Modified Need for Trauma Intervention Criteria Reduces Cribari Trauma Overtriage Rate.

INTRODUCTION: The American College of Surgeons Committee on Trauma (ACS-CoT) sets standards for appropriate trauma activation criteria. Overtriage and undertriage rates are traditionally determined by the Cribari matrix using the Injury Severity Score (ISS). In 2016, the Need for Trauma Intervention (NFTI) criteria were developed by Baylor University Medical Center to overcome weaknesses in the Cribari matrix methodology. METHODS: A retrospective review of trauma triage rates was conducted from March 2018 to February 2019. Overtriage rates were calculated using the Cribari matrix and then further evaluated using modified NFTI (MNFTI) criteria. Overtriaged patients meeting MNFTI criteria were considered appropriately triaged and deleted from the overtriage category, and adjusted triage rates were determined. Demographic, injury, and outcome data were compared between MNFTI-positive and MNFTI-negative groups. A logistic regression analysis was performed to assess for predictors of patient mortality. RESULTS: Using the Cribari matrix, 248 patients were identified as overtriaged. Of these, 133 (53.6%) were found to meet MNFTI criteria. The average monthly overtriage rate was reduced from 55% using the Cribari matrix to 26% after applying the MNFTI criteria. Within the Cribari overtriage patient group, MNFTI-positive patients had significantly longer hospital length of stay (LOS) (3.7 vs. 6.0 days, p = .016), intensive care unit LOS (1.2 vs. 4.2 days, p < .001), and ventilator days (0.6 vs. 1.6 days, p = .002) than MNFTI-negative patients. A multivariable logistic regression analysis found that meeting any of the MNFTI criteria significantly increased the odds of mortality (OR = 10.38; 95% CI [3.87, 27.84], p < .001). CONCLUSIONS: Discharge ISS may not accurately reflect the patient's acuity on presentation. Applying MNFTI criteria to the Cribari matrix improved overtriage rates and may more accurately reflect need for full trauma team activation. Patients meeting MNFTI criteria had worse outcomes overall and had a 10-fold increase in the odds of mortality.

Gold Medal Forum Winner. Unfractionated heparin three times a day versus enoxaparin in the prevention of deep vein thrombosis in trauma patients.

Venous thromboembolic disease is a significant source of morbidity and mortality in hospitalized trauma patients. Multiple drugs and dosing regimens have been suggested for pharmacoprophylaxis. In this study, we compared efficacy, complications, and cost of unfractionated heparin administered subcutaneously three times a day with standard-dosed enoxaparin for prophylaxis of deep venous thrombosis (DVT) in adult trauma patients over 1 year. Patients admitted for greater than 72 hours who received pharmacoprophylaxis as part of a comprehensive DVT protocol were included. A change was made in the protocol from enoxaparin (30 mg twice a day or 40 mg per day) to heparin (5000 U three times a day) at midyear. Surveillance lower extremity venous ultrasound was performed according to established institutional guidelines. Data, including demographics, associated injuries, complications, and cost, were collected and analyzed. Four hundred seventy-six patients met inclusion criteria. Two hundred thirty-seven (49.8%) patients received enoxaparin and 239 (50.2%) received heparin. Proximal lower extremity DVTs were detected in 16 (6.75%) patients in the enoxaparin group and 17 (7.11%) in the heparin group (P = 0.999). Risk factors for DVT in these patients included spinal cord injury (P = 0.001) and closed head injury (P = 0.031). There was no difference between the incidence of pulmonary emboli and bleeding. There was an estimated yearly pharmacy cost savings of $135,606. In trauma patients, subcutaneous heparin dosed three times a day may be as effective as standard-dosed enoxaparin for prophylaxis of venous thromboembolism without increased complications. Heparin three times a day for venous thromboembolism prophylaxis was associated with significant pharmaceutical cost savings.

A randomized prospective trial of airway pressure release ventilation and low tidal volume ventilation in adult trauma patients with acute respiratory failure.

