-risk clinical screening criteria identified virtually all blunt trauma patients with acute TL spine injuries. These criteria, however, have poor specificity and positive predictive value.

Adolescent↗

PubMed2003

A decision rule for identifying children at low risk for brain injuries after blunt head trauma.

STUDY OBJECTIVE: Computed tomography (CT) is frequently used in evaluating children with blunt head trauma. Routine use of CT, however, has disadvantages. Therefore, we sought to derive a decision rule for identifying children at low risk for traumatic brain injuries. METHODS: We enrolled children with blunt head trauma at a pediatric trauma center in an observational cohort study between July 1998 and September 2001. We evaluated clinical predictors of traumatic brain injury on CT scan and traumatic brain injury requiring acute intervention, defined by a neurosurgical procedure, antiepileptic medications for more than 1 week, persistent neurologic deficits, or hospitalization for at least 2 nights. We performed recursive partitioning to create clinical decision rules. RESULTS: Two thousand forty-three children were enrolled, 1,271 (62%) underwent CT, 98 (7.7%; 95% confidence interval [CI] 6.3% to 9.3%) had traumatic brain injuries on CT scan, and 105 (5.1%; 95% CI 4.2% to 6.2%) had traumatic brain injuries requiring acute intervention. Abnormal mental status, clinical signs of skull fracture, history of vomiting, scalp hematoma (in children < or =2 years of age), or headache identified 97/98 (99%; 95% CI 94% to 100%) of those with traumatic brain injuries on CT scan and 105/105 (100%; 95% CI 97% to 100%) of those with traumatic brain injuries requiring acute intervention. Of the 304 (24%) children undergoing CT who had none of these predictors, only 1 (0.3%; 95% CI 0% to 1.8%) had traumatic brain injury on CT, and that patient was discharged from the ED without complications. CONCLUSION: Important factors for identifying children at low risk for traumatic brain injuries after blunt head trauma included the absence of: abnormal mental status, clinical signs of skull fracture, a history of vomiting, scalp hematoma (in children < or =2 years of age), and headache.

Adolescent↗

PubMed2002

Enhanced diagnosis of narrow complex tachycardias with increased electrocardiograph speed.

The objective of this study was to determine if the addition of rapid speed (50 mm/s) electrocardiograms (EKGs) improves the clinician's diagnostic accuracy of narrow complex tachycardias when compared to standard speed (25 mm/s) EKGs. We conducted a prospective, comparative trial. Forty-five difficult narrow complex tachycardias (heart rate range: 150-250 beats per minute) were printed at both 25 mm/s and 50 mm/s. Eight board certified emergency physicians initially interpreted the standard speed EKG (standard group) and chose a therapy for the hypothetical patient. These eight participants later interpreted the same 45 EKGs by using both the standard and rapid speed EKGs (rapid group) and again chose a therapy. The gold standard for each EKG was based on the patient's clinical diagnosis and was independently confirmed in all cases by a board-certified cardiologist. The rhythm distribution was as follows: atrial flutter (17), atrial fibrillation (11), paroxysmal supraventricular tachycardia (15), and sinus tachycardia (2). Participants were masked to all clinical information and EKG ratios. Diagnostic accuracy was compared by using McNemar's chi(2) test. Correct diagnosis improved from 226/360 (63%), in the standard group to 257/360 (71%) in the rapid group (difference in means 8.6%, p = 0.002). The incorrect use of adenosine was decreased from 43/240 (18%) in the standard group to 32/240 (13%) in the rapid group (difference in means 4.5%, p = 0.06). In conclusion, correct diagnosis of difficult narrow complex tachycardias was improved when EKGs at both 25 mm/s and 50 mm/s were used for interpretation. It appears that the simple technique of increasing the EKG paper speed, and thus effectively spacing out the rhythm, enhances the diagnostic ability of the observer.

Adenosine↗

PubMed2002

Clinical importance of intraperitoneal fluid in patients with blunt intra-abdominal injury.

