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Harris DG, Koo G, McCrone MP, Weltz AS, Chiu WC, Sarkar R, Scalea TM, Diaz JJ, Lissauer ME, Crawford RS. Acute Kidney Injury in Critically Ill Vascular Surgery Patients is Common and Associated with Increased Mortality. Front Surg 2015; 2:8. [PMID: 25806372 PMCID: PMC4353172 DOI: 10.3389/fsurg.2015.00008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 02/20/2015] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Vascular surgery patients have multiple risk factors for renal dysfunction, but acute kidney injury (AKI) is poorly studied in this group. The purpose of this study was to define the incidence, risk factors, and outcomes of AKI in high-risk vascular patients. METHODS Critically ill vascular surgery patients admitted during January-December 2012 were retrospectively analyzed with 1-year follow-up. The endpoint was AKI by established RIFLE creatinine criteria. The primary analysis was between patients with or without AKI, with secondary analysis of post-operative AKI. Outcomes were inpatient and 1-year mortality, inpatient lengths of stay, and discharge renal function. RESULTS One-hundred and thirty six vascular surgery patients were included, representing 27% of all vascular surgery admissions during the study period. Sixty-five (48%) developed AKI. Independent global risk factors for AKI were diabetes, increasing critical illness severity, and sepsis. While intraoperative blood loss and hypotension were associated with subsequent renal dysfunction, post-operative AKI rates were similar for patients undergoing aortic, carotid, endovascular, or peripheral vascular procedures. All RIFLE grades of AKI were associated with worse outcomes. Overall, patients with AKI had significantly increased short- and long-term mortality, longer inpatient lengths of stay, and worse discharge renal function. CONCLUSION AKI is common among critically ill vascular surgery patients. Importantly, the type of surgical procedure appears to be less important than intra- and perioperative management in determining renal dysfunction. Regardless of its severity, AKI is a clinically significant complication that is associated with substantially worse patient outcomes.
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Affiliation(s)
- Donald G Harris
- Department of Surgery, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Grace Koo
- Department of Surgery, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Michelle P McCrone
- Department of Surgery, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Adam S Weltz
- Department of Surgery, University of Maryland School of Medicine , Baltimore, MD , USA
| | - William C Chiu
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Rajabrata Sarkar
- Department of Surgery, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Jose J Diaz
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Matthew E Lissauer
- Department of Surgery, Rutgers - Robert Wood Johnson Medical School , New Brunswick, NJ , USA
| | - Robert S Crawford
- Department of Surgery, University of Maryland School of Medicine , Baltimore, MD , USA
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Saksobhavivat N, Shanmuganathan K, Chen HH, DuBose JJ, Richard H, Khan MA, Menaker J, Mirvis SE, Scalea TM. Blunt Splenic Injury: Use of a Multidetector CT–based Splenic Injury Grading System and Clinical Parameters for Triage of Patients at Admission. Radiology 2015; 274:702-11. [DOI: 10.1148/radiol.14141060] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, del Junco DJ, Brasel KJ, Bulger EM, Callcut RA, Cohen MJ, Cotton BA, Fabian TC, Inaba K, Kerby JD, Muskat P, O'Keeffe T, Rizoli S, Robinson BRH, Scalea TM, Schreiber MA, Stein DM, Weinberg JA, Callum JL, Hess JR, Matijevic N, Miller CN, Pittet JF, Hoyt DB, Pearson GD, Leroux B, van Belle G. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA 2015; 313:471-82. [PMID: 25647203 PMCID: PMC4374744 DOI: 10.1001/jama.2015.12] [Citation(s) in RCA: 1470] [Impact Index Per Article: 163.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials. OBJECTIVE To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. DESIGN, SETTING, AND PARTICIPANTS Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013. INTERVENTIONS Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled). MAIN OUTCOMES AND MEASURES Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status. RESULTS No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, -4.2% [95% CI, -9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, -3.7% [95% CI, -10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, -5.4% [95% CI, -10.4% to -0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P < .001) and platelets (12 U vs 6 U, P < .001) and similar amounts of red blood cells (9 U) over the first 24 hours, no differences between the 2 groups were found for the 23 prespecified complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications. CONCLUSIONS AND RELEVANCE Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01545232.
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Affiliation(s)
- John B Holcomb
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston
| | - Barbara C Tilley
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center, Houston
| | - Sarah Baraniuk
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center, Houston
| | - Erin E Fox
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston
| | - Charles E Wade
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston
| | - Jeanette M Podbielski
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston
| | - Deborah J del Junco
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston
| | - Karen J Brasel
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee22Dr Brasel is now with the Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland
| | - Eileen M Bulger
- Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington, Seattle
| | - Rachael A Callcut
- Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Francisco
| | - Mitchell Jay Cohen
- Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Francisco
| | - Bryan A Cotton
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston
| | - Timothy C Fabian
- Division of Trauma and Surgical Critical Care, Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis
| | - Kenji Inaba
- Division of Trauma and Critical Care, University of Southern California, Los Angeles
| | - Jeffrey D Kerby
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, School of Medicine, University of Alabama, Birmingham
| | - Peter Muskat
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio23Dr Muskat is now with the Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Franc
| | - Terence O'Keeffe
- Division of Trauma, Critical Care and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Sandro Rizoli
- Trauma and Acute Care Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bryce R H Robinson
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Thomas M Scalea
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Martin A Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland
| | - Deborah M Stein
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Jordan A Weinberg
- Division of Trauma and Surgical Critical Care, Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis
| | - Jeannie L Callum
- Sunnybrook Research Institute, Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - John R Hess
- Department of Laboratory Medicine, School of Medicine, University of Washington, Seattle
| | - Nena Matijevic
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston
| | - Christopher N Miller
- Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jean-Francois Pittet
- Division of Critical Care and Perioperative Medicine, Department of Anesthesiology, School of Medicine, University of Alabama, Birmingham
| | | | - Gail D Pearson
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Brian Leroux
- Department of Biostatistics, School of Public Health, University of Washington, Seattle
| | - Gerald van Belle
- Department of Biostatistics, School of Public Health, University of Washington, Seattle21Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle
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Harris DG, McCrone MP, Koo G, Weltz AS, Chiu WC, Scalea TM, Diaz JJ, Lissauer ME. Epidemiology and outcomes of acute kidney injury in critically ill surgical patients. J Crit Care 2015; 30:102-6. [DOI: 10.1016/j.jcrc.2014.07.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 07/05/2014] [Accepted: 07/29/2014] [Indexed: 02/02/2023]
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Affiliation(s)
- Thomas M Scalea
- School of Medicine, University of Maryland, Baltimore, Maryland, USA
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
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Colton K, Yang S, Hu PF, Chen HH, Stansbury LG, Scalea TM, Stein DM. Responsiveness to therapy for increased intracranial pressure in traumatic brain injury is associated with neurological outcome. Injury 2014; 45:2084-8. [PMID: 25304159 DOI: 10.1016/j.injury.2014.08.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/26/2014] [Accepted: 08/28/2014] [Indexed: 02/02/2023]
Abstract
In patients with severe traumatic brain injury, increased intracranial pressure (ICP) is associated with poor functional outcome or death. Hypertonic saline (HTS) is a hyperosmolar therapy commonly used to treat increased ICP; this study aimed to measure initial patient response to HTS and look for association with patient outcome. Patients >17 years old, admitted and requiring ICP monitoring between 2008 and 2010 at a large urban tertiary care facility were retrospectively enrolled. The first dose of hypertonic saline administered after admission for ICP >19mmHg was recorded and correlated with vital signs recorded at the bedside. The absolute and relative change in ICP at 1 and 2h after HTS administration was calculated. Patients were stratified by mortality and long-term (≥6 months) functional neurological outcome. We identified 46 patients who received at least 1 dose of HTS for ICP>19, of whom 80% were male, mean age 34.4, with a median post-resuscitation GCS score of 6. All patients showed a significant decrease in ICP 1h after HTS administration. Two hours post-administration, survivors showed a further decrease in ICP (43% reduction from baseline), while ICP began to rebound in non-survivors (17% reduction from baseline). When patients were stratified for long-term neurological outcome, results were similar, with a significant difference in groups by 2h after HTS administration. In patients treated with HTS for intracranial hypertension, those who survived or had good neurological outcome, when compared to those who died or had poor outcomes, showed a significantly larger sustained decrease in ICP 2h after administration. This suggests that even early in a patient's treatment, treatment responsiveness is associated with mortality or poor functional outcome. While this work is preliminary, it suggests that early failure to obtain a sustainable response to hyperosmolar therapy may warrant greater treatment intensity or therapy escalation.
