Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society

BACKGROUND

Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia.

METHODS

Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used.

RESULTS

Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality.

CONCLUSION

We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level IV.

Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.

Survey of surgical critical care applicant and program director views on virtual interviews for fellowship training: a Surgical Critical Care Program Directors Society sponsored study

Background

The COVID-19 pandemic forced postgraduate interview processes to move to a virtual platform. There are no studies on the opinions of faculty and applicants regarding this format. The aim of this study was to assess the opinions of surgical critical care (SCC) applicants and program directors regarding the virtual versus in-person interview process.

Methods

An anonymous survey of the SCC Program Director’s Society members and applicants to the 2019 (in-person) and 2020 (virtual) interview cycles was done. Demographic data and Likert scale based responses were collected using Research Electronic Data Capture.

Results

Fellowship and program director responses rates were 25% (137/550) and 58% (83/143), respectively. Applicants in the 2020 application cycle attended more interviews. The majority of applicants (57%) and program faculty (67%) strongly liked/liked the virtual interview format but felt an in-person format allows better assessment of the curriculum and culture of the program. Both groups felt that an in-person format allows applicants and faculty to establish rapport better. Only 9% and 16% of SCC program directors wanted a purely virtual or purely in-person interview process, respectively. Applicants were nearly evenly split between preferring a purely in-person versus virtual interviews in the future.

Discussion

The virtual interview format allows applicants and program directors to screen a larger number of programs and applications. However, the virtual format is less useful than an in-person interview format for describing unique aspects of a training program and for allowing faculty and applicants to establish rapport. Future strategies using both formats may be optimal, but such an approach requires further study.

Level of evidence

Epidemiologic level IV

Mortality in hypotensive trauma patients requiring laparotomy is related to degree of hypotension and provides evidence for focused interventions

Background

Mortality in hypotensive patients requiring laparotomy is reported to be 46% and essentially unchanged in 20 years. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been incorporated into resuscitation protocols in an attempt to decrease mortality, but REBOA can have significant complications and its use in this patient group has not been validated. This study sought to determine the mortality rate for hypotensive patients requiring laparotomy and to evaluate the mortality risk related to the degree of hypotension. Additionally, this study sought to determine if there was a presenting systolic blood pressure (SBP) that was associated with a sharp increase in mortality to target the appropriate patient group most likely to benefit from focused interventions such as REBOA.

Methods

The trauma registry at a level I trauma center was reviewed for patients undergoing emergent laparotomy from January 2007 to June 2020. Data included demographics, mechanism of injury, physiological data, Injury Severity Score, blood products transfused, and outcomes. Group comparisons were based on initial SBP (0 to 50 mm Hg, 60 to 69 mm Hg, 70 to 79 mm Hg, 80 to 89 mm Hg, and ≥90 mm Hg).

Results

During the study period, 52 016 trauma patients were treated and 1174 required laparotomy within 90 min of arrival; 424 had an initial SBP of <90 mm Hg. The overall mortality rate was 18%, but mortality increased as SBP decreased (≥90=9%, 80 to 89=20%, 70 to 79=21%, 60 to 69=48%, 0 to 59=66%). Mortality increased sharply with SBP of <70 mm Hg.

Discussion

Mortality rate increases with worsening hypotension and increases sharply with an SBP of <70 mm Hg. Further study on focused interventions such as REBOA should target this patient group.

Level of evidence

Therapeutic/care management, level III.

Admission base deficit is superior to lactate in identifying shock and resuscitative needs in trauma patients

BACKGROUND

Base Deficit (BD) and lactate have been used as indicators of shock and resuscitation. This study was done to evaluate the utility of BD and lactate in identifying shock and resuscitative needs in trauma patients.

METHODS

A prospective observational study was performed from 3/2014-12/2018. Data included demographics, admission systolic BP, ISS, BD, lactate, blood transfusion, and outcomes. BD and lactate were modeled continuously and categorically and compared.

RESULTS

2271 patients were included. BD and lactate were moderately correlated (r² = 0.63 p < 0.001). On univariate regression, BD and lactate were associated with transfusion requirement and mortality (p < 0.001), but on multivariate regression, only BD was associated with transfusion requirement and mortality (OR = 1.2, p < 0.001; OR = 1.1, p < 0.001, respectively). BD discriminated better than lactate for hypotension, higher ISS, increased transfusion requirements and mortality.

CONCLUSIONS

Admission BD and lactate levels are correlated following injury, but BD is superior to lactate in identifying shock, resuscitative needs and mortality in severely injured trauma patients.

After the embo: predicting non-hemorrhagic indications for splenectomy after angioembolization in patients with blunt trauma

Background

Successful non-operative management (NOM) of blunt splenic trauma is enhanced with splenic angioembolization (SAE). Patients may still require splenectomy post-SAE for splenic infarction/necrosis. Prior studies have used white blood cell count (WBC), platelet count (PLT), and PLT:WBC ratio after splenectomy to predict complications, but none have evaluated these findings prior to splenectomy in patients who have undergone SAE. Changes in these values may indicate clinically significant splenic infarction, facilitating management of these patients.

Methods

Patients admitted to an American College of Surgeons verified level 1 trauma center from January 2007 to August 2017 who underwent SAE were identified. Patients with successful NOM after SAE (SAE/NOM) were compared with those requiring splenectomy (SAE/SPLEN). Data included demographics, splenic injury grade, Injury Severity Score (ISS), time to SAE and splenectomy, intensive care unit and hospital length of stay (LOS), and complete blood count. Lab values were analyzed immediately post-SAE (time 1) and day 5 post-SAE (or day of discharge) for SAE/NOM patients and day of SPLEN for SAE/SPLEN patients (time 2). Data were analyzed using Mann-Whitney U, χ² tests, and receiver operating characteristic (ROC) curves with significance attributed to P<0.05.

