Measurement of Trauma Caregiver Stress: Validation of Heart rate variability in a Real-World Surgical Setting

BACKGROUND

Acute stress is a potentially modifiable risk-factor that contributes to errors in trauma care. Research on stress mitigation is limited by the lack of a validated objective measure of surgeon stress. We sought to validate HRV in a real-world surgical setting by comparison to the Subjective Units of Distress Score (SUDS), and correlation with self-reported peak stress moments.

METHODS

Attending and resident surgeons on the trauma team at a Level I Trauma Center wore armbands to measure HRV. Stress-associated blunting of HRV was analyzed using the standard deviation of N-N intervals (SDNN) and the root mean square of successive differences . Perceived stress was measured with the SUDS at random intervals and at perceived stress peaks. SUDS and HRV metrics were compared with a mixed effect regression model. Correlation between binned SUDS quartiles and HRV was evaluated. HRV at reported peak-stress moments were compared to shift baseline values.

RESULTS

Twelve participants were monitored for 340 h, producing 135 SUDS responses and 65 peak-stress time points. Regression analysis demonstrated no correlation between HRV and SUDS. With a binned approach, decreased SDNN was associated with an elevated SUDS (P = 0.03). The self-identified peak-stress moments correlated with decreases in both SDNN and root mean square of successive differences (P = 0.02; P < 0.01).

CONCLUSIONS

HRV by SDNN analysis correlated with heightened perceived stress, supporting its validity as a measure. However, the wide, frequent variation of HRV tracings within subjects, the sensitivity of HRV to of analytic technique, and the impact of confounders may limit its utility as an education or research tool.

LEVEL OF EVIDENCE

V Diagnostic test.

Rectal Injury After Foreign Body Insertion: Secondary Analysis From the AAST Contemporary Management of Rectal Injuries Study Group

BACKGROUND

Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion.

METHODS

Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative).

RESULTS

After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management.

CONCLUSIONS

Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.

Safety of early ambulation following blunt abdominal solid organ injury: A prospective observational study

BACKGROUND

There is continued debate regarding the optimal period of bed-rest and in-hospital monitoring for non-operative management of solid organ injury following blunt trauma.

METHODS

Single center, prospective, observational study of blunt solid organ injuries from 07/2014-02/2016, managed initially without surgical or angiographic intervention. Early ambulation was defined as ≤24 h.

RESULTS

79 patients met inclusion criteria, with 36 (45.6%) in the early ambulation group and 43 (54.4%) in the late ambulation group. There were zero complications in the early ambulation group, and three complications in the late ambulation group (complications, p = 0.246; further interventions, p = 0.498). Median ICU LOS was zero days and three days for early vs. late ambulation, p = 0.001. Median total LOS was two days and five days for early vs. late ambulation, p < 0.001.

CONCLUSION

Early ambulation is safe in patients undergoing non-operative management of their solid organ injury, and may result in a reduced length of stay.

A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study

BACKGROUND

Inter-professional collaboration is an integral component of a successful healthcare team. We sought to evaluate the impact of nursing student participation in a one-day intensive inter-professional education (IPE) training session with surgical interns on participant attitudes toward inter-professional collaboration.

METHODS

Following IRB approval, pre and post IPE session survey responses were compared to determine the impact on participant attitudes toward inter-professional collaboration. Pre and post session semi-structured interviews were transcribed and analyzed to identify relevant themes.

RESULTS

Surgical interns (n = 38) more than nursing students (n = 11), demonstrated a measurable improvement in attitude towards 'collaboration and shared education' (interns: median score pre = 26, post = 28, p = 0.0004; nursing student: median score pre = 27, post = 28, p = 0.02). Qualitative analysis of interviews identified major themes that supplemented this finding.

CONCLUSION

An eight hour, one day IPE session has a positive impact on collaborative attitudes and supports the case for increased inter-professional education amongst interns and nursing students.

Is Informed Consent in Trauma a Lost Cause? A Prospective Evaluation of Acutely Injured Patients’ Ability to Give Consent

BACKGROUND

Obtaining informed consent in acute trauma patients is often impossible, forcing investigators to abandon important projects. To better understand the likelihood of -- and barriers to -- informed consent in trauma patients, we evaluated when and how consent is possible in acutely injured patients.

