Design and preliminary results of a pilot randomized controlled trial on a 1:1:1 transfusion strategy: the trauma formula-driven versus laboratory-guided study.

J Trauma. 2011 Nov;71(5 Suppl 1):S418-26

Authors: Nascimento B, Rizoli S, Rubenfeld G, Lin Y, Callum J, Tien HC

Abstract

BACKGROUND: Retrospective reviews have recently shown an survival benefit for adopting a resuscitation strategy that transfuses plasma and platelets at a near 1:1 ratio with red blood cells (RBCs). However, a randomized controlled trial on the topic is lacking. We report on the design and preliminary results of our ongoing randomized control pilot trial (ClinicalTrial.gov NCT00945542).

METHODS: This is a 2-year feasibility randomized control trial at a single tertiary trauma center. Bleeding trauma patients were randomized to either a laboratory-driven or a formula-driven (1 plasma:1 platelet:1 RBC) transfusion protocols. Feasibility was assessed by analyzing for ability to enroll patients, appropriate activation of transfusion protocols, time to transfusion of each type of blood product, laboratory turnaround time, ratio of blood products transfused, and wastage of blood products.

RESULTS: From July 6, 2009, to May 31, 2010, n = 18 patients were randomized and included in the study. Issues that we noted were the need to do postrandomization exclusions, the need to have rapid and accurate predictors of massive bleeding to enroll patients quickly, and the need to have waived consent for study participation. As well, we noted that the logistics of administering 1:1:1 were formidable and required rapid access to thawed plasma. Similarly, challenges in the control arm of such a study included the turnaround time for obtaining laboratory results.

CONCLUSION: Despite major challenges, our initial experience suggests that with an organized system, it is possible to prospectively randomize massively bleeding trauma patients. The accomplishment of high ratios of plasma to RBCs is challenging with current thawing methods and unavailability of thawed plasma in Canada. Longer shelf-life for plasma and faster plasma thawing microwaves should overcome some of these obstacles. For a laboratory-guided transfusion protocol, massive transfusion protocols should be in place with faster turnaround time for coagulation tests. Finally, further research on predictors of massive transfusion is needed.

PMID: 22071998 [PubMed - indexed for MEDLINE]

On the road with injury prevention–an analysis of the efficacy of a mobile injury prevention exhibit.

J Trauma. 2011 Nov;71(5 Suppl 2):S505-10

Authors: Manno M, Rook A, Yano-Litwin A, Maranda L, Burr A, Hirsh M

Abstract

BACKGROUND: To assess the effectiveness of a mobile injury prevention vehicle (mobile safety street [MSS]) with a hands-on curriculum on instruction and retention of safety knowledge compared with traditional classroom safety curriculum among grade 5 elementary school children.

METHODS: Grade 5 students (n = 1,692) were asked to participate in the study as either the intervention group (MSS experience) or the comparison group (traditional classroom safety curriculum). Each student in the intervention group was asked to complete a series of three surveys. The first survey was given before the MSS visit (Fall 2009), the second immediately following the MSS visit (Fall 2009), and a third given 6 months after the MSS visit (Spring 2010) to measure knowledge retention. Students in the comparison group were asked to complete two surveys. The first survey was given at the same time as the intervention group (Fall 2009) and the second was given after the completion of the traditional classroom safety curriculum (Spring 2010).

RESULTS: Students scored on average 5.67 of 10 (5.56-5.80) before any safety instruction was given. After MSS instruction, mean scores showed a significant increase to 7.43 of 10 (7.16-7.71). Such increase was still measurable 6 months after the intervention 7.34 (7.04-7.66). The comparison group saw a significant increase in their mean scores 6.48 (6.10-6.89), but the increase was much smaller than the intervention group.

CONCLUSIONS: Community-based injury prevention programs are essential to reducing preventable injury and deaths from trauma. This study demonstrates that a hands-on program is more effective than traditional methods for providing safety knowledge.

PMID: 22072036 [PubMed - indexed for MEDLINE]

Valete et bona fortuna.

J Trauma. 2011 Dec;71(6):1483

Authors: Pruitt BA

PMID: 22182856 [PubMed - in process]

Novel Simulation for Training Trauma Surgeons.

J Trauma. 2011 Dec;71(6):1484-1490

Authors: Aboud ET, Krisht AF, Oʼkeeffe T, Nader R, Hassan M, Stevens CM, Ali F, Luchette FA

Abstract

BACKGROUND:: Clinical training in operative technique is important to boost self-confidence in residents in all surgical fields but particularly in trauma surgery. The fully trained trauma surgeon must be able to provide operative intervention for any injury encountered in practice. In this report, we describe a novel training model using a human cadaver in which circulation in the major vessels can be simulated to mimic traumatic injuries seen in clinical practice. METHODS:: Fourteen human cadavers were used for simulating various life-threatening traumatic injuries. The carotid and femoral arteries and the jugular and femoral vein were cannulated and connected to perfusate reservoirs. The arterial reservoir was connected to an intra-aortic balloon pump, which adds pulsatile flow through the heart and major arteries.Fully trained trauma surgeons evaluated the utility of this model for repairing various injuries in the thoracic and abdominal cavity involving the heart, lungs, liver, and major vessels while maintaining emergent airway control. RESULTS:: Surgeons reported that this perfused cadaver model allowed simulation of the critical challenges faced during operative trauma while familiarizing the student with the operative techniques and skills necessary to gain access and control of hemorrhage associated with major vascular injuries. CONCLUSION:: In this report, we describe a novel training model that simulates the life-threatening injuries that confront trauma surgeons. An alternative to living laboratory animals, this inexpensive and readily available model offers good educational value for the acquisition and refinement of surgical skills that are specific to trauma surgery.

PMID: 22182857 [PubMed - as supplied by publisher]

Potential Role of the Advanced Surgical Skills for Exposure in Trauma (ASSET) Course in Canada.

J Trauma. 2011 Dec;71(6):1491-3

Authors: Ali J, Sorvari A, Haskin D, Luchette F, Bowyer M

PMID: 22182858 [PubMed - in process]

Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy.

J Trauma. 2011 Dec;71(6):1503-11

Authors: Hatch QM, Osterhout LM, Podbielski J, Kozar RA, Wade CE, Holcomb JB, Cotton BA

Abstract

BACKGROUND: : Damage control laparotomy (DCL) is a lifesaving technique initially employed to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. Recently, it has been recognized that DCL itself carries significant morbidity and may be overutilized. The purpose of this study was to determine (1) whether early fascial closure is associated with a reduction in postoperative complications and (2) whether patients at our institution met traditional DCL indications (acidosis, hypothermia, and coagulopathy).

METHODS: : This is a retrospective review of all patients undergoing immediate laparotomy at a Level I trauma center between 2004 and 2008. DCL was defined as temporary abdominal closure at the initial surgery. Early closure was defined as primary fascial closure at initial take back laparotomy. Patients were excluded if they died before first take back. Acidosis (pH <7.30), hypothermia (temperature <95.0°F), and coagulopathy (international normalized ratio >1.5) were measured on intensive care unit (ICU) arrival.

RESULTS: : Totally, 925 patients were eligible. Thirty percent had DCL employed. Of these, 86 subjects (34%) were closed at first take back while 161 (66%) were not. Both groups were similar in demographics, injury severity score, resuscitation volumes, blood products, and prehospital, emergency department, and operating room vital signs. Univariate analyses noted that intra-abdominal abscesses (8.4% vs. 21.3%), respiratory failure (14.4% vs. 37.1%), sepsis (8.4% vs. 25.1%), and renal failure (3.6% vs. 25.1%) were lower in patients closed at first take back (all <0.05). Controlling for age, gender, injury severity score, and transfusions, logistic regression analysis noted that closure at the first take back was associated with a reduction in infectious (odds ratio, 0.28; 95% confidence interval [CI], 0.12-0.66; p = 0.004) and noninfectious abdominal complications (odds ratio, 0.23; 95% CI, 0.09-0.56; p = 0.001) as well as wound (odds ratio, 0.31; 95% CI, 0.13-0.72; p = 0.007) and pulmonary complications (odds ratio, 0.35; CI, 0.20-0.62; p < 0.001). Of patients closed at the initial take back, 78% were acidotic (35%), coagulopathic (49%), or hypothermic (44%) on initial ICU admission.

CONCLUSION: : Early fascial closure is an independent predictor of reduced complications in DCL patients. One in five patients closed at initial take back did not meet any of the traditional indications for DCL upon initial ICU admission. This may represent an overutilization of this valuable technique, exposing patients to increased complications. Further efforts should be directed at achieving both early facial closure as well as redefining the appropriate indications for DCL.

PMID: 22182860 [PubMed - in process]

Validating the Western trauma association algorithm for managing patients with anterior abdominal stab wounds: a Western trauma association multicenter trial.

J Trauma. 2011 Dec;71(6):1494-502

Authors: Biffl WL, Kaups KL, Pham TN, Rowell SE, Jurkovich GJ, Burlew CC, Elterman J, Moore EE

Abstract

UNLABELLED: The optimal management of stable patients with anterior abdominal stab wounds (AASWs) remains a matter of debate. A recent Western Trauma Association (WTA) multicenter trial found that exclusion of peritoneal penetration by local wound exploration (LWE) allowed immediate discharge (D/C) of 41% of patients with AASWs. Performance of computed tomography (CT) scanning or diagnostic peritoneal lavage (DPL) did not improve the D/C rate; however, these tests led to nontherapeutic (NONTHER) laparotomy (LAP) in 24% and 31% of cases, respectively. An algorithm was proposed that included LWE, followed by either D/C or admission for serial clinical assessments, without further imaging or invasive testing. The purpose of this study was to evaluate the safety and efficacy of the algorithm in providing timely interventions for significant injuries.

METHODS: : A multicenter, institutional review board-approved study enrolled patients with AASWs. Management was guided by the WTA AASW algorithm. Data on the presentation, evaluation, and clinical course were recorded prospectively.

RESULTS: : Two hundred twenty-two patients (94% men, age, 34.7 years ± 0.3 years) were enrolled. Sixty-two (28%) had immediate LAP, of which 87% were therapeutic (THER). Three (1%) died and the mean length of stay (LOS) was 6.9 days. One hundred sixty patients were stable and asymptomatic, and 81 of them (51%) were managed entirely per protocol. Twenty (25%) were D/C’ed from the emergency department after (-) LWE, and 11 (14%) were taken to the operating room (OR) for LAP when their clinical condition changed. Two (2%) of the protocol group underwent NONTHER LAP, and no patient experienced morbidity or mortality related to delay in treatment. Seventy-nine (49%) patients had deviations from protocol. There were 47 CT scans, 11 DPLs, and 9 laparoscopic explorations performed. In addition to the laparoscopic procedures, 38 (48%) patients were taken to the OR based on test results rather than a change in the patient’s clinical condition; 17 (45%) of these patients had a NONTHER LAP. Eighteen (23%) patients were D/C’ed from the emergency department. The LOS was no different among patients who had immediate or delayed LAP. Mean LOS after NONTHER LAP was 3.6 days ± 0.8 days.

CONCLUSIONS: : The WTA proposed algorithm is designed for cost- effectiveness. Serial clinical assessments can be performed without the added expense of CT, DPL, or laparoscopy. Patients requiring LAP generally manifest early in their course, and there does not appear to be any morbidity related to a delay to OR. These data validate this approach and should be confirmed in a larger number of patients to more convincingly evaluate the algorithm’s safety and cost-effectiveness compared with other approaches.

PMID: 22182859 [PubMed - in process]

Safety of performing a delayed anastomosis during damage control laparotomy in patients with destructive colon injuries.

J Trauma. 2011 Dec;71(6):1512-8

Authors: Ordoñez CA, Pino LF, Badiel M, Sánchez AI, Loaiza J, Ballestas L, Puyana JC

Abstract

BACKGROUND: : Recent studies report the safety and feasibility of performing delayed anastomosis (DA) in patients undergoing damage control laparotomy (DCL) for destructive colon injuries (DCIs). Despite accumulating experience in both civilian and military trauma, questions regarding how to best identify high-risk patients and minimize the number of anastomosis-associated complications remain. Our current practice is to perform a definitive closure of the colon during DCL, unless there is persistent acidosis, bowel wall edema, or evidence of intra-abdominal abscess. In this study, we evaluated the safety of this approach by comparing outcomes of patients with DCI who underwent definitive closure of the colon during DCL versus patients managed with colostomy with or without DCL.

METHODS: : We performed a retrospective chart review of patients with penetrating DCI during 2003 to 2009. Severity of injury, surgical management, and clinical outcome were assessed.

RESULTS: : Sixty patients with severe gunshot wounds and three patients with stab wounds were included in the analysis. DCL was required in 30 patients, all with gunshot wounds. Three patients died within the first 48 hours, three underwent colostomy, and 24 were managed with DA. Thirty-three patients were managed with standard laparotomy: 26 patients with primary anastomosis and 7 with colostomy. Overall mortality rate was 9.5%. Three late deaths occurred in the DCL group, and only one death was associated with an anastomotic leak.

CONCLUSIONS: : Performing a DA in DCI during DCL is a reliable and feasible approach as long as severe acidosis, bowel wall edema, and/or persistent intra-abdominal infections are not present.

PMID: 22182861 [PubMed - in process]

Minimal aortic injury after blunt trauma: selective nonoperative management is safe.

J Trauma. 2011 Dec;71(6):1519-23

Authors: Paul JS, Neideen T, Tutton S, Milia D, Tolat P, Foley D, Brasel K

Abstract

BACKGROUND: : An increasing number of minimal aortic injuries (MAIs) are being identified with modern computed tomography (CT) imaging techniques. The optimal management and natural history of these injuries are unknown. We have adopted a policy of selective multidisciplinary nonoperative management of MAI. This study examines our experience with these patients from July 2004 to June 2009.

METHODS: : Retrospective chart review of all blunt trauma patients who underwent chest CT angiography to evaluate for blunt aortic injury (BAI) was undertaken. All patients deemed to have a MAI were managed nonoperatively, and those with a severe aortic injury underwent repair. Data collected included age, mechanism of injury, Injury Severity Score, type and location of aortic injury, intensive care unit length of stay (LOS), overall LOS, ventilator days, disposition, and mortality. In addition, all BAIs were graded according to the Presley Trauma Center CT Grading System of Aortic Injury.

RESULTS: : Forty-seven patients with BAI were identified. Thirty-two were classified as severe injuries, and 15 were considered MAI (32%). Nineteen underwent operative repair, 13 underwent endovascular stent graft repair, and 15 were managed nonoperatively. The average Injury Severity Score was 31 ± 10, and the average age was 44 ± 20 with no significant difference across treatment groups. There was no difference in overall or intensive care unit LOS. The nonoperative group had a shorter duration of ventilator days (1.1 vs. 4.28, p = 0.02). There were five deaths, none in the nonoperative group. None of these patients required subsequent intervention. All nonoperative patients had follow-up imaging at median of 4 days; on CT chest angiography, five injuries had resolved, eight had stable intimal flaps or pseudoaneurysm, and two had no detectable injury on subsequent aortogram.

CONCLUSION: : Almost one-third of our BAI were safely managed nonoperatively. Patients with MAI should be considered for selective nonoperative management in a multidisciplinary approach with close radiographic follow-up. We recommend that patients with MAIs should be considered for selective nonoperative management.

PMID: 22182862 [PubMed - in process]

Induced hypothermia after cardiac arrest in trauma patients: a case series.

J Trauma. 2011 Dec;71(6):1524-7

Authors: Tuma MA, Stansbury LG, Stein DM, McQuillan KA, Scalea TM

Abstract

BACKGROUND: : Induced hypothermia after cardiac arrest is an accepted neuroprotective strategy. However, its role in cardiac arrest during acute trauma care is not yet defined. To characterize recent experience with this technique at our center, we undertook a detailed chart review of acute trauma patients managed with induced hypothermia after cardiac arrest.

PATIENTS: : From Trauma Registry records, we identified all adult patients (older than 17 years) admitted to our Level I trauma center from July 1, 2008, through June 30, 2010, who experienced cardiac arrest during acute trauma care and were managed via our induced hypothermia protocol. This requires maintenance of core body temperature between 32°C and 34°C for 24 hours after arrest. Patient clinical records were then reviewed for selected factors.

RESULTS: : Six acute trauma patients (3 male and 3 female; median age, 53 years) with cardiac arrest managed per protocol were identified. All injuries were due to blunt impact, and five of six injuries were motor-vehicle-associated. Median Injury Severity Score was 27; median prearrest Glasgow Coma Scale (GCS) score was 15. One patient arrested prehospital and the other 5 in-hospital. Median duration of arrest was 8 minutes. All were comatose after arrest. One death occurred, in the patient with a prehospital cardiac arrest. Two patients were discharged to chronic care facilities with GCS11-tracheostomy; three were discharged to active rehabilitation care facilities with GCS score of 14 to 15. There were no obvious complications related to cooling.

CONCLUSIONS: : Mild induced hypothermia can be beneficial in a selected group of trauma patients after cardiac arrest. Prospective trials are needed to explore the effects of targeted temperature management on coagulation in this patient group.

PMID: 22182863 [PubMed - in process]

Simple, Almost Anywhere, With Almost Anyone: Remote Low-Cost Telementored Resuscitative Lung Ultrasound.

J Trauma. 2011 Dec;71(6):1528-1535

Authors: McBeth PB, Crawford I, Blaivas M, Hamilton T, Musselwhite K, Panebianco N, Melniker L, Ball CG, Gargani L, Gherdovich C, Kirkpatrick AW

Abstract

BACKGROUND:: Apnea (APN) and pneumothorax (PTX) are common immediately life-threatening conditions. Ultrasound is a portable tool that captures anatomy and physiology as digital information allowing it to be readily transferred by electronic means. Both APN and PTX are simply ruled out by visualizing respiratory motion at the visceral-parietal pleural interface known as lung sliding (LS), corroborated by either the M-mode or color-power Doppler depiction of LS. We thus assessed how economically and practically this information could be obtained remotely over a cellular network. METHODS:: Ultrasound images were obtained on handheld ultrasound machines streamed to a standard free internet service (Skype) using an iPhone. Remote expert sonographers directed remote providers (with variable to no ultrasound experience) to obtain images by viewing the transmitted ultrasound signal and by viewing the remote examiner over a head-mounted webcam. Examinations were conducted between a series of remote sites and a base station. Remote sites included two remote on-mountain sites, a small airplane in flight, and a Calgary household, with base sites located in Pisa, Rome, Philadelphia, and Calgary. RESULTS:: In all lung fields (20/20) on all occasions, LS could easily and quickly be seen. LS was easily corroborated and documented through capture of color-power Doppler and M-mode images. Other ultrasound applications such as the Focused Assessment with Sonography for Trauma examination, vascular anatomy, and a fetal wellness assessment were also demonstrated. CONCLUSION:: The emergent exclusion of APN-PTX can be immediately accomplished by a remote expert economically linked to almost any responder over cellular networks. Further work should explore the range of other physiologic functions and anatomy that could be so remotely assessed.

