Prehospital blood transfusion versus crystalloid alone in the air medical transport of trauma patients

INTRODUCTION

Differences in prehospital resuscitation measures and outcomes of trauma patients transported by two air medical programs were assessed comparing the prehospital administration of crystalloid only (Group A) with the administration of 2 liters of crystalloid followed by blood (Group B).

METHODS

A 1-year retrospective review of flight and hospital records of patients taken to Level I trauma centers by two separate air medical programs was completed. Physiologic variables, total fluids infused, and flight times were compared.

RESULTS

Thirty-one patients (Group A) received crystalloids in flight, and 17 patients received in-flight blood (Group B). No statistical differences were found between the two groups when comparing age, ISS, PS, RTS, GCS, survival, and total fluid volume. Group B had statistically greater mean flight times compared with Group A (P < .05). A difference was demonstrated between groups A and B in pH and HCO3 measurements (P < .05), with Group B presenting in a more acidotic state on admission to the hospital.

CONCLUSION

Patients with lengthy flight times, despite the administration of blood products, presented to the trauma center more acidotic than trauma patients receiving only crystalloid. The true impact of blood products on outcome could not be demonstrated because of statistical differences in flight times between the groups. A multicenter study matching flight times, head injury status, and flight type of assess benefit of prehospital utilization of blood products is warranted.

A trauma systems assessment of boating safety: a comparison of commercial and recreational boating practices

OBJECTIVE

With contemporary interest of Trauma Systems and injury prevention strategists focusing upon boating safety, a prospective study was designed to survey practices of commercial and recreational boaters' compliance with United States Coast Guard (USCG) regulations. Data were collected by interview survey. Information was obtained from 24 commercial and 57 recreational boaters. Prevalence rates were calculated for compliance with USCG regulations. An analysis for statistical difference was conducted using the Wilcoxon rank sum test. Data analysis revealed that commercial boaters statistically spend more days on the water per year and have more years of boating experience than do recreational boaters (P < 0.05). No statistical difference was demonstrated between commercial and recreational boaters for life jacket-to-crew member ratio, swimming competency, or compliance with USCG safety equipment, with exception to flotation suits. The prevalence of alcohol use by the operators of commercial and recreational boats was found to be 8 and 12 per cent (P < 0.60) respectively, and for crew members 8 and 35 per cent (P < 0.01), respectively. Boating practices in these sample populations conform to USCG regulations. Swimming competency exhibited by these boaters is complementary to safe boating behaviors. The consumption of alcohol while boating, although comparable to reported statistics, is still of concern to injury prevention strategists.

Maximizing tolerance of enteral nutrition in severely injured trauma patients: a comparison of enteral feedings by means of percutaneous endoscopic gastrostomy versus percutaneous endoscopic gastrojejunostomy

BACKGROUND

Intolerance of enteral nutrition interrupts caloric balance and increases hospital costs. This study proposes that enteral feeding by percutaneous endoscopic gastrojejunostomy (PEGJ) provides continuous uninterrupted nutrition with greater consistency than percutaneous endoscopic gastrostomy (PEG).

METHODS

This prospective nonrandomly assigned study was conducted at a Level I trauma center from December of 1997 through October of 1998. All feeding tubes were placed by trauma/critical care surgeons for nutritional support. Feeding course was monitored for 14 days from time of tube placement. Demographic data and outcome variables compared were age, sex, Injury Severity Score, Abbreviated Injury Score, hospital length of stay, number of days to reach nutritional goal feedings, caloric goal, protein goal, cc/hr at goal, total parenteral nutrition usage, complications, and hospital charges. Statistical analyses used the independent samples t test, Cox regression, and Pearson chi2 with significance level set at 0.05.

RESULTS

Patients receiving enteral nutrition by PEGJ reached nutritional goal sooner than patients who received enteral nutrition by PEG (p = 0.02). Thirty-seven of 46 PEGJ patients (80%) were at goal rate at day 3, whereas 28 of 43 PEG patients (65%) were at goal on day 3. Nine of 43 PEG patients (21%) and 3 of 46 PEGJ patients (7%) failed to reach goal within 14 days.

