Search

BackgroundOlder adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidence-based guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care.Materials and methodsWe analyzed patients ≥50y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs.ResultsAmong 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry

Trauma is the leading cause of death among patients 46 years or younger, and having a system in place for the care of the injured is of paramount importance to the health of a community. The growth and development of civilian trauma systems has not been an easy process. The concept of regionalized health care that the trauma system models has been emulated by other specialized and time-sensitive areas of medicine, notably stroke and acute cardiac events. Continued process improvement, public education, support and involvement, a sound infrastructure, and integrated technology should remain our focus.

BackgroundThe optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown.MethodsPostinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours.ResultsForty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance).ConclusionsPatients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.

Objective In 2005, the American College of Surgeons passed a mandate requiring that Level I trauma centers have a mechanism to identify patients who are problem drinkers and have the capacity to provide an intervention for patients who screen positive. The aim of the Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) cluster randomized trial is to test a multilevel intervention targeting the implementation of high-quality alcohol screening and brief intervention (SBI) services at trauma centers. Method Twenty sites selected from all United States Level I trauma centers were randomized to participate in the trial. Intervention site providers receive a combination of workshop training in evidence-based motivational interviewing (MI) interventions and organizational development activities prior to conducting trauma-center-based alcohol SBI with blood-alcohol-positive injured patients. Control sites implement care as usual. Provider MI skills, patient alcohol consumption, and organizational acceptance of SBI implementation outcomes are assessed. Results The investigation has successfully recruited provider, patient and trauma center staff samples into the study, and outcomes are being followed longitudinally. Conclusion When completed, the DO-SBIS trial will inform future American College of Surgeons' policy targeting the sustained integration of high-quality alcohol SBI at trauma centers nationwide.

There are increasing efforts towards improving the quality and safety of surgical care while decreasing the costs. In Washington state, there has been a regional and unique approach to surgical quality improvement. The development of the Surgical Care and Outcomes Assessment Program (SCOAP) was first described 5 years ago. SCOAP is a peer-to-peer collaborative that engages surgeons to determine the many process of care metrics that go into a “perfect” operation, track on risk adjusted outcomes that are specific to a given operation, and create interventions to correct under performance in both the use of these process measures and outcomes. SCOAP is a thematic departure from report card oriented QI. SCOAP builds off the collaboration and trust of the surgical community and strives for quality improvement by having peers change behaviors of one another. We provide, here, the progress of the SCOAP initiative and highlight its achievements and challenges.

Introduction While computed tomography (CT) scan usage in acute trauma patients is currently part of the standard complete diagnostic workup, little is known regarding the time factors involved when CT scanning is added to the standard workup. An analysis of the current time factors and intervals in a high-volume, streamlined level-1 trauma center can potentially expose points of improvement in the trauma resuscitation phase. Materials and methods During a 5-week period, data on current time factors involved in CT scanned trauma patients were prospectively collected. All consecutive trauma patients seen in the Emergency Department following severe trauma, or inter-hospital transfer following initial stabilizing elsewhere, and that underwent CT scanning, were included. Patients younger than 16 years of age were excluded. For all eligible patients, a complete time registration was performed, including admission time, time until completion of trauma series, time until CT imaging, and completion of CT imaging. Subgroup analyses were performed to differentiate severity of injury, based on ISS, and on primary or transfer presentations, surgery, and ICU admittance. Results Median time between the arrival of the patient and completion of the screening X-ray trauma series was 9 min. Median start time for the first CT scan was 82 min. The first CT session was completed in a median of 105 min after arrival. Complete radiological workup was finished in 114 min (median). In 62% of all patients requiring CT scanning, a full body CT scan was obtained. Patients with ISS >15 had a significant shorter time until CT imaging and time until completion of CT imaging. Conclusion In a high-volume level-1 trauma center, the complete radiological workup of trauma patients stable enough to undergo CT scanning, is completed in a median of 114 min. Patients that are more severely injured based on ISS were transported faster to CT, resulting in faster diagnostic imaging.