PMID: 22182864 [PubMed - as supplied by publisher]

Continuous intercostal nerve blockade for rib fractures: ready for primetime?

J Trauma. 2011 Dec;71(6):1548-52

Authors: Truitt MS, Murry J, Amos J, Lorenzo M, Mangram A, Dunn E, Moore EE

Abstract

BACKGROUND: : Providing analgesia for patients with rib fractures continues to be a management challenge. The objective of this study was to examine our experience with the use of a continuous intercostal nerve block (CINB). Although this technique is being used, little data have been published documenting its use and efficacy. We hypothesized that a CINB would provide excellent analgesia, improve pulmonary function, and decrease length of stay (LOS).

METHODS: : Consecutive adult blunt trauma patients with three or more unilateral rib fractures were prospectively studied over 24 months. The catheters were placed at the bedside in the extrathoracic, paravertebral location, and 0.2% ropivacaine was infused. Respiratory rate, preplacement (PRE) numeric pain scale (NPS) scores, and sustained maximal inspiration (SMI) lung volumes were determined at rest and after coughing. Parameters were repeated 60 minutes after catheter placement (POST). Hospital LOS comparison was made with historical controls using epidural analgesia.

RESULTS: : Over the study period, 102 patients met inclusion criteria. Mean age was 69 (21-96) years, mean injury severity score was 14 (9-16), and the mean number of rib fractures was 5.8 (3-10). Mean NPS improved significantly (PRE NPS at rest = 7.5 vs. POST NPS at rest = 2.6, p < 0.05, PRE NPS after cough = 9.4, POST after cough = 3.6, p < 0.05) which was associated with an increase in the SMI (PRE SMI = 0.4 L and POST SMI = 1.3 L, p < 0.05). Respiratory rate decreased significantly (p < 0.05) and only 2 of 102 required mechanical ventilation. Average LOS for the study population was 2.9 days compared with 5.9 days in the historical control. No procedural or drug-related complications occurred.

CONCLUSION: : Utilization of CINB significantly improved pulmonary function, pain control, and shortens LOS in patients with rib fractures.

PMID: 22182865 [PubMed - in process]

Effects of continuous venous-venous hemofiltration on heat stroke patients: a retrospective study.

J Trauma. 2011 Dec;71(6):1562-8

Authors: Zhou F, Song Q, Peng Z, Pan L, Kang H, Tang S, Yue H, Liu H, Xie F

Abstract

BACKGROUND: : Heat stroke (HS) is a fatal illness characterized by an elevated core body temperature above 40°C and complicated with rhabdomyolysis and acute renal failure. We retrospectively analyzed the effect of continuous veno-venous hemofiltration (CVVH) in patients with HS.

METHODS: : A total of 16 patients with HS were retrospectively analyzed. All patients were treated by CVVH for at least 96 hours, and CVVH was initiated with replacement fluid between 25°C and 30°C for 2 hours to 2.5 hours, and 36°C thereafter. The vital signs were monitored and blood samples were collected during CVVH to measure serum urea, creatinine, myoglobin, creatine kinase, and total bilirubin.

RESULTS: : All patients survived. The core temperature of the patients decreased from 41.3 ± 0.2°C to 38.7 ± 0.1°C after 2 hours and to 36.7 ± 0.1°C after 5 hours during CVVH (p < 0.05). Compared with values before starting CVVH, there were remarkable improvements in mean arterial blood pressure, heart rate, and oxygenation index (p < 0.05). The serum creatinine, urea, myoglobin, and creatine kinase decreased significantly (p < 0.05), while the bilirubinemia had no obvious decline (p > 0.05). The scores of APACHE II and arterial lactate had also obvious decline (p < 0.05). The hemodynamic variables were stabilized during CVVH, and no obvious side effects related to CVVH were found.

CONCLUSIONS: : CVVH is safe and feasible in the treatment of patients with HS by lowering core temperature, removal of myoglobin, support of multiorgan function, and modulating systemic inflammatory response syndrome (SIRS). The impact of CVVH on patient outcome, however, still needs proof by larger randomized controlled trials.

PMID: 22182867 [PubMed - in process]

Percutaneous tracheostomy: to bronch or not to bronch-that is the question.

J Trauma. 2011 Dec;71(6):1553-6

Authors: Jackson LS, Davis JW, Kaups KL, Sue LP, Wolfe MM, Bilello JF, Lemaster D

Abstract

BACKGROUND: : Percutaneous tracheostomy is a routine procedure in the intensive care unit (ICU). Some surgeons perform percutaneous tracheostomies using bronchoscopy believing that it increases safety. The purpose of this study was to evaluate percutaneous tracheostomy in the trauma population and to determine whether the use of a bronchoscope decreases the complication rate and improves safety.

METHODS: : A retrospective review was completed from January 2007 to November 2010. Inclusion criteria were trauma patients undergoing percutaneous tracheostomy. Data collected included age, Abbreviated Injury Score by region, Injury Severity Score, ventilator days, and outcomes. Complications were classified as early (occurring within <24 hours) or late (>24 hours after the procedure).

RESULTS: : During the study period, 9,663 trauma patients were admitted, with 1,587 undergoing intubation and admission to the ICU. Tracheostomies were performed in 266 patients and 243 of these were percutaneous; 78 (32%) were performed with the bronchoscope (Bronch) and 168 (68%) without bronchoscope (No Bronch). There were no differences between the groups in Abbreviated Injury Score by region, Injury Severity Score, probability of survival, ventilator days, and length of ICU or overall hospital stay. There were 16 complications, 5 (Bronch) and 11 (No Bronch). Early complications were primarily bleeding (Bronch 3% vs. No Bronch 4%, not statistically significant). Late complications included tracheomalacia, tracheal granulation tissue, bleeding, and stenosis; Bronch 4% versus No Bronch 3%, (not statistically significant). One major complication occurred, with loss of airway and cardiac arrest, in the bronchoscopy group.

CONCLUSION: : Percutaneous tracheostomy was safely and effectively performed by an experienced surgical team both with and without bronchoscopic guidance with no difference in the complication rates. This study suggests that the use of bronchoscopic guidance during tracheostomy is not routinely required but may be used as an important adjunct in selected patients, such as those with HALO cervical fixation, obesity, or difficult anatomy.

PMID: 22182866 [PubMed - in process]

Talk and die revisited: bifrontal contusions and late deterioration.

J Trauma. 2011 Dec;71(6):1588-92

Authors: Peterson EC, Chesnut RM

Abstract

BACKGROUND: : Severe bifrontal contusions in an awake traumatic brain injury (TBI) patient is a challenging clinical picture, as they are prone to late deterioration. We evaluated our series of patients with severe bifrontal contusions, characterizing their clinical course and suggestions for management.

METHODS: : We examined a prospectively collected database of TBIs for patients with severe bifrontal contusions, defined as >30 cm. Only patients with Glasgow Coma Scale score of 10 or greater were included. Patients were divided into two groups: deterioration and nondeterioration. Clinical variables were compared between the two groups.

RESULTS: : Thirteen patients met the above criteria. The mean Glasgow Coma Scale score was 13, and all were low mechanism injuries. All patients were managed with intensive care unit observation and hyperosmolar therapy to maintain serum osmolarity >300. Overall, 7 of 13 (54%) suffered an acute clinical deterioration a mean of 4.5 days postinjury. Of those managed with immediate surgical decompression, all had good outcomes and returned to work. There was no difference in contusion or edema volumes between the two groups.

CONCLUSIONS: : Awake patients with bifrontal contusions represent a unique cohort of TBI patients who are prone to rapid deterioration late in their clinical course. They have extensive frontal edema and mass effect, yet we were unable to find a correlation between edema volumes and incidence of deterioration. Based on this series and our experience in other TBI patients, we no longer utilize prophylactic infusions of hypertonic saline in the setting of TBI. We recommend managing these patients with intensive care unit admission and early intracranial pressure monitoring. If they do deteriorate despite these measures, rapid bifrontal decompression can lead to good functional outcomes.

PMID: 22182868 [PubMed - in process]

Early Parenchymal Contrast Extravasation Predicts Subsequent Hemorrhage Progression, Clinical Deterioration, and Need for Surgery in Patients With Traumatic Cerebral Contusion.

J Trauma. 2011 Dec;71(6):1593-1599

Authors: Huang AP, Lee CW, Hsieh HJ, Yang CC, Tsai YH, Tsuang FY, Kuo LT, Chen YS, Tu YK, Huang SJ, Liu HM, Tsai JC

Abstract

BACKGROUND:: This study aimed to identify early radiologic signs that are predictive of hemorrhage progression and clinical deterioration in patients with traumatic cerebral contusion. We hypothesized that contrast extravasation (CE) and blood-brain barrier disruption might be associated with hemorrhage progression, brain edema, and clinical deterioration in these patients. METHODS:: Twenty-two patients with traumatic cerebral contusion (diagnosed on initial noncontrast head computed tomography [CT]) who initially did not require surgical intervention were enrolled in this study. Contrast-enhanced and perfusion CT scans were performed within 6 hours of injury, and follow-up noncontrast CT scans were performed at 24 hours and 72 hours. RESULTS:: In each noncontrast CT scan, the volumes of the contusion hemorrhage and edema were calculated using computerized planimetric techniques. The initial Glasgow Coma Scale, hemorrhage progression, clinical deterioration, and the need for subsequent surgery were recorded. The early radiologic findings were compared with these parameters and functional outcome at 6 months to identify predictive radiologic signs. CE was present in 9 of 22 patients (41%) and was highly associated with hemorrhage progression (p < 0.05), clinical deterioration (p < 0.01), and need for subsequent surgery (p < 0.01). In addition, patients with CE had a greater volume of edema at 24 hours (p < 0.01) and 72 hours (p < 0.01) than those who did not have CE. However, CE was not found to be associated with poor outcome. CONCLUSIONS:: Early parenchymal CE is associated with hemorrhage progression, cerebral edema, clinical deterioration, and need for subsequent surgery. These patients should be monitored closely, and early surgery may be needed if deterioration occurs. Further elucidation of the pathophysiology is needed to formulate effective treatment for these high-risk patients.

PMID: 22182869 [PubMed - as supplied by publisher]

Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulants and prescription antiplatelet agents at risk?

J Trauma. 2011 Dec;71(6):1600-4

Authors: Peck KA, Sise CB, Shackford SR, Sise MJ, Calvo RY, Sack DI, Walker SB, Schechter MS

Abstract

BACKGROUND: : Trauma centers are more frequently evaluating patients who are receiving anticoagulant or prescription antiplatelet (ACAP) therapy at the time of injury. Because there are reports of delayed intracranial hemorrhage (ICH) after blunt trauma in this patient group, we evaluated patients receiving ACAP with a head computed tomography (CT) on admission (CT1) followed by a routine repeat head CT (CT2) in 6 hours. We hypothesized that among patients with no traumatic findings on CT1 and a normal or unchanged interval neurologic examination, the incidence of clinically significant delayed ICH would be zero.

METHODS: : We retrospectively reviewed adult blunt trauma patients admitted to our Level I trauma center from January 2006 to August 2009 who were receiving preinjury ACAP therapy. We reviewed medications, mechanism of injury, head CT results, and outcomes. Demographic data, injury severity scores, international normalized ratio, and neurologic examinations were recorded. We determined the incidence of delayed ICH on CT2 for patients with a negative CT1.

RESULTS: : Five hundred patients qualified for the protocol. Of these, 424 patients (85%) had a negative CT1. Among these patients, mean age was 75 years; 210 (50%) were male. Fall from standing was the most common mechanism of injury found in 357 patients (84%). Warfarin alone was taken in 68%, clopidogrel alone in 24%, and other agents in 2%. Six percent of patients were taking two agents. Mean international normalized ratio for patients on warfarin was 2.5. Among patients with a negative CT1, CT2 was obtained in 362 patients (85%) and was negative in 358 patients (99%). Four patients (1%) with a negative CT1 had a positive (n = 3) or equivocal (n = 1) CT2. All the changes on CT2 were minor and had either resolved or stabilized on third head CT. Of the four patients with positive or equivocal CT2, none had a change in neurologic examination; however, two had symptoms that could be attributed to head injury. Three were discharged home and one died of cardiac disease unrelated to head trauma.

CONCLUSIONS: : The incidence of delayed ICH in our study was 1%. However, none of the delayed findings were clinically significant. Among patients on ACAP therapy with a negative CT1 and a normal or unchanged neurologic examination, a routine CT2 is unnecessary. We recommend a period of observation to recognize those patients with symptoms that could be due to delayed ICH.

PMID: 22182870 [PubMed - in process]

The association between skull bone fractures and outcomes in patients with severe traumatic brain injury.

J Trauma. 2011 Dec;71(6):1611-4

Authors: Tseng WC, Shih HM, Su YC, Chen HW, Hsiao KY, Chen IC

Abstract

BACKGROUND: : In traumatic brain injury (TBI), computed tomography (CT) provides a good assessment of anatomic pathologic findings and the prognostic value of CT characteristics has been well discussed. However, few studies have focused on skull bone fracture and its clinical prognostic importance. Hence, this study aims to evaluate the effects of skull bone fracture on patients with severe TBI admitted to the emergency unit.

METHODS: : We reviewed the medical records of patients with isolated severe TBI admitted to the emergency unit of a university hospital from July 2003 to June 2008. Patients were divided into two groups based on the presence of skull bone fracture identified by the CT scan while in the emergency unit. Mann-Whitney U test and a Student’s t test were used to identify the differences between the two groups, whereas logistic regression was applied to determine any significant differences found in the statistical analysis.

RESULTS: : A total of 197 patients were signed up in our study. Based on the presence of skull bone fracture on CT scan at emergency department, 92 patients (46.7%) comprised the skull bone fracture group and 59 patients (64.1%) of these died. One hundred five patients (53.3%) comprised the nonskull bone fracture group, of which 33 patients (31.4%) died. There is significant difference between the two groups (p = 0.004).

CONCLUSION: : This study shows that skull bone fracture is a mortality risk factor for patients with isolated severe blunt TBI.

PMID: 22182871 [PubMed - in process]

Cost-effectiveness of decompressive craniectomy as a lifesaving rescue procedure for patients with severe traumatic brain injury.

J Trauma. 2011 Dec;71(6):1637-44

Authors: Ho KM, Honeybul S, Lind CR, Gillett GR, Litton E

Abstract

BACKGROUND: : Decompressive craniectomy has been traditionally used as a lifesaving rescue procedure for patients with refractory intracranial hypertension after severe traumatic brain injury (TBI), but its cost-effectiveness remains uncertain.

METHODS: : Using data on length of stay in hospital, rehabilitation facility, procedural costs, and Glasgow Outcome Scale (GOS) up to 18 months after surgery, the average total hospital costs per life-year and quality-adjusted life-year (QALY) were calculated for patients who had decompressive craniectomy for TBI between 2004 and 2010 in Western Australia. The Corticosteroid Randomisation After Significant Head Injury prediction model was used to quantify the severity of TBI.

RESULTS: : Of the 168 patients who had 18-month follow-up data available after the procedure, 70 (42%) achieved a good outcome (GOS-5), 27 (16%) had moderate disability (GOS-4), 34 (20%) had severe disability (GOS-3), 5 (3%) were in vegetative state (GOS-2), and 32 (19%) died (GOS-1). The hospital costs increased with the severity of TBI and peaked when the predicted risk of an unfavorable outcome was about 80%. The average cost per life-year gained (US$671,000 per life-year) and QALY (US$682,000 per QALY) increased substantially and became much more than the usual acceptable cost-effective limit (US$100,000 per QALY) when the predicted risk of an unfavorable outcome was >80%. Changing different underlying assumptions of the analysis did not change the results significantly.

CONCLUSIONS: : Severity of TBI had an important effect on cost-effectiveness of decompressive craniectomy. As a lifesaving procedure, decompressive craniectomy was not cost-effective for patients with extremely severe TBI.

PMID: 22182872 [PubMed - in process]

A useful tool for the initial assessment of blood-brain barrier permeability after traumatic brain injury in rabbits: dynamic contrast-enhanced magnetic resonance imaging.

J Trauma. 2011 Dec;71(6):1645-51

Authors: Wei XE, Wang D, Li MH, Zhang YZ, Li YH, Li WB

Abstract

OBJECTIVE: : The aim of this study was to evaluate the role of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and its quantitative coefficient (K) in the assessment of the extent of traumatic brain injury (TBI) in a rabbit model.

METHODS: : A weight-drop device (height, 20 cm) was used with varying impact force, 30-, 60-, or 90-g weight, to induce mild, moderate, or severe TBI, respectively. DCE-MRI and T2-weighted MRI was used to examine the injured groups and a sham group 1 day after TBI. We analyzed the relationship between K and the lesion volume on the basis of T2-weighted images in each group.

RESULTS: : The lesion volumes in both the severe and the moderate injury groups were greater than those observed in the mild injury group (p < 0.01). Furthermore, the lesion volumes in the severe injury group tended to be greater than those seen in the moderate injury group (p = 0.053). The K values in all injury groups were greater than those observed in the sham group (p < 0.01). In addition, the K values in the severe and moderate injury groups were greater than those of the mild injury group (p < 0.01), and the values seen in the severe injury group tended to be greater than those of the moderate injury group (p = 0.08). Moreover, we observed a correlation between the K value and lesion volume in all injury groups (mild injury group: r = 0.766, p = 0.01; moderate injury group: r = 0.731, p = 0.04; and severe injury group: r = 0.886, p = 0.019).

CONCLUSIONS: : DCE-MRI and its quantitative coefficient, K, have the potential to accurately assess the blood-brain barrier and the extent of injury in an in vivo model of TBI.