BACKGROUND: Airway pressure release ventilation (APRV) is a mode of mechanical ventilation, which has demonstrated potential benefits in trauma patients. We therefore sought to compare relevant pulmonary data and safety outcomes of this modality to the recommendations of the Adult Respiratory Distress Syndrome Network. METHODS: Patients admitted after traumatic injury requiring mechanical ventilation were randomized under a 72-hour waiver of consent to a respiratory protocol for APRV or low tidal volume ventilation (LOVT). Data were collected regarding demographics, Injury Severity Score, oxygenation, ventilation, airway pressure, failure of modality, tracheostomy, ventilator-associated pneumonia, ventilator days, length of stay (LOS), pneumothorax, and mortality. RESULTS: Sixty-three patients were enrolled during a 21-month period ending in February 2006. Thirty-one patients were assigned to APRV and 32 to LOVT. Patients were well matched for demographic variables with no differences between groups. Mean Acute Physiology and Chronic Health Evaluation II score was higher for APRV than LOVT (20.5 ± 5.35 vs. 16.9 ± 7.17) with a p value = 0.027. Outcome variables showed no differences between APRV and LOVT for ventilator days (10.49 days ± 7.23 days vs. 8.00 days ± 4.01 days), ICU LOS (16.47 days ± 12.83 days vs. 14.18 days ± 13.26 days), pneumothorax (0% vs. 3.1%), ventilator-associated pneumonia per patient (1.00 ± 0.86 vs. 0.56 ± 0.67), percent receiving tracheostomy (61.3% vs. 65.6%), percent failure of modality (12.9% vs. 15.6%), or percent mortality (6.45% vs. 6.25%). CONCLUSIONS: For patients sustaining significant trauma requiring mechanical ventilation for greater than 72 hours, APRV seems to have a similar safety profile as the LOVT. Trends for APRV patients to have increased ventilator days, ICU LOS, and ventilator-associated pneumonia may be explained by initial worse physiologic derangement demonstrated by higher Acute Physiology and Chronic Health Evaluation II scores.

Intraoperative Resuscitation by Specialized Trauma Nurse Clinicians Improves Adherence to Massive Transfusion Protocol.

A massive transfusion protocol (MTP) was implemented at a Level I trauma center in 2007 for patients with massive blood loss. A goal ratio of plasma to pheresed platelets to packed red blood cells (PRBCs) of 1:1:1 was established. From 2007 to 2014, trauma nurse clinicians (TNCs) administered the MTP during initial resuscitation and anesthesia personnel administered the MTP intraoperatively. In 2015, TNCs began administering the MTP intraoperatively. This study evaluates intraoperative blood product ratios and crystalloid volume administered by anesthesia personnel or TNCs. A retrospective review of trauma registry patients requiring MTP from 2007 to 2017 was performed. Patient data were stratified according to MTP administration by either anesthesia personnel (2007-2015) or TNCs (2015-2017). Ninety-seven patients were included with 54 anesthesia patients and 44 TNC patients. Patients undergoing resuscitation by MTP administered by TNCs received less median crystalloid (3000 mL vs 1500 mL, P < 0.001). The ratio of plasma:PRBC (0.75 vs 0.93, P = 0.027) and platelets:PRBC (0.75 vs 1.04, P = 0.003) was found to be significantly closer to 1:1 for TNC patients. MTP intraoperative blood product administration by TNCs reduced the amount of infused crystalloid and improved adherence to MTP in achieving a 1:1:1 ratio of blood products.

Late Operative Rib Fixation is Inferior to Nonoperative Management.

BACKGROUND: Operative rib fixation (ORF) of traumatic rib fractures has been shown to decrease hospital length of stay (LOS), ventilator days, and mortality. ORF performed within 1 day of admission has been shown to have favorable outcomes compared to later ORF. This report examines the ORF experience over 10 years at a level I trauma center. METHODS: ORF patients from January 2007-January 2018 were matched to nonoperative controls in a 1:2 ratio based on age, injury severity score (ISS), chest Abbreviated Injury Score (AIS), and head AIS. Patient demographic, injury, and outcome data were collected from the trauma registry and medical records. Hospital day of ORF was identified for each ORF patient. Hospital LOS, ICU LOS, ventilator days, and mortality were compared against matched nonoperative controls. RESULTS: Ninety-five ORF patients were matched to 190 nonoperative patients. ORF patients had a higher number of rib fractures (9.6 vs 6.4, P < .001). ORF patients with short time to operation (0-2 days) had a shorter average hospital stay than those with delayed operations (11.8 vs 12.6 vs 13.4 vs 19.6 days, P = .003). ORF patients with operations performed 3-4 days and >6 days after admission also had statistically significant longer ICU LOS and ventilator days. Patient mortality was higher when ORF was performed after 6 days. DISCUSSION: Early ORF may improve pulmonary function, patient outcomes, and decrease LOS. Shifting practice toward early fixation may help further solidify the benefits of this procedure in the treatment of blunt chest trauma.

