Incidence of and Factors Associated With Recurrent Firearm Injury Among Patients Presenting to St. Louis Trauma Centers, 2010 to 2019 : A Cohort Study.

BACKGROUND: Firearm injuries are a public health crisis in the United States. OBJECTIVE: To examine the incidence and factors associated with recurrent firearm injuries and death among patients presenting with an acute (index), nonfatal firearm injury. DESIGN: Multicenter, observational, cohort study. SETTING: Four adult and pediatric level I trauma hospitals in St. Louis, Missouri, 2010 to 2019. PARTICIPANTS: Consecutive adult and pediatric patients (n = 9553) presenting to a participating hospital with a nonfatal acute firearm injury. MEASUREMENTS: Data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and death were collected from the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository. The Centers for Disease Control and Prevention (CDC) Social Vulnerability Index was used to characterize the social vulnerability of the census tracts of patients' residences. Analysis included descriptive statistics and time-to-event analyses estimating the probability of experiencing a recurrent firearm injury. RESULTS: We identified 10 293 acutely firearm-injured patients of whom 9553 survived the injury and comprised the analytic sample. Over a median follow-up of 3.5 years (IQR, 1.5 to 6.4 years), 1155 patients experienced a recurrent firearm injury including 5 firearm suicides and 149 fatal firearm injuries. Persons experiencing recurrent firearm injury were young (25.3 ± 9.5 years), predominantly male (93%), Black (96%), and uninsured (50%), and resided in high social vulnerability regions (65%). The estimated risk for firearm reinjury was 7% at 1 year and 17% at 8 years. LIMITATIONS: Limited data on comorbidities and patient-level social determinants of health. Inability to account for recurrent injuries presenting to nonstudy hospitals. CONCLUSION: Recurrent injury and death are frequent among survivors of firearm injury, particularly among patients from socially vulnerable areas. Our findings highlight the need for interventions to prevent recurrence. PRIMARY FUNDING SOURCE: Emergency Medicine Foundation-AFFIRM and Missouri Foundation for Health.

The risk of thromboembolic events with early intravenous 2- and 4-g bolus dosing of tranexamic acid compared to placebo in patients with severe traumatic bleeding: A secondary analysis of a randomized, double-blind, placebo-controlled, single-center trial.

BACKGROUND: Screening for the risk of thromboembolism (TE) due to tranexamic acid (TXA) in patients with severe traumatic injury has not been performed in randomized clinical trials. Our objective was to determine if TXA dose was independently-associated with thromboembolism. STUDY DESIGN AND METHODS: This is a secondary analysis of a single-center, double-blinded, randomized controlled trial comparing placebo to a 2-g or 4-g intravenous TXA bolus dose in trauma patients with severe injury. We used multivariable discrete-time Cox regression models to identify associations with risk for thromboembolic events within 30 days post-enrollment. Event curves were created using discrete-time Cox regression. RESULTS: There were 50 patients in the placebo group, 49 in the 2-g, and 50 in the 4-g TXA group. In adjusted analyses for thromboembolism, a 2-g dose of TXA had an hazard ratio (HR, 95% confidence interval [CI]) of 3.20 (1.12-9.11) (p = .029), and a 4-g dose of TXA had an HR (95% CI) of 5.33 (1.94-14.63) (p = .001). Event curves demonstrated a higher probability of thromboembolism for both doses of TXA compared to placebo. Other parameters independently associated with thromboembolism include time from injury to TXA administration, body mass index, and total blood products transfused. DISCUSSION: In patients with severe traumatic injury, there was a dose-dependent increase in the risk of at least one thromboembolic event with TXA. TXA should not be withheld, but thromboembolism screening should be considered for patients receiving a dose of at least 2-g TXA intravenously for traumatic hemorrhage.

The use of low-titer group O whole blood is independently associated with improved survival compared to component therapy in adults with severe traumatic hemorrhage.

