RESUMO
OBJECTIVE: The aim of this study was to identify a mortality benefit with the use of whole blood (WB) as part of the resuscitation of bleeding trauma patients. BACKGROUND: Blood component therapy (BCT) is the current standard for resuscitating trauma patients, with WB emerging as the blood product of choice. We hypothesized that the use of WB versus BCT alone would result in decreased mortality. METHODS: We performed a 14-center, prospective observational study of trauma patients who received WB versus BCT during their resuscitation. We applied a generalized linear mixed-effects model with a random effect and controlled for age, sex, mechanism of injury (MOI), and injury severity score. All patients who received blood as part of their initial resuscitation were included. Primary outcome was mortality and secondary outcomes included acute kidney injury, deep vein thrombosis/pulmonary embolism, pulmonary complications, and bleeding complications. RESULTS: A total of 1623 [WB: 1180 (74%), BCT: 443(27%)] patients who sustained penetrating (53%) or blunt (47%) injury were included. Patients who received WB had a higher shock index (0.98 vs 0.83), more comorbidities, and more blunt MOI (all P <0.05). After controlling for center, age, sex, MOI, and injury severity score, we found no differences in the rates of acute kidney injury, deep vein thrombosis/pulmonary embolism or pulmonary complications. WB patients were 9% less likely to experience bleeding complications and were 48% less likely to die than BCT patients ( P <0.0001). CONCLUSIONS: Compared with BCT, the use of WB was associated with a 48% reduction in mortality in trauma patients. Our study supports the use of WB use in the resuscitation of trauma patients.
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Injúria Renal Aguda , Hemostáticos , Trombose Venosa , Ferimentos e Lesões , Transfusão de Sangue , Hemorragia/etiologia , Hemorragia/terapia , Humanos , Ressuscitação , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapiaRESUMO
INTRODUCTION: The average age and number of comorbidities is increasing among trauma patients. Primary care providers (PCPs) provide pre-injury diagnosis and management of comorbidities that may affect outcomes for injured patients. The role of primary care in trauma systems is currently unknown. METHODS: Observational retrospective review of an institutional trauma databank from 2013 - 2019. PCP was extracted from the electronic medical record and combined with trauma data. Case-control matching was performed to compare outcomes between patients with and without primary care based on age, injury severity score, sex, and injury mechanism. Mann-Whitney U test, chi-square test, and multivariate regression described differences between subgroups. Primary outcome was difference in mortality rate for injured patients with and without PCPs. RESULTS: Within the study period, 19,096 patients were included. 6,626 (34.7%) had a PCP recorded. Of these, 2,158 were matched in a case-control design. Patients with PCPs had a lower mortality rate (1.6%) compared to patients without PCPs (3.6%, P < 0.01). PCP retention was associated with longer length of stay overall, equivalent rates of complications (5.4% vs. 5.7%, P = 0.63), and similar numbers of ICU and ventilator days. Multivariate logistic regression controlling for case-control factors, insurance, and comorbidities conferred an odds ratio of 2.58 (95% Confidence Interval: 1.59 - 4.19, P < 0.001) for survival to discharge. CONCLUSION: Pre-injury primary care significantly improves the odds of survival to discharge for injured patients. Prospective study of this relationship may identify strategies to promote primary care within health systems.