Summary Background and objectives Rib fractures are associated with significant morbidity and mortality. Previous studies have demonstrated a significant reduction in pneumonia and duration of mechanical ventilation with epidural analgesia (EA) following multiple rib fractures. There remains controversy regarding the appropriate indications and contraindications for EA in multiply injured patients. We sought to determine the factors underlying the decision to use or not to use EA in these patients. Methods A survey was sent to the directors of pain management services at all American College of Surgeons Committee on Trauma (ACS-COT) designated Level I trauma centers in the U.S. The survey queried their opinion regarding the appropriateness of 33 contraindications and eight indications for EA after rib fractures. Results The response rate was 43% (81/188). Ninety-five percent of responding centers indicated that EA is used after rib fractures, but only 15% had guidelines defining the indications and contraindications. There was general agreement (>80%) regarding the indications for EA but disagreement regarding the contraindications. Contraindications were categorised based on the degree of agreement of respondents. The areas of greatest controversy involved minor spine injuries and minor coagulopathy. Conclusions There is wide variability regarding contraindications employed for thoracic epidural analgesia following rib fractures. These data support the need for evidenced based guidelines to define the use of EA in the multiply injured patient.

This paper describes an adaptation of behavioral activation (BA) for the early intervention of posttraumatic stress disorder (PTSD) and depression among physically injured survivors of traumatic injury, and presents pilot data on a small randomized effectiveness trial ( N = 8). The application of BA to PTSD is based on the theory that increases in guided activity may break patterns of avoidance that can maintain PTSD. Compared to treatment as usual (TAU), those who received BA showed improvement in PTSD symptom severity from pre- to posttreatment, and there was a trend for the BA group to score better than the TAU group on physical functioning. Contrary to expectation, this brief adaptation did not have an impact on depression. Implications of these results for the effective early intervention after trauma are discussed.

Within the context of modern health care, the field of trauma surgery has been remarkably successful. The American College of Surgeons Committee on Trauma (ACS-COT) can trace its roots directly to the Committee on Fractures in 1950. The group was a largely quiescent committee until the 1966 publication of “Accidental Death and Disability: The Neglected Disease” by the National Academy of Sciences. Following its publication, national interest focused on injury prevention and injury care. Trauma fellowships began to appear in the late 1970s, and clinical research conducted primarily in the 1980s demonstrated the beneficial effect of a trauma service on diminishing preventable mortality. By 1976, the ACS-COT had developed criteria for categorizing hospitals according to the level of trauma care available; this set of criteria is now called the “Optimal Resources for the Care of the Injured Patient” and has largely laid the foundation for how trauma care is practiced in North America today. The ACS-COT began its verification site visits of trauma hospitals in 1987 and, by the 1990s, most academic surgery departments had incorporated a trauma section or division into its academic and research structure. In 2001, the ACS-COT began a consultation program on entire regional or state trauma systems and, in 2002, there were reported to be more than 1100 trauma centers in the United States, including 190 Level I centers and 263 Level II centers, with 84% of the population within 1 hour of a level I or II trauma center. This remarkable adaptation of regionalized medical care is virtually unique to trauma and has been fostered by

More than 650 deaths from hypothermia occur each year in the United States. Even minor deviation from normal temperature leads to important symptoms and disability. The most significant risk factors are advanced age, mental impairment, substance abuse, and injury. This article examines the incidence of hypothermia, its detrimental effect on trauma patients, and methods of rewarming the hypothermic patient. It also looks at the controversial protective role hypothermia might play in shock, organ transplantation, cardiac arrest, and brain injury. Finally, it examines cold injuries, including frostbite, chilblain, and trench foot, and makes recommendations for their treatment.

Objective Adolescents constitute a high-risk population for traumatic physical injury, yet few longitudinal investigations have assessed the development of posttraumatic stress disorder (PTSD) symptoms over time in representative samples. Method Between July 2002 and August 2003, 108 randomly selected injured adolescent patients ages 12 to 18 and their parents were interviewed at baseline and again 2, 5, and 12 months postinjury. Initially, participants were screened for PTSD symptoms with the PTSD Reaction Index (PTSD-RI) and depressive symptoms with the Center for Epidemiologic Studies Depression Scale, as well as preinjury trauma. Random-coefficient regression was used to assess the association between baseline clinical, injury, and demographic characteristics and the development and maintenance of PTSD symptoms longitudinally. Results Between 19% and 32% of adolescents screened positive for PTSD (i.e., had PTSD-RI scores of ≥38) during the course of the 12 months after the injury. Higher initial adolescent PTSD and depressive symptoms, higher emergency department heart rate, greater objective event severity, and greater parental preinjury trauma were significant independent predictors of higher adolescent PTSD symptoms. Conclusions For a substantive minority of hospitalized adolescents, high PTSD symptom levels persist during the 12 months after injury. Clinical characteristics readily identifiable after the acute injury predict the development of PTSD symptoms over time. Real-world clinical trials that test screening and intervention procedures for representative samples of at-risk youths are warranted. J. Am. Acad. Child Adolesc. Psychiatry , 2006;45(10):1188-1195.