Results

Of 124 patients undergoing SAE, 16 (13%) later required SPLEN for infarction/necrosis at a median of 5 days post-SAE (IQR: 3–10 days). SAE/SPLEN and SAE/NOM patients did not differ by age, gender, ISS, or grade of splenic injury. SAE/SPLEN patients had longer hospital LOS (23 vs. 10 days, P<0.001). WBC, PLT, and PLT:WBC ratio did not differ between the groups at time 1. At time 2, WBC was higher and PLT:WBC ratio was lower in SAE/SPLEN patients. Using ROC curves at time 2, the area under the curve was 0.90 (P<0.001) for WBC and 0.71 (P<0.007) for PLT:WBC ratio.

Discussion

Patients requiring splenectomy for clinically significant infarction/necrosis after SAE develop leukocytosis and decreased PLT:WBC ratio when compared with SAE/NOM patients. Monitoring these parameters allows more prompt diagnosis and operative intervention.

Level of evidence

Therapeutic/care management, level III.

Base deficit is superior to lactate in trauma

BACKGROUND

Base Deficit (BD) and lactate have been used as indicators of shock and resuscitation. This study was done to determine the association of BD and lactate and to determine if one is superior.

METHODS

A retrospective review from 3/2014-12/2016 was performed. Data included demographics, systolic BP, ISS, BD, lactate, blood transfusion, and outcomes. BD and lactate were modeled continuously and categorically and compared.

RESULTS

1191 patients were included. BD and lactate correlated strongly (r = -0.76 p < 0.001). Higher lactate and more negative BD were associated with transfusion and mortality. On multivariate regression, only BD was associated with transfusion (OR = 0.8, p < 0.001). As a categorical variable, worsening BD was associated with decreased BP, higher ISS, increased transfusions and worse outcomes.

CONCLUSIONS

BD and lactate are strongly related. BD was superior to lactate in assessing the need for transfusion. The BD categories discriminate high risk trauma patients better than lactate.

Current outcomes of blunt open pelvic fractures: how modern advances in trauma care may decrease mortality

Background

Open pelvic fracture, caused by a blunt mechanism, is an uncommon injury with a high mortality rate. In 2008, evidence-based algorithm for managing pelvic fractures in unstable patients was published by the Western Trauma Association (WTA). The use of massive transfusion protocols has become widespread as has the availability and use of pelvic angiography. The purpose of this study was to evaluate the outcome of open pelvic fractures in association with related advances in trauma care.

Methods

A retrospective review was performed, at an American College of Surgeon verified level I trauma center, of patients with blunt open pelvic fractures from January 2010 to April 2016. The WTA algorithm, including massive transfusion protocol, and pelvic angiography were uniformly used. Data collected included injury severity score, demographic data, transfusion requirements, use of pelvic angiography, length of stay, and disposition. Data were compared with a similar study from 2005.

Results

During the study period, 1505 patients with pelvic fractures were analyzed; 87 (6%) patients had open pelvic fractures. Of these, 25 were from blunt mechanisms and made up the study population. Patients in both studies had similar injury severity scores, ages, Glasgow Coma Scale, and gender distributions. Use of angiography was higher (44% vs. 16%; P=0.011) and mortality was lower (16% vs. 45%; P=0.014) than in the 2005 study.

Conclusions

Changes in trauma care for patients with open blunt pelvic fracture include the use of an evidence-based algorithm, massive transfusion protocols and increased use of angioembolization. Mortality for open pelvic fractures has decreased with these advances.

Level of evidence

Level IV.

Competence not Age Determines Ability to Practice: Ethical Considerations about Sensorimotor Agility, Dexterity, and Cognitive Capacity

Consideration of the effects of aging on physicians' practice is crucial to addressing aging clinicians' competence, that is, their ability to practice with reasonable skill and safety. Given physician workforce shortages even in resource abundant countries, the establishment of a compulsory retirement age in the US is impractical and unlikely. Several US hospitals and institutions have sought to address concerns about competence by establishing mandatory age-linked testing and evaluation for physicians. However, these procedures have raised questions regarding age discrimination and test validity.

Time is now: venous thromboembolism prophylaxis in blunt splenic injury

BACKGROUND

The safety and timing of venous thromboembolism (VTE) prophylaxis in patients with blunt splenic injuries is not well known. We hypothesized that early initiation of VTE prophylaxis does not increase failure of nonoperative management or transfusion requirements in these patients.

METHODS

A retrospective review of trauma patients with blunt splenic injury was performed. Patients were compared based on initiation and timing of VTE prophylaxis (<24 hours, 24 to 48 hours, 48 to 72 hours, and >72 hours). Patients who received VTE prophylaxis were matched with those who did not. Primary outcomes included were operation or angioembolization.

RESULTS

A total of 497 patients (256 received VTE prophylaxis and 241 did not) were included. There was no difference in the number of interventions based on presence of or time to VTE prophylaxis initiation.

CONCLUSIONS

Early initiation (<48 hours) of VTE prophylaxis is safe in patients with blunt splenic injuries treated nonoperatively, and may be safe as early as 24 hours.

An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons

OBJECTIVE

Evaluate the utility of a computer-based, interactive, and individualized intervention for promoting well-being in US surgeons.

BACKGROUND

Distress and burnout are common among US surgeons. Surgeons experiencing distress are unlikely to seek help on their own initiative. A belief that distress and burnout are a normal part of being a physician and lack of awareness of distress level relative to colleagues may contribute to this problem.

METHODS

Surgeons who were members of the American College of Surgeons were invited to participate in an intervention study. Participating surgeons completed a 3-step, interactive, electronic intervention. First, surgeons subjectively assessed their well-being relative to colleagues. Second, surgeons completed the 7-item Mayo Clinic Physician Well-Being Index and received objective, individualized feedback about their well-being relative to national physician norms. Third, surgeons evaluated the usefulness of the feedback and whether they intended to make specific changes as a result.

RESULTS

A total of 1150 US surgeons volunteered to participate in the study. Surgeons' subjective assessment of their well-being relative to colleagues was poor. A majority of surgeons (89.2%) believed that their well-being was at or above average, including 70.5% with scores in the bottom 30% relative to national norms. After receiving objective, individualized feedback based on the Mayo Clinic Physician Well-Being Index score, 46.6% of surgeons indicated that they intended to make specific changes as a result. Surgeons with lower well-being scores were more likely to make changes in each dimension assessed (all Ps<0.001).

