Design of a Novel Online, Modular, Flipped-classroom Surgical Curriculum for East, Central, and Southern Africa.

Objective: We describe a structured approach to developing a standardized curriculum for surgical trainees in East, Central, and Southern Africa (ECSA). Summary Background Data: Surgical education is essential to closing the surgical access gap in ECSA. Given its importance for surgical education, the development of a standardized curriculum was deemed necessary. Methods: We utilized Kern's 6-step approach to curriculum development to design an online, modular, flipped-classroom surgical curriculum. Steps included global and targeted needs assessments, determination of goals and objectives, the establishment of educational strategies, implementation, and evaluation. Results: Global needs assessment identified the development of a standardized curriculum as an essential next step in the growth of surgical education programs in ECSA. Targeted needs assessment of stakeholders found medical knowledge challenges, regulatory requirements, language variance, content gaps, expense and availability of resources, faculty numbers, and content delivery method to be factors to inform curriculum design. Goals emerged to increase uniformity and consistency in training, create contextually relevant material, incorporate best educational practices, reduce faculty burden, and ease content delivery and updates. Educational strategies centered on developing an online, flipped-classroom, modular curriculum emphasizing textual simplicity, multimedia components, and incorporation of active learning strategies. The implementation process involved establishing thematic topics and subtopics, the content of which was authored by regional surgeon educators and edited by content experts. Evaluation was performed by recording participation, soliciting user feedback, and evaluating scores on a certification examination. Conclusions: We present the systematic design of a large-scale, context-relevant, data-driven surgical curriculum for the ECSA region.

Choosing Surgery: Identifying Factors Leading to Increased General Surgery Matriculation Rate.

Tulane graduates have, over the past six years, chosen general surgical residency at a rate above the national average (mean 9.6% vs 6.6%). With much of the recent career choice research focusing on disincentives and declining general surgery applicants, we sought to identify factors that positively influenced our students' decision to pursue general surgery. A 50-question survey was developed and distributed to graduates who matched into a general surgery between the years 2006 and 2014. The survey evaluated demographics, exposure to surgery, and factors affecting interest in a surgical career. We achieved a 54 per cent (61/112) response rate. Only 43 per cent considered a surgical career before medical school matriculation. Fifty-nine per cent had strongly considered a career other than surgery. Sixty-two per cent chose to pursue surgery during or immediately after their surgery clerkship. The most important factors cited for choosing general surgery were perceived career enjoyment of residents and faculty, resident/faculty relationship, and mentorship. Surgery residents and faculty were viewed as role models by 72 and 77 per cent of responders, respectively. This study demonstrated almost half of those choosing a surgical career did so as a direct result of the core rotation experience. We believe that structuring the medical student education experience to optimize the interaction of students, residents, and faculty produces a positive environment encouraging students to choose a general surgery career.

Role of computed tomography angiography in the management of Zone II penetrating neck trauma in patients with clinical hard signs.

BACKGROUND: The Western Trauma Association (WTA) describes the management of Zone 2 penetrating neck trauma (PNT) and recommends neck exploration (NE) for patients with clinical hard signs (HS). We hypothesize that in stable patients with HS, the management of PNT augmented by computed tomography angiography (CTA) results in fewer negative NE results. METHODS: This was a 4-year retrospective review of adult patients with Zone 2 PNT at a Level I trauma center. Stable patients with WTA-defined HS (airway compromise, massive subcutaneous emphysema/air bubbling through wound, expanding/pulsatile hematoma, active bleeding, shock, focal neurologic deficit, and hematemesis) who underwent CTA instead of emergent exploration were identified. Sensitivity, specificity, positive predictive value, and negative predictive value for CTA were calculated. A comparison was made between the rates of negative NE results in patients with HS who received a CTA versus the rate that would have occurred in the same patients if the WTA algorithm had been followed. Missed injury rates were also compared. RESULTS: Of 183 PNT patients, 23 had HS and underwent CTA. Of the 23, 5 had a positive CTA findings and underwent NE, while 17 had a negative CTA findings and did not require NE. There was one false-negative in a patient who developed an expanding hematoma following negative neck CTA finding. Sensitivity, specificity, positive predictive value, and negative predictive value for CTA in the presence of HS were found to be 83%, 100%, 100%, and 94%, respectively. The addition of CTA to the WTA algorithm for this patient group significantly decreased the rate of negative NE (0 of 23 vs. 18 of 23, p < 0.001) without a significant increase in the rate of missed injury (1 of 23 vs. 0 of 23, p = 0.323). The use of CTA prevented 17 unnecessary NEs. CONCLUSION: CTA addition to the management of hemodynamically stable patients with HS in PNT significantly decreased the rate of negative NE result without increasing missed injury rate. Prospective study of CTA addition to the WTA algorithm is needed. LEVEL OF EVIDENCE: Care management/therapeutic study, level IV.