The purpose of this study was to determine the prevalence of intraperitoneal fluid (IF) in blunt trauma patients with intra-abdominal injuries, to determine the rate of exploratory laparotomy in patients with and without IF, and to identify the location of this IF. We retrospectively reviewed the records of 604 patients with intra-abdominal injuries after blunt trauma who were admitted to a level 1 trauma center over a 42-month period. Patients were considered to have intra-abdominal injuries if an injury to the spleen, liver, urinary tract, pancreas, adrenal glands, gallbladder, or gastrointestinal tract was identified on abdominal computed tomography (CT) or at exploratory laparotomy. Patients were considered to have IF if fluid was identified on abdominal CT or during exploratory laparotomy. In patients undergoing abdominal CT or abdominal ultrasound (US), the specific location of the IF was identified. Four hundred forty-three (73%, 95% confidence interval [CI] 69 - 77%) of the 604 patients with intra-abdominal injuries had IF. Patients with IF had an increased risk of laparotomy (344/443 [78%] v 44/161 [27%], odds ratio = 9.2, 95% CI 6.1-13.9). Of the 539 patients undergoing abdominal CT or abdominal US, IF was identified in 389 (72%) and was visualized in the following locations: 258 of 389 (66%) in Morison's pouch, 216 of 389 (56%) in the left upper quadrant, 187 of 389 (48%) in the pelvis, and 139 of 390 (36%) in paracolic gutters. Three patients with IF visualized solely in the paracolic gutters underwent laparotomy. The majority of patients with intra-abdominal injuries have IF, and these patients are more likely to undergo laparotomy. Morison's pouch is the most common location for IF to be detected with radiologic imaging. However, visualization of the paracolic gutters with abdominal US may detect IF in patients with intra-abdominal injuries that would otherwise not be detected by US.

Abdominal Injuries↗

PubMed2002

Identification of children with intra-abdominal injuries after blunt trauma.

STUDY OBJECTIVE: We sought to determine the utility of laboratory testing after adjusting for physical examination findings in the identification of children with intra-abdominal injuries after blunt trauma. METHODS: The study was a prospective observational series of children younger than 16 years old who sustained blunt trauma and were at risk for intra-abdominal injuries during a 2(1/2)-year period at an urban Level I trauma center. Patients were examined by faculty emergency physicians and underwent standardized laboratory testing. Clinical and laboratory findings were recorded on a standardized data sheet. Intra-abdominal injury was considered present if an injury was documented to the spleen, liver, pancreas, kidney, adrenal glands, or gastrointestinal tract. We performed multiple logistic regression and binary recursive partitioning analyses to identify which physical examination findings and laboratory variables were independently associated with intra-abdominal injury. RESULTS: Of 1,095 enrolled patients, 107 (10%, 95% confidence interval [CI] 8% to 12%) had intra-abdominal injuries. The mean age was 8.4+/-4.8 years. From both analyses, we identified 6 findings associated with intra-abdominal injury: low systolic blood pressure (adjusted odds ratio [OR] 4.1; 95% CI 1.1 to 15.2), abdominal tenderness (adjusted OR 5.8; 95% CI 3.2 to 10.4), femur fracture (adjusted OR 1.3; 95% CI 0.5 to 3.7), serum aspartate aminotransferase concentration more than 200 U/L or serum alanine aminotransferase concentration more than 125 U/L (adjusted OR 17.4; 95% CI 9.4 to 32.1), urinalysis with more than 5 RBCs per high-powered field (adjusted OR 4.8; 95% CI 2.7 to 8.4), and an initial hematocrit of less than 30% (adjusted OR 2.6; 95% CI 0.9 to 7.5). CONCLUSION: After adjusting for physical examination findings, laboratory testing contributes significantly to the identification of children with intra-abdominal injuries after blunt trauma.

Abdominal Injuries↗

PubMed2002

A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma.

STUDY OBJECTIVE: We sought to determine the prevalence of thoracic injuries in children sustaining blunt torso trauma and to develop a clinical prediction rule to identify children with these injuries. METHODS: We prospectively enrolled pediatric patients (<16 years) who presented to the emergency department of a Level I trauma center with blunt torso trauma and underwent chest radiography. Clinical findings were recorded in a standardized fashion by the ED faculty physician. Thoracic injuries included the following: pulmonary contusion, hemothorax, pneumothorax, pneumomediastinum, tracheal-bronchial disruption, aortic injury, hemopericardium, pneumopericardium, cardiac contusion, rib fracture, sternal fracture, or any injury to the diaphragm. Multiple logistic regression and recursive partitioning analyses were performed to generate a clinical prediction rule for identifying children with these injuries. RESULTS: Nine hundred eighty-six patients with a mean age of 8.3+/-4.8 years were enrolled. Eighty (8.1%; 95% confidence interval [CI] 6.5% to 10.0%) patients sustained thoracic injuries. Multiple logistic regression and recursive partitioning analyses identified the following predictors of thoracic injuries: low systolic blood pressure (14% with injury versus 2% without injury; adjusted odds ratio [OR] 4.6), elevated age-adjusted respiratory rate (51% versus 16%; adjusted OR 2.9), abnormal results on examination of the thorax (68% versus 36%; adjusted OR 3.6), abnormal chest auscultation findings (14% versus 1%; adjusted OR 8.6), femur fracture (13% versus 5%; adjusted OR 2.2), and a Glasgow Coma Scale (GCS) score of less than 15 (61% versus 26%; adjusted OR 3.3). Seventy-eight (98%; 95% CI 91% to 100%) of the 80 patients with thoracic injuries had at least 1 of these predictive factors. Three hundred thirty-six (37%) children had none of these predictive factors, including 2 (0.6%; 95% CI 0.1% to 2.1%) with thoracic injuries. These 2 injuries, however, did not require any intervention. CONCLUSION: Predictors of thoracic injury in children sustaining blunt torso trauma include low systolic blood pressure, elevated respiratory rate, abnormal results on thoracic examination, abnormal chest auscultation findings, femur fracture, and a GCS score of less than 15. These predictors can be used to create a sensible clinical decision rule for the identification of children with thoracic injuries.

