Relative device stability of anterior versus axillary needle decompression for tension pneumothorax during casualty movement: Preliminary analysis of a human cadaver model.

BACKGROUND: Tension pneumothorax (tPTX) remains a significant cause of potentially preventable death in military and civilian settings. The current prehospital standard of care for tPTX is immediate decompression with a 14-gauge 8-cm angiocatheter; however, failure rates may be as high as 17% to 60%. Alternative devices, such as 10-gauge angiocatheter, modified Veress needle, and laparoscopic trocar, have shown to be potentially more effective in animal models; however, little is known about the relative insertional safety or mechanical stability during casualty movement. METHODS: Seven soft-embalmed cadavers were intubated and mechanically ventilated. Chest wall thickness was measured at the second intercostal space at the midclavicular line (2MCL) and the fifth intercostal space along the anterior axillary line (5AAL). CO2 insufflation created a PTX, and needle decompression was then performed with a randomized device. Insertional depth was measured between hub and skin before and after simulated casualty transport. Thoracoscopy was used to evaluate for intrapleural placement and/or injury during insertion and after movement. Cadaver demographics, device displacement, device dislodgment, and injuries were recorded. Three decompressions were performed at each site (2MCL/5AAL), totaling 12 events per cadaver. RESULTS: Eighty-four decompressions were performed. Average cadaver age was 59 years, and body mass index was 24 kg/m. The CWT varied between cadavers because of subcutaneous emphysema, but the average was 39 mm at the 2MCL and 31 mm at the 5AAL. Following movement, the 2MCL site was more likely to become dislodged than the 5AAL (67% vs. 17%, p = 0.001). Median displacement also differed between 2MCL and 5AAL (23 vs. 2 mm, p = 0.001). No significant differences were noted in dislodgement or displacement between devices. Five minor lung injuries were noted at the 5AAL position. CONCLUSION: Preliminary results from this human cadaver study suggest the 5AAL position is a more stable and reliable location for thoracic decompression of tPTX during combat casualty transport. LEVEL OF EVIDENCE: Therapeutic study, level III.

An acute care surgery model improves outcomes in patients with appendicitis.

OBJECTIVE: To compare outcomes of appendectomy in an Acute Care Surgery (ACS) model to that of a traditional home-call attending surgeon model. SUMMARY BACKGROUND DATA: Acute care surgery (ACS, a combination of trauma surgery, emergency surgery, and surgical critical care) has been proposed as a practice model for the future of general surgery. To date, there are few data regarding outcomes of surgical emergencies in the ACS model. METHODS: Between September 1999 and August 2002, surgical emergencies were staffed at the faculty level by either an in-house trauma/emergency surgeon (ACS model) or a non-trauma general surgeon taking home call (traditional [TRAD] model). Coverage alternated monthly. Other aspects of hospital care, including resident complement, remained unchanged. We retrospectively reviewed key time intervals (emergency department [ED] presentation to surgical consultation; surgical consultation to operation [OR]; and ED presentation to OR) and outcomes (rupture rate, negative appendectomy rate, complication rate, and hospital length of stay [LOS]) for patients treated in the ACS and TRAD models. Questions of interest were examined using chi tests for discrete variables and independent sample t test for comparison of means. RESULTS: During the study period, 294 appendectomies were performed. In-house ACS surgeons performed 167 procedures, and the home-call TRAD surgeons performed 127 procedures. No difference was found in the time from ED presentation to surgical consultation; however, the time interval from consultation to OR was significantly decreased in the ACS model (TRAD 7.6 hours vs. ACS 3.5 hours, P < 0.05). As a result, the total time from ED presentation to OR was significantly shorter in the ACS model (TRAD 14.0 hours vs. ACS 10.1 hour, P < 0.05). Rupture rates were decreased in the ACS model (TRAD 23.3% vs. ACS 12.3%, P < 0.05); negative appendectomy rates were similar. The complication rate in the ACS model was decreased (TRAD 17.4% vs. ACS 7.7%, P < 0.05), as was the hospital LOS (TRAD 3.5 days vs. ACS 2.3 days, P < 0.001). CONCLUSIONS: In patients with acute appendicitis, the presence of an in-house acute care surgeon significantly decreased the time to operation, rupture rate, complication rate, and hospital length of stay. The ACS model appears to improve outcomes of acute appendicitis compared with a TRAD home-call model. This study supports the efficacy and efficiency of the ACS model in the management of surgical emergencies.

Anemia management program reduces transfusion volumes, incidence of ventilator-associated pneumonia, and cost in trauma patients.

BACKGROUND: Strategies to restrict transfusions are gaining acceptance in critical care. We implemented an anemia management program (AMP) for trauma patients in the Surgical Intensive Care Unit. AMP was based on a transfusion trigger of 7 g/dL hemoglobin once hemodynamic sufficiency was achieved. We hypothesized that AMP would decrease the transfusion of packed red blood cells (PRBCs) and cost without detriment in clinical outcomes. METHODS: Transfusion data were retrospectively collected for all trauma patients treated in our Surgical Intensive Care Unit between July 2002 and December 2003. AMP was implemented in a step-wise fashion during a 6-month period (January to June 2003). Data were compared for the 6-month period before (Group I, July to December 2002) and after (Group II, July to December 2003) complete AMP implementation. Blood transfusion volumes were compared using negative binomial regression. Clinical outcomes (length of stay [LOS], death, myocardial infarction [MI], and ventilator-associated pneumonia [VAP]) were compared using risk ratios. Age, sex, and injury severity score (ISS) were examined as potential confounders. RESULTS: In all, 514 trauma patients were treated during the study period (n = 270 in Group I and n = 244 in Group II). Group I and Group II were similar in age (mean: 43.6 versus 42.9) and ISS (mean: 18.3 versus 17.0). Mean PRBCs per patient transfused decreased from 23.1 units to 17.1 units (p = 0.057), reflecting a 22.5% reduction adjusted for confounders (p = 0.097). Outcome data revealed no differences in LOS (mean: 6.4 versus 5.9, p = 0.920), risk of death (4.1% versus 6.1%, p = 0.158), or MI (0.7% versus 0.8%, p = 0.974), but a significant reduction in the incidence of VAP (8.1% versus 0.8%, p = 0.002). Total PRBC cost decreased during the study period from 503,000 dollars to 397,000 dollars. CONCLUSIONS: An anemia management program appears to be safe when applied in the acute ICU phase of trauma care. Implementation of AMP in the ICU reduced the volume of PRBCs transfused with significant cost savings. No significant differences in length of stay, mortality rate, or MI rate were seen. The significant decrease in the rate of VAP requires further elucidation. Further long-term and larger studies are indicated.