Methicillin-resistant Staphylococcus aureus in a trauma population: does colonization predict infection?

Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly responsible for infections in hospitalized patients. Patients colonized with MRSA appear to be at higher risk for subsequent MRSA infections than those who are not colonized. In this study, we determined MRSA colonization status of trauma patients at hospital admission and compared the incidence of subsequent MRSA infections between MRSA colonized and noncolonized patients. Collected data were entered into databases at a single, Level I trauma center over a 13-month period. Three hundred fifty-five adult trauma patients were screened for MRSA on admission to the trauma intensive care unit. The patients were categorized into two groups, those colonized with MRSA at admission and those who were not. Thirty-six of 355 patients (10.1%) were colonized. Of the 319 patients not colonized, 21 (6.6%) developed MRSA infections. Twelve of 36 (33.3%) colonized patients developed MRSA infections (P < 0.001). No differences in types of MRSA infections were found between the two groups. Colonized patients who developed MRSA infections had higher death rates, 22.2 versus 5.0 per cent (P < 0.001). Patients colonized with MRSA on admission may be at higher risk for developing MRSA infections during hospitalization. MRSA screening protocols should be used to identify these at-risk patients.

Adrenal suppression following a single dose of etomidate for rapid sequence induction: a prospective randomized study.

BACKGROUND: The administration of etomidate for rapid sequence induction (RSI) has been linked to subsequent adrenocortical insufficiency in nontrauma patients. However, etomidate-related adrenocortical insufficiency has not been well studied in the trauma population. PURPOSE: We performed a prospective, randomized, controlled study to assess the effect of one dose of etomidate for RSI on adrenal function and its clinical significance during and after resuscitation in trauma patients. METHODS: Adult trauma patients admitted to our Level I trauma center requiring RSI were randomized to receive etomidate 0.3 mg/kg and succinylcholine 1 mg/kg (E group) or fentanyl 100 microg, midazolam 5 mg, and succinylcholine 1 mg/kg (FM group) for induction. A baseline serum cortisol level was drawn before RSI. Four to six hours after RSI, a postintubation serum cortisol level was drawn. An ACTH stimulation test was performed. RESULTS: Thirty patients were enrolled: 18 E group patients and 12 FM group patients. No statistical difference was detected between the two groups with respect to age, injury severity score, and baseline serum cortisol. Mean serum cortisol levels were significantly lower in E group patients than in FM group patients 4 to 6 hours after intubation (18.2 vs. 27.8 mug/dL, p < 0.05). Change in serum cortisol between baseline and postintubation levels was different (-12.8 mg/dL +/- 9.6 microg/dL vs. 1.1 microg/dL +/- 7.6 microg/dL, p < 0.01). Patients in the E group had an average increase in cortisol after ACTH administration of 4.2 microg/dL +/- 4.9 microg/dL vs. 11.2 microg/dL +/- 6.1 microg/dL in the FM group, p < 0.001. Patients in the E group required longer ICU lengths of stay (mean, 6.3 days vs. 1.5 days, p < 0.05), more ventilator days (mean, 28 days vs. 17 days, p < 0.01), and longer hospital lengths of stay (mean, 11.6 days vs. 6.4 days, p < 0.01). CONCLUSIONS: The use of etomidate for RSI in trauma patients led to chemical evidence of adrenocortical insufficiency and may have contributed to increased hospital and ICU lengths of stay and increased ventilator days. Further studies should be considered to evaluate the safety profile of this drug in trauma patients.

Experience with vacuum-pack temporary abdominal wound closure in 258 trauma and general and vascular surgical patients.

