Allocation of intensive care resources during an infectious disease outbreak: a rapid review to inform practice.

BACKGROUND: The COVID-19 pandemic has placed sustained demand on health systems globally, and the capacity to provide critical care has been overwhelmed in some jurisdictions. It is unknown which triage criteria for allocation of resources perform best to inform health system decision-making. We sought to summarize and describe existing triage tools and ethical frameworks to aid healthcare decision-making during infectious disease outbreaks. METHODS: We conducted a rapid review of triage criteria and ethical frameworks for the allocation of critical care resources during epidemics and pandemics. We searched Medline, EMBASE, and SCOPUS from inception to November 3, 2020. Full-text screening and data abstraction were conducted independently and in duplicate by three reviewers. Articles were included if they were primary research, an adult critical care setting, and the framework described was related to an infectious disease outbreak. We summarized each triage tool and ethical guidelines or framework including their elements and operating characteristics using descriptive statistics. We assessed the quality of each article with applicable checklists tailored to each study design. RESULTS: From 11,539 unique citations, 697 full-text articles were reviewed and 83 articles were included. Fifty-nine described critical care triage protocols and 25 described ethical frameworks. Of these, four articles described both a protocol and ethical framework. Sixty articles described 52 unique triage criteria (29 algorithm-based, 23 point-based). Few algorithmic- or point-based triage protocols were good predictors of mortality with AUCs ranging from 0.51 (PMEWS) to 0.85 (admitting SOFA > 11). Most published triage protocols included the substantive values of duty to provide care, equity, stewardship and trust, and the procedural value of reason. CONCLUSIONS: This review summarizes available triage protocols and ethical guidelines to provide decision-makers with data to help select and tailor triage tools. Given the uncertainty about how the COVID-19 pandemic will progress and any future pandemics, jurisdictions should prepare by selecting and adapting a triage tool that works best for their circumstances.

A 30-day prospective audit of all inpatient complications following acute care surgery: How well do we really perform?

Background: Acute care surgery (ACS) and emergency general surgery (EGS) services must provide timely care and intervention for patients who have some of the most challenging needs. Patients treated by ACS services are often critically ill and have both substantial comorbidities and poor physiologic reserve. Despite the widespread implemention of ACS/EGS services across North America, the true postoperative morbidity rates remain largely unknown. Methods: In this prospective study, inpatients at 8 high-volume ACS/EGS centres in geographically diverse locations in Canada who underwent operative interventions were followed for 30 days or until they were discharged. Readmissions during the 30-day window were also captured. Preoperative, intraoperative and postoperative variables were tracked. Standard statistical methodology was employed. Results: A total of 601 ACS/EGS patients were followed for up to 30 inpatient or readmission days after their index emergent operation. Fifty-one percent of patients were female, and the median age was 51 years. They frequently had substantial medical comorbidities (42%) and morbid obesity (15%). The majority of procedures were minimally invasive (66% laparoscopic). Median length of stay was 3.3 days and the early readmission (< 30 d) rate was 6%. Six percent of patients were admitted to the critical care unit. The overall complication and mortality rates were 34% and 2%, respectively. Cholecystitis (31%), appendicitis (21%), bowel obstruction (18%), incarcerated hernia (12%), gastrointestinal hemorrhage (7%) and soft tissue infections (7%) were the most common diagnoses. The morbidity and mortality rates for open surgical procedures were 73% and 5%, respectively. Conclusion: Nontrauma ACS/EGS procedures are associated with a high postoperative morbidity rate. This study will serve as a prospective benchmark for postoperative complications among ACS/EGS patients and subsequent quality improvement across Canada.