CONCLUSIONS

US surgeons do not reliably calibrate their level of distress. After self-assessment and individualized feedback using the Mayo Clinic Physician Well-Being Index, half of participating surgeons reported that they were contemplating behavioral changes to improve personal well-being.

Post-extubation dysphagia in trauma patients: it's hard to swallow

BACKGROUND

There is a significant incidence of unrecognized postextubation dysphagia in trauma patients. The purpose of this study was to evaluate the incidence, ascertain the risk factors, and identify patients with postextubation dysphagia who will require clinical swallow evaluation.

METHODS

A prospective observational study was performed on 270 trauma patients. Bedside clinical swallow evaluation was done within 24 hours of extubation. Logistic regression analysis was used to adjust for confounding variables.

RESULTS

The incidence of oropharyngeal dysphagia (OD) in our study was 42%. Ventilator days was the strongest independent risk factor for OD (3.6 vs 8.0, P < .001). The odds ratio showed a 25% risk for OD for each additional ventilator day. Silent aspiration was found in 37% of patients with OD.

CONCLUSIONS

Trauma patients requiring mechanical ventilation for ≥2 days are at increased risk for dysphagia and should undergo routine swallow evaluations after extubation.

Prevalence of alcohol use disorders among American surgeons

OBJECTIVES

To determine the point prevalence of alcohol abuse and dependence among practicing surgeons.

DESIGN

Cross-sectional study with data gathered through a 2010 survey.

SETTING

The United States of America.

PARTICIPANTS

Members of the American College of Surgeons.

MAIN OUTCOME MEASURES

Alcohol abuse and dependence.

RESULTS

Of 25,073 surgeons sampled, 7197 (28.7%) completed the survey. Of these, 1112 (15.4%) had a score on the Alcohol Use Disorders Identification Test, version C, consistent with alcohol abuse or dependence. The point prevalence for alcohol abuse or dependence for male surgeons was 13.9% and for female surgeons was 25.6%. Surgeons reporting a major medical error in the previous 3 months were more likely to have alcohol abuse or dependence (odds ratio, 1.45; P < .001). Surgeons who were burned out (odds ratio, 1.25; P = .01) and depressed (odds ratio, 1.48; P < .001) were more likely to have alcohol abuse or dependence. The emotional exhaustion and depersonalization domains of burnout were strongly associated with alcohol abuse or dependence. Male sex, having children, and working for the Department of Veterans Affairs were associated with a lower likelihood of alcohol abuse or dependence.

CONCLUSIONS

Alcohol abuse and dependence is a significant problem in US surgeons. Organizational approaches for the early identification of problematic alcohol consumption followed by intervention and treatment where indicated should be strongly supported.

Prehospital Hypoxia Affects Outcome in Patients With Traumatic Brain Injury: A Prospective Multicenter Study

BACKGROUND

The goals of this study were to determine the incidence and duration of hypotension and hypoxia in the prehospital setting in patients with potentially survivable brain injuries, and to prospectively examine the association of these secondary insults with mortality and disability at hospital discharge.

METHODS

Trauma patients with suspected brain injuries underwent continuous blood pressure and pulse oximetry monitoring during helicopter transport. Postadmission inclusion criteria were (1) diagnosis of acute traumatic brain injury (TBI) confirmed by computed tomography (CT) scan, operative findings, or autopsy findings; and (2) Head Abbreviated Injury Scale (AIS) score of > or = 3 or Glasgow Coma Scale (GCS) score of < or = 12 within the first 24 hours of admission. Patients were excluded with (1) no abnormal intracranial findings on the patient's CT scan; (2) determination of a nonsurvivable injury (based on an AIS score of 6 for any body region; or, (3) death in less than 12 hours after injury. Primary outcome measures included mortality and Disability Rating Scale score at discharge.

RESULTS

We enrolled 150 patients into the study. Fifty-seven patients had at least one secondary insult; 37 had only hypoxic episodes, 14 had only hypotensive episodes, and 6 patients had both. Demographics and injury characteristics did not differ between those with and those without secondary insults. The mortality for patients without secondary insults was 20%, compared with 37% for patients with hypoxic episodes, 8% for patients with hypotensive episodes, and 24% for patients with both. The Disability Rating Scale score at discharge was significantly higher in patients with secondary insults. Using multivariate analysis, the calculated odds ratio of mortality caused by prehospital hypoxia after head injury was 2.66 (p < 0.05).

CONCLUSIONS

Secondary insults after TBI are common, and these insults are associated with disability. Hypoxia in the prehospital setting significantly increases the odds of mortality after brain injury controlled for multiple variables.

The Association between Chance Fractures and Intra-abdominal Injuries Revisited: A Multicenter Review

The association between Chance fractures and intra-abdominal injuries is reported to be as high as 89 per cent. Because prior studies were small series or case reports, we conducted a multicenter review to learn the true association between Chance fractures and intra-abdominal injuries as well as diagnostic trends. Trauma registry data, medical records, and radiology reports from 7 trauma centers were used to characterize 79 trauma patients with Chance fractures. Initial methods of abdominal assessment were computed tomography (CT) scan (79%), clinical examination (16%), and diagnostic peritoneal lavage (DPL) (5%). Twenty-six (33%) patients had intraabdominal injuries of which hollow viscus injuries predominated (22%). Twenty patients (25%) underwent laparotomy. The presence of an abdominal wall contusion and automobile restraint use were highly predictive of intra-abdominal injury and the need for laparotomy. The association between a Chance fracture and intra-abdominal injury is not as high as previously reported. CT scan has become the primary modality to assess the abdominal cavity of patients with Chance fractures, whereas the role of DPL has diminished.