BACKGROUND: Temporary closure of an open abdominal wound by vacuum-pack is the method of choice for patients requiring open abdomen management in our institution. We have previously reported our experience with a vacuum-pack in trauma patients and have expanded its use to general and vascular surgery patients. STUDY DESIGN: This is a descriptive study performed through review of medical records of all patients undergoing vacuum-pack closure after celiotomy from January 1999 to May 2006. Clinical and demographic data were collected. RESULTS: Seven hundred seventeen vacuum-pack closures were performed in 258 surgical patients (116 trauma versus 142 general and vascular surgery). The most common indication for open abdomen management was damage control in trauma patients and planned reexploration in general and vascular surgery patients. Total abdominal complication rate was 15.5% (14.7% trauma versus 16.2% general and vascular surgery). Fistulas occurred in 13 (5%), intraabdominal abscesses in 9 (3.5%), bowel obstruction in 3 (1.2%), abdominal compartment syndrome in 3 (1.2%), and evisceration in 1 (0.4%). Two hundred twenty-six patients survived to permanent abdominal wound closure. Of these, 154 (68.1%) patients underwent primary fascial closure of their abdominal wounds. Seventy-two patients (31.9%) required delayed closure. In-hospital mortality rate was 26.0% (25.9% trauma versus 26.1% general and vascular surgery). The cost of vacuum-pack materials is less than $50. CONCLUSIONS: Indication for open abdomen management varied between general and vascular surgery and trauma patients. Complication rates were similar. Primary closure of open abdominal wounds was achieved in 68.4% of patients. Vacuum-pack temporary abdominal wound closure, initially used in trauma patients, continues to demonstrate ease of mastery, effectiveness in patient care and comfort, consistently low associated complication rate, and low cost in both general and vascular surgery and trauma patients.

Methicillin-Resistant Staphylococcus aureus in a Trauma Population: Does Decolonization Prevent Infection?

The purpose of this study was to determine if a decolonization regimen reduces the frequency of methicillin-resistant Staphylococcus aureus (MRSA) infections and if colonization isolates are genetically related to subsequent infectious strains. Trauma patients admitted to the intensive care unit with positive MRSA nasal swabs were randomized to either daily chlorhexidine gluconate (CHG) baths and mupirocin (MUP) ointment to the nares or soap and water baths and placebo ointment for five days. Nasal swabs performed at the end of treatment and invasive MRSA infections during the remaining hospitalization were compared with the original nasal isolate via polymerase chain reaction for genetic relatedness as well as CHG and MUP resistance genes. Six hundred and seventy-eight intensive care unit admissions were screened, and 92 (13.6%) had positive (+) MRSA nasal swabs over a 22-month period ending in 3/2014. After the five day treatment period, there were 13 (59.1%) +MRSA second nasal swabs for CHG + MUP and 9 (90%) for soap and water baths and placebo, P = 0.114. No isolates tested positive for the MUP or CHG resistance genes mupA and qacA/B but 7 of 20 (35%) contained smr. There were seven (31.8%) MRSA infections in the CHG group and six (60%) for soap, P = 0.244. All 13 patients with MRSA infections had the same MRSA isolate present in the original nasal swab. There was no difference in all-cause Gram-negative or positive infections for CHG versus soap, 12 (54.5%) versus 7 (70%), P = 0.467. CHG + MUP are ineffective in eradicating MRSA from the anterior nares but may reduce the incidence of infection. Subsequent invasive MRSA infections are typically caused by the endogenous colonization strain.

Trauma nurse specialists' performance of advanced skills positively impacts surgical residency time constraints.

The Accreditation Council for Graduate Medical Education imposed 80-hour work week constraints on residency programs in July 2003. Certain programs were granted an additional 10 per cent for specific educational purposes, bringing restrictions to 88 hours per week. The increased demand for residents to leave the hospital has placed teaching institutions in exhaustive situations to provide comprehensive patient care. In response to the work hour constraints among residents and emergency room staff, a unique group of registered nurses, trauma nurse specialists (TNSs), were credentialed with advanced practice skill sets. Governed by practice guidelines and overseen by a medical director, TNSs perform invasive procedures that are normally the responsibility of the surgical resident. The purpose of this study was to evaluate work hours saved for surgery residents using credentialed nurses (TNSs). Procedure logs were maintained by the TNSs over a 6-month period, and surgical house staff (postgraduate year 1-3) over a 4-month period. A total of 423 procedures were recorded, reflecting time taken for attempted/completed procedures and complications. Resident procedures numbered 98; TNS procedures numbered 325. TNSs spent an average of 42 hours per month (10.6 hours per week) completing advanced procedures with no statistical difference in time or complications compared with surgical residents. By using the TNSs, work hours for surgery residents were saved while maintaining a safe and reliable work atmosphere for patients.

