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Withdrawal of care has increased in recent years as the population older than 65 years of age has increased. We sought to investigate the impact of this decision on our mortality rate. We retrospectively reviewed a prospectively collected database to determine the percentage of cases in which care was actively withdrawn. Neurologic injury as the cause for withdrawal, age of the patient, number of days to death, number of cases thought to be treatment failures, and the reason for failure were analyzed. Between January 2008 and December 2012, there were 536 trauma service deaths; 158 (29.5%) had care withdrawn. These patients were 67 (± 18.5) years old and neurologic injury was responsible in 63 per cent (± 5.29%). Fifty-two per cent of the patients died by Day 3; 65 per cent by Day 5; and 74 per cent Day 7. A total of 22.7 per cent (± 7.9%) could be considered a treatment failure. Accounting for cases in which care was withdrawn for futility would decrease the overall mortality rate by approximately 23 per cent. Trauma center mortality calculation does not account for care withdrawn. Treating an active, aging population, with advance directives, requires methodologies that account for such decision-making when determining mortality rates.

Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability has the potential to inject confusion and miscommunication into the disaster incident, particularly when multiple jurisdictions are involved. The Model Uniform Core Criteria for Mass Casualty Triage were developed to be a national guideline for mass casualty triage to ensure interoperability and standardization when responding to a mass casualty incident. The Core Criteria consist of 4 categories: general considerations, global sorting, lifesaving interventions, and individual assessment of triage category. The criteria within each of these categories were developed by a workgroup of experts representing national stakeholder organizations who used the best available science and, when necessary, consensus opinion. This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.

Background: Ventilator-associated pneumonia (VAP) remains a major source of morbidity, mortality, and expense in the ICU despite therapies directed against it., Study Design: A retrospective review of a prospectively developed performance-improvement project monitoring the incidence of VAP in two adjacent ICUs was conducted. In response to an excessive VAP rate, weekly multidisciplinary team meetings were instituted to review data, develop care protocols, and modify care routines. Protocol compliance was monitored daily and feedback provided weekly to the care teams. VAP rates were determined by the institutional Infection Control Committee and reviewed monthly with the ICU multidisciplinary team. Duration of the investigational period was 10 years., Results: A standardized ventilator-weaning protocol was instituted with confirmed 95% use. Additional modifications of care, such as patient positioning, use of specific endotracheal tubes to minimize aspiration of supraglottic secretions, an oral-care regimen, and aggressive antibiotic stewardship were standardized, with a compliance rate >90%. VAP rates dropped from 12.8 per 1,000 patient-days in 1998 to 1.1 in 2007 in the burn trauma ICU and from 21.2 to <1 in the neurotrauma ICU in the same time frame. Also, mean ventilator length of stay decreased from 6 days to 4.2 and from 5.8 days to 4.75 simultaneously in the respective ICUs. Such performance improvement has been sustained since implementation of the program., Conclusion: A systematic, monitored program of standardized care protocols can markedly reduce VAP rate in the ICU.

Background: Human polymerized hemoglobin (PolyHeme, Northfield Laboratories) is a universally compatible oxygen carrier developed to treat life-threatening anemia. This multicenter phase III trial was the first US study to assess survival of patients resuscitated with a hemoglobin-based oxygen carrier starting at the scene of injury., Study Design: Injured patients with a systolic blood pressure

Lung protective ventilation strategies for patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are well documented, and many medical centers fail to apply these strategies in ALI/ARDS. The objective of this study was to determine if we apply these strategies in trauma patients at risk for ALI/ARDS. We undertook a retrospective review of trauma patients mechanically ventilated for > or = 4 days with an ICD-9 for traumatic pneumothorax, hemothorax, lung contusion, and/or fractured ribs admitted from May 1, 1999 through April 30, 2000 (Group 1), the pre-ARDS Network study, and from May 1, 2003 through April 30, 2004 (Group 2), the post-ARDS Network study. Tidal volume (VT)/kg admission body weight, VT/kg ideal body weight (IBW), and plateau and peak pressures were analyzed with respect to mortality. VT/Kg admission body weight and IBW were significantly reduced when comparing Group 1 with Group 2 (9.27 to 8.03 and 11.67 to 10.04, respectively). VT/kg IBW was greater (P < 0.01) for patients who died in Group 1 (13.81) compared with patients who lived (10.29) or died (9.89) in Group 2. Peak and plateau pressures were greater (P < 0.01) in patients who died in Group 1 than patients who lived or died in Group 2. A strict ARDS Network ventilation strategy (VT < 6 mL/kg) is not followed, rather a low plateau/peak pressure strategy is used, which is a form of lung protective ventilation.

