Human immunodeficiency virus and hepatitis B virus seroprevalence in an urban trauma population

Occupational exposure during emergency department thoracotomy: A prospective, multi-institution study

BACKGROUND

Occupational exposure is an important consideration during emergency department thoracotomy (EDT). While human immunodeficiency virus/hepatitis prevalence in trauma patients (0-16.8%) and occupational exposure rates during operative trauma procedures (1.9-18.0%) have been reported, exposure risk during EDT is unknown. We hypothesized that occupational exposure risk during EDT would be greater than other operative trauma procedures.

METHODS

A prospective, observational study at 16 US trauma centers was performed (2015-2016). All bedside EDT resuscitation providers were surveyed with a standardized data collection tool and risk factors analyzed with respect to the primary end point, EDT occupational exposure (percutaneous injury, mucous membrane, open wound, or eye splash). Provider and patient variables and outcomes were evaluated with single and multivariable logistic regression analyses.

RESULTS

One thousand three hundred sixty participants (23% attending, 59% trainee, 11% nurse, 7% other) were surveyed after 305 EDTs (gunshot wound, 68%; prehospital cardiopulmonary resuscitation, 57%; emergency department signs of life, 37%), of which 15 patients survived (13 neurologically intact) their hospitalization. Overall, 22 occupational exposures were documented, resulting in an exposure rate of 7.2% (95% confidence interval [CI], 4.7-10.5%) per EDT and 1.6% (95% CI, 1.0-2.4%) per participant. No differences in trauma center level, number of participants, or hours worked were identified. Providers with exposures were primarily trainees (68%) with percutaneous injuries (86%) during the thoracotomy (73%). Full precautions were utilized in only 46% of exposed providers, while multiple variable logistic regression determined that each personal protective equipment item utilized during EDT correlated with a 34% decreased risk of occupational exposure (odds ratio, 0.66; 95% CI, 0.48-0.91; p = 0.010).

CONCLUSIONS

Our results suggest that the risk of occupational exposure should not deter providers from performing EDT. Despite the small risk of viral transmission, our data revealed practices that may place health care providers at unnecessary risk of occupational exposure. Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with personal protective equipment is paramount and would further minimize occupational exposure risks during EDT.

LEVEL OF EVIDENCE

Therapeutic/care management study, level III.

Postoperative CD4 counts predict anastomotic leaks in patients with penetrating abdominal trauma

INTRODUCTION

The influence of trauma- and surgical stress-induced decrease of CD4 count on anastomotic leaks after penetrating abdominal trauma has to date not been investigated. A prospective study was performed to explore the effect of CD4 count 24 h after surgery on the anastomotic leak rate and to identify risk factors for anastomotic leaks.

METHODS

This was a prospective study including 98 patients with small or large bowel resection and subsequent anastomosis due to penetrating abdominal trauma. Univariate analysis identified risk factors for the development of anastomotic leak and also investigated the predictive value of the CD4 count for this complication.

RESULTS

Of the 98 patients 23 patients (23%) were HIV-infected. The overall leak rate was 13%. Univariate analysis including all potential risk factors with p-values<0.05 identified six factors leading to a significantly higher rate of anastomotic complications: postoperative CD4 count<250 cells/μl, postoperative albumin <30 g/L, penetrating abdominal trauma index≥25, gunshot wound as mechanism of injury, blood transfusion requirement >6units and delayed anastomosis after damage control surgery. Survival rates were analysed with the χ² test and did not show a significantly higher mortality rate in patients with low CD4 count. The negative impact of trauma and subsequent surgery on the cell mediated immunity was demonstrated by the fact that 55 (73%) of the HIV-negative patients had a CD4 count less than 500 cells/μl 24 h postoperatively. HIV-infection had no significant influence on the leak rate, however all HIV infected patients that developed an anastomotic leak died.

CONCLUSION

A low post-operative CD4 count is a predictor for anastomotic leaks irrespective of HIV-serostatus. Low postoperative serum albumin, high injury severity, gunshot wound as mechanism of injury, blood transfusion requirement >6 units and delayed anastomosis were further risk factors for anastomotic complications. Postoperative CD4 count and serum albumin should be considered in the decision making process of performing an anastomosis or diverting stoma for patients after "clip and drop" of the bowel as part of damage control surgery.

Improving survival after an emergency resuscitative thoracotomy: a 5-year review of the Trauma Quality Improvement Program

BACKGROUND

Advancement in trauma care has led to the evolution of emergency resuscitative thoracotomy (ERT) for the revival of trauma patients. We now have more precise understanding of selecting suitable patients for achieving optimal outcomes. The aim of our study was to analyze the utilization and survival trends during the past 5 years, as well as factors that influence survival after ERT.

METHODS

A 5-year (2010-2014) analysis of all trauma patients ≥18 years who underwent ERT in the American College of Surgeons Trauma Quality Improvement Program. Outcome measures were utilization rates and survival trends after ERT during the 5-year period. Regression analysis was performed.

RESULTS

2229 patients underwent ERT, mean age was 37±17 years, 81% were male. Overall 56% patients had penetrating mechanism, location of major injury was thorax in 48, and 71% had signs of life (SOL) on arrival. The overall survival rate was 9.6%. From 2010-2014 ERT utilization has decreased from 331/100 000 to 243/100 000 trauma admissions (p=0.002) and the survival rate has improved from 7.9% to 11.3% (p<0.001). On regression, the independent predictors of survival were penetrating mechanism, age<60 years, SOL on arrival, no prehospital CPR and ISS. No patient aged >60 years with a blunt mechanism of injury (MOI) survived, and there were no survivors above the age of 70 years, regardless of injury mechanism.

DISCUSSION

Utilization of ERT has been decreased during the study period along with improved survival rates. The results of our study demonstrate that performing ERT on patients aged >60 years with a blunt MOI or on any patient aged ≥70 years, regardless of MOI, is futile and should be avoided.

LEVEL OF EVIDENCE

Level III, prognostic studies.

A systematic review of 3251 emergency department thoracotomies: is it time for a national database?

