Search

Introduction: Body mass index (BMI) has commonly been used as a parameter to assess obesity in trauma patients. However, the variability of height and weight data in trauma patients limits the use of BMI as an accurate assessment tool in the trauma population. Quantitative radiologic measurements of visceral adiposity is an accurate method for assessing obesity in patients but requires further analysis before it can be accepted as a measurement tool for trauma patients., Methods: A retrospective review of trauma cases with pre-operative CT scan from 2008 to 2015 produced 57 patients for evaluation. Preoperative BMI was calculated using measured height (m2) and weight (kg). Radiologic measurements of adiposity were obtained from preoperative CT scans using OsiriX DICOM viewer software. Visceral fat areas (VFA) and subcutaneous fat areas (SFA) were measured from a single axial slice at the level of L4-L5 intervertebral space., Results: No statistically significant results were found relating visceral fat:subcutaneous fat ratios to length of stay or post-operative complications. Initial clinical observations noting an increased incidence of complications among patients with a V/S ≥ 0.4 demonstrates a possible link between obesity and poor outcomes in trauma patients. A statistically significant correlation was noted between length of stay, peri-nephric fat and injury severity score., Discussion and Conclusion: Our pilot study should be viewed as the foundation for a larger prospective study, utilizing quantitative measurements of visceral adiposity to assess outcomes in trauma patients., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Digital rectal exams (DRE) are routinely used on trauma patients during the secondary survey as recommended by current Advanced Trauma Life Support (ATLS) protocols. However, recent literature has called the blanket use of the DRE on each trauma patient into question. The purpose of this study was to evaluate the efficacy of the DRE as a diagnostic tool in the setting of urethral, spinal cord, small bowel, colon, and rectal injuries and determine if it can be eliminated from routine use in the trauma setting. Trauma patients with small bowel, colon, rectal, urethral, and spinal cord injuries, age of 18 years or older, and a noted DRE were included. Exclusion criteria included an age less than 18, patients who received paralytics, a Glasgow Coma Scale (GCS) of 3, and a history of paraplegia or quadriplegia. One-hundred eleven patient records were retrospectively reviewed. Ninety-two male (82.9 %) and 19 (17.1 %) females with a GCS of 13.7 were evaluated. Sixty-two (55.9 %) injuries were penetrating with 49 (44.1) being blunt. The DRE missed 100 % of urethral, 91.7 % of spinal cord, 93.1 % of small bowel, 100 % of colon, and 66.7 % of rectal injuries. For injuries confirmed with radiologic modalities, the DRE missed 93.3 %. For injuries confirmed on exploratory laparotomy, the DRE missed 94.9 %. The DRE has poor sensitivity for the diagnosis of urethral, spinal cord, small bowel, and large bowel injury. The DRE was found to be the most sensitive in the setting of rectal injuries. The DRE offers no benefit or predictive value when compared to other imaging modalities.

The literature reports delayed intracranial hemorrhage (ICH) after blunt trauma in patients taking preinjury anticoagulant and antiplatelet (AC/AP) medications. We sought to evaluate the incidence of delayed ICH at our institution and hypothesize that patients taking AC/AP medications who are found to have a negative first computed tomography (CT) scan will not require a second CT scan. A total of 303 patients were retrospectively reviewed. Age, gender, mechanism of injury, international normalized ratio (INR), initial and secondary cranial CT findings, and outcomes were recorded. One hundred sixty-eight (55.4%) were found to be taking AP/AC medications. Ninety-six (57%) were male and 72 (43%) female. Aspirin use was 42.8 per cent (72 of 168), clopidogrel next (39 of 168 [23.0%]), and warfarin least (18 of 168 [10.7%]). One hundred sixty-six (98.8%) presented with significant findings on the first CT scan. Fourteen (87.5%) of the 16 patients with an INR 2.0 or higher presented with an ICH on the first CT. Ninety percent of patients with an INR 1.5 or higher presented with positive findings on the first CT scan. One hundred per cent of patients with an INR 3.0 or higher presented with an ICH on the first CT scan. The incidence of a delayed ICH was two of 168 (1.19%). Of those two patients with a delayed ICH, 100 per cent were taking warfarin and had an INR greater than 2.0. The incidence of delayed ICH was 1.19 per cent. The protocol requiring a second CT scan for all patients on AC/AP medications after a negative first CT scan should be questioned. For patients with blunt head trauma taking warfarin or a warfarin-aspirin combination, a repeat cranial CT scan after a negative initial CT is acceptable. For patients taking clopidogrel, a period of observation may be warranted.

Background: Occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Increased use of computed tomography has led to a rise in the detection of OPTX. Optimal management remains undefined., Methods: A pediatric subgroup analysis (age <18 years) from a multicenter, observational study evaluating OPTX management. Data analyzed were pneumothorax size, management outcome, and associated risk factors to characterize those that may be safely observed., Results: Fifty-two OPTX (7.3 ± 6.2 mm) in 51 patients were identified. None were greater than 27 mm; all those under 16.5 mm (n = 48) were successfully managed without intervention. Two patients underwent initial tube thoracostomy (one [21 mm] and the other with bilateral OPTX [24 mm, 27 mm]). Among patients under observation (n = 49), OPTX size progressed in 2; one (6.4mm) required no treatment, while one (16.5 mm) received elective intervention. Respiratory distress occurred in one patient (10.7 mm) who did not require tube thoracostomy. Nine received positive pressure ventilation; 8 did not have a tube thoracostomy. Twenty-four patients (51%) had one or more rib fractures; 3 required tube thoracostomy., Conclusion: No pediatric OPTX initially observed developed a tension pneumothorax or adverse event related to observation. Pediatric patients with OPTX less than 16 mm may be safely observed. Neither the presence of rib fractures nor need for PPV alone necessitates intervention., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma patients. Indications for intervention remain controversial. We sought to determine which factors predicted failed observation in blunt trauma patients., Methods: A prospective, observational, multicenter study was undertaken to identify patients with OPTX. Successfully observed patients and patients who failed observation were compared. Multivariate logistic regression was used to identify predictors of failure of observation. OPTX size was calculated by measuring the largest air collection along a line perpendicular from the chest wall to the lung or mediastinum., Results: Sixteen trauma centers identified 588 OPTXs in 569 blunt trauma patients. One hundred twenty-one patients (21%) underwent immediate tube thoracostomy and 448 (79%) were observed. Twenty-seven patients (6%) failed observation and required tube thoracostomy for OPTX progression, respiratory distress, or subsequent hemothorax. Fourteen percent (10 of 73) failed observation during positive pressure ventilation. Hospital and intensive care unit lengths of stay, and ventilator days were longer in the failed observation group. OPTX progression and respiratory distress were significant predictors of failed observation. Most patient deaths were from traumatic brain injury. Fifteen percentage of patients in the failed observation group developed complications. No patient who failed observation developed a tension PTX, or experienced adverse events by delaying tube thoracostomy., Conclusion: Most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy; however, OPTX progression and respiratory distress are independently associated with observation failure.