Nonoperative management of traumatic aortic injury

BACKGROUND

The standard management for patients with blunt aortic injury is surgery; however, a small number of patients have been medically managed. The outcome of these nonoperatively managed patients is unknown.

METHODS

Seven patients diagnosed as blunt aortic injury were managed without aortic surgery between January 1993 and April 2002, and their outcomes were retrospectively investigated.

RESULTS

There were three men and four women, with a mean age of 48.7+/-22.7 years and Injury Severity Score of 37.7+/-16.9. The reason for nonoperative management was refusal of surgery (2), do-not-resuscitate order (1), diffuse brain injury (2), small intimal tear (1), and technical difficulty (1). Two patients died resulting from associated injuries. Five patients are alive, and in three patients complete resolution of aortic injury was observed.

CONCLUSIONS

In selected patients with multiple associated injuries or severe comorbidity, nonoperative management after blunt aortic injury can be a treatment of choice.

Evolutive standard base excess and serum lactate level in severe sepsis and septic shock patients resuscitated with early goal-directed therapy: still outcome markers?

PURPOSE

To compare the evolution of standard base excess and serum lactate level between surviving and non surviving patients with severe sepsis and septic shock resuscitated with early goal-directed therapy.

METHODS

This is a retrospective study in an intensive care unit of a university tertiary hospital where 65 consecutive severe sepsis and septic shock patients were observed without any intervention in the treatment by the authors of this report.

RESULTS

In our study, the mortality of severe sepsis and septic shock patients was 38%. The central venous oxygen saturation of both groups was above 70% after the resuscitative period, excluding the second day of the non survivors group (69.8%). After the second day, the central venous oxygen saturation was significantly higher in the survivors group (P < .001). Standard base excess was initially low in both groups, but from the second day on, the correction of standard base excess was significantly more successful and linear in the survivor group (P < .001). Lactate levels were similar during the evolution of both groups.

CONCLUSIONS

Although evolutive standard base excess and serum lactate level are still outcome markers in severe sepsis and septic shock patients resuscitated with early goal-directed therapy, other studies must be performed to clarify if hemodynamic interventions based on standard base excess and serum lactate level could be reliable to improve clinical outcomes in severe sepsis and septic shock patients.

The utility of routine trauma laboratories in pediatric trauma resuscitations

BACKGROUND

Because of the difficulties in evaluating injured children, screening blood tests are recommended.

METHODS

Resuscitation blood tests (complete blood count, chem12, coagulation panel, urinalysis) were reviewed for abnormality frequency, injury correlation, managements, and outcome.

RESULTS

Panels were obtained on 240 children (age < 16 years) meeting trauma system criteria. Abnormalities were identified as follows: white blood cell/hematocrit/platelets (41%, 27%, 1%), Na/K/Cl/CO(2) (3%, 30%, 23%, 14%), blood ureal nitrogen/creatinine (6%, 0%), prothrombin time/international normalized ratio/partial thromboplastin time (22%, 16%, 6%), aspartate aminotransferase/alanine transferase (43%, 35%), amylase (2%), glucose (77%), and urinalysis (31%). Organ-specific chemistries predicted injury poorly. Transaminasemia correlated with liver injury when levels exceeded 400 U/L. Two children (1%) with hyperamylasemia had abdominal injuries. Coagulation abnormalities correlated with intracranial injury (43%) and Glasgow Coma Scale (GCS 3 to 8; 56%, GCS 9 to 14; 20%, GCS 15; 14%, P <0.05). Only 25 (10%) had interventions for test abnormalities (11 transfusions, 8 fresh frozen plasma, 3 tests repeated, 3 KCl).

CONCLUSIONS

Routine laboratory panels are little value in the management of injured children.