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Affiliation(s)
- K Colton
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA; Duke University School of Medicine, Durham, NC, USA.
| | - S Yang
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - P F Hu
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - H H Chen
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - L G Stansbury
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - T M Scalea
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - D M Stein
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Abstract
Trauma is an increasingly common problem in geriatric patients; fractures are frequent among the elderly. Life expectancy continues to rise. Advances in medical care allow people to live longer and better lives. Medications, surgical advances (treatment for coronary artery disease, coronary bypass grafting), and joint replacement surgery can be safely performed in elderly patients. Thus, geriatric patients are no longer confined to a life of inactivity. They are out of their homes and interacting in the community, exercising and leading active lives. Thus, they are more likely to become injured and present to trauma centers for care.
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Affiliation(s)
- Jide Tinubu
- R Adams Cowley Shock Trauma Center, Department of Orthopedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, Department of Orthopedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
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Kalpakis K, Yang S, Hu PF, Mackenzie CF, Stansbury LG, Stein DM, Scalea TM. Permutation entropy analysis of vital signs data for outcome prediction of patients with severe traumatic brain injury. Comput Biol Med 2014; 56:167-74. [PMID: 25464358 DOI: 10.1016/j.compbiomed.2014.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 11/03/2014] [Accepted: 11/07/2014] [Indexed: 11/30/2022]
Abstract
Permutation entropy is computationally efficient, robust to outliers, and effective to measure complexity of time series. We used this technique to quantify the complexity of continuous vital signs recorded from patients with traumatic brain injury (TBI). Using permutation entropy calculated from early vital signs (initial 10-20% of patient hospital stay time), we built classifiers to predict in-hospital mortality and mobility, measured by 3-month Extended Glasgow Outcome Score (GOSE). Sixty patients with severe TBI produced a skewed dataset that we evaluated for accuracy, sensitivity and specificity. The overall prediction accuracy achieved 91.67% for mortality, and 76.67% for 3-month GOSE in testing datasets, using the leave-one-out cross validation. We also applied Receiver Operating Characteristic analysis to compare classifiers built from different learning methods. Those results support the applicability of permutation entropy in analyzing the dynamic behavior of TBI vital signs for early prediction of mortality and long-term patient outcomes.
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Affiliation(s)
- Konstantinos Kalpakis
- Department of Computer Science and Electric Engineering, University of Maryland, Baltimore County, MD 21250, United States.
| | - Shiming Yang
- University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Peter F Hu
- University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Colin F Mackenzie
- University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Lynn G Stansbury
- University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Deborah M Stein
- University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Thomas M Scalea
- University of Maryland School of Medicine, Baltimore, MD 21201, United States
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Colton K, Yang S, Hu PF, Chen HH, Bonds B, Stansbury LG, Scalea TM, Stein DM. Pharmacologic Treatment Reduces Pressure Times Time Dose and Relative Duration of Intracranial Hypertension. J Intensive Care Med 2014; 31:263-9. [PMID: 25320157 DOI: 10.1177/0885066614555692] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 09/18/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Past work has shown the importance of the "pressure times time dose" (PTD) of intracranial hypertension (intracranial pressure [ICP] > 19 mm Hg) in predicting outcome after severe traumatic brain injury. We used automated data collection to measure the effect of common medications on the duration and dose of intracranial hypertension. METHODS Patients >17 years old, admitted and requiring ICP monitoring between 2008 and 2010 at a single, large urban tertiary care facility, were retrospectively enrolled. Timing and dose of ICP-directed therapy were recorded from paper and electronic medical records. The ICP data were collected automatically at 6-second intervals and averaged over 5 minutes. The percentage of time of intracranial hypertension (PTI) and PTD (mm Hg h) were calculated. RESULTS A total of 98 patients with 664 treatment instances were identified. Baseline PTD ranged from 27 (before administration of propofol and fentanyl) to 150 mm Hg h (before mannitol). A "small" dose of hypertonic saline (HTS; ≤250 mL 3%) reduced PTD by 38% in the first hour and 37% in the second hour and reduced the time with ICP >19 by 38% and 39% after 1 and 2 hours, respectively. A "large" dose of HTS reduced PTD by 40% in the first hour and 63% in the second (PTI reduction of 36% and 50%, respectively). An increased dose of propofol or fentanyl infusion failed to decrease PTD but reduced PTI between 14% (propofol alone) and 30% (combined increase in propofol and fentanyl, after 2 hours). Barbiturates failed to decrease PTD but decreased PTI by 30% up to 2 hours after administration. All reductions reported are significantly changed from baseline, P < .05. CONCLUSION Baseline PTD values before drug administration reflects varied patient criticality, with much higher values seen before the use of mannitol or barbiturates. Treatment with HTS reduced PTD and PTI burden significantly more than escalation of sedation or pain management, and this effect remained significant at 2 hours after administration.
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Affiliation(s)
- Katharine Colton
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA Duke University School of Medicine, Durham, NC, USA
| | - S Yang
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - P F Hu
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - H H Chen
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - B Bonds
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - L G Stansbury
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - T M Scalea
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - D M Stein
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Harris DG, Rabin J, Kufera JA, Taylor BS, Sarkar R, O'Connor JV, Scalea TM, Crawford RS. A new aortic injury score predicts early rupture more accurately than clinical assessment. J Vasc Surg 2014; 61:332-8. [PMID: 25195146 DOI: 10.1016/j.jvs.2014.08.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 08/01/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The optimal timing for repair of a high-grade blunt thoracic aortic injury (BTAI) is uncertain. Delayed repair is common and associated with improved outcomes, but some lesions may rupture during observation. To determine optimal patient selection for appropriate management, we developed a pilot clinical risk score to evaluate aortic stability and predict rupture. METHODS Patients presenting in stable condition with Society for Vascular Surgery grade III or IV BTAI diagnosed on computed tomography (CT) were retrospectively reviewed. To determine clinical and radiographic factors associated with aortic rupture, patients progressing to aortic rupture (defined by contrast extravasation on CT or on operative or autopsy findings) were compared with those who had no intervention ≤48 hours of admission. A model targeting 100% sensitivity for rupture was generated and internally validated by bootstrap analysis. Clinical utility was tested by comparison with clinical assessment by surgeons experienced in BTAI management who were provided with CT images and clinical data but were blinded to outcome. RESULTS The derivation cohort included 18 patients whose aorta ruptured and 31 with stable BTAI. There was no difference in age, gender, injury mechanism, nonchest injury severity, blood pressure, or Glasgow Coma Scale on admission between patient groups. As dichotomous factors, admission lactate >4 mM, posterior mediastinal hematoma >10 mm, and lesion/normal aortic diameter ratio >1.4 on the admission CT were independently associated with aortic rupture. The model had an area under the receiver operator curve of .97, and in the presence of any two factors, was 100% sensitive and 84% specific for predicting aortic rupture. No aortic lesions ruptured in patients with fewer than two factors. In contrast, clinical assessment had lower accuracy (65% vs 90% total accuracy, P < .01). CONCLUSIONS This novel risk score can be applied on admission using clinically relevant factors that incorporate patient physiology, size of the aortic lesion, and extent of the mediastinal hematoma. The model reliably identifies and distinguishes patients with high-grade BTAI who are at risk for early rupture from those with stable lesions. Although preliminary, because it is more accurate than clinical assessment alone, the score may improve patient selection for emergency or delayed intervention.