PURPOSE

Emergency department thoracotomy (EDT) is a potentially life-saving procedure, performed on patients suffering traumatic cardiac arrest. Multiple indications have been reported, but overall survival remains unclear for each indication. The objective of this systematic review is to determine overall survival, survival stratified by indication, and survival stratified by geographical location for patients undergoing EDT across the world.

METHODS

Articles published between 2000 and 2016 were identified which detailed outcomes from EDT. All articles referring to pre-hospital, delayed, or operating room thoracotomy were excluded. Pooled odds ratios (OR) were calculated comparing differing indications.

RESULTS

Thirty-seven articles, containing 3251 patients who underwent EDT, were identified. There were 277 (8.5%) survivors. OR demonstrate improved survival for; penetrating vs blunt trauma (OR 2.10; p 0.0028); stab vs gun-shot (OR 5.45; p < 0.0001); signs of life (SOL) on admission vs no SOL (OR 5.36; p < 0.0001); and SOL in the field vs no SOL (OR 19.39; p < 0.0001). Equivalence of survival was demonstrated between cardiothoracic vs non-cardiothoracic injury (OR 1.038; p 1.000). Survival was worse for USA vs non-USA cohorts (OR 1.59; p 0.0012).

CONCLUSIONS

Penetrating injury remains a robust indication for EDT. Non-cardiothoracic cause of cardiac arrest should not preclude EDT. In the absence of on scene SOL, survival following EDT is extremely unlikely. Survival is significantly higher in the non-USA publications; reasons for this are highly complex. A UK multicentre prospective study which collects standardised data on all EDTs could provide robust evidence for better patient stratification.

Out of hospital thoracotomy for cardiac arrest after penetrating thoracic trauma

INTRODUCTION

Emergency department thoracotomy is an established procedure for cardiac arrest in patients suffering from penetrating thoracic trauma and yields relatively high survival rates (up to 21%) in patients with cardiac tamponade. To minimize the delay between arrest and thoracotomy, some have advocated thoracotomy on the accident scene. The aim of this study was to determine the proportion of patients with return of spontaneous circulation and subsequent survival after out of hospital thoracotomy in the Netherlands.

METHODS

A retrospective analysis of data collected on all out of hospital thoracotomies performed in the Netherlands after penetrating trauma between April 1st, 2011 and September 30th, 2016 was performed. Data on patient characteristics, trauma mechanism and outcome were collected and analyzed. Primary outcome measure was return of spontaneous circulation after the intervention. Survival to hospital discharge was the secondary outcome variable.

RESULTS

Thirty-three prehospital emergency thoracotomies were performed. Ten patients (30%) had gunshot wounds and 23 patients (70%) had stab wounds. Nine patients (27%) had return of spontaneous circulation and were presented to the hospital. Of these, one patient survived until discharge without neurological damage. Five died in the emergency department or operating room and three died in ICU.

CONCLUSION

Return of spontaneous circulation after out of hospital thoracotomy for cardiac arrest due to penetrating thoracic injury is achievable, but a substantial number of patients die during the in hospital resuscitation phase. However, neurologic intact survival can be achieved.

An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Within the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present pulseless after critical injuries (with and without signs of life after penetrating thoracic, extrathoracic, or blunt injuries) undergo emergency department thoracotomy (EDT) (vs. resuscitation without EDT) to improve survival and neurologically intact survival?

METHODS

All patients who underwent EDT were included while those involving either prehospital resuscitative thoracotomy or operating room thoracotomy were excluded. Quantitative synthesis via meta-analysis was not possible because no comparison or control group (i.e., survival or neurologically intact survival data for similar patients who did not undergo EDT) was available for the PICO questions of interest.

RESULTS

The 72 included studies provided 10,238 patients who underwent EDT. Patients presenting pulseless after penetrating thoracic injury had the most favorable EDT outcomes both with (survival, 182 [21.3%] of 853; neurologically intact survival, 53 [11.7%] of 454) and without (survival, 76 [8.3%] of 920; neurologically intact survival, 25 [3.9%] of 641) signs of life. In patients presenting pulseless after penetrating extrathoracic injury, EDT outcomes were more favorable with signs of life (survival, 25 [15.6%] of 160; neurologically intact survival, 14 [16.5%] of 85) than without (survival, 4 [2.9%] of 139; neurologically intact survival, 3 [5.0%] of 60). Outcomes after EDT in pulseless blunt injury patients were limited with signs of life (survival, 21 [4.6%] of 454; neurologically intact survival, 7 [2.4%] of 298) and dismal without signs of life (survival, 7 [0.7%] of 995; neurologically intact survival, 1 [0.1%] of 825).

CONCLUSION

We strongly recommend that patients who present pulseless with signs of life after penetrating thoracic injury undergo EDT. We conditionally recommend EDT for patients who present pulseless and have absent signs of life after penetrating thoracic injury, present or absent signs of life after penetrating extrathoracic injury, or present signs of life after blunt injury. Lastly, we conditionally recommend against EDT for pulseless patients without signs of life after blunt injury.

LEVEL OF EVIDENCE

Systematic review/guideline, level III.

Survival of pediatric blunt trauma patients presenting with no signs of life in the field

BACKGROUND

Prehospital traumatic cardiopulmonary arrest is associated with dismal prognosis, and patients rarely survive to hospital discharge. Recently established guidelines do not apply to the pediatric population because of paucity of data. The study objective was to determine the survival of pediatric patients presenting in the field with no signs of life after blunt trauma.

METHODS

We conducted a retrospective analysis of the National Trauma Data Bank research data set (2002-2010). All patients 18 years and younger with blunt traumatic injuries were identified (DRG International Classification of Diseases-9th Rev. codes 800-869). No signs of life (SOL) was defined on physical examination findings and included the following: pulse, 0; respiratory rate, 0; systolic blood pressure, 0; and no evidence of neurologic activity. These same criteria were reassessed on arrival at the emergency department (ED). Furthermore, we examined patients presenting to the ED who underwent resuscitative thoracotomy (Current Procedural Terminology code 34.02). Our primary outcome was survival to discharge from the hospital.