PMID: 22182873 [PubMed - in process]

Testosterone depletion or blockade in male rats protects against trauma hemorrhagic shock-induced distant organ injury by limiting gut injury and subsequent production of biologically active mesenteric lymph.

J Trauma. 2011 Dec;71(6):1652-8

Authors: Sheth SU, Palange D, Xu DZ, Wei D, Feketeova E, Lu Q, Reino DC, Qin X, Deitch EA

Abstract

BACKGROUND: : We tested the hypothesis that testosterone depletion or blockade in male rats protects against trauma hemorrhagic shock-induced distant organ injury by limiting gut injury and subsequent production of biologically active mesenteric lymph.

METHODS: : Male, castrated male, or flutamide-treated rats (25 mg/kg subcutaneously after resuscitation) were subjected to a laparotomy (trauma), mesenteric lymph duct cannulation, and 90 minutes of shock (35 mm Hg) or trauma sham-shock. Mesenteric lymph was collected preshock, during shock, and postshock. Gut injury was determined at 6 hours postshock using ex vivo ileal permeability with fluorescein dextran. Postshock mesenteric lymph was assayed for biological activity in vivo by injection into mice and measuring lung permeability, neutrophil activation, and red blood cell deformability. In vitro neutrophil priming capacity of the lymph was also tested.

RESULTS: : Castrated and flutamide-treated male rats were significantly protected against trauma hemorrhagic shock (T/HS)-induced gut injury when compared with hormonally intact males. Postshock mesenteric lymph from male rats had a higher capacity to induce lung injury, Neutrophil (PMN) activation, and loss of red blood cell deformability when injected into naïve mice when compared with castrated and flutamide-treated males. The increase in gut injury after T/HS in males directly correlated with the in vitro biological activity of mesenteric lymph to prime neutrophils for an increased respiratory burst.

CONCLUSIONS: : After T/HS, gut protective effects can be observed in males after testosterone blockade or depletion. This reduced gut injury contributes to decreased biological activity of mesenteric lymph leading to attenuated systemic inflammation and distant organ injury.

PMID: 22182874 [PubMed - in process]

Neurological, functional, and biomechanical characteristics after high-velocity behind armor blunt trauma of the spine.

J Trauma. 2011 Dec;71(6):1680-8

Authors: Zhang B, Huang Y, Su Z, Wang S, Wang S, Wang J, Wang A, Lai X

Abstract

BACKGROUND: : Behind armor blunt trauma (BABT) describes a nonpenetrating injury to the organs of an individual wearing body armor. The aim of this study was to investigate the neurologic and functional changes that occur in the central nervous system after high-velocity BABT of the spine as well as its biomechanical characteristics.

METHODS: : This study evaluated 28 healthy adult white pigs. Animals were randomly divided into three experimental groups: (1) 15 animals (9 in the exposed group and 6 in the control group) were tested for neurologic changes; (2) 10 animals (5 in the exposed group and 5 in the control group) were used for studies of cognitive function; (3) and 3 animals were used for examination of biomechanics. In the group tested for neurologic changes, 9 anesthetized pigs wearing body armor (including a ceramic plate and polyethylene body armor) on the back were shot on the eighth thoracic vertebrae (T8) with a 5.56-mm rifle bullet (velocity appropriately 910 m/s). As a control, six pigs were shot with blank ammunition. Ultrastructural changes of the spinal cord and brain tissue were observed with light and electron microscopy. Expression levels of myelin basic protein, neuron-specific enolase (NSE), and glial cytoplasmic protein (S-100B) were investigated in the serum and cerebrospinal fluid using enzyme-linked immunosorbent assays. Electroencephalograms (EEGs) were monitored before and 10 minutes after the shot. Pressures in the spine, common carotid artery, and brain were detected. Acceleration of the 10th vertebrae (T10) was tested. Finally, cognitive outcomes between exposed and control groups were compared.

RESULTS: : Neuronal degeneration and nerve fiber demyelination were seen in the spinal cord. The concentrations of neuron-specific enolase, myelin basic protein, and S-100B were significantly increased in the serum and cerebrospinal fluid 3 hours after trauma (p < 0.05). The electroencephalogram was suppressed within 3 to 6 minutes after trauma. The pressure detected in the brain was higher than that detected in the common carotid artery (p < 0.01). The trauma resulted in paralysis of two hind limbs and in cognitive dysfunction.

CONCLUSION: : The results from our animal model indicate that high-velocity BABT of the spine generates high pressure and acceleration in the spine, induces varying degrees of paralysis of hind limbs, and disturbs cerebral function. The neuronal degeneration caused by the pressure wave may be one of the important pathologic events involved in the development of trauma-related complications.

PMID: 22182875 [PubMed - in process]

Elevated admission systolic blood pressure after blunt trauma predicts delayed pneumonia and mortality.

J Trauma. 2011 Dec;71(6):1689-93

Authors: Ley EJ, Singer MB, Clond MA, Gangi A, Mirocha J, Bukur M, Brown CV, Salim A

Abstract

BACKGROUND: : Although avoiding hypotension is a primary focus after trauma, elevated systolic blood pressure (SBP) is frequently disregarded. The purpose of this study was to determine the association between elevated admission SBP and delayed outcomes after trauma.

METHODS: : The Los Angeles County Trauma System Database was queried for all patients between 2003 and 2008 with blunt injuries who survived for at least 2 days after admission. Demographics and outcomes (pneumonia and mortality) were compared at various admission SBP subgroups (≥160 mm Hg, ≥170 mm Hg, ≥180 mm Hg, ≥190 mm Hg, ≥200 mm Hg, ≥210 mm Hg, and ≥220 mm Hg). Patients with moderate-to-severe traumatic brain injury (TBI), defined as head Abbreviated Injury Score ≥3, were then identified and compared with those without using multivariable logistic regression.

RESULTS: : Data accessed from 14,382 blunt trauma admissions identified 2,601 patients with moderate-to-severe TBI (TBI group) and 11,781 without moderate-to-severe TBI (non-TBI group) who were hospitalized ≥2 days. Overall mortality was 2.9%, 7.1% for TBI patients, and 1.9% for non-TBI patients. Overall pneumonia was 4.6%, 9.5% for TBI patients, and 3.6% for non-TBI patients. Regression modeling determined SBP ≥160 mm Hg was a significant predictor of mortality in TBI patients (adjusted odds ratio [AOR], 1.59; confidence interval [CI], 1.10-2.29; p = 0.03) and non-TBI patients (AOR, 1.47; CI, 1.14-1.90; p = 0.003). Similarly, SBP ≥160 mm Hg was a significant predictor for increased pneumonia in TBI patients (AOR, 1.79; CI, 1.30-2.46; p = 0.0004), compared with non-TBI patients (AOR, 1.28; CI, 0.97-1.69; p = 0.08).

CONCLUSIONS: : In blunt trauma patients with or without TBI, elevated admission SBP was associated with worse delayed outcomes. Prospective research is necessary to determine whether algorithms that manage elevated blood pressure after trauma, especially after TBI, affect mortality or pneumonia.

PMID: 22182876 [PubMed - in process]

Treatment of Posttraumatic Equinus Deformity and Concomitant Soft Tissue Defects of the Heel.

J Trauma. 2011 Dec;71(6):1699-1704

Authors: Shu H, Ma B, Kan S, Wang H, Shao H, Watson JT

Abstract

BACKGROUND:: To evaluate the operative method and clinical outcome for the treatment of posttraumatic equinus deformity and concomitant soft tissue defect of the heel. METHODS:: Between June 2006 and May 2010, seven cases of posttraumatic equinus deformity and concomitant unstable scar or ulcer of the heels were treated by using a hinged Ilizarov apparatus and reversed sural fasciocutaneous island flap transfer. Achilles tendon lengthening was also done in all patients. The average duration of follow-up was 21 months. The sizes of sural flaps were from 7 cm × 6 cm to 10 cm ×9 cm. Two weeks after the flap transfer, distraction of the Ilizarov fixator was initiated to gradually correct the equinus position of the foot. RESULTS:: Results were evaluated by using the following criteria: (1) the degree of active dorsiflexion of the ankle, (2) the total active range of motion of the ankle, and (3) walking ability and flap durability. For active dorsiflexion of the ankle, the results were good in three patients and fair in four patients. For range of active motion of the ankle, the results were good in five patients and fair in two patients. For walking ability and flap durability, the results were good in six patients and fair in one patient. CONCLUSION:: This study showed that posttraumatic equinus deformity accompanied by soft tissue defect of the heel can be treated effectively with Achilles tendon lengthening, reversed sural fasciocutaneous island flap transfer, and a hinged Ilizarov technique.

PMID: 22182877 [PubMed - as supplied by publisher]

Delayed Flap Reconstruction With Vacuum-Assisted Closure Management of the Open IIIB Tibial Fracture.

J Trauma. 2011 Dec;71(6):1705-8

Authors: Hou Z, Irgit K, Strohecker KA, Matzko ME, Wingert NC, Desantis JG, Smith WR

Abstract

OBJECTIVE: : Vacuum-assisted closure (VAC) therapy has been shown to be effective at reducing bacterial counts in wounds until definitive bony coverage. However, there is continued debate over timing and type of definitive wound coverage even with VAC therapy application.

METHODS: : From 2004 to 2009, 32 patients with Gustilo type IIIB open tibia fractures were initially treated with VAC therapy were included. The number of debridements, length of treatment with VAC dressing, definitive wound coverage management, and length of hospital stay, flap-related complications, and time to radiographic fracture healing were recorded.

RESULTS: : The mean Injury Severity Score was 17.3 ± 2.0. All wounds closed after being treated with the primary VAC closure. The mean interval between the initial injury and definitive intervention was 10.9 days ± 0.3 days. Twenty of 27 patients (74%) underwent rotational muscle flaps; four received free muscle flaps and three only with split-thickness skin grafts for definitive wound coverage. Nine of 32 patients (28%) underwent below knee amputation, five without flap coverage after several VAC sessions and four after definitive flap coverage. The average time to union was 10.0 months ± 2.0 months. Eight patients developed nonunion and 11 patients developed infections. The average follow-up time is 2.4 years ± 0.2 years. Patients were divided into two groups for analysis according to the interval time. The rate of infection was significantly increased in patients who had an interval of more than 7 days from the time of injury to flap coverage.

CONCLUSIONS: : The VAC therapy may help to reduce the flap size and need for a flap transfer for type IIIB open tibial fractures. However, prolonged periods of VAC usage, greater than 7 days, should be avoided to reduce higher infection and amputation risks.

PMID: 22182878 [PubMed - in process]

Treatment of interprosthetic fractures of the femur.

J Trauma. 2011 Dec;71(6):1715-9

Authors: Hou Z, Moore B, Bowen TR, Irgit K, Matzko ME, Strohecker KA, Smith WR

Abstract

BACKGROUND: : The treatment of interprosthetic femoral fractures is challenging because of several factors. Poor bone stock, advanced age, potential prosthetic instability, and limited fracture fixation options both proximally and distally can complicate standard femur fracture treatment procedures. The purpose of this report was to describe our experience treating interprosthetic femoral fractures, providing an emphasis on treatment principles and specific intraoperative management.

METHODS: : All patients with fractures occurring between ipsilateral hip and knee prostheses between 2004 and 2010 were identified from a comprehensive database and included in this study. Patients had been treated using principles adapted from two isolated periprosthetic fracture classification systems, the Vancouver and Su classifications. The electronic medical record (including inpatient medical records, operative notes, outpatient medical records, and all radiographs) was reviewed for each patient and demographic and treatment-related variables as well as complications and outcomes were recorded.

RESULTS: : Thirteen consecutive patients with interprosthetic fractures were included. Four fractures occurred around a clearly loose prosthesis, which were subsequently treated with long-stemmed revisions. The remaining 12 fractures were treated with a locked-plate construct. Two of nine patients (22.2%) died before fracture union. Follow-up averaged 28 months ± 4 months, with fracture union achieved at an average of 4.7 months ± 0.3 months. All patients returned to their self-reported preoperative ambulatory status except one who developed a loose hip prosthesis at 3-year follow-up after fracture union.

CONCLUSIONS: : The principles for treatment of isolated periprosthetic fractures are useful to guide the fixation of interprosthetic fractures. Locked plating is an effective method for the treatment of interprosthetic femoral fractures. Bypassing the adjacent prosthesis by a minimum of two femoral diameters is a necessary technique to prevent a stress riser.

PMID: 22182879 [PubMed - in process]

Orthopaedic Trauma Clinical Research: Is 2-Year Follow-Up Necessary? Results From a Longitudinal Study of Severe Lower Extremity Trauma.

J Trauma. 2011 Dec;71(6):1726-1731

Authors: Castillo RC, Mackenzie EJ, Bosse MJ,

Abstract

BACKGROUND:: The ideal length of follow-up for orthopedic trauma research studies is unknown. This study compares 1- and 2-year complications, clinical recovery, and functional outcomes from a large prospective clinical study. METHODS:: Patients (n = 336) with limb threatening unilateral lower extremity injuries were followed at the 12, 24, and 84 months. Major outcomes observed were complications requiring hospital re-admission, fracture and wound healing, attainment of full weight bearing status, return to work, and self-reported functional outcome using the Sickness Impact Profile. RESULTS:: The rate of newly observed complications beyond year 1 was small, ranging from 0 to <2%. In addition, 85% to 90% of the clinical recovery outcomes were attained by 1 year, and patients not achieving clinical recovery during the first year had significantly worse functional outcomes. Only 5% of patients returned to work between 1 year and 2 years. Although, a substantial number of patients achieved functional recovery between 1 year and 2 years, of the patients not achieving functional recovery at year 1, 85% of those who would go on to achieve functional recovery during the second year could be predicted using year 1 data. CONCLUSIONS:: Although long-term follow-up provides a more complete picture of final outcomes and rate of recovery, follow-up beyond 1 year is difficult and expensive. In our study, it accounted for 20% of the total cost. The analysis of our data suggests that 1-year data were sufficient to address our major study hypotheses.

PMID: 22182880 [PubMed - as supplied by publisher]

Racial odds for amputation ratio in traumatic lower extremity fractures.

J Trauma. 2011 Dec;71(6):1732-6

Authors: Weber DJ, Shoham DA, Luke A, Reed RL, Luchette FA

Abstract

BACKGROUND: : Recent studies have demonstrated that black patients receive substandard care compared with white patients across healthcare settings. The purpose of this study was to evaluate the association of race on the management (salvage vs. amputation) of traumatic lower extremity open fractures.

METHODS: : Data analysis was conducted using the American College of Surgeon’s National Trauma Data Bank. Open tibial and fibular (OTFF) and open femoral (OFF) fractures among adults above the age of 18 were identified by International Classification of Diseases, 9th Revision codes. Injuries were identified as amputated based on the presence of one of three types of knee amputations. Statistical analysis included logistic regression stratified for sex, age, race, mechanism of injury, severity, and insurance type.

RESULTS: : From the National Trauma Data Bank, 10,082 OFF and 22,479 OTFF were identified. Amputation rates were 3.1% for OFF and 4.2% for OTFF. With age stratification, the ratio of amputation odds for blacks to amputation odds for whites (i.e., the Racial Odds for Amputation Ratio [ROAR]) demonstrated a significant interaction between black and age in both the OFF (p = 0.028) and OTFF (p = 0.008) groups. In younger patients, a lower ROAR (p = 0.016) favored salvage in blacks, while the ROAR in older patients favored amputation in blacks (p = 0.013). The higher prevalence of penetrating injuries in blacks only accounted for 12.7% of the lower ROAR among younger adults.

CONCLUSIONS: : There exists a racial disparity in the management of lower extremity open fractures. Older blacks have greater odds of amputation that is not explained by mechanism. In contrast, younger blacks have lower odds for amputation that is only partially explained by mechanism of injury.

PMID: 22182881 [PubMed - in process]

Minimally invasive polyaxial locking plate fixation of proximal humeral fractures: a prospective study.

J Trauma. 2011 Dec;71(6):1737-44

Authors: Ruchholtz S, Hauk C, Lewan U, Franz D, Kühne C, Zettl R

Abstract

BACKGROUND: : The surgical treatment for displaced humeral head fractures overlooks a broad variety of surgical techniques and implant systems. A standard operative procedure has not yet been established. In this article, we report our experience with a second-generation locking plate for the humeral head fracture that is applied in a standardized nine-step minimally invasive surgical technique (MIS).

METHODS: : In a prospective study from May 2008 until November 2009, a cohort of 79 patients with 80 proximal humerus fractures were operated in a MIS procedure using a polyaxial locking plate. Follow-up examination at 6 weeks and 6 months postoperative included radiologic examinations and a clinical outcome analysis by the Constant Score, the Visual Analog Scale for pain, and the Daily Activity Score.

RESULTS: : The mean patient age was 65.5 years ± 19 years. According to the Neer classification, there were 18 (22.5%) two-part (Neer III), 48 (60%) three-part (Neer IV), and 14 (17.5%) four-part fractures (Neer IV/V). The operation time averaged 65.6 minutes ± 27 minutes. In 13 patients (16.3%), revision was necessary because of procedure-related complications. After 6 months, the Visual Analog Scale for pain was 2.7 ± 1.6 and the Daily Activity Score showed 19.6 ± 6 points. The average age-related Constant Score after 6 months was 67.5 ± 24 points.

CONCLUSIONS: : MIS surgery of displaced humeral head fractures can be performed in all types of humeral head fractures leading to low complication rates and good clinical outcome. A standardized stepwise procedure in fracture reduction and fixation is recommended to achieve reliable good results.

PMID: 22182882 [PubMed - in process]

Reconstruction of severe contracture of the first web space using the reverse posterior interosseous artery flap.

J Trauma. 2011 Dec;71(6):1745-9

Authors: Gong X, Lu LJ

Abstract

BACKGROUND: : To evaluate the outcome and highlight the operative tips of using the reverse posterior interosseous artery (PIA) flap in the treatment of severe contractures of the first web space.