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Affiliation(s)
- Donald G Harris
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md.
| | - Joseph Rabin
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md
| | - Joseph A Kufera
- National Study Center; Shock, Trauma and Anesthesiology Research Center, University of Maryland Medical Center, Baltimore, Md
| | - Bradley S Taylor
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, Md
| | - Rajabrata Sarkar
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, Md
| | - James V O'Connor
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md
| | - Thomas M Scalea
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md; National Study Center; Shock, Trauma and Anesthesiology Research Center, University of Maryland Medical Center, Baltimore, Md
| | - Robert S Crawford
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, Md
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Colton K, Yang S, Hu PF, Chen HH, Bonds B, Scalea TM, Stein DM. Intracranial pressure response after pharmacologic treatment of intracranial hypertension. J Trauma Acute Care Surg 2014; 77:47-53; discussion 53. [PMID: 24977754 DOI: 10.1097/ta.0000000000000270] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The accepted treatment of increased intracranial pressure (ICP) in patients experiencing severe traumatic brain injury is multimodal and algorithmic, obscuring individual effects of treatment. Using continuous vital signs monitoring, we sought to measure treatment effect and ascertain the accuracy of manual data recording. METHODS Patients older than 17 years, admitted and requiring ICP monitoring between 2008 and 2010 at a high-volume urban trauma center, were retrospectively evaluated. Timing and dose of ICP-directed therapy were recorded from paper and electronic medical records. ICP data were collected automatically at 6-second intervals and from manual charts. A statistical mixed model was applied to all data to account for multiple sampling. RESULTS A total of 117 patients met inclusion criteria; 450 treatments were administered when nursing records indicate an ICP greater than 20 mm Hg, while 968 treatments were given when ICP was greater than 20 mm Hg by automated data. Pharmacologic treatments identified include hypertonic saline (HTS), mannitol, barbiturates, and dose escalations of propofol or fentanyl infusions. Treatment with HTS resulted in the largest ICP decrease of the treatments examined, with a 1-hour ICP reduction of 8.8/9.9 mm Hg (for a small/large dose) according to manual data and a reduction of 3.0/2.4 mm Hg according to automated data. Propofol and fentanyl escalations resulted in smaller but significant ICP reductions. Mannitol (n = 8) resulted in statistically insignificant trends down in the first hour but rebounded by the second hour after administration. The average ICP in the hour before medication administration was higher for barbiturates (27 mm Hg) and mannitol (32 mm Hg) than for the other interventions (18-19 mm Hg). CONCLUSION ICP fell after administration of HTS, mannitol, or barbiturates and showed continued improvement after 2 hours. ICP fell initially after treatment with short-acting propofol and fentanyl but trended back up after 2 hours. Manually recorded data consistently overestimated treatment effectiveness. Automated data collection gives a more accurate assessment of patient status and responsiveness to treatment. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Affiliation(s)
- Katharine Colton
- From the Shock Trauma Anesthesia Research Organized Research Center (K.C., S.Y., P.F.H., H.H.C., B.B., T.M.S., D.M.S.), University of Maryland School of Medicine; and R Adams Cowley Shock Trauma Center (K.C., S.Y., P.F.H., H.H.C., B.B., T.M.S., D.M.S.), Baltimore, Maryland; and Duke University School of Medicine (K.C.), Durham, North Carolina
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Bruns BR, DuBose J, Pasley J, Kheirbek T, Chouliaras K, Riggle A, Frank MK, Phelan HA, Holena D, Inaba K, Diaz J, Scalea TM. Loop versus end colostomy reversal: has anything changed? Eur J Trauma Emerg Surg 2014; 41:539-43. [PMID: 26037983 DOI: 10.1007/s00068-014-0444-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 08/26/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Though primary repair of colon injuries is preferred, certain injury patterns require colostomy creation. Colostomy reversal is associated with significant morbidity and healthcare cost. Complication rates may be influenced by technique of diversion (loop vs. end colostomy), though this remains ill-defined. We hypothesized that reversal of loop colostomies is associated with fewer complications than end colostomies. METHODS This is a retrospective, multi-institutional study (four, level-1 trauma centers) of patients undergoing colostomy takedown for trauma during the time period 1/2006-12/2012. Data were collected from index trauma admission and subsequent admission for reversal and included demographics and complications of reversal. Student's t test was used to compare continuous variables against loop versus end colostomy. Discrete variables were compared against both groups using Chi-squared tests. RESULTS Over the 6-year study period, 218 patients underwent colostomy takedown after trauma with a mean age of 30; 190 (87%) were male, 162 (74%) had penetrating injury as their indication for colostomy, and 98 (45%) experienced at least one complication. Patients in the end colostomy group (n = 160) were more likely to require midline laparotomy (145 vs. 18, p < 0.001), had greater intra-operative blood loss (260.7 vs. 99.4 mL, p < 0.001), had greater hospital length of stay (8.4 vs. 5.5 days, p < 0.001), and had more overall complications (81 vs. 17, p = 0.005) than patients managed with loop colostomy (n = 58). CONCLUSIONS Local takedown of a loop colostomy is safe and leads to shorter hospital stays, less intra-operative blood loss, and fewer complications when compared to end colostomy.
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Affiliation(s)
- B R Bruns
- R Adams Cowley Shock Trauma Center, University of Maryland, 22 S Greene St S4D07, Baltimore, MD, 21201, USA.
| | - J DuBose
- The University of Texas Health Science Center, Houston, TX, USA.
| | - J Pasley
- R Adams Cowley Shock Trauma Center, University of Maryland, 22 S Greene St S4D07, Baltimore, MD, 21201, USA.
| | - T Kheirbek
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, PA, USA.
| | - K Chouliaras
- Department of Surgery, University of Southern California, Los Angeles, CA, USA.
| | - A Riggle
- Parkland Memorial Hospital, The University of Texas Southwestern, Dallas, TX, USA.
| | - M K Frank
- R Adams Cowley Shock Trauma Center, University of Maryland, 22 S Greene St S4D07, Baltimore, MD, 21201, USA.
| | - H A Phelan
- Parkland Memorial Hospital, The University of Texas Southwestern, Dallas, TX, USA.
| | - D Holena
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, PA, USA.
| | - K Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA, USA.
| | - J Diaz
- R Adams Cowley Shock Trauma Center, University of Maryland, 22 S Greene St S4D07, Baltimore, MD, 21201, USA.
| | - T M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland, 22 S Greene St S4D07, Baltimore, MD, 21201, USA.
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Scalea TM, Carco D, Reece M, Fouche YL, Pollak AN, Nagarkatti SS. Effect of a Novel Financial Incentive Program on Operating Room Efficiency. JAMA Surg 2014; 149:920-4. [DOI: 10.1001/jamasurg.2014.1233] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Thomas M. Scalea
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Darlene Carco
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Melissa Reece
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Yvette L. Fouche
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Andrew N. Pollak
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Sushruta S. Nagarkatti
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
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215
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Baraniuk S, Tilley BC, del Junco DJ, Fox EE, van Belle G, Wade CE, Podbielski JM, Beeler AM, Hess JR, Bulger EM, Schreiber MA, Inaba K, Fabian TC, Kerby JD, Cohen MJ, Miller CN, Rizoli S, Scalea TM, O’Keeffe T, Brasel KJ, Cotton BA, Muskat P, Holcomb JB. Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: design, rationale and implementation. Injury 2014; 45:1287-95. [PMID: 24996573 PMCID: PMC4137482 DOI: 10.1016/j.injury.2014.06.001] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/01/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Forty percent of in-hospital deaths among injured patients involve massive truncal haemorrhage. These deaths may be prevented with rapid haemorrhage control and improved resuscitation techniques. The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial was designed to determine if there is a difference in mortality between subjects who received different ratios of FDA approved blood products. This report describes the design and implementation of PROPPR. STUDY DESIGN PROPPR was designed as a randomized, two-group, Phase III trial conducted in subjects with the highest level of trauma activation and predicted to have a massive transfusion. Subjects at 12 North American level 1 trauma centres were randomized into one of two standard transfusion ratio interventions: 1:1:1 or 1:1:2, (plasma, platelets, and red blood cells). Clinical data and serial blood samples were collected under Exception from Informed Consent (EFIC) regulations. Co-primary mortality endpoints of 24h and 30 days were evaluated. RESULTS Between August 2012 and December 2013, 680 patients were randomized. The overall median time from admission to randomization was 26min. PROPPR enrolled at higher than expected rates with fewer than expected protocol deviations. CONCLUSION PROPPR is the largest randomized study to enrol severely bleeding patients. This study showed that rapidly enrolling and successfully providing randomized blood products to severely injured patients in an EFIC study is feasible. PROPPR was able to achieve these goals by utilizing a collaborative structure and developing successful procedures and design elements that can be part of future trauma studies.