BACKGROUND: There is a resurgence in the use of low-titer group O whole blood (LTOWB) for hemorrhagic shock. We hypothesized the use of LTOWB compared to component therapy (CT) would be independently associated with improved 24-hour mortality. STUDY DESIGN AND METHODS: In this prospective observational study, trauma patients 18 years of age or older with massive transfusion protocol activations were included from August 17, 2018, to May 14, 2019. The primary outcome was 24-hour mortality. Secondary outcomes included 72-hour blood product totals, multiple organ dysfunction scores (MODS), and 28-day mortality. Multivariable logistic regression (MVLR) and Cox regression were performed to determine independent associations. RESULTS: There were no clinically meaningful differences in measures of injury severity between study groups (CT, n = 42; LTOWB, n = 44). There was no difference in MODS between study groups. The unadjusted mortality was not statistically different between the study groups (9/42 [21%] for CT vs. 7/44 [16%] for LTOWB; p = 0.518). In the MVLR model, LTOWB increased the odds of 24-hour survival by 23% (odds ratio 0.81, 95% confidence interval 0.69-0.96; p = 0.017). Adjusted survival curve analysis indicated improved survival at both 24 hours and 28 days for LTOWB patients (p < 0.001). Further stratification showed an association between LTOWB use and survival when maximum clot firmness (MCF) was 60 mm or less (p = 0.009). CONCLUSIONS: The use of LTOWB is independently associated with improved 24-hour and 28-day survival, and does not increase organ dysfunction at 72 hours. Use of LTOWB most impacted survival of patients with reduced clot firmness (MCF ≤60 mm). Collectively, these data support the clinical use and continued study of LTOWB for hemostatic resuscitation.

Single-Contrast CT for Detecting Bowel Injuries in Penetrating Abdominopelvic Trauma.

OBJECTIVE: Many centers advocate use of triple-contrast (IV, oral, and rectal) CT for assessing hemodynamically stable patients with penetrating abdominopelvic trauma. Enteric contrast material has several disadvantages, leading our practice to pursue use of single-contrast (IV) CT. We conducted a retrospective review of electronic medical records at our institution to assess the accuracy of single-contrast CT for diagnosing bowel injuries in cases of penetrating abdominopelvic trauma. MATERIALS AND METHODS: We retrospectively reviewed patients who presented to our emergency department between January 1, 2004, and March 1, 2014, with penetrating abdominopelvic trauma, underwent an abdominopelvic CT, and had surgery performed thereafter. We reviewed pertinent emergency department records for details regarding the site of injury, the number of injuries per patient, and the type of weapon used. We correlated CT reports with operative notes for presence and sites of bowel injury. RESULTS: A total of 274 patients (median age, 27 years old) met our inclusion criteria; 77% had sustained gunshot wounds (GSWs). CT showed bowel injury in 173 cases; surgery revealed bowel injury in 162 cases. CT had 142 true-positive, 31 false-positive, 81 true-negative, and 20 false-negative cases, resulting in sensitivity of 88%, specificity of 72%, positive predictive value of 82%, and negative predictive value of 80% for detecting bowel injuries. CT had the highest sensitivity and specificity in patients with multiple GSWs (94% and 79%, respectively) and those with injuries to the stomach and rectum. CONCLUSION: Single-contrast CT can show bowel injuries in patients with penetrating abdominopelvic trauma with accuracy comparable with that reported for triple-contrast CT.

CT Appearance of Traumatic Inferior Vena Cava Injury.

