Mental Illness as a Predictor of Subjective Happiness Among University Employees Working in Hawai'i.

The World Health Organization adopted happiness as an indicator of societal progress in addressing conditions that directly affect psychological well-being and recommended communities address the determinants and obstacles to subjective well-being. Therefore, we conducted an online survey, informed by the Sustainable Happiness Model, among university employees that measured life circumstances (sociodemographics) and intentional leisure-time moderate-to-vigorous physical activity as potential predictors of subjective happiness (assessed using the Subjective Happiness Scale [SHS]). The multiethnic sample (N = 85) primarily included those who identified as White (44%), Asian (33%), and Native Hawaiian and other Pacific Islander (16%). The most prevalent age range was 41 to 50 years (31%), and 55% of the sample identified as female, 78% as faculty, and 22% as staff. Reporting a current mental health condition had significantly lower SHS scores compared to all other factors. Future research should explore interventions to support and improve university employee's mental health and overall well-being. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].

Interrupted time series analysis to evaluate the performance of drug overdose morbidity indicators shows discontinuities across the ICD-9-CM to ICD-10-CM transition.

INTRODUCTION: On 1 October 2015, the USA transitioned from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to the International Classification of Diseases, 10th Revision (ICD-10-CM). Considering the major changes to drug overdose coding, we examined how using different approaches to define all-drug overdose and opioid overdose morbidity indicators in ICD-9-CM impacts longitudinal analyses that span the transition, using emergency department (ED) and hospitalisation data from six states' hospital discharge data systems. METHODS: We calculated monthly all-drug and opioid overdose ED visit rates and hospitalisation rates (per 100 000 population) by state, starting in January 2010. We applied three ICD-9-CM indicator definitions that included identical all-drug or opioid-related codes but restricted the number of fields searched to varying degrees. Under ICD-10-CM, all fields were searched for relevant codes. Adjusting for seasonality and autocorrelation, we used interrupted time series models with level and slope change parameters in October 2015 to compare trend continuity when employing different ICD-9-CM definitions. RESULTS: Most states observed consistent or increased capture of all-drug and opioid overdose cases in ICD-10-CM coded hospital discharge data compared with ICD-9-CM. More inclusive ICD-9-CM indicator definitions reduced the magnitude of significant level changes, but the effect of the transition was not eliminated. DISCUSSION: The coding change appears to have introduced systematic differences in measurement of drug overdoses before and after 1 October 2015. When using hospital discharge data for drug overdose surveillance, researchers and decision makers should be aware that trends spanning the transition may not reflect actual changes in drug overdose rates.

Descriptive exploration of overdose codes in hospital and emergency department discharge data to inform development of drug overdose morbidity surveillance indicator definitions in ICD-10-CM.

BACKGROUND: In October 2015, discharge data coding in the USA shifted to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), necessitating new indicator definitions for drug overdose morbidity. Amid the drug overdose crisis, characterising discharge records that have ICD-10-CM drug overdose codes can inform the development of standardised drug overdose morbidity indicator definitions for epidemiological surveillance. METHODS: Eight states submitted aggregated data involving hospital and emergency department (ED) discharge records with ICD-10-CM codes starting with T36-T50, for visits occurring from October 2015 to December 2016. Frequencies were calculated for (1) the position within the diagnosis billing fields where the drug overdose code occurred; (2) primary diagnosis code grouped by ICD-10-CM chapter; (3) encounter types; and (4) intents, underdosing and adverse effects. RESULTS: Among all records with a drug overdose code, the primary diagnosis field captured 70.6% of hospitalisations (median=69.5%, range=66.2%-76.8%) and 79.9% of ED visits (median=80.7%; range=69.8%-88.0%) on average across participating states. The most frequent primary diagnosis chapters included injury and mental disorder chapters. Among visits with codes for drug overdose initial encounters, subsequent encounters and sequelae, on average 94.6% of hospitalisation records (median=98.3%; range=68.8%-98.8%) and 95.5% of ED records (median=99.5%; range=79.2%-99.8%), represented initial encounters. Among records with drug overdose of any intent, adverse effect and underdosing codes, adverse effects comprised an average of 74.9% of hospitalisation records (median=76.3%; range=57.6%-81.1%) and 50.8% of ED records (median=48.9%; range=42.3%-66.8%), while unintentional intent comprised an average of 11.1% of hospitalisation records (median=11.0%; range=8.3%-14.5%) and 28.2% of ED records (median=25.6%; range=20.8%-40.7%). CONCLUSION: Results highlight considerations for adapting and standardising drug overdose indicator definitions in ICD-10-CM.