RESULTS

There were a total of 3,115,597 pediatric patients who were found in the field after experiencing blunt trauma. Of those, 7,766 (0.25%) had no SOL. Seventy percent of the patients with no SOL in the field were male. Survival to hospital discharge of all patients presenting with no SOL was 4.4% (n = 340). Twenty-five percent of the patients in the field with no SOL were successfully resuscitated in the field and regained SOL by the time they arrived to the ED (n = 1,913). Of those patients who regained SOL, 13.8% (n = 265) survived to hospital discharge. For patients in the field with no SOL, survival to discharge was significantly higher in patients who did not receive a resuscitative thoracotomy than in those who did.

CONCLUSION

Survival of pediatric blunt trauma patients in the field without SOL is dismal. Resuscitative thoracotomy poses a heightened risk of blood-borne pathogen exposure to involved health care workers and is associated with a significantly lower survival rate.

LEVEL OF EVIDENCE

Prognostic study, level III; therapeutic study, level IV.

Brief intervention to increase emergency department uptake of combined rapid human immunodeficiency virus and hepatitis C screening among a drug misusing population

OBJECTIVES

In this study, Increasing Viral Testing in the Emergency Department (InVITED), the authors investigated if a brief intervention about human immunodeficiency virus (HIV) and hepatitis C virus (HCV) risk-taking behaviors and drug use and misuse in addition to a self-administered risk assessment, compared to a self-administered risk assessment alone, increased uptake of combined screening for HIV and HCV, self-perception of HIV/HCV risk, and impacted beliefs and opinions on HIV/HCV screening.

METHODS

InVITED was a randomized, controlled trial conducted at two urban emergency departments (EDs) from February 2011 to March 2012. ED patients who self-reported drug use within the past 3 months were invited to enroll. Drug misuse severity and need for a brief or more intensive intervention was assessed using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Participants were randomly assigned to one of two study arms: a self-administered HIV/HCV risk assessment alone (control arm) or the assessment plus a brief intervention about their drug misuse and screening for HIV/HCV (intervention arm). Beliefs on the value of combined HIV/HCV screening, self-perception of HIV/HCV risk, and opinions on HIV/HCV screening in the ED were measured in both study arms before the HIV/HCV risk assessment (pre), after the assessment in the control arm, and after the brief intervention in the intervention arm (post). Participants in both study arms were offered free combined rapid HIV/HCV screening. Uptake of screening was compared by study arm. Multivariable logistic regression models were used to evaluate factors related to uptake of screening.

RESULTS

Of the 395 participants in the study, the median age was 28 years (interquartile range [IQR] = 23 to 38 years), 44.8% were female, 82.3% had ever been tested for HIV, and 67.3% had ever been tested for HCV. Uptake of combined rapid HIV/HCV screening was nearly identical by study arm (64.5% vs. 65.2%; Δ = -0.7%; 95% confidence interval [CI] = -10.1% to 8.7%). Of the 256 screened, none had reactive HIV antibody tests, but seven (2.7%) had reactive HCV antibody tests. Multivariable logistic regression analysis results indicated that uptake of screening was not related to study arm assignment, total ASSIST drug scores, need for an intervention for drug misuse, or HIV/HCV sexual risk assessment scores. However, uptake of screening was greater among participants who indicated placing a higher value on combined rapid HIV/HCV screening for themselves and all ED patients and those with higher levels of perceived HIV/HCV risk. Uptake of combined rapid HIV/HCV screening was not related to changes in beliefs regarding the value of combined HIV/HCV screening or self-perceived HIV/HCV risk (post- vs. pre-risk assessment with or without a brief intervention). Opinions regarding the ED as a venue for combined rapid HIV/HCV screening were not related to uptake of screening.

CONCLUSIONS

Uptake of combined rapid HIV/HCV screening is high and considered valuable among drug using and misusing ED patients with little concern about the ED as a screening venue. The brief intervention investigated in this study does not appear to change beliefs regarding screening, self-perceived risk, or uptake of screening for HIV/HCV in this population. Initial beliefs regarding the value of screening and self-perceived risk for these infections predict uptake of screening.

Scaling up routine HIV testing at specialty clinics: assessing the effectiveness of an academic detailing approach

INTRODUCTION

Scaling up routine HIV testing represents a key component of the National HIV/AIDS Strategy. Barriers to routine HIV testing have limited widespread adoption. Although many patients visit specialty care providers, few efforts to increase routine HIV testing in specialty care settings have been made. We report on use of a survey of barriers to routine testing coupled with academic detailing-type educational sessions to increase routine testing at specialty clinics in Chicago's main safety-net health system.

METHODS

We devised a survey to assess specialty provider knowledge, attitudes, and barriers to routine HIV testing. We administered this at 3 specialty clinics. Each clinic's survey responses informed content for academic detailing-type presentations to each clinic's medical providers. We provide descriptive statistics summarizing survey responses. We report changes in the HIV testing rates and use logistic regression to examine associations between time period and odds of testing at each clinic.

RESULTS

Specialty clinic providers demonstrated varying knowledge regarding routine HIV testing guidelines-with trauma providers having the least knowledge. Concerns regarding arranging follow-up for patients with positive results was the most cited barrier to testing. Two of the 3 specialty clinics experienced significant increases in routine HIV testing, whereas the third specialty service, which uses more rotating residents, had downtrending routine testing rates.

DISCUSSION

The increase in routine HIV testing in 2 of 3 specialty services suggests that academic detailing-type interventions can improve routine testing uptake in public safety-net specialty care settings and may represent a useful component to incorporate into system-wide scale-up efforts.

Life after near death: long-term outcomes of emergency department thoracotomy survivors

BACKGROUND

Predictors of hospital survival after emergency department thoracotomy (EDT) are well established, but little is known of long-term outcomes after hospital survival. Our primary study objective was to analyze the long-term social, cognitive, functional, and psychological outcomes in EDT survivors.

METHODS

Review of our Level I trauma center registry (2000-2010) revealed that 37 of 448 patients survived hospitalization after EDT. Demographics and clinical characteristics were analyzed. After attempts to contact survivors, 21 patients or caretakers were invited to an outpatient study evaluation; 16 were unreachable (none of whom were present in the Social Security Death Index). Study evaluation included demographic and social data and an outpatient multidisciplinary assessment with validated scoring instruments (Mini-Mental Status Exam, Glasgow Outcome Scores, Timed Get-Up and Go Test, Functional Independence Measure Scoring, SF-36 Health Survey, and civilian posttraumatic stress disorder checklist).