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Affiliation(s)
- Sarah Baraniuk
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Barbara C. Tilley
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Deborah J. del Junco
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | - Erin E. Fox
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | | | - Charles E. Wade
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | - Jeanette M. Podbielski
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | - Angela M. Beeler
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | | | - Eileen M. Bulger
- Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington
| | - Martin A. Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University
| | - Kenji Inaba
- Division of Trauma and Critical Care, University of Southern California
| | - Timothy C. Fabian
- Division of Trauma and Surgical Critical Care, Department of Surgery, Medical School, University of Tennessee Health Science Center
| | - Jeffrey D. Kerby
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, School of Medicine, University of Alabama at Birmingham
| | - Mitchell J. Cohen
- Division of General Surgery, Department of Surgery, School of Medicine, University of California San Francisco
| | | | - Sandro Rizoli
- Trauma and Acute Care Surgery, St Michael’s Hospital, University of Toronto
| | - Thomas M. Scalea
- R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine
| | - Terence O’Keeffe
- Division of Trauma, Critical Care and Emergency Surgery, Department of Surgery, University of Arizona
| | - Karen J. Brasel
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin
| | - Bryan A. Cotton
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | - Peter Muskat
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati
| | - John B. Holcomb
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
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216
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Rabin J, Harris DG, Crews GA, Ho M, Taylor BS, Sarkar R, O'Connor JV, Scalea TM, Crawford RS. Early Aortic Repair Worsens Concurrent Traumatic Brain Injury. Ann Thorac Surg 2014; 98:46-51; discussion 51-2. [DOI: 10.1016/j.athoracsur.2014.04.025] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 03/28/2014] [Accepted: 04/04/2014] [Indexed: 10/25/2022]
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Pommerening MJ, DuBose JJ, Zielinski MD, Phelan HA, Scalea TM, Inaba K, Velmahos GC, Whelan JF, Wade CE, Holcomb JB, Cotton BA. Time to first take-back operation predicts successful primary fascial closure in patients undergoing damage control laparotomy. Surgery 2014; 156:431-8. [PMID: 24962190 DOI: 10.1016/j.surg.2014.04.019] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 04/14/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Failure to achieve primary fascial closure (PFC) after damage control laparotomy is costly and carries great morbidity. We hypothesized that time from the initial laparotomy to the first take-back operation would be predictive of successful PFC. METHODS Trauma patients managed with open abdominal techniques after damage control laparotomy were prospectively followed at 14 Level 1 trauma centers during a 2-year period. Time to the first take-back was evaluated as a predictor of PFC using hierarchical multivariate logistic regression analysis. RESULTS A total of 499 patients underwent damage control laparotomy and were included in this analysis. PFC was achieved in 327 (65.5%) patients. Median time to the first take-back operation was 36 hours (interquartile range 24-48). After we adjusted for patient demographics, resuscitation volumes, and operative characteristics, increasing time to the first take-back was associated with a decreased likelihood of PFC. Specifically, each hour delay in return to the operating room (24 hours after initial laparotomy) was associated with a 1.1% decrease in the odds of PFC (odds ratio 0.989; 95% confidence interval 0.978-0.999; P = .045). In addition, there was a trend towards increased intra-abdominal complications in patients returning after 48 hours (odds ratio 1.80; 95% confidence interval 1.00-3.25; P = .05). CONCLUSION Data from this prospective, multicenter study demonstrate that delays in returning to the operating room after damage control laparotomy are associated with reductions in PFC. These findings suggest that emphasis should be placed on returning to the operating room within 24 hours after the initial laparotomy if possible (and no later than 48 hours).
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Affiliation(s)
- Matthew J Pommerening
- Department of Surgery, The University of Texas Health Science Center, Houston, TX; Center for Translational Injury Research, The University of Texas Health Science Center, Houston, TX
| | - Joseph J DuBose
- Department of Surgery, The University of Texas Health Science Center, Houston, TX
| | | | - Herb A Phelan
- Department of Surgery, University Of Texas Southwestern Medical Center, Dallas, TX
| | - Thomas M Scalea
- The R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD
| | - Kenji Inaba
- Department of Surgery, Los Angeles County + University of Southern California Hospital, Los Angeles, CA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, MA
| | - James F Whelan
- Division of Trauma, Critical Care, and Emergency Surgery, Virginia Commonwealth University, Richmond, VA
| | - Charles E Wade
- Department of Surgery, The University of Texas Health Science Center, Houston, TX; Center for Translational Injury Research, The University of Texas Health Science Center, Houston, TX
| | - John B Holcomb
- Department of Surgery, The University of Texas Health Science Center, Houston, TX; Center for Translational Injury Research, The University of Texas Health Science Center, Houston, TX
| | - Bryan A Cotton
- Department of Surgery, The University of Texas Health Science Center, Houston, TX; Center for Translational Injury Research, The University of Texas Health Science Center, Houston, TX.
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218
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Harris DG, Koo G, McCrone MP, Sarkar R, Chiu WC, Scalea TM, Diaz JJ, Lissauer ME, Crawford RS. PS56 Acute Kidney Injury in Critically Ill Vascular Surgery Patients Is Associated With Increased Mortality Regardless of Severity and Type of Index Procedure. J Vasc Surg 2014. [DOI: 10.1016/j.jvs.2014.03.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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219
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Haan JM, Bochicchio GV, Conway A, Bochicchio KM, Scalea TM. Splenic Embolization Decreases Infectious Complications and Resource Utilization Compared to Splenectomy in Severely Injured Patients. Kans J Med 2014. [DOI: 10.17161/kjm.v7i2.11485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction. Increasing use of main coil angioembolization for splenic injury has raised concerns of increased complication rates and resource utilization compared to splenectomy. This study examined complication rates for severely injured patients undergoing splenectomy versus main coil angioembolization. Methods. Demographic data (age, sex, and race), Injury Severity Score (ISS), and splenic injury grade were collected prospectively on all patients admitted to the intensive care unit with blunt splenic injury treated with splenectomy or main coil angioembolization. Outcome measures (transfusion requirements, mechanical ventilation use and duration, mortality, intensive care unit and hospital length of stay, infection rate, and systemic inflammatory response syndrome or SIRS score) were reviewed daily. Results. Of 116 patients reviewed, 65 underwent splenectomy and 51 underwent main coil angioembolization. Groups were comparable for age, sex, race, and mechanism of injury. Splenectomized patients had a higher ISS (41 vs 31) and splenic injury grade (3.7 vs 3.2). The main coil angioembolization group had a lower transfusion requirement, hospital length of stay, incidence of mechanical ventilation, nosocomial infection rate, and SIRS score. Overall, mortality and ventilator days were lower but not statistically significant. Conclusions. Severely injured patients treated with splenectomy had significantly higher infection rates and resource utilization compared to those treated with main coil angioembolization.
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220
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Thom KA, Li S, Custer M, Preas MA, Rew CD, Cafeo C, Leekha S, Caffo BS, Scalea TM, Lissauer ME. Successful implementation of a unit-based quality nurse to reduce central line-associated bloodstream infections. Am J Infect Control 2014; 42:139-43. [PMID: 24360354 DOI: 10.1016/j.ajic.2013.08.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/19/2013] [Accepted: 08/20/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND Central line (CL)-associated bloodstream infections (CLABSI) are an important cause of patient morbidity and mortality. Novel strategies to prevent CLABSI are needed. METHODS We described a quasiexperimental study to examine the effect of the presence of a unit-based quality nurse (UQN) dedicated to perform patient safety and infection control activities with a focus on CLABSI prevention in a surgical intensive care unit (SICU). RESULTS From July 2008 to March 2012, there were 3,257 SICU admissions; CL utilization ratio was 0.74 (18,193 CL-days/24,576 patient-days). The UQN program began in July 2010; the nurse was present for 30% (193/518) of the days of the intervention period of July 2010 to March 2012. The average CLABSI rate was 5.0 per 1,000 CL-days before the intervention and 1.5 after the intervention and decreased by 5.1% (P = .005) for each additional 1% of days of the month that the UQN was present, even after adjusting for CLABSI rates in other adult intensive care units, time, severity of illness, and Comprehensive Unit-based Safety Program participation (5.1%, P = .004). Approximately 11.4 CLABSIs were prevented. CONCLUSION The presence of a UQN dedicated to perform infection control activities may be an effective strategy for CLABSI reduction.