OBJECTIVE: CT plays a crucial role in the evaluation of stable patients with blunt and penetrating trauma in the emergency department. Among the more severe injuries that may occur in penetrating and blunt trauma are those to the inferior vena cava (IVC). The purpose of this study was to evaluate and differentiate the CT findings associated with penetrating versus blunt trauma to the IVC to aid the radiologist in diagnosing IVC injuries. MATERIALS AND METHODS: Cases of blunt and penetrating IVC injury were retrospectively identified using search queries. Criteria for inclusion were preoperative contrast-enhanced CT and surgically confirmed caval injury or direct findings of caval injury on CT with patient death before surgical confirmation could be obtained. RESULTS: Twelve cases of traumatic IVC injury were identified over a 9-year period: six blunt and six penetrating. The most common finding was a retroperitoneal hematoma, seen in 75% of cases. Eighty-three percent of blunt injuries were associated with hepatic lacerations and contrast material extravasation. Thirty-three percent of penetrating IVC injuries were associated with extravasation. Contour abnormalities were seen in 50% of blunt and 17% of penetrating injuries to the IVC. All three cases of IVC injury resulting in mortality occurred in the retrohepatic segment. CONCLUSION: Injury to the IVC is frequently fatal in patients with penetrating or blunt trauma. The CT appearance of IVC injury is dichotomous between the two causes, with blunt IVC injury more likely to show extravasation, contour abnormality, and associated hepatic laceration. Injury of the retrohepatic IVC portends a poor outcome. With the continued use of CT for evaluation of trauma patients, the radiologist should be familiar with IVC injury and its different CT appearances.

Traumatic lumbar hernias: do patient or hernia characteristics predict bowel or mesenteric injury?

Traumatic lumbar hernias are rare but important injuries to diagnose in blunt abdominal trauma, both because of delayed complications of the hernia itself and because of well-documented association with bowel and mesenteric injuries. No study to our knowledge has determined whether specific features of the hernia-size of the wall defect, inferior or superior location, or the side of the hernia-bear any predictive value on the presence of underlying bowel and mesenteric injury. A retrospective query of the radiology information system yielded 21 patients with lumbar hernias which were diagnosed on CT. These were reviewed by three radiologists to confirm the presence of an acute lumbar hernia and to determine the size and location of the hernia. The patients' medical records were reviewed to determine the presence of operatively confirmed bowel and/or mesenteric injuries, which occurred in 52 % of patients. A significant (p < 0.001) difference was found in the frequency of bowel and/or mesenteric injury with hernia defects greater than 4.0 cm (100 %) and those less than 4.0 cm (17 %). Larger hernias also resulted in more procedures (p = 0.042) and a trend towards longer ICU stay, but no difference in injury severity score (ISS) or overall hospital stay. No significant difference was seen in the frequency of bowel and/or mesenteric injuries based on side or location of the hernia, though distal colonic injuries were more commonly seen with left-sided hernias (50 %) compared to right-sided hernias (18 %). Although based on a small patient population, these results suggest that larger traumatic lumbar hernias warrant particularly close evaluation for an underlying bowel and/or mesenteric injury.

Doing more with less: low-titer group O whole blood resulted in less total transfusions and an independent association with survival in adults with severe traumatic hemorrhage.

BACKGROUND: Low-titer group O whole blood (LTOWB) or component therapy (CT) may be used to resuscitate hemorrhaging trauma patients. LTOWB may have clinical and logistical benefits and may improve survival. OBJECTIVES: We hypothesized LTOWB would improve 24-hour survival in hemorrhaging patients and would be safe and equally efficacious in non-group O compared with group O patients. METHODS: Adult trauma patients with massive transfusion protocol activations were enrolled in this observational study. The primary outcome was 24-hour mortality. Secondary outcomes included 72-hour total blood product use. A Cox regression determined the independent associations with 24-hour mortality. RESULTS: In total, 348 patients were included (CT, n = 180; LTOWB, n = 168). Demographics were similar between cohorts. Unadjusted 24-hour mortality was reduced in LTOWB vs CT: 8% vs 19% (P = .003), but 6-hour and 28-day mortality were similar. In an adjusted analysis with multivariable Cox regression, LTOWB was independently associated with reduced 24-hour mortality (hazard ratio, 0.21; 95% CI, 0.07-0.67; P = .004). LTOWB patients received significantly less 72-hour total blood products (80.9 [41.6-139.3] mL/kg vs 48.9 [25.9-106.9] mL/kg; P < .001). In stratified 24-hour survival analyses, LTOWB was associated with improved survival for patients in shock or with coagulopathy. LTOWB use in non-group O patients was not associated with increased mortality, organ injury, or adverse events. CONCLUSION: In this hypothesis-generating study, LTOWB use was independently associated with improved 24-hour survival, predominantly in patients with shock or coagulopathy. LTOWB also resulted in a 40% reduction in blood product use which equates to a median 2.4 L reduction in transfused products.

