Protocol-driven ventilator management in a trauma intensive care unit population.

HYPOTHESIS: The use of weaning and sedation protocols affects the intensive care unit (ICU) course of a trauma population. DESIGN: Nonrandomized before-after trial. SETTING: A level I trauma center. PATIENTS: Three hundred twenty-eight consecutive trauma patients receiving mechanical ventilation treated in the ICU between October 1, 1997, and November 1, 1999. INTERVENTION: Sedation and weaning protocols were used to treat patients receiving mechanical ventilation during the second year of this study. MAIN OUTCOME MEASURES: Self-extubation rates, ventilator days, number of ICU days, and charges. RESULTS: There were 168 patients in the preprotocol group (year 1: October 1, 1997, to October 31, 1998) and 160 patients in the postprotocol group (year 2: November 1, 1998, to November 30, 1999). The groups were similar in age (P =.68), Injury Severity Score (P =.06), and Glasgow Coma Scale score (P =.29). There were no differences in self-extubation rates (P =.57), ventilator days (P =.83), ventilator charges (P =.83), number of ICU days (P =.67), or ICU charges (P =.67) between the 2 groups. No statistical difference was identified in any of these categories when long-term ventilator patients (defined as ventilator length of stay > or =3 SDs above the mean) were excluded. CONCLUSIONS: Use of weaning and sedation protocols did not affect the measured outcomes in this study. These findings may reflect difficulties inherent in the protocols or with their utilization. Further subgroup analysis focusing on ventilator-associated pneumonias and mortality may demonstrate benefits not identified herein.

Blunt trauma and the role of routine pelvic radiographs: a prospective analysis.

BACKGROUND: We hypothesized that clinical factors accurately identify those trauma patients at high risk for pelvic fractures making routine films unnecessary. METHODS: Blunt trauma patients were prospectively analyzed both with and without a clinical protocol. The protocol group had pelvic films obtained only if they had a Glasgow Coma Scale score < 13 or had signs and symptoms of pelvic or back injury. RESULTS: The protocol patients with fractures (n = 45) had a higher Injury Severity Score (p = 0.001) and lower systolic blood pressure (p = 0.04) than those without fractures (n = 475). All 45 patients with pelvic fractures were identified by history and physical examination (p = 0.001). The clinical assessment resulted in a sensitivity and a negative predictive value of 100%. A total of 273 films were eliminated, resulting in a charge savings of $51,051. A comparison between the protocol and nonprotocol groups showed the nonprotocol patients with pelvic fractures to have a higher Injury Severity Score (p < 0.002). All of these patients' pelvic fractures were identified by clinical evaluation (67 of 67). CONCLUSION: In the awake and alert patient, the need for a pelvic radiograph was readily identified by clinical examination. Because elimination of this film would result in financial savings, its routine use should be removed from standard trauma protocols in the minimally injured patient and limited to severely injured patients as recommended by the Advanced Trauma Life Support protocol.