CONCLUSION

This study suggests that enteral nutrition delivered by means of PEGJ is better tolerated than enteral nutrition delivered by means of PEG in trauma patients with no abdominal conditions that preclude percutaneous feeding tube placement.

Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients

BACKGROUND

Temporary abdominal wound closure after celiotomy for trauma is often desirable. The ideal method of temporary closure should allow rapid closure, easy maintenance, and allow reexploration and wound repair with minimal tissue damage. Over the past 7 years, we have successfully used a vacuum closure system (the vacuum pack) for temporary management of the open abdomen.

METHODS

Medical records of trauma patients undergoing exploratory celiotomy from April of 1992 to February of 1999 were reviewed. Demographic data as well as indications for open-abdominal management and complications of open-abdominal management were collected.

RESULTS

Two hundred sixteen vacuum packs were performed in 112 trauma patients. Of the 216 vacuum packs placed, 2.8% were placed for increased intra-abdominal pressure, 5.3% for inability to achieve tension-free fascial closure, 20% for damage control, 55% for reexploration, and 16.7% for a combination of factors. Sixty-two patients (55.4%) went on to primary closure and 25 patients (22.3%) underwent polyglactin mesh repair of the defect followed by wound granulation and eventual skin grafting. Twenty-two patients (19.6%) died before abdominal closure was attempted. Five patients (4.5%) developed enterocutaneous fistulae. Five patients (4.5%) developed intra-abdominal abscesses. There were no eviscerations. Three patients (2.7%) required further explorations after abdominal closure. Overall mortality rate was 25.9%, none related to the vacuum pack.

CONCLUSIONS

The vacuum pack is the temporary abdominal wound closure of choice in patients undergoing open abdominal management at our institution. Primary closure is achieved in the majority of patients with a low rate of complication. The technique is simple and easily mastered. Technical complications are rare and easily repaired.

Traumatic fracture of the hyoid bone: three case presentations of cardiorespiratory compromise secondary to missed diagnosis

Hyoid bone fractures secondary to blunt trauma other than strangulation are rare (ML Bagnoli et al., J Oral Maxillofac Surg 1988; 46: 326-8), accounting for only 0.002 per cent of all fractures. The world literature reports only 21 cases. Surgical intervention involves airway management, treatment of associated pharyngeal perforations, and management of painful symptomatology. The importance of hyoid fracture, however, rests not with the rarity of it, but with the lethal potential of missed diagnosis. We submit three cases with varying presentations and management strategies. All three of our cases incurred injury by blunt trauma to the anterior neck. Two patients required emergent surgical airway after unsuccessful attempts at endotracheal intubation. One patient presented without respiratory distress and was managed conservatively. After fracture, the occult compressive forces of hematoma formation and soft tissue swelling may compromise airway patency. It is our clinical observation that hypoxia develops rapidly and without warning, leading to cardiorespiratory collapse. With endotracheal intubation prohibited by obstruction, a surgical airway must be established and maintained. Recognition of subtle clinical and physical findings are critical to the diagnosis of laryngotracheal complex injuries and may be life-saving in many instances. To ensure a positive outcome, a strong degree of suspicion based on mechanism of injury is mandated.

Posttraumatic carotid cavernous fistula: frequency analysis of signs, symptoms, and disability outcomes after angiographic embolization

OBJECTIVE

To increase awareness and understanding of posttraumatic carotid cavernous fistula (PTCCF) with the intent to expedite diagnosis and treatment of this disabling injury, a 14-year retrospective review of patients with angiographically identified PTCCF was conducted at this Level I trauma center. A frequency analysis of signs, symptoms, and disability was performed. The impact on disability of demographics, number of embolization attempts required for closure of the PTCCF, and time from injury to diagnosis was assessed by t test for independent samples.

RESULTS

Nine patients were diagnosed with 10 PTCCFs. Mean patient age was 41.5 years. All patients with PTCCF had basilar skull fracture, loss of consciousness, bruit, and chemosis; 90% had exophthalmos; 70% had visual changes; 50% complained of headache; and 80% had some lasting disability. Mean age of patients with partial to total disability was 47 years, while the mean age of patients without lasting disability was 19.5 years (p = 0.013). No statistical correlation could be found between disability and sex, blunt versus penetrating injury, days to diagnosis, or number of embolization attempts.