Contexte: Les services de chirurgie dans les unités de soins actifs (CSA) et de chirurgie générale dans les services d'urgence (CGSU) doivent fournir rapidement des soins et des interventions à des patients dont les besoins sont parmi les plus complexes. En effet, les patients pris en charge par les services de CSA sont souvent gravement malades et présentent des comorbidités sur fond de faible réserve physiologique. Même si les services de CSA/CGSU se sont répandus en Amérique du Nord, les taux réels de morbidité postopératoire demeurent pour une bonne part inconnus. Méthodes: Dans cette étude prospective, on a suivi pendant 30 jours ou jusqu'à leur congé, les patients hospitalisés pour des interventions chirurgicales dans 8 centres de CSA/CGSU achalandés de divers endroits au Canada. On a également tenu compte des réadmissions dans les 30 jours. Les paramètres pré-, per- et postopératoires ont été enregistrés. Une méthodologie statistique standard a été appliquée. Résultats: En tout, 601 patients de CSA/CGSU ont ainsi été suivis pendant une durée allant jusqu'à 30 jours d'hospitalisation ou de réadmission après leur intervention urgente initiale. Cinquante et un pour cent étaient de sexe féminin et l'âge moyen était de 51 ans. Ces patients étaient nombreux à présenter des comorbidités de nature médicale substantielles (42 %) et une obésité morbide (15 %). La majorité des interventions ont été minimalement effractives (66 % laparoscopiques). La durée médiane des séjours a été de 3,3 jours et le taux de réadmission précoce (< 30 j) a été de 6 %. Six pour cent des patients ont été admis aux soins intensifs. Les taux globaux de complications et de mortalité ont été respectivement de 34 % et de 2 %. Cholécystite (31 %), appendicite (21 %), obstruction intestinale (18 %), hernie incarcérée (12 %), hémorragie digestive (7 %) et infections des tissus mous (7 %) comptent parmi les diagnostics les plus fréquents. Les taux de morbidité et de mortalité dans les cas de chirurgies ouvertes ont été respectivement de 73 % et 5 %. Conclusion: Les interventions de CSA/CGSU non liées à la traumatologie sont associées à un taux de morbidité postopératoire élevé. Cette étude fournira un ensemble de valeurs de références pour l'étude prospective des complications chez les patients pris en charge par les services de CSA/CGSU et l'amélioration subséquente des soins partout au Canada.

Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review.

OBJECTIVE: To determine whether the reported clinical presentation of tension pneumothorax differs between patients who are breathing unassisted versus receiving assisted ventilation. BACKGROUND: Animal studies suggest that the pathophysiology and physical signs of tension pneumothorax differ by subject ventilatory status. METHODS: We searched electronic databases through to October 15, 2013 for observational studies and case reports/series reporting clinical manifestations of tension pneumothorax. Two physicians independently extracted clinical manifestations reported at diagnosis. RESULTS: We identified 5 cohort studies (n = 310 patients) and 156 case series/reports of 183 cases of tension pneumothorax (n = 86 breathing unassisted, n = 97 receiving assisted ventilation). Hypoxia was reported among 43 (50.0%) cases of tension pneumothorax who were breathing unassisted versus 89 (91.8%) receiving assisted ventilation (P < 0.001). Pulmonary dysfunction progressed to respiratory arrest in 9.3% of cases breathing unassisted. As compared to cases who were breathing unassisted, the adjusted odds of hypotension and cardiac arrest were 12.6 (95% confidence interval, 5.8-27.5) and 17.7 (95% confidence interval, 4.0-78.4) times higher among cases receiving assisted ventilation. One cohort study reported that none of the patients with tension pneumothorax who were breathing unassisted versus 39.6% of those receiving assisted ventilation presented without an arterial pulse. In contrast to cases breathing unassisted, the majority (70.4%) of those receiving assisted ventilation who experienced hypotension or cardiac arrest developed these signs within minutes of clinical presentation. DISCUSSION: The reported clinical presentation of tension pneumothorax depends on the ventilatory status of the patient. This may have implications for improving the diagnosis and treatment of this life-threatening disorder.

The right treatment at the right time in the right place: a population-based, before-and-after study of outcomes associated with implementation of an all-inclusive trauma system in a large Canadian province.