A U.S. Army Forward Surgical Team’s Experience in Operation Iraqi Freedom

BACKGROUND

The Forward Army Surgical Team (FST) was designed to provide surgical capability far forward on the battlefield to stabilize and resuscitate those soldiers with life and limb threatening injuries. Operation Iraqi Freedom represents the largest military operation in which the FST concept of health care delivery has been employed. The purpose of our review is to describe the experience of the 555FST during the assault phase of Operation Iraqi Freedom.

METHODS

During the 23 days beginning 21 March 2003, data on all patients seen by the 555 FST were recorded. These data included combatant status, injuries according to anatomic location, and operative procedures performed.

RESULTS

During the twenty-three day period, the 555 FST evaluated 154 patients. There were 52 EPWs, 79 U.S. soldiers, and 23 Iraqi civilians treated. Injuries to the lower extremity and chest (48% and 25%) were the most common in the EPW group. Upper extremity and lower extremity injuries were the most common in the civilian (57% and 39%) and U.S. soldier groups (32% and 30%). The number of injured regions per patient were 1.14 for U.S. soldiers, 1.33 for EPWs, and 1.52 for Iraqi civilians (p < 0.003). EPWs had proportionately more thoracic and abdominal injuries than the other groups (p < 0.05).

CONCLUSIONS

Majority of the life threatening injuries evaluated involved EPWs. A combination of body armor and armored vehicles used by U.S. soldiers limited the number of torso injuries presenting to the FST. Early resuscitation and stabilization of U.S. soldiers, EPWs, and civilians can be successfully accomplished at the front lines by FSTs. Further modification of the FST's equipment will be needed to improve its ability in providing far forward surgical care.

Frequency and outcome of in-hospital resuscitation outside the ICU-setting

BACKGROUND

Guidelines on performing cardiopulmonary resuscitation and its research have been published. Only few data concerning in-hospital resuscitation are available from Switzerland. The aim of our study was to evaluate the frequency and outcome of cardiopulmonary arrests in our hospital and to look for ways of improving our resuscitation management.

METHODS

The prospective study was performed in the Kantonsspital Liestal, a primary care hospital with 360 beds, where about 24'300 in-patients were treated during the 2 year observation period. Only in-hospital resuscitations outside the ICU were included and recorded according to the Utstein criteria.

RESULTS

Within a 24 months period, 61 emergency calls were registered. 25 patients needed cardiopulmonary resuscitation. Initial cardiac rhythms were available for all subjects: 8 patients had asystole, 7 ventricular fibrillation and 10 pulseless electrical activity. 12 of 25 resuscitated patients had a return of spontaneous circulation, 7 lived longer than 24 hours and 6 patients (24%) survived to hospital discharge, 4 of them in a very good or good neurological condition. After 12 months 3 patients (12%) were living independently at home, 2 patients had to be treated in a nursing home and 1 patient had died.

CONCLUSIONS

Our data correspond to survival rates in larger studies from abroad but are limited by the number of patients investigated. Improvements are necessary in documentation of resuscitation efforts. Rapid defibrillation must be further stressed. The implementation of a multicentre study is suggested because quality control and further improvement of in-hospital resuscitation are needed in Switzerland.

Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates*

OBJECTIVE

To determine whether the introduction of an intensive care unit-based medical emergency team, responding to hospital-wide preset criteria of physiologic instability, would decrease the rate of predefined adverse outcomes in patients having major surgery.

DESIGN

Prospective, controlled before-and-after trial.

SETTING

University-affiliated hospital.

PATIENTS

Consecutive patients admitted to hospital for major surgery during a 4-month control phase and during a 4-month intervention phase.

INTERVENTIONS

Introduction of a hospital-wide intensive care unit-based medical emergency team to evaluate and treat in-patients deemed at risk of developing an adverse outcome by nursing, paramedical, and/or medical staff.