RESULTS

After extended hospitalization (43 ± 41 days), disposition varied (home, 62%; rehabilitation, 32%; skilled nursing facility, 6%), but readmission was common (33%) in the 37 EDT hospital survivors. Of the 21 contacted, 16 completed the study evaluation, 2 had died, 1 remained in a comatose state, and 2 were available by telephone only. While unemployment (75%), daily alcohol (50%), and drug use (38%) were common, of the 16 patients who underwent the comprehensive, multidisciplinary outpatient assessment after a median of 59 months following EDT, 75% had normal cognition and returned to normal activities, 81% were freely mobile and functional, and 75% had no evidence of posttraumatic stress disorder upon outpatient screening.

CONCLUSION

Despite the common belief that EDT survivors often live with severe neurologic or functional impairment, we have found that most of our sampled EDT survivors had no evidence of long-term impairment. It is our hope that these results are considered by physicians making life or death decisions regarding the "futility" of EDT in our most severely injured patients.

The use of emergency department thoracotomy for traumatic cardiopulmonary arrest

Despite the establishment of evidence-based guidelines for the resuscitation of critically injured patients who have sustained cardiopulmonary arrest, rapid decisions regarding patient salvageability in these situations remain difficult even for experienced physicians. Regardless, survival is limited after traumatic cardiopulmonary arrest. One applicable, well-described resuscitative technique is the emergency department thoracotomy-a procedure that, when applied correctly, is effective in saving small but significant numbers of critically injured patients. By understanding the indications, technical details, and predictors of survival along with the inherent risks and costs of emergency department thoracotomy, the physician is better equipped to make rapid futile versus salvageable decisions for this most severely injured subset of patients.

Seroprevalence of cytomegalovirus, Toxoplasma gondii, syphilis, and hepatitis B and C virus infections in a regional population seropositive for HIV infection

OBJECTIVE

To determine the prevalence of exposure to cytomegalovirus (CMV), Toxoplasma gondii, syphilis, hepatitis B virus (HBV) and hepatitis C virus (HCV) in a large, well characterized, regional population presenting for human immunodeficency virus (HIV) care.

DESIGN

Demographic and serological data compiled prospectively in a relational database used for routine patient care. Results were analyzed for statistically significant trends within demographic subpopulations known to be at risk of such infections.

PATIENTS AND SETTING

A total of 1274 persons with documented HIV infection in southern Alberta have sought medical care since 1985. Serological status to CMV, T gondii, syphilis, HBV and HCV infections were routinely requested as part of the initial assessment. All patients with serological results available were included in the analysis.

RESULTS

CMV infection was found in 84.1% of patients. A lower prevalence of CMV infection in those under 30 yeasr old (P<0.001), intravenous drug users (IVDUs) (P=0.001) and in patients with transfusion-acquired HIV (P<0.001) was seen. T gondii seropositivity was found in 10.6% of patients, with an increased risk of seropositivity in those born outside of Canada (P<0.001). Syphilis seropositivity was present in 5.1% of patients, with a higher prevalence in gay males (P=0.1). HBV carrier status was noted in 8.0% of patients, with males having an increased risk (P=0.025). Since 1990, there has been a 17.6% prevalence of HCV, predominantly in IVDUs (P<0.001).

CONCLUSION

Seroprevalence to common pathogens in HIV disease varies significantly among subpopulations, necessitating individual testing.

Compliance with barrier precautions during paediatric trauma resuscitations

PURPOSE

Barrier precautions protect patients and providers from blood-borne pathogens. Although barrier precaution compliance has been shown to be low among adult trauma teams, it has not been evaluated during paediatric resuscitations in which perceived risk of disease transmission may be low. The purpose of this study was to identify factors associated with compliance with barrier precautions during paediatric trauma resuscitations.

METHODS

Video recordings of resuscitations performed on injured children (<18 years old) were reviewed to determine compliance with an established policy requiring gowns and gloves. Depending on activation level, trauma team members included up to six physicians, four nurses, and a respiratory therapist. Multivariate logistic regression was used to determine the effect of team role, resuscitation factors, and injury mechanism on barrier precaution compliance.

RESULTS

Over twelve weeks, 1138 trauma team members participated in 128 resuscitations (4.7% penetrating injuries, 9.4% highest level activations). Compliance with barrier precautions was 81.3%, with higher compliance seen among roles primarily at the bedside compared to positions not primarily at the bedside (90.7% vs. 65.1%, p<0.001). Bedside residents (98.4%) and surgical fellows (97.6%) had the highest compliance, while surgical attendings (20.8%) had the lowest (p<0.001). Controlling for role, increased compliance was observed during resuscitations of patients with penetrating injuries (OR=3.97 [95% CI: 1.35-11.70], p=0.01), during resuscitations triaged to the highest activation level (OR=2.61 [95% CI: 1.34-5.10], p=0.005), and among team members present before patient arrival (OR=4.14 [95% CI: 2.29-7.39], p<0.001).

CONCLUSIONS

Compliance with barrier precautions varies by trauma team role. Team members have higher compliance when treating children with penetrating and high acuity injuries and when arriving before the patient. Interventions integrating barrier precautions into the workflow of team members are needed to reduce this variability and improve compliance with universal precautions during paediatric trauma resuscitations.

HIV and hepatitis in an urban penetrating trauma population: unrecognized and untreated

BACKGROUND

Despite limited prospective data, it is commonly believed that human immunodeficiency virus (HIV) and hepatitis infections are widespread in the penetrating trauma population, placing healthcare workers at risk for occupational exposure. Our primary study objective was to measure the prevalence of HIV (anti-HIV), hepatitis B (HB surface antigen [HBsAg]), and hepatitis C virus (anti-HCV) in our penetrating trauma population.