A comparison of continuous renal replacement therapy to intermittent dialysis in the management of renal insufficiency in the acutely III surgical patient.

Acute renal failure (ARF) occurs in 10 per cent to 23 per cent of intensive care unit patients with mortality ranging from 50 per cent to 90 per cent. ARF is characterized by an acute decline in renal function as measured by urine output (UOP), serum creatinine, and blood urea nitrogen (BUN). Causes may be prerenal, intrarenal, or postrenal. Treatment consists of renal replacement therapy (RRT), either intermittent (ID) or continuous (CRRT). Indications for initiation of dialysis include oliguria, acidemia, azotemia, hyperkalemia, uremic complications, or significant edema. Overall, the literature comparing CRRT to ID is poor. No studies of only surgical/trauma patients have been published. We hypothesize that renal function and hemodynamic stability in trauma/ surgical critical care patients are better preserved by CRRT than by ID. We performed a retrospective review of trauma/surgical critical care patients requiring renal supportive therapy. Thirty patients received CRRT and 27 patients received ID. The study was controlled for severity of illness and demographics. Outcomes assessed were survival, renal function, acid-base balance, hemodynamic stability, and oxygenation/ventilation parameters. Populations were similar across demographics and severity of illness. Renal function, measured by creatinine clearance, was statistically greater with CRRT (P = 0.035). There was better control of azotemia with CRRT: BUN was lower (P = 0.000) and creatinine was lower (P = 0.000). Mean arterial blood pressure was greater (P = 0.021) with CRRT. No difference in oxygenation/ventilation parameters or pH was found between groups. CRRT results in an enhancement of renal function with improved creatinine clearance at the time of dialysis discontinuation. CRRT provides better control of azotemia while preserving hemodynamic stability in patients undergoing renal replacement therapy. Prospective randomized controlled studies and larger sample sizes are needed to further evaluate these modalities.

The impact of pelvic and lower extremity fractures on the incidence of lower extremity deep vein thrombosis in high-risk trauma patients. Winner of the Best Paper Award from the Gold Medal Forum.

Lower extremity fractures (LEFx) and pelvic fractures (PFx) are believed to increase the risk of lower extremity deep vein thrombosis (LEDVT). We studied trauma patients at high risk for LEDVT to determine whether an increased incidence of LEDVT was associated with LEFx and/or PFx. From January 1995 through December 1997 4163 trauma patients were admitted to our Level I trauma center. One thousand ninety-three patients at high risk for LEDVT were screened with serial lower extremity venous duplex ultrasound. Their medical records were retrospectively reviewed for demographics, mechanism of injury, and fracture data. The occurrence of LEDVT, pulmonary embolus, and LEDVT prophylaxis and treatment were noted. The incidence of LEDVT in the fracture group (Fx) was compared with that in the nonfracture group (NFx) using chi-square analysis and logistic regression. Statistical significance was set at < or = 0.05. Complete data were available for 1059 of 1093 patients. Five hundred sixty-nine (53.73%) patients had PFx and/or LEFx, 151 (14.26%) patients had PFx only, 317 (29.3%) patients had LEFx only, and 101 (9.54%) patients had both PFx and LEFx. Four hundred ninety (46.27%) patients had NFx. In 1059 patients LEDVT was detected in 125 (11.8%). Sixty-three patients in the Fx groups developed LEDVT (50.4%): 19 (15.2%) PFx patients, 15 (12.0%) PFx/LEFx patients, and 29 (23.2%) LEFx patients. Sixty-two (49.6%) NFx patients developed LEDVT. LEDVT incidence was not significantly different between the Fx and NFx groups or among the PFx, LEFx, and PFx/LEFx groups (P = 0.317). Nine patients developed pulmonary embolism: four NFx patients, two LEFx patients, two PFx patients, and one PFx/LEFx patient. Significant predictors of LEDVT were age and hospital length of stay. Mean age in patients with LEDVT was 47.58 years and in patients without LEDVT it was 40.89 years (P < 0.001). Mean hospital length of stay in patients with LEDVT was 29.81 days and in patients without LEDVT it was 16.84 days. The power of this study to detect differences representing medium effect sizes was greater than 90 per cent. We conclude that LEFx and/or PFx was not associated with an increased incidence of LEDVT in trauma patients at high risk for LEDVT. Lower extremity venous duplex ultrasound needs to be performed in both Fx and NFx groups to detect LEDVTs.