Myths and Misinformation About Gunshot Wounds may Adversely Affect Proper Treatment.

BACKGROUND: Poorly designed experiments and popular media have led to multiple myths about wound ballistics. Some of these myths have been incorporated into the trauma literature as fact and are included in Advanced Trauma Life Support (ATLS). We hypothesized that these erroneous beliefs would be prevalent, even among those providing care for patients with gunshot wounds (GSWs), but could be addressed through education. METHODS: ATLS course content was reviewed. Several myths involving wound ballistics were identified. Clinically relevant myths were chosen including wounding mechanism, lead poisoning, debridement, and antibiotic use. Subsequently, surgery and emergency medicine services at three different trauma centers were studied. All three sites were busy, urban trauma centers with a significant amount of penetrating trauma. A pre-test was administered prior to a lecture on wound ballistics followed by a post-test. Pre- and post-test scores were compared and correlated with demographic data including ATLS course completion, firearm/ballistics experience, and years of post-graduate medical experience (PGME). RESULTS: One-hundred and fifteen clinicians participated in the study. A mean pre-test score of 34 % improved to 78 % on the post-test with associated improvements in all areas of knowledge (p < 0.001). Years of PGME correlated with higher pre-test score (p = 0.021); however, ATLS status did not (p = 0.774). CONCLUSIONS: Erroneous beliefs involving wound ballistics are prevalent even among clinicians who frequently treat victims of GSWs and could lead to inappropriate treatment. Focused education markedly improved knowledge. The ATLS course and manual promulgate some of these myths and should be revised.

Increases in heroin overdose deaths - 28 States, 2010 to 2012.

Nationally, death rates from prescription opioid pain reliever (OPR) overdoses quadrupled during 1999-2010, whereas rates from heroin overdoses increased by <50%. Individual states and cities have reported substantial increases in deaths from heroin overdose since 2010. CDC analyzed recent mortality data from 28 states to determine the scope of the heroin overdose death increase and to determine whether increases were associated with changes in OPR overdose death rates since 2010. This report summarizes the results of that analysis, which found that, from 2010 to 2012, the death rate from heroin overdose for the 28 states increased from 1.0 to 2.1 per 100,000, whereas the death rate from OPR overdose declined from 6.0 per 100,000 in 2010 to 5.6 per 100,000 in 2012. Heroin overdose death rates increased significantly for both sexes, all age groups, all census regions, and all racial/ethnic groups other than American Indians/Alaska Natives. OPR overdose mortality declined significantly among males, persons aged <45 years, persons in the South, and non-Hispanic whites. Five states had increases in the OPR death rate, seven states had decreases, and 16 states had no change. Of the 18 states with statistically reliable heroin overdose death rates (i.e., rates based on at least 20 deaths), 15 states reported increases. Decreases in OPR death rates were not associated with increases in heroin death rates. The findings indicate a need for intensified prevention efforts aimed at reducing overdose deaths from all types of opioids while recognizing the demographic differences between the heroin and OPR-using populations. Efforts to prevent expansion of the number of OPR users who might use heroin when it is available should continue.

Factors associated with poor glycemic control or wide glycemic variability among diabetes patients in Hawaii, 2006-2009.