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Alta do Paciente , Ferimentos e Lesões , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Razão de Chances , Estudos Prospectivos , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos e Lesões/terapiaRESUMO
OBJECTIVE: Our objective was to investigate whether racial/ethnic-based or payer-based disparities existed in the transfer practices of pediatric trauma patients from adult trauma center (ATC) to pediatric trauma center (PTC) in Pennsylvania. METHODS: Data on trauma patients aged 14 years or less initially evaluated at level I and II ATC were obtained from the Pennsylvania Trauma Outcome Study (2008-2012) (n = 3446). Generalized estimating equations regression analyses were used to evaluate predictors of subsequent transfer controlling for confounders and clustering. Recent literature has described racial and socioeconomic disparities in outcomes such as mortality after trauma; it is unknown whether these factors also influence the likelihood of subsequent interfacility transfer between ATC and PTC. RESULTS: Patients identified as nonwhite comprised 36.1% of the study population. Those without insurance comprised 9.9% of the population. There were 2790 patients (77.4%) who were subsequently transferred. Nonwhite race (odds ratio [OR], 4.3), female sex (OR, 1.3), and lack of insurance (OR, 2.3) were associated with interfacility transfer. Additional factors were identified influencing likelihood of transfer (increased odds: younger age, intubated status, cranial, orthopedic, and solid organ injury; decreased odds: operative intervention at the initial trauma center) (P < 0.05 for all). CONCLUSIONS: Although we assume that a desire for specialized care is the primary reason for transfer of injured children to PTCs, our analysis demonstrates that race, female sex, and lack of insurance are also associated with transfers from ATCs to PTCs for children younger than 15 years in Pennsylvania. Further research is needed to understand the basis of these health care disparities and their impact.
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Seguro , Ferimentos e Lesões , Adulto , Criança , Feminino , Humanos , Escala de Gravidade do Ferimento , Razão de Chances , Avaliação de Resultados em Cuidados de Saúde , Transferência de Pacientes , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Institutional variation in outcome of patients with do-not-resuscitate (DNR) orders has not been well described in the setting of trauma. The purpose of this study was to assess the impact of trauma center designation on outcome of patients with DNR orders. MATERIALS AND METHODS: A statewide trauma database (Pennsylvania Trauma Outcome Study) was used for the analysis. Characteristics of patients with DNR orders were compared between state-designated level 1 and 2 trauma centers. Inhospital mortality and major complication rates were compared using hierarchical logistic regression models that included a random effect for trauma centers. We adjusted for a number of potential confounders and allowed for nonlinearity in injury severity score and age in these models. RESULTS: A total of 106,291 patients (14 level 1 and 11 level 2 trauma centers) were identified in the Pennsylvania Trauma Outcome Study database between 2007 and 2011. We included 5953 patients with DNR orders (5.6%). Although more severely injured patients with comorbid disease were made DNR in level 1 trauma centers, trauma center designation level was not a significant factor for inhospital mortality of patients with DNR orders (odds ratio, 1.33; 95% confidence interval, 0.81-2.18; P = 0.26). Level 1 trauma centers were significantly associated with a higher rate of major complications (odds ratio, 1.75; 95% confidence interval, 1.11-2.75; P = 0.016). CONCLUSIONS: Inhospital mortality of patients with DNR orders was not significantly associated with trauma designation level after adjusting for case mix. More aggressive treatment or other unknown factors may have resulted in a significantly higher complication rate at level 1 trauma centers.
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Disparidades em Assistência à Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Ordens quanto à Conduta (Ética Médica) , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Pennsylvania , Estudos Retrospectivos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidadeRESUMO
BACKGROUND: The critically ill can have persistent dysglycemia during the "subacute" recovery phase of their illness because of altered gene expression; it is also not uncommon for these patients to receive continuous enteral nutrition during this time. The optimal short-acting subcutaneous insulin therapy that should be used in this clinical scenario, however, is unknown. Our aim was to conduct a qualitative numerical study of the glucose-insulin dynamics within this patient population to answer the above question. This analysis may help clinicians design a relevant clinical trial. METHODS: Eight virtual patients with stress hyperglycemia were simulated by means of a mathematical model. Each virtual patient had a different combination of insulin resistance and insulin deficiency that defined their unique stress hyperglycemia state; the rate of gluconeogenesis was also doubled. The patients received 25 injections of subcutaneous regular or Lispro insulin (0-6 U) with 3 rates of continuous nutrition. The main outcome measurements were the change in mean glucose concentration, the change in glucose variability, and hypoglycemic episodes. These end points were interpreted by how the ultradian oscillations of glucose concentration were affected by each insulin preparation. RESULTS: Subcutaneous regular insulin lowered both mean glucose concentrations and glucose variability in a linear fashion. No hypoglycemic episodes were noted. Although subcutaneous Lispro insulin lowered mean glucose concentrations, glucose variability increased in a nonlinear fashion. In patients with high insulin resistance and nutrition at goal, "rebound hyperglycemia" was noted after the insulin analog was rapidly metabolized. When the nutritional source was removed, hypoglycemia tended to occur at higher Lispro insulin doses. Finally, patients with severe insulin resistance seemed the most sensitive to insulin concentration changes. CONCLUSIONS: Subcutaneous regular insulin consistently lowered mean glucose concentrations and glucose variability; its linear dose-response curve rendered the preparation better suited for a sliding-scale protocol. The longer duration of action of subcutaneous regular insulin resulted in better glycemic-control metrics for patients who were continuously postprandial. Clinical trials are needed to examine whether these numerical results represent the glucose-insulin dynamics that occur in intensive care units; if present, their clinical effects should be evaluated.
