Early Placement of Optional Vena Cava Filter in High-Risk Patients with Traumatic Brain Injury

Objectives: Patients sustaining severe trauma are at high risk for the development of venous thromboembolic events (VTE). Pharmacologic VTE prophylaxis may be contraindicated early after trauma due to potential bleeding complications. The purpose of this study was to evaluate safety and feasibility of early prophylactic vena cava filter (VCF) placement and subsequent retrieval in multiple injured patients with traumatic brain injury (TBI). Methods: Analysis of single-institution case series of consecutive patients who received a prophylactic VCF after severe TBI (Abbreviated Injury Scale, AiS ‡ 3) between August 2003 and October 2006. Results: A total of 34 optional VCF were prophylactically placed with a median delay of 1 day after trauma (range, 0–7 days). All patients had sustained multiple injuries (median Injury Severity Score 41, range, 18–59) with severe TBI (median AiS 4, range 3–5). Median age was 41 years (range, 17–67 years). Two patients had succumbed before potential filter retrieval. Of the remaining patients, 27 (84%) had their filters uneventfully retrieved between 11 and 32 days (median, 18 days) after placement with no retrieval-related morbidity. Five VCF (16%) were left permanently. In one patient (3%) early inferior vena cava occlusion and deep venous thrombosis occurred 14 days after VCF placement. Symptomatic pulmonary embolism was observed in one patient (3%) 5 days after VCF retrieval. Overall trauma-related mortality was 9%. Conclusions: Early VCF placement may be of benefit for multiple injured patients with TBI when pharmacologic VTE prophylaxis is contraindicated. VCF retrieval is safe and feasible. Filter placement- and retrieval-related morbidity is low

Identifying Pitfalls in Chest Tube Insertion: Improving Teaching and Performance

Chest tube thoracostomies are common surgical procedures, but little is known about how practitioners learn the skill. This study evaluates the frequency with which correctly performed tasks are executed by subjects during chest tube thoracostomies. In this prospective study, we developed a mobile-learning module, containing stepwise multimedia guidance on chest tube insertion. Next, we developed and tested a 14-item checklist, modeled after key skills in the module. Participants, defined as “novice” (fewer than 10 chest tubes placed) or “expert” (10 or more placed), were assigned to either the video or control group. A trained clinician used the checklist to rate participants while they inserted a chest tube on a TraumaMan simulator. University of Miami, Miller School of Medicine, a tertiary care academic institution. Current medical students, residents, and the United States Army Forward Surgical Team members rotating through the institution. One hundred twenty-eight subjects entered and finished the study. One hundred twenty-eight subjects enrolled in the study; 86 (67%) were residents or US Army Forward Surgical Team members, 66 (77%) were novices, and 20 (23%) were experts. Novices most frequently connected the tube to suction (91%), adequately dissected the soft tissue (82%), and scrubbed or anesthetized appropriately (80%). They least frequently completed full finger sweeps (33%), avoided the neurovascular bundle (35%), and performed a controlled pleural puncture (39%). Comparing the novice video group with the novice control group, the video group was more likely to correctly perform a finger sweep (42%, p<0.001) and clamp the distal end of the chest tube (42%, p<0.001). Of all the steps, experts least frequently completed full finger sweeps (70%) and avoided the neurovascular bundle (75%). Comparing the expert video group with the expert control group, the video group was more likely to correctly perform finger sweeps, the incision, and clamping the distal chest tube (20%, p = not significant). Avoiding the neurovascular bundle, controlled pleural entry, and finger sweeps are most often performed incorrectly among novices. This information can help instructors to emphasize key didactic steps, possibly easing trainees' learning curve