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Biomedical subjects

F B Rogers

Publications and source records attributed to F B Rogers.

At least 19 recordsLinked to original sources
PubMed1998

Five-year follow-up of prophylactic vena cava filters in high-risk trauma patients.

OBJECTIVE: To assess the short- and long-term outcomes of vena cava filter (VCF) placement for prophylaxis against pulmonary embolism in patients at high risk due to trauma. DESIGN AND SETTING: Case series at a level I trauma center. PATIENTS: Patients were considered for prophylactic VCF placement if they met 1 of the injury criteria--spinal cord injuries with neurologic deficit, severe fractures of the pelvis or long bone (or both), and severe head injury--and had a contraindication to anticoagulation. INTERVENTION: Vena cava filters were placed percutaneously by the interventional radiologists when the acute trauma condition was stabilized following admission. MAIN OUTCOME MEASURES: Filter tilt of 14 degrees or more, strut malposition, insertion-related deep vein thrombosis, pulmonary embolism, or inferior vena cava patency. RESULTS: There were 132 prophylactic VCFs placed. A 3.1% rate of insertion-related deep vein thrombosis occurred, all of which were asymptomatic. Filter tilt occurred in 5.5% of patients and strut malposition in 38%. Three cases of pulmonary embolism (1 fatal) occurred in a prophylactic VCF, and all patients had either filter tilt or strut malposition. The risk of pulmonary embolism developing was higher in those patients with filter tilt or strut malposition than in those who did not have these complications (6.3% vs 0%; P=.05; Fisher exact test). The 1-, 2-, and 3-year inferior vena cava patency rates (+/-SD) were 97%+/-3%. CONCLUSIONS: Prophylactic VCF can be placed safely with an acceptable rate of insertion-related deep vein thrombosis and long-term inferior vena cava patency. Patients with prophylactic VCF remain at risk for pulmonary embolism if the filter is tilted 14 degrees or more or has strut malposition. In such patients, consideration should be given to placing a second filter.

Adult↗
PubMed1998

Hypertonic saline resuscitation of patients with head injury: a prospective, randomized clinical trial.

BACKGROUND: Experimental and clinical work has suggested that hypertonic saline (HTS) would be better than lactated Ringer's solution (LRS) for the resuscitation of patients with head injuries. No clinical study has examined the effect of HTS infusion on intracranial pressure (ICP) and outcome in patients with head injuries. We hypothesized that HTS infusion would result in a lower ICP and fewer medical interventions to lower ICP compared with LRS. METHODS/DESIGN: Prospective, randomized clinical trial at two teaching hospitals. RESULTS: Thirty-four patients were enrolled and were similar in age and Injury Severity Score. HTS patients had a lower admission Glasgow Coma Scale score (HTS: 4.7+/-0.7; LRS: 6.7+/-0.7; p = 0.057), a higher initial ICP (HTS: 16+/-2; LRS: 11+/-2; p = 0.06), and a higher initial mean maximum ICP (HTS: 31+/-3; LRS: 18+/-2; p < 0.01). Treatment effectively lowered ICP in both groups, and there was no significant difference between the groups in ICP at any time after entry. HTS patients required significantly more interventions (HTS: 31+/-4; LRS: 11+/-3; p < 0.01). During the study, the change in maximum ICP was positive in the LRS group but negative in the HTS group (LRS: +2+/-3; HTS: -9+/-4; p < 0.05). CONCLUSION: As a group, HTS patients had more severe head injuries. HTS and LRS used with other therapies effectively controlled the ICP. The widely held conviction that sodium administration will lead to a sustained increase in ICP is not supported by this work.

Adult↗
PubMed1998

Predicting survival, length of stay, and cost in the surgical intensive care unit: APACHE II versus ICISS.

