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.

Observation for nonoperative management of the spleen: how long is long enough?

BACKGROUND: Nonoperative management of splenic injury is common with reported success rates between 83% and 97%. However, there are no specific protocols for nonoperative observation published in the literature. The purpose of this study is to analyze the safety and effectiveness of our institutional guideline for observation of patients managed nonoperatively for splenic injury. METHODS: A retrospective registry and chart review was conducted for all patients with splenic injury who were admitted for nonoperative management (NOM). Our guideline for observation is admission with bed rest, serial hemoglobins every 6 hour, and discharge when hemoglobin is stable. Data collected for this study was age, gender, Injury Severity Score, grade of splenic injury, length of stay, NOM failures while in hospital and readmissions after discharge for nonoperative failure. RESULTS: From August 2002 through June 2007, 449 patients were admitted for NOM of splenic injury. Sixteen (4%) patients failed NOM and went to the operating room for splenectomy. CONCLUSIONS: NOM of blunt splenic injuries had a 96% success rate following our protocol. The guideline successfully identified all the patients failing NOM during the inpatient observation period with the exception of one patient that was noncompliant to protocol. This guideline for observation is safe and effective.

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

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

Is surgical airway necessary for airway management in deep neck infections and Ludwig angina?

BACKGROUND: Deep neck infections are potentially life-threatening conditions because of airway compromise. Management requires early recognition, antibiotics, surgical drainage, and effective airway control. The Surgical Education and Self-Assessment Program 12 states that awake tracheostomy is the treatment of choice for these patients. HYPOTHESIS: With advanced airway control techniques such as retrograde intubation, GlideScope, and fiberoptic intubation, surgical airway is not required. DESIGN: A retrospective analysis of all deep neck abscesses treated from December 1999 to July 2006 was performed. METHODS: All patients who underwent urgent or emergent surgery for Ludwig angina and submental, submandibular, sublingual, and parapharyngeal abscesses (Current Procedural Terminology codes 41015, 41016, 41017, 42320, and 42725) were included in our review. Charts were studied for age, presence of true Ludwig angina, presence of airway compromise, airway management, morbidity/mortality, and the requirement for surgical airway. RESULTS: Of 29 patients, 6 (20%) had symptoms consistent with true Ludwig angina. Nineteen (65.5%) had evidence of airway compromise. Eight (42%) of these 19 patients required advanced airway control techniques. No patient required a surgical airway, and no mortality resulted from airway compromise. Advance airway control techniques were required more often in patients with airway compromise (P < .05). CONCLUSION: Treatment of Ludwig angina and deep neck abscesses requires good clinical judgment. Patients with deep neck infections and symptoms of airway compromise may be safely managed with advanced airway control techniques.

Prone ventilation in trauma or surgical patients with acute lung injury and adult respiratory distress syndrome: is it beneficial?

BACKGROUND: To compare the effectiveness of supine versus prone kinetic therapy in mechanically ventilated trauma and surgical patients with acute lung injury (ALI) and adult respiratory distress syndrome (ARDS). METHODS: A retrospective review of all patients with ALI/ARDS who were placed on either a supine (roto-rest) or prone (roto-prone) oscillating bed was performed. Data obtained included age, revised trauma score (RTS), base deficit, Injury Severity Score (ISS), head Abbreviated Injury Scale score (AIS), chest (AIS), PaO2/FiO2 ratio, FiO2 requirement, central venous pressure (CVP), days on the bed, ventilator days, use of pressors, complications, mortality, and pulmonary-associated mortality. Data are expressed as mean+/-SE with significance attributed to p<0.05. RESULTS: From March 1, 2004 through May 31, 2006, 4,507 trauma patients were admitted and 221 were identified in the trauma registry as having ALI or ARDS. Of these, 53 met inclusion criteria. Additionally, 8 general surgery patients met inclusion criteria. Of these 61 patients, 44 patients were positioned supine, 13 were placed prone, and 4 patients that were initially placed supine were changed to prone positioning. There was no difference between the groups in age, CVP, ISS, RTS, base deficit, head AIS score, chest AIS score, abdominal AIS score, or probability of survival. The PaO2/FiO2 ratios were not different at study entry (149 vs. 153, p=NS), and both groups showed improvement in PaO2/FiO2 ratios. However, the prone group had better PaO2/FiO2 ratios than the supine group by day 5 (243 vs. 200, p=0.066). The prone group had fewer days on the ventilator (13.6 vs. 24.2, p=0.12), and shorter hospital lengths of stay (22 days vs. 40 days, p=0.08). There were four patients who failed to improve with supine kinetic therapy that were changed to prone kinetic therapy. These patients had significant improvements in PaO2/FiO2 ratio, and significantly lower FiO2 requirements. There were 18 deaths (7 pulmonary related) in the supine group and 1 death in the prone group (p < 0.01 by chi test). CONCLUSIONS: ALI/ARDS patients who received prone kinetic therapy had greater improvement in PaO2/FiO2 ratio, lower mortality, and less pulmonary-related mortality than did supine positioned patients. The use of a prone-oscillating bed appears advantageous for trauma and surgical patients with ALI/ARDS and a prospective, randomized trial is warranted.

