Altered thyroid function in severely injured patients.

BACKGROUND: Hemorrhagic shock profoundly affects the neuroendocrine profile of trauma patients, and we hypothesized that massive resuscitation would negatively impact thyroid function. METHODS: A prospective, observational study investigating thyroid function in hypotensive trauma patients (systolic blood pressure <90 mm Hg × 2) who survived >48 h was conducted at a Level I center over a 6-mo period. Blood samples for thyroid function were collected at time of presentation to the trauma bay and serially for 48 h. Collected data included demographics, injury data, vital signs, transfusion needs, crystalloid use, and vasopressor requirements. Patients receiving >5 units packed red blood cells (PRBC) within 12 h were compared with those receiving ≤5 units. RESULTS: Patients who required >5 units of PRBC/12 h had significantly lower total and free T4 levels on initial presentation, and levels remained significantly depressed over the next 48 h when compared with patients who required a less aggressive resuscitative effort. T3 values were markedly suppressed during the initial 48 h post trauma in all patients, but were significantly lower in patients requiring >5 units PRBC. TSH levels remained within the normal range for all time points. Lower trauma admission T4 levels were associated with the need for greater crystalloid resuscitation within the first 24 h. CONCLUSION: Measurements of thyroid function are significantly altered in severely injured patients on initial presentation, and low T4 levels predict the need for large resuscitation. Further research investigating the profile and impact of thyroid function in trauma patients during resuscitation and recovery is warranted.

Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial.

Importance: Current therapies for traumatic blood loss focus on hemorrhage control and blood volume replacement. Severe hemorrhagic shock, however, is associated with a state of arginine vasopressin (AVP) deficiency, and supplementation of this hormone may decrease the need for blood products in resuscitation. Objective: To determine whether low-dose supplementation of AVP in patients with trauma (hereinafter referred to as trauma patients) and with hemorrhagic shock decreases their need for transfused blood products during resuscitation. Design, Setting, and Participants: This randomized, double-blind placebo-controlled clinical trial included adult trauma patients (aged 18-65 years) who received at least 6 U of any blood product within 12 hours of injury at a single urban level 1 trauma center from May 1, 2013, through May 31, 2017. Exclusion criteria consisted of prehospital cardiopulmonary resuscitation, emergency department thoracotomy, corticosteroid use, chronic renal insufficiency, coronary artery disease, traumatic brain injury requiring any neurosurgical intervention, pregnancy, prisoner status, or AVP administration before enrollment. Data were analyzed from May 1, 2013, through May 31, 2017, using intention to treat and per protocol. Interventions: After administration of an AVP bolus (4 U) or placebo, participants received AVP (≤0.04 U/min) or placebo for 48 hours to maintain a mean arterial blood pressure of at least 65 mm Hg. Main Outcomes: The primary outcome was total volume of blood product transfused. Secondary end points included total volume of crystalloid transfused, vasopressor requirements, secondary complications, and 30-day mortality. Results: One hundred patients underwent randomization (49 to the AVP group and 51 to the placebo group). Patients were primarily young (median age, 27 years [interquartile range {IQR}, 22-25 years]) and male (n = 93) with penetrating trauma (n = 79). Cohort characteristics before randomization were well balanced. At 48 hours, patients who received AVP required significantly less blood products (median, 1.4 [IQR, 0.5-2.6] vs 2.9 [IQR, 1.1-4.8] L; P = .01) but did not differ in requirements for crystalloids (median, 9.9 [IQR, 7.9-13.0] vs 11.0 [8.9-15.0] L; P = .22) or vasopressors (median, 400 [IQR, 0-5900] vs 1400 [IQR, 200-7600] equivalent units; P = .22). Although the groups had similar rates of mortality (6 of 49 [12%] vs 6 of 51 [12%]; P = .94) and total complications (24 of 44 [55%] vs 30 of 47 [64%]; P = .37), the AVP group had less deep venous thrombosis (5 of 44 [11%] vs 16 of 47 [34%]; P = .02). Conclusions and Relevance: Low-dose AVP during the resuscitation of trauma patients in hemorrhagic shock decreases blood product requirements. Additional research is necessary to determine whether including AVP improves morbidity or mortality. Trial Registration: ClinicalTrials.gov identifier: NCT01611935.

Does proximity to violence negatively influence attitudes toward exception from informed consent in emergency research?