INTRODUCTION: Although glycemic control is known to reduce complications associated with diabetes, it is an elusive goal for many patients with diabetes. The objective of this study was to identify factors associated with sustained poor glycemic control, some glycemic variability, and wide glycemic variability among diabetes patients over 3 years. METHODS: This retrospective study was conducted among 2,970 diabetes patients with poor glycemic control (hemoglobin A1c [HbA1c] >9%) who were enrolled in a health plan in Hawaii in 2006. We conducted multivariable logistic regressions to examine factors related to sustained poor control, some glycemic variability, and wide glycemic variability during the next 3 years. Independent variables evaluated as possible predictors were age, sex, type of insurance coverage, morbidity, diabetes duration, history of cardiovascular disease, and number of medications. RESULTS: Longer duration of diabetes, being under age 35, and taking 15 or more medications were significantly associated with sustained poor glycemic control. Preferred provider organization and Medicare (vs health maintenance organization) enrollees and patients with high morbidity were less likely to have sustained poor glycemic control. Wide glycemic variability was significantly related to being younger than age 50, longer duration of diabetes, having coronary artery disease, and taking 5 to 9 medications per year. CONCLUSION: Results indicate that duration of diabetes, age, number of medications, morbidity, and type of insurance coverage are risk factors for sustained poor glycemic control. Patients with these characteristics may need additional therapies and targeted interventions to improve glycemic control. Patients younger than age 50 and those with a history of coronary heart disease should be warned of the health risks of wide glycemic variability.

Endovascular treatment of axillosubclavian arterial injuries is a safe alternative to open repair.

BACKGROUND: Injuries to the axillosubclavian arteries are rare, comprising 5% of all extremity trauma. This study aims to examine contemporary outcomes of traumatic axillosubclavian injuries. METHODS: A retrospective review was performed on patients admitted with innominate, subclavian, and/or axillary artery injuries to a level 1 trauma center from 2011 to 2021. Patients undergoing endovascular repair were compared to those with open repair. RESULTS: Thirty two patients met inclusion criteria. Injuries were approached open in 22 (59%) cases and endovascular in 10 (27%). There was no difference in 30-day mortality or hospital length of stay between endovascular and open repair. Endovascular repairs had shorter operative times (1.9 vs 3.1 h, p = 0.009) and lower blood loss (72 vs 1662 mL, p < 0.001). CONCLUSIONS: Endovascular repair of axillosubclavian arterial injuries demonstrate similar outcomes to open repair. Significantly shorter operative times and lower blood loss suggest potential decreased morbidity.

Does autotransfusion from a contaminated trauma laparotomy field increase the risk of complications?

BACKGROUND: Autotransfusion (AT) in trauma laparotomy is limited by concern that enteric contamination (EC) increases complications, including infections. Our goal was to determine if AT use increases complications in trauma patients undergoing laparotomy with EC. METHODS: Trauma patients undergoing laparotomy from October 2011-November 2020 were reviewed. Patients were excluded if they did not receive blood in the operating room, did not have a full thickness hollow viscus injury, or died <24 h from admission. AT and non-AT patients were matched. Outcomes were compared. RESULTS: 185 patients were included, 60 received AT, and 46 pairs were matched. After matching, demographics were similar. No differences were noted in septic complications (33 vs 41%, p = 0.39), overall complications (59% vs 54%, p = 0.67), or mortality (13 vs 6%, p = 0.29). CONCLUSIONS: AT use in contaminated trauma laparotomy fields was not associated with a higher rate of complications.

Observation for nonoperative management of blunt liver injuries: how long is long enough?

BACKGROUND: Nonoperative management (NOM) of blunt liver injury is the standard of care in hemodynamically stable patients. However, there are no data regarding the optimum length of inpatient observation. The purpose of this study is to review NOM guidelines for patient safety and optimal length of stay (LOS). METHODS: A retrospective review of the trauma registry at a Level I trauma center was performed to identify all patients admitted with blunt liver injuries. Guidelines for length of observation were developed, such that patients were discharged with normal physical examination and stable hemoglobin, regardless of grade of injury. Data collected include injury severity score, grade of liver injury, LOS, success rate of NOM, time to failure of NOM, and reason for failure of NOM. RESULTS: From August 2002 to March 2009, 591 patients were admitted for NOM of blunt liver injuries. Of these, 35 patients (6%) failed NOM; 19 failed secondary to hemorrhage, mostly from associated injuries. Average LOS for patients with isolated liver injuries was 2.2 days. Only one patient failed NOM as an outpatient. There were no adverse outcomes from these NOM guidelines. CONCLUSIONS: The length of observation should be based solely on clinical criteria. Patients with liver injuries may be safely discharged home in the presence of a normal abdominal examination and stable hemoglobin, regardless of the grade of injury. This guideline is safe and reduces LOS without increasing morbidity or mortality.

