Changing the Playing Field: A Prehospital Blood Product Pilot Project in Rural North Georgia.

BACKGROUND: In Georgia, the paramedic's scope of practice prohibited the initiation of blood products. Due to the rural landscape in Georgia, one region's Regional Trauma Advisory Committee (RTAC) advocated expanding the scope of practice for Georgia's paramedics to allow them to initiate blood products in the prehospital environment. This study evaluated the safety and feasibility of allowing paramedics to initiate blood products for hemorrhaging patients utilizing a regionally established prehospital blood pilot program. MATERIALS AND METHODS: Approval was obtained from the state medical directors and the Office of EMS and Trauma. The project team addressed product selection, equipment, prehospital service selection, education, policies and procedures, monitoring, and performance improvement. Four EMS services were identified to participate. Liquid plasma was selected due to cost and availability. Equipment was secured for blood storage and temperature monitoring to ensure the hospital's blood bank could maintain standards for exchange. A transfusion guideline was created, an administrative policy was developed, and an education plan was developed. A process with the trauma center's blood bank was also instituted to minimize waste and reduce costs. RESULTS AND DISCUSSION: The pilot project began in spring of 2020, and as of January 2023, there have been 100 field initiations and no adverse effects, demonstrating the safety of paramedics to initiate blood products in the field. A post-licensure skill for paramedics is now available in Georgia for the initiation of blood products. The repeatability of a similar project depends on the resources available, the stakeholder commitment, and the partnerships across disciplines.

Glucocorticoid rescue for late-phase acute respiratory distress syndrome in trauma/surgical critical care patients.

High-dose glucocorticoid therapy (GCT) for the late fibroproliferative phase of acute respiratory distress syndrome (ARDS) is controversial and has shown mixed results in medical patients. No studies have evaluated GCT in trauma/surgical critical care patients. The purpose of this study is to review the outcomes of trauma/surgical critical care patients with refractory ARDS treated with GCT. From January 2001 through September 2005, a pharmacy log was used to identify critically ill trauma/surgical patients in refractory ARDS (7 males and 2 females) who received GCT in an attempt to salvage them. GCT consisted of 200 mg intravenous methylprednisolone bolus for one dose and then 3 mg/kg per day divided every 6 hours for 6 weeks or until weaned off the ventilator. All patients as well as the survivors were analyzed. Outcome data was analyzed with SPSS (Chicago, IL) and the paired sample test. A P value < or = 0.05 was considered significant. Data is presented as mean +/- standard deviation. The Institutional Review Board approved this retrospective chart review. Seven patients (6 males and 1 female; age, 31 +/- 16 years) survived (78%), weaned off of the ventilator, and were discharged from the hospital. The 2 deaths were secondary to refractory respiratory failure as well as cardiac arrest (n = 1) and anoxic brain injury from septic hypotension (n = 1). In survivors (n = 7), hospital length of stay (LOS) and intensive care unit LOS was 71 +/- 30 days and 53 +/- 16 days, respectively. Duration of GCT administration was 17 +/- 6.4 days (range, 11-30 days). Ventilator time before GCT, during GCT, and after GCT was 22 +/- 8.4, 15 +/- 7.5, and 1.6 +/- 6.0 days, respectively. During GCT, 8 patients developed pneumonia, 5 had urinary tract infection, and 3 had bacteremia. All infections were effectively treated with broad-spectrum antibiotics, except in one patient who died of sepsis. PaO2/FIO2 ratio just before and after GCT was 100 +/- 36 and 247 +/- 56, respectively (n = 7; P < 0.001). Sequential organ failure assessment score just before and after GCT was 9.1 +/- 2.3 and 5.0 +/- 1.6, respectively (n = 7; P < 0.001). GCT rescue may have a role in salvaging critically ill trauma/surgical critical care patients in late-stage ARDS. More patients, however, need to be studied.

Trauma nurse specialists' performance of advanced skills positively impacts surgical residency time constraints.

