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This is a recommended evaluation and management algorithm from the Western Trauma Association (WTA) Algorithms Committee addressing the prehospital and in-hospital airway management of adult trauma patients. Because there is a paucity of published prospective randomized clinical trials that have generated class I data, these recommendations are based primarily on published prospective and retrospective cohort studies and expert opinion of the WTA members. The final algorithm is the result of an iterative process including an initial internal review and revision by the WTA Algorithm Committee members and then final revisions based on input during and after presentation of the algorithm to the full WTA membership. Airway management in the severely injured adult trauma patients begins from the time of first responder arrival and continues until a definitive airway can be established and maintained. Though airway management is important in both the prehospital setting and emergency department, the priorities differ slightly due to alterations in environment, personnel, equipment, expertise and experience. This WTA algorithm will review with most recent evidence and provide recommendations for airway management for the adult trauma patient in both the prehospital setting and emergency department. Cervical spine protection and immobilization, if indicated, will be assumed throughout all airway interventions in the algorithms below. The algorithms (figures 1 and 2) and accompanying comments represent a safe and sensible approach to the evaluation and management of the airway in the acutely injured patient. We recognize that there will be multiple factors that may warrant or require deviation from any single recommended algorithm and that no algorithm can completely replace expert bedside clinical judgment. We encourage institutions to use this as a general framework in the approach to these patients and to customize and adapt the algorithm to better suit the specifics of that program or location. Figure 1 Algorithm for prehospital …

BACKGROUND Procalcitonin (PCT), the prohormone of calcitonin, has an early and highly specific increase in response to systemic bacterial infection. The objectives of this study were to determine the natural history of PCT for patients with critical illness and trauma, the utility of PCT as a marker of sepsis versus systemic inflammatory response syndrome (SIRS), and the association of PCT level with mortality. METHODS PCT assays were done on eligible patients with trauma admitted to the trauma intensive care unit (ICU) of a Level I trauma center from June 2009 to June 2010, at hours 0, 6, 12, 24, and daily until discharge from ICU or death. Patients were retrospectively diagnosed with SIRS or sepsis by researchers blinded to PCT results. RESULTS A total of 856 PCT levels from 102 patients were analyzed, with mean age of 49 years, 63% male, 89% blunt trauma, mean Injury Severity Score of 21, and hospital mortality of 13%. PCT concentration for patients with sepsis, SIRS, and neither were evaluated. Mean PCT levels were higher for patients with sepsis versus SIRS (p < 0.0001). Patients with a PCT concentration of 5 ng/mL or higher had an increased mortality when compared with those with a PCT of less than 5 ng/mL in a univariate analysis (odds ratio, 3.65; 95% confidence interval, 1.03-12.9; p = 0.04). In a multivariate logistic analysis, PCT was found to be the only significant predictor for sepsis (odds ratio, 2.37; 95% confidence interval,1.23-4.61, p = 0.01). CONCLUSION PCT levels are significantly higher in ICU patients with trauma and sepsis and may help differentiate sepsis from SIRS in critical illness. An elevated PCT level was associated with increased mortality.

Elderly patients, an increasing segment of the population, who sustain traumatic brain injury (TBI) are known to have worse outcomes, including higher mortality. This objective of this study was to examine the Crash Injury Research Engineering Network and to determine at what age motor vehicle crash fatalities from head injuries increased.The Crash Injury Research Engineering Network database was queried from 1996 to 2009. Study inclusion criteria were adult vehicle occupants with TBI, with an Abbreviated Injury Scale score ≥2. The age at which mortality increased was calculated. Patients younger and older than this cutoff age were compared to determine differences in crash characteristics. The determined cutoff age was compared with one found in a larger, population-based database.There were 915 patients who met the study criteria. An increase in mortality was seen at age 60 years despite no difference in Injury Severity Score and a decrease in crash severity. Patients ≤60 years were more likely to have alcohol involved, to be in a rollover crash, and had higher crash speeds. Comparing the element of the crash attributed to the head injury, the patients60 years were more likely to have struck the airbag, door, and seat. An analysis of the larger database revealed an increase in mortality at age 70 years.There was a higher mortality secondary to head injuries in those older than 60 years involved in motor vehicle crashes. Improved safety measures in vehicle design may decrease the number of head injuries seen in the older population.