Percutaneous tracheostomy: to bronch or not to bronch--that is the question.

BACKGROUND: Percutaneous tracheostomy is a routine procedure in the intensive care unit (ICU). Some surgeons perform percutaneous tracheostomies using bronchoscopy believing that it increases safety. The purpose of this study was to evaluate percutaneous tracheostomy in the trauma population and to determine whether the use of a bronchoscope decreases the complication rate and improves safety. METHODS: A retrospective review was completed from January 2007 to November 2010. Inclusion criteria were trauma patients undergoing percutaneous tracheostomy. Data collected included age, Abbreviated Injury Score by region, Injury Severity Score, ventilator days, and outcomes. Complications were classified as early (occurring within <24 hours) or late (>24 hours after the procedure). RESULTS: During the study period, 9,663 trauma patients were admitted, with 1,587 undergoing intubation and admission to the ICU. Tracheostomies were performed in 266 patients and 243 of these were percutaneous; 78 (32%) were performed with the bronchoscope (Bronch) and 168 (68%) without bronchoscope (No Bronch). There were no differences between the groups in Abbreviated Injury Score by region, Injury Severity Score, probability of survival, ventilator days, and length of ICU or overall hospital stay. There were 16 complications, 5 (Bronch) and 11 (No Bronch). Early complications were primarily bleeding (Bronch 3% vs. No Bronch 4%, not statistically significant). Late complications included tracheomalacia, tracheal granulation tissue, bleeding, and stenosis; Bronch 4% versus No Bronch 3%, (not statistically significant). One major complication occurred, with loss of airway and cardiac arrest, in the bronchoscopy group. CONCLUSION: Percutaneous tracheostomy was safely and effectively performed by an experienced surgical team both with and without bronchoscopic guidance with no difference in the complication rates. This study suggests that the use of bronchoscopic guidance during tracheostomy is not routinely required but may be used as an important adjunct in selected patients, such as those with HALO cervical fixation, obesity, or difficult anatomy.

Prehospital hypotension in blunt trauma: identifying the "crump factor".

BACKGROUND: Trauma activation for prehospital hypotension in blunt trauma is controversial. Some patients subsequently arrive at the trauma center normotensive, but they can still have life-threatening injuries. Admission base deficit (BD)≤-6 correlates with injury severity, transfusion requirement, and mortality. Can admission BD be used to discriminate those severely injured patients who arrive normotensive but "crump," (i.e., become hypotensive again) in the Emergency Department? The purpose is to determine whether admission BD<-6 discriminates patients at risk for future bouts of unexpected hypotension during evaluation. METHODS: Retrospective chart review was performed on all blunt trauma admissions at a Level I trauma center from August 2002 through July 2007. Hypotension was defined as a systolic blood pressure≤90 mm Hg. Patients who were hypotensive in the field but normotensive upon arrival in the emergency department (ED) were included. Age, gender, injury severe score, arterial blood gas analysis, results of focused abdominal sonogram for trauma (FAST), computed tomography, intravenous fluid administration, blood transfusions, and the presence of repeat bouts of hypotension were noted. Patients were stratified by BD≤-6 or ≥-5. Statistical analysis was performed using paired t test, χ, and logistic regression analysis with significance attributed to p<0.05. RESULTS: During the 5-year period, 231 blunt trauma patients had hypotension in the field with subsequent normotension on admission to the ED. Of these, 189 patients had admission BD data recorded. Patients with a BD≤-6 were significantly more likely to have repeat hypotension (78% vs. 30%, p<0.001). Overall mortality was 13% (24 of 189), but patients with repeat hypotension had greater mortality (24% vs. 5%, p<0.003). CONCLUSION: Blunt trauma patients with repeat episodes of hypotension have significantly greater mortality. Patients with transient field hypotension and a BD≤-6 are more than twice as likely to have repeat hypotension (crump). This study reinforces the need for early arterial blood gases and trauma team involvement in the evaluation of these patients. Patients with BD≤-6 should have early invasive monitoring, liberal use of repeat FAST exams, and careful resuscitation before computed tomography scanning. Surgeons should have a low threshold for taking such patients to the operating room.