The Accreditation Council for Graduate Medical Education imposed 80-hour work week constraints on residency programs in July 2003. Certain programs were granted an additional 10 per cent for specific educational purposes, bringing restrictions to 88 hours per week. The increased demand for residents to leave the hospital has placed teaching institutions in exhaustive situations to provide comprehensive patient care. In response to the work hour constraints among residents and emergency room staff, a unique group of registered nurses, trauma nurse specialists (TNSs), were credentialed with advanced practice skill sets. Governed by practice guidelines and overseen by a medical director, TNSs perform invasive procedures that are normally the responsibility of the surgical resident. The purpose of this study was to evaluate work hours saved for surgery residents using credentialed nurses (TNSs). Procedure logs were maintained by the TNSs over a 6-month period, and surgical house staff (postgraduate year 1-3) over a 4-month period. A total of 423 procedures were recorded, reflecting time taken for attempted/completed procedures and complications. Resident procedures numbered 98; TNS procedures numbered 325. TNSs spent an average of 42 hours per month (10.6 hours per week) completing advanced procedures with no statistical difference in time or complications compared with surgical residents. By using the TNSs, work hours for surgery residents were saved while maintaining a safe and reliable work atmosphere for patients.

Preliminary experience with airway pressure release ventilation in a trauma/surgical intensive care unit.

BACKGROUND: Airway pressure-release ventilation (APRV) is a pressure-limited, time-cycled mode of mechanical ventilation. The purpose of this study was to evaluate our initial experience with the use of APRV in acutely injured, ventilated patients. METHODS: Since March 2003, APRV has been used selectively in adult trauma patients with or at risk for acute lung injury/acute respiratory distress syndrome. Data were obtained before and during the 72 hours after switching to APRV. A retrospective analysis of these data was then performed. RESULTS: Complete data were available on 46 of 60 patients (77%) for the first 72 hours of APRV. Before APRV, the average Pao2/Fio2 ratio was 243 and the average peak airway pressure was 28 cm H2O. Peak airway pressure decreased 19% (p = 0.001), Pao2/Fio2 improved by 23% (p = 0.017) and release tidal volumes improved by 13% (p = 0.020) over the course of the analysis. CONCLUSION: APRV significantly improved oxygenation by alveolar recruitment and allowed for a reduction in peak airway pressures. This relatively new modality had favorable results and appears to be an effective alternative for lung recruitment in traumatically injured patients at risk for acute lung injury/acute respiratory distress syndrome.

A comparison of continuous renal replacement therapy to intermittent dialysis in the management of renal insufficiency in the acutely III surgical patient.

Acute renal failure (ARF) occurs in 10 per cent to 23 per cent of intensive care unit patients with mortality ranging from 50 per cent to 90 per cent. ARF is characterized by an acute decline in renal function as measured by urine output (UOP), serum creatinine, and blood urea nitrogen (BUN). Causes may be prerenal, intrarenal, or postrenal. Treatment consists of renal replacement therapy (RRT), either intermittent (ID) or continuous (CRRT). Indications for initiation of dialysis include oliguria, acidemia, azotemia, hyperkalemia, uremic complications, or significant edema. Overall, the literature comparing CRRT to ID is poor. No studies of only surgical/trauma patients have been published. We hypothesize that renal function and hemodynamic stability in trauma/ surgical critical care patients are better preserved by CRRT than by ID. We performed a retrospective review of trauma/surgical critical care patients requiring renal supportive therapy. Thirty patients received CRRT and 27 patients received ID. The study was controlled for severity of illness and demographics. Outcomes assessed were survival, renal function, acid-base balance, hemodynamic stability, and oxygenation/ventilation parameters. Populations were similar across demographics and severity of illness. Renal function, measured by creatinine clearance, was statistically greater with CRRT (P = 0.035). There was better control of azotemia with CRRT: BUN was lower (P = 0.000) and creatinine was lower (P = 0.000). Mean arterial blood pressure was greater (P = 0.021) with CRRT. No difference in oxygenation/ventilation parameters or pH was found between groups. CRRT results in an enhancement of renal function with improved creatinine clearance at the time of dialysis discontinuation. CRRT provides better control of azotemia while preserving hemodynamic stability in patients undergoing renal replacement therapy. Prospective randomized controlled studies and larger sample sizes are needed to further evaluate these modalities.