OBJECTIVE: To evaluate the implementation of an all-inclusive philosophy of trauma care in a large Canadian province. BACKGROUND: Challenges to regionalized trauma care may occur where transport distances to level I trauma centers are substantial and few level I centers exist. In 2008, we modified our predominantly regionalized model to an all-inclusive one with the hopes of increasing the role of level III trauma centers. METHODS: We conducted a population-based, before-and-after study of patient admission and transfer practices and outcomes associated with implementation of an all-inclusive provincial trauma system using multivariable Poisson and linear regression and Cox proportional hazard models. RESULTS: In total, 21,772 major trauma patients were included. Implementation of the all-inclusive model of trauma care was associated with a decline in transfers directly to level I trauma centers [risk ratio (RR) = 0.91; 95% confidence interval (CI): 0.88-0.94; P < 0.001] and an increase in transfers from level III to level I centers (RR = 1.10; 95% CI: 1.00-1.21; P = 0.04). These changes in trauma care occurred in conjunction with a 12% reduction in the hazard of mortality (hazard ratio = 0.88; 95% CI: 0.84-0.98; P = 0.003) and a decrease in mean trauma patient hospital length of stay by 1 day (95% CI: 1.02-1.11; P = 0.02) after adjustment for differences in case mix. CONCLUSIONS: In this study, introduction of an all-inclusive provincial trauma system was associated with an increased number of injured patients cared for in their local systems and improved trauma patient mortality and hospital length of stay.

The evolution of trauma surgery at a high-volume Canadian centre: implications for public health, prevention, clinical care, education and recruitment.

BACKGROUND: Trauma centres continue to evolve with respect to clinical care and their impact on public health. Despite improvements in patient outcomes, operative volumes, and therefore maintenance of surgical skills, has become a challenging issue. We sought to determine whether injury demographics and treatments at a high-volume centre changed over time. METHODS: We used the Alberta Trauma Registry to analyze all severely injured (injury severity score [ISS] ≥ 12) patient admissions over a 16-year period (1995-2011). RESULTS: Of the 12,879 severely injured patients requiring admission, there was a 1.5- fold increase in the annual admission rate despite population normalization (p = 0.001). Over the 16-year interval, patients were older with a subsequent lower mortality (p = 0.001) and length of hospital stay (p = 0.007). In patients with the most severe ISS (≥ 48), there was no change in mortality (27%, p = 0.26). In 2011, falls were the most common mechanism compared with motor vehicle crashes (41% v. 23%; p < 0.001); this was a complete reversal compared with 1995 (25% v. 41%). Motorized recreational vehicle and motorcycle injuries also increased (p < 0.001). The mean number of operations performed by trauma surgeons decreased (laparotomies: 67 [17%] in 1995 v. 47 [5%] in 2011, p < 0.001). Thoracotomies and tracheostomies remained unchanged (p = 0.19). CONCLUSION: Clinical care has improved despite an increasing overall volume of severely injured patient admissions. The number of operative interventions performed by trauma surgeons continues to decrease concurrent to a change in injury mechanisms. Despite these improvements, maintenance of technical skills among trauma surgeons has become an important issue.

CONTEXTE: Les centres de traumatologie continuent d'évoluer au plan des soins cliniques et de leur impact sur la santé publique. Malgré certaines améliorations, les résultats pour les patients, le volume opératoire et par conséquent, le maintien des habiletés chirurgicales sont devenus un enjeu délicat. Nous avons voulu déterminer si les caractéristiques démographiques et les traitements en traumatologie ont évolué avec le temps dans un centre qui traite un volume élevé de cas. MÉTHODES: Nous avons eu recours au Registre albertain des traumatismes pour analyser toutes les admissions de grands blessés (indice de gravité des blessures [IGB] ≥ 12) au cours d'une période de 16 ans (1995­2011). RÉSULTANTS: Chez les 12 879 grands blessés ayant dû être hospitalisés, nous avons noté une augmentation selon un facteur de 1,5 du taux annuel d'admissions, malgré une normalisation de la population (p = 0,001). Au cours de cet intervalle de 16 ans, les patients ont graduellement été plus âgés, et la mortalité (p = 0,001) et la durée des séjours hospitaliers (p = 0,007) ont subséquemment diminué. Chez les patients présentant les IGB les plus élevés (≥ 48), on n'a noté aucun changement de la mortalité (27 %, p = 0,26). En 2011, les chutes ont été la cause la plus fréquente des traumatismes, par rapport aux accidents de la route (41 % c. 23 %, p < 0,001), ce qui s'est révélé être un renversement complet par rapport à 1995 (25 % c. 41 %). Le nombre de blessures subies avec des véhicules motorisés récréatifs et des motocyclettes a aussi augmenté (p < 0,001). Le nombre moyen d'interventions effectuées par les chirurgiens en traumatologie a diminué (laparotomies : 67 [17 %] en 1995 c. 47 [5 %] en 2011, p < 0,001). Le nombre de thoracotomies et de trachéotomies est resté inchangé (p = 0,19). CONCLUSION: Les soins cliniques se sont améliorés malgré l'augmentation du volume global d'hospitalisations de patients grièvement blessés. Le nombre d'interventions chirurgicales effectuées par les chirurgiens en traumatologie continue de diminuer parallèlement à une évolution des causes de traumatismes. Malgré ces améliorations, le maintien des habiletés techniques des chirurgiens en traumatologie est devenu un enjeu important.