BACKGROUND: Risk stratification of patients in the intensive care unit (ICU) is an important tool because it permits comparison of patient populations for research and quality control. Unfortunately, currently available scoring systems were developed primarily in medical ICUs and have only mediocre performance in surgical ICUs. Moreover, they are very expensive to purchase and use. We conceived a simple risk-stratification tool for the surgical ICU that uses readily available International Classification of Diseases, Ninth Revision, codes to predict outcome. Called ICISS (International Classification of Disease Illness Severity Score), our score is the product of the survival risk ratios (obtained from an independent data set) for all International Classification of Diseases, Ninth Revision, diagnosis codes. METHODS: A total of 5,322 noncardiac patients admitted to a surgical ICU during an 8-year period had their Acute Physiology and Chronic Health Evaluation (APACHE) II scores compared with their ICISS as predictors of outcome (survival/nonsurvival, length of stay, and charges). RESULTS: ICISS proved to be a much better predictor of survival than APACHE (receiver operating characteristic (ROC) APACHE = 0.806; Hosmer-Lemeshow (HL) APACHE = 22.56; ROC ICISS = 0.892; HL ICISS = 12.06) or the APACHE survival probability (ROC = 0.836; HL = 34.47). These differences were highly statistically significant (p < 0.001). ICISS was also better correlated with ICU length of stay (APACHE R2 = 0.06; ICISS R2 = 0.32) and ICU charges (APACHE R2 = 0.07; ICISS R2 = 0.39). When combined in a logistic model with ICISS, APACHE II added slightly to the predictive power of ICISS alone (combined ROC = 0.903) but degraded the calibration of the model (combined HL = 16.29; p = 0.038). CONCLUSION: Because ICISS is both more accurate and much less expensive to calculate than APACHE II score, ICISS should replace APACHE II score as the standard risk stratification tool in surgical ICUs.

APACHE↗
PubMed1997

Trauma deaths in a mature urban vs rural trauma system. A comparison.

OBJECTIVE: To compare the timing, severity, and injury characteristics of patients dying from trauma in an urban vs a rural setting. DESIGN: Retrospective review of autopsy database (urban) and medical examiner database (rural), with selected medical chart review. SETTING: An organized urban trauma system with 6 trauma centers and a rural state with no formal trauma system and 1 trauma center. PATIENTS: All trauma fatalities occurring in an urban (n = 612) and a rural (n = 143) setting during a 1-year period. RESULTS: In the urban system, 248 patients (40.5%) died at the scene of injury compared with 103 (72%) patients in a rural environment. During the first 24 hours of hospitalization 243 (39.7%) urban patients died compared with 23 (16%) rural patients. Eighty-nine urban patients (14.5%) and 17 rural patients (11.8%) survived for more than 24 hours but later died in the hospital. The mean age of those who died was significantly greater in the rural trauma system than in the urban trauma system (P < .001), and the Injury Severity Score was significantly less in the rural trauma system than in the urban trauma system (P < .01). In the patients who died after being admitted to the hospital for more than 24 hours there was a significantly higher rate of preexisting comorbidity in the rural patients than in the urban patients (P < .05). The most frequent cause of death in the rural setting was multisystem organ failure; head injury was the most common cause of death in the urban setting. CONCLUSIONS: Patients who die in a rural area without a formal trauma system are more likely to die at the scene, are less severely injured, and are older. Rural trauma patients who are admitted to a hospital and who survived for at least 24 hours before dying are older, less severely injured, have significantly more comorbidities, and are more likely to die of multisystem organ dysfunction than their urban counterparts. These differences reflect the different patient populations and injury patterns that confront urban and rural trauma centers. The higher proportion of scene deaths in the rural environment may reflect the longer discovery and transport times that occur in a rural setting.

Adolescent↗
PubMed1997

Upper torso cyanosis: a marker for blunt cardiac rupture.

Cardiac rupture is a frequent cause of death following blunt trauma. Most of these patients die at the scene with only a few surviving to make it to the hospital. With improvements in prehospital care and rapid regional transport, more of these patients may arrive at the hospital with signs of life. Classically, these patients arrive with the constellation of symptoms that characterize cardiac tamponade (hypotension, distended neck veins, and distant heart sounds). The differential appearance of upper body cyanosis frequently accompanies these injuries. Prompt recognition and expeditious surgical treatment may increase the number of survivors of this catastrophic injury. Presented here is an illustrative case report and review of the literature.

Adolescent↗
PubMed1997

Prophylactic vena cava filter insertion in selected high-risk orthopaedic trauma patients.