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Affiliation(s)
- Kerri A Thom
- University of Maryland School of Medicine, Baltimore, MD.
| | - Shanshan Li
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | | | | | - Cindy D Rew
- University of Maryland Medical Center, Baltimore, MD
| | | | - Surbhi Leekha
- University of Maryland School of Medicine, Baltimore, MD
| | - Brian S Caffo
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Thomas M Scalea
- University of Maryland School of Medicine, Program in Trauma, Baltimore, MD
| | - Matthew E Lissauer
- University of Maryland School of Medicine, Program in Trauma, Baltimore, MD
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221
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Stein DM, Brenner M, Hu PF, Yang S, Hall EC, Stansbury LG, Menaker J, Scalea TM. Timing of intracranial hypertension following severe traumatic brain injury. Neurocrit Care 2014; 18:332-40. [PMID: 23494545 DOI: 10.1007/s12028-013-9832-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND We asked whether continuous intracranial pressure (ICP) monitoring data could provide objective measures of the degree and timing of intracranial hypertension (ICH) in the first week of neurotrauma critical care and whether such data could be linked to outcome. METHODS We enrolled adult (>17 years old) patients admitted to our Level I trauma center within 6 h of severe TBI. ICP data were automatically captured and ICP 5-minute means were grouped into 12-hour time periods from admission (hour 0) to >7 days (hour 180). Means, maximum, percent time (% time), and pressure-times-time dose (PTD, mmHg h) of ICP >20 mmHg and >30 mmHg were calculated for each time period. RESULTS From 2008 to 2010, we enrolled 191 patients. Only 2.1% had no episodes of ICH. The timing of maximum PTD20 was relatively equally distributed across the 15 time periods. Median ICP, PTD20, %time20, and %time30 were all significantly higher in the 84-180 h time period than the 0-84 h time period. Stratified by functional outcome, those with poor functional outcome had significantly more ICH in hours 84-180. Multivariate analysis revealed that, after 84 h of monitoring, every 5% increase in PTD20 was independently associated with 21% higher odds of having a poor functional outcome (adjusted odds ratio = 1.21, 95% CI 1.02-1.42, p = 0.03). CONCLUSIONS Although early elevations in ICP occur, ICPs are the highest later in the hospital course than previously understood, and temporal patterns of ICP elevation are associated with functional outcome. Understanding this temporal nature of secondary insults has significant implications for management.
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Affiliation(s)
- Deborah M Stein
- Program in Trauma, Division of Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
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222
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Bradley MJ, Dubose JJ, Scalea TM, Holcomb JB, Shrestha B, Okoye O, Inaba K, Bee TK, Fabian TC, Whelan JF, Ivatury RR. Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy: results from the prospective AAST Open Abdomen registry. JAMA Surg 2013; 148:947-54. [PMID: 23965658 DOI: 10.1001/jamasurg.2013.2514] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Enterocutaneous fistula (ECF), enteroatmospheric fistula (EAF), and intra-abdominal sepsis/abscess (IAS) are major challenges for surgeons caring for patients undergoing damage control laparotomy after trauma. OBJECTIVE To determine independent predictors of ECF, EAF, or IAS in patients undergoing damage control laparotomy after trauma, using the AAST Open Abdomen Registry. DESIGN The AAST Open Abdomen registry of patients with an open abdomen following damage control laparotomy was used to identify patients who developed ECF, EAF, or IAS and to compare these patients with those without these complications. Univariate analyses were performed to compare these groups of patients. Variables from univariate analyses differing at P < .20 were entered into a stepwise logistic regression model to identify independent risk factors for ECF, EAF, or IAS. SETTING Fourteen level I trauma centers. PARTICIPANTS A total of 517 patients with an open abdomen following damage control laparotomy. MAIN OUTCOMES AND MEASURES Complication of ECF, EAF, or IAS. RESULTS More patients in the ECF/EAF/IAS group than in the group without these complications underwent bowel resection (63 of 111 patients [57%] vs 133 of 406 patients [33%]; P < .001). Within the first 48 hours after surgery, the ECF/EAF/IAS group received more colloids (P < .03) and total fluids (P < .03) than did the group without these complications. The ECF/EAF/IAS group underwent almost twice as many abdominal reexplorations as did the group without these complications (mean [SD] number, 4.1 [4.1] vs 2.2 [3.4]; P < .001). After multivariate analysis, the independent predictors of ECF/EAF/IAS were a large bowel resection (adjusted odds ratio [AOR], 3.56 [95% CI, 1.88-6.76]; P < .001), a total fluid intake at 48 hours of between 5 and 10 L (AOR, 2.11 [95% CI, 1.15-3.88]; P = .02) or more than 10 L (AOR, 1.93 [95% CI, 1.04-3.57]; P = .04), and an increasing number of reexplorations (AOR, 1.14 [95% CI, 1.06-1.21]; P < .001). CONCLUSIONS AND RELEVANCE Large bowel resection, large-volume fluid resuscitation, and an increasing number of abdominal reexplorations were statistically significant predictors of ECF, EAF, or IAS in patients with an open abdomen after damage control laparotomy.
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Affiliation(s)
- Matthew J Bradley
- Division of Trauma and Acute Care Surgery, University of Maryland Medical System, R. Adams Cowley Shock Trauma Center, Baltimore
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O'Connor JV, Chi A, Joshi M, DuBose J, Scalea TM. Post-traumatic empyema: aetiology, surgery and outcome in 125 consecutive patients. Injury 2013; 44:1153-8. [PMID: 22534461 DOI: 10.1016/j.injury.2012.03.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Revised: 02/26/2012] [Accepted: 03/24/2012] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Empyema remains a potentially serious condition with multiple etiologies including post-pneumonic, post-resection, and post-traumatic. There are few studies describing the latter. We reviewed our experience at a high volume trauma centre in injured patients with empyema, examining pre-operative status, surgical procedures, pathogens and outcome. METHODS Retrospective trauma registry review, from 9/01 to 4/10. Empyema was defined as culture positive pleural fluid or purulence at operation. Data collected included demographics, injury mechanism, thoracic injuries, organ dysfunction, pathogens isolated, surgical procedures, outcomes and follow up. RESULTS One hundred twenty-five consecutive patients with empyema were identified. Average injury severity score and age were 27.3 and 37.2 years respectively; 89.6% were male, 63.2% sustained blunt chest trauma. Time from injury to diagnosis averaged 12.1 days. All underwent decortication; 80% by thoracotomy, the remainder thoracoscopically. At operation over half were mechanically ventilated and 13.6% required vasoactive infusions. Monomicrobial cultures with Gram positive cocci predominating were obtained in 44%, 48% had polymicrobial cultures and 18.4% had a ruptured lung abscess. There were five deaths (4%); two occurring after a ruptured lung abscess. Recurrent empyema occurred in 6.4%, all successfully treated by re-operation or catheter drainage. Intensive care and hospital stays were 18.1 and 30.6 days respectively. All survivors achieved resolution of empyema. CONCLUSIONS Trauma patients with empyema represent a subset of severely injured critically ill patients with diverse pathogens and polymicrobial flora. Appropriate surgical management and specific antibiotic therapy yields excellent results with acceptable risk. A ruptured lung abscess may be the aetiology of the post-traumatic empyema in a subset of patients and may represent an increased operative risk.
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Affiliation(s)
- James V O'Connor
- University of Maryland Medical System, R Adams Cowley Shock Trauma Center, United States.
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Ray-Mazumder N, Lau BD, Haider AH, Scalea TM, Kim P, Martin ND, Santora TA, Benoit SR, Efron DT, Haut ER. Pre-hospital care of urban gunshot wound patients: a tale of two cities. J Am Coll Surg 2013. [DOI: 10.1016/j.jamcollsurg.2013.07.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bochicchio GV, De Castro GP, Bochicchio KM, Weeks J, Rodriguez E, Scalea TM. Comparison study of acellular dermal matrices in complicated hernia surgery. J Am Coll Surg 2013; 217:606-13. [PMID: 23973102 DOI: 10.1016/j.jamcollsurg.2013.04.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 04/29/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Damage control surgery and management of the open abdomen has led to a significant improvement in survival in trauma and emergency surgical patients. However, subsequent abdominal reconstruction has become a significant challenge. The objective of this study was to compare 2 different acellular dermal matrices in regard to hernia recurrence and complications in patients who present with a large complicated ventral hernia as a result of trauma or emergency surgery. STUDY DESIGN A prospective quasi-experimental time-interrupted series design was used to evaluate the incidence of hernia recurrence in trauma/emergency surgery patients who had a ventral hernia repair with a biologic matrix. From January 2005 to December 2007, 55 patients with a complicated ventral hernia were repaired with AlloDerm (Life Cell Corporation). Beginning in February 2008 to January 2010, 40 patients with the same criteria were repaired with FlexHD (Musculoskeletal Transplant Foundation) and followed prospectively over the following year. The primary outcome for this study was hernia recurrence (functional or real) at 1 year. Other outcomes variables included abdominal laxity, seroma formation, and wound or intra-abdominal infection. RESULTS There was no significant difference in age, sex, and body mass index between the groups. In addition, there was no significant difference in the mean hernia size and size of the acellular dermis that was inserted. At 1 year postsurgery, all of the AlloDerm patients were diagnosed with recurrence requiring a second formal repair. Eleven patients (31%) whose hernias were repaired with FlexHD were diagnosed with a recurrence requiring a second formal repair. CONCLUSIONS FlexHD appears to have reduced the recurrence and laxity rates while maintaining a similar complication profile compared with AlloDerm in trauma/emergency surgery patients with large complicated ventral hernias.