METHODS

We prospectively analyzed penetrating trauma patients admitted to Temple University Hospital between August 2008 and February 2010. Patients (n = 341) were tested with an oral swab for anti-HIV and serum evaluated for HBsAg and anti-HCV. Positives were confirmed with western blot, neutralization immunoassay, and reverse transcription polymerase chain reaction, respectively. Demographics, risk factors, and clinical characteristics were analyzed.

RESULTS

Of 341 patients, 4 patients (1.2%) tested positive for anti-HIV and 2 had a positive HBsAg (0.6%). Hepatitis C was the most prevalent measured infection as anti-HCV was detected in 26 (7.6%) patients. Overall, 32 (9.4%) patients were tested positive for anti-HIV, HBsAg, or anti-HCV. Twenty-eight (75%) of these patients who tested positive were undiagnosed before study enrollment. When potential risk factors were analyzed, age (odds ratio, 1.07, p = 0.031) and intravenous drug use (odds ratio 14.4, p < 0.001) independently increased the likelihood of anti-HIV, HBsAg, or anti-HCV-positive markers.

CONCLUSIONS

Greater than 9% of our penetrating trauma study population tested positive for anti-HIV, HBsAg, or anti-HCV although patients were infrequently aware of their seropositive status. As penetrating trauma victims frequently require expedient, invasive procedures, universal precautions are essential. The prevalence of undiagnosed HIV and hepatitis in penetrating trauma victims provides an important opportunity for education, screening, and earlier treatment of this high-risk population.

Prevalence and characteristics of patients with undiagnosed HIV infection in an urban emergency department

The Centers for Disease Control and Prevention (CDC) recommends offering HIV testing to persons admitted to emergency departments (EDs). Whether by opt-in or opt-out, many EDs (including our own) have found a seroprevalence of 0.8-1.5% when rapid testing is offered. The true seropositivity rate is unknown. We performed a retrospective chart analysis upon all patients presenting to our ED over a 2-week period in the fall of 2007 who had serum drawn as a part of their emergency care. Demographics and clinical characteristics were linked via de-identified serum, which was sent for HIV testing. Nine hundred fifty nine patients had sera available for rapid HIV testing. One hundred twenty one (13%) samples were reactive via the OraQuick(®) test (OraSure Technologies, Bethlehem, PA), a point of care rapid antibody test. Due to concerns about the appropriateness of sera as substrate for the OraQuick(®) technology, reactive samples were retested via standard enzyme immunoassay (EIA)/Western blot. One hundred twelve analyzable samples were retested-38 were positive and 27 of these were from patients who reported a history of HIV infection. The rate of undiagnosed HIV infection was 1.2% (11/914 potentially analyzable samples). Of all patients with HIV in our ED, 29% of them were presumably unaware of their diagnosis. In conclusion, HIV seroprevalence in our urban ED is high, and a large fraction of the patients appears to be unaware of the infection.

Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers

BACKGROUND

Historically, patients with penetrating cardiac injuries have enjoyed the best survival after emergency department thoracotomy (EDT), but further examination of these series reveals a preponderance of cardiac stab wound (SW) survivors with only sporadic cardiac gunshot wound (GSW) survivors. Our primary study objective was to determine which patients requiring EDT for penetrating cardiac or great vessel (CGV) injury are salvageable.

METHODS

All patients who underwent EDT for penetrating CGV injuries in two urban, level I trauma centers during 2000 to 2007 were retrospectively reviewed. Demographics, injury (mechanism, anatomic injury), prehospital care, and physiology (signs of life [SOL], vital signs, and cardiac rhythm) were analyzed with respect to hospital survival.

RESULTS

The study population (n = 283) comprised young (mean age, 27.1 years +/- 10.1 years) men (96.1%) injured by gunshot (GSW, 88.3%) or SWs (11.7%). Patients were compared by injury mechanism and number of CGV wounds with respect to survival (SW, 24.2%; GSW, 2.8%; p < 0.001; single, 9.5%; multiple, 1.4%; p = 0.003). Three predictors-injury mechanism, ED SOL, and number of CGV wounds-were then analyzed alone and in combination with respect to hospital survival. Only one patient (0.8%) with multiple CGV GSW survived EDT.

CONCLUSION

When the cumulative impact of penetrating injury mechanism, ED SOL, and number of CGV wounds was analyzed together, we established that those sustaining multiple CGV GSWs (regardless of ED SOL) were nearly unsalvageable. These results indicate that when multiple CGV GSWs are encountered after EDT, further resuscitative efforts may be terminated without limiting the opportunity for survival.

Emergency department patient perceptions and preferences on opt-in rapid HIV screening program components

The aim of this investigation was to assess emergency department (ED) patients' perceptions and preferences about an opt-in, universal, rapid HIV screening program and identify patient groups who expressed stronger beliefs about components of the testing program. From July 2005 to July 2006, ED patients in the opt-in, universal, rapid HIV screening program were interviewed in person. Multivariable regression models were used to compare participants on their beliefs about the program components. Of the 561 participants, 62.0% had previously been tested for HIV. The majority of participants (58.8%) believed the rapid and standard/conventional HIV tests to be equally accurate, 27.7% believed the rapid test to be less or much less accurate, and 8.7% believed the rapid test to be more or much more accurate. Almost two-thirds (65.1%) favored having a rapid instead of a standard/conventional HIV test, 94.6% wanted the test results within one hour, and 61.3% would be likely or very likely to undergo testing in the ED if it prolonged their ED visit. Almost all (92.5%) believed that their medical care was "not at all" delayed because of being tested, 94.1% believed that testing did "not at all" divert attention from the reason for their ED visit, and 80.9% thought that testing in the ED was "not at all" stressful. In multivariable logistic regression models, males and those with more than 12 years of formal education showed greater concerns about the rapid HIV test's accuracy. Hispanic/Latinos, participants with governmental insurance, and those previously HIV tested were more apt to be screened for HIV even if testing delayed their ED departure. Overall, participants were highly accepting of the components of this opt-in rapid HIV screening program. However, concerns regarding the accuracy of the rapid HIV test might limit test acceptance and should be addressed during pre-test information procedures.