The association between Chance fractures and intra-abdominal injuries revisited: a multicenter review

The association between Chance fractures and intra-abdominal injuries is reported to be as high as 89 per cent. Because prior studies were small series or case reports, we conducted a multicenter review to learn the true association between Chance fractures and intra-abdominal injuries as well as diagnostic trends. Trauma registry data, medical records, and radiology reports from 7 trauma centers were used to characterize 79 trauma patients with Chance fractures. Initial methods of abdominal assessment were computed tomography (CT) scan (79%), clinical examination (16%), and diagnostic peritoneal lavage (DPL) (5%). Twenty-six (33%) patients had intraabdominal injuries of which hollow viscus injuries predominated (22%). Twenty patients (25%) underwent laparotomy. The presence of an abdominal wall contusion and automobile restraint use were highly predictive of intra-abdominal injury and the need for laparotomy. The association between a Chance fracture and intra-abdominal injury is not as high as previously reported. CT scan has become the primary modality to assess the abdominal cavity of patients with Chance fractures, whereas the role of DPL has diminished.

Placement of Intracranial Pressure Monitors: Are ???Normal??? Coagulation Parameters Necessary?

INTRODUCTION

Patients with head injuries frequently have abnormal coagulation studies. Monitoring intracranial pressure (ICP) in head injured patients is common practice, but no best practice guidelines exist for coagulation parameters for ICP monitor placement.

PURPOSE

To test the hypothesis that hemorrhagic complication rates from ICP monitor placement are low and that the use of FFP to correct coagulation parameters to "normal" is not indicated.

METHODS

Retrospective review of all patients admitted to a Level I trauma center over a 3 year period, who underwent fiberoptic intraparenchymal ICP monitoring was undertaken. Inclusion criteria were coagulation studies (prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), platelet count) before ICP monitor placement and head CT scans to assess for hemorrhage before and after monitor placement. Data collected included age, Glasgow coma score (GCS), head region abbreviated injury score (H_AIS), time to ICP monitor placement, complications and outcomes.

RESULTS

From 8/1/00 through 7/31/03, 5163 trauma patients were admitted, and 157 met inclusion criteria. Patients were stratified by INR, at the time of ICP placement as normal (0.8-1.2, 103 patients), borderline (1.3-1.6, 42 patients) and increased (>/=1.7, 12 patients). There was no difference between the groups in age, gender or H_AIS. Twenty two patients had component therapy to correct coagulopathy before ICP insertion, but 10 had INRs in the borderline group and 12 remained with INRs >/=1.7. Eleven patients had platelet counts 50,000-100,000 at ICP monitor placement, despite platelet transfusions. Time from admission to ICP monitor placement was significantly longer in patients who received component therapy (19.2 +/- 19.7 hours versus 8.8 +/- 13.9 hours, p < 0.002). Three patients had clinically insignificant, petechial hemorrhages (1.9%); one in each group, with INRs of 1.2, 1.3, and 2.5, respectively.

CONCLUSIONS

In patients with INR </=1.6, hemorrhagic complications after ICP monitor placement were infrequent. The use of FFP to "normalize" INR below this threshold is not supported by this data and delays monitor placement.

Routinely Repeated Computed Tomography after Blunt Head Trauma: Does it Benefit Patients?

BACKGROUND

Computed tomography of the head (HCT) is an integral part of the diagnosis and management of the patient with head injury, but the utility of repeated HCT performed solely for routine follow-up in the patient with blunt head trauma has not been defined. In the absence of clinical indications, routinely repeated HCT, even in patients with significant brain injury, does not contribute to patient care.

METHODS

Trauma registry records at a Level I trauma center from July 1, 1997, to June 30, 2002, were reviewed. Patients with severe blunt head injury (Abbreviated Injury Scale score > or = 3) admitted to the intensive care unit and who had a repeat HCT scan obtained for scheduled follow-up were included. Those patients with initial craniotomy, repeat HCT more than 72 hours after the initial HCT, or repeat HCT ordered for clinical indications were excluded. Data included were age, mechanism of injury, time to initial (HCT1) and repeat HCT (HCT2), indications for HCT2, and HCT findings. Additional data included Glasgow Coma Scale (GCS) score (admission and at HCT2); Injury Severity Score; occurrence of hypotension, coagulopathy, or elevated intracranial pressure (ICP); interventions made; and patient outcome.

RESULTS

Entry criteria were met in 462 patients. Most were injured in motor vehicle crashes; the average age was 36 years and the mean initial GCS score was 9. The mean time to HCT1 was 1.3 hours and the mean time to HCT2 was 22.6 hours. HCT2 showed worsening in 85 patients (18.4%), and 16 patients had interventions in response to HCT2 (repeat HCT in 8, ICP monitoring or drainage in 6, and craniotomy in 2). No patient undergoing routine repeat HCT without other clinical findings required intervention. All patients with worsening HCT findings requiring intervention had coagulopathy, hypotension, ICP elevation, or marked decrease in GCS score.

CONCLUSION

In the absence of clinical indicators or risk factors, repeat HCT after blunt head injury does not alter patient management and is unnecessary.

Are Automated Blood Pressure Measurements Accurate in Trauma Patients?

BACKGROUND

Automated blood pressure (BP) determinations by oscillometry are reported to be as accurate as invasive monitoring for systolic pressures as low as 80 mm Hg. Automated BP devices are widely used by prehospital providers and in hospital operating rooms, emergency departments, and intensive care units, although the accuracy of automated BP has not been demonstrated in trauma patients. We hypothesized that automated BP is less accurate than manual BP in trauma patients. The purpose of this study was to determine the accuracy of automated BP versus manual BP in trauma patients.

METHODS

A retrospective review of patients who met trauma activation criteria admitted to a Level I trauma center over a 30-month period was conducted. Patients were included if both manual BP and automated BP were measured within 5 minutes of admission. Additional data collected included Injury Severity Score, base deficit, and emergency department resuscitation volume. Statistical analysis was performed using paired t test, chi2, and linear regression analysis. Significance was attributed to a value of p < 0.05.

