A Smartphone Application for Teamwork and Communication in Trauma: Pilot Evaluation "in the Wild".

OBJECTIVE: To evaluate the potential for a smartphone application to improve trauma care through shared and timely access to patient and contextual information. BACKGROUND: Disruptions along the trauma pathway that arise from communication, coordination, and handoffs problems can delay progress through initial care, imaging diagnosis, and surgery to intensive care unit (ICU) disposition. Implementing carefully designed and evaluated information distribution and communication technologies may afford opportunities to improve clinical performance. METHODS: This was a pilot evaluation "in the wild" using a before/after design, 3 month, and pre- post-intervention data collection. Use statistics, usability assessment, and direct observation of trauma care were used to evaluate the app. Ease of use and utility were assessed using the technology acceptance model (TAM) and system usability scale (SUS). Direct observation deployed measures of flow disruptions (defined as "deviations from the natural progression of an procedure"), teamwork scores (T-NOTECHS), and treatment times (total time in emergency department [ED]). RESULTS: The app was used in 367 (87%) traumas during the trial period. Usability was generally acceptable, with higher scores found by operating room (OR), ICU, and neuro and orthopedic users. Despite positive trends, no significant effects on flow disruptions, teamwork scores, or treatment times were observed. CONCLUSIONS: Pilot trials of a clinician-centered smartphone app to improve teamwork and communication demonstrate potential value for the safety and efficiency of trauma care delivery as well as benefits and challenges of "in-the-wild" evaluation.

Delayed Intracranial Hemorrhage in Anticoagulated Geriatric Patients After Ground Level Falls.

BACKGROUND: The reported risk of delayed intracranial hemorrhage (ICH) in a trauma patient on warfarin is estimated to be between 0.6% and 6%. The risk of delayed ICH in trauma patients taking novel oral anticoagulants (NOACs) is not well-defined. OBJECTIVE: We hypothesized that there was a significant number of delayed presentations of ICH in patients on NOACs. METHODS: A retrospective review of our trauma registry was performed on geriatric patients (age older than 64 years) who were initially evaluated at our level I trauma center, had fall from standing height or less, and were anticoagulated (warfarin or NOACs), from April 2017 to March 2018. RESULTS: Seventy-seven patients met inclusion criteria. The mean age was 80 ± 7.7 years and 46% of patients were male. The admission head computed tomography scan was positive in 20.8% of patients. Positive scans were more common in patients on warfarin vs. NOACs (30% vs. 14%; p = 0.074) and had a significantly higher Injury Severity Score (median [interquartile range]: 9 [3-15] vs. 5 [1-9]; p = 0.030) and Abbreviated Injury Scale-Head score (median [interquartile range]: 1 [0-3] vs. 1 [0-2]; p = 0.035). The agreement between loss of consciousness (LOC) and ICH was 72% (κ = -0.064; p = 0.263). Fifty-one percent of patients had a repeat head CT. New ICH was diagnosed in 9.6% of patients. All of these patients were on NOACs. CONCLUSIONS: A fall from standing or less in anticoagulated geriatric patients is a significant mechanism of injury resulting in ICH. The absence of LOC does not eliminate the possibility of ICH. There is a significant risk of delayed ICH for patients on NOACs and repeat evaluations should be performed. A prospective multicenter evaluation of this finding is warranted.

Evaluation of a Device Combining an Inferior Vena Cava Filter and a Central Venous Catheter for Preventing Pulmonary Embolism Among Critically Ill Trauma Patients.

