Evaluating blunt abdominal trauma with sonography: a cost analysis.

Ultrasonography (US) is becoming increasingly utilized in the United States for the evaluation of blunt abdominal trauma (BAT). The objective of this study was to assess the cost impact of utilizing US in the evaluation of patients with BAT in a major trauma center. All patients sustaining BAT during a 6-month period before US was used at our institution (Jan-Jun 1993) were compared to BAT patients from a recent period in which US has been utilized (Jan-Jun 1995). The numbers of US, computed tomography (CT), and diagnostic peritoneal lavage (DPL) were tabulated for each group. Financial cost for each of these procedures as determined by our finance department were as follows: US $96, CT $494, DPL $137. These numbers are representative of actual hospital expenditures exclusive of physician fees as calculated in 1994 U.S. dollars. Cost analysis was performed with t test and chi squared test, and significance was defined as P < 0.05. There were 890 BAT admissions in the 1993 study period and 1033 admissions in the 1995 study period. During the 1993 period, 642 procedures were performed on the 890 patients to evaluate the abdomen: 0 US, 466 CT, and 176 DPL (see table) [table: see text]. This compares to 801 procedures on the 1,033 patients in 1995: 552 US, 228 CT, and 21 DPL. Total cost was $254,316 for the 1993 group and $168,501 for the 1995 group. Extrapolated to a 1-year period, a significant (P < 0.05) cost savings of $171,630 would be realized. Cost per patient evaluated was significantly reduced from $285.75 in 1993 to $163.12 in 1995 (P < 0.05). This represents a 43 per cent reduction in per patient expenditure for evaluating the abdomen. By effectively utilizing ultrasonography in the evaluation of patients with blunt abdominal trauma, a significant cost savings can be realized. This effect results chiefly from an eight-fold reduction in the use of DPL, and a two-fold reduction in the use of CT.

Measuring service-specific performance and educational value within a general surgery residency: the power of a prospective, anonymous, Web-based rotation evaluation system in the optimization of resident satisfaction.

BACKGROUND: We used a Web-based evaluation system to institute specific changes to various clinical teaching services in our integrated residency in an effort to optimize the overall quality of the educational experience and measured the resident satisfaction in these rotations. METHODS: Residents rated 8 categories of experience on a scale of 1 to 5 (maximum summation score, 40 points). Data were analyzed by t-test for equality of means. A probability value of less than.05 was considered significant. RESULTS: Compliance with completion of the evaluations was 100%. The Chronbach's alpha reliability coefficient of the tool was 0.826. Tukey's estimate of power to achieve additivity was 1.5. Six under-performing services were re-engineered with prominent effects on 7 postgraduate year (PGY) rotations. On 2 general surgery services at 1 hospital, the workload was redistributed, and a dedicated team teaching time was instituted (PGY-3 [a]: before, 22 points/after, 31 points; P =.003; PGY-3 [b]: before, 25 points/after, 31 points; P =.004; PGY-1: before, 24 points/after, 29 points; P =.07). A general surgery service at another hospital redistributed coverage of the attending surgeons to create a nonteaching service (PGY-1: before, 22 points/-after, 27 points; P =.01). The transplantation service (PGY-3) was examined, and the role of the point was redefined (before, 24 points/after, 31 points; P =.01). One vascular service (PGY-2) redistributed cases and workload (before, 27 points/after, 22 points; P =.07). The vascular PGY-2 position was eliminated and replaced by a mid-level practitioner. The cardiothoracic service (PGY-1) rotation was converted into a preceptorship (before, 23 points/after, 30 points; P =.015). CONCLUSIONS: A web-based clinical rotation evaluation provides a means for the assessment of the impact of programmatic changes while preserving resident anonymity and maintaining accountability.

Beyond requirements: residency management through the Internet.