MEASUREMENTS AND MAIN RESULTS

We measured incidence of serious adverse events, mortality after major surgery, and mean duration of hospital stay. There were 1,369 operations in 1,116 patients during the control period and 1,313 in 1,067 patients during the medical emergency team intervention period. In the control period, there were 336 adverse outcomes in 190 patients (301 outcomes/1,000 surgical admissions), which decreased to 136 in 105 patients (127 outcomes/1,000 surgical admissions) during the intervention period (relative risk reduction, 57.8%; p <.0001). These changes were due to significant decreases in the number of cases of respiratory failure (relative risk reduction, 79.1%; p <.0001), stroke (relative risk reduction, 78.2%; p =.0026), severe sepsis (relative risk reduction, 74.3%; p =.0044), and acute renal failure requiring renal replacement therapy (relative risk reduction, 88.5%; p <.0001). Emergency intensive care unit admissions were also reduced (relative risk reduction, 44.4%; p =.001). The introduction of the medical emergency team was also associated with a significant decrease in the number of postoperative deaths (relative risk reduction, 36.6%; p =.0178). Duration of hospital stay after major surgery decreased from a mean of 23.8 days to 19.8 days (p =.0092).

CONCLUSIONS

The introduction of an intensive care unit-based medical emergency team in a teaching hospital was associated with a reduced incidence of postoperative adverse outcomes, postoperative mortality rate, and mean duration of hospital stay.

The role of cardiac morbidity in short- and long-term mortality in injured older patients who survive initial resuscitation

BACKGROUND

Elderly patients are an increasingly larger group of injured trauma care patients. Comorbidities influence outcome. Little is known of short- and long-term mortality in the elderly who survive initial resuscitation.

METHODS

Short- and long-term mortality was retrospectively analyzed in 363 consecutively injured patients (Injury severity score >15) surviving more than 3 days after admission to a level 1 trauma center (including 197 patients >60 years). Cardiac morbidity was the focus.

RESULTS

Survival to hospital discharge was similar comparing older patients with the entire group. Mortality increased incrementally with age. In older patients, cardiac morbidity was observed in 28% (fatal in 7); 2-year mortality was 36% (older group) and 60% (patients sustaining cardiac complications). Most elderly (80%) were discharged to long-term care.

CONCLUSIONS

Elderly who survive initial resuscitation are as likely to survive to discharge as younger patients, but long-term survival is significantly lower as age increases. Cardiac morbidity is associated with higher long-term mortality. Most elderly are discharged to long-term care.

Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital

AIMS

To determine the incidence of avoidable cardiac arrest among patients who had received resuscitation in a district general hospital. To establish how location and individual or system factors influence avoidable cardiac arrest in order to develop an evidence-based preventive strategy.

METHODS

Expert panel review of case-notes from 139 consecutive adult in-hospital cardiac arrests over 1 year.

RESULTS

There were 32,348 adult admissions in 1999 with 1,023 deaths. The cardiac arrest team was activated 139 times: 118 were for primary in-hospital cardiac arrest. The cardiac arrest rate excluding 'do not attempt resuscitation' (DNAR) cases was 3.8/1000 admissions. In 88.5% of deaths there was a DNAR policy. Survival to hospital discharge following resuscitation was 14%. Among the 118 cases, the panel unanimously agreed that 61.9% of arrests were potentially avoidable, rising to 68% when emergency department arrests were excluded (66 and 73% for majority opinion). Cardiac arrests were more likely at the weekend than during the week (P = 0.02). The odds of potentially avoidable cardiac arrest was 5.1 times greater for patients in general wards than critical care areas (P < 0.001); patients in critical care areas were more likely to survive (P < 0.001). The odds of potentially avoidable cardiac arrest was 12.6 times greater for patients nursed in a clinical area judged 'inappropriate' for their main complaint (P < 0.002, Fisher's exact test) compared to those nursed in 'appropriate' areas. The panel agreed that 100% of potentially avoidable arrests were judged to have received inadequate prior treatment. Clinical signs of deterioration in the preceding 24 h were not acted upon in 48%, and review was confined to a house officer in 45%.

CONCLUSION

The majority of treated in-hospital cardiac arrests are potentially avoidable. Multiple system failures include delays and errors in diagnosis, inadequate interpretation of investigations, incomplete treatment, inexperienced doctors and management in inappropriate clinical areas.