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Affiliation(s)
- Grant V Bochicchio
- Department of Surgery, Washington University in St Louis School of Medicine, St Louis, MO.
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226
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Harris DG, Drucker CB, Brenner ML, Narayan M, Sarkar R, Scalea TM, Crawford RS. Patterns and Management of Blunt Iliac Arterial Injuries. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.02.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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227
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Sheth KN, Stein DM, Aarabi B, Hu P, Kufera JA, Scalea TM, Hanley DF. Intracranial Pressure Dose and Outcome in Traumatic Brain Injury. Neurocrit Care 2012; 18:26-32. [DOI: 10.1007/s12028-012-9780-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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228
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Abstract
TICS is a complex disease that is clearly multifactorial in the traumatically injured patient (Fig. 2). Although systemic inflammation that occurs directly as a result of injury plays the most prominent role, the local tissue and organ injury effects of trauma not only cause local capillary leak and edema but also further amplify the SIRS response. High volume fluid administration and hypoproteinemic states further exacerbate the problem. All of this leads to organ dysfunction and failure, which is the third leading cause of death following injury. Strategies to treat TICS and attenuate its effects once it occurs by targeting inflammatory pathways have been wholly unsuccessful. The mainstay of therapy for TICS is prevention and minimization of its lethal effects. Newer resuscitation strategies such as hemostatic resuscitation and early goal-directed therapies are currently the best available strategies to combat TICS. Whether these result in better outcomes remains to be seen and the authors anxiously await the results of well-designed prospective trials.
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Affiliation(s)
- Deborah M Stein
- University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
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229
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Stansbury LG, Hess AS, Thompson K, Kramer B, Scalea TM, Hess JR. The clinical significance of platelet counts in the first 24 hours after severe injury. Transfusion 2012; 53:783-9. [PMID: 22882316 DOI: 10.1111/j.1537-2995.2012.03828.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Admission platelet (PLT) counts are known to be associated with all-cause mortality for seriously injured patients admitted to a trauma center. The course of subsequent PLT counts, their implications, and the effects of PLT therapy are less well known. STUDY DESIGN AND METHODS Trauma center patients who were directly admitted from the scene of injury, received 1 or more units of uncrossmatched red blood cells in the first hour of care, survived for at least 15 minutes, and had a PLT count measured in the first hour were analyzed for the association of their admission and subsequent PLT counts in the first 24 hours with injury severity and hemorrhagic and central nervous system (CNS) causes of in-hospital mortality. RESULTS Over an 8.25-year period, 1292 of 45,849 direct trauma admissions met entry criteria. Admission PLT counts averaged 228×10(9) ±90×10(9) /L and decreased by 104×10(9) /L by the second hour and 1×10(9) /L each hour thereafter. The admission count was not related to time to admission. Each 1-point increase in the injury severity score was associated with a 1×10(9) /L decrease in the PLT count at all times in the first 24 hours of care. Admission PLT counts were strongly associated with hemorrhagic and CNS injury mortality and subsequent PLT counts. Effects of PLT therapy could not be ascertained. DISCUSSION Admission PLT counts in critically injured trauma patients are usually normal, decreasing after admission. Low PLT counts at admission and during the course of trauma care are strongly associated with mortality.
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Affiliation(s)
- Lynn G Stansbury
- Program in Trauma, Epidemiology, and Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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230
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Rabinowitz RP, Tabatabai A, Stein DM, Scalea TM. Infectious complications in GSW's through the gastrointestinal tract into the spine. Injury 2012; 43:1058-60. [PMID: 22306933 DOI: 10.1016/j.injury.2012.01.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 12/05/2011] [Accepted: 01/13/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Trans-gastrointestinal tract GSW's to the spine are devastating injuries with significant potential for infectious complications. We sought to address antimicrobial management of these injuries. METHODS We retrospectively analysed all patients with penetrating trauma through the GI tract into the spine admitted to a level I trauma centre from 1/02 to 12/09. Patients were excluded if they died within 24h. Patients received 24-48 h of peri-operative prophylactic antibiotics, except in damage control where antibiotics were continued until packs were removed. RESULTS 51 patients were included. 94% were male with a mean age of 27 years. The mean ISS was 28 (9-50). The mean length of stay was 19 days (3-53) and mortality was 9.8%. The mean follow up period was 277 days (0-1765). There were 12 gastric, 25 small bowel, 26 colonic, and 4 esophageal injuries. There were 48 exploratory laparotomies, of which 12 were damage control procedures. 18 patients had no infections. There were 20 abdominal infections and 7 surgical wound infections. There were 23 infections not related to the abdomen. One patient developed a CNS infection 4 days after discharge despite receiving a two week course of piperacillin/tazobactam for Escherichia coli bacteremia during his initial hospital stay. There were no other CNS infections. CONCLUSION Despite the potential for significant deep infections of the spine, standard antimicrobial prophylaxis is sufficient for the initial management of these patients.
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Affiliation(s)
- Ronald P Rabinowitz
- Department of Medicine, University of Maryland School of Medicine, Infectious Diseases, R Adams Cowley Shock Trauma Center, Room T3N11, 22 S. Greene Street, Baltimore, MD 21201, USA.
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231
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Stein DM, Lindel AL, Murdock KR, Kufera JA, Menaker J, Scalea TM. Use of Serum Biomarkers to Predict Secondary Insults Following Severe Traumatic Brain Injury. Shock 2012; 37:563-8. [DOI: 10.1097/shk.0b013e3182534f93] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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232
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Stein DM, Lindell AL, Murdock KR, Kufera JA, Menaker J, Bochicchio GV, Aarabi B, Scalea TM. Use of serum biomarkers to predict cerebral hypoxia after severe traumatic brain injury. J Neurotrauma 2012; 29:1140-9. [PMID: 22360297 DOI: 10.1089/neu.2011.2149] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The management of severe traumatic brain injury (TBI) focuses on prevention and treatment of secondary insults such as cerebral hypoxia (CH). There are a number of biomarkers that are thought to play a part in secondary injury following severe TBI. This study evaluates the association between S100β, neuron-specific enolase (NSE), and glial fibrillary acidic protein (GFAP), detected in the serum of severe TBI patients and CH as measured by brain tissue oxygen partial pressure (Pbo(2)). Patients with severe TBI were prospectively enrolled. Pressure times time (PTD; mm Hg*h), measuring the depth and duration of CH, was calculated for 12-h periods for episodes of moderate (Pbo(2) < 20 mm Hg) and severe (Pbo(2) < 15 mm Hg) CH, and compared to serum levels of S100β, NSE, and GFAP drawn prior to periods of monitoring. An adjusted mixed model analysis was applied as was receiver operating characteristic (ROC) curve analysis. Of 76 patients enrolled, 24 had Pbo(2) monitoring. One hundred and thirty serum samples were matched with 12-h periods of monitoring. Significant associations were found in adjusted analyses between increasing serum levels of S100β (coefficient=0.57, 0.56; p<0.001), NSE (coefficient=0.48, 0.52; p<0.001), and GFAP (coefficient=0.29, 0.30; p=0.003 and 0.002), and increasing PTD of moderate (Pbo(2)<20 mm Hg) and severe (Pbo(2)<15 mm Hg) CH. AUCs for the prediction of moderate and severe CH were 0.62 and 0.66 for S100β, 0.55 and 0.71 for NSE, and 0.50 and 0.62 for GFAP, respectively. Specificities were between 76% and 90% for S100β and NSE. S100β, NSE, and GFAP demonstrate promise as candidate serum markers of impending CH. The fact that these biomarker elevations occur prior to the onset of clinical manifestations suggests that we may be able to predict imminent events following TBI. Given the morbidity of CH, early intervention and prevention may have a significant impact on outcomes and help guide decisions about the timing of interventions.