Background Rib fractures are common and associated with significant pulmonary morbidity. We hypothesized that epidural analgesia would provide superior pain relief, and reduce the risk of subsequent pneumonia. Methods A prospective, randomized trial of epidural analgesia versus IV opioids for the management of chest wall pain after rib fractures was carried out. Entry criteria included patients older than 18 years with more than 3 rib fractures and no contraindications to epidural catheter placement. Results From March 2000 to December 2003, 408 patients were admitted with more than 3 rib fractures; 282 met exclusion criteria, 80 could not be consented, and 46 were enrolled (epidural n = 22, opioids n = 24). The groups were comparable for mean age, injury severity score, gender, chest Abbreviated Injury Scale, and mean number of rib fractures. The epidural group tended to have more flail segments (38% vs 21%, P = .20) and pulmonary contusions (59% vs 38%, P = .14), and required more chest tubes (95% vs 71%, P = .03) Despite the greater direct pulmonary injury in the epidural group, their rate of pneumonia was 18% versus 38% for the intravenous opioid group. When adjusted for direct pulmonary injury, there was a greater risk of pneumonia in the opioid group: OR, 6.0; 95% CI, 1.0-35; P = .05. When stratified for the presence of pulmonary contusion there was a 2.0-fold increase in the number of ventilator days for the opioid group: incident rate ratio, 2.0; 95% CI, 1.6-2.6; P Conclusions The use of epidural analgesia is limited in the trauma population due to numerous exclusion criteria. However, when feasible, epidural analgesia is associated with a decrease in the rate of nosocomial pneumonia and a shorter duration of mechanical ventilation after rib fractures.

Background The ability to massively transfuse and resuscitate critically ill surgical patients has resulted in unprecedented survival and a new set of complications including abdominal compartment syndrome (ACS) and the “unclosable” abdomen. Traditional methods of temporary abdominal closure have met with several limitations, not the least of which is a marked delay in achieving definitive fascial closure. Since 1991, we have consistently used reinforced silicone elastomer (Silastic) sheeting as a form of temporary abdominal closure in these settings. We report our results using this technique in a large cohort of critically ill surgical patients. Methods All patients undergoing silicone elastomer temporary abdominal closure since 1991 were identified and their charts abstracted for principal diagnosis and indication for temporary abdominal closure, fluid requirements, number of operations, and time to fascial closure. Time to definitive closure in the respective groups was analyzed using Kaplan-Meir survival curves and the Wilcoxon rank-sum test. Odds ratios for death were analyzed using logistic regression. Results One hundred thirty-four patients underwent temporary abdominal closure with silicone elastomer over this period and only 62% (83) survived their hospital admission. Trauma and ruptured abdominal aortic aneurysm were the most frequent diagnoses. The most frequent indication was edema precluding abdominal closure. The mean crystalloid and blood requirements in the 24 hours preceding temporary abdominal closure were 21 ± 16 L and 15 ± 11 U, respectively. Of survivors, 75% (63 of 83) achieved fascial closure during their index admission. The median time to fascial closure in patients ultimately closed was 5 days. The median time to closure and the proportion of patients ultimately closed varied with the indication for closure with an earlier and greater chance of success in patients who could not tolerate closure (ACS) or could not be closed primarily (edema). Age-adjusted mortality was 5 times (95% confidence interval: 2 to 13) higher in patients developing ACS. Conclusions Nylon reinforced silicone elastomer is a safe, reliable material for temporary abdominal closure in severely ill patients. Primary fascial closure can be obtained in a timely fashion in the majority of patients. The success of obtaining definitive fascial closure depends on the indication for temporary abdominal closure, with visceral edema and ACS having the highest likeliest of early success.

