Findings on Repeat Posttraumatic Brain Computed Tomography Scans in Older Patients With Minimal Head Trauma and the Impact of Existing Antithrombotic Use.

STUDY OBJECTIVE: Evaluate the utility of routine rescanning of older, mild head trauma patients with an initial negative brain computed tomography (CT), who is on a preinjury antithrombotic (AT) agent by assessing the rate of delayed intracranial hemorrhage (dICH), need for surgery, and attributable mortality. METHODS: Participating centers were trained and provided data collection instruments per institutional review board-approved protocols. Data were obtained from manual chart review and electronic medical record download. Adults ≥55 years seen at Level I/II Trauma Centers, between 2017 and 2019 with suspected head trauma, Glasgow Coma Scale 14 to 15, negative initial brain CT, and no other Abbreviated Injury Scale injuries >2 were identified, grouped by preinjury AT therapy (AT- or AT+) and compared on dICH rate, need for operative neurosurgical intervention, and attributable mortality using univariate analysis (α=.05). RESULTS: A total of 2,950 patients from 24 centers were enrolled; 280 (9.5%) had a repeat brain CT. In those rescanned, the dICH rate was 15/126 (11.9%) for AT- and 6/154 (3.9%) in AT+. Assuming nonrescanned patients did not suffer clinically meaningful dICH, the dICH rate would be 15/2001 (0.7%) for AT- and 6/949 (0.6%) for AT+. No surgical operations were done for dICH. All-cause mortality was 9/2950 (0.3%) and attributable mortality was 1/2950 (0.03%). The attributable death was an AT+, dICH patient whose family declined intervention. CONCLUSION: In older patients with an initial Glasgow Coma Scale of 14 to 15 and a negative initial brain CT scan, the dICH rate is low (<1%) and of minimal clinical consequence, regardless of AT use. In addition, no patient had operative neurosurgical intervention. Therefore, routine rescanning is not supported based on the results of this study.

Nonoperative management of acute epidural hematomas: a "no-brainer".

BACKGROUND: Acute epidural hematomas are generally considered to require urgent operation for clot evacuation and bleeding control. It has become increasingly apparent, however, that many epidural hematomas will resolve with nonoperative management. The purpose of the current study was to review our experience with nonoperative management of acute epidural hematomas. METHODS: Patients admitted to our busy urban level I trauma center with an epidural hematoma were identified using our trauma registry. Patients were excluded if they suffered other significant intracranial injury mandating operative intervention. Patient records were reviewed and relevant data collected. Patients who required subsequent craniotomy were compared to those who did not in order to identify risk factors for failure of nonoperative treatment. RESULTS: Between January 1995 and June 2004, 84 patients were identified. The mean age was 27 +/- 1.6 years and 68 (81%) were male. Mean Glasgow Coma Scale in the emergency department was 13.7 +/- 0.3. The most common mechanism of injury was a fall. Fifty-four (64%) patients were initially managed nonoperatively and 30 (36%) were taken directly to the operating room for craniotomy. Nonoperative management was successful in 47/54 (87%) patients. Failure of initial nonoperative management was not associated with adverse outcome. There were no deaths in patients managed operatively or nonoperatively. Seventy-two (86%) patients were discharged to home with excellent neurologic outcome. CONCLUSIONS: Epidural hematomas can be successfully managed nonoperatively in an appropriately selected group of patients. Moreover, failure of initial nonoperative management has no adverse effect on outcome.

General surgery residents improve efficiency but not outcome of trauma care.

BACKGROUND: Current American College of Surgeons Level I trauma center verification requires the presence of a residency program in which trauma care is an integral part of the training. The rationale for this requirement remains unclear, with no scientific evidence that resident participation improves the quality of trauma care. The purpose of this study was to determine whether quality or efficiency of trauma care is influenced by general surgery residents. METHODS: Our urban Level I trauma center has traditionally used 24-hour in-house postgraduate year-4 general surgery residents in conjunction with at-home trauma attending backup to provide trauma care. As of July 1, 2000, general surgery residents no longer participated in trauma patient care, leaving sole responsibility to an in-house trauma attending. Data regarding patient outcome and resource use with and without surgery resident participation were tabulated and analyzed. Continuous data were compared using Student's t test if normally distributed and the Mann-Whitney U test if nonparametric. Categorical data were compared using chi2 analysis or Fisher's exact test as appropriate. RESULTS: During the 5-month period with resident participation, 555 trauma patients were admitted. In the identical time period without residents, 516 trauma patients were admitted. During the period without housestaff, patients were older and more severely injured. Mechanism was not different during the two time periods. Mortality was not affected; however, time in the emergency department and hospital lengths of stay were significantly shorter with residents. Multiple regression confirmed these findings while controlling for age, mechanism, and Injury Severity Score. CONCLUSION: Although resident participation in trauma care at a Level I trauma center does not affect outcome, it does significantly improve the efficiency of trauma care delivery.