PURPOSE: To evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter (CVC) for prevention of pulmonary embolism (PE) in critically ill patients. MATERIALS AND METHODS: In a multicenter, prospective, single-arm clinical trial, the device was inserted at the bedside without fluoroscopy and subsequently retrieved before transfer from the intensive care unit (ICU). The primary efficacy endpoint was freedom from clinically significant PE or fatal PE 72 hours after device removal or discharge, whichever occurred first. Secondary endpoints were incidence of acute proximal deep venous thrombosis (DVT), catheter-related thrombosis, catheter-related bloodstream infections, major bleeding events, and clinically significant thrombus (occupying > 25% of volume of filter) detected by cavography before retrieval. RESULTS: The device was placed in 163 critically ill patients with contraindications to anticoagulation; 151 (93%) were critically ill trauma patients, 129 (85%) had head or spine trauma, and 102 (79%) had intracranial bleeding. The primary efficacy endpoint was achieved for all 163 (100%) patients (95% confidence interval [CI], 97.8%-100%, P < .01). Diagnosis of new or worsening acute proximal DVT was time dependent with 11 (7%) occurring during the first 7 days. There were no (0%) catheter-related bloodstream infections. There were 5 (3.1%) major bleeding events. Significant thrombus in the IVC filter occurred in 14 (8.6%) patients. Prophylactic anticoagulation was not initiated for a mean of 5.5 days ± 4.3 after ICU admission. CONCLUSIONS: This novel device prevented clinically significant and fatal PE among critically ill trauma patients with low risk of complications.

Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry.

Introduction: Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD). Methods: Patients from the prospective, observational CLOTT-1 registry receiving prophylactic enoxaparin (n=5539) were categorized as WB (0.45-0.55 mg/kg two times per day) or SFD (30 mg two times per day, 40 mg once a day). Multivariate logistic regression was used to generate a predicted probability of VTE for WB and SFD patients. Results: Of 4360 patients analyzed, 1065 (24.4%) were WB and 3295 (75.6%) were SFD. WB patients were younger, female, more severely injured, and underwent major operation or major venous repair at a higher rate than individuals in the SFD group. Obesity was more common among the SFD group. Unadjusted VTE rates were comparable (WB 3.1% vs. SFD 3.9%; p=0.221). Early prophylaxis was associated with lower VTE rate (1.4% vs. 5.0%; p=0.001) and deep vein thrombosis (0.9% vs. 4.4%; p<0.001), but not pulmonary embolism (0.7% vs. 1.4%; p=0.259). After adjustment, VTE incidence did not differ by dosing strategy (adjusted OR (aOR) 0.75, 95% CI 0.38 to 1.48); however, early administration was associated with a significant reduction in VTE (aOR 0.47, 95% CI 0.30 to 0.74). Conclusion: In young trauma patients, WB prophylaxis is not associated with reduced VTE rate when compared with SFD. The timing of the initiation of chemoprophylaxis may be more important than the dosing strategy. Further studies need to evaluate these findings across a wider age and comorbidity spectrum. Level of evidence: Level IV, therapeutic/care management.

Implementation of a Stepped Care Program to Address Emotional Recovery among Traumatic Injury Patients.

BACKGROUND: Annually, over 600,000 adults served in US trauma centers (≥20%) develop posttraumatic stress disorder (PTSD) and/or depression in the first year after injury. American College of Surgeons guidelines include screening and addressing mental health recovery in trauma centers. Yet, many trauma centers do not monitor and address mental health recovery, and it is a priority to learn how to implement evidence-informed mental health programs in trauma centers. STUDY DESIGN: This report describes our application of the Exploration, Preparation, Implementation, Sustainment model to implement the Trauma Resilience and Recovery Program (TRRP) in 3 Level I and II trauma centers to address patients' mental health needs. TRRP is a scalable and sustainable stepped model of care-one of the few in the US-that provides early intervention and direct services after traumatic injury. RESULTS: Trauma centers are well positioned to accelerate patients' mental health recovery via early identification, education, screening, and referrals to mental health agencies that provide best-practice care. We found that TRRP was acceptable to the 3 partnering trauma centers we studied. Early engagement of patient, provider, and hospital administration stakeholders enhanced buy-in during the early stages of the implementation process and promoted sustainability. Active processes to support monitoring, evaluation, and adaptation were critical. CONCLUSIONS: Our work demonstrates the feasibility of implementing and adapting TRRP, a cost-efficient and sustainable stepped care intervention, in Level I and II trauma centers. Several factors should be carefully considered by trauma centers seeking to integrate behavioral health interventions into their trauma program.

A core outcome set for damage control laparotomy via modified Delphi method.