Prevalence of comorbid conditions with aging among patients with diabetes and cardiovascular disease.

OBJECTIVES: The objectives were to develop a methodology to understand the prevalence of medically complex patients, and to apply the methodology to examine patients with one or more of hypertension, hyperlipidemia, diabetes, and heart disease. METHODS: Prevalence was measured using insurance data by calculating the proportion of days patients in a health state of interest contributed to the total days of enrollment. Graphs summarized the prevalence patterns within age and morbidity categories. Results by age and gender were supplemented with cubic spline curves that closely fit the prevalence data. RESULTS: The study provides basic epidemiologic information on changes with aging in the prevalence of patients with one or more comorbid conditions. Patients such as those with hyperlipidemia alone rose in prevalence at younger ages and fell at older ages, whereas the prevalence of other patients, such as patients having hypertension, diabetes, and heart disease, progressively increased with age. With straightforward extensions of the methodology other issues such as the incidence of emergency department visits and hospitalizations might be investigated.

Mortality in hypotensive trauma patients requiring laparotomy is related to degree of hypotension and provides evidence for focused interventions.

BACKGROUND: Mortality in hypotensive patients requiring laparotomy is reported to be 46% and essentially unchanged in 20 years. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been incorporated into resuscitation protocols in an attempt to decrease mortality, but REBOA can have significant complications and its use in this patient group has not been validated. This study sought to determine the mortality rate for hypotensive patients requiring laparotomy and to evaluate the mortality risk related to the degree of hypotension. Additionally, this study sought to determine if there was a presenting systolic blood pressure (SBP) that was associated with a sharp increase in mortality to target the appropriate patient group most likely to benefit from focused interventions such as REBOA. METHODS: The trauma registry at a level I trauma center was reviewed for patients undergoing emergent laparotomy from January 2007 to June 2020. Data included demographics, mechanism of injury, physiological data, Injury Severity Score, blood products transfused, and outcomes. Group comparisons were based on initial SBP (0 to 50 mm Hg, 60 to 69 mm Hg, 70 to 79 mm Hg, 80 to 89 mm Hg, and ≥90 mm Hg). RESULTS: During the study period, 52 016 trauma patients were treated and 1174 required laparotomy within 90 min of arrival; 424 had an initial SBP of <90 mm Hg. The overall mortality rate was 18%, but mortality increased as SBP decreased (≥90=9%, 80 to 89=20%, 70 to 79=21%, 60 to 69=48%, 0 to 59=66%). Mortality increased sharply with SBP of <70 mm Hg. DISCUSSION: Mortality rate increases with worsening hypotension and increases sharply with an SBP of <70 mm Hg. Further study on focused interventions such as REBOA should target this patient group. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Do health educator telephone calls reduce at-risk drinking among older adults in primary care?

BACKGROUND: Alcohol screening and brief intervention for unhealthy alcohol use has not been consistently delivered in primary care as part of preventive healthcare. OBJECTIVE: To explore whether telephone-based intervention delivered by a health educator is efficacious in reducing at-risk drinking among older adults in primary care settings. DESIGN: Secondary analyses of data from a randomized controlled trial. PARTICIPANTS: Subjects randomized to the intervention arm of the trial (n = 310). INTERVENTIONS: Personalized risk reports, advice from physicians, booklet about alcohol and aging, and up to three telephone calls from a health educator. All interventions were completed before the three-month follow-up. MEASUREMENTS: Risk outcomes (at-risk or not at-risk) at 3 and 12 months after enrollment. MAIN RESULTS: In univariate analyses, compared to those who remained at risk, those who achieved not at-risk outcome at 3 months were more likely to be women, Hispanic or non-white, have lower levels of education, consume less alcohol, drink less frequently, and have lower baseline number of risks. In mixed-effects logistic regression models, completing all three health educator calls increased the odds of achieving not at-risk outcome compared to not completing any calls at 3 months (OR 5.31; 95% CI 1.92-14.7; p = 0.001), but not at 12 months (OR 2.01; 95% CI 0.71-5.67; p = 0.18). CONCLUSIONS: Telephone-based intervention delivered by a health educator was moderately efficacious in reducing at-risk drinking at 3 months after enrollment among older adults receiving a multi-faceted intervention in primary care settings; however, the effect was not sustained at 12 months.