STUDY DESIGN

Over a 7-month period, at a large, urban, adult Level I trauma center, we prospectively assessed each patient's ability to give hypothetical informed consent. Patients were considered consentable when they were alert, unintoxicated, and stable, with no prohibitive language barrier, or when a proxy (first-degree relative) was available. When consent was not feasible on arrival, we documented the reason and the time at which consent became possible, either by the patient or proxy.

RESULTS

Of 1,328 consecutive trauma patients, 1,020 (77%) were candidates for consent (personal or proxy) within 30 minutes of arrival. Twenty-five percent of patients with hypotension in the resuscitation area were consentable, as were 31% of severely injured (Injury Severity Score>24) patients. Eight hours after injury, 88% of all patients were consentable, as were 60% of severely injured patients and 36% of patients with initial hypotension. Primary barriers to consent included brain injury or unspecified alteration in awareness (41%), intoxication (28%), shock (26%), language barrier (2%), or medication (3%).

CONCLUSIONS

Although an overall majority of trauma patients are candidates for early informed consent, the likelihood of early consent is substantially lower in patients with severe injury or shock. Alternatives to individual informed consent may be necessary to advance the early care of acutely, severely injured patients.

Contemplating the Pentagon attack after five years of space and time: unheard voices from the ramparts of our burn center

Marking the fifth year after the attack on the Pentagon, staff at the burn center in Washington, DC, memorialize in a contemplative frame of mind. These reflections are drawn from members of the extended burn team and render an interwoven sketch in prose that previously has not been heard.

Thoracolumbar Fracture in Blunt Trauma: Is Clinical Exam Enough for Awake Patients?

BACKGROUND

Physical examination is widely used to screen trauma patients for thoracolumbar fracture (TLFx). Retrospective data suggests that patients with altered sensorium may not manifest symptoms after TLFx. This study was designed to prospectively test the sensitivity of physical examination for detection of TLFx in patients with altered mentation.

METHODS

Prospective data collection in a large urban Level I trauma center from April 2002 to December 2003. During the study period, thoracolumbar radiography was performed on patients with signs or symptoms of TLFx, and also on patients with significant blunt trauma and any alteration in mentation, including drowsiness or apparent intoxication. All patients were classified as reliable if Glasgow coma score was >13 and the treating physician judged them capable of accurately reporting pain, and those who did not met both these conditions were deemed unreliable. Patients with normal mentation and no signs or symptoms were excluded. Injuries, mental status, symptoms, physical examination, and X-ray film results were recorded.

RESULTS

There were 3,028 blunt trauma patients evaluated during the study period. Thoracolumbar radiography was performed on 537 patients. Of these, 442 patients were deemed reliable, and 166 had no signs or symptoms of TLFx. Of these asymptomatic patients, 10 were found to have TLFx. Of these 10 reliable patients with TLFx despite negative examination, none required surgery, but four required a brace.

CONCLUSIONS

Thoracolumbar fractures are often clinically silent in blunt trauma patients with altered sensorium, even when they appear able to reliably report pain. X-ray screening of these patients is appropriate to prevent missed injury.

Abdominal Insufflation Decreases Blood Loss and Mortality after Porcine Liver Injury

BACKGROUND

Uncontrolled intra-abdominal bleeding is a common cause of death in trauma patients in the prehospital and perioperative settings. The detrimental effects of abdominal hypertension are well studied, but the potential therapeutic use of abdominal insufflation for hemostasis has not been fully explored. We measured the effect of abdominal insufflation on blood loss and physiologic outcomes in a swine model of blunt liver injury.

METHODS

Twenty-one anticoagulated swine (32 +/- 3 kg) were anesthesized; laparotomy was performed to localize liver anatomy and to place loose tourniquettes isolating the porta hepatis and supra/infrahepatic vena cava. A captive bolt gun was used to create a grade V hepatic laceration, producing massive parenchymal injury as well as complex tears of the middle and right hepatic veins. Animals were randomized into either control (n = 10) or abdominal insufflation at 20 cm H(2)O pressure (n = 11) groups. Crystalloid was used to maintain a mean arterial pressure of 30 mm Hg. Arterial pressure and other physiologic variables were recorded for 20 minutes. Animals were then sacrificed and blood loss measured.