Aggressive traffic enforcement: a simple and effective injury prevention program.

PURPOSE: To investigate whether an aggressive traffic violation enforcement program could reduce motor vehicle crashes (MVCs), injury collisions, fatalities, and fatalities related to speed, and decrease injury severity in crash victims treated at the trauma center. METHODS: A vigorous enforcement program was established within Fresno, Calif, city boundaries using increased traffic patrol officers. Data on citations, collisions, fatal collisions, and fatalities related to speed, as well as injury severity from the trauma registry, were collected for the year before program onset (2002), during the first year (2003), and after full implementation (2004). U.S. Census Bureau information was used for population. Statistical analysis was performed using Fisher's exact test and independent samples t test with significance attributed to p < 0.05. RESULTS: There were significant increases in citations issued, with marked decreases in motor vehicle crashes, injury collisions, fatalities, and fatalities related to speed. There was a decrease in admissions from MVCs, a significant decrease in the number of patients with moderate injury severity (Injury Severity Score of 10-16; p < 0.01), a decrease in hospital length of stay for all MVC victims, and a decrease in hospital charges for MVC patients. These changes were not seen in the area of Fresno County outside the area of increased enforcement. CONCLUSIONS: Aggressive traffic enforcement decreased MVCs, crash fatalities, and fatalities related to speed, and it decreased injury severity. This is a simple, easily implemented injury prevention program with immediate benefit.

Routinely repeated computed tomography after blunt head trauma: does it benefit patients?

BACKGROUND: Computed tomography of the head (HCT) is an integral part of the diagnosis and management of the patient with head injury, but the utility of repeated HCT performed solely for routine follow-up in the patient with blunt head trauma has not been defined. In the absence of clinical indications, routinely repeated HCT, even in patients with significant brain injury, does not contribute to patient care. METHODS: Trauma registry records at a Level I trauma center from July 1, 1997, to June 30, 2002, were reviewed. Patients with severe blunt head injury (Abbreviated Injury Scale score > or = 3) admitted to the intensive care unit and who had a repeat HCT scan obtained for scheduled follow-up were included. Those patients with initial craniotomy, repeat HCT more than 72 hours after the initial HCT, or repeat HCT ordered for clinical indications were excluded. Data included were age, mechanism of injury, time to initial (HCT1) and repeat HCT (HCT2), indications for HCT2, and HCT findings. Additional data included Glasgow Coma Scale (GCS) score (admission and at HCT2); Injury Severity Score; occurrence of hypotension, coagulopathy, or elevated intracranial pressure (ICP); interventions made; and patient outcome. RESULTS: Entry criteria were met in 462 patients. Most were injured in motor vehicle crashes; the average age was 36 years and the mean initial GCS score was 9. The mean time to HCT1 was 1.3 hours and the mean time to HCT2 was 22.6 hours. HCT2 showed worsening in 85 patients (18.4%), and 16 patients had interventions in response to HCT2 (repeat HCT in 8, ICP monitoring or drainage in 6, and craniotomy in 2). No patient undergoing routine repeat HCT without other clinical findings required intervention. All patients with worsening HCT findings requiring intervention had coagulopathy, hypotension, ICP elevation, or marked decrease in GCS score. CONCLUSION: In the absence of clinical indicators or risk factors, repeat HCT after blunt head injury does not alter patient management and is unnecessary.

Motor vehicle restraints: primary versus secondary enforcement and ethnicity.