Reduction of Surgical Site Infection After Trauma Laparotomy Through Use of a Specific Protocol for Antibiotic Prophylaxis.

Background: Emergency laparotomy for abdominal trauma is associated with high rates of surgical site infection (SSI). A protocol for antimicrobial prophylaxis (AMP) for trauma laparotomy was implemented to determine whether SSI could be reduced by adhering to established principles of AMP. Patients and Methods: A protocol utilizing ertapenem administered immediately before initiation of trauma laparotomy was adopted. Compliance with measures of adequate AMP were determined before and after protocol implementation, as were rates of SSI and other infections related to abdominal trauma. Univariable and multivariable analyses were performed to determine risk factors for development of infection related to trauma laparotomy. Results: Over a four-year period, 320 patient operations were reviewed. Ertapenem use for prophylaxis increased to 54% in the post-intervention cohort. Compliance with individual measures of appropriate AMP improved modestly. Overall, infections related to trauma laparotomy decreased by 46% (absolute decrease of 13%) in the post-intervention cohort. Multivariable analysis confirmed that treatment during the post-intervention phase was associated with this decrease, with a separate analysis suggesting that ertapenem use was an important factor in this decrease. Conclusions: Development of a standardized protocol for AMP in trauma laparotomy led to decreases in infectious complications after that procedure.

When REBOA grows wings: Resuscitative endovascular balloon occlusion of the aorta to facilitate aeromedical transport.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a helpful adjunct in the control of non-compressible truncal hemorrhage. Concerns regarding ischemia time limits its applicability in transfer. We describe the first reported case of civilian transfer via aeromedical transport to a higher level of care with a zone 3 REBOA catheter deployed. CASE REPORT: We present the case of a patient in hemorrhagic shock with a complex pelvic fracture exceeding the capability of a rural level-two trauma center requiring the use of REBOA catheter to permit aeromedical transport to a level-one trauma center for definitive embolization. CONCLUSION: Deployment of REBOA catheter to facilitate aeromedical transport to an appropriate level of care may be considered if travel times can be kept brief and there is a process and training in place to empower flight medics to consider transporting with a REBOA deployed.

Racial disparities in triage of adolescent patients after bullet injury.

BACKGROUND: While pediatric trauma centers (PTCs) and adult trauma centers (ATCs) exhibit equivalent trauma mortality, the optimal care environment for traumatically injured adolescents remains controversial. Race has been shown to effect triage within emergency departments (EDs) with people of color receiving lower acuity triage scores. We hypothesized that African-American adolescents were more likely triaged to an ATC than a PTC compared with their White peers. METHODS: Institutional trauma databases from a neighboring, urban Level I PTC and ATC were queried for gunshot wounds in adolescents (15-18 years) presenting to the ED from 2015 to 2017. The PTC and ATC were compared in terms of demographics, services, and outcomes. Results were analyzed using univariate analysis and logistic regression. RESULTS: Among 316 included adolescents, 184 were treated in an ATC versus 132 in a PTC. Patients at the PTC were significantly more likely to be younger (16.1 vs. 17.5 years; p < 0.001), White (16% vs. 5%; p = 0.001), and privately insured (41% vs. 30%; p = 0.002). At each age, the proportion of Whites treated at the PTC exceeded the proportion of African-Americans. At the PTC, patients were more likely to receive inpatient and outpatient social work follow-up (89% vs. 1%, p < 0.001). Adolescents treated at the PTC were less likely to receive opioids (75% vs. 56%, p = 0.001) at discharge and to return to ED within 6 months (25% vs. 11%, p = 0.005). On multivariate logistic regression, African-American adolescents were less likely to be treated at a PTC (odds ratio, 0.30; 95% confidence interval, 0.10-0.85; p = 0.02) after controlling for age and Injury Severity Score. CONCLUSION: Disparities in triage of African-American and White adolescents after bullet injury lead to unequal care. African-Americans were more likely to be treated at the ATC, which was associated with increased opioid prescription, decreased social work support, and increased return to ED. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