HYPOTHESIS: An Internet application could collect information to satisfy documentation required by the Residency Review Committee. Beyond replacing a difficult and inefficient paper system, it would collect, process, and distribute information to administration, faculty, and residents. DESIGN: Descriptive study. SETTING: An integrated residency of 18 services at a university teaching hospital with 4 affiliated institutions. PARTICIPANTS: Residency administrators, faculty, and residents. INTERVENTIONS: The application included a procedure recorder, resident evaluation of faculty and rotations, goals and objectives (stratified by service and resident level), and matching faculty evaluation of residents with these goals as competencies. Policies, schedules, research opportunities, clinical site information, and curriculum support were created. MAIN OUTCOME MEASURES: Degree of compliance with Residency Review Committee standards, number of deficiencies corrected, and quantity and quality of information available to administration, faculty, and residents. RESULTS: The Internet system increased resident compliance for faculty and rotation evaluations from 20% and 34%, respectively, to 100%, which was maintained for 22 months. These evaluations can be displayed individually, in summary grids, and as postgraduate year-specific averages. Faculty evaluations of residents can be reviewed throughout the system. The defined category report for procedures, which had deficiencies in the preceding 6 years, had none for the last 2 years. The Internet application provides Accreditation Council for Graduate Medical Education-validated operative logs to regulatory agencies. CONCLUSIONS: A Web-based system can satisfy requirements and provide processed data that are of better quality and more complete than our paper system. We are now able to use scarce time and personnel to nurture developing surgical residents instead of shuffling paper.

Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma.

OBJECTIVE: The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay. METHODS: This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fisher's exact test, Student's T test, and logistic regression analysis. RESULTS: The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47). CONCLUSION: Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

Perioperative antibiotic use in high-risk penetrating hollow viscus injury: a prospective randomized, double-blind, placebo-control trial of 24 hours versus 5 days.

BACKGROUND: The purpose of this study was to compare the safety and therapeutic efficacy of a 24-hour versus 5-day course of ampicillin/sulbactam for the prevention of postoperative infections in high-risk patients sustaining hollow viscus injury from penetrating abdominal trauma. METHODS: A total of 317 patients from four Level I trauma centers with penetrating abdominal injuries and at least one hollow viscus perforation each received one preoperative and three postoperative doses of ampicillin/sulbactam 3 g intravenously. After receiving 24 hours of unblinded ampicillin/sulbactam, patients were then randomized into one of two groups. Group 1 received 4 additional days of blinded ampicillin/sulbactam (5 days total of antibiotic), and Group 2 received 4 days of placebo (24 hours of antibiotic). Patients were assessed postoperatively for occurrence of deep surgical-site infections (intra-abdominal abscess, fasciitis, and peritonitis) and superficial (wound) surgical-site infections. Development of nonsurgical-site infections (e.g., pneumonia, urinary tract infection, phlebitis, and cellulitis) was also recorded. Continuous variables were analyzed by analysis of variance and discrete variables by the Cochran-Mantel-Haenszel chi2 test. Multivariate logistic regression analyses were also performed to identify independent risk factors for postoperative infection. RESULTS: A total of 159 patients were randomized into Group 1, and 158 patients were randomized into Group 2. The Injury Severity Score and penetrating abdominal trauma index were 18+/-8 and 21+/-13, respectively, for Group 1 and 18+/-9 and 20+/-15, respectively, for Group 2. A total of 162 (51%) patients sustained one or more colon injuries (82 in Group 1 and 80 in Group 2). There were 16 (10%) surgical-site infections in Group 1 and 13 (8%) surgical-site infections in Group 2 (p = 0.74). Group 1 patients experienced 17 (11%) nonsurgical-site infections, whereas Group 2 had 32 (20%) nonsurgical-site infections. This difference, however, was not statistically significant (p = 0.16). Only the total number of blood units transfused and the presence of a PATI score greater than or equal to 25 were found to be independently associated with the development of a postoperative surgical- and nonsurgical-site infections (p = 0.001 and p = 0.003, respectively). Of note, the presence of a colon injury was not found to be an independent risk factor (p = 0.11) for either surgical or nonsurgical site postoperative infection in our study. CONCLUSION: High-risk patients with colon or other hollow viscus injuries from penetrating abdominal trauma are at no greater risk for surgical-site or nonsurgical-site infection when treated with only a 24-hour course of a broad-spectrum antibiotic.

Critical care medicine education of surgeons: recommendations from the Surgical Section of the Society of Critical Care Medicine.

