Predictors of outcome in patients who have sustained trauma and who undergo emergency thoracotomy.

OBJECTIVE: To reassess the use of emergency thoracotomy in resuscitating victims of abdominal or thoracic trauma. DESIGN: Retrospective review of records and autopsy reports of patients who underwent an emergency thoracotomy between 1983 and 1989. SETTING: Washington Hospital Center's Level I trauma center. PATIENTS: Two hundred eighty-four hemodynamically unstable trauma patients (212 [75%] with penetrating injuries and 72 [25%] with blunt injuries). INTERVENTION: Emergency thoracotomy performed in the trauma operating room or in one of the trauma bays. MAIN OUTCOME MEASURES AND KEY FINDINGS: In which subset of trauma patients is emergency thoracotomy a useful therapeutic modality? Performance of an emergency thoracotomy for blunt trauma resulted in an overall survival rate of 6% compared with 27% for penetrating trauma. The survival rate for patients with penetrating cardiac trauma was 32% (44% for stab wounds and 21% for gunshot wounds). Tamponade is a major factor associated with survival in this subset of patients and may act as a pathophysiologic filter. CONCLUSIONS: Emergency thoracotomy is a useful therapeutic modality for victims of penetrating trauma who have vital signs on admission to the hospital, and it should be considered in blunt trauma patients who present with any evidence of life. This modality is largely ineffective, however, in resuscitating victims of penetrating and blunt trauma who present to the hospital without vital signs.

Epidemiologic changes in gunshot wounds in Washington, DC, 1983-1990.

The purpose of this study was to examine temporal patterns in gunshot wound admission rates and wound profiles from 1983 through 1990 at a level I trauma center in Washington, DC. Data on trauma admissions were collected at the time of admission. Records were reviewed to identify patients admitted for gunshot wounds from assaults. Data on the number and location of entrance gunshot wounds, survival, complications, length of stay in the intensive care unit, and total inpatient days were recorded. Admissions due to gunshot wounds grew at an exponential rate beginning in 1987 and reached a level from 1989 through 1990 three times higher than the preepidemic rate. The mean number of entrance gunshot wounds per patient grew from 1.44 before the epidemic to 2.04 from 1988 through 1990. Multiple thoracic wounds became relatively more common from 1988 through 1990. This increase was partially responsible for reversing a downward trend in patient mortality. Temporal changes in admission rates and wound profiles were consistent with the city's epidemic of drug-related violence and with a shift in weaponry toward high-capacity, semiautomatic handguns.

Improvement in outcome from trauma center care.

Survival and death outcomes for patients with blunt injuries treated at one urban hospital were evaluated during a 6-year period of increasing commitment to trauma care, as evidenced by the construction of a resuscitation facility with integrated operating rooms. Patient survival, when controlled for severity mix, showed a trend of improvement during the study period. Improvement in survival outcome was more notable after the opening of the trauma resuscitation facility and among the more severely injured. When data from years 1 and 2 combined were compared with those from years 5 and 6, a statistically significant difference in survival was found, with an average of 13.44 more survivors per 100 patients treated per year with Injury Severity Scores greater than 15.

A youth violence prevention program. Description and preliminary evaluation.

PROBLEM STATEMENT: In response to growing violence, primary prevention programs have been launched, but scientific rationale and credible evaluations have been lacking. METHODS: Fifth and seventh-grade students in three inner-city schools (n = 135) participated in a violence prevention program. Controls consisted of students from the same schools and grades during the following school year (n = 115). Students were taught social problem-solving skills and risk factors for violence. Multivariate analyses were performed on posttest measures while controlling for base-line differences. RESULTS: Program participants were much less likely to define social problems in adversarial ways, were less likely to provide violent solutions in hypothetical conflict situations, listed more negative consequences to using violence, and were less inclined to legitimatize violence. Risk factor knowledge also was significantly increased. No increase was shown in the students' abilities to identify viable nonviolent solutions. CONCLUSIONS: The program produced immediate influences on knowledge and some attitudes and social skills shown to be related to aggressive behavior.

Trauma in pregnancy. Predicting pregnancy outcome.