Under-resuscitation of near-lethal uncontrolled hemorrhage: effects on mortality and end-organ function at 72 hours

Laboratory studies of uncontrolled hemorrhage demonstrate that under resuscitation (UR) improves short-term survival, but at the expense of tissue perfusion. The long-term effects of UR have not been studied. The purpose of this study was to evaluate survival and the incidence of end-organ injury (EOI), 3 days following moderate and severe UR of uncontrolled hemorrhage. Thirty-four swine (14-24 kg) were assigned to 4 groups: Groups I, II, and III were hemorrhaged to a pulse pressure = 5 mmHg in the presence of a 4-mm aortic tear: Group I (control; n = 6) was not resuscitated; Group II (n = 11) was severely under resuscitated (MAP [mean arterial pressure] = 40 mmHg) for 75 min; Group III (n = 9) was moderately under resuscitated (MAP = 60 mmHg) for 75 min. After 75 min, the aortotomy was repaired, and animals were resuscitated to baseline physiologic parameters. Group IV (sham; n = 8) was instrumented, but not hemorrhaged. Seventy-two-hour mortality was 100%, 36%, 22%, and 0% for Groups I through IV (P = .001 Fisher's exact). Cardiac indices, serum bicarbonate, and systemic oxygen delivery were significantly lower in Group II as compared to Group III during the 75 min of UR (P < 0.05; repeated measures ANOVA). By 72 h, physiologic parameters in surviving animals had returned to baseline levels. Measures of kidney, liver, neurologic, and pulmonary function did not change from baseline. There was no histologic evidence of EOI. In this model, 75 min of UR did not result in EOI. There was a trend toward greater survival, and tissue perfusion was better preserved with moderate as compared to severe UR.

Resuscitation in the hospital: relationship of year and rhythm to outcome

OBJECTIVE

determine the frequency of initial rhythms in in-hospital resuscitation and examine its relationship to survival. Assess changes in outcome over time.

METHODS

retrospective cohort (registry) including all admissions to the Medical Center of Central Georgia in which a resuscitation was attempted between 1 January, 1987 and 31 December, 1996.

RESULTS

the registry includes 3327 admissions in which 3926 resuscitations were attempted. Only the first event is reported. There were 961 hospital survivors. Survival increased from 24.2% in 1987 to 33.4% in 1996 (chi(2)=39.0, df=1, P<0.0001). Survival was affected strongly by initial rhythm (chi(2)=420.0, df=1, P<0.0001) and decreased from 63.2% for supraventricular tachycardia (SVT) to 55.3% for ventricular tachycardia (VT), 51.0% for perfusing rhythms (PER), 34.8% for ventricular fibrillation (VF), 14.3% for pulseless electrical activity (PEA) and 10.0% for asystole (ASYS). PEA was the most frequent rhythm (1180 cases) followed by perfusing (963), asystole (580), VF (459), VT (94) and SVT (38).

DISCUSSION

the powerful effect of initial rhythm on survival has been reported in pre-hospital and in-hospital resuscitation. VF is considered the dominant rhythm and generally accounts for the most survivors. We report good outcome for each; however, VF represents only 13.8% of events and 16.7% of survivors. PEA accounts for more survivors (169) than does VF (160). Our improved outcome is partially explained by changes in rhythms, but other institutional variables need to be identified to fully explain the results. Further studies are needed to see if our findings can be sustained or replicated.

Lessons for management of anaphylaxis from a study of fatal reactions

BACKGROUND

The unpredictability of anaphylactic reactions and the need for immediate, often improvised treatment will make controlled trials impracticable; other means must therefore be used to determine optimal management.

OBJECTIVES

This study aimed to investigate the circumstances leading to fatal anaphylaxis.