BACKGROUND: Trauma research has been limited by perceived patient reluctance to participate in exception from informed consent (EFIC) studies. We hypothesized that race, socioeconomic status, and proximity to violence influence willingness to participate in and perception of EFIC research among at-risk populations. METHODS: Trauma patients, families, and community members ranked statements regarding attitude toward EFIC in the context of an upcoming trial and willingness to participate in emergency research using a 5-point Likert scale during a community consultation. Higher total scores reflected a more positive attitude regarding EFIC (range, 6-30; neutral, 18) and willingness (range, 23-115; neutral, 69). Subject zip code was used to calculate median income, as an estimate for socioeconomic status, and proximity to the five most violent city zip codes. Linear regression, Spearman's correlation, and Kruskal-Wallis tests (p < 0.05) were used to evaluate relationships between estimated socioeconomic status, race, mechanism of injury, proximity to violence, and attitudes toward EFIC. RESULTS: A total of 179 subjects participated including trauma patients (n = 99), families (n = 33), and community members (n = 47). Overall, participants were supportive of EFIC and reported high scores in willingness to participate (median, 24; interquartile range, 21-25; median 89, interquartile range, 82-95, respectively). Proximity to violence did correlate with race (p = 0.03) but was not associated with violent mechanism of injury, perception of EFIC, or willingness to participate in emergency research. Estimated socioeconomic status and race did not correlate with perception of or willingness to participate in EFIC. CONCLUSION: Based on our data, there is no correlation between either proximity to violence or estimated socioeconomic status and willingness to participate in EFIC research. Given this lack of correlation, researchers should partner with at-risk communities to conduct EFIC studies without concern for limited participation. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Incidence and factors associated with sensorineural and conductive hearing loss among survivors of congenital diaphragmatic hernia.

PURPOSE: The reported incidence of sensorineural hearing loss (SNHL) in long-term survivors of congenital diaphragmatic hernia varies widely in the literature. Conductive hearing loss (CHL) is also known to occur in CDH patients, but has been less widely studied. We sought to characterize the incidence and risk factors associated with SNHL and CHL in a large cohort of CDH patients who underwent standardized treatment and follow-up at a single institution. METHODS: We retrospectively reviewed charts of all CDH patients in our pulmonary hypoplasia program from January 2004 through December 2012. Categorical variables were analyzed by Fisher's exact test and continuous variables by Mann-Whitney t-test (p≤0.05). RESULTS: A total of 112 patients met study inclusion criteria, with 3 (2.7%) patients diagnosed with SNHL and 38 (34.0%) diagnosed with CHL. SNHL was significantly associated with requirement for ECMO (p=0.0130), prolonged course of hospitalization (p=0.0011), duration of mechanical ventilation (p=0.0046), requirement for tracheostomy (p=0.0013), and duration of loop diuretic (p=0.0005) and aminoglycoside therapy (p=0.0003). CONCLUSIONS: We have identified hearing anomalies in over 30% of long-term CDH survivors. These findings illustrate the need for routine serial audiologic evaluations throughout childhood for all survivors of CDH and stress the importance of targeted interventions to optimize long-term developmental outcomes pertaining to speech and language.

Detecting intimate partner violence: more than trauma team education is needed.

BACKGROUND: Intimate partner violence (IPV) is an underappreciated cause of morbidity and mortality in female trauma patients. We investigated the impact of a domestic violence education program for trauma residents on the detection of IPV. STUDY DESIGN: In January 2008, an educational IPV program was implemented for all trauma residents. A retrospective review of all female patients evaluated by the trauma service before and after institution of the IPV program was performed. Medical records were reviewed for demographic data, injury mechanism, social habits, and IPV documentation. Chi-square and Fisher's exact tests were used to compare patients before and after institution of the educational IPV program. RESULTS: The records of 645 female trauma patients evaluated in 2007 and 2008 were reviewed. Patients were not routinely asked about IPV, despite implementation of the educational program; 39.9% were asked about IPV in 2007 versus 46.1% in 2008 (p = 0.11). The positive disclosure of IPV did not increase from 2007 to 2008 (20.1% versus 21.2%; p = 0.83). Documentation about social habits increased considerably. In 2008, patients were asked more regularly about alcohol (71.8% versus 80.8%; p = 0.01), drugs (64.1% versus 73.7%; p = 0.01), and tobacco use (67.0% versus 78.1%; p = 0.002). Importantly, patients with documented IPV (n = 57) frequently presented to the trauma team with nonviolent mechanisms of injury (n = 30, 52.6%). CONCLUSIONS: IPV is a frequent finding in female trauma patients. Despite increased education, questions about IPV are not documented routinely. In addition, screening at-risk patients by mechanism will underestimate the prevalence of IPV. Universal screening should be mandated to increase IPV detection and enhance opportunities for intervention.