METHODS: : From 1985 to 2008, the reverse PIA flaps, which included fasciocutaneous flaps in 25 patients and composite flaps in 2 patients were used to cover skin defects over the first web space after release of severe contractures of the first web space. The severe contracture of the first web space was defined as the distance of less than 2 cm between the interphalangeal joint of the thumb and the metacarpophalangeal joint of the index. The flap dimensions varied between 6 cm and 22 cm (average, 13 cm) in length and 3 cm to 9 cm (average, 6 cm) in width. The largest flap was 22 cm × 6 cm and the smallest 6 cm × 3 cm. The length of the pedicle ranged from 2 cm to 10 cm (average, 8 cm). Skin defects of the donor site were covered by split-thickness skin grafts in 26 patients and direct closure in 1 patient.

RESULTS: : Twenty-six of 27 PIA flaps survived completely except venous congestion occurred in 1 patient, which led to necrosis of the distal 1/4 flap. Skin grafts over the donor sites survived completely without complications. The follow-up period ranged from 1 month to 2 years. Lipectomy or revision was performed in two patients because of scar contractures or bulkiness. The postoperative distance of the reconstructed web space was 6 cm on average.

CONCLUSION: : The reverse PIA flap is suited for defect cover in the treatment of severe contractures of the first web space. A usual pitfall using the reverse PIA flap is that the skin paddle is inadvertently outlined over the proximal 1 of 3 forearm to increase its distal reach, which usually leads to postoperative venous congestion. However, if the distal flap pole is placed at or distal to the midpoint from the lateral epicondyle to the radial side of the ulnar head, choosing the proximal 1 of 2 forearm as the donor site of the skin paddle to increase its distal reach is reliable.

PMID: 22182883 [PubMed - in process]

Pain as an indication for rib fixation: a bi-institutional pilot study.

J Trauma. 2011 Dec;71(6):1750-4

Authors: de Moya M, Bramos T, Agarwal S, Fikry K, Janjua S, King DR, Alam HB, Velmahos GC, Burke P, Tobler W

Abstract

BACKGROUND: : In trauma patients, open reduction and internal fixation of rib fractures remain controversial. We hypothesized that patients who have open reduction and internal fixation of rib fractures would experience less pain compared with controls and thus require fewer opiates. Further, we hypothesized that improved pain control would result in fewer pulmonary complications and decreased length of stay.

METHODS: : This is a retrospective bi-institutional matched case-control study. Cases were matched 1:2 by age, injury severity Score, chest abbreviated injury severity score, head abbreviated injury severity score, pulmonary contusion score, and number of fractured ribs. The daily total doses of analgesic drugs were converted to equianalgesic intravenous morphine doses, and the primary outcome was inpatient narcotic administration.

RESULTS: : Sixteen patients between July 2005 and June 2009 underwent rib fixation in 5 ± 3 days after injury using an average of 3 (1-5) metallic plates. Morphine requirements decreased from 110 mg ± 98 mg preoperatively to 63 ± 57 mg postoperatively (p = 0.01). There were no significant differences between cases and controls in the mean morphine dose (79 ± 63 vs. 76 ± 55 mg, p = 0.65), hospital stay (18 ± 12 vs. 16 ± 11 days, p = 0.67), intensive care unit stay (9 ± 8 vs. 7 ± 10 days, p = 0.75), ventilation days (7 ± 8 vs. 6 ± 10, p = 0.44), and pneumonia rates (31% vs. 38%, p = 0.76).

CONCLUSION: : The need for analgesia was significantly reduced after rib fixation in patients with multiple rib fractures. However, no difference in outcomes was observed when these patients were compared with matched controls in this pilot study. Further study is required to investigate these preliminary findings.

PMID: 22182884 [PubMed - in process]

Hextend and 7.5% Hypertonic Saline With Dextran Are Equivalent to Lactated Ringer’s in a Swine Model of Initial Resuscitation of Uncontrolled Hemorrhagic Shock.

J Trauma. 2011 Dec;71(6):1755-60

Authors: Riha GM, Kunio NR, Van PY, Hamilton GJ, Anderson R, Differding JA, Schreiber MA

Abstract

BACKGROUND: : The optimal fluid strategy for the early treatment of trauma patients remains highly debated. Our objective was to determine the efficacy of an initial bolus of resuscitative fluids used in military and civilian settings on the physiologic response to uncontrolled hemorrhagic shock in a prospective, randomized, blinded animal study.

METHODS: : Fifty anesthetized swine underwent central venous and arterial catheterization followed by celiotomy. Grade V liver injury was performed, followed by 30 minutes of uncontrolled hemorrhage. Then, liver packing was completed, and fluid resuscitation was initiated over 12 minutes with 2 L normal saline (NS), 2 L Lactated Ringer’s (LR), 250 mL 7.5% hypertonic saline with 3% Dextran (HTS), 500 mL Hextend (HEX), or no fluid (NF). Animals were monitored for 2 hours postinjury. Blood loss after initial hemorrhage, mean arterial pressure (MAP), tissue oxygen saturation (StO2), hematocrit, pH, base excess, and lactate were measured at baseline, 1 hour, and 2 hours.

RESULTS: : NF group had less post-treatment blood loss compared with other groups. MAP and StO2 for HEX, HTS, and LR at 1 hour and 2 hours were similar and higher than NF. MAP and StO2 did not differ between NS and NF, but NS resulted in decreased pH and base excess.

CONCLUSIONS: : Withholding resuscitative fluid results in the least amount of posttreatment blood loss. In clinically used volumes, HEX and HTS are equivalent to LR with regard to physiologic outcomes and superior to NF. NS did not provide a measurable improvement in outcome compared with NF and resulted in increased acidosis.

PMID: 22182885 [PubMed - in process]

Impact of the Duration of Platelet Storage in Critically Ill Trauma Patients.

J Trauma. 2011 Dec;71(6):1766-1774

Authors: Inaba K, Branco BC, Rhee P, Blackbourne LH, Holcomb JB, Spinella PC, Shulman I, Nelson J, Demetriades D

Abstract

BACKGROUND:: There is increasing evidence that the duration of red blood cell (RBC) storage negatively impacts outcomes. Data regarding prolonged storage of other blood components, however, are lacking. The aim of this study was to evaluate how the duration of platelet storage affects trauma patient outcomes. METHODS:: Trauma patients admitted to a Level I trauma center requiring platelet transfusion (2006-2009) were retrospectively identified. Apheresis platelets (aPLT) containing ≥3 × 10 platelets/unit were used exclusively. Patients were analyzed in three groups: those who received only aPLT stored for ≤3 days, 4 days, and 5 days. The outcomes included mortality and complications (sepsis, acute respiratory distress syndrome, renal, and liver failure). RESULTS:: Three hundred eighty-one patients were available for analysis (128 received aPLT ≤3 days old; 109 = 4 days old; and 144 = 5 days old). There were no significant demographic differences between groups. Patients receiving aPLT aged = 4 days had significantly higher Injury Severity Score (p = 0.022) and were more likely to have a head Abbreviated Injury Scale ≥3 (p = 0.014). There were no differences in volumes transfused or age of RBC, plasma, cryoprecipitate, or factor VIIa. After adjusting for confounders, exposure to older aPLT did not impact mortality; however, with increasing age, complications were significantly higher. The rate of sepsis, in particular, was significantly increased (5.5% for aPLT ≤3 days vs. 9.2% for aPLT = 4 days vs. 16.7% for aPLT = 5 days, adjusted p = 0.033). For acute respiratory distress syndrome and renal and liver failure, similar trends were observed. CONCLUSIONS:: In critically ill trauma patients, there was a stepwise increase in complications, in particular sepsis, with exposure to progressively older platelets. Further evaluation of the underlying mechanism and methods for minimizing exposure to older platelets is warranted.

PMID: 22182887 [PubMed - as supplied by publisher]

Use of freeze-dried plasma in French intensive care unit in afghanistan.

J Trauma. 2011 Dec;71(6):1761-5

Authors: Martinaud C, Ausset S, Deshayes AV, Cauet A, Demazeau N, Sailliol A

Abstract

BACKGROUND: : Modern warfare causes severe injuries, and despite rapid transportation to theater regional trauma centers, casualties frequently arrive coagulopathic and in shock. Massive hemorrhage management includes transfusion of red blood cells and plasma in a 1:1 ratio. Fresh frozen plasma requires thawing and badly fits the emergency criteria. Since 1994, the French Military Blood Bank has been producing freeze-dried plasma (FDP) and providing it for overseas operation. The aim of our study was to evaluate the use of FDP in war settings and to assess its clinical efficiency and safety.

PATIENTS: : We performed a prospective study of the FDP delivered at the International Security Assistance Force Role 3 Military Medical Treatment Facility in the Kabul Afghanistan International Airport between February 2010 and February 2011. We included every patient who received at least one unit of FDP. Basic clinical data were recorded at admission. Transfusion requirements were monitored. Biological testing were performed before and after administration of FDP including hemoglobin concentration, platelets count, fibrinogen level, prothrombin time (PT), and thromboelastography.

RESULTS: : Eighty-seven casualties received FDP during 93 episodes of transfusion. On average, 3.5 FDP units were transfused per episodes of transfusion. Of the 87 patients studied, 7 died because of nonsurvivable injuries and outcomes were unavailable for 11. The other 59 patients survived. PT significantly declined by an average of 3.3 seconds after FDP transfusion. This moderate decrease in PT reflects continued bleeding and resuscitation. It nevertheless suggests improvement in hemostasis before surgical control of bleeding. All FDP users reported ease of use, clinically observed efficacy equivalent to fresh frozen plasma and the absence of adverse effects associated with FDP.

CONCLUSION: : Our results provide evidence of the effectiveness of FDP for the prevention or correction of coagulopathy and hemorrhage in combat casualties.

PMID: 22182886 [PubMed - in process]

Thirty Consecutive Uses of a Hemostatic Bandage at a US Army Combat Support Hospital and Forward Surgical Team in Operation Iraqi Freedom.

J Trauma. 2011 Dec;71(6):1775-8

Authors: King DR

Abstract

BACKGROUND: : Topical hemostatic agents have generated intense research interest in recent years, prompted in part by the demands of wartime medicine. Numerous animal studies demonstrate variable degrees of efficacy of a variety of agents; however, little clinical data are available in severely traumatized patients. This report describes 30 consecutive uses of the modified rapid deployment hemostat (MRDH) during combat operations in Operation Iraqi Freedom.

METHODS: : In a prospective observational fashion, traumatized patients presenting to a combat support hospital or a forward surgical team with difficult to control hemorrhage (due to anatomy, limited resources, or tactical environment) had the MRDH applied to severely bleeding wounds. Basic demographics, wounding mechanism, wound characteristics, circumstances, and efficacy were recorded. Presence of a clinical coagulopathy was also noted.

RESULTS: : Thirty hemostatic bandages were applied to 19 patients with a wide variety of wounds. All but one application occurred in the operating room. The demographics were mean age 27 years (range, 9-55 years), 95% male, 68% penetrating or fragmentation, and four casualties had a clinical coagulopathy. Hemostasis was achieved following application of the hemostatic agent in 16 of 19 wounds. Rebleeding occurred upon removal in three cases. In all cases, the patient failed conventional interventions at hemostasis before the hemostat was applied.

CONCLUSIONS: : This is the single largest description of the clinical efficacy of the MRDH and the first description during combat operations. The MRDH bandage was an effective hemostat for temporarily controlling hemorrhage in difficult circumstances. Caution should be exercised when removing the dressing as rebleeding may occur.

PMID: 22182888 [PubMed - in process]

Microcirculatory responses to hypovolemic shock.

J Trauma. 2011 Dec;71(6):1779-88

Authors: Szopinski J, Kusza K, Semionow M

PMID: 22182889 [PubMed - in process]

Facial nerve decompression surgery in patients with temporal bone trauma: analysis of 66 cases.

J Trauma. 2011 Dec;71(6):1789-93

Authors: Hato N, Nota J, Hakuba N, Gyo K, Yanagihara N

Abstract

BACKGROUND: : In the treatment of facial nerve paralysis after temporal bone trauma, it is important to appropriately determine whether nerve decompression surgery is indicated. The aim of this study was to examine the efficacy of facial nerve decompression surgery according to fracture location and the ideal time for surgery after trauma by analyzing the therapeutic outcome of traumatic facial nerve paralysis.

METHODS: : In total, 66 patients with facial nerve paralysis after temporal bone trauma who were treated at our institution between 1979 and 2009 were studied retrospectively. The patients were divided into five subgroups, according to the fracture location and the period of time between trauma and surgery.

RESULTS: : The number of patients who achieved complete recovery of House-Brackmann (H-B) grade 1 was 31 of 66 (47.0%). There was no difference in therapeutic outcomes among the subgroups classified by fracture location. The rate of good recovery to H-B grade 1 or 2 in patients undergoing decompression surgery within 2 weeks after trauma reached 92.9%, resulting in a significantly better outcome than that of patients undergoing later decompression surgery (p < 0.01).

CONCLUSIONS: : The results of this study demonstrated that the ideal time for decompression surgery for facial nerve paralysis after temporal bone fracture was the first 2 weeks after trauma in patients with severe, immediate-onset paralysis. Our study also showed that surgery should be performed within 2 months at the latest. These findings provide useful information for patients and help to determine the priority of treatment when concomitant disease exists.

PMID: 22182890 [PubMed - in process]

Prognostic factors influencing final visual acuity in open globe injuries.

J Trauma. 2011 Dec;71(6):1794-800

Authors: Yalcin Tök O, Tok L, Eraslan E, Ozkaya D, Ornek F, Bardak Y

Abstract

BACKGROUND: : To investigate the factors that influence final visual acuity (VA) in open globe injuries.

METHODS: : The records of patients with open globe injuries who were followed for longer than 6 months between 1998 and 2009 in two different centers were retrospectively reviewed. The data collected included patients’ demographics as well as their initial VA, wound location, mechanism and type of injury, clinical findings, and final best-corrected VA. Statistical analysis was conducted using univariate analysis and multiple logistic regression analysis.

RESULTS: : Of 313 patients, 73.2% were men, and the mean age was 32.01 years ± 21.04 years. Penetrating injury was the most common type of injury. Of 313 injuries, 212 were caused by sharp/projectile objects, and injuries most commonly occurred in the workplace. In a univariate analysis, the factors contributing to a final VA worse than 20/200 included being older than 50 years, injury in zone 2 or 3, blunt injury, rupture-type injury, poor initial VA, and the presence of endophthalmitis, retinal detachment, relative afferent papillary defect, hyphema, vitreous prolapse, and uveal prolapse. In a multiple logistic regression analysis in which all factors that may influence final VA were analyzed together, poor initial VA, retinal detachment, and vitreous prolapse were found to be statistically significant.

CONCLUSION: : In this retrospective study, the most important factors influencing final VA were initial VA, retinal detachment, and vitreous prolapse, all of which are important with regard to informing the patient of the prognosis and determining the approach the physician will take.

PMID: 22182891 [PubMed - in process]

Shaken Baby Syndrome and a Triple-Dose Strategy for Its Prevention.

J Trauma. 2011 Dec;71(6):1801-1807

Authors: Stewart TC, Polgar D, Gilliland J, Tanner DA, Girotti MJ, Parry N, Fraser DD

Abstract

OBJECTIVES:: Inflicted traumatic brain injury associated with Shaken Baby Syndrome (SBS) is a leading cause of injury mortality and morbidity in infants. A triple-dose SBS prevention program was implemented with the aim to reduce the incidence of SBS. The objectives of this study were to describe the epidemiology of SBS, the triple-dose prevention program, and its evaluation. METHODS:: Descriptive and spatial epidemiologic profiles of SBS cases treated at Children’s Hospital, London Health Sciences Centre, from 1991 to 2010 were created. Dose 1 (in-hospital education): pre-post impact evaluation of registered nurse training, with a questionnaire developed to assess parents’ satisfaction with the program. Dose 2 (public health home visits): process evaluation of additional education given to new parents. Dose 3 (media campaign): a questionnaire developed to rate the importance of factors on a 7-point Likert scale. These factors were used to create weights for statistical modeling and mapping within a geographic information system to target prevention ads. RESULTS:: Forty-three percent of severe infant injuries were intentional. A total of 54 SBS cases were identified. The mean age was 6.7 months (standard deviation, 10.9 months), with 61% of infant males. The mean Injury Severity Score was 26.3 (standard deviation, 5.5) with a 19% mortality rate. Registered nurses learned new information on crying patterns and SBS, with a 47% increase in knowledge posttraining (p < 0.001). Over 10,000 parents were educated in-hospital, a 93% education compliance rate. Nearly all parents (93%) rated the program as useful, citing “what to do when the crying becomes frustrating” as the most important message. Only 6% of families needed to be educated during home visits. Locations of families with a new baby, high population density, and percentage of lone parents were found to be the most important factors for selecting media sites. The spatial analysis revealed six areas needed to be targeted for ad locations. CONCLUSIONS:: SBS is a devastating intentional injury that often results in poor outcomes for the child. Implementing a triple-dose prevention program that provides education on crying patterns, coping strategies, and the dangers of shaking is key to SBS prevention. The program increased knowledge. Parents rated the program as useful. The media campaign allowed us to extend the primary prevention beyond new parents to help create a cultural change in the way crying, the primary trigger for SBS, is viewed. Targeting our intervention increased the likelihood that our message was reaching the population in greatest need.

PMID: 22182892 [PubMed - as supplied by publisher]

Validation of a modified table to map the 1998 abbreviated injury scale to the 2008 scale and the use of adjusted severities.

J Trauma. 2011 Dec;71(6):1829-34

Authors: Tohira H, Jacobs I, Mountain D, Gibson N, Yeo A, Ueno M, Watanabe H

Abstract

BACKGROUND: : The Abbreviated Injury Scale 2008 (AIS 2008) is the most recent injury coding system. A mapping table from a previous AIS 98 to AIS 2008 is available. However, AIS 98 codes that are unmappable to AIS 2008 codes exist in this table. Furthermore, some AIS 98 codes can be mapped to multiple candidate AIS 2008 codes with different severities. We aimed to modify the original table to adjust the severities and to validate these changes.

METHODS: : We modified the original table by adding links from unmappable AIS 98 codes to AIS 2008 codes. We applied the original table and our modified table to AIS 98 codes for major trauma patients. We also assigned candidate codes with different severities the weighted averages of their severities as an adjusted severity. The proportion of cases whose injury severity scores (ISSs) were computable were compared. We also compared the agreement of the ISS and New ISS (NISS) between manually determined AIS 2008 codes (MAN) and mapped codes by using our table (MAP) with unadjusted or adjusted severities.