METHODS

A register was established including all fatal anaphylactic reactions in the UK since 1992 that could be traced from the certified cause of death. Data obtained from other sources suggested that deaths certified as due to anaphylaxis underestimate the true incidence. Details of the previous medical history, the reaction and necropsy were sought for all cases.

RESULTS

Approximately half the 20 fatal reactions recorded each year in the UK were iatrogenic, and a quarter each due to food or insect venom. All fatal reactions thought to have been due to food caused difficulty breathing that in 86% led to respiratory arrest; shock was more common in iatrogenic and venom reactions. The median time to respiratory or cardiac arrest was 30 min for foods, 15 min for venom and 5 min for iatrogenic reactions. Twenty-eight per cent of fatal cases were resuscitated but died 3 h-30 days later, mostly from hypoxic brain damage. Adrenaline (epinephrine) was used in treatment of 62% of fatal reactions but before arrest in only 14%.

CONCLUSIONS

Immediate recognition of anaphylaxis, early use of adrenaline, inhaled beta agonists and other measures are crucial for successful treatment. Nevertheless, a few reactions will be fatal whatever treatment is given; optimal management of anaphylaxis is therefore avoidance of the cause whenever this is possible. Predictable cross-reactivity between the cause of the fatal reaction and that of previous reactions had been overlooked. Adrenaline overdose caused at least three deaths and must be avoided. Kit for self-treatment had proved unhelpful for a variety of reasons; its success depends on selection of appropriate medication, ease of use and good training.

Blunt trauma resuscitation: the old can respond

HYPOTHESIS

Old and young trauma patients are capable of hyperdynamic response during standardized shock resuscitation.

DESIGN

The responses of old and young trauma patients resuscitated using a standardized protocol are compared in an inception cohort study. A standardized resuscitation protocol was used to attain and maintain an oxygen delivery index of 600 mL/min x m2 or greater (DO2I > or = 600) for the first 24 hours in the intensive care unit. Interventions, responses, and outcomes for old (> or = 65 years) and young (<65 years) patients are described. Data were analyzed using analysis of variance, the chi2 test, and the t test; P<.05 was considered significant.

SETTING

A 20-bed shock trauma intensive care unit in a regional level I trauma center.

PATIENTS

Patients at high risk of postinjury multiple organ failure, ie, major organ or vascular injury and/or skeletal fractures, initial base deficit of 6 mEq/L or greater, need for 6 units or more of packed red blood cells in the first 12 hours, or age of 65 years or older with any 2 previous criteria.

INTERVENTIONS

Pulmonary artery catheter, crystalloid fluid infusion, packed red blood cell transfusion, and moderate inotrope support, as needed in that sequence, to attain DO2I > or = 600.

MAIN OUTCOME MEASURES

Intensive care unit length of stay and survival.

RESULTS

During 19 months ending June 1999, 12 old patients (58% male; age, 76 +/- 2 years [mean +/- SEM] [P<.0011; Injury Severity Score, 20 +/- 2 [P=.02]) and 54 young patients (61% male; age, 37 +/- 2 years; Injury Severity Score, 32 +/- 2) were resuscitated. Initially, for old patients (cardiac index, 2.0 +/- 0.2 L/min x m2) and for young patients (cardiac index, 3.0 +/- 0.2 L/min x m2; P=.01), 24-hour volumes were as follows: 16 +/- 3 L of crystalloid and 12 +/- 3 units of packed red blood cells for the old patients and 21 +/- 2 L of crystalloid and 19 +/- 2 units of packed red blood cells for the young patients. For old patients, 9 (75%) attained DO2I > or = 600, and 11 (92%) survived 7 or more days and 5 (42%) 30 or more days. For young patients, 45 (83%) attained the DO2I goal, and 48 (89%) survived 30 or more days. Intensive care unit length of stay was 25 +/- 9 days for the old patients and 23 +/- 2 days for the young patients.

CONCLUSIONS

Elderly patients have initially depressed cardiac index but generate hyperdynamic response. Although ultimate outcome is poorer than in the younger cohort, resuscitation is not futile.