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Affiliation(s)
- Deborah M Stein
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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233
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Abstract
Intensive insulin therapy can reduce mortality. Hypoglycemia related to intensive therapy may worsen outcomes. This study compared risk adjusted mortality for different glycemic states. A retrospective review of patients admitted to a surgical intensive care unit over 4 years was performed. Patients were divided into glycemic groups: HYPER (≥1 episode > 180 mg/dL, any <60), HYPO (≥1 episode < 60 mg/dL, any >180), BOTH (≥1 episode < 60 and ≥1 episode > 180 mg/dL), NORMO (all episodes 60-180 mg/dL), HYPER-Only (≥1 episode > 180, none <60 mg/dL), and HYPO-Only (≥1 episode < 60, none >180 mg/dL). Observed to expected Acute Physiology and Chronic Health Evaluation (APACHE) III mortality ratios (O/E) were studied. Number of adverse glycemic events was compared with mortality. Hypoglycemia and hyperglycemia occurred in 18 per cent and 50 per cent of patients. Mortality was 12.4 per cent (O/E = 0.88). BOTH had the highest O/E ratio (1.43) with HYPO the second highest (1.30). Groups excluding hypoglycemia (NORMO and HYPER-only) had the lowest O/E ratios: 0.56 and 0.88. Increasing number of hypoglycemic events were associated with increasing O/E ratio: 0.69 O/E for no events, 1.19 for 1-3 events, 1.35 for 4-6 events, 1.9 for 7-9 events, and 3.13 for ≥ 10 events. Ten or more hyperglycemic events were needed to significantly associate with worse mortality (O/E 1.53). Hyper- and hypoglycemia increase mortality compared with APACHE III expected mortality, with highest mortality risk if both are present. Hypoglycemia is associated with worse risk. Glucose control may need to be loosened to prevent hypoglycemia and reduce glucose variability.
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Affiliation(s)
- Albert Chi
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
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234
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Maureen M, York GB, Hirshon JM, Jenkins DH, Scalea TM. Trauma readiness training for military deployment: a comparison between a U.S. trauma center and an Air Force Theater Hospital in Balad, Iraq. Mil Med 2012; 176:769-76. [PMID: 22128718 DOI: 10.7205/milmed-d-10-00349] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The U.S. Air Force created the Center for Sustainment of Trauma and Readiness Skills at the Shock Trauma Center (STC) where staffs rotate before deployment. We sought to investigate the value of this training. A retrospective review of prospectively collected data of patient volume, injury severity, mechanism of injury, operative cases, and massive transfusion data from September 2006 to August 2007 was obtained from the STC in Baltimore and the Air Force Theater Hospital (AFTH) in Balad. Severity of injury and massive transfusions were higher at the AFTH. Soft tissue wound care represented approximately 25% of AFTH cases; a soft tissue service performed 465 operative debridements for severe soft tissue infections at STC. The STC's high-volume of major soft tissue debridement cases may offer the closest approximation of high energy wound care. Training at selected U.S. trauma centers may prepare military staff to care for war injuries, particularly those who do not practice in high-volume Level 1 trauma centers.
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Affiliation(s)
- McCunn Maureen
- Division of Trauma Anesthesiology and Surgical Critical Care, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
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235
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Abstract
In 2008, we reviewed the practical interface between transfusion medicine and the surgery and critical care of severely injured patients. Reviewed topics ranged from epidemiology of trauma to patterns of resuscitation to the problems of transfusion reactions. In the interim, trauma specialists have adopted damage control resuscitation and become much more knowledgeable and thoughtful about the use of blood products. This new understanding and the resulting changes in clinical practice have raised new concerns. In this update, we focus on which patients need damage control resuscitation, current views on the optimal form of damage control resuscitation with blood products, the roles of newer blood products, and appropriate transfusion triggers in the postinjury setting. We will also review the role of new technology in patient assessment, therapy and monitoring.
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Affiliation(s)
- Sarah B Murthi
- University of Maryland School of Medicine, Baltimore, MD 21201, USA
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236
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Levi M, Fries D, Gombotz H, van der Linden P, Nascimento B, Callum JL, Bélisle S, Rizoli S, Hardy JF, Johansson PI, Samama CM, Grottke O, Rossaint R, Henny CP, Goslings JC, Theusinger OM, Spahn DR, Ganter MT, Hess JR, Dutton RP, Scalea TM, Levy JH, Spinella PC, Panzer S, Reesink HW. Prevention and treatment of coagulopathy in patients receiving massive transfusions. Vox Sang 2011; 101:154-74. [PMID: 21749403 DOI: 10.1111/j.1423-0410.2011.01472.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- M Levi
- Academic Medical Center, Department of Internal Medicine Amsterdam, the Netherlands.
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237
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Menaker J, Boswell S, Philp A, Scalea TM. Letter of apology for minor copying. J Trauma 2011; 71:1925. [PMID: 22182909 DOI: 10.1097/ta.0b013e31824434bc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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238
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Lissauer ME, Naranjo LS, Kirchoffner J, Scalea TM, Johnson SB. Patient Characteristics Associated with End-of-Life Decision Making in Critically Ill Surgical Patients. J Am Coll Surg 2011; 213:766-70. [DOI: 10.1016/j.jamcollsurg.2011.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 09/02/2011] [Accepted: 09/02/2011] [Indexed: 11/25/2022]
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239
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Scalea TM. Invited Commentary. J Vasc Interv Radiol 2011; 22:1569. [DOI: 10.1016/j.jvir.2011.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 09/14/2011] [Indexed: 11/30/2022] Open
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240
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Abstract
Injured patients stress the transfusion service with frequent demands for uncrossmatched red cells and plasma, occasional requirements for large amounts of blood products and the need for new and better blood products. Transfusion services stress trauma centers with demands for strict accountability for individual blood component units and adherence to indications in a clinical field where research has been difficult, and guidance opinion-based. New data suggest that the most severely injured patients arrive at the trauma center already coagulopathic and that these patients benefit from prompt, specific, corrective treatment. This research is clarifying trauma system requirements for new blood products and blood-product usage patterns, but the inability to obtain informed consent from severely injured patients remains an obstacle to further research.
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Affiliation(s)
- Sarah B Murthi
- University of Maryland School of Medicine, Baltimore, MD, USA
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241
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de Biasi AR, Stansbury LG, Dutton RP, Stein DM, Scalea TM, Hess JR. Blood product use in trauma resuscitation: plasma deficit versus plasma ratio as predictors of mortality in trauma (CME). Transfusion 2011; 51:1925-32. [PMID: 21332727 DOI: 10.1111/j.1537-2995.2010.03050.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Resuscitation of rapidly bleeding trauma patients with units of red blood cells (RBCs) and plasma given in a 1:1 ratio has been associated with improved outcome. However, demonstration of a benefit is confounded by survivor bias, and past work from our group has been unable to demonstrate a benefit. STUDY DESIGN AND METHODS We identified 438 adult direct primary trauma admissions at risk for massive transfusion who received 5 or more RBC units in the first 24 hours and had a probability of survival of 0.010 to 0.975. We correlated survival with RBC and plasma use by hour, both as a ratio (units of plasma/units of RBC) and as a plasma deficit (units of RBC - units of plasma) in the group as a whole and among those using 5 to 9 and more than 9 units of RBCs. RESULTS Resuscitation was essentially complete in 58.3% by the end of the third hour and 77.9% by the end of the sixth hour. Mortality by hour was significantly associated with worse plasma deficit status in the first 2 hours of resuscitation (p < 0.001 and p < 0.01) but not with plasma ratio. In a subgroup with a Trauma Revised Injury Severity Score of 0.200 to 0.800, early plasma repletion was associated with less blood product use independently of injury severity (p < 0.001). CONCLUSIONS 1) The efficacy of plasma repletion plays out in the first few hours of resuscitation, 2) plasma deficit may be a more sensitive marker of efficacy in some populations, and 3) early plasma repletion appears to prevent some patients from going on to require massive transfusion.
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Affiliation(s)
- Andreas R de Biasi
- Department of Anesthesia, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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242
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Abstract
Trauma resuscitation paradigms have changed considerably over the last twenty years. Originally, the goal was to normalize a blood pressure as quickly as possible. Large volume crystalloid resuscitation was used to accomplish this. Standard therapy was that any patient with suspected bleeding received a two liter crystalloid bolus as initial therapy. It was often repeated and blood transfusion therapy was used relatively late. Fresh frozen plasma and platelets were also used relatively late, often after patients had received ten units of red cells. Dilutional anemia was relatively common. Patients with large volume blood loss often died from what was termed, "the bloody vicious cycle," of hypothermia, acidosis and coagulopathy.
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Affiliation(s)
- Thomas M Scalea
- Surgical Critical Care and Emergency Medicine, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, USA.
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243
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Abstract
Tight glucose control is associated with improved outcome among critically ill trauma patients. Further research is necessary, however, to better elucidate the etiology of this beneficial therapy. Additionally, future randomized trials on this important topic are warranted, as are investigations of emerging technologies that better facilitate tight glucose control in the ICU after trauma.