A simulation-based training system for surgical wound debridement was developed and comprises a multimedia introduction, a surgical simulator (tutorial component), and an assessment component. The simulator includes two PCs, a haptic device, and mirrored display. Debridement is performed on a virtual leg model with a shallow laceration wound superimposed. Trainees are instructed to remove debris with forceps, scrub with a brush, and rinse with saline solution to maintain sterility. Research and development issues currently under investigation include tissue deformation models using mass-spring system and finite element methods; tissue cutting using a high-resolution volumetric mesh and dynamic topology; and accurate collision detection, cutting, and soft-body haptic rendering for two devices within the same haptic space.

Hypothesis: The use of weaning and sedation protocols affects the intensive care unit (ICU) course of a trauma population., Design: Nonrandomized before-after trial., Setting: A level I trauma center., Patients: Three hundred twenty-eight consecutive trauma patients receiving mechanical ventilation treated in the ICU between October 1, 1997, and November 1, 1999., Intervention: Sedation and weaning protocols were used to treat patients receiving mechanical ventilation during the second year of this study., Main Outcome Measures: Self-extubation rates, ventilator days, number of ICU days, and charges., Results: There were 168 patients in the preprotocol group (year 1: October 1, 1997, to October 31, 1998) and 160 patients in the postprotocol group (year 2: November 1, 1998, to November 30, 1999). The groups were similar in age (P =.68), Injury Severity Score (P =.06), and Glasgow Coma Scale score (P =.29). There were no differences in self-extubation rates (P =.57), ventilator days (P =.83), ventilator charges (P =.83), number of ICU days (P =.67), or ICU charges (P =.67) between the 2 groups. No statistical difference was identified in any of these categories when long-term ventilator patients (defined as ventilator length of stay > or =3 SDs above the mean) were excluded., Conclusions: Use of weaning and sedation protocols did not affect the measured outcomes in this study. These findings may reflect difficulties inherent in the protocols or with their utilization. Further subgroup analysis focusing on ventilator-associated pneumonias and mortality may demonstrate benefits not identified herein.

Background: We hypothesized that clinical factors accurately identify those trauma patients at high risk for pelvic fractures making routine films unnecessary., Methods: Blunt trauma patients were prospectively analyzed both with and without a clinical protocol. The protocol group had pelvic films obtained only if they had a Glasgow Coma Scale score < 13 or had signs and symptoms of pelvic or back injury., Results: The protocol patients with fractures (n = 45) had a higher Injury Severity Score (p = 0.001) and lower systolic blood pressure (p = 0.04) than those without fractures (n = 475). All 45 patients with pelvic fractures were identified by history and physical examination (p = 0.001). The clinical assessment resulted in a sensitivity and a negative predictive value of 100%. A total of 273 films were eliminated, resulting in a charge savings of $51,051. A comparison between the protocol and nonprotocol groups showed the nonprotocol patients with pelvic fractures to have a higher Injury Severity Score (p < 0.002). All of these patients' pelvic fractures were identified by clinical evaluation (67 of 67)., Conclusion: In the awake and alert patient, the need for a pelvic radiograph was readily identified by clinical examination. Because elimination of this film would result in financial savings, its routine use should be removed from standard trauma protocols in the minimally injured patient and limited to severely injured patients as recommended by the Advanced Trauma Life Support protocol.