PERSPECTIVE: The role of surgeons in critical care medicine has a long and esteemed past. The presence of surgeons in intensive care units provides specific insights and perspectives to the care of surgical patients sometimes not fully appreciated by the non-surgical practitioners caring for the same patients. The training and education of surgeons is becoming more complex, fragmented, and lengthy. The knowledge base and skill set required to manage critically ill or injured surgical patients is also becoming more extensive but has the potential of becoming lost in the process of providing the overall educational program for surgical trainees. Simultaneously, nonsurgical specialties are continuing to train individuals with special skills in critical care medicine and the concept of "hospitalists" is becoming more accepted by institutions across the United States. The certification exams in critical care medicine remain under the aegis of the individual medical specialty boards, and there is still not a unified examination process in critical care. Surgeons, in particular, have tremendous pressures these days to spend more clinical time in the operating room, and the task of consistently conducting high quality research is also becoming arduous. This list of reasons could continue but are simply examples for why surgeons need to spend focused attention on how best to train and educate upcoming surgical trainees in regards to the principles of critical care medicine. The critically ill or injured patients need this focused attention and the specialty of surgical critical care medicine needs this attention. The Surgical Section of the Society of Critical Care Medicine has developed this position statement in the hopes that ongoing discussion and refinement of this particular aspect of surgery will continue on several levels.

A multi-institutional study of factors associated with fetal death in injured pregnant patients.

HYPOTHESIS: Factors associated with fetal death in injured pregnant patients are related to increasing injury severity and abnormal maternal physiologic profile. DESIGN: A multi-institutional retrospective study of 13 level I and level II trauma centers from 1992 to 1996. MAIN OUTCOME MEASURE: Fetal survival. RESULTS: Of 27,715 female admissions, there were 372 injured pregnant patients (1.3%); 84% had blunt injuries and 16% had penetrating injuries. There were 14 maternal deaths (3.8%) and 35 fetal deaths (9.4%). The population suffering fetal death had higher injury severity scores (P<.001), lower Glascow Coma Scale scores (P<.001), and lower admitting maternal pH (P = .002). Most women who lost their fetus arrived in shock (P = .005) or had a fetal heart rate of less than 110 beats/min at some time during their hospitalization (P<.001). An Injury Severity Score greater than 25 was associated with a 50% incidence of fetal death. Placental abruption was the most frequent complication, occurring in 3.5% of patients and associated with 54% mortality. Cardiotrophic monitoring to detect potentially threatening fetal heart rates was performed on only 61% of pregnant women in their third trimester. Of these patients, 7 had abnormalities on cardiotrophic monitoring and underwent successful cesarean delivery. CONCLUSIONS: Fetal death was more likely with greater severity of injury. Cardiotrophic monitoring is underused in injured pregnant patients in their third trimester even after admission to major trauma centers. Increased use of cardiotrophic monitoring may decrease the mortality caused by placental abruption.

Reengineering respiratory support following extubation: avoidance of critical care unit costs.

STUDY OBJECTIVE: We prospectively investigated alternative clinical practice strategies for critically ill trauma patients following extubation to evaluate the cost-effectiveness of these maneuvers. The primary change was elimination of the routine use of postextubation supplemental oxygen, with concurrent utilization of noninvasive positive pressure ventilatory support (NPPV) to manage occurrences of postextubation hypoxemia. DESIGN: Prospective, consecutive accrual of patients undergoing extubation. SETTING: Trauma ICU in a university hospital. INTERVENTIONS AND MEASUREMENTS: All patients received mechanical ventilation using pressure support ventilation (PSV) with continuous positive airway pressure (CPAP) as the primary mode. The patients were extubated to room air following a 20-min preextubation trial of 5 cm H(2)O CPAP at FIO(2) of 0.21, and demonstrating a spontaneous respiratory rate /= 7.30, PaCO(2) /= 50 mm Hg. The subgroup of patients who became hypoxemic (pulse oximetric saturation < 88%) within 24 h of extubation were treated with NPPV for up to 48 h duration. Patients who failed NPPV were reintubated. Four hundred fifty-one (84%) patients were successfully extubated to room air. Seventy-two patients (13%) became hypoxemic within 24 h, and NPPV was administered. Fifty-two patients (72% of those who were hypoxemic) responded to NPPV, while 20 patients failed to respond to therapy, were reintubated, and received mechanical ventilation for a mean of 4 days. Thirteen additional patients (2%) were reintubated for reasons other than hypoxemia. The overall reintubation rate for the group (n = 536) was 6.2%; for the postextubation hypoxemic group who failed NPPV, the reintubation rate was 3.7%. The elimination of routine supplemental oxygen via nasal cannula following extubation resulted in a potential direct cost avoidance of $50,006.88 for 451 patient days. Moreover, the 52 patients who were spared reintubation and mechanical ventilation provided an additional potential cost avoidance of $19,740.24 in unused ventilator days per patient. CONCLUSION: Eliminating the routine use of supplemental oxygen and employing NPPV as a method to prevent reintubation can facilitate a more aggressive, cost-effective strategy for the management of the trauma ICU patient who has been extubated.

