Quantifying Pain Associated With Rib Fractures.

INTRODUCTION: Rib fractures are a major problem in trauma patients, and the associated pain is not well understood. Measuring total pain experience, duration, and intensity could facilitate comparisons of treatments. This study was intended to evaluate the feasibility of quantifying pain over the course of an admission and identify factors associated with increased pain experience in adults with rib fractures. METHODS: Patients admitted to a level I trauma center with rib fractures between 2015 and 2017 were included. Maximum pain score (verbal or nonverbal) was captured for each hospital day. Total pain was defined as the sum of the area under the curve (AUC) of the max pain scores plotted against time. A general linear model was used to determine demographic, injury, and clinical predictors of the pain AUC. RESULTS: We identified 3713 patients. Increased pain experienced (greater AUC) was associated with age group 40-59 y compared with 18-39 y (B = 6.1, P = 0.002); Injury Severity Score 9-14 (B = 11.5, P < 0.001) and ≥16 (B = 36.9, P < 0.0001); patients with flail chest versus multiple rib fractures (B = 17.1, P < 0.001); and patients who underwent rib fixation (B = 20.7, P = 0.004). Decreased pain experience was observed for male gender (B = -3.7, P = 0.032) and blunt mechanism of injury (B = -13.7, P < 0.0001). CONCLUSIONS: This study demonstrates the feasibility of measuring patients' total pain experience over the duration of their admission. Pain is a subjective but relevant measure of patients' experience. Our study identifies a number of predictive factors, some expected and some unexpected. Increased overall experience pain following fixation may be the result of severe pain before intervention.

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury.

Importance: Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI. Objective: To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI. Design, Setting, and Participants: Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher. Interventions: Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309). Main Outcomes and Measures: The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 [moderate disability or good recovery]) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 [no disability] to 30 [death]), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events. Results: Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 [74%] male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; [90% 1-sided confidence limit for benefit, -0.9%]; P = .16; [97.5% 1-sided confidence limit for harm, 10.2%]; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, -2.9% [95% CI, -7.9% to 2.1%]; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, -0.9 [95% CI, -2.5 to 0.7]; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, -5.4% [95% CI, -12.8% to 2.1%]; P = .16). Conclusions and Relevance: Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. Trial Registration: ClinicalTrials.gov Identifier: NCT01990768.

Complications Associated With Placement of Chest Tubes: A Trauma System Perspective.

BACKGROUND: The insertion of a chest tube is a common procedure in trauma care, and the Advanced Trauma Life Support program teaches the insertion of chest tubes as an essential and life-saving skill. It is also recognized that the insertion of chest tubes is not without risks or complications. The purpose of this study was to evaluate complications of chest tube placement in a level 1 trauma center compared with those placed in surrounding referral hospitals. METHODS: A retrospective matched cohort study of trauma patients was performed between those who underwent chest tube placement at the level 1 trauma center and those with a chest tube placed before transfer to the level 1 center between 2004 and 2013. Conditional logistic regression was used to compare the likelihood of complications and death between chest tube placement groups. RESULTS: Four thousand two hundred and sixteen trauma patients had a chest tube placed at the level 1 center, and 364 patients had a chest tube placed at an outside hospital before transfer. Two hundred and eighty-one patients were matched. Patients with a chest tube placed outside the trauma center had an increased likelihood of malposition (OR 7.2, 95% CI 3.6-14.6), residual hemothorax (OR 6.3, 95% CI 3.4-11.6), residual pneumothorax (OR 6.7, 95% CI 3.9-11.4), and having a second chest tube placed (OR 3.77, 95% CI 2.37-6.01). However, the patients with a chest tube placed outside of the trauma center were also less likely to develop pneumonia (OR 0.32, 95% CI 0.14-0.73). There were no differences in the odds of developing an empyema, the need for video-assisted thoracoscopic surgery, thoracotomy, or death. CONCLUSIONS: There are opportunities for improving the care of patients who require chest tubes at both referring hospitals and the receiving trauma center. Improving the care of patients who require intercostal drainage requires a systems-based approach, focusing on training and quality improvement.

Acute brain trauma, lung injury, and pneumonia: more than just altered mental status and decreased airway protection.

Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. Even when patients survive the initial insult, there is significant morbidity and mortality secondary to subsequent pulmonary edema, acute lung injury (ALI), and nosocomial pneumonia. Whereas the relationship between TBI and secondary pulmonary complications is recognized, little is known about the mechanistic interplay of the two phenomena. Changes in mental status secondary to acute brain injury certainly impair airway- and lung-protective mechanisms. However, clinical and translational evidence suggests that more specific neuronal and cellular mechanisms contribute to impaired systemic and lung immunity that increases the risk of TBI-mediated lung injury and infection. To better understand the cellular mechanisms of that immune impairment, we review here the current clinical data that support TBI-induced impairment of systemic and lung immunity. Furthermore, we also review the animal models that attempt to reproduce human TBI. Additionally, we examine the possible role of damage-associated molecular patterns, the chlolinergic anti-inflammatory pathway, and sex dimorphism in post-TBI ALI. In the last part of the review, we discuss current treatments and future pharmacological therapies, including fever control, tracheostomy, and corticosteroids, aimed to prevent and treat pulmonary edema, ALI, and nosocomial pneumonia after TBI.