A multi-institutional analysis of prehospital tourniquet use.

BACKGROUND: Recent military studies demonstrated an association between prehospital tourniquet use and increased survival. The benefits of this prehospital intervention in a civilian population remain unclear. The aims of our study were to evaluate tourniquet use in the civilian population and to compare outcomes to previously published military experience. We hypothesized that incorporation of tourniquet use in the civilian population will result in an overall improvement in mortality. METHODS: This is a preliminary multi-institutional retrospective analysis of prehospital tourniquet (MIA-T) use of patients admitted to nine urban Level 1 trauma centers from January 2010 to December 2013. Patient demographics and mortality from a previous military experience by Kragh et al. (Ann Surg. 2009;249:1-7) were used for comparison. Patients younger than 18 years or with nontraumatic bleeding requiring tourniquet application were excluded. Data were analyzed using a two-tailed unpaired Student's t test with p < 0.05 as significant. RESULTS: A total of 197 patients were included. Tourniquets were applied effectively in 175 (88.8%) of 197 patients. The average Injury Severity Score (ISS) for MIA-T versus military was 11 ± 12.5 versus 14 ± 10.5, respectively (p = 0.02). The overall mortality and limb amputation rates for the MIA-T group were significantly lower than previously seen in the military population at 6 (3.0%) of 197 versus 22 (11.3%) of 194 (p = 0.002) and 37 (18.8%) of 197 versus 97 (41.8%) of 232 (p = 0.0001), respectively. CONCLUSION: Our study is the largest evaluation of prehospital tourniquet use in a civilian population to date. We found that tourniquets were applied safely and effectively in the civilian population. Adaptation of this prehospital intervention may convey a survival benefit in the civilian population. LEVEL OF EVIDENCE: Epidemiologic study, level V.

Impact of infusion rates of fresh frozen plasma and platelets during the first 180 minutes of resuscitation.

BACKGROUND: Whether high-ratio resuscitation (HRR) provides patients with survival advantage remains controversial. We hypothesized a direct correlation between HRR infusion rates in the first 180 minutes of resuscitation and survival. STUDY DESIGN: This was a retrospective analysis of massively transfused trauma patients surviving more than 30 minutes and undergoing surgery at a level 1 trauma center. Mean infusion rates (MIR) of packed red blood cells (PRBC), fresh frozen plasma (FFP), and platelets (Plt) were calculated for length of intervention (emergency department [ED] time + operating room [OR] time). Patients were categorized as HRR (FFP:PRBC > 0.7, and/or Plts: PRBC > 0.7) vs low-ratio resuscitation (LRR). Student's t-tests and chi-square tests were used to compare survivors with nonsurvivors. Cox proportional hazards regression models and Kaplan-Meier curves were generated to evaluate the association between MIR for FFP:PRBC and Plt:PRBC and 180-minute survival. RESULTS: There were 151 patients who met criteria: 121 (80.1%) patients survived 180 minutes (MIR:PRBC 71.9 mL/min, FFP 92.0 mL/min, Plt 3.5 mL/min) vs 30 (19.9%) who did not survive (MIR:PRBC 47.3 mL/min, FFP 33.7 mL/min, Plt 1.1 mL/min), p = 0.43, p < 0.0001 and p < 0.011, respectively. A Cox regression model evaluated PRBC rate, FFP rate, and Plt rate (mL/min) as mortality predictors within 180 minutes to assess if they significantly affected survival (hazard ratios 1.01 [p = 0.054], 0.97 [p < 0.0001], and 0.75 [p = 0.01], respectively). Another model used stepwise Cox regression including PRBC rate, FFP rate, and Plt rate (hazard ratios 1.00 [p = 0.85], 0.97 [p < 0.0001], and 0.88 [p = 0.24], respectively), as well as possible confounding variables. CONCLUSIONS: This is the first study to examine effects of MIRs on survival. Further studies on the effects of narrow time-interval analysis for blood product resuscitation are warranted.