Management of pelvic fractures.

PURPOSE OF REVIEW: The management of patients with pelvic fractures can be demanding. Severe pelvic fractures pose a great challenge for physicians and can greatly contribute to significant patient morbidity and mortality. The purpose of this review is to highlight recent, positive changes in the management of patients with pelvic fractures. RECENT FINDINGS: The current status of pelvic fracture management is presented, including a recently proposed algorithm for management, an evaluation of roles of angioembolization and preperitoneal packing. Additionally, the approach of bilateral internal iliac artery ligation as a salvage procedure is reviewed, and the outcome of acute (<24 h) pelvic fracture operative fixation. Regardless of the strategy adopted, a multidisciplinary approach is required for the proper management of hemodynamically unstable patients with pelvic fractures. SUMMARY: The key elements in managing patients with pelvic fractures are swift and adequate resuscitation, reversal of shock and acidosis, and rapid control of hemorrhage to facilitate survival of these patients. Multimodality therapies including external pelvic stabilization, angioembolization and preperitoneal pelvic packing are useful adjuncts that require appropriately trained and immediately available personnel. A multidisciplinary approach has been shown to be beneficial for patient outcomes.

Identifying characteristics of patients with low urgency emergency department visits in a managed care setting.

PURPOSE: Studies worldwide in emergency departments (ED) find that a substantial proportion of patients seek care for non-urgent conditions. Managed care programs may help address this overuse of ED facilities, but non-urgent ED care is not easily identified outside of ED settings. This article employed an algorithm using insurance data to identify and characterize patients having low urgency ED visits. Non-urgentis the term used in the ED literature for ED visits that might have been managed outside an ED setting such as in a physician office. Low urgency ED visits could include visits that require an ED setting but for less severe conditions than high urgency ED visits. DESIGN: Analysis of ED visits by members of the largest health insurer in Hawaii. METHODOLOGY: Visits were defined as low urgency if classified by the ED as low severity and if, in addition, the patients required no procedures beyond physician and nursing care. A simple example would be a physician order for a laboratory test. Even if the test was routine, the fact the doctor ordered the test during the ED visit suggests the result might be needed right away to make a management decision. Another example of a procedure would be a radiograph. PRINCIPAL FINDING: Medicaid participants, children age 1 to 5, and people living on less populated Hawaiian Islands most frequently had low urgency visits. The visits were also more common on weekends than weekdays, and more common among males compared to females. Of all low urgency visits by Medicaid participants, 32% were by repeat users of the ED. The percentage for members of non-Medicaid plans was 16%. People with one low urgency visit in the past year were more than twice as likely as others to have a similar visit in the next year. People with two or more low urgency visits in the past year were five times as likely to have a low urgency ED visit in the next year. CONCLUSION: The results identify several areas such as youth, island of residence, and past history of low urgency ED visits that might become the focus of managed care programs.

Gastrobronchial Fistula after Robotic Repair of Traumatic Diaphragmatic Hernia.

Gastrobronchial fistulas are a rare occurrence in the literature. We report a case of a gastrobronchial fistula after robotic repair of a chronic traumatic diaphragmatic hernia. The patient had severe respiratory symptoms with multiple studies that were inconclusive. The fistula was ultimately discovered after an esophagogastroduodenoscopy (EGD). The patient underwent a left thoracotomy for takedown of his fistula and eventually recovered. Earlier EGD and a lower threshold for differential that included this diagnosis would have led to an earlier identification and treatment of a rare disease process.

Incidence of hyponatremia in patients given levetiracetam vs. phenytoin for early posttraumatic seizure prophylaxis.

