Unexpected findings in trauma patients dying in the intensive care unit: results of 153 consecutive autopsies.

BACKGROUND: The true incidence of missed injuries in trauma-related deaths is unknown, because in only about 60% of injury-related deaths nationwide is an autopsy performed. Few studies have documented the frequency of missed diagnoses leading to deaths specifically in the trauma ICU population. We attempted to evaluate the incidence and nature of missed injuries and complications in trauma- and burn-related deaths in our ICU given an autopsy rate of close to 100%. STUDY DESIGN: The medical records of all trauma- and burn-related deaths in the ICU over a 2-year period were reviewed retrospectively. Missed diagnoses were classified as class 1: major diagnosis that if recognized and treated appropriately might have changed outcomes; class II: major diagnosis that if recognized and treated appropriately would not have changed outcomes; and class III: minor diagnosis. RESULTS: Complete antemortem records were available for 158 patients, of which 153 (97%) underwent autopsy. Mean age was 50 years, and 72% were males. Mean ICU stay was 10 15 days. Four (3%) patients had class I missed diagnoses: bowel infarction, meningitis, retroperitoneal abscess, and bleeding gastric ulcer. Twenty-five (16%) patients had class II diagnoses, and 12 (8%) patients had class III diagnoses. Overall, 81% of 153 patients had either class III diagnoses or no missed injuries or complications. Pneumonia was the most common missed diagnosis. CONCLUSIONS: With an autopsy rate of 97%, 3% of deaths bad missed major diagnoses that might have affected outcomes if recognized antemortem. Autopsy findings can still provide valuable feedback in Improving the quality of care of critically ill trauma patients.

The development of a method to measure head acceleration and motion in high-impact crashes.

OBJECTIVE: To establish a mechanism to obtain precise measurements of the accelerations of the head in the high-speed racing environment and during crash impacts. The long-term goal is to apply this system to the assessment of head injury in automobile racing drivers and then in participants in other helmeted sports. METHODS: A multidisciplinary team conceptualized, designed, and successfully tested a triaxial accelerometer system capable of measuring head acceleration and motion in high-impact crashes. The system has been implemented successfully in the professional racing environment. RESULTS: Accurate and reproducible data have been obtained from the accelerometer system in tests on manikins and cadavers and in actual racing events. The system has been implemented in two professional racing series in 2003. Information gained from the accelerometer system is currently being entered into a database. Eventually, the data should aid in the development of improved cockpit head protection in racing cars. Improved helmet design not only in motor sports but also in other helmeted sports should benefit from the data collected. These data will also aid the development of improved head injury protection in military aircraft and passenger vehicles. CONCLUSION: Although there has been a significant decrease in the overall rate of injury during the past 25 years, head injury remains a serious safety concern in motor sports and the greatest cause of death. Sports-related head injuries are also of great concern because repeated mild head injury has become an important health issue with potential long-term disability. True human tolerance to brain injury has yet to be established. Our scientific knowledge of brain injury is currently based on results derived from manikin, cadaver, and human volunteer testing, along with animal and computer models. The racing environment represents a venue to ethically measure and evaluate the forces involved in human brain injury.

Oral creatine supplementation enhances upper extremity work capacity in persons with cervical-level spinal cord injury.

OBJECTIVE: To examine the effects of short-term creatine monohydrate supplementation on the upper extremity work capacity of persons with cervical-level spinal cord injury (SCI). DESIGN: Randomized, double-blind, placebo-controlled, crossover design study. Consists of 2 treatment phases lasting for 7 days, separated by a 21-day washout period. SETTING: University research laboratory trial. PARTICIPANTS: Sixteen men with complete cervical-level SCI (C5-7). INTERVENTION: Subjects were randomly assigned to 1 of 2 groups and received either 20g/d of creatine monohydrate supplement powder or placebo maltodextrin powder for the first treatment phase; the treatment was reversed in the second phase. Incremental peak arm ergometry tests, using 2-minute work stages and 1-minute recovery periods, were performed immediately before and after each treatment phase (total of 4 assessments). The initial stage was performed unloaded, with power output progressively increased 10 watts/stage until subjects had achieved volitional exhaustion. MAIN OUTCOME MEASURES: Peak power output, time to fatigue, heart rate, and metabolic measurements, including oxygen uptake (VO2), minute ventilation, tidal volume (VT), and respiration frequency. RESULTS: Significantly greater values of VO2, VCO2, and VT at peak effort after creatine supplementation (P <.001). CONCLUSIONS: Creatine supplementation enhances the exercise capacity in persons with complete cervical-level SCI and may promote greater exercise training benefits.