Emergency medical services response time and mortality in an urban setting.

BACKGROUND: A common tenet in emergency medical services (EMS) is that faster response equates to better patient outcome, translated by some EMS operations into a goal of a response time of 8 minutes or less for advanced life support (ALS) units responding to life-threatening events. OBJECTIVE: To explore whether an 8-minute EMS response time was associated with mortality. METHODS: This was a one-year retrospective cohort study of adults with a life-threatening event as assessed at the time of the 9-1-1 call (Medical Priority Dispatch System Echo- or Delta-level event). The study setting was an urban all-ALS EMS system serving a population of approximately 1 million. Response time was defined as 9-1-1 call receipt to ALS unit arrival on scene, and outcome was defined as all-cause mortality at hospital discharge. Potential covariates included patient acuity, age, gender, and combined scene and transport interval time. Stratified analysis and logistic regression were used to assess the response time-mortality association. RESULTS: There were 7,760 unit responses that met the inclusion criteria; 1,865 (24%) were ≥8 minutes. The average patient age was 56.7 years (standard deviation = 21.5). For patients with a response time ≥8 minutes, 7.1% died, compared with 6.4% for patients with a response time ≤7 minutes 59 seconds (risk difference 0.7%; 95% confidence interval [CI]: -0.5%, 2.0%). The adjusted odds ratio of mortality for ≥8 minutes was 1.19 (95% CI: 0.97, 1.47). An exploratory analysis suggested there may be a small beneficial effect of response ≤7 minutes 59 seconds for those who survived to become an inpatient (adjusted odds ratio = 1.30; 95% CI: 1.00, 1.69). CONCLUSIONS: These results call into question the clinical effectiveness of a dichotomous 8-minute ALS response time on decreasing mortality for the majority of adult patients identified as having a life-threatening event at the time of the 9-1-1 call. However, this study does not suggest that rapid EMS response is undesirable or unimportant for certain patients. This analysis highlights the need for further research on who may benefit from rapid EMS response, whether these individuals can be identified at the time of the 9-1-1 call, and what the optimum response time is.

New technologies and surgical innovation: five years of a local health technology assessment program in a surgical department.

There is pressure for surgical departments to introduce new and innovative health technologies in an evidence-based manner while ensuring that they are safe and effective and can be managed with available resources. A local health technology assessment (HTA) program was developed to systematically integrate research evidence with local operational management information and to make recommendations for subsequent decision by the departmental executive committee about whether and under what conditions the technology will be used. The authors present a retrospective analysis of the outcomes of this program as used by the Department of Surgery & Surgical Services in the Calgary Health Region over a 5-year period from December 2005 to December 2010. Of the 68 technologies requested, 15 applications were incomplete and dropped, 12 were approved, 3 were approved for a single case on an urgent/emergent basis, 21 were approved for "clinical audit" for a restricted number of cases with outcomes review, 14 were approved for research use only, and 3 were referred to additional review bodies. Subsequent outcome reports resulted in at least 5 technologies being dropped for failure to perform. Decisions based on local HTA program recommendations were rarely "yes" or "no." Rather, many technologies were given restricted approval with full approval contingent on satisfying certain conditions such as clinical outcomes review, training protocol development, or funding. Thus, innovation could be supported while ensuring safety and effectiveness. This local HTA program can be adapted to a variety of settings and can help bridge the gap between evidence and practice.