The experience in the treatment of patients with extensive full-thickness burns

The aim of the present study is to analyze the changes of cure rate and the main causes of death in the last 40 years, and to summarize our experience in the treatment of extensive full-thickness burn patients. The clinical characteristics, cure rate and main causes of death of 73 cases with total burned area more than 90% TBSA and full-thickness burn area more than 70% TBSA were analyzed retrospectively. Among them, 21 cases (28.8%) were cured and 52 cases (71.2%) died. The cure rate increased significantly in the recent years, and the main causes of death changed from shock and sepsis in the time period 1959-1978 to sepsis and MODS in the past two decades. Due to the improvement of early comprehensive management of burn shock, aggressive surgical approach to full-thickness burn wound and potent systemic supporting measures, the survival rate increased significantly.

Combined effects of buffer and adrenergic agents on postresuscitation myocardial function

Although buffer agents alone have failed to improve the success of resuscitation, we now examine the widely held concept that it is the combined effect of alkaline buffer and adrenergic agents that improves outcomes of cardiopulmonary resuscitation. In the present report, the effects of both CO(2)-consuming and CO(2)-generating buffer agents in combination with adrenergic vasopressor drugs were investigated. Ventricular fibrillation was electrically induced in Sprague-Dawley rats weighing between 450 and 550 g. Precordial compression and mechanical ventilation were initiated after 8 min of untreated ventricular fibrillation. Animals were then randomized to receive bolus injections of either inorganic sodium bicarbonate buffer, organic tromethamine buffer, or saline placebo. The beta(1) adrenergic effects of epinephrine were blocked with esmolol. The vasopressor amine was injected 2 min after injection of the buffer agent. Electrical defibrillation was attempted at the end of 8 min of precordial compression. In 15 additional animals, the sequence of administration of the adrenergic vasopressor and buffer agents was reversed such that the adrenergic vasopressor was injected before the buffer agents. All animals were restored to spontaneous circulation. Both bicarbonate and tromethamine significantly decreased coronary perfusion pressure from 26 to 15 mm Hg and reduced the magnitude of the vasopressor effect of the adrenergic vasopressor. When the vasopressor preceded the buffer, declines in coronary perfusion pressure after administration of buffer agents were prevented. In each instance, however, greater impairment of postresuscitation myocardial function and decreased postresuscitation survival were observed after treatment with buffer agents.

Extracorporeal membrane oxygenation for adult cardiac support: the Allegheny experience

BACKGROUND

A mix of cardiac assist options is necessary to meet the diverse indications for cardiac support in a comprehensive heart failure program. At our institution, an adult extracorporeal membrane oxygenation (ECMO) system comprising a centrifugal pump and hollow fiber membrane oxygenator is used for short-term and temporary cardiac assist.

METHODS

Between December 1991 and August 1997, 82 adult cardiac patients were supported on ECMO. Indications for cardiac assist included postcardiotomy cardiogenic shock (PCCS, 55 patients), high-risk cardiology intervention (27 patients), perioperative cardiac graft failure (4 patients), and emergency cardiac resuscitation (6 patients). Data for analysis were collected by prospective completion of standardized ECMO report forms and retrospective review of hospital charts.

RESULTS

The ECMO system was inexpensive to operate, uncomplicated to implant, and adaptable for diverse indications. Survival in PCCS was 20 of 55 patients (36%), with an increased survival rate of 56% (18 of 32 patients) in patients with PCCS after isolated coronary bypass. Catheter-based revascularizations were successfully performed in 26 of 27 (96%) high-acuity patients temporarily supported by ECMO, and 23 of 27 patients (85%) survived to discharge. Survival in the cardiac graft failure group was 2 of 4 (50%). No patient supported on ECMO for cardiac resuscitation survived.

CONCLUSIONS

ECMO provides good cardiopulmonary and end-organ support; survival rates are similar to or higher than those seen with centrifugal pump support in comparable patient populations.