OBJECTIVES: (a) To determine the incidence and risk factors for the development of pulmonary embolism in orthopaedic trauma patients and (b) to determine whether prophylactic vena cava filters are efficacious against pulmonary edema in high-risk patients. DESIGNS: Before and after trial on the incidence of pulmonary embolism in the orthopaedic trauma population before and after the introduction of prophylactic vena cava filters. SETTING: Tertiary care level I trauma center. PATIENTS: Thirty-five patients received prophylactic vena cava filters. These patients had a long bone and pelvic, multiple long bone fractures, or a complex (Kane's III or IV) pelvic fracture with at least one additional risk-factor at an age of > 55 years and an Injury Severity Score of > 16 or requiring prolonged (> 6 weeks) immobilization. INTERVENTION: Thirty-five patients had vena cava filters placed (32 titanium Greenfield filters, Medi-tech/Boston Scientific, Watertown, MA; and three Bird's Nest filters, Cook Bloomington, IN). Most filters (n = 33) were placed percutaneously in radiology. MAIN OUTCOME MEASURES: (a) Morbidity related to filter insertion, (b) incidence of pulmonary embolism in orthopaedic trauma population compared with historical controls who did not receive filters, and (c) patency of filters. RESULTS AND CONCLUSIONS: Minimal morbidity was related to prophylactic vena cava filter insertion. There was a significant (p < 0.04); (Fisher's exact) decrease in the incidence of pulmonary embolism in the orthopaedic trauma population as a whole after the use of prophylactic vena cava filters. Follow-up ultrasound showed a 1 and 2-year inferior vena cava patency rate of 93.6% +/- 6.2% by life table analysis. We conclude that selected use of prophylactic vena cava filters in orthopaedic trauma is safe and decreases the incidence of pulmonary embolism.

Fractures, Bone↗
PubMed1997

Financial outcome of treating trauma in a rural environment.

The financial plight of the urban trauma center is well documented. However, the financial status of the rural trauma center is largely unknown. We hypothesized that our rural trauma center with a high number of blunt trauma patients, a wide spectrum of injury severity, and a large percentage of insured patients would prove to be financially advantageous to the institution. From January 1994 to June 1995, 1,119 consecutive trauma admissions had a complete financial profile compiled including actual costs, reimbursements, and reimbursement ratio (RR = reimbursement/actual costs). Our injury severity profile was very skewed with a preponderance of less severely injured patients (mean Injury Severity Score = 9.6 +/- 7.8). The payor profile of these patients included 49.2% fee-for-service (RR = 1.43), 25.4% diagnosis-related group-based (RR = 0.92), 8.77% per diem (RR = 0.51), and 1.25% capitated (RR = 0.47). Overall, the RR for the trauma unit was 1.11, representing a net profit overall. Cost closely tracked both hospital and intensive-care unit length of stay (R2 = 0.925). Likewise, reimbursement also was reflected in both hospital and intensive-care unit length of stay (R2 = 0.735). We conclude that our rural trauma center, with a favorable payor mix and low injury severity, is financially profitable.

Adult↗
PubMed1997

Trauma registry injury coding is superfluous: a comparison of outcome prediction based on trauma registry International Classification of Diseases-Ninth Revision (ICD-9) and hospital information system ICD-9 codes.

