scholarly journals Computed tomography angiography is associated with low added utility for detecting clinically relevant vascular injuries among patients with extremity trauma

2021 ◽  
Vol 6 (1) ◽  
pp. e000828
Author(s):  
Riley Brian ◽  
Daniel J Bennett ◽  
Woon Cho Kim ◽  
Deborah M Stein
Keyword(s):  
Physical Examination ◽  
Vascular Injury ◽  
Vascular Injuries ◽  
Level Of Evidence ◽  
Vascular Intervention ◽  
Vascular Abnormalities ◽  
Extremity Trauma ◽  
Level 1 ◽  
Injured Patients ◽  
Level 1 Trauma Center

BackgroundExtremity CT angiography (CTA) is frequently used to assess for vascular injury among patients with extremity trauma. The injured extremity index (IEI), defined as the ratio of systolic occlusion pressure between injured and uninjured extremities, has been implemented to screen patients being considered for CTA. Physical examination together with IEI is extremely sensitive for significant extremity vascular injury. Unfortunately, IEI cannot always be calculated. This study aimed to determine whether patients with normal pulse examinations and no hard signs of vascular injury benefitted from further imaging with CTA. We hypothesized that CTA has become overused among patients with extremity trauma, as determined by the outcome of vascular abnormalities that underwent vascular intervention but were missed by physical examination.MethodsThe charts of traumatically injured patients who underwent extremity CTA were retrospectively reviewed. This study was performed at a level 1 trauma center for patients who presented as trauma activations from September 1, 2019 to September 1, 2020.ResultsOne hundred and thirty-six patients with 167 injured limbs were included. Eight limbs (4.8%) underwent an open vascular operation, whereas five limbs (3.0%) underwent an endovascular procedure. One of the 167 limbs (0.6%) had a vascular injury seen on CTA and underwent intervention that was not associated with a pulse abnormality or hard signs of vascular injury. This patient presented in a delayed fashion after an initially normal IEI and examination. Proximity injuries and fractures alone were not highly associated with vascular injuries.DiscussionMany patients with normal pulse examination and no hard signs of vascular injury underwent CTA; the vast majority of these patients did not then have a vascular intervention. Given the consequences of missed vascular injuries, further work is required to prospectively assess the utility of CTA among patients with extremity trauma.Level of evidenceIII.

scholarly journals The Role of CT Angiography in Evaluating Lower Extremity Trauma: 157 Patient Case Series at a Military Treatment Facility

2019 ◽  
Vol 184 (9-10) ◽  
pp. e490-e493
Author(s):  
Sean P Kelly ◽  
Genevieve Rambau ◽  
David J Tennent ◽  
Patrick M Osborn
Keyword(s):  
Lower Extremity ◽  
Physical Examination ◽  
Vascular Injury ◽  
Clinical Care ◽  
Case Series ◽  
High Energy ◽  
Physical Exam ◽  
Vascular Injuries ◽  
Lower Extremity Trauma ◽  
Extremity Trauma

Abstract Introduction Physical exam and angiography have important roles in the diagnosis of traumatic lower extremity vascular injury with similar reported high rates of sensitivity and specificity. It has been previously shown that CTA is not universally indicated in the setting of acute lower extremity trauma when a reliable physical examination is obtained. As such, the purpose of this study was to determine if obtaining a CTA following physical examination altered the clinical care of patients following high-energy lower extremity trauma and the generalizability to the military population. Materials and Methods Retrospective review of all patients who underwent lower extremity CTA during the initial trauma evaluation at a Level 1 Trauma Center from 2007 to 2014. Results One hundred and fifty-seven patients met inclusion criteria. One hundred and seventeen patient’s initial physical exam excluded limb ischemia with 67 vascular injuries on CTA (9 underwent angiogram in the OR) with no reperfusions required. 40 patients had hard signs of ischemia or ABI’s <0.90, 29 had injuries on CTA, and fifteen underwent a vascular reperfusion procedure for acute vascular injury. Ten of 15 reperfusions required no further angiography after CTA. The sensitivity and negative predictive value of physical exam for needed reperfusion were both 100%. There were no instances of missed vascular injury or readmission and 53 patients were discharged directly from the emergency room after a negative CTA. Conclusions This study suggests that physical exam alone achieves a high sensitivity for vascular injury in lower extremity trauma. Physical exam excluded all lower extremity ischemia without the need for advanced imaging. While CTA was useful to confirm and localize the source of acute vascular injury, the majority of vascular injuries identified on CTA did not affect immediate clinical care and lead to additional unnecessary procedures. However, in patients with suspected vascular injury, a negative CTA was also used as rationale for immediate discharge from the emergency department without further clinical observation. When applied to the deployed military setting the results of this study support the use of physical exam to accurately diagnose limb threatening ischemia at the time of injury or Role 1 facilities with CTA reserved for diagnosing the level of the vascular injury and for potential patient clearance prior to prolonged evacuation.