RESULTS: : All and 72.3% of cases had their ISSs computed by our modified table and the original table, respectively. The agreement between MAN and MAP with respect to the ISS and NISS was substantial (intraclass correlation coefficient = 0.939 for ISS and 0.943 for NISS). Using adjusted severities, the agreements of the ISS and NISS improved to 0.953 (p = 0.11) and 0.963 (p = 0.007), respectively.

CONCLUSION: : Our modified mapping table seems to allow more ISSs to be computed than the original table. Severity scores exhibited substantial agreement between MAN and MAP. The use of adjusted severities improved these agreements further.

PMID: 22182893 [PubMed - in process]

Using principal component analysis to aid bayesian network development for prediction of critical care patient outcomes.

J Trauma. 2011 Dec;71(6):1841-9

Authors: Crump C, Silvers CT, Wilson B, Schlachta-Fairchild L, Lingley-Papadopoulos CA, Ashley JS

Abstract

BACKGROUND: : Predicting an intensive care unit patient’s outcome is highly desirable. An end goal is for computational techniques to provide updated, accurate predictions about changing patient condition using a manageable number of physiologic parameters.

METHODS: : Principal component analysis was used to select input parameters for critical care patient outcome models. Vital signs and laboratory values from each patient’s hospital stay along with outcomes (“Discharged” vs. “Deceased”) were collected retrospectively at a Level I Trauma-Military Medical Center in the southwest; intensive care unit patients were included if they had been admitted for burn, infection, or hypovolemia during a 5-year period ending October 2007. Principal component analysis was used to determine which of the 24 parameters would serve as inputs in a Bayesian network developed for outcome prediction.

RESULTS: : Data for 581 patients were collected. Pulse pressure, heart rate, temperature, respiratory rate, sodium, and chloride were found to have statistically significant differences between Discharged and Deceased groups for “Hypovolemia” patients. For “Burn” patients, pulse pressure, hemoglobin, hematocrit, and potassium were found to have statistically significant differences. For a “Combined” group, heart rate, temperature, respiratory rate, sodium, and chloride had statistically significant differences. A Bayesian network based on these results, developed for the Combined group, achieved an accuracy of 75% when predicting patient outcome.

CONCLUSIONS: : Outcome prediction for critical care patients is possible. Future work should explore model development using additional temporal data and should include prospective validation. Such technology could serve as the basis of real-time intelligent monitoring systems for critical patients.

PMID: 22182894 [PubMed - in process]

Emergent cricothyroidotomy in the morbidly obese: a safe, no-visualization technique.

J Trauma. 2011 Dec;71(6):1873-4

Authors: King DR

PMID: 22182897 [PubMed - in process]

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an Adjunct for Hemorrhagic Shock.

J Trauma. 2011 Dec;71(6):1869-1872

Authors: Stannard A, Eliason JL, Rasmussen TE

PMID: 22182896 [PubMed - as supplied by publisher]

Fixation of sternal fractures: a systematic review.

J Trauma. 2011 Dec;71(6):1875-9

Authors: Harston A, Roberts C

Abstract

BACKGROUND: : Traumatic sternal fractures occur in approximately 3% to 8% of all blunt trauma patients. Most of these fractures are treated conservatively, but a small number require operative intervention. Only a few studies have reported operative fixation of sternal fractures, and no investigation to our knowledge has systematically reviewed the literature on this intervention.

METHODS: : We conducted a systematic review of the literature published from 1990 through September 2010 regarding the treatment of traumatic sternal fractures. We analyzed the available evidence regarding the surgical fixation of these fractures, the type of fixation used, the timing of the surgery, complications, and patient outcomes.

RESULTS: : Twelve articles with 76 cases of surgically repaired sternal fractures met our study criteria. The indications for surgery, timing, and methods used for fixation were diverse. For instance, plates were used in 52 patients and wiring was selected in 24 patients for fixation. General and cardiothoracic surgeons treated the majority of sternal fractures requiring operative fixation. No serious postoperative complications were found in our review.

CONCLUSIONS: : Although the outcomes were generally positive, only one-half of the articles documented patient follow-up. In future studies, focus needs to be placed on long-term results and specific indications for surgery. The first step toward a standardized sternal fracture operative trial must be a prospective study of incidence and nonoperative long-term outcomes. It is likely that as the interest and demand for plate fixation increases, the demand for orthopedic involvement with sternal fractures will also increase.

PMID: 22182898 [PubMed - in process]

Transplantation for severe hepatic trauma.

J Trauma. 2011 Dec;71(6):1880-4

Authors: Plackett TP, Barmparas G, Inaba K, Demetriades D

PMID: 22182899 [PubMed - in process]

Impact of Interhospital Transfer on Outcomes for Trauma Patients: A Systematic Review.

J Trauma. 2011 Dec;71(6):1885-1901

Authors: Hill AD, Fowler RA, Nathens AB

Abstract

BACKGROUND:: Evidence suggests that there may be an association between transfer status (direct admission or interhospital transfer) and outcomes in trauma patients. The purpose of this study was to systematically review the current evidence of the association between transfer status and outcomes for patients. METHODS:: Systematic search of Medline and EMBASE databases to identify eligible control trials or observational studies that examined the impact of transfer status on trauma patient outcomes. Data were extracted on study design, quality, participants, outcomes, and risk estimates reported. Pooled odds ratio based on data from retrieved studies was calculated using a random effect model. RESULTS:: Thirty-six observational studies were identified. There were no significant differences in length of stay (LOS) between transfer and direct admissions although costs were marginally higher for transferred patients, (relative increase, 1.09; 95% confidence interval, 1.08-1.09). We found no significant association between transfer status (transfer vs. direct) and in-hospital mortality (pooled odds ratio, 1.06; 95% confidence interval, 0.90-1.25); however, heterogeneity of the studies was high (I = 82%). CONCLUSION:: Available evidence suggests there is no difference in mortality between transfer and direct admissions. However, the significant heterogeneity across studies precludes deriving any definitive conclusions regarding the impact of interhospital transfer on mortality after major trauma. Moreover, most studies excluded patients dying at outlying hospitals, which may underestimate the association of transfer status with mortality. Prospective studies that address the limitations of the current evidence, including use of population-based trauma registries, are warranted to establish whether the process of interhospital transfer to higher level care when compared with direct admission to a trauma center negatively impacts clinical outcomes for trauma patients.

PMID: 22182900 [PubMed - as supplied by publisher]

Heating pad for the bleeding: external warming during hemorrhage improves survival.

J Trauma. 2011 Dec;71(6):1915-9

Authors: Wang Y, Feng J, You G, Kan X, Qiu L, Chen G, Gao D, Guo W, Zhao L, Zhou H

Abstract

BACKGROUND: : Hypothermia is common during hemorrhagic shock. To warm the victims or not has been controversial. This study aims to investigate the effect of warming during the initial time of hemorrhage on body temperature, blood pressure, and survival in rat hemorrhagic shock models.

METHODS: : Forty anesthetized rats were divided into control group (n = 20) and warming group (n = 20). The rats of control group were placed on a wooden pad without heating, and the rats of warming group were placed on a heating pad maintained at 37°C ± 0.1°C. Blood withdrawal reached 40% of the total blood volume within 60 minutes. Numbers of survival rats, rectal temperature, and mean arterial pressure (MAP) were recorded when blood loss reached 0 (T0), 20% (T20), 30% (T30), and 40% (T40) of the total blood volume, respectively.

RESULTS: : Rectal temperature and MAP decrease gradually in both groups during hemorrhage. Warming continuously makes the rectal temperature of the warming group (36.68°C ± 0.63°C) slightly higher than that of the control group (36.17°C ± 0.69°C) at T0. The rectal temperature and MAP of the warming group are higher than that of the control group at T20, T30, and T40 (p < 0.05). Survival rates of the warming group are higher than that of the control group (p < 0.01).

CONCLUSIONS: : Warming during hemorrhage may prevent exacerbation of hypothermia and hypotension and therefore improve survival.

PMID: 22182901 [PubMed - in process]

Double vena cavas requiring filtration.

J Trauma. 2011 Dec;71(6):1922

Authors: Rogers FB, Rogers A, Miller JA, Lee JC

PMID: 22182903 [PubMed - in process]

Attraction of magnetic foreign bodies leading to intestinal obstruction and gastro-colon-jejunum fistula.

J Trauma. 2011 Dec;71(6):1921

Authors: Shih YJ, Hsu KF, Shih MT, Yu JC, Chan DC, Chen CJ

PMID: 22182902 [PubMed - in process]

Nephrectomy versus renorrhaphy.

J Trauma. 2011 Dec;71(6):1923

Authors: Abbasi H

PMID: 22182904 [PubMed - in process]

Traumatic brain injury and posttraumatic stress disorder: overlap in underlying substrates.

J Trauma. 2011 Dec;71(6):1923-4

Authors: Le Moullec D, Salvadori A, Constantin P, Tourtier JP

PMID: 22182905 [PubMed - in process]

Response to “traumatic brain injury and post-traumatic stress disorder: overlap in underlying substrates?”.

J Trauma. 2011 Dec;71(6):1924

Authors: Shussman N, Almogy G

PMID: 22182906 [PubMed - in process]

Most suitable modality to assess the inferior vena cava in the trauma patient.

J Trauma. 2011 Dec;71(6):1924-5

Authors: Sefidbakht S

PMID: 22182907 [PubMed - in process]

Reply to Letter to the Editor “Most Suitable Modality to Assess the IVC in the Trauma Patient”.

J Trauma. 2011 Dec;71(6):1925

Authors: Liao YY, Chen KT

PMID: 22182908 [PubMed - in process]

Meetings/Courses.

J Trauma. 2011 Dec;71(6):1926

Authors:

PMID: 22182910 [PubMed - in process]

Letter of apology for minor copying.

J Trauma. 2011 Dec;71(6):1925

Authors: Menaker J, Boswell S, Philp A, Scalea TM

PMID: 22182909 [PubMed - in process]

Author index, volume 71.

J Trauma. 2011 Dec;71(6):1930-41

Authors:

PMID: 22182911 [PubMed - in process]

Subject index volume 71.

J Trauma. 2011 Dec;71(6):1942

Authors:

PMID: 22182912 [PubMed - in process]

Incidental findings in focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients: speaking about cost to benefit.

J Trauma. 2011 Dec;71(6):E123-7

Authors: Sgourakis G, Lanitis S, Korontzi M, Kontovounisios C, Zacharioudakis C, Armoutidis V, Karaliotas C, Dedemadi G, Lepida N, Karaliotas C

Abstract

BACKGROUND: : The purpose of this study was to identify which age-related groups of hemodynamically stable blunt trauma patients will present a positive cost-to-benefit ratio, in regard to the screening of incidental findings on Focused Assessment with Sonography for Trauma (FAST).

METHODS: : We conducted a prospective study using retrospective data taken from the trauma registry of 6,041 consecutive hemodynamically stable blunt trauma patients who underwent FAST at our Level I urban trauma hospital during the year 2009. A receiver operating characteristic curve was used to determine whether age level is useful in detecting organ-/system-specific incidental findings in trauma patients undergoing FAST and to establish the required diagnostic cutoff value of this selected test. A cost-benefit analysis was then performed for the age-specific cutoff values of each organ/system evaluated by FAST.

RESULTS: : We found 522 incidental findings in 468 patients (7.8%). Further diagnostic workup was instructed in 35% (168 of 468) of patients with incidental findings. The cost-benefit analysis for the age-specific cutoff values found in the receiver operating characteristic curve analysis showed that the project of screening for incidental findings on FAST was viable only when the ultrasound operator additionally searches the liver/biliary tree (≥43 years) and the kidneys (≥56 years).

CONCLUSIONS: : A systematic examination of the liver and biliary tree and both kidneys of specific age groups during FAST screening of hemodynamically stable blunt trauma patients may disclose a potentially unknown pathology with a positive cost-to-benefit ratio.

PMID: 22182913 [PubMed - in process]

Posttraumatic brachial plexitis.

J Trauma. 2011 Dec;71(6):E136

Authors: Aydin S, Abuzayed B, Bozkus H, Keles E, Boyaciyan A, Sarioglu AC

PMID: 22182914 [PubMed - in process]

Optimal Positioning for Emergent Needle Thoracostomy: A Cadaver-Based Study.

J Trauma. 2011 Nov;71(5):1099-1103

Authors: Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D

Abstract

BACKGROUND:: Needle thoracostomy is an emergent procedure designed to relieve tension pneumothorax. High failure rates because of the needle not penetrating into the thoracic cavity have been reported. Advanced Trauma Life Support guidelines recommend placement in the second intercostal space, midclavicular line using a 5-cm needle. The purpose of this study was to evaluate placement in the fifth intercostal space, midaxillary line, where tube thoracostomy is routinely performed. We hypothesized that this would result in a higher successful placement rate. METHODS:: Twenty randomly selected unpreserved adult cadavers were evaluated. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. The needles were secured and thoracotomy was then performed to assess penetration into the pleural cavity. The right and left sides were analyzed separately acting as their own controls for a total of 80 needles inserted into 20 cadavers. The thickness of the chest wall at the site of penetration was then measured for each entry position. RESULTS:: A total of 14 male and 6 female cadavers were studied. Overall, 100% (40 of 40) of needles placed in the fifth intercostal space and 57.5% (23 of 40) of the needles placed in the second intercostal space entered the chest cavity (p < 0.001); right chest: 100% versus 60.0% (p = 0.003) and left chest: 100% versus 55.0% (p = 0.001). Overall, the thickness of the chest wall was 3.5 cm ± 0.9 cm at the fifth intercostal space and 4.5 cm ± 1.1 cm at the second intercostal space (p < 0.001). Both right and left chest wall thicknesses were similar (right, 3.6 cm ± 1.0 cm vs. 4.5 cm ± 1.1 cm, p = 0.007; left, 3.5 ± 0.9 cm vs. 4.4 cm ± 1.1 cm, p = 0.008). CONCLUSIONS:: In a cadaveric model, needle thoracostomy was successfully placed in 100% of attempts at the fifth intercostal space but in only 58% at the traditional second intercostal position. On average, the chest wall was 1 cm thinner at this position and may improve successful needle placement. Live patient validation of these results is warranted.

PMID: 22071914 [PubMed - as supplied by publisher]

Two-Year Experience of Using Pigtail Catheters to Treat Traumatic Pneumothorax: A Changing Trend.

J Trauma. 2011 Nov;71(5):1104-1107

Authors: Kulvatunyou N, Vijayasekaran A, Hansen A, Wynne JL, Oʼkeeffe T, Friese RS, Joseph B, Tang A, Rhee P

Abstract

BACKGROUND:: The traditional treatment of patients with traumatic hemopneumothorax has been an insertion of a chest tube (CT). But CT, because of its large caliber and significant trauma during an insertion, can cause pain, prevent full lung expansion, and worsen pulmonary outcome. Pigtail catheters (PCs) are smaller and less invasive; they have worked well in patients with nontraumatic pneumothorax (PTX). The purpose of this study was to review our early experience of PC use in trauma patients. METHODS:: We retrospectively reviewed the charts of trauma patients who required CT or PC placement over a 2-year period (January 2008 through December 2009) at a Level I trauma center. The PCs were 14-French (14-F) Cook catheters placed by the trauma team, using a Seldinger technique. We compared outcome for the subgroups that had CT or PC placed for a PTX. For our statistical analysis, we used the unpaired Student t-test, χ test, and Wilcoxon rank-sum test; we considered a p value < 0.05 as significant. RESULTS:: Of 9,624 trauma patients evaluated, 94 were treated with PC and 386 with CT. Of the PC patients, 89% was inserted for PTX. When comparing patients with PC and CT inserted for PTX, demographics, tube days, need for mechanical ventilation, and insertion-related complications were similar. The tube failure rate, defined by a requirement for an additional tube or by recurrence that needed intervention, was higher in PC (11%) than in CT (4%) (p = 0.06), but the difference was not statistically significant. We observed a trend of increased PC use over time. CONCLUSION:: PC is safe and can be performed at the bedside. It has a comparable efficacy to CT in patients with PTX. A prospective study is needed to determine the precise role of PC placement, including its indication, the associated tube-site pain, and any significant clinical advantages.

PMID: 22071915 [PubMed - as supplied by publisher]

Finding the sweet spot: identification of optimal glucose levels in critically injured patients.

J Trauma. 2011 Nov;71(5):1108-14

Authors: Kutcher ME, Pepper MB, Morabito D, Sunjaya D, Knudson MM, Cohen MJ

Abstract

BACKGROUND: : Conflicting data exist regarding optimal glycemic control in critically ill trauma patients. We therefore compared glucose parameters and outcomes among three different glycemic control regimens in a single trauma intensive care unit (ICU), hypothesizing that a moderate regimen would yield optimal avoidance of hyper- and hypoglycemia with equivalent outcomes when compared with a more aggressive approach.

METHODS: : We retrospectively reviewed 1,422 trauma patients with at least 3-day ICU stay and five glucose measurements from May 2001 to January 2010, spanning three nonoverlapping, sequential glucose control protocols: “relaxed,” “aggressive,” and “moderate.” For each, we extracted mean blood glucose, hypoglycemic and hyperglycemic event frequency, and glucose variability and investigated their association with outcomes.

RESULTS: : Mortality was associated with elevated mean glucose (135.6 mg/dL vs. 126.2 mg/dL), more frequent hypoglycemic (2.67 ± 7 vs. 1.28 ± 5) and hyperglycemic (30.6 ± 28 vs. 16.0 ± 22 per 100 patient-ICU days) events, and higher glucose variability (37.1 ± 20 vs. 29.4 ± 20; all p < 0.001). Regression identified hyperglycemic episodes (p < 0.05) as an independent predictor of mortality. The “moderate” regimen had rare hyperglycemia, low glucose variability, and intermediate mean blood glucose range and frequency of hypoglycemia. Multiorgan failure and mortality did not differ between groups.

CONCLUSIONS: : Hyperglycemic events (glucose >180 mg/dL) most strongly predicted mortality. Of glucose control protocols analyzed, the “moderate” protocol had fewest hyperglycemic events. As outcomes were otherwise equivalent between “moderate” and “aggressive” protocols, we conclude that hyperglycemia can be safely avoided using a moderate glycemic control protocol without inducing hypoglycemia.