RESULTS

From January 2000 through June 2002, 388 patients met inclusion criteria. Patients were grouped by manual BP levels: group 1, BP < or = 90 mm Hg (n = 92); group 2, BP 91-110 mm Hg (n = 119); and group 3, BP > or = 110 mm Hg (n = 177). The mean automated BP measurements were significantly higher than the manual measurements in groups 1 and 2 (26 and 16 mm Hg, respectively; p < 0.001). Of the 92 patients with manual BP < or = 90, 45 (49%) had automated BP > or = 100. The base deficit (-5, -3, and -2 for groups 1, 2, and 3, respectively; p < 0.01), Injury Severity Score (30, 25, and 18; p < 0.01), and volume of resuscitative fluid and blood (p < 0.001) all decreased with higher BP group.

CONCLUSION

Injury severity, degree of acidosis, and resuscitation volume were more accurately reflected by manual BP. Automated BP determinations were consistently higher than manual BP, particularly in hypotensive patients. Automated BP devices should not be used for field or hospital triage decisions. Manual BP determinations should be used until systolic blood pressure is consistently > or = 110 mm Hg.

Victims of domestic violence on the trauma service: unrecognized and underreported

BACKGROUND

Domestic violence (DV) has received increased recognition as a significant mechanism of injury. To improve awareness about DV at our institution, an educational program was presented to the departments of surgery and emergency medicine. Pre and posttests were given and improvement in knowledge was demonstrated. In addition, a screening question for DV was added to the trauma history and physical (H & P) form. This study was done to determine the long-term efficacy of these efforts in increasing recognition of DV and referral to social services in patients admitted to the trauma service. Recognition of DV and appropriate referral should be increased after education and change in H & P form.

METHODS

All patients admitted to the trauma service at a Level I trauma center over a 10 month period with the mechanism of injury "assault" were reviewed. DV was determined to be present, likely, unknown, or absent based on information from the prehospital report and medical records. The DV screen question was reviewed for use and accuracy.

RESULTS

During the study period, 1,550 patients were admitted to the trauma service, with assault listed as the mechanism of injury for 217 (14%). DV was confirmed or likely in 27 patients (12.4% of the assaults). Of patients with confirmed or likely DV, only 7 received appropriate referrals, with 2 generated by the nursing staff. Of the confirmed and likely DV patients, 17 (63%) were sent home without investigation of safety and only 21% of all assault victims had any social services evaluation (usually to investigate funding or placement). The DV screen was used in only 12 patients. Reasons given for failure to complete the DV screen on the H & P included examiner discomfort in asking the question, and an environment judged to be inappropriate (resuscitation area in the emergency department).

CONCLUSION

DV is unrecognized and underreported. Efforts to improve recognition and reporting of DV events need to be ongoing. Screening for DV is not effectively done as part of the initial evaluation. Assessment for DV may be more appropriate as part of the tertiary survey.

Motor vehicle restraints: primary versus secondary enforcement and ethnicity

BACKGROUND

Efforts to increase motor vehicle restraint use have been broadly based rather than focused on specific populations. Identifying specific issues, including populations with low restraint use, can help target educational campaigns. Previous studies have reported differences in restraint use by ethnicity. This study was performed to determine whether differences exist in motor vehicle restraint use by ethnicity and whether these differences are altered by the presence of primary versus secondary restraint laws.

METHODS

Data were collected on motor vehicle crash victims admitted to two Level I trauma centers from October 1, 1997, through March 31, 1998; one in a state with primary restraint enforcement (motorist can be stopped for the restraint violation), the other with a secondary restraint law (restraint violation may be enforced if the motorist is stopped for another violation). Data were obtained concurrently with hospitalization and entered into computerized trauma registry databases.

RESULTS

Restraint use in all motor vehicle crash victims was significantly different between the primary and secondary enforcement states (58% vs. 37%, p < 0.001). Additionally, restraint use varied markedly by ethnicity in the secondary enforcement state (Caucasian, 42%; vs. African-American, 21%, and Hispanic, 26%, p < 0.02, chi(2)). Comparison of restraint use in primary versus secondary enforcement states demonstrated significantly increased restraint use in all ethnic groups (p < 0.01).

CONCLUSION

In a state with secondary enforcement laws, restraint use varied significantly with ethnicity. Restraint use was markedly increased in all ethnic groups by the presence of a primary enforcement law. Implementation and enforcement of primary restraint laws is essential to improving motor vehicle restraint use. Educational campaigns to increase restraint use need to target specific populations.

Delayed pulmonary hemorrhage 17 years after gunshot wound to the chest

A 45-year-old male returned 17 years after a gunshot wound to the chest with intermittent hemoptysis that progressed to frank pulmonary hemorrhage. The complications of retained intrathoracic foreign bodies are briefly reviewed.

Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal

BACKGROUND

The mechanism for clearing the cervical spine in patients with altered mental status remains controversial. Recommendations have ranged from removal of the cervical collar after 24 hours in patients with normal radiographs, to indefinite immobilization in a cervical collar, and recently cervical flexion-extension examinations using dynamic fluoroscopy. The purpose of this study was to evaluate the efficacy and safety of dynamic fluoroscopy flexion-extension examinations in identifying ligamentous cervical spine injury and clearing the cervical spine in patients with altered mental status after trauma.

METHODS

Patients with a Glasgow Coma Scale score < 13 for greater than 48 hours after admission and normal cervical spine radiographs were candidates for fluoroscopic evaluation. The protocol required visualization of the entire cervical spine, through T1, through full extension and flexion under the direct supervision of a radiologist. Oblique fluoroscopic views were obtained, as necessary, to visualize the cervicothoracic junction. Demographic data, fluoroscopy time, total time per study, true and false positives and negatives, and complications were recorded.

RESULTS

From July 1992 through December 1999, fluoroscopic examinations were performed on 301 patients. There were 297 true-negative examinations, 2 true-positive examinations (stable injuries), 1 false-negative examination, and 1 false-positive examination. The incidence of ligamentous injury identified by fluoroscopy in this study was 2 of 301 (0.7%). Unstable cervical spine ligamentous injuries were identified in only 0.02% of all trauma patients. One patient developed quadriplegia when fluoroscopic evaluation was performed after two protocol violations.