Platelet transfusion: an unnecessary risk for mild traumatic brain injury patients on antiplatelet therapy.

INTRODUCTION: To determine whether there is a benefit to platelet transfusion in mild traumatic brain injury (MTBI) patients with intracranial hemorrhage (ICH), taking antiplatelet therapy before hospitalization. MATERIALS AND METHODS: The study design retrospectively reviewed patients admitted to a Level I trauma center during a 2-year period with an isolated MTBI (Glasgow Coma Scale score ≥13, ICH seen on a head computed tomographic scan (head computed tomography [HCT]), and taking an antiplatelet agent before hospitalization. HCT's were categorized based on the Marshall Classification, Rotterdam Score, and ICH volume. Hospital records were reviewed noting neurologic, cardiac, respiratory events, and discharge Glasgow Outcome Scale. RESULTS: There were 1,101 patients with TBI hospitalized during the 2-year study period. Three hundred twenty-one of these patients had an MTBI with ICH at the time of admission, and from this group, 113 were taking an antiplatelet agent. Only 4 (1.2%) of the 321 patients suffered a neurologic decline. All were gradual in nature, and none required emergent intervention. An analysis of the 113 patients taking antiplatelet agents, comparing patients who were not given a platelet transfusion with those who received a platelet transfusion, found no significant difference in the rate of HCT progression, neurologic decline, or Glasgow Outcome Scale at hospital discharge between the two groups. There was a trend, which was not significant, toward more medical declines in patients who received a platelet transfusion. A further review, analyzing all 321 patients with ICH showed receiving a transfusion of any type (i.e., platelets, fresh frozen plasma, or blood) was a strong predictor of medical decline (p < 0.0001). The odds ratio of having a medical decline after transfusion was 5.8 (95% confidence interval, 1.2-28.2). CONCLUSIONS: Platelet transfusion did not improve short-term outcomes after MTBI. Further randomized controlled trials need to be done to truly assess if there is no benefit in platelet transfusion in patients taking antiplatelet agents suffering an MTBI. Because the overall outcome in MTBI patients is favorable, platelet transfusion in these patients may not be indicated.

SAVE 2.0: Identifying and strengthening resident leadership skills through simulation based team training.

BACKGROUND: The "Surgery for Abdomino-thoracic ViolencE (SAVE)" animate lab engages surgical residents in the management of penetrating injuries in a team setting. Senior residents, representing postgraduate year (PGY) 3-5, assume the role of team leader and facilitate the junior residents, PGY1-2, in operative management of simulated penetrating wounds. Residents completed five scenarios with increasing level of difficulty within set time limits. Senior residents were evaluated on their team's ability to "SAVE" their patient within the time allotted, as well as their communication and leadership skills. METHODS: General, vascular, urology, and plastic surgery residents (n = 79) were divided into 25 teams of three to four residents by "resident scores" (R scores, the sum of the team members' PGY) to create balanced teams with comparable years of clinical experience. Residents completed assessments of their senior resident's leadership ability and style. RESULTS: Evaluation of a resident's desired learning style changed across PGY with junior residents preferring more hands-on guidance compared with senior residents preferring only verbal correction. Resident leadership evaluations demonstrated that team leaders of varied resident years achieved the highest scores. Greater differences in the mismatch between autonomy provided to and desired by junior residents correlated to greater junior resident discomfort in expressing their opinion, confidence, and leadership ratings of senior residents. However, greater autonomy mismatch also correlated to more rapid time to task completion. CONCLUSION: Different from our expectations, clinical experience alone did not define team leader success. Leadership is a powerful influence on the outcome of team performance and may be a skill, which can transcend overall clinical experience. A match between desired and provided resident autonomy and team cohesion may demonstrate a stronger effect on team success in stressful operative situations, such as trauma resuscitation. Enhancement of leadership skills early in residency training may represent an important focus for trauma surgery education.