In trauma practice, basilar skull fracture is an extremely common finding while transverse/sigmoid venous sinus thrombosis is generally considered quite a rare complication. During evaluation of cervical computed tomography (CT) angiography after trauma, we identified five patients in just three months with unexpected transverse/sigmoid venous sinus obstruction ipsilateral to a basilar skull fracture. This number represented a surprisingly high percentage of our neurosurgical trauma consults for the study period (31%). Three of the five patients were found to have sinus thrombosis: two with right transverse/sigmoid sinus thrombosis experienced significant neurological deficits and prolonged hospital courses even with anti-coagulation therapy; one patient with a left transverse/sigmoid sinus thrombosis had a good outcome with anti-coagulation therapy. The other two of the five patients had outflow obstruction, likely from focal epidural bleeding and extrinsic compression: one patient with partial obstruction in the right transverse-sigmoid junction, due to epidural bleeding, experienced a difficult recovery; one patient with a right sigmoid sinus obstruction presented and remained asymptomatic and experienced a benign hospital course. Two of the five patients had a posterior temporal hemorrhagic area ipsilateral to the affected sinus, suggesting that this finding may have represented hemorrhagic venous infarction rather than traumatic contusion. We propose that a basilar skull fracture in the region of temporal or occipital bone should be considered as a significant risk factor for the development of transverse/sigmoid venous sinus obstruction and may be an under-recognized and treatable cause of increased intracranial pressure. Failure to detect this complication may explain, in part, unexpected clinical outcomes.

BACKGROUND: Research suggests that weight influences patient care and outcomes. Health-care providers (HCPs) sometimes rely on patient self-reports or HCP estimates of height and weight. The purpose of this study was to determine the accuracy of self-reported height and weight and HCP estimations of height, weight, and body mass index (BMI) classification when compared with measured height, weight, and calculated BMI. STUDY DESIGN: Attending physicians, residents, and nurses provided height and weight estimates along with BMI categorizations for 110 trauma patients at a large, teaching hospital with a Level I trauma center. Patients provided reports of their heights and weights. Measured heights and weights were obtained with appropriate calibrated devices, and BMIs were calculated. Estimates and categorizations were then compared with measured and calculated values. RESULTS: HCPs were 41% and 53% accurate in estimating height and weight, respectively. Self-reports had higher accuracy (69% and 92%, respectively) but still resulted in a BMI misclassification of 32%. Twenty-two percent of patient self-reports were unobtainable. When HCPs attempted to categorize a patient into a BMI group, the accuracy was 56%. Functioning, calibrated instruments for measuring height and weight were frequently unavailable in relevant hospital locations. CONCLUSIONS: This study demonstrated that HCPs' estimates of height, weight, and BMI category are highly inaccurate. Patient self-reports are better, but are unavailable at times. Objective measurements with calibrated instruments are necessary for accuracy in research studies and for patient safety in clinical practice. Efforts to ensure the availability of calibrated instruments may be necessary in the hospital setting.

Prolonged open sternotomy is a well-known phenomenon in the pediatric and adult cardiac surgery literature. It is usually an adjuvant in the treatment of a severely compromised heart. We present a case of thoracic compartment syndrome that developed postoperatively from a noncardiac thoracic procedure. Management, diagnosis, and literature review are presented.

To describe the long-term consequences of laparoscopic surgery during pregnancy.Laparoscopic surgery is well established in the surgical community. Laparoscopic surgery in the pregnant patient is not yet broadly accepted; concern has been for fetal wastage, effects of carbon dioxide (CO(2)) on the developing fetus, and long-term sequelae during childhood development.This report documents 11 laparoscopic cases in pregnancy with follow-up of 1 to 8 years. The patients were in their 16th to 28th week of pregnancy. Two patients had chronic cholecystitis and biliary colic resulting in weight loss and multiple admissions. Three patients had acute cholecystitis, and three patients had acute appendicitis. Two patients underwent exploration for a diagnosis of acute abdomen, and both were found to have small bowel obstruction. All patients had general anesthesia and underwent an open Hasson trocar procedure with end-tidal CO(2) monitoring, sequential compression devices, and partial left decubitus positioning. Insufflation pressure was maintained at 10 mm Hg. The operative time ranged from 25 to 90 minutes.Successful laparoscopic surgery was performed in 10 cases, with one conversion to an open procedure. Intraoperative and postoperative fetal monitoring was performed for at least 24 hours. No fetal distress or demise occurred, nor were any tocolytics used. The resultant children were then monitored, and no evidence of developmental or physical abnormalities was detected during the study period.Laparoscopic surgery is now proving to be as safe as open surgery in pregnancy. This article reports long-term follow-up with no deleterious effects to either mothers or children.