CONCLUSION

Patients sustaining head trauma with basilar skull fractures and presenting with the described signs and symptoms should be evaluated for PTCCF. Risk of disability does not appear to be influenced by number of attempts at embolization or time to diagnosis. However, age may have a significant impact on outcome.

Outcome assessment of physiologic and clinical predictors of survival in patients after traumatic injury with a trauma score less than 5

OBJECTIVE

To define those physiologic and clinical variables that have a positive or negative predictive value in discriminating survivors from nonsurvivors with traumatic injuries and a Trauma Score of 5 or less.

METHODS

A retrospective review of 2,622 trauma patients transported by an air medical service from the scene of injury to a Level I trauma center was performed. Demographic, physiologic, and clinical variables were evaluated.

RESULTS

One hundred thirty-six patients were studied; 14 patients survived trauma resuscitation. Survivors had statistically significant improvement in the Glasgow Coma Scale from the field to arrival in the emergency room. Revised Trauma Score, probability of survival, pulse, respiratory rate, cardiac rhythm, central nervous system activity, and signs of life were statistically more favorable in survivors.

CONCLUSION

In patients who survived to discharge, signs of central nervous system activity in the field was a positive predictor of survival, and severe head injury served as a negative predictor of survival.

Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries

BACKGROUND

Recognizing the significant mortality and complications inherent in the operative management of blunt hepatic injuries, hepatic arterial embolization was evaluated as a bridge between operative and nonoperative interventions in patients defined as hemodynamically stable only with continuous resuscitation.

METHODS

Seven of 11 patients with grade IV or V hepatic injuries identified by computed tomography underwent hepatic arterial embolization. A prospective evaluation of hepatic embolization based on subsequent hemodynamic parameters was assessed by matched-pair analysis. A summary of this study population's demographic data and outcomes is presented, including age, Glasgow Coma Scale score, Injury Severity Score, Revised Trauma Score, computed tomography grade, intensive care unit and hospital length of stay, transfusion requirements, complications, and mortality.

RESULTS

No statistical difference was demonstrated between pre-embolization and postembolization hemodynamics and volume requirements. After embolization, however, continuous resuscitation was successfully reduced to maintenance fluids. Hepatic embolization was the definitive therapy for all seven patients who underwent embolization.

CONCLUSION

Results of this preliminary investigation suggest that hepatic arterial embolization is a viable alternative bridging the therapeutic options of operative and nonoperative intervention for a subpopulation of patients with hepatic injury.

Initial cervical exploration for parathyroidectomy is not benefited by preoperative localization studies

Published data is controversial as to the ability of preoperative localization studies (PLS) to enhance the outcome of initial cervical exploration in patients with primary hyperparathyroidism (PHPT). One surgeon's experience was reviewed to compare surgical success, operative time, and morbidity of initial cervical exploration for PHPT in patients who had undergone PLS versus those who had not. From August 1991 to September 1997, 95 patients who had not undergone prior central cervical exploration presented for surgical management of PHPT. Sixty-seven patients underwent initial cervical exploration without any PLS having been performed (Group A). Twenty-eight patients underwent PLS, either alone or in combination, before surgical intervention (Group B). Analysis of intergroup variability was conducted upon the data available using a two-tailed t test for independent samples. In addition, the sensitivities and positive predictive values of the PLS were calculated using study reports and operative and histologic findings. There was no statistically significant difference in surgical success between those patients who had PLS and those that did not undergo PLS. Sixty-four of 67 patients (95.5%) not having PLS were cured with initial surgery, while 27 of 28 patients (96.4%) who had PLS were surgically cured. Mean postoperative calcium and intact parathormone levels were similar between the two groups, and the mean operative time did not differ. Permanent hypocalcemia occurred in one patient, and five patients had transient hoarseness. Thirty-six total PLS were obtained at an average cost of $752.68/patient, and seven patients underwent multiple tests. Overall, sestamibi scan had the highest positive predictive value (81%). For adenomatous disease alone, sestamibi scan was the most sensitive (83%). Our study shows that for matched groups limited to age, sex, and clinical diagnosis, the use of PLS did not shorten operative time, decrease complication frequency, nor alter the success of the operation as measured by postoperative calcium and parathormone levels. Therefore, routine use of preoperative localization studies before initial cervical exploration for PHPT cannot be recommended.