OBJECTIVES: Damage control laparotomy (DCL) remains an important tool in the trauma surgeon's armamentarium. Inconsistency in reporting standards have hindered careful scrutiny of DCL outcomes. We sought to develop a core outcome set (COS) for DCL clinical studies to facilitate future pooling of data via meta-analysis and Bayesian statistics while minimizing reporting bias. METHODS: A modified Delphi study was performed using DCL content experts identified through Eastern Association for the Surgery of Trauma (EAST) 'landmark' DCL papers and EAST ad hoc COS task force consensus. RESULTS: Of 28 content experts identified, 20 (71%) participated in round 1, 20/20 (100%) in round 2, and 19/20 (95%) in round 3. Round 1 identified 36 potential COS. Round 2 achieved consensus on 10 core outcomes: mortality, 30-day mortality, fascial closure, days to fascial closure, abdominal complications, major complications requiring reoperation or unplanned re-exploration following closure, gastrointestinal anastomotic leak, secondary intra-abdominal sepsis (including anastomotic leak), enterocutaneous fistula, and 12-month functional outcome. Despite feedback provided between rounds, round 3 achieved no further consensus. CONCLUSIONS: Through an electronic survey-based consensus method, content experts agreed on a core outcome set for damage control laparotomy, which is recommended for future trials in DCL clinical research. Further work is necessary to delineate specific tools and methods for measuring specific outcomes. LEVEL OF EVIDENCE: V, criteria.

Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism.

Importance: Pulmonary clots are seen frequently on chest computed tomography performed after trauma, but recent studies suggest that pulmonary thrombosis (PT) and pulmonary embolism (PE) after trauma are independent clinical events. Objective: To assess whether posttraumatic PT represents a distinct clinical entity associated with the nature of the injury, different from the traditional venous thromboembolic paradigm of deep venous thrombosis (DVT) and PE. Design, Setting, and Participants: This prospective, observational, multicenter cohort study was conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted at 17 US level I trauma centers during a 2-year period (January 1, 2018, to December 31, 2020). Consecutive patients 18 to 40 years of age admitted for a minimum of 48 hours with at least 1 previously defined trauma-associated venous thromboembolism (VTE) risk factor were followed up until discharge or 30 days. Exposures: Investigational imaging, prophylactic measures used, and treatment of clots. Main Outcomes and Measures: The main outcomes of interest were the presence, timing, location, and treatment of any pulmonary clots, as well as the associated injury-related risk factors. Secondary outcomes included DVT. We regarded pulmonary clots with DVT as PE and those without DVT as de novo PT. Results: A total of 7880 patients (mean [SD] age, 29.1 [6.4] years; 5859 [74.4%] male) were studied, 277 with DVT (3.5%), 40 with PE (0.5%), and 117 with PT (1.5%). Shock on admission was present in only 460 patients (6.2%) who had no DVT, PT, or PE but was documented in 11 (27.5%) of those with PE and 30 (25.6%) in those with PT. Risk factors independently associated with PT but not DVT or PE included shock on admission (systolic blood pressure <90 mm Hg) (odds ratio, 2.74; 95% CI, 1.72-4.39; P < .001) and major chest injury with Abbreviated Injury Score of 3 or higher (odds ratio, 1.72; 95% CI, 1.16-2.56; P = .007). Factors associated with the presence of PT on admission included major chest injury (14 patients [50.0%] with or without major chest injury with an Abbreviated Injury Score >3; P = .04) and major venous injury (23 [82.1%] without major venous injury and 5 [17.9%] with major venous injury; P = .02). No deaths were attributed to PT or PE. Conclusions and Relevance: To our knowledge, this CLOTT study is the largest prospective investigation in the world that focuses on posttraumatic PT. The study suggests that most pulmonary clots are not embolic but rather result from inflammation, endothelial injury, and the hypercoagulable state caused by the injury itself.

Telemedicine to a moving ambulance improves outcome after trauma in simulated patients.