RESULTS

Blood loss was 69% lower in insufflated animals compared with controls (384 +/- 51 versus 1252 +/- 88 cc, p < 0.001). After 20 minutes, insufflated animals had significantly higher mean arterial blood pressure (32.2 +/- 4.2 versus 21.2 +/- 4.0 mm Hg) and lower total resuscitation volume (195 +/- 83 versus 1356 +/- 95 cc). Three pigs died in the control group (30%), whereas no insufflated animals died (p < 0.05).

CONCLUSION

In a swine model of catastrophic blunt hepatic injury, abdominal insufflation significantly decreased blood loss and mortality.

Multiple laparotomies are a predictor of fascial dehiscence in the setting of severe trauma

The purpose of this study was to determine the incidence of wound dehiscence after repeat trauma laparotomy. We performed a retrospective analysis of adult trauma patients who underwent laparotomy at an urban level 1 trauma center during the past 5 years. Patients were divided into single (SL) and multiple laparotomy (ML) groups. Demographic, clinical, and outcome data were collected. Data were analyzed using chi2, t testing, and ANOVA. Overall dehiscence rate was 0.7 per cent. Multiple laparotomy patients had damage control, staged management of their injuries, or abdominal compartment syndrome as the reason for reexploration. SL and ML patients had similar age and sex. ML patients had a higher rate of intra-abdominal abscess than SL patients (13.7% vs 1.2% P < 0.0001), but intra-abdominal abscess did not predict wound dehiscence in the ML group (P = 0.24). This was true in spite of the fact that ML patients had a significantly higher Injury Severity Score (ISS) than SL patients (21.68 vs 14.35, P < 0.0001). Interestingly, wound infection did not predict dehiscence. Patients undergoing repeat laparotomy after trauma are at increased risk for wound dehiscence. This risk appears to be associated with intraabdominal abscess and ISS, but not wound infection. Surgeons should leave the skin open in the setting of repeat trauma laparotomy, which will allow serial assessment of the integrity of the fascial closure.

Multiple Laparotomies are a Predictor of Fascial Dehiscence in the Setting of Severe Trauma

The purpose of this study was to determine the incidence of wound dehiscence after repeat trauma laparotomy. We performed a retrospective analysis of adult trauma patients who underwent laparotomy at an urban level 1 trauma center during the past 5 years. Patients were divided into single (SL) and multiple laparotomy (ML) groups. Demographic, clinical, and outcome data were collected. Data were analyzed using χ2, t testing, and ANOVA. Overall dehiscence rate was 0.7 per cent. Multiple laparotomy patients had damage control, staged management of their injuries, or abdominal compartment syndrome as the reason for reexploration. SL and ML patients had similar age and sex. ML patients had a higher rate of intra-abdominal abscess than SL patients (13.7% vs 1.2% P < 0.0001), but intra-abdominal abscess did not predict wound dehiscence in the ML group ( P = 0.24). This was true in spite of the fact that ML patients had a significantly higher Injury Severity Score (ISS) than SL patients (21.68 vs 14.35, P < 0.0001). Interestingly, wound infection did not predict dehiscence. Patients undergoing repeat laparotomy after trauma are at increased risk for wound dehiscence. This risk appears to be associated with intraabdominal abscess and ISS, but not wound infection. Surgeons should leave the skin open in the setting of repeat trauma laparotomy, which will allow serial assessment of the integrity of the fascial closure.

The Pentagon and 9/11

OBJECTIVE

The objective of this study was to review and discuss the medical response to the Pentagon attack on September 11, 2001.

DESIGN

The authors conducted a retrospective review of hospital records and emergency agency report.

SETTING

This study was conducted at an adult tertiary hospital with regional burn and trauma centers.

INTERVENTIONS

Observational.

RESULTS

One hundred eighty-nine persons lost their lives. Area health facilities received 106 patients; 49 were admitted for treatments and 57 were treated and released. Nine patients were admitted to the burn center. The average total body burn surface was 34%. The average age was 45 yrs. A total of 108 operations were performed. The average burn critical care and hospital length of stays were 31 and 61.7 days, respectively. One patient died of an inhalation injury on day 7.