Clinical analysis of the utility of repeat computed tomographic scan before discharge in blunt hepatic injury

OBJECTIVES

Nonoperative management of hemodynamically stable blunt hepatic injury has emerged as an acceptable and safe treatment. Surveillance of this population's injuries is costly. As a prelude to establishing practice guidelines, the utility of repeat computed tomographic (CT) scans was investigated.

METHODS

A retrospective study was conducted on 243 hepatic injuries. The CT scans of 95 patients managed nonoperatively who did not have ongoing transfusion requirements were reviewed and graded according to the American Association for the Surgery of Trauma (AAST) hepatic injury scale. Patients were grouped according to injury grade, assigned to two subgroups (patients with one CT scan versus more than one CT scan) and compared with respect to several physiologic and clinical variables.

RESULTS

Statistical analysis revealed no significant difference between subgroups with the same grade of injury. No significant difference was demonstrated between subgroups' length of stay.

CONCLUSIONS

No patients failed nonoperative treatment or succumbed to their injuries. Findings on repeat CT scan have not altered the decision to discharge the clinically stable patient having suffered a grade III or lower liver injury.

Do surgical residents, emergency medicine physicians, and nurses experience significant radiation exposure during the resuscitation of trauma patients?

During this study we investigated the yearly risk of radiation exposure for surgical residents (group 1, n = 8), emergency department (ED) physicians (group 2, n = 6) and nurses (group 3, n = 97) participating in the resuscitation of trauma victims in the emergency department of a 500-bed teaching hospital. Dosimeter readings of the three study groups were recorded monthly over the 1-year study period. During the study interval, 758 patients underwent resuscitation following trauma; 2098 portable radiographs (758 chest films, 758 lateral cervical spine films, and 582 radiographs of the pelvis) were obtained during the resuscitation phase of these patients. The total radiation exposure for group 3 was significantly greater than that for groups 1 and 2 (340 +/- 50 vs. 160 +/- 112 and 20 +/- 14 mrem, respectively, p < 0.01). Individual residents received a significantly greater amount of radiation than ED physicians and nurses (20 +/- 28 vs. 3.3 +/- 2.0 and 3.5 +/- 2.0 mrem, respectively, p < 0.05). However, despite repeated exposure to radiation, individuals in the three groups did not exceed the safety limits of 0.05 Gy/year set by the National Council on Radiation Protection and Measurements. Based on the results of this study, we conclude that trauma resuscitation teams can provide quality care to their patients without concern over the detrimental effects of radiation exposure, provided that the basic principles of radiation protection are followed.

Flail chest as a marker for significant injuries

The records of 92 patients with flail chest injury treated at a Level I trauma center were analyzed retrospectively. Associated intrathoracic injuries included pulmonary contusion (46 percent) and pneumothorax or hemothorax, or both (70 percent). The incidence of great vessel, tracheobronchial and diaphragmatic injuries was no different from that of a control population with simple rib fractures. Adult respiratory distress syndrome developed in 27 percent of patients with flail chest; 69 percent of all patients required ventilation (mean duration, 22 days). Mean length of hospital stay was 24 days. The mortality rate was 33 percent. We conclude that flail chest serves as a marker of significant intrathoracic injury, highly associated with pulmonary contusion, but even more so with pneumothorax or hemothorax. Flail chest does not seem to be a marker for great vessel, tracheobronchial, or diaphragmatic injuries. The majority of patients (more than two-thirds) will require mechanical ventilation for prolonged periods. Of paramount importance is the recognition of flail chest as a marker of high kinetic energy absorption, resulting in life-threatening thoracic as well as nonthoracic injuries.