PMID: 22071916 [PubMed - in process]

Aged plasma transfusion increases mortality in a rat model of uncontrolled hemorrhage.

J Trauma. 2011 Nov;71(5):1115-9

Authors: Letourneau PA, McManus M, Sowards K, Wang W, Wang YW, Matijevic N, Pati S, Wade CE, Holcomb JB

Abstract

INTRODUCTION: : Recent data have associated improved survival after hemorrhagic shock with the early use of plasma-based resuscitation. Our laboratory has shown that FFP5 has decreased hemostatic potential compared with freshly thawed plasma (FFP0). We hypothesized that FFP5 would increase bleeding and mortality compared with FFP0 in a rodent bioassay model of uncontrolled liver hemorrhage.

METHODS: : Hemostatic potential of plasma was assessed with the Calibrated Automated Thrombogram (CAT) assay. Rats underwent isovolemic hemodilution by 15% of blood volume with the two human plasma groups (FFP0 and FFP5) and two controls (sham and lactated Ringers). A liver injury was created by excising a portion of liver resulting in uncontrolled hemorrhage. Rats that lived for 30 minutes after liver injury were resuscitated to their baseline blood pressure and followed for 6 hours. Hemostasis was assessed by thromboelastography.

RESULTS: : Hemostatic potential of FFP5 decreased significantly in all areas measured in the CAT assay as compared with FFP0 (p < 0.01). In the FFP5 group, overall survival was 54%, compared with 100% in the FFP0 and sham group (p = 0.03). For animals that survived 30 minutes and were resuscitated, there was no difference in bleeding and/or coagulopathy between groups. Irrespective of treatment, animals that died after resuscitation demonstrated increased intraperitoneal fluid volume (14.85 mL ± 1.9 mL vs. 7.02 mL ± 0.3 mL, p < 0.001).

CONCLUSION: : In this model of mild preinjury hemodilution with plasma, rats that received FFP5 had decreased survival after uncontrolled hemorrhage from hepatic injury. There were no differences in coagulation function or intraperitoneal fluid volume between the two plasma groups.

PMID: 22071917 [PubMed - in process]

An assessment of patient satisfaction with nonoperative management of clavicular fractures using the disabilities of the arm, shoulder and hand outcome measure.

J Trauma. 2011 Nov;71(5):1126-9

Authors: Thormodsgard TM, Stone K, Ciraulo DL, Camuso MR, Desjardins S

Abstract

BACKGROUND: : Clavicle fractures historically have been managed without internal fixation. Current literature is raising questions regarding this management as opposed to offering operative fixation in some instances. This study addresses the use of the Disabilities of the Arm, Shoulder and Hand (DASH) outcomes measure to identify those that have the least satisfaction with nonoperative care of the clavicle fracture based upon clavicular deformity and variation in fracture location based upon Allman Classification.

METHODS: : Patients having suffered clavicle fractures were mailed the DASH Outcomes Questionnaire to be completed and returned. A total of 113 surveys were returned completed with 92 being of value for evaluation. Patient chest or clavicle radiographs were evaluated, and measurements were made of the clavicle fractures for amount of separation or shortening and grade according to Allman Classification. Statistical evaluation compared DASH Scores (patient satisfaction as outcome measure) to the Allman Classification and the degree of separation or shortening. Comparison of categorical variables was performed using Fisher’s exact test. Comparison of continuous variables was preformed using Student’s t test. Statistical significance was demonstrated by a p value of less than 0.05.

RESULTS: : Patients with clavicular shortening of greater than 2 cm were found to have the highest DASH score indicating dissatisfaction and disability with their outcome postinjury (p = 0.0001). Separation or lengthening seemed to be associated with lower DASH Scores. Patients with Allmen Classification I (midshaft clavicle) fractures had higher DASH score than other fracture locations (p = 0.0001).

CONCLUSIONS: : Patients with midshaft clavicle fractures with shortening of greater than 2 cm may be good candidates for operative repair given the degree of dissatisfaction with nonoperative management of these fractures as assessed by long-term outcome measures of disability.

PMID: 22071918 [PubMed - in process]

Je le pansay … (I bound his wound …).

J Trauma. 2011 Nov;71(5):1130-3

Authors: McKenney JC

PMID: 22071919 [PubMed - in process]

Cardiac Changes After Simulated Behind Armor Blunt Trauma or Impact of Nonlethal Kinetic Projectile Ammunition.

J Trauma. 2011 Nov;71(5):1134-1143

Authors: Kunz SN, Arborelius UP, Gryth D, Sonden A, Gustavsson J, Wangyal T, Svensson L, Rocksén D

Abstract

BACKGROUND:: Cardiac-related injuries caused by blunt chest trauma remain a severe problem. The aim of this study was to investigate pathophysiological changes in the heart that might arise after behind armor blunt trauma or impacts of nonlethal projectiles. METHODS:: Sixteen pigs were shot directly at the sternum with “Sponge Round eXact I Mpact” (nonlethal ammunition; diameter 40 mm and weight 28 g) or hard-plastic ammunition (diameter 65 mm and weight 58 g) to simulate behind armor blunt trauma. To evaluate the influence of the shot location, seven additional pigs where exposed to an oblique heart shot. Physiologic parameters, electrocardiography, echocardiogram, the biochemical marker troponin I (TnI), and myocardial injuries were analyzed. RESULTS:: Nonlethal kinetic projectiles (101-108 m/s; 143-163 J) did not cause significant pathophysiological changes. Five of 18 pigs shot with 65-mm plastic projectiles (99-133 m/s; 284-513 J) to the front or side of the thorax died directly after the shot. No major physiologic changes could be observed in surviving animals. Animals shot with an oblique heart shot (99-106 m/s; 284-326 J) demonstrated a small, but significant decrease in saturation. Energy levels over 300 J caused increased TnI and myocardial damages in most of the pigs. CONCLUSION:: This study indicates that nonlethal kinetic projectiles “eXact iMpact” does not cause heart-related damage under the examined conditions. On impact, sudden heart arrest may occur independently from the cardiac’s electrical cycle. The cardiac enzyme, TnI, can be used as a reliable diagnostic marker to detect heart tissue damages after blunt chest trauma.

PMID: 22071920 [PubMed - as supplied by publisher]

Blood component ratios in massively transfused, blunt trauma patients – a time-dependent covariate analysis.

J Trauma. 2011 Nov;71(5):1144-51

Authors: Lustenberger T, Frischknecht A, Brüesch M, Keel MJ

Abstract

BACKGROUND: : This study evaluated critical thresholds for fresh frozen plasma (FFP) and platelet (PLT) to packed red blood cell (PRBC) ratios and determined the impact of high FFP:PRBC and PLT:PRBC ratios on outcomes in patients requiring massive transfusion (MT).

METHODS: : Retrospective review of a cohort of massively transfused blunt trauma patients admitted to a Level I trauma center. MT was defined as transfusion of ≥10 units of PRBC within 24 hours of admission. Critical thresholds for FFP:PRBC and PLT:PRBC ratios associated with mortality were identified using Cox regression with time-dependent variables. Impacts of high blood component ratios on 12-hour and 24-hour survival were evaluated.

RESULTS: : During the 10-year study period, a total of 229 blunt trauma patients required a MT. At 12 hours and 24 hours after admission, a FFP:PRBC ratio threshold of 1:1.5 was found to have the strongest association with mortality. At 12 hours, 58 patients (25.4%) received a low (<1:1.5) and 171 patients (74.6%) a high (≥1:1.5) FFP:PRBC ratio. Patients in the low ratio group had a significantly higher mortality compared with those in the high ratio group (51.7% vs. 9.4%; adjusted hazard ratio [95% confidence interval] = 1.18 [1.04-1.34]; adjusted p = 0.008). A similar statistically significant difference was found at 24 hours after admission. For PLTs, a PLT:PRBC ratio of 1:3 was identified as the best cut-off associated with both 12-hour and 24-hour survival. At 12 hours, 79 patients (34.5%) received a low (<1:3) and 150 patients (65.5%) a high (≥1:3) PLT:PRBC ratio. After adjusting for differences between the ratio groups, no statistically significant survival advantage associated with a high PLT:PRBC ratio was found (40.5% vs. 9.3%; adjusted hazard ratio [95% confidence interval] = 1.11 [0.99-1.26]; adjusted p = 0.082).

CONCLUSION: : For massively transfused blunt trauma patients, a plasma to PRBC ratio of ≥1:1.5 was associated with improved survival at 12 hours and 24 hours after hospital admission. However, for PLTs, no statistically significant survival benefit with increasing ratio was observed. The results of this analysis highlight the need for prospective studies to evaluate the clinical significance of high blood component ratios on outcome.

PMID: 22071921 [PubMed - in process]

Using the Abbreviated Injury Severity and Glasgow Coma Scale Scores to Predict 2-Week Mortality After Traumatic Brain Injury.

J Trauma. 2011 Nov;71(5):1172-1178

Authors: Timmons SD, Bee T, Webb S, Diaz-Arrastia RR, Hesdorffer D

Abstract

BACKGROUND:: Prediction of outcome after traumatic brain injury (TBI) remains elusive. We tested the use of a single hospital Glasgow Coma Scale (GCS) Score, GCS Motor Score, and the Head component of the Abbreviated Injury Scale (AIS) Score to predict 2-week cumulative mortality in a large cohort of TBI patients admitted to the eight U.S. Level I trauma centers in the TBI Clinical Trials Network. METHODS:: Data on 2,808 TBI patients were entered into a centralized database. These TBI patients were categorized as severe (GCS score, 3-8), moderate (9-12), or complicated mild (13-15 with positive computed tomography findings). Intubation and chemical paralysis were recorded. The cumulative incidence of mortality in the first 2 weeks after head injury was calculated using Kaplan-Meier survival analysis. Cox proportional hazards regression was used to estimate the magnitude of the risk for 2-week mortality. RESULTS:: Two-week cumulative mortality was independently predicted by GCS, GCS Motor Score, and Head AIS. GCS Severity Category and GCS Motor Score were stronger predictors of 2-week mortality than Head AIS. There was also an independent effect of age (<60 vs. ≥60) on mortality after controlling for both GCS and Head AIS Scores. CONCLUSIONS:: Anatomic and physiologic scales are useful in the prediction of mortality after TBI. We did not demonstrate any added benefit to combining the total GCS or GCS Motor Scores with the Head AIS Score in the short-term prediction of death after TBI.

PMID: 22071922 [PubMed - as supplied by publisher]

Effect of the modified glasgow coma scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified glasgow coma scale score model scores of 13.

J Trauma. 2011 Nov;71(5):1185-93

Authors: Mena JH, Sanchez AI, Rubiano AM, Peitzman AB, Sperry JL, Gutierrez MI, Puyana JC

Abstract

BACKGROUND: : The Glasgow Coma Scale (GCS) classifies traumatic brain injuries (TBIs) as mild (14-15), moderate (9-13), or severe (3-8). The Advanced Trauma Life Support modified this classification so that a GCS score of 13 is categorized as mild TBI. We investigated the effect of this modification on mortality prediction, comparing patients with a GCS score of 13 classified as moderate TBI (classic model) to patients with GCS score of 13 classified as mild TBI (modified model).

METHODS: : We selected adult TBI patients from the Pennsylvania Outcome Study database. Logistic regressions adjusting for age, sex, cause, severity, trauma center level, comorbidities, and isolated TBI were performed. A second evaluation included the time trend of mortality. A third evaluation also included hypothermia, hypotension, mechanical ventilation, screening for drugs, and severity of TBI. Discrimination of the models was evaluated using the area under receiver operating characteristic curve (AUC). Calibration was evaluated using the Hosmer-Lemershow goodness of fit test.

RESULTS: : In the first evaluation, the AUCs were 0.922 (95% CI, 0.917-0.926) and 0.908 (95% CI, 0.903-0.912) for classic and modified models, respectively. Both models showed poor calibration (p < 0.001). In the third evaluation, the AUCs were 0.946 (95% CI, 0.943-0.949) and 0.938 (95% CI, 0.934-0.940) for the classic and modified models, respectively, with improvements in calibration (p = 0.30 and p = 0.02 for the classic and modified models, respectively).

CONCLUSION: : The lack of overlap between receiver operating characteristic curves of both models reveals a statistically significant difference in their ability to predict mortality. The classic model demonstrated better goodness of fit than the modified model. A GCS score of 13 classified as moderate TBI in a multivariate logistic regression model performed better than a GCS score of 13 classified as mild.

PMID: 22071923 [PubMed - in process]

Population-based study of the risk of in-hospital death after traumatic brain injury: the role of sepsis.

J Trauma. 2011 Nov;71(5):1226-34

Authors: Selassie AW, Fakhry SM, Ford DW

Abstract

BACKGROUND: : Traumatic brain injury (TBI) accounts for the largest proportion of injury-related deaths and disability in the United States. The proportion of TBI-related deaths that occur after admission in a hospital remains high despite improvement in medical technology. We provide findings on the risk factors of in-hospital death and demonstrate the risk associated with sepsis occurring in the hospital environment.

METHODS: : Population-based retrospective cohort study of 41,395 patients with TBI from all nonfederal hospitals in South Carolina, 1998 to 2009. TBI was ascertained by International Classification of Diseases-9th Rev.-Clinical Modification codes of 800 to 801, 803 to 804, 850 to 854, and 959.01. Observation was censored at the 120th day. Days elapsing from the date of injury to date of death established the survival time (T). Cox regression was used to examine the risk of death, whereas Kaplan-Meier survival curves compared survival probabilities across time.

RESULTS: : Sepsis was independently associated with risk of in-hospital death with hazard ratio of 1.34 (p < 0.001). Severity of TBI was the strongest risk factor with hazard ratio of 4.97 (p < 0.001). Nearly 90% of patients with sepsis were identified with one of the nosocomial etiologies included in the analyses compared with 7% of patients without sepsis (p < 0.001). The survival probabilities were significantly lower for persons with sepsis compared with those without (log-rank test p < 0.001).

CONCLUSION: : Sepsis occurring in the hospital environment and associated with nosocomial etiologies is a strong risk factor for in-hospital death after TBI. Reducing the risk of infections and subsequent sepsis through adherence with infection control measures is a critical step to reduce in-hospital deaths among patients with TBI.

PMID: 22071924 [PubMed - in process]

Risk of venous thromboembolism after spinal cord injury: not all levels are the same.

J Trauma. 2011 Nov;71(5):1241-5

Authors: Maung AA, Schuster KM, Kaplan LJ, Maerz LL, Davis KA

Abstract

BACKGROUND: : Venous thromboembolism (VTE), a diagnosis that includes both deep vein thrombosis and pulmonary embolism, is a well-recognized complication following injury. Previous studies have identified multiple risk factors including spinal cord injury (SCI). We hypothesized that the level of SCI also influences the likelihood of VTE.

METHODS: : The National Trauma Data Bank was queried to identify all patients with SCI admitted in 2007 and 2008. Rates of VTE, demographics, admitting comorbidities, in-hospital complications, level of SCI (divided by National Trauma Data Bank into five groups), associated injuries, and outcome variables were abstracted. Multiple regression was used to identify independent risk factors for VTE.

RESULTS: : During the 2-year period, 18,302 patients were admitted with SCI. The overall rate of VTE was 4.3% but varied significantly depending on the level of SCI injury (χ, 44.8; p < 0.05). Patients with high cervical spine (C1-4) injury had a rate VTE of 3.4%, whereas patients with high thoracic spine (T1-6) injury had the highest rate of VTE at 6.3%. The lowest rate of VTE was in patients with lumbar injury (3.2%). There were no significant differences in the preexisting comorbidities or in-hospital complications among the five SCI groups with the exception of pneumonia. In a multiple logistic regression model, the level of SCI was an independent risk factor for VTE as was increasing age, increasing Injury Severity Score, male gender, traumatic brain injury, and chest trauma.

CONCLUSIONS: : The rate of VTE differs with various SCI levels. Patients with high thoracic (T1-6) injury seem to be at the highest risk and patients with high cervical (C1-4) injury at one of the lowest. A higher index of suspicion for VTE should therefore be maintained in patients with a high thoracic SCI. Further studies are required to elucidate the underlying mechanisms.

PMID: 22071925 [PubMed - in process]

Identification of motor and sensory fascicles in peripheral nerve trunk using immunohistochemistry and micro-Raman spectroscopy.

J Trauma. 2011 Nov;71(5):1246-51

Authors: Wang H, Ma F, Wang F, Liu D, Li X, Du S

Abstract

OBJECTIVE: : To explore a time-efficient method of identifying motor and sensory fascicles in peripheral nerve trunk.

METHODS: : Thirty Wistar rats were selected to obtain whole spine. The spinal dorsal roots and ventral roots, and sciatic nerve were harvested as sensor, motor, and mixed samples, annexin V and agrin specificities were observed with Western blot and immunohistochemistry. A total of 32 New Zealand rabbits were selected and killed. The roots of spinal nerves were exposed under an operating microscope, and the ventral and dorsal roots, ∼3 mm to 5 mm, were dissociated, and frozen as transverse sections of 30-μm thickness. The sections were examined by micro-Raman spectroscopy.

RESULTS: : The annexin V and agrin were special substances of sensory and motor nerves, respectively, and can act as specific antigens for identifying different nerve fascicles. Sections of the same type of nerve fascicles showed reproducibility with similar spectral features. Significant differences in the spectral properties, such as the intensity and breadth of the peak, were found between motor and sensory fascicles in the frequency regions of 1,088 cm, 1,276 cm, 1,439 cm, 1,579 cm, and 1,659 cm. With the peak intensity ratio of 1.06 (I1276/I1439) as a standard, we could identify motor fascicles with a sensitivity of 88%, specificity of 94%, positive predictive value of 93%, and negative predictive value of 88%. In the range of 2,700 cm to 3,500 cm, the half-peak width of the motor fascicles was narrow and sharp, whereas that of the sensory fascicles was relatively wider. A total of 91% of the peak features were in accordance with the identification standard.

CONCLUSION: : Motor and sensory fascicles exhibit different characteristics in Raman spectra, which are constant and reliable. Therefore, it is more effective than immunohistochemistry method in identifying different nerve fascicles according to the specific spectrum, and it possesses feasibility for clinical application.

PMID: 22071926 [PubMed - in process]

Alcohol use by pedestrians who are struck by motor vehicles: how drinking influences behaviors, medical management, and outcomes.