CONCLUSIONS

The Pentagon attack produced few severely injured patients. The regional hospitals were back to normal function the day after. The severely burned patients increased the workload of the burn service but did not affect admissions of subsequent non-Pentagon patients after the second day. In case of a much larger number of critically injured patients, regional to national cooperation and transfer of patients should be considered.

Imipenem levels are not predictable in the critically ill patient

BACKGROUND

Critically ill patients often demonstrate extremely unusual volumes of distribution (Vd) and half-lives (t1/2) of drugs. Imipenem is a widely used antibiotic in critically ill patients.

METHODS

We performed high-performance liquid chromatography analysis of imipenem in samples from 50 critically ill patients treated with either 500 or 1,000 mg.

RESULTS

Peak imipenem levels varied from 1.56 microg/mL to 58.8 microg/mL. Trough levels varied between 0.0 microg/mL and 15.62 microg/mL. Only 54% of patients maintained a trough level greater than 4 microg/mL. Both the Vd and the t1/2 of imipenem were much greater than observed in other patient populations.

CONCLUSION

The pharmacokinetic activity of imipenem in critically ill patients is different from that in other patient populations. There is a very weak correlation between dosage and serum concentrations. Therapeutic failures of imipenem may be because of unpredictable pharmacodynamics (Vd and t1/2) in critically ill surgical patients.

Does volume matter? The effect of trauma surgeons' caseload on mortality

BACKGROUND

Evidence suggests that trauma centers treating high volumes of severely injured patients produce lower mortality rates than those with low volumes. However, the effect of individual surgeons' trauma caseload on outcomes has not been studied. This study compares outcomes between high-volume (HV) trauma surgeons admitting many patients with high injury severity, and low-volume (LV) surgeons treating fewer critical patients per year.

METHODS

All trauma patients admitted to a large Level I trauma center over a 12-year period were assigned to either the HV or LV group, depending on the yearly volume of their admitting surgeon. Surgeons treating > 35 severely injured (Injury Severity Score > 15) patients per year were considered HV. Student's t test and chi2 analysis were used to test comparability of LV and HV patient groups and to compare mortality rates. Mortality rates of HV and LV surgeons' patients were compared in six injury patterns selected to represent moderate to severe injury. TRISS methodology (z score) was also used to assess outcomes in the two groups. The inherent bias of the TRISS method in comparing trauma outcomes was minimized by the homogeneity of the studied patient population.

RESULTS

A total of 16,481 patients were admitted to HV surgeons, and 4,214 patients were admitted to LV surgeons. In all subgroups, HV and LV patients were similar regarding age, sex, physiologic status at admission, injury pattern, and injury severity. Mortality rates for HV and LV surgeons were not significantly different between the two groups in any injury pattern. The z score was 1.88 in the HV patient group versus 0.47 in the LV group.

CONCLUSION

Within a single institution, mortality rates for patients treated by surgeons admitting many severely injured patients were not significantly different from low-volume surgeons' patients, although there was a trend toward higher mortality in the less active surgeons' patients in some subgroups.

Abdominal insufflation for prevention of exsanguination

BACKGROUND

Currently, traumatic intra-abdominal hemorrhage continues unchecked during transport and triage, and a simple technique of prehospital hemostasis might improve outcomes. The hemostatic effect of abdominal hypertension has not been studied.

PURPOSE

To examine the effect of iatrogenic abdominal insufflation on blood loss and hemodynamic performance after major abdominal vascular injury.

METHODS

Following laparotomy, a 2.7 mm hole was created in the inferior vena cava of 10 anticoagulated pigs and controlled with a partially occlusive, laparoscopic vascular clamp. After abdominal closure the clamp was released and the pig was randomized to either control (n = 5) or immediate abdominal CO2 insufflation at 20 cm H2O pressure (n = 5). Lactated Ringer's solution was used as needed to maintain a mean arterial pressure of 60 mm Hg. After 15 minutes of hemorrhage and hemodynamic monitoring, the animals were killed and blood loss measured. Mean blood loss was compared between groups using the Student test, as were final values for physiologic variables. Temporal changes in physiologic parameters were compared using analysis of variance.