BACKGROUND: Rural trauma victims often require prolonged transport by s with limited scopes of practice. We evaluated the impact of telemedicine (TM) to a moving ambulance on outcomes in simulated trauma patients. METHODS: This is an institutional review board approved, prospective double-blind study. Three trauma scenarios (blunt torso trauma, epigastric stab wound, and closed head injury) were created for a human patient simulator. Intermediate emergency medical technicians (EMTs; n = 20) managed the human patient simulator, in a moving ambulance. In the TM group, physicians (n = 12) provided consultation. In the non-TM group, EMTs communicated with medical control by radio, as necessary. We tabulated the fraction of 13 key signs, 5 pathologic processes, and 12 key interventions that were performed. Vital signs and Sao2 (%) were recorded. Data were compared using the Wilcoxon rank-sum test. RESULTS: Lowest Sao2 (84 ± 0.7 vs. 78 ± 0), lowest systolic blood pressure (70 ± 1 vs. 53 ± 1), and highest heart rate (144 ± 0.9 vs. 159 ± 0.5) were significantly improved in the TM group (p < 0.001). Recognition rates for key signs (0.96 ± 0.01 vs. 0.79 ± 0.05), processes (0.98 ± 0.02 vs. 0.75 ± 0.05), and critical interventions (0.92 ± 0.02 vs. 0.49 ± 0.03) were higher in the TM group (p < 0.003). EMTs were successfully guided through needle decompression procedures in 22 of 24 cases (zero in the non-TM group). CONCLUSION: TM to a moving ambulance improved the care of simulated trauma patients. Furthermore, procedurally naïve EMTs were able to perform needle thoracostomy and pericardiocentesis with TM guidance.

Decreased Incidence of Rib Fractures in Pregnant Patients After Motor Vehicle Collisions.

BACKGROUND: Rib fractures are common after motor vehicle collisions. The hormonal changes associated with pregnancy decrease the stiffness and increase the laxity of cartilage and tendons. The effect of these changes on injury mechanics is not completely understood. OBJECTIVES: To compare the incidences of chest wall injury following blunt thoracic trauma between pregnant and nonpregnant women. METHODS: The authors conducted a retrospective review of female patients seen at a level I trauma center from 2009 to 2017 after a motor vehicle collision. Patient characteristics were compared to determine if pregnancy affected the incidence of chest wall injury. Statistics were calculated with SPSS version 24 and are presented as mean (SD) or median (interquartile range). RESULTS: In total, 1618 patients were identified. The incidence of rib/sternal fracture was significantly lower in pregnant patients (7.9% vs 15.2%, P = .047), but the incidence of intrathoracic injury was similar between the groups. Pregnant and nonpregnant patients with rib/sternal fractures had similar Injury Severity Score results (21 [13-27] vs 17 [11-22], P = .36), but pregnant patients without fractures had significantly lower scores (1 [0-5] vs 4 [1-9], P < .001). CONCLUSIONS: Pregnant patients have a lower rate of rib fracture after a motor vehicle collision than nonpregnant patients. The difference in injury mechanics may be due to hormonal changes that increase elasticity and resistance to bony injury of the ribs. In pregnant trauma patients, intrathoracic injury without rib fracture should raise concerns about injury severity. A multicenter evaluation of these findings is needed.

"Never be wrong": the morbidity of negative and delayed laparotomies after blunt trauma.

BACKGROUND: The objective of this study was to investigate the 30-day morbidity of a negative laparotomy (NEGLAP) in blunt abdominal trauma. No previous work has exclusively examined blunt abdominal trauma patients, used a control group, or determined the complication burden incurred by a NEGLAP. METHODS: In this retrospective cohort study of a prospectively maintained database, demographics, Injury Severity Score, Revised Trauma Score (TRISS), hospital length of stay, mortality, and findings at laparotomy (LAP) were analyzed. Patients were assigned to four groups as follows: NEGLAP (n = 28), positive LAP (n = 126), delay to LAP (DELAY, n = 18), and no LAP (NOLAP, n = 427). Complications during hospitalization and 30 days postdischarge were extracted from our complication database and adjusted for severity using a complication scoring system (Complication Impact Score [CIS]). The effect of LAP on the log transformed CIS was assessed using a linear regression model, controlling for age and TRISS. RESULTS: Complications per patient ranged from 1.73 (DELAY) to 0.38 (NOLAP), and the average CIS per patient ranged from 7.29 (NEGLAP) to 1.8 (NOLAP). When controlled for TRISS and age, NEGLAP did not significantly increase the CIS (p = 0.620), whereas positive LAP (p = 0.004) and DELAY (p = 0.034) were associated with a significant increase in CIS. CONCLUSIONS: When controlled for TRISS and age, NEGLAP does not increase the complication burden compared with NOLAP. In blunt abdominal trauma patients, operations to establish diagnosis do not add significantly to complication burden.