Errors in administrative-reported ventilator-associated pneumonia rates: are never events really so?

Ventilator-associated pneumonia (VAP) is a common problem in an intensive care unit (ICU), although the incidence is not well established. This study aims to compare the VAP incidence as determined by the treating surgical intensivist with that detected by the hospital Infection Control Service (ICS). Trauma and surgical patients admitted to the surgical critical care service were prospectively evaluated for VAP during a 5-month time period. Collected data included the surgical intensivist's clinical VAP (SIS-VAP) assessment using Centers for Disease Control and Prevention (CDC) VAP criteria. As part of the hospital's VAP surveillance program, these patients' medical records were also reviewed by the ICS for VAP (ICS-VAP) using the same CDC VAP criteria. All patients suspected of having VAP underwent bronchioalveolar lavage (BAL). The SIS-VAP and ICS-VAP were then compared with BAL-VAP. Three hundred twenty-nine patients were admitted to the ICU during the study period. One hundred thirty-three were intubated longer than 48 hours and comprised our study population. Sixty-two patients underwent BAL evaluation for the presence of VAP on 89 occasions. SIS-VAP was diagnosed in 38 (28.5%) patients. ICS-VAP was identified in 11 (8.3%) patients (P < 0.001). The incidence of VAP by BAL criteria was 23.3 per cent. When compared with BAL, SIS-VAP had 61.3 per cent sensitivity and ICS-VAP had 29 per cent sensitivity. VAP rates reported by hospital administrative sources are significantly less accurate than physician-reported rates and dramatically underestimate the incidence of VAP. Proclaiming VAP as a never event for critically ill for surgical and trauma patients appears to be a fallacy.

Scheduled repeat CT scanning for traumatic brain injury remains important in assessing head injury progression.

BACKGROUND: Scheduled repeat brain CT (SRBCT) is used to monitor progression of traumatic brain injury (TBI). Previous studies have suggested that routine SRBCT can be replaced by an unscheduled repeat brain CT after deterioration on serial neurological examination. In this study, we evaluated if SRBCT has a role in the management of TBI. STUDY DESIGN: Retrospective observational study of 1,019 consecutive adult patients admitted to a Level I trauma center with CT evidence of TBI on initial brain CT (IBCT). All patients with intracranial pathology on IBCT were scheduled for SRBCT and underwent sequential neurological physical examinations. Interventions (surgical or medical) after IBCT, SRBCT, or neurological change were recorded. RESULTS: One thousand nineteen patients with IBCT evidence of TBI were identified from the trauma registry during a 50-month study period beginning in November 2001. Eighty-six (8.9%) of these patients went directly for craniotomy. After exclusions, 887 patients were analyzed. A total of 692 (78%) patients had a no worse first SRBCT and neurologic changes requiring intervention later developed in 11 (1.6%) of these patients. One hundred ninety-five (22%) patients had a worse first SRBCT, with 14 (7.2%) requiring immediate intervention. Seven (3.6%) worse first SRBCT patients had a subsequent SRBCT that worsened, leading to an intervention. A neurologic change that precipitated an intervention developed subsequently in an additional 19 (9.7%) patients with a worse first SRBCT. Chi-square analysis demonstrated that a first SRBCT that was worse was more likely to result in an intervention than if the first SRBCT was no worse. CONCLUSIONS: A worse SRBCT is more likely to result in neurologic intervention. SRBCT remains useful in assessing patients with TBI.

Prospective evaluation of a critical care pathway for clearance of the cervical spine using the bolster and active range-of-motion flexion/extension techniques.