Patterns of maxillofacial injuries in powered watercraft collisions.

Because of the widespread popularity of water sports, plastic and reconstructive surgeons can expect to manage an increasing number of injuries associated with these activities, particularly those related to powered watercraft vehicles. Although seat belts for motorists and helmets for motorcyclists may be efficacious, such devices currently do not serve a similar role in powered watercraft sports. In this study, a retrospective chart review of 194 consecutive patients who presented to the University of Miami/Jackson Memorial Hospital (Level I trauma center) as a result of powered watercraft collisions is presented. The purpose of this investigation was to assess the incidence, cause, demographics, and available management options for head and neck injuries secondary to powered watercraft. Identified were 194 patients who presented because of watersports-related injuries during the period January 1, 1991, through December 31, 1996. From this group, 81 patients (41.8 percent) sustained injuries directly attributable to powered watercraft collisions, including 41 personal watercraft collisions (50.6 percent), 39 boat collisions (48.1 percent), and 1 airboat collision (1.2 percent). The patient population, as expected, tended to be young and male with an average age of 29 years (range, 8 to 64 years old). Interestingly, 41 of the patients (50.6 percent) who presented to this trauma center as a result of powered watercraft collisions also sustained associated head and neck trauma. Of 74 injuries 24 were facial fractures (32.4 percent), 18 were facial lacerations (24.3 percent), 14 were closed head injuries (18.9 percent), 8 were skull fractures (10.8 percent), 4 were scalp lacerations (5.4 percent), 4 were C-spine fractures (5.4 percent), 1 was an ear laceration (1.4 percent), and 1 was a fatality (1.4 percent). Le Fort fractures were the most commonly identified facial fracture in this series. The number of these injuries seen in hospital emergency rooms will most likely increase in the future as the popularity of water-related recreational activities becomes even more widespread. Based on these findings, it is strongly recommended that future efforts be directed toward the prevention of these injuries through patient education and the eventual development of efficacious and safe protective equipment.

Strategies to prevent organ failure.

The gastrointestinal tract and the generalized inflammatory response initiated by severe injury or infection have been implicated in the pathophysiology of multiple-organ system failure. Once multiple-organ system failure has occurred, treatment focuses on supporting end-organ function. Recent studies have shown, however, that it may be possible to reduce the incidence and prevalence of multiple-organ system failure by controlling the reperfusion injury cascade, normalizing gastrointestinal blood flow and preserving the integrity of the gastrointestinal immune barrier.

The role of computed tomography in selective management of gunshot wounds to the abdomen and flank.

OBJECTIVE: To determine whether computed tomography (CT) is an accurate diagnostic modality for the triage of hemodynamically stable patients with gunshot wounds of the abdomen and flank. METHODS: A chart review of 83 trauma patients for whom abdominal CT was used as initial screening. RESULTS: In 53 patients, CT revealed no evidence of peritoneal penetration, and in 15 patients, there was evidence of either peritoneal penetration or liver injury. There were no false results in these patients. Among 15 patients with questionable peritoneal penetration, cavitary endoscopy was performed in 11 and exploratory laparotomy was performed in 3, and 1 patient was initially observed and subsequently underwent exploratory surgery for a missed colonic injury. CONCLUSION: In selected centers and in hemodynamically stable patients with abdominal and flank gunshot wounds, abdominal CT can be an effective and safe initial screening modality to document the presence or absence of peritoneal penetration and to manage nonoperatively stable patients with liver injuries. If there is any question of peritoneal penetration, cavitary endoscopy should be part of the protocol of nonoperative management.

Immune responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy.