To TQIP or not to TQIP? That is the question.

The Trauma Quality Improvement Program (TQIP) reports a feasible mortality prediction model. We hypothesize that our institutional characteristics differ from TQIP aggregate data, questioning its applicability. We conducted a 2-year (2008 to 2009) retrospective analysis of all trauma activations at a Level 1 trauma center. Data were analyzed using TQIP methodology (three groups: blunt single system, blunt multisystem, and penetrating) to develop a mortality prediction model using multiple logistic regression. These data were compared with TQIP data. Four hundred fifty-seven patients met TQIP inclusion criteria. Penetrating and blunt trauma differed significantly at our institution versus TQIP aggregates (61.9 vs 7.8%; 38.0 vs 92.2%, P < 0.01). There were more firearm mechanisms of injury and less falls compared with TQIP aggregates (28.9 vs 4.2%; 8.5 vs 34.8%, P < 0.01). All other mechanisms were not significantly different. Variables significant in the TQIP model but not found to be predictors of mortality included Glasgow Coma Score motor 2 to 5, systolic blood pressure greater than 90 mmHg, age, initial pulse rate in the emergency department, mechanism of injury, head Abbreviated Injury Score, and abdominal Abbreviated Injury Score. External benchmarking of trauma center performance using mortality prediction models is important in quality improvement for trauma patient care. From our results, TQIP methodology from the pilot study may not be applicable to all institutions.

Mechanism of injury is not a predictor of trauma center admission.

Most trauma systems use mechanism of injury (MOI) as an indicator for trauma center transport, often overburdening the system as a result of significant overtriage. Before 2005 our trauma center accepted all MOI. After 2005 we accepted only those patients meeting anatomic and physiologic (A&P) triage criteria. Patients entered into the trauma center database were divided into two groups: 2001 to 2005 (Group 1) and 2007 to 2010 (Group 2) and also categorized based on trauma team activation for either A&P or MOI criteria. Overtriage was defined as patient discharge from the emergency department within 6 hours of trauma activation. A total of 9899 patients were reviewed. Group 1 had 6584 patients with 3613 (55%) activated for A&P criteria and 2971 (45%) for MOI. Group 2 had 3315 patients with 3149 (95%) activated for A&P criteria and 166 (5%) for MOI. Accepting only those patients meeting A&P criteria resulted in a decrease in the overtriage rate from 66 to 9 per cent. By accepting only those patients meeting A&P criteria, we significantly reduced our overtriage rate. Patients meeting MOI criteria were transported to community hospitals and transferred to the trauma center if major injuries were identified. Trauma center transport for MOI results in significant overtriage and may not be justified.

Not all mechanisms are created equal: a single-center experience with the national guidelines for field triage of injured patients.