BACKGROUND: Levetiracetam and phenytoin are comparable for acute posttraumatic seizure(PTS) prophylaxis. Levetiracetam-induced hyponatremia has been reported in non-trauma patients. We studied hyponatremia in posttraumatic intracranial hemorrhage(ICH) patients receiving either drug. METHODS: Retrospective review of patients with ICH receiving PTS prophylaxis was performed. Patients were categorized by degree of sodium nadir: normal, mild, moderate, or severe, and analyzed by levetiracetam versus phenytoin. Patients were matched 2:1 regarding age and injury severity score(ISS). Incidence and treatment for hyponatremia was examined. RESULTS: 1735 ICH patients received PTS prophylaxis over an 8-year period. After exclusions and matching, there were 282 phenytoin and 564 levetiracetam patients. Age, ISS and initial sodium were comparable between the matched cohorts. There was no clinically significant difference in the rate or degree of hyponatremia. Treatment was more common in levetiracetam patients. DISCUSSION: There was a small but clinically insignificant difference in the incidence of hyponatremia in traumatic ICH patients receiving levetiracetam vs. phenytoin for PTS prophylaxis. There was an increased rate of intervention for hyponatremia in the levetiracetam group, possibly due to a coincidental preventive paradigm shift.

Prospective evaluation of admission cortisol in trauma.

BACKGROUND: A low cortisol level has been shown to occur soon after trauma, and is associated with increased mortality. The purpose of this study was to investigate the impact of low cortisol levels in acute critically ill trauma patients. We hypothesized that patients would require increase vasopressor use, have a greater blood product administration, and increased mortality rate. METHODS: A blinded, prospective observational study was performed at an American College of Surgeons verified Level I trauma center. Adult patients who met trauma activation criteria, received initial treatment at Community Regional Medical Center and were admitted to the intensive care unit were included. Total serum cortisol levels were measured from the initial blood draw in the emergency department. Patients were categorized according to cortisol ≤15 µg/dL (severe low cortisol, SLC), 15.01-25 µg/dL (relative low cortisol, RLC), or >25 µg/dL (normal cortisol, NC) and compared on demographics, injury severity score, initial vital signs, blood product usage, vasopressor requirements, and mortality. RESULTS: Cortisol levels were ordered for 280 patients; 91 were excluded and 189 were included. Penetrating trauma accounted for 19% of injuries and blunt trauma for 81%. 22 patients (12%) had SLC, 83 (44%) had RLC, and 84 (44%) had NC. This study found patients with admission SLC had higher rates of vasopressor requirements, required more units of blood, and had a higher mortality rate than both the RLC and NC groups. CONCLUSION: Low cortisol level can be identified acutely after severe trauma. Trauma patients with SLC had larger blood product requirements, vasopressor use, and increase mortality. Initial cortisol levels are useful in identifying these high-risk patients. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Intercostal Nerve Block with Liposomal Bupivacaine vs Epidural Analgesia for the Treatment of Traumatic Rib Fracture.

BACKGROUND: Rib fractures are common among trauma patients and analgesia remains the cornerstone of treatment. Intercostal nerve blocks provide analgesia but are limited by the duration of the anesthetic. This study compares outcomes of epidural analgesia with intercostal nerve block using liposomal bupivacaine for the treatment of traumatic rib fractures. METHODS: A retrospective chart review was used to identify patients who received either epidural analgesia or intercostal nerve block with liposomal bupivacaine for the treatment of traumatic rib fractures. Patients were matched in a 1:1 ratio on age, Injury Severity Score, and number of rib fractures. Outcomes included intubations, mechanical ventilation days, ICU length of stay (LOS), hospital LOS, and mortality. RESULTS: After matching, 116 patients were included in the study. Patients receiving intercostal nerve blocks with liposomal bupivacaine were less likely to require intubation (3% vs 17%; p = 0.015), had shorter hospital LOS (mean ± SD 8 ± 6 days vs 11 ± 9 days; p = 0.020) and ICU LOS (mean ± SD 2 ± 5 days vs 5 ± 6 days; p = 0.007). There were no differences in ventilator days or mortality. Minor complications occurred in 26% of patients that received an epidural catheter for rib fractures. No complications occurred in the patients receiving intercostal nerve block. CONCLUSIONS: Patients who received intercostal nerve blocks with liposomal bupivacaine required intubation less frequently and had shorter ICU and hospital LOS compared with epidural analgesia patients. These results suggest that intercostal nerve blocks with liposomal bupivacaine might be equal or superior to epidural analgesia.