RESULTS

Mean blood loss was reduced by 61% in insufflated pigs versus controls (695 +/- 244 versus 1764 +/- 328 cc, p < 0.001). Compared with controls, insufflated pigs had significantly higher mean arterial pressure (64 versus 25 mm Hg, p < 0.001), end-tidal CO2 (40.8 versus 17.8 mm Hg, p < 0.001), and pulmonary capillary wedge pressure (10.2 versus 5.8 mm Hg, p = 0.026) immediately before the pigs were killed.

CONCLUSION

Iatrogenic abdominal insufflation significantly decreased blood loss and improved hemodynamics in a porcine model of traumatic venous hemorrhage. Iatrogenic abdominal insufflation may be useful in the prehospital management of abdominal injury.

Wound Management after Colon Injury: Open or Closed? A Prospective Randomized Trial

It is unknown whether leaving the skin wound open to heal by secondary intention is associated with a lower rate of wound infections compared with primary skin-wound closure after operations for colon injuries. From June 1998 to December 2000 at our Level I academic trauma center 48 patients entered into a randomized controlled trial (RCT) and were randomized to have their skin wound primarily closed (CLOSED-RCT) or left open (OPEN-RCT). At the same time patients not included in the RCT were followed prospectively. At the discretion of the surgeon their skin wounds were managed by primary closure (CLOSED-nonRCT) or were left open (OPEN-nonRCT). Univariate and multivariate analysis was done to identify independent risk factors of wound infection, wound dehiscence, and necrotizing soft tissue infection. Wound infection developed in 65 per cent of CLOSED-RCT and 36 per cent of OPEN-RCT patients ( P = 0.04) and wound dehiscence in 31 per cent and 14 per cent respectively ( P = 0.18). No remarkable differences were noted in any other variable including length of hospital stay. Wound infection developed in 29 per cent of CLOSED-nonRCT and 15 per cent of OPEN-nonRCT patients ( P = 0.46). There were three independent risk factors of wound infection: primary wound closure [odds ratio (OR) = 5.5, 95% confidence interval (CI) = 1.8–19.4], colectomy (OR = 3.4, 95% CI = 1.2–10.4), and intraabdominal infection (OR = 5.3, 95% CI = 1.3–24.2). There were two independent risk factors for wound dehiscence and/or necrotizing soft tissue infection: wound infection (OR = 20.9,95% CI = 4.9–152.3) and intra-abdominal infection (OR = 19.3, 95% CI = 4.0–146.9). Primary closure of the wound almost doubles the rate of wound infection compared with leaving the wound open in operations for colon injuries. Primary wound closure is a risk factor for wound infection and wound infection is a risk factor for wound dehiscence or necrotizing soft tissue infection. Because of the complexity of evaluating the real clinical significance of superficial wound infection larger studies on trauma patients are required.

Wound management after colon injury: open or closed? A prospective randomized trial

It is unknown whether leaving the skin wound open to heal by secondary intention is associated with a lower rate of wound infections compared with primary skin-wound closure after operations for colon injuries. From June 1998 to December 2000 at our Level I academic trauma center 48 patients entered into a randomized controlled trial (RCT) and were randomized to have their skin wound primarily closed (CLOSED-RCT) or left open (OPEN-RCT). At the same time patients not included in the RCT were followed prospectively. At the discretion of the surgeon their skin wounds were managed by primary closure (CLOSED-nonRCT) or were left open (OPEN-nonRCT). Univariate and multivariate analysis was done to identify independent risk factors of wound infection, wound dehiscence, and necrotizing soft tissue infection. Wound infection developed in 65 per cent of CLOSED-RCT and 36 per cent of OPEN-RCT patients (P = 0.04) and wound dehiscence in 31 per cent and 14 per cent respectively (P = 0.18). No remarkable differences were noted in any other variable including length of hospital stay. Wound infection developed in 29 per cent of CLOSED-nonRCT and 15 per cent of OPEN-nonRCT patients (P = 0.46). There were three independent risk factors of wound infection: primary wound closure [odds ratio (OR) = 5.5, 95% confidence interval (CI) = 1.8-19.4], colectomy (OR = 3.4, 95% CI = 1.2-10.4), and intraabdominal infection (OR = 5.3, 95% CI = 1.3-24.2). There were two independent risk factors for wound dehiscence and/or necrotizing soft tissue infection: wound infection (OR = 20.9, 95% CI = 4.9-152.3) and intra-abdominal infection (OR = 19.3, 95% CI = 4.0-146.9). Primary closure of the wound almost doubles the rate of wound infection compared with leaving the wound open in operations for colon injuries. Primary wound closure is a risk factor for wound infection and wound infection is a risk factor for wound dehiscence or necrotizing soft tissue infection. Because of the complexity of evaluating the real clinical significance of superficial wound infection larger studies on trauma patients are required.