Peri-Operative Care.

In the history of surgery, 1911 was a sentinel year [...].

Parasternal intercostal, costal, and crural diaphragm neural activation during hypercapnia.

The parasternal intercostal is an obligatory inspiratory muscle working in coordination with the diaphragm, apparently sharing a common pathway of neural response. This similarity has attracted clinical interest, promoting the parasternal as a noninvasive alternative to the diaphragm, to monitor central neural respiratory output. However, this role may be confounded by the distinct and different functions of the costal and crural diaphragm. Given the anatomic location, parasternal activation may significantly impact the chest wall via both mechanical shortening or as a "fixator" for the chest wall. Either mechanical function of the parasternal may also impact differential function of the costal and crural. The objectives of the present study were, during eupnea and hypercapnia, 1) to compare the intensity of neural activation of the parasternal with the costal and crural diaphragm and 2) to examine parasternal recruitment and changes in mechanical action during progressive hypercapnia, including muscle baseline length and shortening. In 30 spontaneously breathing canines, awake without confounding anesthetic, we directly measured the electrical activity of the parasternal, costal, and crural diaphragm, and the corresponding mechanical shortening of the parasternal, during eupnea and hypercapnia. During eupnea and hypercapnia, the parasternal and costal diaphragm share a similar intensity of neural activation, whereas both differ significantly from crural diaphragm activity. The shortening of the parasternal increases significantly with hypercapnia, without a change in baseline end-expiratory length. In conclusion, the parasternal shares an equivalent intensity of neural activation with the costal, but not crural, diaphragm. The parasternal maintains and increases its active inspiratory shortening during augmented ventilation, despite high levels of diaphragm recruitment. Throughout hypercapnic ventilation, the parasternal contributes mechanically; it is not relegated to chest wall fixation.NEW & NOTEWORTHY This investigation directly compares neural activation of the parasternal intercostal muscle with the two distinct segments of the diaphragm, costal and crural, during room air and hypercapnic ventilation. During eupnea and hypercapnia, the parasternal intercostal muscle and costal diaphragm share a similar neural activation, whereas they both differ significantly from the crural diaphragm. The parasternal intercostal muscle maintains and increases active inspiratory mechanical action with shortening during ventilation, even with high levels of diaphragm recruitment.

Cervical spine clearance in obtunded blunt trauma patients: a prospective study.

BACKGROUND: : An acceptable algorithm for clearance of the cervical spine (C-spine) in the obtunded trauma patient remains controversial. Undetected C-spine injuries of an unstable nature can have devastating consequences. This has led to reluctance toward C-spine clearance in these patients. OBJECTIVE: : To objectify the accuracy of computed tomography (CT) scanning compared with dynamic radiographs within a well established C-spine clearance protocol in obtunded trauma patients at a level I trauma center. METHODS: : This was a prospective study of consecutive blunt trauma patients (18 years or older) admitted to a single institution between December 2004 and April 2008. To be eligible for study inclusion, patients must have undergone both a CT scan and dynamic plain radiographs of their C-spine as a part of their clearance process. RESULTS: : Among 402 patients, there was one injury missed on CT but detected by dynamic radiographs. This resulted in a percentage of missed injury of 0.25%. Subsequent independent review of the CT scan revealed that in fact pathologic changes were present on the scan indicative of the injury. CONCLUSIONS: : Our results indicate that CT of the C-spine is highly sensitive in detecting the vast majority (99.75%) of clinically significant C-spine injuries. We recommend that CT be used as the sole modality to radiographically clear the C-spine in obtunded trauma patients and do not support the use of flexion-extension radiographs as an ancillary diagnostic method.

Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length.