We evaluated clinical factors that are predictive of pelvic X-ray findings. We sought to identify whether routine pelvic films are necessary in blunt trauma and addressed whether removal of these films would minimize cost. We performed a retrospective chart review of 111 patients without pelvic fractures and 108 with pelvic fractures seen at our Level 1 trauma center between August 1998 and September 1999. We evaluated initial hemodynamics, physical examination findings, laboratory data, and hospital charges. Patients with fractures had higher Injury Severity Scores (P < 0.001), a higher number of associated injuries (P < 0.001), and lower blood pressures (P < 0.001). The back and pelvic examinations were significantly associated with X-ray results (P < 0.001), and the potential savings with selective radiography was $168,300.00 per year. We believe that clinical factors identified in our study predict the need for pelvic X-ray. Because removal of these films would minimize cost we recommend the elimination of routine pelvic films for the awake and alert blunt trauma patient.

This study was undertaken to determine the safety and feasibility of inferior vena cava (IVC) filter insertion at the bedside using duplex imaging in multi-trauma and/or critically ill patients. From February 1996 to August 1997, 53 multi-trauma and/or critically ill patients, who were in the intensive care unit and referred for an IVC filter, were prospectively evaluated for possible duplex directed caval filter (DDCF) insertion. Screening IVC duplex scans were performed in all patients. Satisfactory ultrasound visualization in 46 patients (87%) allowed attempted DDCF insertion. All procedures were percutaneously performed at the bedside using Vena Tech IVC filters. The results from this series showed that DDCF insertion can be safely and rapidly performed at the bedside in multi-trauma or critically ill patients. The procedure is dependent on satisfactory visualization of the IVC by duplex ultrasonography, which was possible in 45 out of 53 (85%) patients. Insertion at the bedside substantially reduces the procedural cost and avoids the need for transport, radiation exposure, and intravenous contrast.

This article discusses many of the aspects of profound shock, including historical perspectives on the concept of shock, the meaning of profound shock, and pathophysiology in shock. Organ systems in shock and methods of shock management also are presented.

The cumulative evidence supports nonoperative management of hepatic trauma in children who are hemodynamically stable and who require less than 50% blood volume replacement to maintain a stable blood count. This management approach, based on the use of either serial computed tomography scans, liver/spleen scans, or ultrasonography to diagnose the injury and document resolution, achieves results that exceed those of operative management for all injuries. Late complications, which may be seen in nonoperated patients, include hemobilia, bile peritonitis, abscesses and bleeding, occur with less frequency than operated patients. We report the first case of late exsanguinating hemorrhage of a resolving hepatic injury.

To determine the effect of admission body weight on blunt trauma victims, a chart review of all patients greater than 12 years of age admitted to Sentara Norfolk General Hospital between January 1 and July 31, 1987 was undertaken. The charts of 351 patients were reviewed; 184 records contained admission height and weight. These 184 patients made up the study group and age, gender, injuries, Injury Severity Score (ISS), ventilator days (VD), complications, length of stay (LOS), and outcome were noted. Body Mass Index (BMI) (weight (kg)/(height(m))2, was calculated for each patient. The average ISS was 21.87 (range, 1-66) and the average BMI was 25.15 kg/m2 (range, 16-46 kg/m2). The overall mortality for the population was 9%. The population was grouped according to BMI: average (less than 27 kg/m2), overweight (27-31 kg/m2), and severely overweight (greater than 31 kg/m2). The mortality of 5.0% and 8.0% in the average and overweight groups was not different. The severely overweight group had a higher mortality at 42.1% compared with the other two groups (p less than 0.0001). The groups did not differ in age, ISS, LOS, nor VD. Age, BMI, and ISS were subjected to regression analysis. By this method BMI and ISS were independent determinants of outcome (p less than 0.0001). There was an increase in complications, mainly pulmonary problems, in the SO group (p less than 0.05). The three groups were subdivided into survivors and nonsurvivors. The nonsurvivors had a longer average LOS at 26.6 days compared with nonsurvivors in the overweight (5.0 days) or severely overweight (8.62 days) groups (p less than 0.007). The severely group was characterized by a rapid deterioration and demise that was unresponsive to intervention. ISS did not differ among nonsuvivors. Among survivors the severely overweight group had a lower ISS, 9.73. This was different from the overweight group (21.57) and from the average group (20.21) (p less than 0.04).