A multicenter study involving three American College of Surgeons Level 1 trauma centers was undertaken to assess parameters that may predict fetal outcome. The records of 93 injured pregnant patients admitted from April 1, 1985, to March 31, 1990, were reviewed. There were three maternal deaths (3%) (mean Injury Severity Score, 43). Fourteen fetal/neonatal deaths (15%) occurred during the acute care admission period. Of these, eight were fetal deaths (two associated with maternal death), four were cases of elective abortions, and two were neonatal deaths. In general, the maternal physiologic and laboratory parameters assessed failed to accurately predict pregnancy outcome, while Injury Severity Score did differ significantly between patients whose pregnancies were viable (Injury Severity Score = 6.2) and those whose pregnancies were nonviable (Injury Severity Score = 21.6). Unique to this study were the findings that the Glasgow Coma Score also differed significantly in patients with viable (Glasgow Coma Score, 14.5) and nonviable (Glasgow Coma Score, 12.0) pregnancies, while fetal heart rate at admission to the emergency department did not. In this study, the incidence of fetal death was increased following direct uteroplacental fetal injury (100% of cases), maternal shock (67%), pelvic fracture (57%), severe head injury (56%), and hypoxia (33%). The adequacy of noninvasive maternal monitoring in assessing fetal well-being is challenged, and a discussion of diagnostic modalities for assessment for the injured gravida is set forth.

Effect of interferon gamma on infection-related death in patients with severe injuries. A randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To assess the efficacy of interferon gamma in reducing infection and death in patients sustaining severe injury. DESIGN: Multicenter, randomized, double-blind, placebo-controlled trial with observation for 60 days and until discharge for patients with major infection on day 60. SETTING: Nine university-affiliated level 1 trauma centers. PATIENTS: Four hundred sixteen patients with severe injuries, assessed by Injury Severity Score and degree of contamination. INTERVENTION: Recombinant human interferon gamma, 100 micrograms, was administered subcutaneously once daily for 21 days (or until patient discharge if prior to 21 days) as an adjunct to standard antibiotic and supportive therapy. MAIN OUTCOME MEASURES: Incidence of major infection, death related to infection, and death. RESULTS: Infection rates were similar in both treatment groups; however, patients treated with interferon gamma experienced fewer deaths related to infection (seven [3%] vs 18 [9%]; P = .008) and fewer overall deaths (21 [10%] vs 30 [14%]; P = .17). While 12 early deaths (days 1 through 7) occurred in each treatment group, late death occurred in 18 placebo-treated patients and nine in interferon gamma-treated patients. The results were dominated by findings at one center, which had the highest enrollment and higher infection and death rates. Statistical analysis did not eliminate the possibility of an unidentified imbalance between arms as an explanation for the results. CONCLUSION: Further evaluation is required to determine the validity of the observed reduction in infection-related deaths in patients treated with interferon gamma.

Regional trauma system design: critical concepts.

Regional trauma system implementation is proceeding in a number of areas of the United States in response to a demonstrated need for improved trauma care to prevent unnecessary death. The critical questions underlying the design of such systems and the current state of knowledge and opinion regarding each of them have been defined and these provide a framework for system planning. Additional data are badly needed in several areas to provide a more rational basis for system configuration. It is hoped that systems currently being implemented will include appropriate data elements in their trauma registries to answer the remaining questions in succeeding years.

Emerging technology for vehicular safety and emergency response to roadway crashes.

Emerging technology for vehicular safety and emergency response to roadway crashes is the topic of this article. Reduction in emergency medical services system notification time, improvements in vehicular safety, crash avoidance and protection, post-crash injury control, triage, national automatic crash notification systems, and technologic improvements in emergency diagnostics and treatment during the past year are discussed.

An objective analysis of process errors in trauma resuscitations.

OBJECTIVE: A computer-based system to apply trauma resuscitation protocols to patients with penetrating thoracoabdominal trauma was previously validated for 97 consecutive patients at a Level 1 trauma center by a panel of the trauma attendings and further refined by a panel of national trauma experts. The purpose of this article is to describe how this system is now used to objectively critique the actual care given to those patients for process errors in reasoning, independent of outcome. METHODS: A chronological narrative of the care of each patient was presented to the computer program. The actual care was compared with the validated computer protocols at each decision point and differences were classified by a predetermined scoring system from 0 to 100, based on the potential impact on outcome, as critical/noncritical/no errors of commission, omission, or procedure selection. RESULTS: Errors in reasoning occurred in 100% of the 97 cases studied, averaging 11.9/case. Errors of omission were more prevalent than errors of commission (2. 4 errors/case vs 1.2) and were of greater severity (19.4/error vs 5. 1). The largest number of errors involved the failure to record, and perhaps observe, beside information relevant to the reasoning process, an average of 7.4 missing items/patient. Only 2 of the 10 adverse outcomes were judged to be potentially related to errors of reasoning. CONCLUSIONS: Process errors in reasoning were ubiquitous, occurring in every case, although they were infrequently judged to be potentially related to an adverse outcome. Errors of omission were assessed to be more severe. The most common error was failure to consider, or document, available relevant information in the selection of appropriate care.

