Decreasing failed extubations with the implementation of an extubation checklist.

BACKGROUND: Failed extubation has been shown to increase ICU stay, transfers to rehabilitation facilities, and mortality. The purpose of this study was to assess the differences in rates of failed extubation before and after implementation of an extubation checklist. METHODS: We performed a retrospective study from January 2013-April 2017 on adult trauma patients (age 18-89) who were admitted to the ICU and required mechanical ventilation. Patients were grouped before and after implementation of an extubation checklist and compared. RESULTS: A total of 993 patients were included in this study. After checklist implementation, significantly fewer patients required reintubation compared to those prior to checklist (7% vs 3%, p = 0.005). There was no difference in mortality (20% vs 21%, p = 0.54) or hospital length of stay between the two groups (16 days vs 15 days, p = 0.16). CONCLUSION: Our study reveals that implementing an extubation checklist is associated with fewer failed extubations.

Do screening and a randomized brief intervention at a Level 1 trauma center impact acute stress reactions to prevent later development of posttraumatic stress disorder?

BACKGROUND: Approximately 20% to 40% of trauma survivors experience posttraumatic stress disorder (PTSD). The American College of Surgeons Committee on Trauma reports that early screening and referral has the potential to improve outcomes and that further study of screening and intervention for PTSD would be beneficial. This prospective randomized study screened hospitalized patients for traumatic stress reactions and assessed the effect of a brief intervention in reducing later development of PTSD. METHODS: The Primary Care PTSD (PC-PTSD) screen was administered to admitted patients. Patients with symptoms were randomized to an intervention or control group. The brief intervention focused on symptom education and normalization, coping strategies, and utilizing supports. The control group received a 3-minute educational brochure review. Both groups completed in-hospital interviews, then 45- and 90-day telephone interviews. Follow-up collected the PTSD checklist-civilian (PCL-C) assessment and qualitative data on treatment-seeking barriers. RESULTS: The PC-PTSD screen was successful in predicting later PTSD symptoms at both 45 days (ß = 0.43, p < 0.001) and 90 days (ß = 0.37, p < 0.001) even after accounting for depression. Correlations of the intervention with the PCL-C scores and factor score estimates did not reach statistical significance at either time point (p = 0.827; p = 0.838), indicating that the brief intervention did not decrease PTSD symptoms over time. Of those at or above the PCL-C cutoff at follow-ups, a minority had sought treatment for their symptoms (43.2%). Primary barriers included focusing on their injury or ongoing rehabilitation, financial concerns, or location of residence. CONCLUSION: The PC-PTSD screen identified patients who later assess positive for PTSD using the PCL-C. The brief intervention did not reduce 45- and 90-day PTSD development. Follow-up interviews revealed lack of treatment infrastructure in the community. It will be important for trauma centers to align with community resources to address the treatment needs of at-risk patients. LEVEL OF EVIDENCE: Prospective randomized controlled trial, level II.

Circulation first - the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial.

Background: The traditional sequence of trauma care: Airway, Breathing, Circulation (ABC) has been practiced for many years. It became the standard of care despite the lack of scientific evidence. We hypothesized that patients in hypovolemic shock would have comparable outcomes with initiation of bleeding treatment (transfusion) prior to intubation (CAB), compared to those patients treated with the traditional ABC sequence. Methods: This study was sponsored by the American Association for the Surgery of Trauma multicenter trials committee. We performed a retrospective analysis of all patients that presented to trauma centers with presumptive hypovolemic shock indicated by pre-hospital or emergency department hypotension and need for intubation from January 1, 2014 to July 1, 2016. Data collected included demographics, timing of intubation, vital signs before and after intubation, timing of the blood transfusion initiation related to intubation, and outcomes. Results: From 440 patients that met inclusion criteria, 245 (55.7%) received intravenous blood product resuscitation first (CAB), and 195 (44.3%) were intubated before any resuscitation was started (ABC). There was no difference in ISS, mechanism, or comorbidities. Those intubated prior to receiving transfusion had a lower GCS than those with transfusion initiation prior to intubation (ABC: 4, CAB:9, p = 0.005). Although mortality was high in both groups, there was no statistically significant difference (CAB 47% and ABC 50%). In multivariate analysis, initial SBP and initial GCS were the only independent predictors of death. Conclusion: The current study highlights that many trauma centers are already initiating circulation first prior to intubation when treating hypovolemic shock (CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted. Trial registration: IRB approval number: HM20006627. Retrospective trial not registered.

Cross-section Trichometry: A Clinical Tool for Assessing the Progression and Treatment Response of Alopecia.

BACKGROUND: To properly assess the progression and treatment response of alopecia, one must measure the changes in hair mass, which is influenced by both the density and diameter of hair. Unfortunately, a convenient device for hair mass evaluation had not been available to dermatologists until the recent introduction of the cross-section trichometer, which directly measures the cross-sectional area of an isolated bundle of hair. OBJECTIVE: We sought to evaluate the accuracy and sensitivity of the HairCheck(®) device, a commercial product derived from the original cross-section trichometer. MATERIALS AND METHODS: Bundles of surgical silk and human hair were used to evaluate the ability of the HairCheck(®) device to detect and measure small changes in the number and diameter of strands, and bundle weight. RESULTS: Strong correlations were observed between the bundle's cross-sectional area, displayed as the numeric Hair Mass Index (HMI), the number of strands, the silk/hair diameter, and the bundle dry weight. CONCLUSION: HMI strongly correlated with the number and diameter of silk/hair, and the weight of the bundle, suggesting that it can serve as a valid indicator of hair mass. We have given the name cross-section trichometry (CST) to the methodology of obtaining the HMI using the HairCheck(®) system. CST is a simple modality for the quantification of hair mass, and may be used as a convenient and useful tool to clinically assess changes in hair mass caused by thinning, shedding, breakage, or growth in males and females with progressive alopecia or those receiving alopecia treatment.