BACKGROUND: Clearance of the cervical spine after blunt trauma remains controversial in patients with normal radiologic evaluation. METHODS: Blunt trauma patients with midline boney cervical tenderness and plain films that disclose no abnormalities and computed tomography (CT) scans were entered into a care pathway for spinal clearance using the Bolster or active range-of-motion (AROM) flexion/extension techniques. The quality of films between the two techniques was then compared. RESULTS: In all, 159 patients entered the pathway with 14 patients (9%) unable to complete the examination secondary to pain. The Bolster was used in 129 patients (89%) and AROM was used in 16 (11%). The total range of motion was significantly better with AROM at 51.4 +/- 19.4 degrees of motion compared with 32.0 +/- 13.0 degrees with the Bolster (p < or = 0.05). The most distal level visualized was not different between groups with 6.6 +/- 0.8 cervical vertebrae visualized on average in the Bolster group and 6.8 +/- 0.7 in the AROM group. Positive findings occurred in five patients (3.4%) in the Bolster group. CONCLUSION: The incidence of occult cervical injury in patients with boney cervical pain despite normal plain films and CT scans in this study was 3.4%. The AROM technique has better total range of motion than the Bolster, although results of the Bolster technique remain within acceptable standards. The present care pathway appears to be an effective screening tool for evaluation of this population of patients. Additional evaluation of the obtunded patient is necessary before broad implementation of this technique.

Endovascular stent graft treatment of a traumatic aortocaval fistula.

Aortocaval fistula (ACF) is an infrequently reported sequela of trauma. Most ACF have been repaired via an open approach. During the past 10 years, there has been one reported case of spontaneous ACF and two cases of traumatic ACF repaired using an endovascular technique. We present a third case of traumatic ACF repaired with an endovascular stent graft. A 40-year-old male sustained two gunshot wounds to the right chest and one to the right upper abdomen. He was taken from the emergency department directly to the operating room, where an exploratory laparotomy was performed. Through-and-through injuries to the stomach and transverse colon were repaired primarily. Subsequently, the patient developed abdominal compartment syndrome. An urgent exploratory laparotomy was performed, revealing a nonbleeding hematoma on the posterior lateral surface of the right lobe of the liver, which was left undisturbed. Open abdominal management was instituted with vacuum pack closure. On the nineteenth hospital day, the patient again had a significant decrease in hematocrit. An aortogram was performed in order to evaluate the patient for intrahepatic arterial bleeding amenable to transcatheter embolization. There was no evidence of hepatic arterial bleeding. However, a supraceliac ACF was identified. The patient was taken to the operating room, and an AneuRx aortic extension cuff was advanced under fluoroscopy and deployed to cover the fistula. Completion angiography revealed total obliteration of the ACF and appropriate placement of the stent graft. Postoperatively, the patient was returned to the intensive care unit, where his hospital course was complicated by ventilator-associated pneumonia and sepsis. Repeat computed tomographic scanning 6 months and 1 year following this repair demonstrated patency of the graft without evidence of graft migration or aortocaval communication. Further research and experience are necessary with this technique regarding long-term outcome and technical aspects. In particular, the sizing problems associated with repair of acute traumatic ACF in emergency situations should be addressed. The endovascular approach provides an attractive and exciting alternative to traditional methods for repair of ACF.

Preliminary experience with airway pressure release ventilation in a trauma/surgical intensive care unit.

BACKGROUND: Airway pressure-release ventilation (APRV) is a pressure-limited, time-cycled mode of mechanical ventilation. The purpose of this study was to evaluate our initial experience with the use of APRV in acutely injured, ventilated patients. METHODS: Since March 2003, APRV has been used selectively in adult trauma patients with or at risk for acute lung injury/acute respiratory distress syndrome. Data were obtained before and during the 72 hours after switching to APRV. A retrospective analysis of these data was then performed. RESULTS: Complete data were available on 46 of 60 patients (77%) for the first 72 hours of APRV. Before APRV, the average Pao2/Fio2 ratio was 243 and the average peak airway pressure was 28 cm H2O. Peak airway pressure decreased 19% (p = 0.001), Pao2/Fio2 improved by 23% (p = 0.017) and release tidal volumes improved by 13% (p = 0.020) over the course of the analysis. CONCLUSION: APRV significantly improved oxygenation by alveolar recruitment and allowed for a reduction in peak airway pressures. This relatively new modality had favorable results and appears to be an effective alternative for lung recruitment in traumatically injured patients at risk for acute lung injury/acute respiratory distress syndrome.