Economic considerations.

The costs to society of trauma care are huge. Multiple-injury patients in critical care units consume a vast percentage of the direct medical costs. This article examines the role that pre-existing diseases have on the length of stay in the critical care unit and the costs associated with this care.

Trauma scoring.

Severity scales to characterize the nature and extent of injury are important adjuncts to trauma care systems, trauma research and many of the elements of a complete public health approach to injury. This article provides a brief overview of severity scale development over the past 30 years during which the science to support such initiatives has matured substantially. Anatomical, physiological, intensive care, composite and complex scales and models now abound and are being applied to a variety of tasks with increasing precision. Trauma registries enable the meaningful aggregation of data for the development and testing of models. Future challenges are identified as are potentially fruitful avenues of research.

Rib spreader laceration: a confusing artifact of emergency thoracotomy.

During emergency thoracotomy, an artifactual injury complex consisting of laceration, abrasion, and, rarely, contusion may be formed by application of a surgical instrument called a rib spreader. Six cases demonstrating this confusing injury are presented, and its formation is discussed.

On the power of a method for comparing survival of trauma patients to a standard survival curve.

This paper investigates the power of a statistical procedure for comparing a unit's survival experience to a standard survival curve. The power of the statistical procedure provides a measure of how sensitive the test is to departures from the nominal values provided by the standard survival curve. This procedure has been used recently in a number of evaluation of care studies. A power study for thirty-two adult blunt trauma patients, contributed by a participating hospital to a national data base collected at Washington Hospital Center, is detailed.

PARTITION: a quantitative method for evaluating prehospital services for trauma patients.

This paper introduces PARTITION, a method for evaluating prehospital services for trauma patients. The method can be used to compare the performance of a particular service to the accumulated experience with many different prehospital care providers. The essential element of the comparison is to separate (partition) the effects of the prehospital ministrations from those of subsequent hospital care.

Decision theory model of the emergency medical triage process.

The major objective of this research project was to apply the scientific discipline of decision-making to the problem of identifying the appropriate receiving hospital for persons injured in accidents. This problem, which is usually referred to as the prehospital triage process, is enormously important in terms of maximizing the critically injured patient's chances for survival. The long term objective of this research program, for which this project was a pilot study, is to develop an interactive computer system to support decisions regarding triage of patients at the scene of medical emergencies. The completed system will offer guidance to the paramedic in deciding whether to transport the emergency victim to the nearest hospital for stabilization and further evaluation or directly to the hospital best equipped to deal with the specific conditions of the victim.

Progress toward a new injury severity characterization: severity profiles.

Presented is a new seven-dimensional injury severity profile. The profile includes three physiologic assessments and four variables which express the number, location, and severity of a patient's injuries in terms of 'Abbreviated injury scale' values. The physiologic assessments are coded values for the 'Glasgow coma scale', systolic blood pressure, and respiratory rate. Also presented are survival-death predictive values of a cluster model based on survival rates of clusters of profiles of 2569 blunt-injured and penetrating-injured patients. The cluster model has a relative information gain (R) of 0.90. R is a measure of predictive value relative to an infallible predictor. It varies from 0 to 1, the higher the value the better the predictive value. The model had 26 false negatives (deaths predicted to survive) and 35 false positives (survivors predicted to die) giving rise to a false negative rate of 9.3%, a false positive rate of 1.4% and a misclassification rate of 2.4%. The R value and false negative rate are particularly noteworthy, the R value being higher than, and the false negative rate much lower than typical values of 30-40% achieved by TRISS (a combination index based on trauma score, injury severity score and patient age). Also noteworthy is that the clustering was independent of survival/death outcome information and that the good results were achieved even though patient age has not yet been incorporated into the model.

Bomb-related injuries.

Between 1980 and 1990 there were 12,216 bombing incidents in the United States, the majority involving pipe-bomb type devices. Victims of such devices may suffer a combination of blast, penetrating, and thermal injuries requiring special surgical approaches. A series of cases is presented which illustrates the management dilemmas faced in such situations. Given the nationwide incidence of bombings, both local emergency medical systems and trauma surgeons should be prepared to deal with blast injuries, be aware of their regional incidence of bombings, and have a planned response that is coordinated with law enforcement agencies.

Admission surgery for the multiple trauma patient. Statistics from a Level I trauma center.

This is the report on a study of patients admitted to a Level I trauma center. For a description of a trauma unit and a detailed analysis of the perioperative nurse's role in caring for the trauma patient in the OR, please see the accompanying article, "Perioperative nursing care of the multiple trauma patient: When seconds count."