BACKGROUND: Trauma systems use prehospital evaluation of anatomic and physiologic criteria and mechanism of injury (MOI) to determine trauma center need (TCN). MOI criteria are established nationally in a collaborative effort between the Centers for Disease Control and Prevention and the American College of Surgeons' Committee on Trauma and have been revised several times, most recently in 2011. Controversy exists as to which MOI criteria truly predict TCN. We review our single-center experience with past and present National Trauma Triage Criteria to determine which MOI predict TCN. METHODS: The trauma registry of an urban Level I trauma center was reviewed from 2001 to 2011 for all patients meeting only MOI criteria. Patients meeting any anatomic and physiologic criteria were excluded. TCN was defined as death, Injury Severity Score (ISS) of greater than 15, emergency department transfusion, intensive care unit admission, need for laparotomy/thoracotomy/vascular surgery within 24 hours of arrival, pelvic fracture, 2 or more proximal long bone fractures, or neurosurgical intervention during admission. Logistic regression analysis was used to identify which MOI predict TCN. RESULTS: A total of 3,569 patients were transported to our trauma center who met only MOI criteria and had the MOI recorded in the registry; 821 MOI patients (23%) were identified who met our definition of TCN. Significant predictors of TCN included death in the same passenger compartment, ejection from vehicle, extrication time of more than 20 minutes, fall from more than 20 feet, and pedestrian thrown/runover. Criteria not meeting TCN include vehicle intrusion, rollover motor vehicle collision, speed of more than 40 mph, injury from autopedestrian/autobicycle of more than 5 mph, and both of the motorcycle crash (MCC) criteria. CONCLUSION: With the exception of vehicle intrusion and MCC, the new National Trauma Triage Criteria accurately predicts TCN. In addition, extrication time of more than 20 minutes was a positive predictor of TCN in our system. Elimination of the vehicle intrusion and MCC criteria and reevaluation of extrication time merits further study.

Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation.

BACKGROUND: High ratios of fresh frozen plasma:packed red blood cells in damage control resuscitation (DCR) are associated with increased survival. The impact of volume and type of resuscitative fluid used during high ratio transfusion has not been analyzed. We hypothesize a difference in outcomes based on the type and quantity of resuscitative fluid used in patients that received high ratio DCR. METHODS: A matched case control study of patients who received transfusions of ≥ four units of PRBC during damage control surgery over 4 1/2 y, was conducted at a Level I Trauma Center. All patients received a high ratio DCR, >1:2 of fresh frozen plasma:packed red blood cells. Demographics and outcomes of the type and quantity of resuscitative fluids used in combination with high ratio DCR were compared and analyzed. A Kaplan-Meier survival analysis was computed among four groups: colloid (median quantity = 1.0 L), <3 L crystalloid, 3-6 L crystalloid, and >6 L crystalloid. RESULTS: There were 56 patients included in the analysis (28 in the crystalloid group and 28 in the colloid group). Demographics were statistically similar. Intraoperative median units of PRBC: crystalloid versus colloid groups was 13 (IQR 8-21) versus 16 (IQR 12-19), P = 0.135; median units of FFP: 12 (IQR 7-18) versus 12 (IQR 10-18), P = 0.440. OR for 10-d mortality in the crystalloid group was 8.41 [95% CI 1.65-42.76 (P = 0.01)]. Kaplan-Meier survival analysis demonstrated lowest mortality in the colloid group and higher mortality with increasing amounts of crystalloid (P = 0.029). CONCLUSIONS: During high ratio DCR, resuscitation with higher volumes of crystalloids was associated with an overall decreased survival, whereas low volumes of colloid use were associated with increased survival. In order to improve outcomes without diluting the survival benefit of hemostatic resuscitation, guidelines should focus on effective low volume resuscitation when high ratio DCR is used. A multi-institutional analysis is needed in order to validate these results.

Diluting the benefits of hemostatic resuscitation: a multi-institutional analysis.