BACKGROUND: Tension pneumothorax requires emergent decompression. Unfortunately, some needle thoracostomies (NTs) are unsuccessful because of insufficient catheter length. All previous studies have used thickness of the chest wall (based on cadaver studies, ultrasonography or computed tomography [CT]) to extrapolate probable catheter effectiveness. The objective of this clinical study was to identify the frequency of NT failure with various catheter lengths. METHODS: We evaluated the records of all patients with severe blunt injury who had a prehospital NT before arrival at a level-1 trauma centre over a 48-month period. Patients were divided into 2 groups: helicopter (4.5-cm catheter sheath) and ground ambulance (3.2 cm) transport. Success of the NT was confirmed by the absence of a large pneumothorax on subsequent thoracic ultrasonography and CT. RESULTS: Needle thoracostomy decompression was attempted in 1.5% (142/9689) of patients. Among patients with blunt injuries, the incidence was 1.4% (101/7073). Patients transported by helicopter (74%) received a 4.5-cm sheath. The remainder (26% ground transport) received a 3.2-cm catheter. A minority in each group (helicopter 15%, ground 28%) underwent immediate chest tube insertion (before thoracic ultrasound) because of ongoing hemodynamic instability. Failure to decompress the pleural space by NT was observed via ultrasound and/or CT in 65% (17/26) of attempts with a 3.2-cm catheter, compared with only 4% (3/75) of attempts with a 4.5-cm catheter (p < 0.001). CONCLUSION: Tension pneumothorax decompression using a 3.2-cm catheter was unsuccessful in up to 65% of cases. When a larger 4.5-cm catheter was used, fewer procedures (4%) failed. Thoracic ultrasonography can be used to confirm NT placement.

Thrombolysis of Postoperative Acute Pulmonary Embolism with a Thrombus in Transit.

Right heart thrombus in transit clot (RHTT) associated with a pulmonary thromboembolism (PTE) is a rare but potentially fatal diagnosis. Early diagnosis and immediate intervention are crucial. This report describes the case of a healthy, physically active 32-year-old female who presented 19 days postoperatively, following an anterior cruciate ligament reconstruction and partial lateral meniscectomy with a saddle PE, RHTT, and right ventricular (RV) strain. The patient received half of the standard dose of intravenous tissue plasminogen activator (TPA) in combination with anticoagulation and survived. Case reports of RHTT will inform future studies designed to evaluate whether and when thrombolysis should be administered.

Complications of appendectomy and cholecystectomy in acute care surgery: A systematic review and meta-analysis.

INTRODUCTION: Acute care surgery (ACS) was initiated two decades ago to address timeliness and quality in emergency general surgery. We hypothesized that ACS has improved the management of acute appendicitis and biliary disease. METHODS: A comprehensive systematic review and meta-analysis of outcome studies for emergent appendectomy and cholecystectomy from 1966 to 2017, comparing studies prior to and following ACS implementation, were performed. RESULTS: Of 1,704 studies, 27 were selected for analysis (appendicitis, 16; biliary pathology, 7; both, 4). Following ACS introduction, the complication rate was significantly reduced in both appendectomy and cholecystectomy (risk ratios, 0.70; 95% confidence interval [CI], 0.57-0.85; I = 9.2% and relative risk, 0.62; 95% CI, 0.41-0.94; I = 63.5%) respectively. There was a significant reduction in the time from arrival in emergency until admission and from admission to operation (-1.37 hours: 95% CI, -1.93 to -0.80; -2.51 hours: 95% CI, -4.44 to -0.58) in the appendectomy cohort. Time to operation was shorter in the cholecystectomy group (-6.46 hours; 95% CI, -9.54 to -3.4). Length of hospital stay was reduced in both groups (appendectomy, -0.9 day; cholecystectomy, -1.09 day). There was a reduction in overall cost in cholecystectomy group (-US $854.37; 95% CI, -1,554.1 to -154.05). No statistical significance was detected for wound infection, abscess, conversion of laparoscopy to open technique, rate of negative appendectomy, after hours, readmission, and cost. CONCLUSION: The implementation of ACS models in general surgery emergency care has significantly improved system and patient outcomes for appendicitis and biliary pathology. LEVEL OF EVIDENCE: Systematic review and meta-analysis of a retrospective study, level III.