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Glicemia/análise , Glucose/metabolismo , Hiperglicemia/sangue , Hiperglicemia/tratamento farmacológico , Hipoglicemia/sangue , Insulina/uso terapêutico , Ritmo Circadiano , Simulação por Computador , Estado Terminal , Humanos , Insulina Lispro/uso terapêutico , Resistência à Insulina , Modelos Teóricos , Oscilometria , Resultado do TratamentoRESUMO
Increased glucose variability (GV) is an independent risk factor for mortality in the critically ill; unfortunately, the optimal insulin therapy that minimizes GV is not known. We simulate the glucose-insulin feedback system to study how stress hyperglycemia (SH) states, taken to be a non-uniform group of physiologic disorders with varying insulin resistance (IR) and similar levels of hyperglycemia, respond to the type and dose of subcutaneous (SQ) insulin. Two groups of 100 virtual patients are studied: those receiving and those not receiving continuous enteral feeds. Stress hyperglycemia was facilitated by doubling the gluconeogenesis rate and IR was stepwise varied from a borderline to a high value. Lispro and regular insulin were simulated with dosages that ranged from 0 to 6 units; the resulting GV was analyzed after each insulin injection. The numerical model used consists of a set of non-linear differential equations with two time delays and five adjustable parameters. The results show that regular insulin decreased GV in both patient groups and rarely caused hypoglycemia. With continuous enteral feeds and borderline to mild IR, Lispro showed minimal effect on GV; however, rebound hyperglycemia that increased GV occurred when the IR was moderate to high. Without a nutritional source, Lispro worsened GV through frequent hypoglycemia episodes as the injection dose increased. The inferior performance of Lispro is a result of its rapid absorption profile; half of its duration of action is similar to the glucose ultradian period. Clinical trials are needed to examine whether these numerical results represent the glucose-insulin dynamics that occur in intensive care units, and if such dynamics are present, their clinical effects should be evaluated.
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Hiperglicemia/sangue , Hiperglicemia/tratamento farmacológico , Hipoglicemiantes/farmacocinética , Insulina Lispro/farmacocinética , Modelos Biológicos , Relação Dose-Resposta a Droga , Gluconeogênese , Humanos , Hipoglicemiantes/administração & dosagem , Injeções Subcutâneas , Insulina Lispro/administração & dosagem , Projetos Piloto , Fatores de TempoRESUMO
Operations in the Middle East have slowed, and near-peer tensions escalate. The U.S. Military has directed its attention from combating insurgencies toward preparedness for large-scale combat operations (LSCOs). The threat of LSCO demands a dramatic shift in strategy and resource and has raised questions about how the military will pivot from the counter-insurgency operations of the previous two decades. Innovation and change are needed to adequately receive, treat, hold, and transport the high volume of anticipated casualties in LSCO. Review of the current deployed medical structure has identified needs to increase emergency medical capabilities near the point of injury, increase patient holding capacity (particularly in critical care) in field hospitals and expeditionary medical facilities, and address likely delayed and prolonged medical evacuation. To address these new challenges, the authors offer recommendations for the addition of Acute Care Nurse Practitioners (ACNPs) to the U.S. Army Medical Department. ACNPs are advanced practice providers, specialized in acute and critical care. ACNPs are a potential medical force multiplier not currently utilized in the U.S. Army. If adapted, ACNPs could contribute significantly to meeting the demands of LSCO medical needs via multiple roles. Recommendations are provided by the authors, such as utilizing the ACNP within the Forward Resuscitative Surgical Detachment, Field Hospital intensive care unit, aeromedical evacuation, and/or Prolonged Care Augmentation Detachment. With support from the U.S. Army Nurse Corp and Army Medical Department, ACNPs could be integrated into the Army healthcare model, emulating the civilian standard of care for every soldier deployed. Furthermore, use of ACNPs in theater could advance deployed medical capabilities and help conserve the fighting force of the U.S. Military and its partners.
