The American surgeon
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The American surgeon · Oct 2008
Comparative StudySuccessful management of occult pneumothorax without tube thoracostomy despite positive pressure ventilation.
The objective of this study was to determine whether tube thoracostomy can be safely avoided in a subset of patients with blunt occult pneumothorax. A retrospective review was performed. Management without tube thoracostomy was attempted for 59 occult pneumothoraces and was successful in 51 (86%). ⋯ Eight delayed tube thoracostomies were required an average of 19.7 hours post admission. Patients who failed observant management had more significant physiologic derangement on admission (revised trauma score 6.96 vs 7.66, P = 0.04), were more likely to have significant multisystem trauma (88% vs 37%, P = 0.007), but were not more likely to require positive pressure ventilation (PPV) (50% vs 31%, P = 0.31). This study demonstrates that a subset of patients with blunt occult pneumothorax requiring positive pressure ventilation may be safely managed without tube thoracostomy.
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The American surgeon · Oct 2008
Comparative StudyTissue oxygen saturation predicts the need for early blood transfusion in trauma patients.
Near-infrared spectroscopy (NIRS) has been used to measure regional tissue oxygen saturation (StO2) in skeletal muscle as an indicator of perfusion in trauma patients. In an effort to prospectively examine the usefulness of StO2 in identifying trauma patients in hemorrhagic shock, we evaluated the need for blood transfusion within 24 hours of injury as a marker of significant hemorrhage. A 6-month prospective, observational study was conducted at a university-affiliated, urban Level I trauma center using a convenience sample of 26 trauma patients thought to be at high risk for hemorrhagic shock. ⋯ The positive predictive value was 64 per cent and the negative predictive value was 93 per cent. The need for blood transfusion within 24 hours of arrival was not predicted by hypotension, tachycardia, arterial lactate, base deficit, or hemoglobin. StO2 may represent an important screening tool for identifying trauma patients who require blood transfusion or other limited medical resources.
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The American surgeon · Oct 2008
Comparative StudyThromboembolic prophylaxis in blunt traumatic intracranial hemorrhage: a retrospective review.
There are few data in the literature on venous thromboembolic (VTE) prophylaxis for the traumatic population with intracranial hemorrhage (ICH). We reviewed our institutional experience and compared the incidence of deep vein thrombosis and pulmonary embolism in patients with ICH receiving either early prophylaxis (< 72 hours from admission) or late prophylaxis (> 72 hours from admission), and the respective incidences in progression of intracranial hemorrhage. We identified 124 patients for this study. ⋯ Three patients with pharmacological VTE prophylaxis developed ICH progression, with one being clinically significant. Our institutional review demonstrated that it seems safe to initiate early pharmacological VTE prophylaxis in blunt head trauma with stable ICH. Nevertheless, further prospective randomized studies are needed to fully elucidate the safety and efficacy in the timing of prophylaxis for blunt head trauma with ICH.
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The American surgeon · Oct 2008
Comparative StudyCan computed tomography scan be performed effectively in the diagnosis of acute appendicitis without the added morbidity of rectal contrast?
The highest degrees of accuracy have been demonstrated for CT scans using rectal contrast in diagnosing appendicitis. However, the administration of rectal contrast is associated with patient discomfort and rarely, rectosigmoid perforation (0.04%). Additionally, the commonly accepted negative appendectomy rate is around 16 per cent. ⋯ Two hundred and forty-five inpatient CT scans were performed for suspected appendicitis with a sensitivity of 90 per cent, specificity of 98 per cent, accuracy of 94 per cent, positive predictive value of 98 per cent, and negative predictive value of 91 per cent. CT scanning without rectal contrast is effective for the diagnosis of acute appendicitis making rectal contrast, with its attendant morbidity, unnecessary. The previously acceptable published negative appendectomy rate is higher than that found in current surgical practice likely due to preoperative CT scanning.
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Blunt thoracic aortic injury (BAI) is a rare but often fatal injury that occurs with severe polytrauma. Immediate diagnosis and treatment of BAI are essential for a successful outcome. We reviewed our experience with 20 patients with BAI treated at a Level I trauma center between 1995 and 2006. ⋯ BAI is rare and often associated with multiple life-threatening injuries complicating diagnosis and treatment. Our data support the aggressive use of CTA even when classic CXR findings are not present. When CT must be delayed for abdominal exploration, intraoperative TEE is useful.