STUDY DESIGN Retrospective chart review. OBJECTIVE To evaluate the outcomes of anterior exposure of the thoracic and lumbar spine by an acute care surgery service. SUMMARY OF BACKGROUND DATA Spine surgeons typically require an "approach surgeon" to provide anterior exposure of the thoracic and lumbar spine. We hypothesized that a dedicated acute care surgery service can perform those operations with acceptable morbidity and mortality. METHODS A retrospective review of 161 trauma and nontrauma patients was performed. All cases were performed at a level I trauma center with a dedicated acute care surgery service. In-hospital morbidity and mortality were evaluated. A brief description of the operative techniques used by our group is also provided. RESULTS Of the 161 patients, 59 (37%) were trauma patients. Ninety-three patients (58%) had anterolateral retroperitoneal exposure of the thoracic and lumbar spine. Sixty-eight patients (42%) had anterior retroperitoneal midline exposure of the lumbar and lumbosacral spine. Total morbidity was 9.3% (7.4% for trauma patients and 1.8% for non trauma patients). Morbidity was highest in patients who had anterolateral exposure of the thoracic and lumbar spine (6.8%). Morbidity in patients who had midline exposure of L4 to S1 was 0%. Total mortality was 1.2% (3.3% for trauma patients and 0% for nontrauma patients). The acute care surgery service gained 3141 physician work relative value units (RVU) by performing those operations. CONCLUSION Anterior exposure of the thoracic and lumbar spine both for trauma and nontrauma related indications can be performed with acceptable morbidity and mortality by a dedicated acute care surgery service. Morbidity and mortality were higher in trauma patients and in those who underwent thoracolumbar procedures. Patients who had midline exposure of L4 to S1 for degenerative disc disease had the lowest morbidity. LEVEL OF EVIDENCE 4.

BACKGROUND Trauma complicates 6% to 7% of all pregnancies. Adverse outcomes are rare when monitoring is normal and early warning signs absent. Trauma systems often use pregnancy as the sole criterion (PSC) for partial trauma team activation. This study compares outcomes of pregnant patients presenting with PSC versus other physiologic, mechanistic, or anatomic (OPMA) activation criteria. METHODS Three hundred fifty-two consecutive obstetric partial trauma team activation patients (2000-2005) were grouped by length of gestation and evaluated for activation criteria and early maternal and fetal outcomes. Data were analyzed using descriptive statistics and analysis of variance. RESULTS Patients ranged in age from 16 to 44 (mean age, 28 +/- 6.4) and in weeks gestation between 1 and 40 weeks (mean, 25 +/- 8 weeks). Eighty-two percent had been in vehicle crashes. One hundred eighty-eight (58%) were activated based on PSC and 137 on OPMA. No PSC patient had injuries sufficient to warrant trauma service admission. Ninety-four percent of all PSCs of

Real-time metabolic monitoring of varied vascular beds provides the raw data necessary to conduct ultraprecise burn shock resuscitation based on second-by-second assessment of regional tissue perfusion. It also illustrates shortcomings of current clinical practices. Arterial base deficit was continuously monitored during 11 clinical resuscitations of patients suffering burn shock using a Paratrend monitor. Separately, in a 30% TBSA rat burn model (N = 70), three Paratrend monitors simultaneously recorded arterial blood gas and tissue pCO 2 of the burn wound and colonic mucosa during resuscitation at 0, 2, 4, 6, and 8 ml/kg/ %TBSA. Paratrend data were analyzed in conjunction with previously reported laser Doppler images of actual burn wound capillary perfusion. With current clinical therapy, continuous monitoring of arterial base deficit revealed repetitive cycles of resolution/worsening/ resolution during burn shock resuscitation. In the rat model, tissue pCO 2 in both burn wounds and splanchnic circulation differed depending on the rate of fluid resuscitation (P