CONCLUSION

Unstable cervical spine ligamentous injury without fracture is a rare occurrence. The cervical spine may be cleared after a normal cervical spine series (plain radiograph and computed tomographic scan) as recommended in the 1998 Eastern Association for the Surgery of Trauma guidelines. If dynamic fluoroscopy is to be used, adherence to the protocol, including review of the cervical spine radiographs before fluoroscopy and visualization of the entire cervical spine, C1-T1, is mandatory to ensure patient safety.

Domestic violence and the trauma surgeon: results of a study on knowledge and education

BACKGROUND

Despite the frequency of domestic violence in trauma patients, little emphasis has been placed on this subject in the education of surgeons and emergency medicine physicians. The 1997 Advanced Trauma Life Support (ATLS) course included, for the first time, education about domestic violence. This study was done to test the hypothesis that baseline knowledge about domestic violence in trauma care providers is poor and is not improved by the 1997 ATLS course.

STUDY DESIGN

A study on domestic violence was designed using attending general surgeons, general surgery and emergency medicine residents, and medical students as test subjects. An educational lecture and pre- and post-tests were developed using the Eastern Association for the Surgery of Trauma position paper on domestic violence and other peer-reviewed literature as information sources. Data collected included level of training, date ATLS course was taken, and pre- and post-test scores. Statistical analysis was performed with ANOVA, with significance attributed to p < 0.05.

RESULTS

Ninety-two subjects attended the lecture and completed the pre- and post-tests. The overall mean pre-test score was 54 +/- 1. There was no difference in scores for the 1997 ATLS cohort (with domestic violence material) versus the group with earlier ATLS courses (52 +/- 2 versus 51 +/- 1). The group that had never taken ATLS scored significantly better on the pre-test than the other groups (58 +/- 2, p < 0.05). All groups had significantly increased scores on the post-test (mean 77 < 1, p < 0.001 versus pre-test).

CONCLUSIONS

Baseline knowledge about domestic violence among surgeons and emergency medicine physicians was poor and was not improved by participation in the 1997 ATLS course. This study strongly supports the need for expanded domestic violence education for trauma care providers.

Pediatric restraint use in motor vehicle collisions: reduction of deaths without contribution to injury

HYPOTHESIS

Restraint use for children in automobiles is mandated in every state, but injury patterns are unknown. Although use of pediatric retraints is associated with reducing morbidity and mortality, the injury distribution for specific anatomic sites may be altered in restrained vs unrestrained children.

DESIGN

Review of trauma registry data, medical records, and autopsy findings.

SETTING

Urban level I trauma center and tertiary care children's hospital.

PATIENTS

All children aged 6 years or younger who were in motor vehicle collisions from June 1, 1990, through March 31, 1997.

MAIN OUTCOME MEASURES

Age, weight, restraint use and type, collision data, Injury Severity Score (ISS), injury type, and outcome.

RESULTS

We included 600 children. The restrained group showed a reduction in severe injuries for every anatomic site and had a lower mean ISS, fewer injuries, and more uninjured children. The restrained group also had a reduction in the incidence of hollow- and solid-organ abdominal injuries.

CONCLUSIONS

Age-appropriate restraint devices decrease mortality and reduce the incidence of significant injury in motor vehicle collisions for all anatomic sites in young children. In contrast to injuries attributed to restraint use in adults, specific restraint-related injury patterns were not seen in children.

Pregnant women and car restraints: beliefs and practices

OBJECTIVE

Motor vehicle collisions are a leading cause of death and disability in pregnant women. The purpose of this study was to examine current restraint practices by pregnant women. Additionally, the beliefs and knowledge of pregnant women about restraint laws and effectiveness were studied.

METHODS

From May of 1997 to January of 1998, women were surveyed at initial prenatal visit at four obstetrical clinics. Data collected included age, gravida, ethnicity, educational level attained, payor source, restraint use, and knowledge of effectiveness of restraint use.

RESULTS

A total of 807 women completed surveys. Most always wore restraints before pregnancy, but increased restraint use during pregnancy (79% vs. 86%, chi2, p = 0.02). Only 52% used restraints properly. Significantly fewer women believed restraints were beneficial to mother and fetus in late pregnancy compared with early pregnancy. Only 21% of women were educated on proper restraint use during pregnancy. Comparison by payor mix showed no difference in use or education received.

CONCLUSIONS

Most women use restraints and continue to do so during pregnancy, but they use them improperly. Pregnant women are familiar with mandatory restraint laws but are less informed about restraint use in pregnancy. Few women receive education from health care providers about proper restraint use. This study highlights the need for aggressive educational efforts to improve car restraint use in pregnant women, thereby reduce maternal and fetal injury and death.

Base deficit in the elderly: a marker of severe injury and death

BACKGROUND

Base deficit has been used as a marker of significant injury and to predict resource utilization and mortality. The significance of base deficit in trauma patients 55 years and older has not been specifically evaluated. The purpose of this study was to determine the utility of base deficit in assessing older trauma patients versus a younger cohort.

METHODS

Data were obtained from the trauma registry on trauma patients admitted to a Level I trauma center. Arterial blood gases were obtained within 1 hour of arrival, by protocol, in 2,631 patients, and of these, 274 patients were 55 years or older. Data are presented as means+/-SEM. Statistical analysis was done by paired t test, analysis of variance, and chi2 analysis. Significance was attributed to a p value < 0.05.

RESULTS

Patients older than 55 years were significantly more likely to have sustained blunt trauma (86 vs. 69%; p < 0.001). Despite similar Injury Severity Scores and base deficit values, older patients had markedly greater mortality and intensive care unit lengths of stay. A base deficit of < or = -6 had positive predictive values for Injury Severity Scores > or = 16 for 76% of patients younger than 55 years and 78 % of patients 55 years and older. The negative predictive value of a normal base deficit for Injury Severity Scores < or = 16 was 60% for the younger cohort and only 40% for patients 55 years and older (p < 0.001; chi2).