BACKGROUND: Although minimization of crystalloids is a widely adopted practice in the resuscitation of patients with severe hemorrhage, its direct impact on high-ratio resuscitation (HRR) outcomes has not been analyzed. We hypothesize that HRR patients will have worse outcomes from crystalloid use. METHODS: This was a 4-year retrospective multi-institutional analysis (MIA) of patients who received massive transfusion protocol (MTP) managed with damage-control laparotomy. Ratios of fresh frozen plasma-packed red blood cell (PRBC) were calculated and divided in two groups: HRR (1-1:2) and low-ratio resuscitation (LRR < 1:2). Major outcome of interest was to analyze the direct impact of 24-hour crystalloid volume on HRR MTP patients who received 10 or more units of PRBC. Statistical analysis included analysis of variance, Fisher's exact, Kaplan-Meier (KM) survival curves, and multiple logistic regression. RESULTS: Total of five Level I trauma centers participated with 451 patients who received MTP with 10 or more units of PRBC (fresh frozen plasma/PRBC ratios, n = 365 (80.9%) HRR vs. n = 86 (19.0%) LRR. Overall 24-hour KM survival for the HRR versus LRR was 85.2% versus 68.6% (p = 0.0004). The volume of crystalloids on KM survival curve in HRR MTP patients was not significant for mortality (p = 0.52). Morbidity odds ratios (95% confidence interval) for complications were not significant for HRR but were for crystalloids: bacteremia, 1.05 (1.0-1.1); adult respiratory distress syndrome, 1.13 (1.0-1.2), and acute renal failure, 1.05 (1.0-1.1). CONCLUSION: Our MIA results support previous studies with decreased mortality in HRR group when compared with LRR. This is the first MIA to demonstrate increased morbidity from crystalloid use in HRR. Within all MTPs with 10 or more units of PRBC, HRR was not a predictor of morbidity, but crystalloid volume was. Caution in overzealous use of crystalloid during HRR is warranted. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Impact of inverse ratios on patients with exsanguinating vascular injuries: should more be the new paradigm?

BACKGROUND: Resuscitation strategies in patients with severe hemorrhage have evolved throughout the years. Optimal resuscitation ratios for civilian exsanguinating vascular injuries has not been determined. We hypothesize improved outcomes in patients with exsanguinating vascular injuries when an aggressive hemostatic resuscitation is used with an inverse ratio of fresh frozen plasma (FFP) to packed red blood cell (PRBC). METHODS: This is a 5-year retrospective analysis of vascular injuries requiring hemostatic resuscitation. Resuscitation groups by ratios of FFP/PRBC were inverse (>1:1), high (1-1:2), and low (<1:2). Patients with 10 or greater units of PRBC (massively transfused patients) were evaluated in each of the resuscitation groups. Demographics and complications throughout hospital length of stay and were compared between the resuscitation groups. Survivability Kaplan-Meier curves were generated at 6 hours and 5 days. RESULTS: A total of 258 patients with vascular injuries required component therapy resuscitation (low, n = 78; high, n = 156; inverse, n = 24). Massively transfused patients (n = 162, 62.7%) showed a significant Kaplan-Meier survivability difference at 6 hours (low, 65.0% vs. high, 75.0% vs. inverse, 100%, p = 0.024) and at 5 days (low, 52.5% vs. high, 62.0% vs. inverse, 100%, p = 0.008). Moreover, for massively transfused patients with extremity vascular injuries (n = 65, 39%), a relationship between resuscitation ratio and amputations was significant (low vs. high vs. inverse was 36.8% vs. 12.8% vs. 0%, respectively; p = 0.033). CONCLUSION: This is the first study that highlights the potential outcomes benefits of an inverse ratio of FFP-PRBC in patients with exsanguinating vascular injuries. Multi-institutional prospective analysis is needed to potentially elucidate the cytoprotective effect of FFP to validate these results. LEVEL OF EVIDENCE: Therapeutic study, level IV; diagnostic study, level III.

Low-volume resuscitation for severe intraoperative hemorrhage: a step in the right direction.