Identification of Risk Factors for the Development of Pressure Ulcers Despite Standard Screening Methodology and Prophylaxis in Trauma Patients.

PURPOSE: To present information about a study of risk factors for development of pressure ulcers (PrUs) in trauma patients. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Describe the previous PrU research, scope of the problem, and methodology of the study.2. Explain the results of the study identifying PrU risk factors for trauma patients. OBJECTIVE: Pressure ulceration prevention has been emphasized over the past several years in inpatient hospital settings with subsequent decreases in the development of pressure ulcers (PrUs). However, there remains a subset of trauma and burn patients that develop PrUs despite standard screening methodology and prophylaxis. This study determines the conditions that predict development of pressure ulcers (PrUs) despite conventional prophylaxis and screening. METHODS: Demographic and PrU data were collected over a 5-year period from June 2008 to May 2013. Patients diagnosed with PrUs upon arrival in the trauma bay were excluded from analysis. An ordinal logistic regression of PrU stage was used to estimate odds ratios (ORs) and associated 95% confidence intervals (CIs) for the association between characteristics of interest and odds of a PrU. A backward selection process was used to select the most parsimonious model. RESULTS: During the study period, 14,616 trauma patients were admitted and had available data. A total of 124 patients (0.85%) that met inclusion criteria went on to develop PrUs during their hospital course. Factors associated with the development of PrUs included spine Abbreviated Injury Scale (AIS) >3 (OR, 5.72; CI, 3.63-9.01), mechanical ventilation (OR, 1.95; CI, 1.23-3.10) and age 40 to 64 (OR, 2.09; CI, 1.24-3.52) and age ≥ 65 (OR, 4.48; CI, 2.52-7.95). Interestingly, head injury AIS >3 was protective from the development of PrUs (OR, 0.56; CI, 0.32-0.96). Hypotension and shock defined as systolic BP <90 mm Hg and base deficit less than -6 were not associated with the development of PrUs. In addition, body mass index was not associated with PrU development. CONCLUSIONS: Spinal injuries, older than age 40, and mechanical ventilation predict the development of PrUs for a subset of patients, despite conventional prophylaxis and screening. Advanced prevention methods, such as low-air-loss mattresses for these patient subgroups should be considered immediately upon identification of these risk factors during the hospital course.

Stress-induced hyperglycemia: is it harmful following trauma?

There is an established association between the presence of SIH and worse morbidity and mortality after trauma. However, given the limitations of existing data, no definitive statements can be made as to whether aggressive treatment of hyperglycemia actually benefits outcome. Although early studies seemed to show a clear benefit in surgical ICU patients, subsequent studies have not duplicated these results. In addition, severe hypoglycemic episodes associated with glycemic control protocols have provided further concern, because they have been associated with higher rates of mortality. These disparate outcomes in prospective, randomized trials have not allowed definitive conclusions to be drawn regarding the exact glucose levels that should be maintained. Regardless, some postinjury control of glucose levels is likely necessary. Without data to support the practice, tight glycemic control keeping glucose levels below 110 mg/dL is likely not necessary and probably detrimental to patient outcome. It seems that a more moderate level of glycemic control, aimed at providing stabilization of glucose levels while reducing hyperglycemic and hypoglycemic events, is being practiced in most institutions. Performance of prospective, randomized trials in the trauma population along with further advancement and refinement of techniques to more precisely reduce glucose variability will further clarify the level of glucose control associated with improved outcomes.

The Association Between ABO Blood Type and Mortality Among Severely Injured Trauma Patients.

BACKGROUND: Prior research has reported an association among trauma patients between blood type O and adverse events. More recently, another study reported that severely injured trauma patients of mostly O Rh positive blood type were more likely to die. OBJECTIVE: The objective of the current study is to examine whether the same increased association is observed for blood type O severely injured patients in a more generalizable population comprised of Rh positive and Rh negative individuals. METHODS: Patients admitted to a Level-I academic trauma center between 2015 and 2018 with severe injury (Injury Severity Score >15) were included in this retrospective cohort study. Logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between blood type and mortality. RESULTS: Among 3,913 patients, a majority were either blood type O (47.5%) or A (34.7%) and 60% were Rh positive. There was no observed difference in complication rates by blood type, and there was no observed significant association with death overall or by cause of death. There were weak, increased associations for blood type B (OR 1.61, 95% CI 0.74-3.53) and type O (OR 1.57, 95% CI 0.90-2.76) compared with blood type A patients. CONCLUSION: Contrary to prior research, the current results suggest no association between blood type and mortality among severely injured trauma patients.