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Affiliation(s)
- Joseph J DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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244
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Brenner M, O'Connor JV, Scalea TM. Use of ECMO for Resection of Post-Traumatic Ruptured Lung Abscess With Empyema. Ann Thorac Surg 2010; 90:2039-41. [DOI: 10.1016/j.athoracsur.2010.01.085] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 01/15/2010] [Accepted: 01/20/2010] [Indexed: 11/29/2022]
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245
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Affiliation(s)
- James V O'Connor
- University of Maryland, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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246
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Abstract
Endograft repair has clearly revolutionized the treatment of traumatic aortic injury. Numerous studies, both retrospective and prospective, have documented the advantages with respect to lower mortality and lower paraplegia rates as compared with traditional open repair. Additionally, 2 recent meta-analyses of the published literature both reported significantly lower mortality and paraplegia rates with endovascular repair. These clear improvements, however, come at an increased rate of device-related complications. Currently, newer devices designed to adapt to more acute bends in the proximal thoracic aorta are in the multicenter trial phase. These devices are also expected to be available in a wider range of diameters and lengths, including smaller diameter devices required to treat younger patients. A conformable Gore TAG design is undergoing trials in the United States. Trials of the Talent thoracic device for the treatment of blunt aortic injury are also ongoing. We await the results of the ongoing multicenter trials and expect that with improvements in technology, the vast majority of patients with traumatic aortic injury can be treated without open thoracic aortic surgery. The long-term durability and natural history of thoracic endograft devices, however, are unknown. Continued regular follow-up is recommended, although this can be difficult in this young population of patients. Because follow-up may be ongoing for decades, the need to identify a potential problem has to be weighed against the oncologic risks of repeated radiation exposure.
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Affiliation(s)
- David G Neschis
- Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
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247
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Abstract
We have recently demonstrated that 16-slice multidetector CT (MDCT) is insufficient for cervical spine (CS) clearance in patients with unreliable examinations after blunt trauma. The purpose of this study was to determine if a negative CS CT using 40-slice MDCT is sufficient for ruling out CS injury in unreliable blunt trauma patients or if MRI remains necessary for definitive clearance. In addition, we sought to elucidate the frequency by which MRI alters treatment in patients with a negative CS CT who have a reliable examination with persistent clinical symptoms. The trauma registry was used to identify all patients with blunt trauma who had a negative CS CT on admission using 40-slice MDCT and a subsequent CS MRI during their hospitalization from July 2006 to July 2007. Two hundred thirteen patients were identified. Overall, 24.4 per cent patients had abnormal MRIs. Fifteen required operative repair; 23 required extended cervical collar; and 14 had collars removed. A total of 8.3 per cent of patients with an unreliable examination and 25.6 per cent of reliable patients had management changed based on MRI findings. Overall, MRI changed clinical practice in 17.8 per cent of all patients. Despite newer 40-slice CT technology, MRI continues to be necessary for CS clearance in patients with unreliable examinations or persistent symptoms.
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Affiliation(s)
- Jay Menaker
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Deborah M. Stein
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Allan S. Philp
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Thomas M. Scalea
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
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248
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Menaker J, Stein DM, Philp AS, Scalea TM. 40-slice multidetector CT: is MRI still necessary for cervical spine clearance after blunt trauma? Am Surg 2010; 76:157-163. [PMID: 20336892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
We have recently demonstrated that 16-slice multidetector CT (MDCT) is insufficient for cervical spine (CS) clearance in patients with unreliable examinations after blunt trauma. The purpose of this study was to determine if a negative CS CT using 40-slice MDCT is sufficient for ruling out CS injury in unreliable blunt trauma patients or if MRI remains necessary for definitive clearance. In addition, we sought to elucidate the frequency by which MRI alters treatment in patients with a negative CS CT who have a reliable examination with persistent clinical symptoms. The trauma registry was used to identify all patients with blunt trauma who had a negative CS CTon admission using 40-slice MDCT and a subsequent CS MRI during their hospitalization from July 2006 to July 2007. Two hundred thirteen patients were identified. Overall, 24.4 per cent patients had abnormal MRIs. Fifteen required operative repair; 23 required extended cervical collar; and 14 had collars removed. A total of 8.3 per cent of patients with an unreliable examination and 25.6 per cent of reliable patients had management changed based on MRI findings. Overall, MRI changed clinical practice in 17.8 per cent of all patients. Despite newer 40-slice CT technology, MRI continues to be necessary for CS clearance in patients with unreliable examinations or persistent symptoms.
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Affiliation(s)
- Jay Menaker
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, T1R60 Baltimore, MD 21201, USA.
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249
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Haan JM, Glassman E, Hartsock R, Radcliffe J, Scalea TM. Isolated rollover mechanism does not warrant trauma center evaluation. Am Surg 2009; 75:1109-1111. [PMID: 19927516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Significant resources are expended on the assessment of trauma patients who arrive at the trauma center based solely on mechanism of injury. We hypothesized that rollover motor vehicle crashes (ROMVC) are not an independent predictor for trauma center care. All patients seen between January 1, 2001, and December 31, 2005, involved in a ROMVC, were reviewed. Patients with any confounding factors were removed, leaving those transported to the trauma center based on mechanism only. Five hundred sixty-nine patients were transported to our center for the mechanism of ROMVC. Of the 569 patients, 369 (65%) were evaluated and discharged with minimal Injury Severity Score and regional Abbreviated Injury Scale scores. Of the remaining 200 (35%) patients admitted, 130 required surgery, predominantly for closed extremity and facial fractures. Six patients required immediate surgery for life-threatening injuries: 3 splenectomies, 1 subdural evacuation, and 2 vascular repairs (1.1%). Of the remaining 123 (4.2%) patients requiring surgery, 24 required urgent surgery (2 craniotomies, 9 laparotomies, and 13 spinal fixations). None of the patients with spinal injury had neurologic deficit. Eight patients were admitted to the intensive care unit for neurologic monitoring (1.4%). Only 6.7 per cent benefited from initial Trauma Triage Criteria. Therefore, ROMVC is not an independent predictor of the need for trauma center evaluation or admission. The majority of these patients could be safely evaluated and treated at nontrauma centers or transferred later.
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Affiliation(s)
- James M Haan
- R. Adams Cowley Shock Trauma Center University of Maryland, Baltimore, Maryland, USA.
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250
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Abstract
Significant resources are expended on the assessment of trauma patients who arrive at the trauma center based solely on mechanism of injury. We hypothesized that rollover motor vehicle crashes (ROMVC) are not an independent predictor for trauma center care. All patients seen between January 1, 2001, and December 31, 2005, involved in a ROMVC, were reviewed. Patients with any confounding factors were removed, leaving those transported to the trauma center based on mechanism only. Five hundred sixty-nine patients were transported to our center for the mechanism of ROMVC. Of the 569 patients, 369 (65%) were evaluated and discharged with minimal Injury Severity Score and regional Abbreviated Injury Scale scores. Of the remaining 200 (35%) patients admitted, 130 required surgery, predominantly for closed extremity and facial fractures. Six patients required immediate surgery for life-threatening injuries: 3 splenectomies, 1 subdural evacuation, and 2 vascular repairs (1.1%). Of the remaining 123 (4.2%) patients requiring surgery, 24 required urgent surgery (2 craniotomies, 9 laparotomies, and 13 spinal fixations). None of the patients with spinal injury had neurologic deficit. Eight patients were admitted to the intensive care unit for neurologic monitoring (1.4%). Only 6.7 per cent benefited from initial Trauma Triage Criteria. Therefore, ROMVC is not an independent predictor of the need for trauma center evaluation or admission. The majority of these patients could be safely evaluated and treated at nontrauma centers or transferred later.
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Affiliation(s)
- James M. Haan
- R. Adams Cowley Shock Trauma Center University of Maryland, Baltimore, Maryland
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, Kansas
- Division of Trauma, Via Christi Regional Medical Center, Wichita, Kansas
| | - Erik Glassman
- R. Adams Cowley Shock Trauma Center University of Maryland, Baltimore, Maryland
| | - Robbi Hartsock
- R. Adams Cowley Shock Trauma Center University of Maryland, Baltimore, Maryland
| | - James Radcliffe
- R. Adams Cowley Shock Trauma Center University of Maryland, Baltimore, Maryland
| | - Thomas M. Scalea
- R. Adams Cowley Shock Trauma Center University of Maryland, Baltimore, Maryland
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