A survey assessment of the level of preparedness for domestic terrorism and mass casualty incidents among Eastern Association for the Surgery of Trauma members.

OBJECTIVE: The goal of this survey was to establish a benchmark for trauma surgeons' level of operational understanding of the command structure for a pre-hospital incident, a mass casualty incident (MCI), and weapons of mass destruction (WMD). The survey was distributed before the World Trade Center destruction on September 11, 2001. METHODS: The survey was developed by the authors and reviewed by a statistician for clarity and performance. The survey was sent to the membership of the 2000 Eastern Association for the Surgery of Trauma spring mailing, with two subsequent mailings and a final sampling at the Eastern Association for the Surgery of Trauma 2001 meeting. Of 723 surveys mailed, 243 were returned and statistically analyzed (significance indicated by p < 0.05). RESULTS: No statistical difference existed between level of designation of a trauma center (state or American College of Surgeons) and a facility's level of pre-paredness for MCIs or WMD. Physicians in communities with chemical plants, railways, and waterway traffic were statistically more likely to work at facilities with internal disaster plans addressing chemical and biological threats. Across all variables, physicians with military training were significantly better prepared for response to catastrophic events. With the exception of cyanide (50%), less than 30% of the membership was prepared to manage exposure to a nerve agent, less than 50% was prepared to manage illness from intentional biological exposure, and only 73% understood and were prepared to manage blast injury. Mobile medical response teams were present in 46% of the respondents' facilities, but only 30% of those teams deployed a trauma surgeon. Approximately 70% of the membership had been involved in an MCI, although only 60% understood the command structure for a prehospital incident. Only 33% of the membership had training regarding hazardous materials. Of interest, 76% and 65%, respectively, felt that education about MCIs and WMD should be included in residency training. CONCLUSION: A facility's level of pre-paredness for MCIs or WMD was not related to level of designation as a trauma center, but may be positively influenced by local physicians with prior military background. Benchmark information from this survey will provide the architecture for the development and implementation of further training in these areas for trauma surgeons.

Management of destructive bowel injury in the open abdomen.

BACKGROUND: Little attention has been focused on destructive injuries of the bowel in patients requiring open abdominal management. We therefore reviewed our institutional experience for destructive bowel injury requiring open abdominal management with the vacuum pack technique (vac). METHODS: The trauma registry at a Level I trauma center was used to identify patients sustaining destructive bowel injury for an 11-year period beginning in May 1990. Patients were assessed for pertinent clinical and demographic information, and individuals requiring open abdominal management were compared with those who did not. RESULTS: One hundred four patients required bowel resection and constitute the study population. Twenty-nine patients had vacs placed, with 22 (75.9%) of the total eventually obtaining delayed fascial closure. Nineteen (183%) patients had resection and primary repair (PR) of large and/or small bowel in conjunction with a vac, 10 (9.6%) patients had stoma formation in conjunction with a vac, 62 (59.6%) patients had resection and PR of small and/or large bowel in conjunction with primary fascial closure, and 13 (12.5%) patients had stoma formation and primary fascial closure. There were no differences in abdominal abscess or leak rates between groups. There were four deaths, none of which was secondary to failure of an anastomosis. CONCLUSION: Bowel resection with PR appears to be a safe alternative after destructive bowel injury and results in acceptable morbidity when performed in conjunction with open abdominal management.

A prospective assessment of diagnostic efficacy of blind protective bronchial brushings compared to bronchoscope-assisted lavage, bronchoscope-directed brushings, and blind endotracheal aspirates in ventilator-associated pneumonia.