Impact of Glycemic Control on Risk of Mortality and Complications in Trauma Patients.

The impact of diabetes mellitus on outcomes in trauma patients continues to attract interest, but data regarding the impact of longer term glycemic control are still lacking. This study evaluated the effect of long-term glycemic control on outcomes. Trauma patients presenting to the University of Alabama at Birmingham Hospital, between 2011 and 2018, were stratified into 4 groups, based on admission Hemoglobin A1c (HbA1c) level. A Poisson regression with robust error variance was used to estimate risk ratios and associated confidence intervals for the association between HbA1C and specific outcomes. A total of 26,134 patients were included. Patients without diabetes or excellent glycemic control (ND-EGC) had shorter hospital and ICU stay as well as fewer days on ventilator support. Compared with those with ND-EGC, the renal failure risk was higher for those with moderate (risk ratio [RR] 2.53, 95% confidence interval [CI] 1.76-3.63) and poor glycemic control (RR 3.20, 95% CI 2.18-4.71). Urinary tract infection risk was also higher for those with poor control (RR 1.83, 95% CI 1.17-2.02). Observed associations were of similar strength for pneumonia and mortality for all less-than-excellent glycemic control groups. In conclusion, trauma patients with worse long-term glycemic control had increased risks of developing pneumonia, renal failure, urinary tract infection, and death. HbA1c can prognosticate the risks and outcomes of diabetic trauma patients.

Clinical examination in complement with computed tomography scan: an effective method for identification of cervical spine injury.

OBJECTIVE: The purpose of this study was to prospectively evaluate a protocol that assesses the efficacy and sensitivity of clinical examination in complement with computed tomographic (CT) scan in screening for cervical spine (c-spine) injury. METHODS: During the 26-month period from March 2005 to May 2007, blunt trauma patients older than 13 years were prospectively entered into a study protocol. If patients were awake and alert with Glasgow Coma Score (GCS) >or=14, clinical examination of the neck was performed. Clinical examination was performed regardless of distracting injuries. If the patient had no complaints of pain or tenderness, the cervical collar was removed. Patients with complaints of c-spine pain or tenderness and patients with GCS score <14 underwent CT scanning for evaluation of the entire c-spine. RESULTS: One thousand six hundred eighty seven patients were prospectively assessed for blunt c-spine injury. Fourteen hundred thirty-nine patients had GCS score >or=14, 897 (62%) of which had a negative clinical examination of the c-spine and subsequently had cervical collars removed. Two patients (0.2%) whose clinical examination results disclosed nothing abnormal were later found to have a c-spine injury. Five hundred forty-two patients with GCS score >or=14 had a positive c-spine clinical examination, of which 134 (24%) were diagnosed with c-spine injury. One hundred thirty-three (99%) c-spine injuries were identified by CT scan. The c-spine injury missed by CT scan was a radiologic misinterpretation. For patients with c-spine injury with GCS score >or=14, both sensitivities of clinical examination and CT scan were 99%. Two hundred forty-eight patients had GCS score <14, of which 5 (2.0%) were diagnosed with c-spine injury. CT scan identified all c-spine injuries for patients with GCS score <14. CONCLUSIONS: In awake and alert blunt trauma patients, clinical examination is a sensitive screening method for c-spine injury. Clinical examination allows for the majority of blunt trauma patients to have their c-spines cleared safely without radiologic screening. Clinical examination in complement with CT scan is a sensitive and an effective method for identification of c-spine injury in awake and alert patients with symptoms of c-spine injury. CT scan is the sensitive and effective test for screening and diagnosis of c-spine injury in blunt trauma patients with altered mental status.

Optimization of Laboratory Ordering Practices for Complete Blood Count With Differential.

Objectives: To investigate the utilization of CBC and CBC with differential (CBC w/diff) tests at University of Alabama at Birmingham Hospital, and to determine if a reduction in CBC w/diff tests could be achieved without negatively impacting patient care. Methods: The quantity of testing and distribution of repeated tests before, during, and after an educational intervention were compared. Results: CBC w/diff tests were ordered 10-fold more frequently than CBC tests. The trauma burn intensive care unit ordered the most CBC w/diff tests, with repeat tests done every 4 or 12 hours. The educational intervention reduced the number of CBC w/diff tests ordered and tests repeated every 12 hours. Conclusions: The educational intervention changed the ordering practices of CBC w/diff and CBC tests. This was sustained after the intervention and no negative effects on patient care were noted. Similar interventions may lead to optimization of ordering practices of other laboratory tests.