The Immunologic Effect of Early Intravenous Two and Four Gram Bolus Dosing of Tranexamic Acid Compared to Placebo in Patients With Severe Traumatic Bleeding (TAMPITI): A Randomized, Double-Blind, Placebo-Controlled, Single-Center Trial.

Background: The hemostatic properties of tranexamic acid (TXA) are well described, but the immunological effects of TXA administration after traumatic injury have not been thoroughly examined. We hypothesized TXA would reduce monocyte activation in bleeding trauma patients with severe injury. Methods: This was a single center, double-blinded, randomized controlled trial (RCT) comparing placebo to a 2 g or 4 g intravenous TXA bolus dose in trauma patients with severe injury. Fifty patients were randomized into each study group. The primary outcome was a reduction in monocyte activation as measured by human leukocyte antigen-DR isotype (HLA-DR) expression on monocytes 72 h after TXA administration. Secondary outcomes included kinetic assessment of immune and hemostatic phenotypes within the 72 h window post-TXA administration. Results: The trial occurred between March 2016 and September 2017, when data collection ended. 149 patients were analyzed (placebo, n = 50; 2 g TXA, n = 49; 4 g TXA, n = 50). The fold change in HLA-DR expression on monocytes [reported as median (Q1-Q3)] from pre-TXA to 72 h post-TXA was similar between placebo [0.61 (0.51-0.82)], 2 g TXA [0.57 (0.47-0.75)], and 4 g TXA [0.57 (0.44-0.89)] study groups (p = 0.82). Neutrophil CD62L expression was reduced in the 4 g TXA group [fold change: 0.73 (0.63-0.97)] compared to the placebo group [0.97 (0.78-1.10)] at 24 h post-TXA (p = 0.034). The fold decrease in plasma IL-6 was significantly less in the 4 g TXA group [1.36 (0.87-2.42)] compared to the placebo group [0.46 (0.19-1.69)] at 72 h post-TXA (p = 0.028). There were no differences in frequencies of myeloid or lymphoid populations or in classical complement activation at any of the study time points. Conclusion: In trauma patients with severe injury, 4 g intravenous bolus dosing of TXA has minimal immunomodulatory effects with respect to leukocyte phenotypes and circulating cytokine levels. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02535949.

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.

OBJECTIVE: To determine a) if a checklist covering a diverse group of intensive care unit protocols and objectives would improve clinician consideration of these domains and b) if improved consideration would change practice patterns. DESIGN: Pre- and post observational study. SETTING: A 24-bed surgical/burn/trauma intensive care unit in a teaching hospital. PATIENTS: A total of 1399 patients admitted between June 2006 and May 2007. INTERVENTIONS: The first component of the study evaluated whether mandating verbal review of a checklist covering 14 intensive care unit best practices altered verbal consideration of these domains. Evaluation was performed using real-time bedside audits on morning rounds. The second component evaluated whether the checklist altered implementation of these domains by changing practice patterns. Evaluation was performed by analyzing data from the Project IMPACT database after patients left the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Verbal consideration of evaluable domains improved from 90.9% (530/583) to 99.7% (669/671, p < .0001) after verbal review of the checklist was mandated. Bedside consideration improved on the use of deep venous thrombosis prophylaxis (p < .05), stress ulcer prophylaxis (p < .01), oral care for ventilated patients (p < 0.01), electrolyte repletion (p < .01), initiation of physical therapy (p < .05), and documentation of restraint orders (p < .0001). Mandatory verbal review of the checklist resulted in a greater than two-fold increase in transferring patients out of the intensive care unit on telemetry (16% vs. 35%, p < .0001) and initiation of physical therapy (28% vs. 42%, p < .0001) compared with baseline practice. CONCLUSIONS: A mandatory verbal review of a checklist covering a wide range of objectives and goals at each patient's bedside is an effective method to improve both consideration and implementation of intensive care unit best practices. A bedside checklist is a simple, cost-effective method to prevent errors of omission in basic domains of intensive care unit management that might otherwise be forgotten in the setting of more urgent care requirements.