The impact on outcomes resulting from crystalloids used with hemostatic close ratio resuscitation (HCRR) in intraoperative hemorrhage (IOH) has not been analyzed. We hypothesize a survival advantage in patients with IOH managed with a low-volume resuscitation (LVR) protocol during HCRR. A 4-year case-control study was conducted to determine the impact on mortality of LVR versus conventional resuscitation efforts (CRE) during HCRR. A total of 45 patients managed with a HCRR + LVR protocol (combination Hextend® and 3% hypertonic saline) and 55 historical cohorts managed with HCRR + CRE (lactated Ringer's) were included. Patient demographics, number of intraoperative units of packed red blood cells (PRBCs) and fresh-frozen plasma (FFP) received, and FFP:PRBC ratio were similar between groups. The mean intraoperative fluid volume was 0.76 L in the HCRR + LVR group versus 4.7 L in the HCRR + CRE group (P = 0.003). In a linear regression model HCRR + LVR versus HCRR + CRE, mean trauma intensive care unit length of stay was 6 versus 11 days (P = 0.009); 30-day overall mortality was 11.1 versus 32.7 per cent (P = 0.009); perioperative mortality was 2.2 to 10.9 per cent (P = 0.13); and intensive care unit mortality 8.8 to 21.8 per cent (P = 0.07). LVR protocol conveyed a survival benefit to patients undergoing HCRR (odds ratio for mortality, 0.07 [95% confidence interval 0.07-0.54]). This is the first civilian study to analyze the impact of LVR in patients managed with HCRR during IOH. Patients with IOH managed with HCRR and a predefined LVR protocol with Hextend® and 3 per cent hypertonic saline had an overall survival advantage and shorter trauma intensive care unit length of stay. LVR can be an effective alternative to CRE when used in combination with HCRR in patients with IOH.

Restrictive fluid resuscitation in combination with damage control resuscitation: time for adaptation.

BACKGROUND: Damage control resuscitation (DCR) conveys a survival advantage in patients with severe hemorrhage. The role of restrictive fluid resuscitation (RFR) when used in combination with DCR has not been elucidated. We hypothesize that RFR, when used with DCR, conveys an overall survival benefit for patients with severe hemorrhage. METHODS: This is a retrospective analysis from January 2007 to May 2011 at a Level I trauma center. Inclusion criteria included penetrating torso injuries, systolic blood pressure less than or equal to 90 mm Hg, and managed with DCR and damage control surgery (DCS). There were two groups according to the quantity of fluid before DCS: (1) standard fluid resuscitation (SFR) greater than or equal to 150 mL of crystalloid; (2) RFR less than 150 mL of crystalloid. Demographics and outcomes were analyzed. RESULTS: Three hundred seven patients were included. Before DCS, 132 (43%) received less than 150 mL of crystalloids, grouped under RFR; and 175 (57%) received greater than or equal to 150 mL of crystalloids, grouped under SFR. Demographics and initial clinical characteristics were similar between the study groups. Compared with the SFR group, RFR patients received less fluid preoperatively (129 mL vs. 2,757 mL; p < 0.001), exhibited a lower intraoperative mortality (9% vs. 32%; p < 0.001), and had a shorter hospital length of stay (13 vs. 18 days; p = 0.02). Patients in the SFR group had a lower trauma intensive care unit mortality (5 vs. 12%; p = 0.03) but exhibited a higher overall mortality. Patients receiving RFR demonstrated a survival benefit, with an odds ratio for mortality of 0.69 (95% confidence interval, 0.37-0.91). CONCLUSION: To the best of our knowledge, this is the first civilian study that analyzes the impact of RFR in patients managed with DCR. Its use in conjunction with DCR for hypotensive trauma patients with penetrating injuries to the torso conveys an overall and early intraoperative survival benefit. LEVEL OF EVIDENCE: Therapeutic study, level IV.

The state of trauma care in Louisiana--impediments and opportunities: a survey of the state's surgeons.