All patients with truncal gunshot wounds deserve trauma team activation

BACKGROUND

Traditional criteria for trauma team activation (TTA) include hypotension, tachycardia, tachypnea, and unresponsiveness. In a recent revision of the Resources for Optimal Care of the Trauma Patient, gunshot wound to the trunk (GSWT) was recommended as an independent criterion for major resuscitation and TTA. To validate this suggestion, we reviewed records of patients with GSWT to see if patients not meeting standard TTA criteria had serious injuries that would benefit from TTA.

METHODS

This study was a retrospective trauma registry study at a large Level I trauma center. Records of all patients over an 8.5-year period with GSW to chest, back, or abdomen/pelvis were included in the study. Patients who died in hospital, required ICU admission within 24 hours, had non-orthopedic operation within 24 hours, or had ISS > 15 were considered severely injured, and were assumed to benefit from TTA.

RESULTS

Between January 1993 and June 2000, 4,198 patients were admitted with GSWT, 94% of whom met traditional TTA criteria. Sixty-one percent of patients meeting traditional TTA criteria had severe injury, compared with 45.7% for those without TTA criteria. Of the 234 patients who did not meet traditional TTA criteria, 9.4% required early ICU admission, 29.5% required non-orthopedic operation within 24 hours, and 1.3% died.

CONCLUSION

Patients with GSWT often require high-level care, even when physiologic TTA criteria are absent on admission. Gunshot wound to the trunk should be an independent criterion for TTA.

Is contrast as bad as we think? Renal function after angiographic embolization of injured patients

BACKGROUND

Angiographic embolization (AE) is increasingly used to control bleeding after severe trauma. Serious concerns have been raised about the safety of high-volume i.v. contrast in hypotensive, hypovolemic patients.

STUDY DESIGN

In a prospective cohort study, 100 consecutive trauma patients underwent AE for bleeding in the abdomen and pelvis. Serum creatinine (Cr) levels were measured before the procedure and up to 5 days after the procedure. Contrast nephropathy was defined as an increase in Cr levels after AE of more than 25% over the baseline measurement. An average of 248 +/- 59 mL of nonionic, low-osmolality contrast was used in all cases.

RESULTS

Compared with the baseline, no increase in Cr levels after AE was observed among all patients (1.02 +/- 0.24 versus 0.94 +/- 0.26 mg/dL; p = 0.01) or among subgroups of patients who had any of the following risk factors for renal failure: older than 60 years, Injury Severity Score > or = 15, shock on arrival, renal injury, elevated Cr levels (> or = 1.5 mg/dL) before AE, or administration of a high volume of contrast (> 250 mL). Contrast nephropathy developed in five patients by means of mild Cr elevations. In all of these patients, Cr returned to baseline within 5 days of AE. Renal failure requiring hemodialysis developed at 41 and 55 days after AE in two patients with multiple organ failure who eventually died.

CONCLUSIONS

Administration of nonionic contrast during AE causes mild and transient contrast nephropathy in 5% of severely injured patients. Our study adds additional support for the safety of AE for trauma.

The role of thyroid hormone administration in potential organ donors

HYPOTHESIS

Levothyroxine sodium therapy should be used in brain-dead potential organ donors to reverse hemodynamic instability and to prevent cardiovascular collapse, leading to more available organs for transplantation.

DESIGN

Prospective, before and after clinical study.

SETTING

A surgical intensive care unit of an academic county hospital.

PATIENTS

During a 12-month period (September 1, 1999, through August 31, 2000), we evaluated 19 hemodynamically unstable patients with traumatic and nontraumatic intracranial lesions, who were candidates for organ donation following brain death declaration.