BACKGROUND: Trauma registries are an essential but expensive tool for monitoring trauma system performance. The time required to catalog patients' injuries is the source of much of this expense. Typically, 15 minutes of chart review per patient are required, which in a busy trauma center may represent 25% of a full-time employee. We hypothesized that International Classification of Disease-Ninth Revision (ICD-9) codes generated by the hospital information system (HI) would be similar to those coded by a dedicated trauma registrar (TR) and would be as accurate as TR ICD-9 codes in predicting outcome. METHODS: One thousand eight hundred twelve patients admitted to a Level I trauma center during 2 years had International Classification of Disease Injury Severity Scores (ICISS) calculated based on HI and TR ICD-9 codes. The relative predictive powers of these two ICISSs were then compared for every patient using Receiver Operator Characteristic Curve Area (ROC) and Hosmer Lemeshow Statistics. RESULTS: Eighty-nine percent of patients (1,608 of 1,812) had identical HI and TR ICISSs. Eleven patients' ICISSs differed by >0.1, and only two patients' scores differed by >0.2. ICISS proved to be a powerful predictor of outcome whether derived from HI (ROC = 0.884; 95% confidence interval (CI) = 0.850-0.917) or TR (ROC = 0.872; 95% CI = 0.837-0.908). Although these predictive powers were not significantly different (p = 0.076), the trend was for HI to perform better than TR. ISS calculated for the same data set using the MacKenzie dictionary proved significantly less predictive of outcome than either ICISS (ROC(MacKenzie) = 0.843; 95% CI = 0.792-0.884; p = 0.034). CONCLUSION: We conclude that in our hospital TR data on individual injuries can be replaced by HI data without loss of predictive power. ISS based on the MacKenzie dictionary should be abandoned because it is much less predictive of outcome than ICISS.

Adolescent↗
PubMed1997

Multicenter, randomized, prospective trial of early tracheostomy.

OBJECTIVES: Determine the effect of early (days 3-5) or late (days 10-14) tracheostomy on intensive care unit length of stay (ICU LOS), frequency of pneumonia, and mortality, and evidence of short-term or long-term pharyngeal, laryngeal, or tracheal injury in head trauma, non-head trauma, and critically ill nontrauma patients. STUDY DESIGN: Randomized, prospective. SETTING: Five Level I trauma centers. METHODS: Data were obtained prospectively and included Acute Physiology and Chronic Health Evaluation III score (AIII), Glasgow Coma Scale score, Emergency Room Trauma Score, Injury Severity Score, Acute Injury Score, type of endotracheal tube or tracheostomy, level of positive end-expiratory pressure, and peak inspiratory pressure. Patients were to undergo laryngoscopy for detection of injury according to the Lindholm criteria at the time of endotracheal tube or tracheostomy removal and be reevaluated at 3 to 5 months after discharge. RESULTS: One hundred fifty-seven patients were entered, 127 to early randomization (3-5 days) and 28 to late randomization (10-14 days); however, only 112 patients with early and 14 with late randomization had completed data forms for the primary study goals. An additional 22 patients from the early entry groups were rerandomized late. Early randomization data: the AIII score was higher (p < 0.05) in the head trauma tracheostomy (65 +/- 4) than in the nontracheostomy group (51 +/- 4) and in the nontrauma tracheostomy (92 +/- 6) than in the nontracheostomy group (68 +/- 7), but was equivalent in the non-head trauma group. Glasgow Coma Scale score, Emergency Room Trauma Score, Injury Severity Score, Acute Injury Score, positive end-expiratory pressure, and peak inspiratory pressure were not significantly different in any of the groups. There were no significant differences in ICU LOS, frequency of pneumonia, or death in any of the groups after either early or late tracheostomy compared with continued endotracheal intubation. Only 83 patients underwent postextubation laryngoscopy. There were no significant differences between the groups; however, there were trends to more vocal cord ulceration and subglottic inflammation in the continued intubation group. No patient was seen in this study with late vocal cord or laryngeal stenosis; there were no tracheal-innominate artery fistulae. Seven of the patients with abnormal findings at extubation had normal 3- to 5-month postextubation laryngoscopy. CONCLUSION: Physician bias limited patient entry into the study. Although there were higher AIII scores in the head trauma early tracheostomy patients, there were no differences in the primary end points of ICU LOS, pneumonia, or death in any of the groups studied. Long-term endoscopic follow-up was poor, but no known late tracheal stenosis was seen.

APACHE↗
PubMed1996

Selective nonoperative management of liver and spleen injuries in neurologically impaired adult patients.