Utility of ampicillin-sulbactam for empiric treatment of ventilator-associated pneumonia in a trauma population.

BACKGROUND: Ampicillin-sulbactam is guideline-recommended treatment for early-onset ventilator-associated pneumonia (VAP). However, intensive care unit clinicians are encountering increasing resistance to ampicillin-sulbactam. We sought to analyze the time period for early-onset VAP in our trauma population by using daily evaluation of resistance to ampicillin-sulbactam. METHODS: A retrospective cohort study was completed on all mechanically ventilated trauma patients admitted to a rural level-1 trauma center from January 2003 to December 2008 who were diagnosed with VAP. Daily bacterial resistance to ampicillin-sulbactam > 15% was defined as the threshold for early empiric antibiotic failure for the first episode of VAP. A univariate analysis of risk factors for multi-drug resistant pathogens (MDRPs) and comorbidities was completed to assess for predisposing factors for ampicillin-sulbactam resistance. RESULTS: One hundred sixty-three pathogens were identified in 121 trauma patients diagnosed with VAP. Of these isolates, 71% were gram-negative, 28% were gram-positive, and 1% was fungal. Methicillin-susceptible Staphylococcus aureus (23.9%), H aemophilus influenzae (20.9%), and Pseudomonas aeruginosa (11.7%) were the most common infecting organisms. Daily ampicillin-sulbactam resistance was 40%, 26%, 32%, 43%, 50%, and 60% on days 3 to 7 and ≥ 8 days, respectively. Only the presence of MDRP risk factors (89% vs. 65%, p < 0.01) and hospital LOS (36.8 [22.8-49.0] vs. 25.7 days [19.0-32.5], p < 0.01) was different between ampicillin- sulbactam resistant and ampicillin-sulbactam susceptible VAP groups. On univariate analysis, hospital length of stay >4 days and antibiotic use within 90 days were associated with ampicillin-sulbactam resistant VAP (p < 0.01). CONCLUSIONS: Ampicillin-sulbactam is not an effective empiric therapy for early-onset VAP in our rural trauma population. The utility of ampicillin-sulbactam should be reviewed at other institutions to assess for appropriate empiricism.

Patient Engagement in a Technology-Enhanced, Stepped-Care Intervention to Address the Mental Health Needs of Trauma Center Patients.

BACKGROUND: Annually, post-traumatic stress disorder, depression, or both, develop in the first year after injury in more than 400,000 adults treated in US trauma centers (≥20%). Yet, few trauma centers monitor and address mental health recovery, and there is limited evaluation and high structural variability across existing programs. More research is needed to guide efforts to establish such programs and to inform national standards and recommendations. STUDY DESIGN: This article describes patient engagement in a stepped-care service to address patients' mental health needs. Trauma-activation patients admitted to our Level I trauma center for at least 24 hours were approached before discharge. Patients were provided education in person at the bedside (step 1), symptom monitoring via a 30-day text-messaging tool (step 2), telephone screening approximately 30 days post injury (step 3), and, when appropriate, mental health treatment referrals and treatment (step 4). RESULTS: We approached and educated 1,122 patients (56%) on the floor during a 33-month period. Of these, 1,096 patients (98%) enrolled in our program and agreed to 30-day follow-up mental health screening. We reached 676 patients for the 30-day screen, 243 (36%) of these patients screened positive for post-traumatic stress disorder and/or depression. Most of the 243 patients who graduated to step 4 accepted treatment referrals (68%) or were already receiving services from a provider (7%). Home-based telemental health was preferred by 66% of patients who accepted referrals. CONCLUSIONS: This work demonstrates the feasibility of an evidence-based, technology-enhanced, stepped-care intervention to address the mental health needs of trauma center patients. Strategies to reach a higher percentage of patients in follow-up are needed. We recommend trauma centers test and adopt broad-based approaches to ensure optimal long-term patient outcomes.