INTERVENTIONS

All patients were resuscitated aggressively for organ preservation by fluids, inotropic agents, and vasopressors. If, despite all measures, the patients remained hemodynamically unstable, a bolus of 1 ampule of 50% dextrose, 2 g of methylprednisolone sodium succinate, 20 U of insulin, and 20 microg of levothyroxine sodium was administered, followed by a continuous levothyroxine sodium infusion at 10 microg/h.

RESULTS

There was a significant reduction in the total vasopressor requirement after levothyroxine therapy (mean +/- SD, 11.1 +/- 0.9 microg/kg per minute vs 6.4 +/- 1.4 microg/kg per minute, P =.02). Ten patients (53%) had complete discontinuation of vasopressors. There were no failures to reach organ donation due to cardiopulmonary arrest.

CONCLUSIONS

Levothyroxine therapy plays an important role in the management of hemodynamically unstable potential organ donors by decreasing vasopressor requirements and preventing cardiovascular collapse. This may result in an increase in the quantity and quality of organs available for transplantation.

Old age as a criterion for trauma team activation

BACKGROUND

Elderly trauma patients have been shown to have a worse prognosis than young patients. Age alone is not a criterion for trauma team activation (TTA). In the present study, we evaluated the role of age > or = 70 years as a criterion for TTA.

METHODS

The present study was a trauma registry study that included injured patients 70 years of age or older. Patients who died in hospital, were admitted to the intensive care unit (ICU) within 24 hours, or had a non-orthopedic operation were assumed to benefit from TTA.

RESULTS

During a 7.5-year period, 883 elderly (> or = 70 years) trauma patients meeting trauma center criteria were admitted to our center. Overall, 223 patients (25%) met at least one of the standard TTA criteria. The mortality in this group was 50%, the ICU admission rate was 39%, and a non-orthopedic operation was required in 35%. The remaining 660 patients (75%) did not meet standard TTA criteria. The mortality was 16%, the need for ICU admission was 24%, and non-orthopedic operations were required in 19%. Sixty-three percent of patients with severe injuries (Injury Severity Score > 15) and 25% of patients with critical injuries (Injury Severity Score > 30) did not have any of the standard hemodynamic criteria for TTA.

CONCLUSION

Elderly trauma patients have a high mortality, even with fairly minor or moderately severe injuries. A significant number of elderly patients with severe injuries do not meet the standard criteria for TTA. It is suggested that age > or = 70 years alone should be a criterion for TTA.

TRISS methodology: an inappropriate tool for comparing outcomes between trauma centers

BACKGROUND

The TRISS methodology has been used for comparison of survival outcomes between trauma centers. The purpose of this study was to evaluate the role of TRISS in comparing outcomes between a small and a large trauma center and evaluate its usefulness in various groups of patients.

STUDY DESIGN

Trauma registry study that compared the survival outcomes between a large academic level I trauma center and a small community level II center. The comparison was made with the standard TRISS probability of survival, M value, and Z score. In the second part of the study the patients from the small center were matched for age, gender, injury severity score, Glasgow Coma Scale, head Abbreviated Injury Score, BP, prehospital respiratory assistance, and transport mode with an equal number of patients from the large center. The Z scores were calculated for each center. In the third part of the study the TRISS usefulness and limitations were evaluated in various subgroups of patients by calculating its sensitivity, specificity, positive predictive value, negative predictive value, and misclassification rate.

RESULTS

The Z value of the large center (3,315 patients) was 2.24, indicating a considerably higher mortality than expected when compared with the Major Trauma Outcomes Study population. The Z value of the small center (331 patients) was -0.92, indicating fewer than the Major Trauma Outcomes Study expected deaths. In the second part of the study, 297 patients from the small center were matched with an equal number from the large center. The Z scores were -0.40 and -0.95, respectively, indicating slightly better outcomes than those of the Major Trauma Outcomes Study. Additional evaluation of the TRISS prediction of survival in various subgroups of patients showed a high misclassification rate in severe trauma, in some groups higher than 25%.

CONCLUSIONS

The TRISS methodology is not a reliable tool for comparing outcomes between trauma centers and has an unacceptably high misclassification rate in patients with severe trauma.