The purpose of this study is to define the current morbidity and mortality associated with penetrating colon injury and to determine the impact of management strategy on outcome. Methods: A retrospective review was performed of all penetrating colon injuries managed at a level I trauma center (1990–2000), n=186. Stepwise logistic regression was used to determine the independent predictors for colostomy and morbidity following colon injury. Results: Fifty-three percent of the patients were managed with primary repair or anastomosis while 47% received a colostomy. Independent predictors of colostomy included gunshot wound (GSW), degree of peritoneal contamination, and location of injury. The complication rate for patients requiring a colostomy was 57% versus 42% for the primary repair group, P=0.01. When adjusted for injury severity and hypotension, the presence of a colostomy was not associated with a significant increase in the complication rate (OR 1.7, 95% CI: 0.9–3.25). Independent predictors for the development of intra-abdominal abscess were hypotension on admission (OR 2.4, 95% CI: 1.1–5.8) and penetrating abdominal trauma index (PATI) score >25 (OR 4.2, 95% CI: 2.0–8.9). The complication rate for colostomy takedown was 17%. Conclusion: Penetrating colon injury carries a high rate of infectious morbidity. The development of infectious complications is related to the injury severity and haemodynamic status of the patient, not the type of operation performed.

Considerable controversy persists regarding the optimal means and indications for airway management, the utility of paralytic agents to facilitate intubation, and the indications for advanced airway access techniques in the prehospital setting. To describe the use of intubation and advanced airway management in a system with extensive experience with both the use of paralytic agents and surgical airway techniques, a retrospective review was conducted of all prehospital airway procedures from January 1997 through November 1999. Data collected included demographics, airway management techniques, use of paralytic agents, and immediate outcome. The results showed there were 2700 patients intubated out of 50,118 patient encounters (5.4%). The indications for intubation included medical emergency in 82% of patients and traumatic injury in 18%. Fifty percent of patients were intubated with the use of succinylcholine. The overall oral intubation success rate was 98.4% and definitive airway access was achieved in all but 12 patients (0.6%), with 30 patients receiving surgical airway access (1%). The successful intubation rate for patients receiving paralytic agents was 97.8%. Previously published rates of prehospital surgical airway access range from 3.8 to 14.9% of patients. In this study, only 1.1% of patients required a surgical airway. We attribute this low rate to the use of paralytic agents. The availability of paralytic agents also allows expansion of the indications for prehospital airway control.

Posttraumatic behavioral and emotional disturbances occur frequently among physically injured hospitalized trauma survivors. This investigation was a pilot randomized effectiveness trial of a 4-month collaborative care intervention for injured motor vehicle crash and assault victims. As surgical inpatients, intervention subjects (N=16) were assigned to a trauma support specialist who provided counseling, consulted with surgical and primary care providers, and attempted postdischarge care coordination. Control subjects (N=18) received usual posttraumatic care. For all participants, posttraumatic stress disorder (PTSD) and depressive symptoms, episodic alcohol intoxication, and functional limitations were evaluated during the hospitalization and 1 and 4 months postinjury. Study logs and field notes revealed that over 75% of intervention activity occurred in the first month after the trauma. One-month post-trauma intervention subjects when compared to controls demonstrated statistically significant decreases in PTSD symptoms as well as a reduction in depressive symptoms. However, at the 4-month assessment, intervention subjects evidenced no significant improvements in PTSD and depressive symptoms, episodic alcohol intoxication, or functional limitations. Future larger scale trials of stepped collaborative care interventions for physically injured trauma survivors are recommended.

We evaluated the accuracy of the field sobriety assessment of police officers following a motor vehicle crash. Using linked data from a statewide traffic crash database and the trauma center registry, the results of a field sobriety evaluation for each driver were compared with a blood alcohol concentration (BAC) drawn in the emergency department. BAC values served as the "gold standard" in which drivers with values over 0.1 mg/dl were classified as intoxicated. The subjects were drivers over age 15 years who were admitted or died at Level I trauma center as a results of motor vehicle crash injuries during 1986-1993. A total of 1336 subjects had both a recorded BAC and a police sobriety assessment. Seventy percent of subjects were male and 79% under the age of 35 years. Overall, 40% of all subjects were judged by police to have been impaired, based on the scene sobriety assessment. Among all drivers, the field assessment had a sensitivity of 91%, a specificity of 90% and a predictive value positive of 85%. After excluding the 419 drivers which had breath testing as part of their assessment, the field assessment had a sensitivity of 74% and a specificity of 97%. The sensitivity of the field assessment did not vary appreciably by gender but was lower among older drivers, and higher among severely injured drivers and those involved in weekend and nighttime crashes. Police officers in this sample appear to recognize drunk driving with a high degree of accuracy when investigating crashes in which the driver is transported to a trauma center.