Fait accompli: suicide in a rural trauma setting.

OBJECTIVES: Over the past 20 years, the rate of suicide in rural communities has surpassed those of urban areas. The number of rural trauma patients who attempt suicide, are treated and survive at a trauma center, but ultimately reattempt suicide and succeed (suicide recidivists) is unknown. We have characterized all adult suicide deaths seen at a rural Level I trauma center and identified predictors of a successful suicide. We hypothesized that rural adult trauma patients exhibit a high rate of suicide recidivism. METHODS: This is a 10-year single institutional retrospective cohort analysis. All adult admissions to our rural, Level I trauma center from 1997 to 2007 (n = 9147) were cross referenced with a Vermont Medical Examiner database containing information regarding all suicide deaths in the state of Vermont from 2002 to 2007 (n = 502); the 32 matches are the subject of this research. RESULTS: One half (16 of 32) of patients who died by suicide had a previous admission to the trauma service. Index hospital length of stay (LOS, p < 0.02), intensive care unit-LOS (p < 0.01), and ventilator days (p < 0.01) were significantly different between trauma patients who subsequently died by suicide and general trauma patients. The average delay from initial presentation to suicide death was 2.8 years. Eighteen of 28 (64%) of suicide attempters had previous trauma admissions for self-inflicted injury (p < 0.001). Eighteen of 156 (12%) of previous self-inflicted injury admissions resulted in future suicide attempt (NNT = 9). A logistic regression model identified the following variables present at the index hospitalization as significant predictors of future suicide: self-inflicted injury, penetrating mechanism of injury, longer hospital LOS, younger age, and female gender. CONCLUSION: The overwhelming majority (94%) of suicide deaths in our rural state were never seen by the trauma center, and only 1.1% were recidivists. Previous admissions for self-inflicted injuries or penetrating injuries were significant predictors of future suicide attempt and should trigger select interventions. Other factors that can to lead a suicidal tendency include a previous mental health history (depression), poly-substance abuse, and chronic pain history. In our small sample, suicidal tendencies could persist for a prolonged period of time.

Oxygen saturation determined from deep muscle, not thenar tissue, is an early indicator of central hypovolemia in humans.

OBJECTIVE: To compare the responses of noninvasively measured tissue oxygen saturation (StO2) and calculated muscle oxygen tension (PmO2) to standard hemodynamic variables for early detection of imminent hemodynamic instability during progressive central hypovolemia in humans. DESIGN: Prospective study. SETTING: Research laboratory. SUBJECTS: Sixteen healthy human volunteers. INTERVENTIONS: Progressive lower body negative pressure (LBNP) to onset of cardiovascular collapse. MEASUREMENTS AND MAIN RESULTS: Noninvasive measurements of blood pressures, heart rate, and stroke volume were obtained during progressive LBNP with simultaneous assessments of StO2, PmO2, and muscle oxygen saturation (SmO2). Forearm SmO2 and PmO2 were determined with a novel near infrared spectroscopic measurement device (UMMS) and compared with thenar StO2 measured by a commercial device (HT). All values were normalized to the duration of LBNP exposure required for cardiovascular collapse in each subject (i.e., LBNP maximum). Stroke volume was significantly decreased at 25% of LBNP maximum, whereas blood pressure was a late indicator of imminent cardiovascular collapse. PmO2 (UMMS) was significantly decreased at 50% of maximum LBNP while SmO2 (UMMS) decreased at 75% of maximum LBNP. Thenar StO2 (HT) showed no statistical change throughout the entire LBNP protocol. CONCLUSIONS: Spectroscopic assessment of forearm muscle PO2 and SmO2 provides noninvasive and continuous measures that are early indicators of impending cardiovascular collapse resulting from progressive reductions in central blood volume.

Frequency of inappropriate continuation of acid suppressive therapy after discharge in patients who began therapy in the surgical intensive care unit.