Delays in Transfer of Elderly Less-injured Trauma Patients Can Have Deadly Consequences

2014 ◽  
Vol 80 (11) ◽  
pp. 1132-1135 ◽  
Author(s):  
Peter E. Fischer ◽  
Paul D. Colavita ◽  
Gregory P. Fleming ◽  
Toan T. Huynh ◽  
A. Britton Christmas ◽  
...  
Keyword(s):  
Trauma Center ◽  
Injury Severity ◽  
Trauma Patients ◽  
Severely Injured ◽  
Severely Injured Patients ◽  
Local Trauma ◽  
Level 1 ◽  
Poor Outcomes ◽  
Injured Patients ◽  
Level 1 Trauma Center

Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals’ length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.

scholarly journals PC172. Comparative Trends in the Management of Peripheral Vascular Injuries at an Urban Level 1 Trauma Center: Trauma Versus Vascular Surgery

2015 ◽  
Vol 61 (6) ◽  
pp. 164S
Author(s):  
Jatin Anand ◽  
Anand V. Ganapathy ◽  
Ahmed F. Khouqeer ◽  
Eric K. Rachlin ◽  
Peter I. Tsai ◽  
...  
Keyword(s):  
Vascular Surgery ◽  
Trauma Center ◽  
Vascular Injuries ◽  
Peripheral Vascular ◽  
Urban Level ◽  
Level 1 ◽  
Level 1 Trauma Center

Lower Extremity Trauma in Vehicular Front-Seat Occupants: Patients Admitted to a Level 1 Trauma Center

1994 ◽  
Author(s):  
Patricia C. Dischinger ◽  
Andrew R. Burgess ◽  
Brad M. Cushing ◽  
Timothy D. O'Quinn ◽  
Carl B. Schmidhauser ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Trauma Center ◽  
Front Seat ◽  
Lower Extremity Trauma ◽  
Extremity Trauma ◽  
Level 1 ◽  
Level 1 Trauma Center

scholarly journals Implementing psychosocial programming at a level 1 trauma center: results from a 5-year period

2020 ◽  
Vol 5 (1) ◽  
pp. e000363 ◽  
Author(s):  
Natasha M Simske ◽  
Trenton Rivera ◽  
Mary A Breslin ◽  
Sarah B Hendrickson ◽  
Megen Simpson ◽  
...  
Keyword(s):  
Support Groups ◽  
Trauma Center ◽  
Psychosocial Support ◽  
Trauma Patients ◽  
Post Traumatic Stress ◽  
Educational Materials ◽  
Level Of Evidence ◽  
Victims Of Crime ◽  
Level 1 ◽  
Level 1 Trauma Center

BackgroundThe primary goal of the present study is to describe the psychosocial support services provided at our institution and the evolution of such programming through time. This study will also report the demographics and injury patterns of patients using available resources.MethodsTrauma Recovery Services (TRS) is a social and psychological support program that provides services and resources to patients and families admitted to our hospital. It includes a number of different services such as emotional coaching from licensed counselors, educational materials, peer mentorship from trauma survivors, monthly support groups, post-traumatic stress disorder (PTSD) screening and programming for victims of crime. Patients using services were prospectively recorded by hired staff, volunteers and students who engaged in distributing programming. Demographics and injury characteristics were retrospectively gathered from patient’s medical records.ResultsFrom May of 2013 through December 2018, a total of 4977 discrete patients used TRS at an urban level 1 trauma center. During the study period, 31.4% of the 15 640 admitted adult trauma patients were exposed to TRS and this increased from 7.2% in 2013 to 60.1% in 2018. During the period of 5.5 years, 3317 patients had ‘direct contact’ (coaching and/or educational materials) and 1827 patients had at least one peer visit. The average number of peer visits was 2.7 per patient (range: 2–15). Of the 114 patients who attended support groups over 4 years, 55 (48%) attended more than one session, with an average of 3.9 visits (range: 2–10) per patient. After the establishment of PTSD screening and Victims of Crime Advocacy and Recovery Program (VOCARP) services in 2017, a total of 482 patients were screened for PTSD and 974 patients used VOCARP resources during the period of 2 years, with substantial growth from 2017 to 2018.ConclusionsHospital-provided resources aimed at educating patients, expanding support networks and bolstering resiliency were popular at our institution, with nearly 5000 discrete patients accessing services during a period of 5.5 years. Moving forward, greater investigation of program usage, development, and efficacy is necessary.Level of evidenceLevel II therapeutic.