BACKGROUND: The purpose of this study is to compare techniques for the diagnosis of suspected ventilator-associated pneumonia in the trauma patient. Per the literature, bronchoscope protected brushings and bronchoalveolar lavage were set as the standards for comparison because of their high specificity and sensitivity. We hypothesized that blind protected brushings were equivalent to bronchoscope-directed techniques and that endotracheal aspirates (ETA) were not. METHODS: With informed consent, 90 trauma patients with two or more of the following were accepted into the study: 48 hours or more on the ventilator, new or increasing infiltrate on chest radiograph, excess or purulent secretions, suspected aspiration, temperature of 38.5 degrees C or above, white blood cell count greater than or equal to 12,000/mm3, and respiratory distress. Four samplings were performed on each patient using bronchoscope-assisted and nonbronchoscopic techniques. Each patient had cultures obtained by and significances quantified as follows: ETA, moderate/many/abundant; bronchoscope-directed protected brushings (BDPB), 103 colony-forming units [CFU]/mL; blind protected brushing via endotracheal tube (BPB), 103 CFU/mL; and bronchoscopic bronchoalveolar lavage (BAL), 104 CFU/mL. Quantitative cultures were obtained and compared for the following pathogens: gram-positive cocci, gram-positive rods, gram-negative cocci, gram-negative rods, anaerobic bacteria, and yeast. An assessment of agreement for cultured pathogens between the sampling modalities was completed using kappa (kappa) analysis, and significance was set at p < or = 0.05. RESULTS: With patients used as their own controls, Gram's stain and pathogens cultured from the various sampling techniques were compared for agreement by kappa analysis. BDPB and BAL were set as the "gold standards" for comparison against each other and against the BPB and ETA. Kappa analysis was used to measure the strength of agreement for these findings; individual values from the comparisons of Gram's stain were then averaged for descriptive purposes of the data. Most kappa values were associated with a statistically significant value of p < 0.05. The greatest strength of agreement was found to be moderate comparing Gram's stain results of BPB and BDPB (kappa = 0.467), ETA and BAL (kappa = 0.535), and BPB and BAL (kappa = 0.547). Fair kappa values were shown in comparing Gram's stain results of ETA and BDPB (kappa = 0.382) and BAL and BDPB (kappa = 0.390). CONCLUSION: A quantitative analysis of bacteriologic cultures obtained by four standard sampling techniques has demonstrated with statistical significance that no difference exists between modality of sampling in reliability or in obtaining clinically significant pathogens. In reviewing the literature, this study is the first assessment of agreement for cultured pathogens between the four different sampling modalities and the largest to assess the efficacy of the blind protected brush technique.

The impact of pelvic and lower extremity fractures on the incidence of lower extremity deep vein thrombosis in high-risk trauma patients. Winner of the Best Paper Award from the Gold Medal Forum.