The role of temporary inferior vena cava filters in critically ill surgical patients.

HYPOTHESIS: Prophylactic temporary inferior vena cava (IVC) filters are safe and effective in critically ill patients at high risk for venous thromboembolism. DESIGN: Prospective cohort study. SETTING: Urban level I trauma center. SUBJECTS: Multiple-trauma patients and critically ill surgical patients undergoing prophylactic temporary IVC filter placement. All patients were at high risk for venous thromboembolism but had contraindications to low-dose heparin therapy. INTERVENTIONS: The interventional radiologist used the femoral or internal jugular approach to place a removable IVC filter in all patients. The filter was removed when the patient could safely be treated with heparin. If the filter could not be removed by 14 days, it was relocated to prevent incorporation precluding retrieval. MAIN OUTCOME MEASURES: Complications of filter insertion and removal, deep venous thrombosis, and pulmonary embolism. RESULTS: From May 1, 2001, to October 1, 2002, 44 patients underwent placement of temporary IVC filters. Thirty-seven patients (84%) were severely injured. The mean +/- SD age was 37 +/- 3 years, and 55% were men. The mean +/- SD Injury Severity Score of the trauma patients was 33 +/- 2, and all had blunt injury. There were no complications associated with filter insertion or removal. Nine patients required filter relocation prior to retrieval. Three filters could not be removed: 2 secondary to significant clots trapped below the filter and 1 because of angulation resulting in the inability to grasp the filter. There were no documented instances of venous thromboembolism following IVC filter placement and removal. CONCLUSIONS: Temporary IVC filters are safe and effective in critically ill surgical and trauma patients and allow an aggressive approach to prevention of venous thromboembolism in this challenging group of patients.

The adrenal response after severe trauma.

BACKGROUND: The integrity of the hypothalamic-pituitary-adrenal axis is a major determinant of the host response to stress. Relative adrenal insufficiency has been implicated in poor outcome from systemic inflammatory states; however, whether low endogenous glucocorticoid levels are adaptive or pathologic remains controversial. The purpose of this study was to prospectively evaluate the cortisol response and determine the incidence of occult adrenal insufficiency after severe trauma. METHODS: Over an 18-month period, 22 severely injured patients admitted to the surgical intensive care unit of our level 1 trauma center were prospectively identified and followed. Demographic and outcome data were tabulated. In addition, random serum cortisol levels were obtained on days 0, 5, and 10 after injury. Relative adrenal insufficiency was defined as a random serum cortisol level less than 18 microg/dL. RESULTS: Mean baseline cortisol levels were elevated (35 +/- 3 microg/dL) and significantly declined over the next 10 days (day 5: 24 +/- 2 microg/dL; and day 10: 22 +/- 2 microg/dL; P <0.01). Thirteen of 22 (60%) patients had random serum cortisol levels less than 18 microg/dL. Only 1 of the 2 patients who died had a serum cortisol level less than 18 microg/dL. The mean cortisol levels at baseline were higher in the 2 patients who died compared with those who survived but this was not statistically significant (43.4 +/- 8.8 microg/dL versus 35.0 +/- 3.6 microg/dL, P = 0.5). CONCLUSIONS: Serum cortisol levels increased immediately and gradually returned towards normal after severe trauma. Occult adrenal insufficiency was common (60%) in this small group of severely injured patients. This did not, however, affect mortality in these patients. Further study is needed to delineate the role of occult adrenal insufficiency after severe injury.

Increased rate of infection associated with transfusion of old blood after severe injury.