Emergency thoracotomy in trauma: rationale, risks, and realities

Emergency department thoracotomy (EDT) may serve as a life-saving tool when performed for the right indications, in selected patients, and in the hands of a trained surgeon. Critically injured patients 'in extremis' arrive at an increasing rate in the trauma bay, as an effect of improved pre-hospital trauma systems and rapid transport. Any patient in near, or full cardiovascular shock prompts the trauma surgeon to rapidly perform a thoracotomy. The EDT procedure is managed best by surgeons familiar with, and experienced in, penetrating cardiothoracic injuries. However, the geographical differences in trauma epidemiology lends no, or only scarce, experience with this procedure in most European trauma centres. Consequently, mandatory training is imperative for success. The rationale for performing an EDT is to: (I) resuscitate the agonal patient with penetrating cardiothoracic injuries; (II) release cardiac tamponade by evacuation of pericardial blood; (III) immediately control hemorrhage and repair cardiac or pulmonary injury; (IV) perform open cardiac massage; and (V) place a thoracic aortic cross-clamp to redistribute the remaining blood volume, and perfuse the carotids and coronary arteries. The prevalence rates of blood-borne viruses reported in critically injured patients in the USA (10-20%) exceed the prevalence in the Nordic countries (HIV prevalence < 1% in general population). However, risk is not negligible and mandated universal precautions are needed. The literature is rich in series describing the use of EDT, however, the best evidence is derived from a few prospective trials. EDT saves about one in every five patients with isolated penetrating cardiac injury, while > 98% die after blunt injury. Based on an updated review of the current available literature, this paper presents the current evidence regarding the rationale, risk, and outcomes for employing EDT in the field of trauma surgery.

Universal precaution compliance by orthopaedic trauma team members in a major trauma resuscitation scenario

INTRODUCTION

We determined the compliance rates of orthopaedic trauma team members in applying universal precautions in major trauma resuscitation scenarios and the availability of universal precautions in accident and emergency (A&E) departments throughout England.

MATERIALS AND METHODS

A national telephone survey was implemented contacting the first on-call orthopaedic surgeon and A&E departments in hospital trusts accepting major trauma throughout England. A questionnaire was employed to ascertain current practice, experience and availability of universal precautions when managing a major trauma patient.

RESULTS

Overall, 112 first on-call orthopaedic surgeons and 99 A&E departments responded. There was good compliance for using gloves (99%) and aprons (86%). There was poor compliance in using eye protectors (21%), face masks (18%), shoe covers (4%) and head caps (4%). Trainees applied universal precautions according to the level of risk they subjectively perceived. All A&E departments had gloves and aprons but the availability of the other universal precautions was less. Of trainees, 76 reported that all universal precautions were not readily available in the A&E department.

CONCLUSION

Orthopaedic trauma team members are very compliant in using gloves and aprons, but should be more compliant in using eye protectors. It is questionable whether face masks, head caps and shoe covers need to be used in all trauma scenarios. In general, universal precautions should be more available in the A&E departments. There should be better communication between A&E departments and the trauma team regarding the availability of universal precautions.

Human immunodeficiency virus and hepatitis testing and prevalence among surgical patients in an urban university hospital

BACKGROUND

Human immunodeficiency virus (HIV), hepatitis B, and hepatitis C represent significant public health problems in an urban community. Early diagnosis and treatment of these infections can improve survival and allow for preventive strategies to reduce further transmission within a community. The aim of this study was to evaluate the surgical setting as a potential opportunity for early diagnosis of HIV, hepatitis B, and hepatitis C among trauma and non-trauma patients.

METHODS

We performed a retrospective review of patients presenting for surgery over a 10-year period (July 1994 to July 2004) in an urban, university-based general surgical practice that includes all trauma services, as well as emergency department, inpatient, and outpatient surgical consultations. Data collected included diagnosis, operation, age, race, history of intravenous drug abuse, and HIV, hepatitis B, and hepatitis C test results.

RESULTS

Among 2876 patients presenting for surgery, testing for blood-borne pathogens was less likely among trauma patients (21%, 79/380) compared to non-trauma patients (47%, 1183/2496) (P < .001). Among patients tested, the incidence of blood-borne pathogens was similar in the two groups: HIV (26% trauma vs 24% non-trauma, not significant [NS]), hepatitis B (4% trauma vs 3% non-trauma, NS), hepatitis C (33% trauma vs 41% non-trauma, NS), and co-infection with HIV and hepatitis C (18% trauma vs 12% non-trauma, NS). In both groups, blood-borne pathogens were associated with intravenous drug abuse (P < .01).

CONCLUSION

HIV, hepatitis B, and hepatitis C are common in an urban community among both trauma and non-trauma surgical patients, although testing is less common among trauma patients. Testing of patients during a surgical admission may represent an excellent opportunity for early disease-specific services and preventive interventions.

The impact of human immunodeficiency virus (HIV) on outcome and practice in trauma: past, present and future

Since the initial description of a concentrated outbreak of pneumocystis carnii pneumonia in 1981, the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) pandemic has accounted for nearly 25 million deaths worldwide. This review focuses on estimations of prevalence by geographic region and identification of high-risk populations within each region, outcome for trauma patients with HIV and AIDS and risk management for health care workers who sustain occupational exposures. Trauma surgeons are more likely to encounter patients infected with HIV in geographic areas where HIV prevalence is high or in areas where intravenous drug use, high-risk sexual behaviours and penetrating trauma are more common. Patients with HIV may be expected to have higher rates of infectious and respiratory complications if they have active AIDS and/or liver disease caused by one of the hepatitis viruses. Certain aspects of therapy may change in this group of patients. Clinicians should be aware that highly active anti-retroviral therapy (HAART) might produce complications. Occupational exposure among healthcare workers is uncommon. Cases of infection in healthcare workers from needlesticks are rare. Certain precautions regarding body fluid and needlestick exposures have been widely adopted over the past decade. When percutaneous injury results in known exposure to HIV, post-exposure prophylaxis (PEP) should be used and can be expected to be effective in preventing infection in the large majority of cases.