OBJECTIVES: Pneumococcal polysaccharide vaccine is given after emergency splenectomy for trauma to lessen the risk of overwhelming postsplenectomy sepsis. This study was undertaken to determine optimal timing of vaccine administration as determined by serum type-specific polysaccharide antibody concentration titer and functional activity of the resulting antibodies. METHODS: Fifty-nine consecutive patients undergoing splenectomy after trauma were randomized to receive pneumococcal vaccine postoperatively at 1, 7, or 14 days. Immunoglobulin G serum antibody concentrations against serogroup 4 and serotypes 6B, 19F, and 23F were measured before vaccination and 4 weeks postvaccination. Antibody concentrations were determined by enzyme-linked immunosorbent assay, and functional antibody by opsonophagocytosis. Results were compared with a normal adult control group (n = 12). RESULTS: Postvaccination enzyme-linked immunosorbent assay immunoglobulin G antibody concentrations for all serogroups and serotypes studied were not significantly different in splenectomized patients and control subjects. Postvaccination functional antibody activity was significantly reduced in early vaccination groups (serotype 6B excepted). However, with the exception of 19F, all titers for the 14-day group approached those of the control subjects (p > 0.05). Fold-increases of opsonophagocytic titers for serogroup 4 and serotypes 6B and 19F showed progressive increases with delay in vaccination. Except for serotype 23F, the number of postsplenectomy patients with opsonophagocytic titers <64 significantly decreased with a delay in vaccination (14 days). CONCLUSIONS: Postvaccination immunoglobulin G serum antibody concentrations were not significantly different from normal control subjects regardless of the time of vaccination (1, 7, or 14 days). Although concentrations approach normal, functional antibody activity was significantly lower. Better functional antibody responses against the serogroup and serotypes studied seemed to occur with delayed (14-day) vaccination.

Failure of splanchnic resuscitation in the acutely injured trauma patient correlates with multiple organ system failure and length of stay in the ICU.

INTRODUCTION: The purpose of our study was to evaluate the relationship between the state of splanchnic perfusion and morbidity and mortality in the hemodynamically unstable trauma patient acutely resuscitated in the ICU. METHODS: Gastric intramucosal pH (pHi) was monitored in a blinded fashion in 19 consecutive critically ill trauma patients with evidence of systemic hypoperfusion (arterial pH [pHa] <7.35, base excess >2.3 mmol/L, lactic acid >2.3 mEq/L) who received right heart catheters to guide resuscitation and subsequent hemodynamic monitoring. DESIGN: Prospective randomized consecutive series with retrospective analysis of data. SETTING: University hospital, surgical ICU. RESULTS: The mean values of APACHE II (acute physiology and chronic health evaluation) Injury Severity Score, pHa, arterial base excess, cardiac index, oxygen delivery index, and oxygen consumption index by 24 h were similar (Student's t test, p>0.1) between survivors and nonsurvivors and between those who developed at most a single (SOF) vs multiple organ system failure (MOSF). Supranormal oxygen delivery and utilization parameters were evenly distributed among survivors and nonsurvivors and patients with SOF and MOSF (chi2, p>0.5). Ten patients had a pHi <7.32 and nine patients had a pHi > or = 7.32 by 24 h. Fifty percent of patients with a pHi <7.32 died, compared with 11% of patients with a pH > or = 7.32 (chi2, p=0.07). Sixty percent of patients with a pHi <7.32 developed MOSF compared with 11% of patients with a pHi > or = 7.32 (chi2, p=0.03). The one patient who developed MOSF and died in the pHi > or = 7.32 cohort suffered from massive head trauma and had all futile medical interventions halted. No other patients who achieved a pH > or = 7.32 by hour 24 developed MOSF. Survivors with a pHi <7.32 at hour 24 had an increased ICU stay (pHi <7.32=46+/-15 days, pHi > or = 7.32=13+/-9 days; p<0.01). A pHi <7.32 carried a relative risk of 4.5 for death and 5.4 for the occurrence of MOSF. CONCLUSION: Attainment of a pHi > or = 7.32 at hour 24 carried a significantly reduced likelihood of MOSF. Being an inference of the state of regional perfusion, in a high-risk microvascular bed, gastric intraluminal tonometry should identify perfusion states of compensated or uncompensated shock during hemodynamic resuscitation of the critically ill injury patient. A low pHi appears to be a marker of postresuscitative morbidity and subsequent increased length of stay.