The Organ Injury Scaling (015) Committee of the American Association for the Surgery of Trauma has developed severity scores for spleen, liver, extrahepatic biliary, pancreas, duodenum, small bowel, colon, rectum, abdominal vascular, diaphragm, kidneys, ureter, bladder, urethra, chest wall, heart, lungs, and thoracic vascular injuries. These OISs are classification schemes based on an anatomic description, scaled from I to VI, representing the least to most severe injury. OISs are designed to facilitate clinical research as well as continuing quality improvement.

Interferon-gamma is an important component of numerous host responses to inflammatory insults. Data from in vitro and animal studies suggest that this agent may have clinical uses in immunocompromised patients who are at increased risk for infectious complications. In addition to reviewing our current understanding of the in vitro and in vivo actions of interferon-gamma, this article cautions that the potential for adverse reactions exists when interferon-gamma is administered to an immunologically competent host.

Interferon-γ (IFN-γ) has been proposed for use following severe trauma to reverse depressed macrophage (Mφ) function and thereby reduce infection, sepsis, and subsequent multiple organ failure syndrome (MOFS). However, an excessive inflammatory response by Mφs and other components of the inflammatory cascade is thought to be central to the underlying pathophysiology of MOFS. Endotoxin (LPS) has been implicated as a principal mediator of sepsis-induced MOFS by stimulating Mφs and leukocytes (WBC). This study addresses the following question: Does IFN-γ predispose normal rabbits to a pathophysiologic response to LPS infusion? Four groups of New Zealand White rabbits ( n = 6, each group) were prepared for measurement of cardiac output, arterial pressure, arterial PO 2 , and WBC counts over a 6-hr period. Group I (control) was instrumented alone, Group II (LPS alone) was given a subclinical dose of 1.0 μg/kg of Escherichia coli LPS iv, Group III (IFN-γ alone) was given recombinant rabbit IFN-γ (5.0 μg/kg subcutaneous) for 3 days prior to preparation for measurements, and Group IV (IFN-γ + LPS) received 3 days of IFN-γ followed by LPS. One hour prior to sacrifice 5.0 μCi of 125 I-albumin was given and bronchoalveolar lavage was performed at death to determine the lavage/plasma 125 I ratio as an index of pulmonary permeability. The results indicate that IFN + LPS animals had significant decreases in cardiac output, PO 2 , and WBC counts, and increased lavage/plasma ratio of 125 I-albumin when compared to all other groups ( P t test). Neither LPS alone nor IFN-γ alone had a significant effect on measured variables. In contrast to immunosuppressed animals, IFN-γ pretreatment of normal animals increases the host pathophysiologic response to endotoxin.

We reviewed the management and clinical course of 21 patients with extrahepatic injuries to the portal triad seen over the past 11 years at a Level I trauma center. These represented only 0.21% of patients with multiple trauma admitted during this time. Portal triad injury was never specifically diagnosed preoperatively. Extrahepatic bile duct injury occurred in 4 patients, portal vein injury in 14, and hepatic artery injury in 7; 3 patients had combined injuries. Eleven patients (52%) died, all due to uncontrolled hemorrhage from either an injured portal vein or associated intra-abdominal injuries. Management of the bile duct injuries included drainage alone, bile duct ligation, and Roux-Y hepaticojejunostomy. Survivors of portal vein injury were managed with lateral venorrhaphy. Ligation of the hepatic artery appeared to be optimal for injuries incurred by this vessel. Complications necessitating reoperation or percutaneous drainage procedures were encountered in 8 of 10 surviving patients (80%). Injuries to the portal triad are uncommon, difficult to diagnose, and technically challenging. Mortality is most directly related to uncontrolled intraabdominal hemorrhage, and salvage requires rapid control of bleeding as the first treatment priority.