Management of destructive bowel injury in the open abdomen.

BACKGROUND: Little attention has been focused on destructive injuries of the bowel in patients requiring open abdominal management. We therefore reviewed our institutional experience for destructive bowel injury requiring open abdominal management with the vacuum pack technique (vac). METHODS: The trauma registry at a Level I trauma center was used to identify patients sustaining destructive bowel injury for an 11-year period beginning in May 1990. Patients were assessed for pertinent clinical and demographic information, and individuals requiring open abdominal management were compared with those who did not. RESULTS: One hundred four patients required bowel resection and constitute the study population. Twenty-nine patients had vacs placed, with 22 (75.9%) of the total eventually obtaining delayed fascial closure. Nineteen (183%) patients had resection and primary repair (PR) of large and/or small bowel in conjunction with a vac, 10 (9.6%) patients had stoma formation in conjunction with a vac, 62 (59.6%) patients had resection and PR of small and/or large bowel in conjunction with primary fascial closure, and 13 (12.5%) patients had stoma formation and primary fascial closure. There were no differences in abdominal abscess or leak rates between groups. There were four deaths, none of which was secondary to failure of an anastomosis. CONCLUSION: Bowel resection with PR appears to be a safe alternative after destructive bowel injury and results in acceptable morbidity when performed in conjunction with open abdominal management.

A prospective assessment of diagnostic efficacy of blind protective bronchial brushings compared to bronchoscope-assisted lavage, bronchoscope-directed brushings, and blind endotracheal aspirates in ventilator-associated pneumonia.

BACKGROUND: The purpose of this study is to compare techniques for the diagnosis of suspected ventilator-associated pneumonia in the trauma patient. Per the literature, bronchoscope protected brushings and bronchoalveolar lavage were set as the standards for comparison because of their high specificity and sensitivity. We hypothesized that blind protected brushings were equivalent to bronchoscope-directed techniques and that endotracheal aspirates (ETA) were not. METHODS: With informed consent, 90 trauma patients with two or more of the following were accepted into the study: 48 hours or more on the ventilator, new or increasing infiltrate on chest radiograph, excess or purulent secretions, suspected aspiration, temperature of 38.5 degrees C or above, white blood cell count greater than or equal to 12,000/mm3, and respiratory distress. Four samplings were performed on each patient using bronchoscope-assisted and nonbronchoscopic techniques. Each patient had cultures obtained by and significances quantified as follows: ETA, moderate/many/abundant; bronchoscope-directed protected brushings (BDPB), 103 colony-forming units [CFU]/mL; blind protected brushing via endotracheal tube (BPB), 103 CFU/mL; and bronchoscopic bronchoalveolar lavage (BAL), 104 CFU/mL. Quantitative cultures were obtained and compared for the following pathogens: gram-positive cocci, gram-positive rods, gram-negative cocci, gram-negative rods, anaerobic bacteria, and yeast. An assessment of agreement for cultured pathogens between the sampling modalities was completed using kappa (kappa) analysis, and significance was set at p < or = 0.05. RESULTS: With patients used as their own controls, Gram's stain and pathogens cultured from the various sampling techniques were compared for agreement by kappa analysis. BDPB and BAL were set as the "gold standards" for comparison against each other and against the BPB and ETA. Kappa analysis was used to measure the strength of agreement for these findings; individual values from the comparisons of Gram's stain were then averaged for descriptive purposes of the data. Most kappa values were associated with a statistically significant value of p < 0.05. The greatest strength of agreement was found to be moderate comparing Gram's stain results of BPB and BDPB (kappa = 0.467), ETA and BAL (kappa = 0.535), and BPB and BAL (kappa = 0.547). Fair kappa values were shown in comparing Gram's stain results of ETA and BDPB (kappa = 0.382) and BAL and BDPB (kappa = 0.390). CONCLUSION: A quantitative analysis of bacteriologic cultures obtained by four standard sampling techniques has demonstrated with statistical significance that no difference exists between modality of sampling in reliability or in obtaining clinically significant pathogens. In reviewing the literature, this study is the first assessment of agreement for cultured pathogens between the four different sampling modalities and the largest to assess the efficacy of the blind protected brush technique.