scholarly journals The Relationship between Hospital Volume and In-Hospital Mortality of Severely Injured Patients in Dutch Level-1 Trauma Centers

2021 ◽  
Vol 10 (8) ◽  
pp. 1700
Author(s):  
Charlie Sewalt ◽  
Esmee Venema ◽  
Erik van Zwet ◽  
Jan van Ditshuizen ◽  
Stephanie Schuit ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Trauma Center ◽  
Hospital Volume ◽  
Injury Severity ◽  
Severely Injured ◽  
Trauma Centers ◽  
Severely Injured Patients ◽  
Level 1 ◽  
Injured Patients ◽  
Level 1 Trauma Center

Centralization of trauma centers leads to a higher hospital volume of severely injured patients (Injury Severity Score (ISS) > 15), but the effect of volume on outcome remains unclear. The aim of this study was to determine the association between hospital volume of severely injured patients and in-hospital mortality in Dutch Level-1 trauma centers. A retrospective observational cohort study was performed using the Dutch trauma registry. All severely injured adults (ISS > 15) admitted to a Level-1 trauma center between 2015 and 2018 were included. The effect of hospital volume on in-hospital mortality was analyzed with random effects logistic regression models with a random intercept for Level-1 trauma center, adjusted for important demographic and injury characteristics. A total of 11,917 severely injured patients from 13 Dutch Level-1 trauma centers was included in this study. Hospital volume varied from 120 to 410 severely injured patients per year. Observed mortality rates varied between 12% and 24% per center. After case-mix correction, no statistically significant differences between low- and high-volume centers were demonstrated (adjusted odds ratio 0.97 per 50 extra patients per year, 95% Confidence Interval 0.90–1.04, p = 0.44). The variation in hospital volume of the included Level-1 trauma centers was not associated with the outcome of severely injured patients. Our results suggest that well-organized trauma centers with a similar organization of care could potentially achieve comparable outcomes.

Syndesmotic Screw Removal in a Clinic Setting Is Safe and Cost-effective

2019 ◽  
Vol 13 (2) ◽  
pp. 144-151 ◽  
Author(s):  
Michelle T. Sugi ◽  
Brandon Ortega ◽  
Lane Shepherd ◽  
Charalampos Zalavras
Keyword(s):  
Operating Room ◽  
Chart Review ◽  
Cost Savings ◽  
Retrospective Chart Review ◽  
Cost Effective ◽  
Level Of Evidence ◽  
Superficial Infection ◽  
Syndesmotic Screw ◽  
Level 1 ◽  
Level 1 Trauma Center

Background. There is no consensus in the literature regarding the necessity of syndesmotic screw removal, but the majority of surgeons prefer screw removal in the operating room. Purpose. The aim of this study is to analyze the safety and cost-effectiveness of syndesmotic screw removal in the clinic. Methods. A retrospective chart review was performed on all acute, traumatic ankle fractures that required syndesmotic stabilization over 5 years at a level 1 trauma center. Radiographs were evaluated for maintenance of syndesmotic reduction. Orthopaedic clinic visits and operating room costs were calculated. Results. Of 269 patients, syndesmotic screws were successfully removed in the clinic in 170 patients and retained in 99 patients. Two superficial infections (1.2%) developed following screw removal. The superficial infection rate was 3.3% (2 of 60) in patients who did not receive antibiotics compared with 0% (0 of 110) in patients who received antibiotics (P = .12). No patient lost syndesmotic reduction after screw removal. Cost savings of $13 829 per patient were achieved by syndesmotic screw removal in the clinic. Conclusion. Our study demonstrates that syndesmotic screw removal in the clinic is safe, does not result in tibiofibular diastasis, is cost-effective, and results in substantial financial savings. Level of Evidence: Level IV

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