CONCLUSIONS

A base deficit of < or = -6 is a marker of severe injury and significant mortality in all trauma patients, but it is particularly ominous in patients 55 years and older. Patients older than 55 years may have significant injuries and mortality risk without manifesting a base deficit out of the normal range.

Intracranial pressure monitor placement by midlevel practitioners

BACKGROUND

The timely treatment of patients with head injuries is affected by the availability and commitment of neurosurgeons. Use of midlevel practitioners (MLPs) may permit more efficient neurosurgical coverage. Intracranial pressure monitoring is among the most frequently used neurosurgical procedures. The purpose of this study was to examine the placement of intracranial pressure (ICP) monitors by MLPs.

METHODS

Medical records and trauma registry data for a Level I trauma center were reviewed from December 1993 to June 1997. Patients who had ICP monitors placed were included. Patient data recorded were age, mechanism of injury, injury type, ICP monitor placement and length of placement, complications related to the ICP monitor, and outcomes.

RESULTS

Two hundred ten patients had 215 monitors placed. ICP monitors were placed by neurosurgeons (105), MLPs (97), and general surgery residents (13), and remained in place a mean of 4 days. No major complications attributable to ICP monitor placement occurred; 19 minor complications (malfunction, dislodgment) were noted. Eleven monitors placed by neurosurgeons (10%), seven placed by MLPs (7%), and one placed by a resident (8%) had complications.

CONCLUSION

ICP monitor placement by MLPs is safe. Use of MLPs may aid neurosurgeons in providing prompt monitoring of patients with head injuries.

Base deficit as an indicator or resuscitation needs in patients with burn injuries

The utility of base deficit (BD) as a marker of shock and as an indicator of resuscitation requirements has been recognized in the trauma population. Base deficit in thermally injured patients has not been closely examined. The purpose of this study was to evaluate the usefulness of initial BD related to other resuscitation parameters in thermally injured patients. Burn center records over a 2-year period were reviewed; patients who survived at least 24 hours and had initial arterial blood gases were included. Parkland estimated fluid requirements underestimated actual volume requirements, but Parkland-calculated fluid requirements were related (p < 0.01) to actual volume requirements. BD had a better correlation to actual volume requirements, and a BD of -6 or less correlated with larger burn size (23% +/- 2% vs 47% +/- 9% total body surface area), and markedly increased mortality rate (9% vs 72%, p < 0.001).

Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation

OBJECTIVE

The purpose of this study was to determine the incidence of indirect spinal column injury in patients sustaining gunshot wounds to the head.

METHODS

A retrospective review of patient records and autopsy reports was conducted of patients admitted with gunshot wounds to the head between July of 1990 and September of 1995 were included. Those with gunshot wounds to the neck and those who were dead on arrival were excluded.

RESULTS

A total of 215 patients were included in the study. Cervical spine clearance in 202 patients (93%) was determined either clinically, radiographically, or by review of postmortem results. No patients sustained indirect (blast or fall-related) spinal column injury. Three patients had direct spinal injury from bullet passage that were apparent from bullet trajectory. More intubation attempts occurred in patients with cervical spine immobilization (49 attempts in 34 patients with immobilization versus five attempts in four patients without cervical spine immobilization, p = 0.008).

CONCLUSIONS

Indirect spinal injury does not occur in patients with gunshot wounds to the head. Airway management was compromised by cervical spine immobilization. Protocols mandating cervical spine immobilization after a gunshot wound to the head are unnecessary and may complicate airway management.

Does free fluid on abdominal computed tomographic scan after blunt trauma require laparotomy?

BACKGROUND

Abdominal computed tomographic (CT) scans are used in the evaluation of blunt trauma. The purpose of this study was to determine if isolated intraperitoneal fluid seen on CT scan necessitates laparotomy.

METHODS

Trauma registry records of patients who underwent abdominal computed tomography from January 1994 through January 1997 were studied. Data were reviewed for age, gender, CT scan interpretation, associated injuries, and operative findings.

RESULTS

Abdominal injury was identified in 126 patients. Seventy-eight patients had evidence of solid-organ injury and 17 patients had extraperitoneal injury. Isolated intraperitoneal fluid was identified in 31 patients. All patients with isolated fluid underwent laparotomy; 29 of these procedures (94%) were therapeutic. Bowel injuries occurred in 18 patients and mesenteric injuries in 8 patients. Five patients had intraperitoneal bladder rupture, and undetected solid-organ injuries were found in two patients. Other organs injured included the stomach, pancreas, ovary, and uterus.

CONCLUSION

Exploratory laparotomy was therapeutic in 94% of patients. Isolated intraperitoneal fluid on CT scan after blunt trauma mandates laparotomy.

Base deficit is superior to pH in evaluating clearance of acidosis after traumatic shock

OBJECTIVE

This study was done to evaluate the differences in base deficit (BD) clearance, pH normalization, and the occurrence of complications between survivors and nonsurvivors after trauma.

DESIGN

Concurrent data entry with retrospective review.

METHODS

Trauma patients meeting registry criteria from July 1990 through August 1995 with arterial blood gases performed within 1 hour of admission and admission BD < or = -6 were included. Data was grouped by BD category (moderate, -6 to -9; severe, < or = -10). Group means +/- SEM were compared with a two-tailed t test.

MEASUREMENTS AND MAIN RESULTS

Six hundred seventy-four patients met entry criteria. Survivors in both the moderate and severe BD groups had improved their BD within 4 hours and normalized their BD by 16 hours. Nonsurvivors did not improve their BD category until 8 hours (for the severe group) and 16 hours (for the moderate group) and did not normalize BD before 24 hours. The BD differences between survivors and nonsurvivors were significant at each time interval, whereas pH differences were significant at 2 hours in the moderate group and at 2, 16, and 24 hours in the severe group. Patients who failed to improve their BD > -6 had an increased frequency of adult respiratory distress syndrome, multiple organ failure, and mortality.