HYPOTHESIS: Blood components undergo changes during storage that may affect the recipient, including the release of bioactive agents, with significant immune consequences. We hypothesized that transfusion of old blood increases infection risk in severely injured patients. DESIGN: Prospective cohort study. SETTING: Urban level I regional trauma center. PATIENTS: Sixty-one trauma patients with an Injury Severity Score greater than 15, age older than 15 years, and survival longer than 48 hours who were transfused with 6 to 20 U of red blood cells in the first 12 hours after injury were studied. By means of blood bank records, the age of each unit of blood was determined. INTERVENTION: Transfusion of allogeneic red blood cells. MAIN OUTCOME MEASUREMENTS: Major infectious complications. RESULTS: The early (<12 hours) transfusion requirement was 12 +/- 0.6 U, with a mean age 27 +/- 1 days. Major infections developed in 32 patients (52%). Age and Injury Severity Score were not significantly different between patients who developed infections and those who did not (age, 39 +/- 4 vs 36 +/- 3 years; Injury Severity Score, 33 +/- 1.5 vs 29 +/- 1.5). Transfusion of older blood was associated with subsequent infection; patients who developed infections received 11.7 +/- 1.0 and 9.9 +/- 1.0 U of red blood cells older than 14 and 21 days, respectively, compared with 8.7 +/- 0.8 and 6.7 +/- 0.08 in patients who did not develop infections (both P<.05, t test). Multivariate analysis confirmed age of blood as an independent risk factor for major infections. CONCLUSIONS: Transfusion of old blood is associated with increased infection after major injury. Other options, such as leukocyte-depleted blood or blood substitutes, may be more appropriate in the early resuscitation of trauma patients requiring transfusion.

The Outreach Trauma Program: a model for survival of the academic trauma center.

BACKGROUND: In the current health care climate, trauma centers face particular economic challenges. Statewide trauma systems provide a network for referral of critically injured patients to academic Level I trauma centers, but favorable reimbursement in states such as Colorado results in intense competition for patients. We hypothesized that a comprehensive Outreach Trauma Program would facilitate our mission as a key resource facility in our trauma system, and would increase referrals of critically injured patients to our center from outside our metropolitan area. METHODS: The Colorado statewide trauma system was formalized in 1995; our Outreach program-including providing visiting trauma call, continuing medical education lectures, 24-hour/7-day immediate consultation and transfers, and public relations/marketing-was fully implemented in 1997. We audited our trauma registry from January 1994 to July 2001 to determine the impact on patient volume and acuity as well as academic productivity. RESULTS: Annual overall trauma admissions have remained stable. Since 1997, high-acuity patients (i.e., Injury Severity Score > 15, intensive care unit admissions, those requiring surgery) have increased 27% to 51%, attributable largely to an approximately 300% increase in high-acuity Outreach patients. In 2000, Outreach patients constituted 8% of our total trauma admissions, but 21% of intensive care unit trauma admissions; notably, they accounted for 25% of our center's trauma charges. Meanwhile, our group's academic productivity has not suffered; in fact, we had 57 publications in 2000, compared with an average of 35 per year from 1993 through 1997. CONCLUSION: The Outreach Trauma Program has proven clinically, academically, and financially rewarding. Our program may serve as a model whereby academic trauma centers, through a demonstrated commitment to serving the clinical and educational needs of their referral base, can satisfy their mission while ensuring their survival.

Evaluation of a new technique for bedside percutaneous tracheostomy.

BACKGROUND: Percutaneous tracheostomy as described by Ciaglia is accepted as a safe technique with minimal associated morbidity. Recent modification of the technique to a single-step dilator prompted us to evaluate this in the critically injured patient. METHODS: A comparison of patients undergoing percutaneous tracheostomy was performed. From May 1998 to May 1999, patients underwent surgery using the sequential multidilator technique (MDT), and from July 1999 to July 2000, patients underwent surgery using the single dilation technique (SDT). RESULTS: Ninety-three tracheostomies were performed, 49 MDT and 44 SDT. Time to tracheostomy and total ventilator days was similar between the groups. Three complications occurred. In the MDT group, 1 patient experienced delayed tracheal hemorrhage not requiring transfusion. In the SDT group, 1 patient had transient right lower lobe collapse, and another patient had unexplained extubation requiring emergent cricothyroidotomy. CONCLUSIONS: Percutaneous tracheostomy using the single-step Rhino dilator technique is technically easier than the currently accepted multidilator technique with equivalent complications.