Accidental Falls↗

PubMed2002

Variability in computed tomography and magnetic resonance imaging in patients with cervical spine injuries.

OBJECTIVE: The purpose of this study was to describe the performance of adjunctive radiologic imaging in patients with cervical spine injury. METHODS: All patients undergoing cervical spine radiography were prospectively enrolled at 16 diverse emergency departments. We recorded the imaging modalities and radiographic interpretations rendered by unblinded faculty radiologists at each center. Only patients with cervical spine injury were included in this analysis. Findings revealed by individual modalities were compared with the final diagnosis (after all evaluations) in each patient. RESULTS: Six hundred eighty-eight patients with 1,302 separate cervical spine injuries were enrolled. Four hundred seventy-six (69%) patients had magnetic resonance imaging (MRI) and/or computed tomography (CT) of the cervical spine. MRI identified the following injuries among 124 imaged patients: osseous fractures, 85 of 154 (55%); spinal cord injury, 69 of 69 (100%); vertebral subluxation/dislocation, 37 of 43 (86%); ligamentous injury, 38 of 38 (100%); and unilateral/bilateral locked facets, 14 of 18 (78%). Among 418 patients undergoing CT, the following injuries were identified: osseous fractures, 721 of 740 (97%); spinal cord injury, 0 of 30 (0%); vertebral subluxation/dislocation, 76 of 88 (86%); ligamentous injury, 9 of 36 (25%); and unilateral/bilateral locked facets, 34 of 35 (97%). CT identified 29 patients with fractures who had normal plain radiographs. Cervical myelograms were obtained in two patients and cervical tomograms in seven patients. CONCLUSION: The majority of patients with cervical spine injury undergo MRI and/or CT imaging. In clinical practice, MRI is superior at identifying soft tissue injuries, whereas CT performs better in identifying bony injuries. Cervical myelograms and tomograms are rarely obtained.

Cervical Vertebrae↗

PubMed2002

Effects of delaying fluid resuscitation on an injury to the systemic arterial vasculature.

OBJECTIVES: To determine the effects of delaying fluid on the rate of hemorrhage and hemodynamic parameters in an injury involving the arterial system. METHODS: Twenty-one adult, anesthetized sheep underwent left anterior thoracotomy and transection of the left internal mammary artery. A chest tube was inserted into the thoracic cavity to provide a continuous measurement of blood loss. The animals were randomly assigned to one of three resuscitation protocols: 1) no fluid resuscitation (NR), 2) standard fluid resuscitation (SR) begun 15 minutes after injury, or 3) delayed fluid resuscitation (DR) begun 30 minutes after injury. All of the animals in the two resuscitation groups received 60 mL/kg of lactated Ringer's solution over 30 minutes. Blood loss and hemodynamic parameters were measured throughout the experiment. RESULTS: Total hemorrhage volume (mean +/- SD) at the end of the experiment was significantly lower (p = 0.006) in the NR group (1,499 +/- 311 mL) than in the SR group (3,435 +/- 721 mL) or the DR group (2,839 +/- 1549 mL). Rate of hemorrhage followed changes in mean arterial pressure in all groups. Hemorrhage spontaneously ceased significantly sooner (p = 0.007) in the NR group (21 +/- 14 minutes) and the DR group (20 +/- 15 minutes) than in the SR group (54 +/- 4 minutes). In the DR group, after initial cessation of hemorrhage, hemorrhage recurred in five of six animals (83%) with initiation of fluid resuscitation. Maximum oxygen (O2) delivery in each group after injury was as follows: 101 +/- 34 mL O2/kg/min at 45 minutes in the DR group, 51 +/- 20 mL O2/kg/min at 30 minutes in the SR group, and 35 +/- 8 mL O2/kg/min at 60 minutes in the NR group. CONCLUSIONS: Rates of hemorrhage from an arterial injury are related to changes in mean arterial pressure. In this animal model, early aggressive fluid resuscitation in penetrating thoracic trauma exacerbates total hemorrhage volume. Despite resumption of hemorrhage from the site of injury, delaying fluid resuscitation results in the best hemodynamic parameters.

Animals↗