Tracheostomy protocol: experience with development and potential utility.

OBJECTIVES: To examine the feasibility and potential utility of a tracheostomy protocol based on a standardized approach to ventilator weaning. DESIGN: Prospective, observational data collection. SETTING: Academic medical center. PATIENTS: Surgical intensive care unit patients requiring mechanical ventilatory support. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Tracheostomy practice in 200 patients was analyzed in relation to spontaneous breathing trial (SBT) weaning. Decision for, and performance of, tracheostomy occurred (median [interquartile range]) 5.0 (3.75-8.0) and 7.0 (5.0-10.0) days following initiation of mechanical ventilation, respectively. Duration of mechanical ventilation was greater in tracheostomy compared with nontracheostomy patients (15.0 [11.0-19.0] vs. 6.0 [4.0-8.0], p < .001). For patients requiring ventilatory support for > or = 20 days, 100% of patients were maintained via tracheostomy. A protocol based on weaning performance, which included technical considerations, was developed. Individuals who failed preliminary weaning assessment or SBT for 3 successive days following 5 days (nonreintubated patients) or 3 days (reintubated patients) of ventilatory support met tracheostomy criteria. The protocol was implemented on a pilot basis in 125 individuals. Of the 55 (44.0%) patients undergoing tracheostomy, 25 (45.5%) did so consistent with criteria. Eighteen patients (32.7%) underwent tracheostomy before the time interval of data collection targeting weaning protocol performance, and 12 patients (21.8%) passed SBT on one or more occasions, were not extubated, and proceeded to tracheostomy. CONCLUSIONS: A standardized approach in which the decision for tracheostomy is based on objective measures of weaning performance may be a means of using this procedure more consistently and effectively.

Extracorporeal membrane oxygenation: current clinical practice, coding, and reimbursement.

Extracorporeal membrane oxygenation (ECMO) is a technique for providing life support for patients experiencing both pulmonary and cardiac failure by maintaining oxygenation and perfusion until native organ function is restored. ECMO is used routinely at many specialized hospitals for infants and less commonly for children with respiratory or cardiac failure from a variety of causes. Its usage is more controversial in adults, but select medical centers have reported favorable findings in patients with ARDS and other causes of severe pulmonary failure. ECMO is also rarely used as a rescue therapy in a small subset of adult patients with cardiac failure. This article will review the current uses and techniques of ECMO in the critical care setting as well as the evidence supporting its usage. In addition, current practice management related to coding and reimbursement for this intensive therapy will be discussed.

Trauma rehabilitation outcome scoring.

PURPOSE OF REVIEW: Appropriate measurements of success in trauma systems are evolving. We review the rationale behind prior trauma and rehabilitation outcomes measures, and how they have led to the current rehabilitation tools in use today. In addition, we review the difficulties with current methods and future improvements that need to occur. RECENT FINDINGS: As medicine marches toward improved used of clinical evidence, trauma practitioners have worked for improved outcomes research. A major part of this is that outcomes such as functional status and quality of life are as important as mortality statistics. Trauma rehabilitation outcomes are thus more important, yet in the past all such tools have had major impediments to implementation across a heterogeneous trauma population. Newly recognized major domains such as quality of life, preinjury status, patient perceptions, and actual function at work have not been adequately addressed with current rehabilitation measures. At this time, no clinically applicable trauma rehabilitation score exists. SUMMARY: Trauma rehabilitation outcomes are an important measurement of trauma system effectiveness. A more effective, easily applied rehabilitation score is needed to adequately assess all appropriate domains of clinical improvement in the injured patient.