Trauma is the leading cause of death in persons under 45 years of age. A looming physician shortage, comparatively high rates of injury in the state, and the high cost of caring for the injured has raised the question of how to best deal with this problem in Louisiana. A 37-question survey was sent to all 324 Louisiana members of the American College of Surgeons. The survey assessed characteristics of surgeons, the hospitals and their resources, and perceived impediments to trauma care. Seventy-three percent of responders provide trauma coverage to their hospitals. Ninety percent of hospitals have a blood bank; only 27.4% had 24-hour operating room availability. Most hospitals had adequate subspecialty availability. Major deterrents to trauma coverage that were identified were no control of schedule, no repayment for care, and interruption of a surgeon's elective schedule. Eighty-six percent of responders agreed the state should implement a statewide network. More than 90% said tertiary trauma centers should be in New Orleans, Shreveport, and Baton Rouge to provide trauma care. Louisiana has a surgical workforce trained and capable of trauma care. Impediments to surgeon involvement revolve upon reimbursement and interruption of elective practice. An organized trauma system will help triage critically ill patients to appropriate trauma centers for improved care by appropriate surgeons.

Damage control resuscitation in combination with damage control laparotomy: a survival advantage.

BACKGROUND: Damage control laparotomy (DCL) improves outcomes when used in patients with severe hemorrhage. Correction of coagulopathy with close ratio resuscitation while limiting crystalloid forms a new methodology known as damage control resuscitation (DCR). We hypothesize a survival advantage in DCL patients managed with DCR when compared with DCL patients managed with conventional resuscitation efforts (CRE). METHODS: This study is a 4-year retrospective study of all DCL patients who required >or=10 units of packed red blood cells (PRBC) during surgery. A 2-year period after institution of DCR (DCL and DCR) was compared with the preceding 2 years (DCL and CRE). Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression. RESULTS: One Hundred twenty-four and 72 patients were managed during the DCL and CRE and DCL and DCR time periods, respectively. Baseline patient characteristics of age, Injury Severity Score, % penetrating, blood pressure, hemoglobin, base deficit, and INR were similar between groups. There was no difference in quantity of intraoperative PRBC utilization between DCL and CRE and DCL and DCR study periods: 21.7 units versus 25.5 units (p = 0.53); however, when compared with DCL and CRE group, patients in the DCL and DCR group received less intraoperative crystalloids, 4.7 L versus 14.2 L (p = 0.009); more fresh frozen plasma (FFP), 18.2 versus 6.4 (p = 0.002); a closer FFP to PRBC ratio, 1 to 1.2 versus 1 to 4.2 (p = 0.002); platelets to PRBC ratio, 1:2.3 versus 1:5.9 (0.002); shorter mean trauma intensive care unit length of stay, 11 days versus 20 days (p = 0.01); and greater 30-day survival, 73.6% versus 54.8% (p < 0.009). The addition of DCR to DCL conveyed a survival benefit (odds ratio; 95% confidence interval: 0.19 (0.05-0.33), p = 0.005). CONCLUSION: This is the first civilian study that analyses the impact of DCR in patients managed with DCL. During the DCL and DCR study period more PRBC, FFP, and platelets with less crystalloid solution was used intraoperatively. DCL and DCR were associated with a survival advantage and shorter trauma intensive care unit length of stay in patients with severe hemorrhage when compared with DCL and CRE.

Alcohol abuse and illegal drug use among Los Angeles County trauma patients: prevalence and evaluation of single item screener.