Airway compromise secondary to upper cervical spine injury.

BACKGROUND: Airway compromise secondary to isolated injury at the atlas (C1) and axis (C2) without an associated spinal cord injury is a rare, but recognized phenomenon that results in significant morbidity and mortality. No previous study in the literature has reported the incidence of this potentially lethal complication of these relatively common fractures. METHODS: The medical records for 625 consecutive patients who presented to a Level I trauma center with C1 and C2 fractures during the years from 1996 to 2005 were reviewed retrospectively. Strict inclusion and exclusion criteria were applied to identify adult patients with isolated fractures and no other injuries. All patients that developed significant airway compromise were identified and correlations were made with the patient's demographic features, clinical presentation, and radiologic findings, to determine potential risk factors. RESULTS: During the 10 years studied, 343 patients with isolated C1 and C2 fractures were identified. Of these, 17 patients developed significant airway compromise. This represents a 4.9% incidence of this potentially life-threatening complication. Older age and male gender were found to be risk factors with a statistically significant association (p value <0.05). The majority of patients also exhibited prevertebral swelling, the presence of significant degenerative changes, and significant fracture displacement. Twelve patients required intubation and admission to Intensive Care Unit (ICU). There were four deaths. CONCLUSIONS: Approximately 5% of patients with isolated C1 and C2 fractures developed airway compromise. All patients with these injuries should be assessed for the risk of developing this complication and some will require close monitoring to detect this problem at an early stage.

Radiation dose from initial trauma assessment and resuscitation: review of the literature.

BACKGROUND: Trauma care benefits from the use of imaging technologies. Trauma patients and trauma team members are exposed to radiation during the continuum of care. Knowledge of exposure amounts and effects are important for trauma team members. METHODS: We performed a review of the published literature; keywords included "trauma," "patients," "trauma team members," "wounds," "injuries," "radiation," "exposure," "dose" and "computed tomography" (CT). We also reviewed the Board on Radiation Effects Research (BEIR VII) report, published in 2005 and 2006. RESULTS: We found no randomized controlled trials or studies. Relevant studies demonstrated that CT accounts for the single largest radiation exposure in trauma patients. Exposure to 100 mSv could result in a solid organ cancer or leukemia in 1 of 100 people. Trauma team members do not exceed the acceptable occupation radiation exposure determined by the National Council of Radiation Protection and Management. Modern imaging technologies such as 16- and 64-slice CT scanners may decrease radiation exposure. CONCLUSION: Multiple injured trauma patients receive a substantial dose of radiation. Radiation exposure is cumulative. The low individual risk of cancer becomes a greater public health issue when multiplied by a large number of examinations. Though CT scans are an invaluable resource and are becoming more easily accessible, they should not replace careful clinical examination and should be used only in appropriate patients.

Distinct neural-mechanical efficiency of costal and crural diaphragm during hypercapnia.

Classic physiology suggests that the two distinct diaphragm segments, costal and crural, are functionally different. It is not known if the two diaphragm muscles share a common neural mechanical activation. We hypothesized that costal and crural diaphragm are recruited differently during hypercapnic stimulated ventilation, and the EMG recordings of the esophageal crural diaphragm segment does not translate to the same level of mechanical shortening for costal and crural segments In 30 spontaneously breathing canines, without confounding anesthetic, we measured directly electrical activity and corresponding mechanical shortening of both the costal and crural diaphragm, at room air and during increasing hypercapnia. During hypercapnic ventilation, the costal diaphragm showed a predominant recruitment over the crural diaphragm. The distinct mechanical contribution of the costal segment was not due to a different level of neural activation between the two muscles as measured by segmental EMG activity. Thus, the two diaphragm segments exhibited a significantly different neural-mechanical relationship.

Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle?