CONCLUSION

Base deficit reveals differences in metabolic acidosis between survivors and nonsurvivors not shown by pH determinations and is clearly a better marker of acidosis clearance after shock.

Medical versus surgical management of diverticulitis in patients under age 40

BACKGROUND

Diverticulitis in patients under age 40 is a distinct entity. We compared the medical versus surgical management of diverticulitis for complications and outcomes in these patients.

METHODS

A retrospective review was performed for treatment, hospitalizations, complications, and outpatient visits. Complications included readmission, recurrent symptoms after antibiotic therapy, and postoperative problems.

RESULTS

Twenty-nine patients had a radiographic or surgical diagnosis of diverticulitis (18 surgical, 11 medical). Medically managed patients had significantly more emergency department visits (4.7 +/- 6.6 versus 0.3 +/- 0.6, P < or =0.01), and readmissions (7 versus 4, P < or =0.02). Three surgical patients (17%) had a total of 6 complications as compared with 6 medical patients (55%) with 25 complications (chi square, P < or =0.05). All medically treated patients had recurrent symptoms, and 6 required surgery.

CONCLUSION

Medically managed patients had significantly more emergency department visits and complications than those managed surgically. Surgery is the indicated treatment for the first episode of diverticulitis in patients under age 40.

More guns and younger assailants. A combined police and trauma center study

OBJECTIVE

To test the hypothesis that guns have become the weapon of choice for assaults and that both assailants and victims have become progressively younger.

DESIGN

Retrospective review of trauma center and police department data sources.

SETTING

Regional trauma center with university affiliation; municipal police department.

SUBJECTS

Victims of assault with a deadly weapon from 3 discontiguous years.

MAIN OUTCOME MEASURES

Age of assailant and victim, type of injury, frequency of blunt vs penetrating injury.

RESULTS

From June 1991 to May 1992 and June 1993 to May 1994, the incidence of penetrating trauma increased from 27% to 35% of trauma center admissions (chi 2 test; P < .001). During the period from June 1985 to May 1994, assault with a deadly weapon increased by 220% and firearms became the most common assault mechanism (from 32% to 54%; chi 2 test; P < .001). Assailants using guns became significantly younger, with the percentage of assailants aged 11 to 20 years increasing from 24% to 47% (chi 2 test; P = .001). The ages of assault victims also decreased (P < .003), but were more evenly distributed across age categories.

CONCLUSIONS

The incidence of penetrating trauma has increased in both absolute numbers and in relative proportion to blunt trauma. Firearms have become the weapon of choice and the single largest group of assailants are 11 to 20 years of age. The use of concurrent police and trauma center databases provides a more cogent basis for developing effective violence prevention strategies.

Effect of alcohol on the utility of base deficit in trauma

OBJECTIVE

Base deficit (BD) is an indicator of metabolic acidosis and is used as an index of shock and resuscitation for trauma patients. Ethanol causes an increase in lactate production and may cause metabolic acidosis in otherwise normal patients. The effects of alcohol on BD have not been investigated. This study was performed to determine the effects of ethanol on the utility of BD for assessing shock and resuscitation among trauma patients.

DESIGN

Retrospective review of trauma registry, blood bank, and medical records data.

METHODS

Data were collected for trauma patients admitted to the University Medical Center Level I trauma service from July 1990 through August 1995 with an arterial blood gas and blood alcohol level obtained within 1 hour of admission.

MEASUREMENTS AND MAIN RESULTS

The Trauma Score and the Revised Trauma Score were slightly higher (p < 0.001), and the Injury Severity Score was significantly lower (p < 0.001) in the presence of alcohol. These changes were present until patients reached the severe BD category (< or = -10), at which point there were no significant differences across all blood alcohol levels. In spite of these changes, there was no difference in intensive care unit or hospital length of stay in any BD or blood alcohol group. In patients with a BD < or = -6, there was a decreased requirement for transfusion in the presence of alcohol (57 vs. 78%; p < 0.001, chi2), but the majority of patients in both groups required blood transfusion.

CONCLUSION

Ethanol can contribute significantly to metabolic acidosis among trauma patients and may confound the utility of BD to some degree. There was no difference in intensive care unit or overall length of stay, however, regardless of ethanol level, and the majority of patients with a BD < or = -6 still required transfusion. Even in the presence of ethanol, a BD < or = -6 remains a powerful indicator of major injury, increased length of stay, and transfusion requirement.

Spinal cord injury. A preventable public burden

BACKGROUND

Spinal cord injury (SCI) is a devastating occurrence with important consequences for the individual and society. Previous studies have documented the epidemiology and costs of SCI and the rehabilitation needs after SCI; however, data about the preventability of SCI are lacking.

OBJECTIVE

To test the hypotheses that most SCIs are preventable and that much of the cost of SCI is borne by the public.

DESIGN

Retrospective review of medical records and trauma registry data.

SETTING

A 417-bed county hospital with a level I trauma center.

METHODS

To evaluate the preventability of SCI, the records of trauma patients sustaining SCI from July 1, 1990, through June 30, 1995, were reviewed. The criteria for preventability of blunt injuries included the following: failure to use restraint devices; intoxication of drivers, motorcyclists, or pedestrians; and falls or diving accidents involving the use of drugs or alcohol. The criteria for preventability of penetrating injuries included the following: illegal possession of a firearm, accidental discharge of a weapon, and suicide attempts. Statistics were performed with the paired Student t test and chi 2 with significance attributed to a P value less than .05.

RESULTS

Spinal cord injury occurred in 150 patients; 71% of the injuries were the result of blunt trauma. Injury was potentially preventable in 74% of the blunt injuries and 66% of the penetrating injuries (P = .15). Patients with a penetrating SCI were younger (P < .001) and relied more on public funding than did those with a blunt SCI (65% vs 81%; P = .05).

CONCLUSIONS

Most SCIs are preventable with strict enforcement of existing statutes. Furthermore, the financial burden of these preventable injuries is largely borne by the public.