J Trauma. 2011 Nov;71(5):1252-7

Authors: Dultz LA, Frangos S, Foltin G, Marr M, Simon R, Bholat O, Levine DA, Slaughter-Larkem D, Jacko S, Ayoung-Chee P, Pachter HL

Abstract

BACKGROUND: : Injuries to pedestrians struck by motor vehicles represent a significant public health hazard in large cities. The purpose of this study is to investigate the demographics of alcohol users who are struck by motor vehicles and to assess the effects of alcohol on pedestrian crossing patterns, medical management, and outcomes.

METHODS: : Data were prospectively collected between December 2008 to September 2010 on all pedestrians who presented to a Level I trauma center after being struck by a motor vehicle. Variables were obtained by interviewing patients, scene witnesses, first responders, and medical records.

RESULTS: : Pedestrians who used alcohol were less likely to cross the street in the crosswalk with the signal (22.6% vs. 64.7%) and more likely to cross either in the crosswalk against the signal (22.6% vs. 12.4%) or midblock (54.8% vs. 22.8%). Alcohol use was associated with more initial computed tomography imaging studies compared with no alcohol involvement. Alcohol use was associated with a higher Injury Severity Score (8.82 vs. 4.85; p < 0.001) and hospital length of stay (3.89 days vs. 1.82 days; p < 0.001) compared with those with no alcohol involvement. Patients who used alcohol had a lower average Glasgow Coma Scale score (13.80 vs. 14.76; p < 0.001) and a higher rate of head and neck, face, chest, abdomen, and extremity/pelvic girdle injuries (based on Abbreviated Injury Scale) than those with no alcohol involvement.

CONCLUSION: : Alcohol use is a significant risk factor for pedestrians who are struck by motor vehicles. These patients are more likely to cross the street in an unsafe manner and sustain more serious injuries. Traffic safety and injury prevention programs must address irresponsible alcohol use by pedestrians.

PMID: 22071927 [PubMed - in process]

Therapeutic Hypothermia Cardioprotection in Murine Hemorrhagic Shock/Resuscitation Differentially Affects p38α/p38γ, Akt, and HspB1.

J Trauma. 2011 Nov;71(5):1262-1270

Authors: Li J, Beiser DG, Wang H, Das A, Berdyshev E, Li J, Leff AR, Stern SA, Vanden Hoek TL

Abstract

BACKGROUND:: Therapeutic hypothermia (TH) has demonstrated great potential for forestalling cardiovascular collapse and improving outcomes in the setting of severe hemorrhagic shock (HS). We used an established mouse model of severe HS to study the response of interrelated cardiac-signaling proteins p38, HspB1, and Akt to shock, resuscitation, and cardioprotective TH. METHODS:: Adult female C57BL6/J mice were bled and maintained at a mean arterial pressure of 35 mm Hg. After 30 minutes, mice were randomized to 120 minutes of TH (33°C ± 0.5°C) or continued normothermia at 37°C. After 90 minutes, animals were resuscitated and monitored for 180 minutes. Cardiac p38, Akt, and HspB1 phosphorylation (p-p38, p-Akt, and p-HspB1), expression, and Akt/HspB1 interactions were measured at serial time points during HS and resuscitation. Markers of mitochondrial damage (plasma cytochrome c), inflammation (myeloperoxidase), and apoptosis (terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling) were analyzed. RESULTS:: By 15 minutes HS, p-p38 and p-HspB1 significantly increased while p-Akt(T308) decreased (p < 0.05). TH attenuated phosphorylation of the p38α isoform during HS and increased phosphorylation of the p38γ isoform during both HS and early resuscitation (p < 0.05). TH increased Akt/HspB1 coimmunoprecipitation during early resuscitation and increased p-Akt and HspB1 expression during late resuscitation (p < 0.05). Finally, TH attenuated the myocardial myeloperoxidase and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling staining and plasma cytochrome c during late resuscitation. CONCLUSIONS:: TH increases phosphorylation of p38γ during both HS and early resuscitation, but attenuates phosphorylation of p38α, increases Akt/HspB1 interaction, and modulates Akt phosphorylation during HS and resuscitation. Such TH-related signaling events are associated with reduced cardiac inflammation, apoptosis, and mitochondrial injury.

PMID: 22071928 [PubMed - as supplied by publisher]

Direct Vascular Control Results in Less Physiologic Derangement Than Proximal Aortic Clamping in a Porcine Model of Noncompressible Extrathoracic Torso Hemorrhage.

J Trauma. 2011 Nov;71(5):1278-1287

Authors: White JM, Cannon JW, Stannard A, Burkhardt GE, Spencer JR, Williams K, Oh JS, Rasmussen TE

Abstract

BACKGROUND:: The optimal method of vascular control and resuscitation in patients with life-threatening, extrathoracic torso hemorrhage remains debated. Guidelines recommend emergency department thoracotomy (EDT) with aortic clamping, although transabdominal aortic clamping followed by vascular control and direct vascular control (DVC) without aortic clamping are alternatives. The objective of this study is to compare the effectiveness of three approaches to extrathoracic torso hemorrhage in a large animal model. METHODS:: Adolescent swine (Sus Scrofa) (mean weight = 80.9 kg) were randomized into three groups all of which had class IV shock established by hemorrhage from an iliac artery injury. Group 1: EDT with thoracic aortic clamping (N = 6); group 2: transabdominal supraceliac aortic clamping (SCC; N = 6); and group 3: DVC of bleeding site without aortic clamping (N = 6). After hemorrhage, EDT or SCC was performed in groups 1 and 2, respectively, with subsequent exploration of the bleeding site and placement of a temporary vascular shunt (TVS). Group 3 (DVC) underwent direct exploration of the injury and placement of a TVS. All groups were resuscitated to predefined physiologic endpoints over 6 hours with repeated measures of central and cerebral perfusion and end-organ function at standardized time points. Postmortem tissue analysis was performed to quantify injury to critical tissue beds. RESULTS:: There was no difference in mortality among the groups and no TVS failures. Central aortic pressure, carotid flow, and partial pressure brain tissue oximetry, all demonstrated increases in EDT and SCC after application of the aortic clamp relative to DVC (p < 0.05). During resuscitation, serum lactate levels were higher in EDT compared with SCC and DVC (6.85 vs. 3.08 and 2.15, respectively; p < 0.05) and serum pH in EDT reflected greater acidosis than SCC and DVC (7.24 vs. 7.36 and 7.39, respectively; p < 0.05). EDT and SCC required more intravenous fluid than DVC (2,166 mL and 2,166 mL vs. 667 mL, respectively; p < 0.05) and more vasopressors were used in EDT and SCC compared with DVC (52.1 μg and 43.5 μg vs. 12.4 μg, respectively; p < 0.05). Brain and myocardial tissue stains demonstrated the same degree of acute ischemic changes in all groups. CONCLUSION:: Although aortic clamping increases central and cerebral perfusion, DVC results in less physiologic derangement. The optimal method of aortic control would incorporate the benefits of maintained central pressure with less associated morbidity. Clinical studies evaluating DVC are warranted.

PMID: 22071929 [PubMed - as supplied by publisher]

Burn injury dampens erythroid cell production through reprioritizing bone marrow hematopoietic response.

J Trauma. 2011 Nov;71(5):1288-96

Authors: Posluszny JA, Muthumalaiappan K, Kini AR, Szilagyi A, He LK, Li Y, Gamelli RL, Shankar R

Abstract

BACKGROUND: : Anemia in burn patients is due to surgical blood loss and anemia of critical illness. Because the commitment paradigm of common bone marrow progenitors dictates the production of erythroid, myeloid, and lymphoid cells, we hypothesized that skewed bone marrow lineage commitment decreases red cell production and causes anemia after a burn injury.

METHODS: : After anesthesia, B6D2F1 mice received a 15% total body surface area dorsal scald burn. The sham group did not receive scald burn. Femoral bone marrow was harvested on 2, 5, 7, 14, and 21 postburn days (PBD). Total bone marrow cells were labeled with specific antibodies to erythroid (CD71/Ter119), myeloid (CD11b), and lymphoid (CD19) lineages and analyzed by flow cytometry. To test whether erythropoietin (EPO) could increase red blood cell production, EPO was administered to sham and burn animals and their reticulocyte response was measured on PBD 2 and PBD 7.

RESULTS: : Burn injury reduced the erythroid cells of the bone marrow from 35% in sham to 17% by PBD 5 and remained at similar level until PBD 21. Myeloid cells, however, increased from 42% in sham to 60% on PBD 5 and 77% on PBD 21. Burn injury reduced reticulocyte counts on PBD 2 and PBD 7 indicating that the erythroid compartment is severely depleted. This depleted compartment, however, responded to EPO but was not sufficient to change red cell production.

CONCLUSION: : Burn injury skews the bone marrow hematopoietic commitment away from erythroid and toward myeloid cells. Shrinkage of the erythroid compartment contributes to resistance to EPO and the anemia of critical illness.

PMID: 22071930 [PubMed - in process]

Open versus closed abdomen treatment on liver function in rats with sepsis and abdominal compartment syndrome.

J Trauma. 2011 Nov;71(5):1319-26

Authors: Chen J, Ren J, Zhang W, Li J

Abstract

BACKGROUND: : Despite recent advances in understanding the mechanisms of sepsis and abdominal compartment syndrome (ACS) and of improvements in their management, the mortality rates from these conditions remain high. Few studies have compared liver injuries in patients undergoing open and closed abdomen treatment. The aim of this study was to compare the effects of open versus conservative abdominal closure approaches upon liver function using a controlled and randomized model of intra-abdominal hypertension and sepsis in a rat model.

METHODS: : Healthy Sprague-Dawley rats underwent cecal ligation and puncture to induce sepsis, followed by intraperitoneal injection of air to induce intra-abdominal hypertension. Twenty-four hours later, the rats were randomly divided into two groups, one (n = 36) undergoing abdominal closure and the other (n = 36) undergoing open abdomen. Rats were killed after 1 hour, 6 hours, 1 day, 3 days, 5 days, and 7 days. Liver injury was evaluated by Hepatic Injury Severity Scoring. The levels of expression of Toll-like receptor 4 (TLR4), tumor necrosis factor-α, interleukin-6, signaling transducer and activator of transcription 3 mRNA, and suppressor of cytokine signaling 3 mRNA were assayed by reverse transcription-polymerase chain reaction.

RESULTS: : The levels of tumor necrosis factor-α, interleukin-6, and signaling transducer and activator of transcription 3 mRNA were higher, and those of TLR4 and suppressor of cytokine signaling 3 mRNA were lower, in the open than in the closed group (p < 0.05 each). Serum concentrations of aspartate aminotransferase and alanine aminotransferase were also lower in the open group (p < 0.05 each).

CONCLUSIONS: : Open abdominal management may improve liver regeneration soon after surgery, as well as reducing inflammatory responses, by reducing TLR4 expression.

PMID: 22071931 [PubMed - in process]

Limited transthoracic echocardiogram: so easy any trauma attending can do it.

J Trauma. 2011 Nov;71(5):1327-32

Authors: Ferrada P, Anand RJ, Whelan J, Aboutanos MA, Duane T, Malhotra A, Ivatury R

Abstract

BACKGROUND: : Limited transthoracic echocardiogram (LTTE) represents an attractive alternative to formal transthoracic echocardiogram (TTE), because it does not require an echocardiogram machine. Our hypothesis is that trauma attendings can learn LTTE effectively with minimal training.

METHODS: : Seven attendings at a Level I trauma center received didactic and hands-on training in LTTE and performed this test on hypotensive patients to evaluate for contractility, fluid status, and pericardial effusion. Therapy to improve perfusion (administration of fluids, ionotropes, or vasopressors) was guided by LTTE findings. Perfusion status was determined by serum lactate level before and 6 hours after LTTE. Findings were compared with cardiology-performed TTE.

RESULTS: : Range of postresidency training was 1 year to 29 years. LTTE teaching entailed 70 minutes of didactics and 25 minutes of hands-on. In all, 52 LTTEs were performed; two patients were excluded due to blunt trauma arrest. Age ranged from 22 years to 89 years with an average of 55 years. Admission diagnosis was blunt trauma (n = 34), penetrating trauma (n = 3), and intra-abdominal sepsis (n = 13). Average time for LTTE was 4 minutes 38 seconds. Cardiology-performed TTE was obtained in all patients, and correlation with LTTE was 100%. A total of 37 patients received intravenous fluid, 9 received vasopressors, and 4 received ionotropes as guided by LTTE findings, with lactate reduction in all patients (p < 0.00001). Attendings scored a mean of 88% in a written test after training.

CONCLUSIONS: : Trauma attendings can successfully learn LTTE with minimal training and use the technique as a resuscitation tool in the hypotensive patient.

PMID: 22071932 [PubMed - in process]

Low-intensity pulsed ultrasound as a useful adjuvant during distraction osteogenesis: a prospective, randomized controlled trial.

J Trauma. 2011 Nov;71(5):1376-80

Authors: Dudda M, Hauser J, Muhr G, Esenwein SA

Abstract

BACKGROUND: : Low-intensity pulsed ultrasound (LIPUS) was proven to have a positive impact on bone healing in animal and clinical studies.

METHODS: : In this prospective, randomized controlled trial the effect of LIPUS during distraction osteogenesis was investigated. Thirty-six patients who underwent distraction osteogenesis (>2 cm) were enrolled. Sixteen patients in the treatment group received LIPUS, and 20 patients as control group did not. Ultrasound treatment device was transcutaneously applied at the distraction gap for 20 minutes daily (frequency 1.5 MHz, signal burst with 200 μs, signal repetition frequency 1.0 kHz, intensity 30 mW/cm). Evaluation of patients was performed by standard radiographs every 3 weeks to 4 weeks.

RESULTS: : Average transport distance was 7.0 cm in the ultrasound group and 6.3 cm in the control group. Mean Paley index for the ultrasound group was 1.09 mo/cm and 1.49 mo/cm for the control group. Mean distraction consolidation index for the ultrasound group was 32.8 d/cm and 44.6 d/cm for the control group. The calculated indices indicated no significant statistical difference between the two groups (p < 0.116) but the fixator gestation period could be decreased for 43.6 days in the treatment group.

CONCLUSIONS: : Therapeutic application of LIPUS during callus distraction constitutes a useful adjuvant treatment during distraction osteogenesis and has a positive effect on healing time with no negative effects.

PMID: 22071933 [PubMed - in process]

Are Certain Fractures at Increased Risk for Compartment Syndrome After Civilian Ballistic Injury?

J Trauma. 2011 Nov;71(5):1385-1389

Authors: Meskey T, Hardcastle J, Oʼtoole RV

Abstract

BACKGROUND:: Compartment syndrome after ballistic fracture is uncommon but potentially devastating. Few data are available to help guide clinicians regarding risk factors for developing compartment syndrome after ballistic fractures. Our primary hypothesis was that ballistic fractures of certain bones would be at higher risk for development of compartment syndrome. METHODS:: A retrospective review at a Level I trauma center from 2001 through 2007 yielded 650 patients with 938 fractures resulting from gunshots. We reviewed all operative notes, clinic notes, discharge summaries, and data from our prospective trauma database. Cases in which the attending orthopedic surgeon diagnosed compartment syndrome and performed fasciotomy were considered cases with compartment syndrome. We excluded all prophylactic fasciotomies. Univariate analyses were conducted to identify risk factors associated with development of compartment syndrome. RESULTS:: Twenty-six (2.8%) of the 938 fractures were associated with compartment syndrome. Only fibular (11.6%) and tibial (11.4%) fractures had incidence significantly higher than baseline for all ballistic fractures (p < 0.001). Fractures of the proximal third of the fibula were more likely to result in compartment syndrome than fractures of the middle or distal third (p = 0.03), as were fractures of the proximal third of the tibia (p = 0.01). No other demographic or injury parameters were associated with compartment syndrome. CONCLUSION:: Ballistic fractures of the fibula and tibia are at increased risk for development of compartment syndrome over other ballistic fractures. We recommend increased vigilance when treating these injuries, particularly if the fracture is in the proximal aspect of the bone or is associated with vascular injury.

PMID: 22071934 [PubMed - as supplied by publisher]

Nontrauma emergency surgery: optimal case mix for general surgery and acute care surgery training.

J Trauma. 2011 Nov;71(5):1422-7

Authors: Cherry-Bukowiec JR, Miller BS, Doherty GM, Brunsvold ME, Hemmila MR, Park PK, Raghavendran K, Sihler KC, Wahl WL, Wang SC, Napolitano LM

Abstract

BACKGROUND: : To examine the case mix and patient characteristics and outcomes of the nontrauma emergency (NTE) service in an academic Division of Acute Care Surgery.

METHODS: : An NTE service (attending, chief resident, postgraduate year-3 and postgraduate year-2 residents, and two physician assistants) was created in July 2005 for all urgent and emergent inpatient and emergency department general surgery patient consults and admissions. An NTE database was created with prospective data collection of all NTE admissions initiated from November 1, 2007. Prospective data were collected by a dedicated trauma registrar and Acute Physiology and Chronic Health Evaluation-intensive care unit (ICU) coordinator daily. NTE case mix and ICU characteristics were reviewed for the 2-year time period January 1, 2008, through December 31, 2009. During the same time period, trauma operative cases and procedures were examined and compared with the NTE case mix.

RESULTS: : Thousand seven hundred eight patients were admitted to the NTE service during this time period (789 in 2008 and 910 in 2009). Surgical intervention was required in 70% of patients admitted to the NTE service. Exploratory laparotomy or laparoscopy was performed in 449 NTE patients, comprising 37% of all surgical procedures. In comparison, only 118 trauma patients (5.9% of admissions) required a major laparotomy or thoracotomy during the same time period. Acuity of illness of NTE patients was high, with a significant portion (13%) of NTE patients requiring ICU admission. NTE patients had higher admission Acute Physiology and Chronic Health Evaluation III scores [61.2 vs. 58.8 (2008); 58.2 vs. 55.8 (2009)], increased mortality [(9.71% vs. 4.89% (2008); 6.78% vs. 5.16% (2009)], and increased readmission rates (15.5% vs. 7.4%) compared with the total surgical ICU (SICU) admissions.