BACKGROUND: The misuse of alcohol and illicit drugs is implicated with injury and repeat injury. Admission to a trauma center provides an opportunity to identify patients with substance use problems and initiate intervention and prevention strategies. To facilitate the identification of trauma patients with substance use problems, we studied alcohol abuse and illegal substance use patterns in a large cohort of urban trauma patients, identified correlates of alcohol abuse, and assessed the utility of a single item binge-drinking screener for identifying patients with past 12-month substance use problems. METHODS: Between February 2004 and August 2006, 677 patients from four large trauma centers in Los Angeles County were interviewed. The sample was broadly representative of the entire Los Angeles County trauma center patient population. RESULTS: Twenty-four percent of patients met criteria for alcohol abuse and 15% reported using an illegal drug other than marijuana in the past 12 months. Male gender, assaultive injury, peritrauma substance use, and history of binge drinking were prominent risk factors. A single item binge drinking screen correctly identified alcohol abuse status in 76% of all patients; the screen also performed moderately well in discriminating between those who had or had not used illegal drugs in the past 12 months, with sensitivity estimates reaching 0.79 and specificity estimates reaching 0.74. CONCLUSIONS: A large proportion of urban trauma patients abuse alcohol and use illegal drugs. Distinct sociodemographic and substance use history may indicate underlying risky behaviors. Interventions and injury prevention programs need to address these causal behaviors to reduce injury morbidity and recidivism. In the busy trauma care setting, a one-item screener could be helpful in identifying patients who would benefit from more thorough assessment and possible brief intervention.

Serum levels of calcium and albumin in survivors versus nonsurvivors after critical injury.

PURPOSE: Injured patients who require aggressive resuscitation with intravenous (IV) fluids and blood products will frequently acquire low levels of serum calcium (CA) and albumin (ALB) in the intensive care unit (ICU) as result of this therapy. The purpose of this longitudinal study was to determine the time course of CA and ALB during ICU admission in survivors (S) compared to nonsurvivors (N) after major trauma. The study design is to verify if CA, ALB, or albumin-corrected CA can be used as indicators of patient survivability after critical injury. MATERIALS AND METHODS: CA and ALB values were retrospectively recorded in 64 random subjects (S= 32 and N= 32) admitted to the Trauma ICU for 3 or more days. CA and ALB data points were partitioned into 6 time frames of ICU care. Mean values and standard error of the mean for each frame were obtained to depict parametric differences in the time profiles for S versus N. Subgroup analysis was used to determine the impact of blood transfusions on CA and ALB levels. Albumin-corrected CA was computed for every patient at each measurement point and then partitioned into the 6 time frames of ICU care. Parametric t-test and nonparametric rank sum analysis were used to evaluate the ability of CA, ALB, and ALB-corrected CA at discriminating S from N. Each predictive covariate was ranked, divided into quartiles (grades = normal, mild, moderate, severe), and correlated with patient survival likelihood (viz., ratio of S to N in each quartile). RESULTS: Parametric and non-parametric analysis of collected data indicates that the response patterns of CA were significantly different ( P<.00005 ) in S versus N. Time profiles of CA and ALB exhibited similar reductions in both S and N during the resuscitation phase (ie, "hypocalcemia of trauma"). But from these nadir points, CA response patterns in S tended to steadily elevate toward normal levels (ie, "responders"), while N exhibited no such increase in CA values (ie, "nonresponders"). Data revealed that survival likelihood in trauma patients after 3 ICU days is proportional to the upward response of CA from depressed values present after the initial resuscitation. Decreased CA levels after 3 ICU days were associated with decreased survival (Table 1). Rank sum testing showed that values of CA corrected for ALB creates less obvious difference in S and N than uncorrected CA. Subgroup analysis showed a linear decrease in CA and ALB levels with increasing units of blood transfused during treatment for trauma. CONCLUSIONS: CA changes during ICU care demonstrate distinct response patterns (P <.00005) for survivors versus nonsurvivors. The magnitude of upward response in CA after the fluid resuscitation phase is a marker that correlates with a patient's ability to withstand the physiologic stresses encountered during ICU treatment after major trauma. Our findings indicate that uncorrected CA values are a better guide for calcium replacement therapy in trauma patients than albumin-adjusted CA. This study suggests that response patterns of CA can be a useful reference to aid in monitoring the progress of critically injured patients.