STUDY OBJECTIVE: To determine the frequency with which patients who begin to receive stress ulcer prophylaxis in the surgical intensive care unit (SICU) are discharged receiving inappropriate acid suppressive therapy (AST). DESIGN: Prospective, observational evaluation. Setting. Level 1 trauma center and academic tertiary care hospital. PATIENTS: A total of 248 consecutive adult patients admitted to the SICU during a 6-month period who began to receive AST with a proton pump inhibitor or histamine(2)-receptor antagonist. MEASUREMENTS AND MAIN RESULTS: In most patients (237 [95.6%] of 248), initiation of AST was associated with one or more risk factors for gastrointestinal bleeding. Continuation of AST during hospitalization outside the SICU occurred in 215 patients (86.7%). Sixty patients (24.2%) were discharged from the hospital receiving AST: 52 patients (21.0%) went to skilled nursing facilities or rehabilitation centers, and eight (3.2%) were discharged home. Compared with those whose AST was discontinued in the hospital, patients who continued to receive AST after hospital discharge required extended mechanical ventilation (p=0.001), had twice as many risk factors for gastrointestinal bleeding (p<0.001), were frequently discharged with anticoagulant therapy (p<0.001), exhibited longer hospital and SICU stays (p<0.001), and more frequently demonstrated Glasgow Coma Scale scores of 8 or lower and/or had head injury (p<0.001), hepatic failure (p=0.004), and major trauma (p=0.049). Evaluation of continuation of AST during hospitalization revealed that only 7.4% (16/215) of patients at SICU transfer and 5.0% (3/60) of patients at hospital discharge had a compelling risk factor to continue AST as demonstrated by a coagulopathy at discharge; no patients required mechanical ventilation at hospital discharge. CONCLUSION: Most patients inappropriately continued to receive stress ulcer prophylaxis during post-SICU hospitalization. Presence of risk factors for stress ulcer-related gastrointestinal bleeding at SICU admission appears to influence continuation of AST after discharge from the hospital. A low percentage (3.2%) of patients was discharged home receiving inappropriate AST, yet overall, few study patients demonstrated a compelling risk factor for continuation of AST.

Evaluation of feeding intolerance in patients with pentobarbital-induced coma.

BACKGROUND: There is considerable debate regarding the appropriateness of feeding patients by the enteral route in conjunction with pentobarbital coma therapy. OBJECTIVE: To determine the incidence of feeding intolerance (FI) in patients receiving pentobarbital in conjunction with enteral nutrition (EN). METHODS: A retrospective, observational evaluation of patients (>14 y of age) who received a therapeutic pentobarbital coma in combination with EN was conducted. Patients were divided into groups, based on the occurrence of FI defined as aspiration of gastric residuals greater than 75 mL for 2 consecutive measurements. RESULTS: Forty-eight percent (29 of 61) of patients experienced FI based on our definition. The median pentobarbital infusion rate did not differ significantly between patients who experienced FI versus those who did not (median [intraquartile range, IQR] 1.8 mg/kg/h [1.4, 2.1] vs 1.7 mg/kg/h [1.4, 2.5]; p = 0.680). The total pentobarbital bolus dose during the first 24 hours of therapy was lower in patients who experienced FI (700 mg [225, 980] vs 1000 mg [600, 1475]; p = 0.029). Median duration of pentobarbital therapy was comparable between groups (141.0 h [93.3, 217.3] vs 116.3 h [64.0, 174.8]; p = 0.115). Other factors with the potential to influence FI, such as catecholamines, neuromuscular blockade, and hyperglycemia, were similar between groups. The higher narcotic doses and greater percentage of patients receiving benzodiazepines in the FI group warrants further study. CONCLUSIONS: Pentobarbital therapy did not preclude use of EN in the entire study population. In addition, FI did not occur at a greater frequency in patients who received a higher dosage, a longer duration, or an earlier initiation of pentobarbital therapy.

Aerosolized tobramycin in the treatment of ventilator-associated pneumonia: a pilot study.