CONCLUSION: : In an era of declining operative caseload in trauma, the NTE service provides ample opportunity for complex general surgery decision making and operative procedures for surgical residency education, including advanced surgical critical care management. In addition, creation of an NTE service provides an optimal general surgery case mix, including major abdominal operations, that can augment declining trauma surgery caseloads, maintain acute care faculty surgical skills, and support general and acute care surgery residency training.

PMID: 22071935 [PubMed - in process]

American college of surgeons’ committee on trauma performance improvement and patient safety program: maximal impact in a mature trauma center.

J Trauma. 2011 Nov;71(5):1447-54

Authors: Sarkar B, Brunsvold ME, Cherry-Bukoweic JR, Hemmila MR, Park PK, Raghavendran K, Wahl WL, Wang SC, Napolitano LM

Abstract

BACKGROUND: : To examine the impact of an ongoing comprehensive performance improvement and patient safety (PIPS) program implemented in 2005 on mortality outcomes for trauma patients at an established American College of Surgeons (ACS)-verified Level I Trauma Center.

METHODS: : The primary outcome measure was in-hospital mortality. Age, Injury Severity Score (ISS), and intensive care unit admissions were used as stratifying variables to examine outcomes over a 5-year period (2004-2008). Institution mortality rates were compared with the National Trauma Data Bank mortality rates stratified by ISS score. Enhancements to our comprehensive PIPS program included revision of trauma activation criteria, development of standardized protocols for initial resuscitation, massive transfusion, avoidance of over-resuscitation, tourniquet use, pelvic fracture management, emphasis on timely angiographic and surgical intervention, prompt spine clearance, reduction in time to computed tomography imaging, reduced dwell time in emergency department, evidence-based traumatic brain injury management, and multidisciplinary efforts to reduce healthcare-associated infections.

RESULTS: : In 2004 (baseline data), the in-hospital mortality rate for the most severely injured trauma patients (ISS >24) at our trauma center was 30%, consistent with the reported mortality rate from the National Trauma Data Bank for patients with this severity of injury. Over 5 years, our mortality rate decreased significantly for severely injured patients with an ISS >24, from 30.1% (2004) to 18.3% (2008), representing a 12% absolute reduction in mortality (p = 0.011). During the same 5-year time period, the proportion of elderly patients (age >65 years) cared for at our trauma center increased from 23.5% in 2004 to 30.6% in 2008 (p = 0.0002). Class I trauma activations increased significantly from 5.5% in 2004 to 15.5% in 2008 based on our reclassification. A greater percentage of patients were admitted to the intensive care unit (25.8% in 2004 to 37.3% in 2007 and 30.4% in 2008). No difference was identified in the rate of blunt (95%) or penetrating (5%) mechanism of injury in our patients over this time period. Trauma Quality Improvement Program confirmed improved trauma outcomes with observed-to-expected ratio and 95% confidence intervals of 0.64 (0.42-0.86) for all patients, 0.54 (0.15-0.91) for blunt single-system patients, and 0.78 (0.51-1.06) for blunt multisystem patients.

CONCLUSION: : Implementation of a multifaceted trauma PIPS program aimed at improving trauma care significantly reduced in-hospital mortality in a mature ACS Level I trauma center. Optimal care of the injured patient requires uncompromising commitment to PIPS.

PMID: 22071936 [PubMed - in process]

Initial treatment of ocular exposure and associated complications in severe periorbital thermal injuries.

J Trauma. 2011 Nov;71(5):1455-9

Authors: Czyz CN, Kalwerisky K, Stacey AW, Foster JA, Hill RH, Everman KR, Cahill KV, Demartelaere S

PMID: 22071937 [PubMed - in process]

Efficacy and safety of intensive insulin therapy for critically ill neurologic patients: a meta-analysis.

J Trauma. 2011 Nov;71(5):1460-4

Authors: Shan L, Hao PP, Chen YG

Abstract

BACKGROUND: : Whether intensive insulin therapy (IIT) may improve clinical outcomes for patients admitted to intensive care units, especially critically ill neurologic patients, is still debated. In the present study, we performed a meta-analysis of literature comparing the efficacy and safety of IIT and conventional insulin therapy (CIT) for critically ill neurologic patients in terms of mortality, infection rate, neurologic outcome, and hypoglycemia.

METHODS: : We searched for published reports of studies of randomized control trials (up to March 10, 2011) of patients admitted to neurologic intensive care units and investigated an IIT (target of blood glucose control <120 mg/dL) with a control of CIT. Data were abstracted by a standardized protocol.

RESULTS: : We retrieved reports of five studies involving 924 patients. The risk of mortality, infection rate, and neurologic outcome did not differ with IIT or CIT. However, the incidence of hypoglycemic episodes was significantly higher with IIT than CIT (78.8% vs. 48.9%), with a relative risk of 2.62 (95% confidence interval [CI]: 1.07-6.43; p < 0.04).

CONCLUSIONS: : As compared with CIT, IIT may not benefit critically ill neurologic patients in terms of mortality, infection rate, or neurologic outcome and in fact may be associated with increased hypoglycemic complications. Therefore, IIT cannot be recommended over conventional control for critical neurologic disease, but further study is warranted.

PMID: 22071938 [PubMed - in process]

A systematic review of an emerging consciousness population: focus on program evolution.

J Trauma. 2011 Nov;71(5):1465-74

Authors: Gray M, Lai S, Wells R, Chung J, Teraoka J, Howe L, Harris OA

PMID: 22071939 [PubMed - in process]

Indirect colonic injury after military wounding: a case series.

J Trauma. 2011 Nov;71(5):1475-7

Authors: Webster C, Mercer S, Schrager J, Carrell TW, Bowley D

Abstract

BACKGROUND: : Colonic trauma in wartime most commonly results from direct injury along the path of a penetrating missile. Rarely, the colon may be injured by primary blast effect or by propagation of energy by the missile, remote from the track of the projectile.

METHODS/RESULTS: : This article describes the clinical presentation and operative findings in five patients who sustained high energy-transfer gunshot wounds (GSWs) or fragmentation injuries from blast who were found to have sustained colonic injuries anatomically remote from the missile track/s.

CONCLUSIONS: : Military surgeons should be aware of the phenomenon of indirect injury to the colon after high-energy transfer GSW and blast injury. A high index of suspicion should be maintained and cross-sectional imaging used where feasible. Primary colonic reconstruction was used safely in these patients with indirect colonic injuries.

PMID: 22071940 [PubMed - in process]

Complete thoracic tracheal transection caused by blunt trauma.

J Trauma. 2011 Nov;71(5):1478

Authors: Enomoto Y, Watanabe H, Nakao S, Matsuoka T

PMID: 22071941 [PubMed - in process]

Left pulmonary artery transection after penetrating thoracic trauma.

J Trauma. 2011 Nov;71(5):1479

Authors: Blanié A, Fadel E, Duranteau J

PMID: 22071942 [PubMed - in process]

Sew it up! A Western trauma association multiinstitutional study of enteric injury management in the postinjury open abdomen.

J Trauma. 2011 Nov;71(5):1480

Authors: Wittmann DH

PMID: 22071943 [PubMed - in process]

Platelet activation accounts for excessive angiopoietin-1 levels in patients’ sera.

J Trauma. 2011 Nov;71(5):1480-1

Authors: Padberg JS, Wiesinger A, Kümpers P

PMID: 22071944 [PubMed - in process]

Meetings/Courses.

J Trauma. 2011 Nov;71(5):1482

Authors:

PMID: 22071945 [PubMed - in process]

Repair of blunt thoracic outlet arterial injuries: an evolution from open to endovascular approach.

J Trauma. 2011 Nov;71(5):E114-21

Authors: Shalhub S, Starnes BW, Hatsukami TS, Karmy-Jones R, Tran NT

Abstract

BACKGROUND: : Thoracic outlet artery injuries due to blunt trauma are uncommon. Exposure of these arteries is associated with significant morbidity and mortality. An endovascular approach is a less invasive alternative approach for these technically challenging injuries.

METHODS: : A retrospective review of patients who presented with blunt traumatic injuries to the innominate, subclavian, and axillary arteries between 1998 and 2009 was performed. Demographic data, concomitant injuries, preoperative workup, treatment, and outcomes were recorded.

RESULTS: : During the study period, 34 patients (80% men) meeting selection criteria were admitted (11 innominate, 16 subclavian, and 7 axillary). Management was nonoperative in 6, open in 16, and endovascular in 12 patients. In the latter group, eight patients had successful stent-graft insertions. These were approached in an antegrade femoral or retrograde brachial fashion. In three cases of complete artery transaction, both methods were used. Shorter operative time (149 minutes vs. 230 minutes; p = 0.03) and less blood loss (50 mL vs. 1,225 mL; p = 0.03) were seen in the endovascular group compared with the open repair group. There was a trend for less blood transfusion, but it was not significant (0 median units vs. 4.5 median units; p = 0.3). Hospital length of stay was shorter (19 days vs. 29 days; p = 0.4).

CONCLUSIONS: : Covered stents are a feasible alternative to open repair in the multiply injured blunt trauma patients with thoracic outlet arterial injuries. This can be used in the damage control setting as it offers shorter operative time, less blood loss, and overall less morbidity to the patient. Long-term follow-up is needed.

PMID: 22071946 [PubMed - in process]

Late iatrogenic coronary artery stenosis after penetrating cardiac trauma repair.

J Trauma. 2011 Nov;71(5):E122

Authors: Lee JW, Hwang JJ, Kim KD

PMID: 22071947 [PubMed - in process]

Postinjury resuscitation with human polymerized hemoglobin prolongs early survival: a post hoc analysis.

J Trauma. 2011 May;70(5 Suppl):S34-7

Authors: Bernard AC, Moore EE, Moore FA, Hides GA, Guthrie BJ, Omert LA, Gould SA, Rodman GH,

PMID: 21841568 [PubMed - indexed for MEDLINE]

Health-Related Quality of Life After Burns: A Prospective Multicentre Cohort Study With 18 Months Follow-Up.

J Trauma. 2011 Oct 24;

Authors: van Loey NE, van Beeck EF, Faber BW, van de Schoot R, Bremer M

Abstract

BACKGROUND:: Health-related quality of life (HRQOL) is an important parameter after medical treatments. Knowledge of (predictors of) diminished quality of life can help improve medical outcome. The aim of this study was to quantify health loss in patients with burns and to assess the contribution of injury extent, age, gender, and psychologic factors to HRQOL and speed of recovery. A multicenter prospective cohort design was used to address these aims. METHODS:: Data were obtained from 260 adults with burns. Patients completed the EQ-5D at 3 weeks, 3, 6, 9, and 18 months after burn and psychologic questionnaires during hospitalization. Patient’s scores were compared with an age- and gender-weighted norm population. RESULTS:: Patients suffered from substantial health losses at short term, but after 18 months the majority reached a HRQOL comparable with the norm population with the exception of patients requiring two or more surgeries. The best predictor of long-term HRQOL and the speed of recovery was the number of surgeries, followed by psychologic problems. Both predicted baseline and trajectories of improvement. Symptoms of traumatic stress were most debilitating over time. CONCLUSIONS:: Both injury severity and psychologic problems play a pivotal role in reduced HRQOL and the speed of recovery. The number of surgeries seems to give a practically useful indication of the expected recovery speed that could aid in decision making and provides adequate information for patients in the aftermath of their initial surgical treatment. Screening for traumatic stress is recommended.

PMID: 22027879 [PubMed - as supplied by publisher]

Accidental and Intentional Perpetration of Serious Injury or Death: Correlates and Relationship to Trauma Exposure.

J Trauma. 2011 Oct 24;

Authors: Nickerson A, Aderka IM, Bryant RA, Litz BT, Hofmann SG

Abstract

BACKGROUND:: The pernicious individual and societal effects of exposure to violence highlight the importance of understanding factors related to trauma perpetration. Little research has investigated the phenomenon of accidental perpetration of serious injury and death, or considered the relationship between perpetration and trauma exposure. METHODS:: This study uses data from the National Comorbidity Survey-Replication to examine the demographic correlates and characteristics of both intentional and accidental perpetration of trauma, as well as the relationship of these types of perpetration to exposure to traumatic events. Participants were 83 individuals who had accidentally perpetrated trauma and 120 individuals who had intentionally perpetrated trauma. RESULTS:: Findings indicated that men were more likely than women to report having intentionally, compared to accidentally, perpetrated trauma. Intentional and accidental perpetration of trauma were both associated with high levels of psychologic disorders, although those who had intentionally perpetrated trauma were more likely to report symptoms of posttraumatic stress disorder compared with those who had accidentally perpetrated trauma. Intentional perpetrators were more likely to have experienced interpersonal trauma in adulthood and childhood compared to accidental perpetrators. Interpersonal and sexual trauma was likely to precede any kind of trauma perpetration. CONCLUSIONS:: Findings suggest that accidental, as well as intentional, perpetration of serious injury or death frequently occurs in the context of trauma and violence. Both types of perpetration are related to psychopathology. Potential mechanisms underlying the relationship between trauma exposure, psychopathology, and perpetration are discussed. Further research is needed to elucidate pathways from trauma exposure to perpetration and mental disorder.

PMID: 22027880 [PubMed - as supplied by publisher]

The Floating Shoulder-Clinical and Radiological Results After Intramedullary Stabilization of the Clavicle in Cases With Minor Displacement of the Scapular Neck Fracture.

J Trauma. 2011 Oct 24;

Authors: Izadpanah K, Jaeger M, Maier D, Kubosch D, Hammer TO, Südkamp NP

Abstract

BACKGROUND:: The aim of this study was to compare the clinical and radiologic results of titanium elastic nail (TEN) and plate osteosynthesis for treatment of clavicle fractures in patients with a floating shoulder injury. PATIENTS AND METHODS:: From 2000 to 2008, 16 patients with a floating shoulder injury (ipsilateral clavicle and minor displaced scapular neck fracture) were treated by isolated stabilization of the clavicle. The patients were treated with open reduction and plate osteosynthesis (group 1 [G1]) or TEN osteosynthesis (group 2 [G2]). Both procedures were compared with regard to functional and radiologic outcome. RESULTS:: Nine patients were treated with a plate osteosynthesis (G1) and seven with a TEN osteosynthesis (G2). The follow-up time was 35.7 months ± 16 months. There was no difference in functional outcome with regard to the intraindividual Constant score 83.9 (G1) versus 86.7 (G2) or the American Shoulder and Elbow Surgeons score 79.1 (G1) versus 85.7 (G2). No significant postoperative dislocation of the glenopolar angle appeared. In the TEN-treated group, a clavicle shortening of 2.4 mm was observed. Subgroup analysis revealed significant greater shortening in type B and C compared with type A (OTA) clavicle fractures (4.7 mm vs. 0.8 mm). No clavicle shortening in the plate-treated group appeared. CONCLUSION:: The treatment of floating shoulder injuries with TEN and plate osteosynthesis of the clavicle and nonoperative treatment of a minimally displaced glenoid neck fracture provide equal functional results. However, in type B and C (but not in type A) fractures of the clavicle, a shortening of ∼5 mm can be expected after titanium elastic nailing.

PMID: 22027881 [PubMed - as supplied by publisher]

A Prospective Study of Thrombophilia in Trauma Patients With Pulmonary Embolism.

J Trauma. 2011 Oct 24;

Authors: Gary JL, Barber RC, Reinert CM, Starr AJ

Abstract

BACKGROUND:: Pulmonary embolism (PE) is a rare, but often fatal, complication of trauma. To date, there has been no study of the prevalence of thrombophilic abnormalities among trauma patients who sustain a PE. Our purpose was to determine whether heritable thrombophilia is associated with the development of PE in trauma patients. METHODS:: All patients admitted to the trauma service over a 5-month period had residual blood from standard laboratory samples stored. Patients were then prospectively followed through their hospital. Greets’ formula was used to estimate risk of thromboembolic disease. For every patient who developed a PE (n = 20), four controls with similar risk were randomly selected. DNA samples were genotyped. The genes screened included MTHFR, Factor II, Factor V, and Protein C. RESULTS:: DNA genotyping for Factor V and Protein C revealed only wild-type alleles in the cases. Genotyping of Factor II revealed mutations in 25% (10 of 40) of alleles in the cases and 17% (27 of 160) of alleles in the controls (p = 0.24). Mutation in alleles of the MTHFR1 gene occurred in 28% (11 of 40) of the cases and in 28% (40 of 150) of the controls (p = 0.92); genotyping in five of the controls (10 alleles) was indeterminate at the MTHFR1 alleles after testing. CONCLUSIONS:: No statistically significant differences were found in genetic abnormalities among trauma patients who developed PE and who did not; however, the sample size was small. Routine screening for thrombophilia in trauma patients is not recommended.

PMID: 22027882 [PubMed - as supplied by publisher]

Surface-Attached Amphipathic Peptides Reduce Hemorrhage In Vivo.

J Trauma. 2011 Oct 24;

Authors: Charbonneau S, Lemarié CA, Peng HT, Ganopolsky JG, Shek PN, Blostein MD

Abstract

BACKGROUND:: The leading causes of death for trauma patients in civilian and combat settings are traumatic brain injury and uncontrolled hemorrhage, respectively. This study examines the hemostatic activity of an ideal amphipathic peptide (IAP) attached to a biocompatible surface. METHODS:: Procoagulant properties of IAP attached to a surface were first tested, in vitro, using factor Xa and thrombin generation assays and thromboelastography. Rabbits and swine were used for in vivo studies. Injuries were performed using scalpel blade 11, and free bleeding was allowed for 5 seconds. While bleeding, IAP coupled to a hydrogel or QuikClot were applied to the wound and the time was recorded until bleeding stopped. RESULTS:: Results show that when IAP is attached to a surface, both factor IXa and factor Xa activities are promoted. Thromboelastography shows that surface-attached IAP results in earlier onset and stronger clot formation. In rabbits, the incorporation of IAP onto a biocompatible hydrogel reduces bleeding times by 40% (p < 0.03). In pigs, bleeding times are reduced 30% to 50% (p < 0.02) by surface-coupled IAP. Finally, using a rabbit liver laceration model, the properties of surface-coupled IAP are less damaging when compared with QuikClot, a currently used material in external hemorrhagic injuries. CONCLUSIONS:: This study provides a relevant proof of concept for the development of IAP coupled to a biocompatible surface as a hemostatic agent, that is potentially safer than the commercially available QuikClot.

PMID: 22027883 [PubMed - as supplied by publisher]