The impact of antioxidant and splanchnic-directed therapy on persistent uncorrected gastric mucosal pH in the critically injured trauma patient.

BACKGROUND: Critically ill trauma patients with gastric intramucosal acidosis, as measured by gastric tonometry, have an increased incidence of multiple organ dysfunction syndrome despite supranormal O2 delivery. We altered our resuscitation protocol to maximize splanchnic blood flow and decrease oxygen-derived free radical damage. DESIGN: Prospective clinical trial with historical controls. METHODS: The protocol differed from control by including administration of folate, mannitol, and low-dose isoproterenol. All patients had gastric tonometers and pulmonary artery catheters. If the intramucosal pH (pHi) was less than 7.25, splanchnic-sparing inotropic and vasodilatory agents were used to optimize systemic cardiac output. Two groups of trauma patients with persistent intramucosal acidosis at 24 hours (pHi < 7.25) were compared: a control group (n = 7), and patients who received the splanchnic/antioxidant protocol (n = 13). RESULTS: The two groups were similar based on Acute Physiology and Chronic Health Evaluation II score, Injury Severity Score, age, cardiac index, oxygen delivery, and oxygen consumption. The "splanchnic therapy" group had fewer organ system failures as well as shortened length of intensive care unit and hospital stay. Three of 7 patients in the control group and 2 of 13 patients in the splanchnic therapy group had a final pHi < 7.25. CONCLUSION: Gastric tonometry-guided resuscitation and antioxidant/splanchnic therapy in critically ill trauma patients with persistent gastric mucosal acidosis may decrease multiple organ dysfunction syndrome.

Personal watercraft crash injuries: an emerging problem.

BACKGROUND: The increased popularity of personal watercraft (PWC) has resulted in an increase in PWC-related injuries. In an effort to better understand the problem, a retrospective review of 37 victims of such injuries seen at a Level I trauma center and fatalities examined by the medical examiner were analyzed. RESULTS: Fourteen percent of the victims were passengers, two of whom were struck from behind, resulting in severe injuries. Twelve patients died of their injuries. For six victims, the cause of death was drowning; only one of these victims was wearing a personal flotation device. Two patients sustained transected aortas, 20% had brain injuries, 20% had spinal fractures, and 48% had skeletal and skull fractures. Abdominal organ injuries were present in only 13.5% of the victims, but they were significant, with liver, spleen, and kidney lacerations and aortic and renal artery injuries. CONCLUSION: In this population of victims of PWC crashes meeting preestablished trauma criteria or on-scene deaths, injuries were significant. Many of the drowning deaths may have been prevented with the use of personal flotation devices. The potential for serious intra-abdominal injury must be recognized and dealt with appropriately.

Spinal cord injuries in adolescents after gunshot wounds: an increasing phenomenon in urban North America.

While much attention is focused on firearm fatalities, the purpose of this study was to determine the expense of acute medical care and the rehabilitation experience of surviving adolescent patients in the USA with spinal cord injury secondary to gunshot wounds. We analyzed a cohort of 19 patients, 18 of whom survived 12 months after spinal cord injury. The need for primary medical care related to the injury, current work and scholastic status, and satisfaction with the quality of rehabilitation were determined. Ten were not involved in any type of academic or meaningful activity, five had returned to school, three were undergoing rehabilitation, and one patient died. Major complications were present in 14 of the 18 patients. Thus, despite a high survival rate after spinal cord injury in this USA population, considerable long-term disability persists, and survivors report a low level of satisfaction with life.

A prospective, randomized comparison of an in-line heat moisture exchange filter and heated wire humidifiers: rates of ventilator-associated early-onset (community-acquired) or late-onset (hospital-acquired) pneumonia and incidence of endotracheal tube occlusion.