Emergency thoracotomy in thoracic trauma-a review

Thoracic trauma is one of the leading causes of death in all age groups and accounts for 25-50% of all traumatic injuries. While the majority of patients with thoracic trauma can be managed conservatively, a small but significant number requires emergency thoracotomy as part of their initial resuscitation. The procedure has been advocated for evacuation of pericardial tamponade, direct control of intrathoracic haemorrhage, control of massive air-embolism, open cardiac massage and cross-clamping of the descending aorta. Emergency thoracotomy can be defined as thoracotomy "occurring either immediately at the site of injury, or in the emergency department or operating room as an integral part of the initial resuscitation process". Following emergency thoracotomy, the overall survival rates for penetrating thoracic trauma are around 9-12% but have been reported to be as high as 38%. The survival rate for blunt trauma is approximately 1-2%. The decision to perform emergency thoracotomy involves careful evaluation of the scientific, ethical, social and economic issues. This article aims to provide a review of the current literature and to outline the pathophysiological features, technical manoeuvres and selective indications for emergency thoracotomy as a component of the initial resuscitation of trauma victims with thoracic injury.

Human Immunodeficiency Virus, Hepatitis B, and Hepatitis C Seroprevalence in a Canadian Trauma Population

BACKGROUND

The current seroprevalence of human immunodeficiency virus (HIV), hepatitis B, and hepatitis C in the Canadian trauma population is unknown. Establishing the seroprevalence of these diseases is vital for education, postexposure prophylaxis, and counseling, and to establish potential screening guidelines. The purpose of this study was to determine the seroprevalence of HIV, hepatitis B, and hepatitis C in the trauma population of London, Ontario, Canada.

METHODS

All adult (aged > or = 18 years) trauma patients treated by the trauma team at London Health Sciences Centre were prospectively studied from January to December 2003. The study was conducted as a linked, confidential serosurvey with delayed full disclosure. Serum was analyzed for HIV, hepatitis C antibody, and Hepatitis B surface antigen.

RESULTS

A total of 287 (76%) of 377 consecutive trauma patients had blood testing completed. Of the 287 patients tested, 1 (0.3%) was positive for hepatitis B, 8 (2.8%) were positive for hepatitis C, and no patients tested positive for HIV. Hepatitis C-positive patients were predominantly men (63%) with a mean age of 46 years and a mean Injury Severity Score of 19; 63% were injured in a motor vehicle crash, and 88% were discharged alive. There were no statistically significant differences in the demographic and injury profiles from the hepatitis C-negative patients (p > 0.2 for all).

CONCLUSION

This is the first study to determine the rates of HIV, hepatitis B, and hepatitis C in the Canadian trauma population. Our trauma population demonstrated a threefold higher hepatitis C seroprevalence rate compared with the general population. Hepatitis C poses the highest risk to the trauma team of the three bloodborne diseases studied. With no vaccine or postexposure prophylaxis currently available for hepatitis C, this study highlights the importance of prevention and the strict use of universal precautions in the setting of trauma.

Human Immunodeficiency Virus Infection in Trauma Patients: Where Do We Stand?

OBJECTIVE

The human immunodeficiency virus (HIV) epidemic is a growing health care problem. The purpose of this study was to examine the relationship between HIV infection and trauma patient treatment, complications, and mortality.

METHODS

The Pennsylvania Trauma Outcome Study database was used to identify trauma patients with known HIV-positive status (HP) and randomly selected age-matched controls (CL). Demographics, Injury Severity Score, Glasgow Coma Scale score, mechanism of injury, preexisting conditions, complications, mortality, hospital length of stay (HLOS), intensive care unit length of stay (ILOS), and operative interventions were compared.

RESULTS

Demographics, vital signs on presentation, and Injury Severity Score were similar between the HP and CL groups. There was no difference in mortality between the two groups (3.6% vs. 3.1%, p = 0.6447). HP patients were more likely to present with penetrating injuries (22.6% vs. 15.8%, p < 0.0031) and had significantly fewer major orthopedic injuries than CL patients (p < 0.01). HP patients were more likely to have a history of a neurologic condition; chronic drug/alcohol use; psychiatric diagnosis; or liver, pulmonary, and/or renal disease (all p < 0.01). HP patients had more pulmonary complications (12.3% vs. 4.1%), renal complications, and infectious/septic complications (all p < 0.01) than controls. Infection/sepsis and pulmonary complications were associated with significant mortality in HP patients. HP patients underwent more thoracostomies (7.5% vs. 4.4%, p = 0.0235) and exploratory laparotomies (7.0% vs. 2.4%, p = 0.0002). HLOS (10.2 +/- 10 vs. 6.8 +/- 8.6 days, p = 0.001) and ILOS (2.3 +/- 7.2 vs. 1.5 +/- 4.9 days, p = 0.0178) were greater for HP patients. HP patients were less likely than controls to be discharged directly to home (67.8% vs. 82.7%, p = 0.0001).

CONCLUSION

HP patients had more preexisting conditions and complications than controls. There was no difference in overall mortality between the two groups. However, pulmonary/infectious complications were associated with significant mortality in HP patients. HP patients consumed more health care resources than controls, as exemplified by greater ILOS and HLOS and more operative procedures.

Documented prevalence of HIV and hepatitis C infection in patients with penetrating trauma

BACKGROUND

Trauma patients infected with human immunodeficiency virus (HIV) or hepatitis C (HCV) pose specific problems to health-care workers due to the risk of exposure to these agents in blood and other body fluids. Studies of patients with penetrating trauma in the USA have shown a higher prevalence of HIV and HCV infection than the general population. No studies have examined the prevalence of these infections in Australian trauma patients.

METHODS

The medical records of all patients presenting to St Vincent's Hospital, Sydney, from January 1994 to December 1998, with a stab wound to the neck, chest or abdomen, or with a gunshot wound to any anatomical site, were retrospectively reviewed. The number of patients with a history of HIV or HCV infection, or with risk factors for these such as male-to-male sexual intercourse and intravenous drug use, were recorded.

RESULTS

The medical records of 148 patients with stab wounds to the neck, chest or abdomen, or with gunshot wounds were examined. Risk factors for HIV or HCV infection were recorded in 31 patients (21%). Two patients (1.3%) had a history of HIV infection and a further eight patients (5.4%) were known to have HCV.

