Hyperbaric oxygen does not improve outcome in patients with necrotizing soft tissue infection.

BACKGROUND: Patients with necrotizing soft tissue infections (NSTIs) require prompt surgical debridement, appropriate intravenous antibiotics, and intensive support. Despite aggressive treatment, their mortality and morbidity rates remain high. The benefit of hyperbaric oxygen (HBO) as an adjunctive treatment is controversial. We investigated the effect of HBO in treating NSTIs. METHODS: We analyzed clinical data retrospectively for 78 patients with NSTIs: 30 patients at one center were treated with surgery, antibiotics, and supportive care; 48 patients at a different center received adjunctive HBO treatment. We compared the two groups in terms of demographic characteristics, risk factors, NSTI microbiology, and patient outcomes. To identify variables associated with higher mortality rates, we used logistic regression analysis. RESULTS: Demographic characteristics and risk factors were similar in the HBO and non-HBO groups. The mean patient age was 49.5 years; 37% of the patients were female, and 49% had diabetes mellitus. Patients underwent a mean of 3.0 excisional debridements. The median hospital length of stay was 16.5 days; the median duration of antibiotic use was 15.0 days. In 36% of patients, cultures were polymicrobial; group A Streptococcus was the organism most commonly isolated (28%). We identified no statistically significant differences in outcomes between the two groups. The mortality rate for the HBO group (8.3%) was lower, although not significantly different (p = 0.48), than that observed for the non-HBO group (13.3%). The number of debridements was greater in the HBO group (3.0; p = 0.03). The hospital length of stay and duration of antibiotic use were similar for the two groups. Multivariable analysis showed that hypotension on admission and immunosuppression were significant independent risk factors for death. CONCLUSIONS: Adjunctive use of HBO to treat NSTIs did not reduce the mortality rate, number of debridements, hospital length of stay, or duration of antibiotic use. Immunosupression and early hypotension were important risk factors associated with higher mortality rates in patients with NSTIs.

Literature Evidence on Live Animal Versus Synthetic Models for Training and Assessing Trauma Resuscitation Procedures.

There are many models currently used for teaching and assessing performance of trauma-related airway, breathing, and hemorrhage procedures. Although many programs use live animal (live tissue [LT]) models, there is a congressional effort to transition to the use of nonanimal- based methods (i.e., simulators, cadavers) for military trainees. We examined the existing literature and compared the efficacy, acceptability, and validity of available models with a focus on comparing LT models with synthetic systems. Literature and Internet searches were conducted to examine current models for seven core trauma procedures. We identified 185 simulator systems. Evidence on acceptability and validity of models was sparse. We found only one underpowered study comparing the performance of learners after training on LT versus simulator models for tube thoracostomy and cricothyrotomy. There is insufficient data-driven evidence to distinguish superior validity of LT or any other model for training or assessment of critical trauma procedures.

Hospital response to a major freeway bridge collapse.

BACKGROUND: We describe the hospital system response to the Interstate 35W bridge collapse in Minneapolis into the Mississippi River on August 1, 2007, which resulted in 13 deaths and 127 injuries. Comparative analysis of response activities at the 3 hospitals that received critical or serious casualties is provided. METHODS: First-hand experiences of hospital physicians, issues identified in after-action reports, injury severity scores, and other relevant patient data were collected from the 3 hospitals that received seriously injured patients, including the closest hospitals to the collapse on each side of the river. RESULTS/DISCUSSION: Injuries were consistent with major acceleration/deceleration force injuries. The most critical patients arrived first at each hospital, suggesting appropriate prehospital triage. Capacity of the health care system was not overwhelmed and the involved hospitals generally reported an overresponse by staff. Communication and patient tracking problems occurred at all of the hospitals. Situational awareness was limited due to the scope of structural collapse and incomplete information from the scene. CONCLUSIONS: Hospitals were generally satisfied with their surge capacity and incident management plan activation. Issues such as communications, patient tracking, and staff overreporting that have been identified in past incidents also were problematic in this event. Hospitals will need to address deficiencies and build on successful actions to cope with future, potentially larger incidents.