Effect of chlorhexidine/silver sulfadiazine-impregnated central venous catheters in an intensive care unit with a low blood stream infection rate after implementation of an educational program: a before-after trial.

BACKGROUND: Current guidelines recommend using antiseptic- or antibiotic-impregnated central venous catheters (CVCs) if, following a comprehensive strategy to prevent catheter-related blood stream infection (CR-BSI), infection rates remain above institutional goals based on benchmark values. The purpose of this study was to determine if chlorhexidine/silver sulfadiazine-impregnated CVCs could decrease the CR-BSI rate in an intensive care unit (ICU) with a low baseline infection rate. METHODS: Pre-intervention and post-intervention observational study in a 24-bed surgical/trauma/burn ICU from October, 2002 to August, 2005. All patients requiring CVC placement after March, 2004 had a chlorhexidine/silver sulfadiazine-impregnated catheter inserted (post-intervention period). RESULTS: Twenty-three CR-BSIs occurred in 6,960 catheter days (3.3 per 1,000 catheter days)during the 17-month control period. After introduction of chlorhexidine/silver sulfadiazine-impregnated catheters, 16 CR-BSIs occurred in 7,732 catheter days (2.1 per 1,000 catheter days; p = 0.16). The average length of time required for an infection to become established after catheterization was similar in the two groups (8.4 vs. 8.6 days; p = 0.85). Chlorhexidine/silver sulfadiazine-impregnated catheters did not result in a statistically significant change in the microbiological profile of CR-BSIs, nor did they increase the incidence of resistant organisms. CONCLUSIONS: Although chlorhexidine/silver sulfadiazine-impregnated catheters are useful in specific patient populations, they did not result in a statistically significant decrease in the CR-BSI rate in this study, beyond what was achieved with education alone.

Survey of American College of Surgeons Committee on trauma members on firearm injury: Consensus and opportunities.

BACKGROUND: In the United States, there is a perceived divide regarding the benefits and risks of firearm ownership. The American College of Surgeons Committee on Trauma Injury Prevention and Control Committee designed a survey to evaluate Committee on Trauma (COT) member attitudes about firearm ownership, freedom, responsibility, physician-patient freedom and policy, with the objective of using survey results to inform firearm injury prevention policy development. METHODS: A 32-question survey was sent to 254 current U.S. COT members by email using Qualtrics. SPSS was used for χ exact tests and nonparametric tests, with statistical significance being less than 0.05. RESULTS: Our response rate was 93%, 43% of COT members have firearm(s) in their home, 88% believe that the American College of Surgeons should give the highest or a high priority to reducing firearm-related injuries, 86% believe health care professionals should be allowed to counsel patients on firearms safety, 94% support federal funding for firearms injury prevention research. The COT participants were asked to provide their opinion on the American College of Surgeons initiating advocacy efforts and there was 90% or greater agreement on 7 of 15 and 80% or greater on 10 of 15 initiatives. CONCLUSION: The COT surgeons agree on: (1) the importance of formally addressing firearm injury prevention, (2) allowing federal funds to support research on firearms injury prevention, (3) retaining the ability of health care professionals to counsel patients on firearms-related injury prevention, and (4) the majority of policy initiatives targeted to reduce interpersonal violence and firearm injury. It is incumbent on trauma and injury prevention organizations to leverage these consensus-based results to initiate prevention, advocacy, and other efforts to decrease firearms injury and death. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level I; therapeutic care, level II.