OBJECTIVE: To evaluate the efficacy and safety of inhaled tobramycin (TOBI) in the treatment of ventilator-associated pneumonia (VAP) in a randomized, double-blind pilot study. PATIENTS AND METHODS: Ten patients from a cohort of 108 mechanically ventilated patients with documented clinical and bacteriological evidence of VAP caused by Pseudomonas aeruginosa or Acinetobacter spp. in the surgical and trauma intensive care units of a university teaching hospital were randomized to receive either TOBI (n = 5) or intravenous tobramycin (TOBRA; n = 5). The two groups were similar in their Acute Physiology and Chronic Health Evaluation (APACHE) score, Clinical Pulmonary Infection Score (CPIS), and Multiple Organ Dysfunction Score (MODS) prior to randomization. The primary outcome measure was resolution of pneumonia. The CPIS and MODS were used as objective indicators of clinical progress. RESULTS: All TOBI patients had clinical resolution of VAP. Two TOBRA patients were considered failures. One had deterioration in MODS, and the other had doubling of his serum creatinine concentration. The patients treated with TOBI may have had more ventilator-free days than those receiving TOBRA, but the difference was not statistically significant owing to the small sample size (24 +/- 3 vs. 14 +/- 13 days; p = 0.12). CONCLUSION: Aerosolized tobramycin for the treatment of VAP appeared safe and effective in this pilot study. A larger study is warranted to determine if aerosolized tobramycin will lead to better outcomes than intravenous tobramycin when used for the treatment of VAP.

A needs assessment for regionalization of trauma care in a rural state.

Systems of trauma care in urban areas have a demonstrated survival benefit. Little is known of the benefit of trauma system organization in rural areas. We hypothesized that examination of all trauma deaths during a 1-year period would provide opportunities to improve care in our rural state. We used a medical examiner database of trauma deaths occurring during a 1-year period. Five board-certified surgeons analyzed deaths as preventable (P), potentially preventable (PP), and non-preventable (NP) using modified Delphi technique. There were 223 trauma deaths during a 1-year period. Most (63%) died at the scene prior to any medical intervention. Adjudication of the deaths demonstrated 5 P (2%; 95% CI 1-5%), 36 PP (16%; 95% CI 12-27%), and 179 NP (81%; 95% CI 76-86%). Agreement among trauma surgeons was only moderate with a k of 0.46. Suicide accounted for a significant number of the overall trauma deaths at 32 per cent. Rural trauma system design should focus on discovery, as that is where the majority of deaths occur. Suicide is a significant problem in this rural state that should be aggressively targeted with prevention programs.

Noninvasive muscle oxygenation to guide fluid resuscitation after traumatic shock.

BACKGROUND: Three different protocols tested the hypothesis that hind limb muscle tissue O(2) saturation (StO(2)), measured noninvasively with near-infrared spectroscopy (NIRS), is as reliable as invasive systemic oxygenation indices to guide fluid resuscitation. METHODS: In series 1, swine (n=30) were hemorrhaged, then received either no fluid, a fixed volume of colloid (15 mL/kg), or shed blood plus lactated Ringer's (LR) titrated to MAP >60 mm Hg. In series 2, swine (n=16) received a penetrating femur injury, a 47% to 55% hemorrhage to determine a median lethal dose (LD(50)) then shed blood plus LR titrated to MAP >60 mm Hg. In series 3, swine (n=5) received the femur injury plus LD(50) hemorrhage, and were resuscitated with LR titrated to StO(2) >50%. RESULTS: In series 1, StO(2) tracked mixed venous O(2) saturation (SvO(2)), but discriminated between 3 survivor groups better than SvO(2), arterial lactate, or arterial base excess. In series 2, StO(2) tracked SvO(2) but discriminated between 2 survivor groups better than SvO(2), arterial lactate, or arterial base excess. In series 3, animals survived to extubation when resuscitated to an StO(2) target. CONCLUSIONS: Noninvasive muscle StO(2) determined by NIRS was more reliable than invasive oxygenation variables as an index of shock. Because muscle StO(2) can be easily monitored in emergency situations, it may represent an improved method to gauge the severity of shock or the adequacy of fluid resuscitation after trauma.