CONCLUSIONS

There was a high prevalence of risk factors for HIV and HCV in patients with major penetrating wounds at St Vincent's Hospital. The prevalence of documented HIV and HCV infection was subsequently greater than that expected in the general population, highlighting the risks to health-care workers managing these patients.

The occupational hazards of emergency physicians

Emergency physicians are exposed to a variety of occupational hazards. Among these are infectious diseases, such the human immunodeficiency virus, hepatitis B and C viruses, and tuberculosis. Hepatitis G virus is transmissible but may not be a cause of illness. The likelihood of being exposed to these agents appears to be higher in the ED than other medical settings but estimates of the prevalence of these diseases in the ED vary, depending on the patient population served. Estimates of risk for contracting these infections are reviewed. Measures to prevent these exposures can reduce risk, but compliance is low, particularly for those involving changes in the behavior of emergency physicians (such as not recapping needles). Latex allergy is a hazard of health care workers. Its prevalence is reported to be quite high, but these findings are difficult to interpret in the absence of a universally accepted definition of the condition. Its prevalence in emergency physicians is not known. Other noninfectious hazards include workplace violence and exposure to nitrous oxide. The health effects of rotating shift work may put emergency physicians at increased risk of coronary artery disease and impaired reproductive health. Emotional stress is another hazard of emergency physicians, and may lead to burnout.

Management of infections in the trauma patient

Infections play a leading role in the morbidity and mortality of injured patients. This article discusses risk factors that can increase the chances of a nosocomial infection. It also discusses common types of infection, causative organisms, and the approach to the febrile trauma patient.

Human immunodeficiency virus among trauma patients in New York City

STUDY OBJECTIVE

To determine the HIV seroprevalence rates in relation to the demographic characteristics of victims, cause of death, and toxicology findings in a sample of victims of violence and accidents who presented to emergency departments before death.

METHODS

This descriptive survey of a complete 3-year sample of homicides and accidents was conducted in 5 boroughs of New York City (population 7,322,564). Persons 15 years of age and older injured by intentional violence or accidents (excluding drug overdoses, falls from short heights, and suicides) who presented to hospitals, died, and were sent to the medical examiner were included. Standard methods were used to test plasma and serum samples for HIV and cocaine or its metabolite. Chi2 Tests compared HIV seroprevalence across groups according to demographic characteristics and toxicology findings. Logistic regression analysis was done for those variables found to be significant with chi2 tests. All statistical tests were conducted with 2-tailed alpha levels of .05.

RESULTS

Among the 1,242 subjects in the sample, 90 (7.2%) had positive findings. Male patients (8%) had higher rates than female patients (3.4%). HIV rates were highest among patients 35 to 44 years of age (20.8%), followed by the 45- to 54-year age group (9.6%) and 25- to 34-year age group (8.1%). Victims of homicide (8.2%) and accidents other than motor vehicle crashes (10.5%) had higher rates than victims of motor vehicle crashes (4%). Patients with positive results for cocaine (16.3%) were more likely than those with negative result (5.8%) to be HIV positive. There were no statistically significant differences by race, except that no Asians were HIV positive. Logistic regression analysis found that only age and positive cocaine results, not sex and race, were related to increased risk of HIV infection.

CONCLUSION

We found the rate of HIV infection among victims of fatal trauma was significant, especially in those with evidence of cocaine use. The HIV infection rate approximates the high end of the range of HIV rates found in studies before 1990. It further emphasizes the need for use of universal precautions in the care of trauma patients.

Outer gloves in orthopaedic procedures: a polyester/stainless steel wire weave glove liner compared with latex

OBJECTIVE

To compare the efficacy of traditional double latex gloving with that of a highly cut-resistant polyester/stainless steel wire weave glove (PSSWWG) over a single latex inner glove for the prevention of perforation of the inner latex glove.

DESIGN

The primary surgeon and first assistant were involved in a prospective randomized study. Group I consisted of twenty-five procedures in which double latex gloves were used. Group II consisted of twenty-five procedures in which a PSSWWG liner was worn over an inner latex glove. All inner gloves were tested for perforations; all gloves exchanged that were presumed to have a perforation were noted and also tested. The type and length of the procedure were recorded. The dominant hand was recorded for all participants, along with their comments on the PSSWWG liner's performance.

SETTING

Orthopaedic Trauma Service, Hospital for Special Surgery. New York.

PATIENTS/PARTICIPANTS

Major operative cases, November 1996 to February 1997.

MAIN OUTCOME MEASUREMENTS

Inner latex glove perforations.

RESULTS

With the use of PSSWWG liners, the percentage of inner gloves found with a perforation dropped from 19 percent in the double latex group to 15 percent in the PSSWWG liner group (not statistically significant, p = 0.4). Two thirds of the perforations were in the primary surgeon's gloves, located in either the index finger or thumb. Nearly 80 percent of all perforations went unrecognized in both groups. Ninety-five percent of all perforations were in gloves that had been in use for more than 120 minutes (statistically significant, p = 0.01).

CONCLUSIONS

The particular cut-resistant glove studied (Sceptor) did not significantly reduce the rate of inner glove perforations. Other studies with different cut-resistant glove types and protocols have proven the liners effective. We would still recommend using outer cloth or cut-resistant type gloves when bone fragments are being manipulated or when using sharp implants or saws. At a minimum, surgical gloves should be changed every two hours.

Special consideration for bloodborne pathogens in the PACU

Routine care of postoperative patients implies considerable exposure to blood products as well as to coughs and secretions. In the PACU, coughed secretions are often frankly contaminated with blood, and coughing is unpredictable after airway irritation. For these reasons, PACU nurses are exposed to many small inocula of potentially infected blood products. This review summarizes the current knowledge regarding transmission of viral pathogens to health care workers, particularly hepatitis and human immunodeficiency viruses. Although the risk of acquiring these bloodborne pathogens from patients via coughs or splashes is small, the precise risks have not been quantified, and the stakes are high. Protection of PACU personnel by the use of universal precautions should be a routine part of patient care in the PACU.