BACKGROUND: Efforts to increase motor vehicle restraint use have been broadly based rather than focused on specific populations. Identifying specific issues, including populations with low restraint use, can help target educational campaigns. Previous studies have reported differences in restraint use by ethnicity. This study was performed to determine whether differences exist in motor vehicle restraint use by ethnicity and whether these differences are altered by the presence of primary versus secondary restraint laws. METHODS: Data were collected on motor vehicle crash victims admitted to two Level I trauma centers from October 1, 1997, through March 31, 1998; one in a state with primary restraint enforcement (motorist can be stopped for the restraint violation), the other with a secondary restraint law (restraint violation may be enforced if the motorist is stopped for another violation). Data were obtained concurrently with hospitalization and entered into computerized trauma registry databases. RESULTS: Restraint use in all motor vehicle crash victims was significantly different between the primary and secondary enforcement states (58% vs. 37%, p < 0.001). Additionally, restraint use varied markedly by ethnicity in the secondary enforcement state (Caucasian, 42%; vs. African-American, 21%, and Hispanic, 26%, p < 0.02, chi(2)). Comparison of restraint use in primary versus secondary enforcement states demonstrated significantly increased restraint use in all ethnic groups (p < 0.01). CONCLUSION: In a state with secondary enforcement laws, restraint use varied significantly with ethnicity. Restraint use was markedly increased in all ethnic groups by the presence of a primary enforcement law. Implementation and enforcement of primary restraint laws is essential to improving motor vehicle restraint use. Educational campaigns to increase restraint use need to target specific populations.

Are automated blood pressure measurements accurate in trauma patients?

BACKGROUND: Automated blood pressure (BP) determinations by oscillometry are reported to be as accurate as invasive monitoring for systolic pressures as low as 80 mm Hg. Automated BP devices are widely used by prehospital providers and in hospital operating rooms, emergency departments, and intensive care units, although the accuracy of automated BP has not been demonstrated in trauma patients. We hypothesized that automated BP is less accurate than manual BP in trauma patients. The purpose of this study was to determine the accuracy of automated BP versus manual BP in trauma patients. METHODS: A retrospective review of patients who met trauma activation criteria admitted to a Level I trauma center over a 30-month period was conducted. Patients were included if both manual BP and automated BP were measured within 5 minutes of admission. Additional data collected included Injury Severity Score, base deficit, and emergency department resuscitation volume. Statistical analysis was performed using paired t test, chi2, and linear regression analysis. Significance was attributed to a value of p < 0.05. RESULTS: From January 2000 through June 2002, 388 patients met inclusion criteria. Patients were grouped by manual BP levels: group 1, BP < or = 90 mm Hg (n = 92); group 2, BP 91-110 mm Hg (n = 119); and group 3, BP > or = 110 mm Hg (n = 177). The mean automated BP measurements were significantly higher than the manual measurements in groups 1 and 2 (26 and 16 mm Hg, respectively; p < 0.001). Of the 92 patients with manual BP < or = 90, 45 (49%) had automated BP > or = 100. The base deficit (-5, -3, and -2 for groups 1, 2, and 3, respectively; p < 0.01), Injury Severity Score (30, 25, and 18; p < 0.01), and volume of resuscitative fluid and blood (p < 0.001) all decreased with higher BP group. CONCLUSION: Injury severity, degree of acidosis, and resuscitation volume were more accurately reflected by manual BP. Automated BP determinations were consistently higher than manual BP, particularly in hypotensive patients. Automated BP devices should not be used for field or hospital triage decisions. Manual BP determinations should be used until systolic blood pressure is consistently > or = 110 mm Hg.

Victims of domestic violence on the trauma service: unrecognized and underreported.

BACKGROUND: Domestic violence (DV) has received increased recognition as a significant mechanism of injury. To improve awareness about DV at our institution, an educational program was presented to the departments of surgery and emergency medicine. Pre and posttests were given and improvement in knowledge was demonstrated. In addition, a screening question for DV was added to the trauma history and physical (H & P) form. This study was done to determine the long-term efficacy of these efforts in increasing recognition of DV and referral to social services in patients admitted to the trauma service. Recognition of DV and appropriate referral should be increased after education and change in H & P form. METHODS: All patients admitted to the trauma service at a Level I trauma center over a 10 month period with the mechanism of injury "assault" were reviewed. DV was determined to be present, likely, unknown, or absent based on information from the prehospital report and medical records. The DV screen question was reviewed for use and accuracy. RESULTS: During the study period, 1,550 patients were admitted to the trauma service, with assault listed as the mechanism of injury for 217 (14%). DV was confirmed or likely in 27 patients (12.4% of the assaults). Of patients with confirmed or likely DV, only 7 received appropriate referrals, with 2 generated by the nursing staff. Of the confirmed and likely DV patients, 17 (63%) were sent home without investigation of safety and only 21% of all assault victims had any social services evaluation (usually to investigate funding or placement). The DV screen was used in only 12 patients. Reasons given for failure to complete the DV screen on the H & P included examiner discomfort in asking the question, and an environment judged to be inappropriate (resuscitation area in the emergency department). CONCLUSION: DV is unrecognized and underreported. Efforts to improve recognition and reporting of DV events need to be ongoing. Screening for DV is not effectively done as part of the initial evaluation. Assessment for DV may be more appropriate as part of the tertiary survey.