BACKGROUND: A tension pneumothorax requires immediate decompression using a needle thoracostomy. According to advanced trauma life support guidelines this procedure is performed in the second intercostal space (ICS) in the midclavicular line (MCL), using a 4.5-cm (2-inch) catheter (5-cm needle). Previous studies have shown a failure rate of up to 40% using this technique. Case reports have suggested that this high failure rate could be because of insufficient length of the needle. OBJECTIVES: To analyze the average chest wall thickness (CWT) at the second ICS in the MCL in a trauma population and to evaluate the length of the needle used in needle thoracostomy for emergency decompression of tension pneumothoraces. METHODS: Retrospective review of major trauma admissions (Injury Severity Score >12) at the Foothills Medical Centre in Calgary, Canada, who underwent a computed tomography chest scan admitted in the period from October 2001 until March 2004. Subgroup analysis on men and women, <40 years of age and >/=40 years of age was defined a priori. CWT was measured to the nearest 0.01 cm at the second ICS in the MCL. RESULTS: The mean CWT in the 604 male patients and 170 female patients studied averaged 3.50 cm at the left second ICS MCL and 3.51 cm on the right. The mean CWT was significantly higher for women than men (p < 0.0001). About 9.9% to 19.3% of the men had a CWT >4.5 cm and 24.1% to 35.4% of the women studied. CONCLUSIONS: A catheter length of 4.5 cm may not penetrate the chest wall of a substantial amount (9.9%-35.4%) of the population, depending on age and gender. This study demonstrates the need for a variable needle length for relief of a tension pneumothorax in certain population groups to improve effectiveness of needle thoracostomy.

Advanced trauma life support, 8th edition, the evidence for change.

The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.

A Case Report of Acute Airway Compromise due to Subcutaneous Emphysema.

In the acute management of a trauma patient, airway patency is of utmost importance. The present case describes a male patient who presented with delayed severe upper airway obstruction secondary to massive subcutaneous emphysema following blunt traumatic injury two days previously. Airway compromise is a rarely described but serious complication of subcutaneous emphysema. Current management of subcutaneous emphysema and its association with pneumothorax is summarized. Early decompression of underlying pneumothoraces in patients with significant subcutaneous emphysema should be performed to avoid this rare complication.

Long-term mortality outcome associated with prolonged admission to the ICU.

STUDY OBJECTIVES: Patients requiring prolonged admission to the ICU consume significant health-care resources and have a high rate of in-hospital death. The long-term mortality outcome of these patients has not been well defined in a nonselected cohort. The objective of this study was to describe the occurrence and factors predictive of prolonged ICU stay at admission, and to define the long-term (>/= 1 year) mortality outcome. DESIGN: Population-based cohort. SETTING: All adult multisystem and cardiovascular surgical ICUs in the Calgary Health Region (CHR) from July 1, 1999, to March 31, 2002. PATIENTS: Adult (>/= 18 years old) residents of the CHR admitted to regional ICUs. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: During the study, 4,845 patients had a median length of stay of 2 days (interquartile range, 1 to 4 days); 2,115 patients (44%) were admitted for < 2 days, 1,496 patients (31%) were admitted for 2 to 3 days; 1,018 patients (21%) were admitted from 4 to 13 days; and 216 patients (4%) had a prolonged (>/= 14 day) admission to the ICU. A higher severity of illness, the presence of shock, and bloodstream infection were independently associated with a prolonged ICU admission, and cardiovascular surgery was associated with a lower risk. Patients with prolonged ICU admissions were nearly twice as likely to die as patients with shorter ICU admissions: 53 of 216 patients (25%) vs 584 of 4,629 patients (13%) [p = 0.0001]. Among the 3,924 survivors to hospital discharge, the rates of mortality during the year following ICU admission were as follows: 59 deaths in 1,758 patients (3%) admitted < 2 days, 74 deaths in 1,267 patients (6%) with 2- to 3-day admissions, 78 deaths in 766 patients (10%) with 4- to 13-day admissions, and 10 deaths in 133 patients (8%) with admissions >/= 14 days. CONCLUSIONS: One in 25 critically ill patients will have prolonged ICU admission and higher ICU-related mortality. However, survivors of prolonged ICU admission have good long-term mortality outcome after acute illness.