PURPOSE: To compare the performance of an in-line heat moisture exchanging filter (HMEF) (Pall BB-100; Pall Corporation; East Hills, NY) to a conventional heated wire humidifier (H-wH) (Marquest Medical Products Inc., Englewood, Colo) in the mechanical ventilator circuit on the incidence of ventilator-associated pneumonia (VAP) and the rate of endotracheal tube occlusion. METHODS: This report describes a prospective, randomized trial of 280 consecutive trauma patients in a 20-bed trauma ICU (TICU). All intubated patients not ventilated elsewhere in the medical center prior to their TICU admission were randomized to either an in-line HMEF or a H-wH in the breathing circuit. Ventilator circuits were changed routinely every 7 days, and closed system suction catheters were changed every 3 days. HMEFs were changed every 24 h, or more frequently if necessary. A specific endotracheal tube suction and lavage protocol was not employed. Patients were dropped from the HMEF group if the filter was changed more than three times a day or the patient was placed on a regimen of ultra high-frequency ventilation. The Centers for Disease Control and Prevention (CDC) criteria for diagnosis of pneumonia were used; early-onset, community-acquired pneumonia was defined if CDC criteria were met in < or =3 days, and late-onset, hospital-acquired pneumonia was defined if criteria were met in >3 days. Laboratory and chest radiograph interpretation were blinded. RESULTS: The patient ages ranged from 15 to 95 years in the HMEF group and 16 to 87 years in the H-wH group (p=not significant), with a mean age of 46 years and 48 years, respectively. The male to female ratio ranged between 78 to 82%/22 to 18%, respectively, and 55% of all admissions were related to blunt trauma, 40% secondary to penetrating trauma, and 5% to major burns. There was no difference in Injury Severity Score (ISS) between the two groups. Moreover, there was no significant difference in mean ISS among those who did not develop pneumonia and those patients who developed either early-onset, community-acquired or late-onset, hospital-acquired pneumonia. The HMEF nosocomial VAP rate was 6% compared to 16% for the H-wH group (p<0.05), and total ventilator circuit costs (per group) were reduced. There were no differences in duration of ventilation (mean+/-SD) if the patient did not develop pneumonia or if the patient developed an early-onset, community-acquired or a late-onset, hospital-acquired pneumonia. Moreover, total TICU days were reduced in the HMEF group. In addition, the incidence of partial endotracheal tube occlusion was not significantly different between the H-wH and the HMEF groups. CONCLUSIONS: The HMEF used in this study reduced the incidence of late-onset, hospital-acquired VAP, but not early-onset, community-acquired VAP, compared to the conventional H-wH circuit. This was associated with a significant reduction in total ICU stay. Disposable ventilator circuit costs in the HMEF group were reduced compared to the H-wH group in whom circuit changes occurred at 7-day intervals. CLINICAL IMPLICATIONS: The use of the HMEF is a cost-effective clinical practice associated with fewer late-onset, hospital-acquired VAPs, and should result in improved resource allocation and utilization.

Do pulmonary artery catheters alter outcome in trauma patients?

OBJECTIVE: To review the literature addressing the use of the pulmonary artery catheter (PAC) in victims of blunt and penetrating trauma and examine the available evidence that supports or refutes the claim that PAC use alters outcome in this patient population. Furthermore, to determine what additional research should be done in this area. DATA SOURCE: All pertinent English language articles dealing with pulmonary artery catheterization in trauma patients were retrieved from 1979 through 1996. STUDY SELECTION: Clinical studies were considered if PACs were used to establish a cardiopulmonary diagnosis, optimize or achieve endpoints of oxygen transport and utilization indices, or guide and/or determine response to therapy. Emphasis was placed on prospective, randomized, controlled trials. However, descriptive case series and retrospectively-analyzed, uncontrolled reviews comprise the majority of available literature. DATA EXTRACTION: From these selective studies, information was obtained regarding patient demographics, therapeutic endpoints, and achieved outcome. DATA SYNTHESIS: Insufficient evidence exists to support a true survival benefit. However, recommendations for indications can be proposed where a reduction in morbidity or improvement in functional outcome is suggested. CONCLUSION: Hemodynamic data obtained from the PAC appear to be beneficial for the following indications: a) to ascertain the status of underlying cardiovascular performance and/or the need for improvement; b) to direct therapy when noninvasive monitoring may be inadequate, misleading, or the endpoints of resuscitation difficult to define; c) to assess response to resuscitation; d) to potentially decrease secondary injury when severe closed-head or acute spinal cord injuries are components of multisystem trauma; e) to augment clinical decision-making when major trauma is complicated by severe adult respiratory distress syndrome, progressive oliguria/anuria, myocardial ischemia, congestive heart failure, or major thermal injury; and f) to establish futility of care.