BACKGROUND: Nonoperative management of blunt liver and spleen injuries in hemodynamically stable, neurologically intact patients has become an accepted treatment in recent years. OBJECTIVE: To determine the morbidity and mortality in neurologically impaired adult patients who had sustained blunt liver or spleen injuries and who had been managed nonoperatively in a monitored setting, owing to the preponderance of blunt trauma and associated head injuries in Vermont. DESIGN: Case-control study. SETTING: Regional level I trauma center in northern Vermont. PATIENTS: One hundred eighty-seven consecutive patients with documented blunt splenic or hepatic trauma who were admitted to a regional rural trauma referral center in Vermont during an 8-year period, beginning in January 1987, were studied. Hemodynamically stable patients underwent diagnostic imaging studies and were classified by mental status as either normal or altered. Patients who required operative intervention were excluded. MAIN OUTCOME MEASURES: Morbidity and mortality rates for each group were recorded and compared to determine if statistically significant differences between the two groups existed. RESULTS: The groups were similar in age, systolic blood pressure, and hematocrit at admission. The group of patients with an altered mental status were more severely injured and had a longer hospital stay. Intensive care unit stays were not significantly different. Transfusion requirements for both groups were minimal; however, the group of patients with an altered mental status received more blood transfusions compared with the group of patients with a normal mental status. There was no significant difference in morbidity and mortality between the two groups. There were no failures of nonoperative management, no complications, and no missed visceral injuries in the group of patients with an altered mental status. Patients older than 50 years had higher morbidity and mortality. CONCLUSIONS: Nonoperative management in patients with an altered mental status can be done safely in a monitored setting. This challenges the current criteria of excluding neurologically impaired patients with liver or spleen trauma from nonoperative management.

Adolescent↗
PubMed1995

Patterns of splenic injuries seen in skiers.

Splenic rupture secondary to skiing appears to fall into two distinct epidemiological patterns: high-speed impact with stationary objects and simple falls (mogul injury). Of 18 splenic injuries seen at a referral hospital over 12 years, six were high-speed collisions with trees, lift towers or other solid objects. Twelve were low-speed falls impacting on moguls, the ski trail or low-speed impact with a trailside object (stump or rock). Those who sustained low-speed injuries frequently skied down the mountain afterwards without assistance (8/12), and had no other significant concomitant injuries other than minor renal contusions compared with the collision group (P < 0.005). The rate of splenic salvage was also higher in this group than in the collision group (68 per cent vs 17 per cent). The six high-speed collision splenic injury victims were all transported down the mountain by toboggan, and all had significant associated injuries. The incidence of concomitant renal injuries with splenic injuries in both groups was higher than in other reported series (10 of 18 patients). Some of those who skied down the mountain themselves sought medical attention only when they experienced haematuria. There were no significant differences in the length of stay in hospital, or intensive care units (ICU), or transfusion requirements or complications between groups. It is suggested that those who ski down the mountain themselves and present in a delayed fashion to medical/first aid facilities may still have serious abdominal injury but have a potentially higher rate of spleen salvage.

Accidental Falls↗
PubMed1995

Venous thromboembolism in trauma patients.

Venous thromboembolism is common in patients with multiple injuries. In addition to having endothelial injury, trauma patients are hypercoagulable and are often confined to bed, thus placing them at high risk for venous thromboembolic events. Duplex ultrasonography and impedance plethysmography are the most practical modalities to screen trauma patients for the presence of DVT. At present, there do not appear to be any effective means of preventing DVT in trauma patients, although low molecular weight heparin appears promising. In particularly high-risk patients vena cava filters have been used safely and effectively to prevent PE.

Humans↗
PubMed1995

Nonoperative treatment of a major hepatic injury in a hemophiliac.

Selective nonoperative management of hepatic injuries from blunt trauma has become an accepted practice over the past 10 years. A case of nonoperative management of a major hepatic injury in a person with Hemophilia A is reported. Treatment with aggressive blood component therapy resulted in a successful outcome.

Blood Component Transfusion↗
PubMed1995

Delayed presentation of splenic artery pseudoaneurysms following blunt abdominal trauma: case reports.

Splenic artery pseudoaneurysms are known to be caused by either pancreatitis or operative trauma. We present two patients who had delayed presentation of splenic artery pseudoaneurysms secondary to blunt abdominal trauma. This is the first report of splenic artery pseudoaneurysms following trauma and demonstrates the importance of follow-up computed tomography scans in patients with splenic injuries who are treated nonoperatively.

Abdominal Injuries↗