Lower extremity fractures (LEFx) and pelvic fractures (PFx) are believed to increase the risk of lower extremity deep vein thrombosis (LEDVT). We studied trauma patients at high risk for LEDVT to determine whether an increased incidence of LEDVT was associated with LEFx and/or PFx. From January 1995 through December 1997 4163 trauma patients were admitted to our Level I trauma center. One thousand ninety-three patients at high risk for LEDVT were screened with serial lower extremity venous duplex ultrasound. Their medical records were retrospectively reviewed for demographics, mechanism of injury, and fracture data. The occurrence of LEDVT, pulmonary embolus, and LEDVT prophylaxis and treatment were noted. The incidence of LEDVT in the fracture group (Fx) was compared with that in the nonfracture group (NFx) using chi-square analysis and logistic regression. Statistical significance was set at < or = 0.05. Complete data were available for 1059 of 1093 patients. Five hundred sixty-nine (53.73%) patients had PFx and/or LEFx, 151 (14.26%) patients had PFx only, 317 (29.3%) patients had LEFx only, and 101 (9.54%) patients had both PFx and LEFx. Four hundred ninety (46.27%) patients had NFx. In 1059 patients LEDVT was detected in 125 (11.8%). Sixty-three patients in the Fx groups developed LEDVT (50.4%): 19 (15.2%) PFx patients, 15 (12.0%) PFx/LEFx patients, and 29 (23.2%) LEFx patients. Sixty-two (49.6%) NFx patients developed LEDVT. LEDVT incidence was not significantly different between the Fx and NFx groups or among the PFx, LEFx, and PFx/LEFx groups (P = 0.317). Nine patients developed pulmonary embolism: four NFx patients, two LEFx patients, two PFx patients, and one PFx/LEFx patient. Significant predictors of LEDVT were age and hospital length of stay. Mean age in patients with LEDVT was 47.58 years and in patients without LEDVT it was 40.89 years (P < 0.001). Mean hospital length of stay in patients with LEDVT was 29.81 days and in patients without LEDVT it was 16.84 days. The power of this study to detect differences representing medium effect sizes was greater than 90 per cent. We conclude that LEFx and/or PFx was not associated with an increased incidence of LEDVT in trauma patients at high risk for LEDVT. Lower extremity venous duplex ultrasound needs to be performed in both Fx and NFx groups to detect LEDVTs.

Routine prophylactic vena cava filtration is not indicated after acute spinal cord injury.

BACKGROUND: Acute spinal cord injury (SCI) is a devastating problem, with over 10,000 new cases annually. Pulmonary embolism (PE) is a well-recognized risk in SCI patients, although no clear recommendations for prophylaxis exist. We therefore evaluated whether routine placement of prophylactic inferior vena cava filters is indicated in SCI patients. METHODS: The trauma registry of a regional trauma center was used to identify patients sustaining acute SCI resulting in tetraplegia or paraplegia after blunt or penetrating trauma for a 5-year period beginning in January 1995. Patients were analyzed for demographics, mechanism of injury, Injury Severity Score, associated long bone or pelvic fracture, severe closed-head injury, type of deep venous thrombosis (DVT) prophylaxis, level of SCI, and incidence of DVT and PE. DVT prophylaxis was performed in all patients with sequential compression devices (SCDs) when extremity fracture status permitted. Data are expressed as mean +/- SD and analyzed using Fisher's exact test. RESULTS: There were 8,269 admissions during the study period, with an overall incidence of DVT and PE of 11.8% and 0.9%, respectively. There were 111 (1.3%) patients who sustained SCI, with an incidence of DVT and PE of 9.0% and 1.8%, respectively, and no deaths. Of these 111 patients, 41.4% were paraplegics and 58.6% were tetraplegics, and 17.1% of patients had severe closed-head injury. Mean hospital length of stay was 23 +/- 20 days for SCI patients. Surveillance duplex ultrasound was performed an average of 2.3 +/- 2.1 times during each hospitalization. Mean Injury Severity Score was 30.0 +/- 12.2. The incidence of DVT and PE in those patients with SCDs alone was 7.1% and 2.3%; for SCDs plus subcutaneous heparin, the incidence was 11.1% and 2.8%; and for SCDs plus low-molecular-weight heparin, the incidence was 7.4% and 0%, respectively, with no statistical difference between groups. The incidence of DVT in SCI patients with long bone fractures was 37.5%, which was significantly greater than the total SCI population (p < 0.02). CONCLUSION: The incidence of DVT and PE in SCI patients was similar to that of the overall trauma population when appropriate DVT prophylaxis was used. Subgroup analysis demonstrated that SCI associated with long bone fracture significantly increases the incidence of DVT. On the basis of the low incidence of PE in the present study, routine placement of prophylactic caval filters does not appear warranted in all SCI patients. However, SCI patients with long bone fractures, patients with DVT formation despite prophylactic anticoagulation, or patients with contraindications to anticoagulation may be appropriate candidates for prophylactic caval filtration.