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Militares , Humanos , Unidades de Terapia Intensiva , Cuidados Críticos , Ressuscitação , Oriente MédioRESUMO
BACKGROUND: The care of the critically ill trauma patients is provided by intensivists with various base specialties of training. The purpose of this study was to investigate the impact of intensivists' base specialty of training on the disparity of care process and patient outcome. METHODS: We performed a retrospective review of an institutional trauma registry at an academic level 1 trauma center. Two intensive care unit teams staffed by either board-certified surgery or anesthesiology intensivists were assigned to manage critically ill trauma patients. Both teams provided care, collaborating with a trauma surgeon in house. We compared patient characteristics, care processes, and outcomes between surgery and anesthesiology groups using Wilcoxon tests or chi-square tests, as appropriate. RESULTS: We identified a total of 620 patients. Patient baseline characteristics including age, sex, transfer status, injury type, injury severity score, and Glasgow coma scale were similar between groups. We found no significant difference in care processes and outcomes between groups. In a logistic regression model, intensivists' base specialty of training was not a significant factor for mortality (odds ratio, 1.46; 95% confidence interval; 0.79-2.80; P = 0.22) and major complication (odds ratio, 1.11; 95% confidence interval, 0.73-1.67; P = 0.63). CONCLUSIONS: Intensive care unit teams collaborating with trauma surgeons had minimal disparity of care processes and similar patient outcomes regardless of intensivists' base specialty of training.
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Cuidados Críticos , Estado Terminal/terapia , Corpo Clínico Hospitalar/educação , Medicina/organização & administração , Avaliação de Processos e Resultados em Cuidados de Saúde , Ferimentos e Lesões/terapia , Adulto , Idoso , Anestesiologia/educação , Anestesiologia/organização & administração , Certificação , Cuidados Críticos/organização & administração , Estado Terminal/epidemiologia , Feminino , Cirurgia Geral/educação , Cirurgia Geral/organização & administração , Humanos , Incidência , Unidades de Terapia Intensiva/organização & administração , Modelos Logísticos , Masculino , Corpo Clínico Hospitalar/organização & administração , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Centros de Traumatologia/organização & administração , Recursos Humanos , Ferimentos e Lesões/epidemiologiaRESUMO
BACKGROUND: With recent technological advances reducing the demand for emergent surgical airway placement, surgeons are less often performing this life-saving procedure. We sought to assess the characteristics and outcomes surrounding patients undergoing modern emergent cricothyrotomy. METHODS: A retrospective case series was performed between January 2010 and January 2020 at a single tertiary academic level 1 trauma center. Patients who underwent tracheostomy (CPT 31600, 31601) within 48 hours of admission or listed in the trauma registry were queried. Charts were individually reviewed to identify patients with cricothyrotomy. Demographic, operative and relevant hospital course data were collected. RESULTS: A total of 1642 patients were identified with 12 of those found to have met inclusion criteria. The population was mostly male (91.7%) with an average age of 43 years and average body mass index of 30. Survival rate of patients was 75%. A total of 7 patients (58%) had appropriate anatomical placement of cricothyrotomy. Of those patients, 75% were performed by Trauma Surgery. Of the 5 patients with misplaced cricothyrotomy, all were male, with an average age and body mass index of 36 years and 25, respectively. Procedures were performed by prehospital personnel (20%), referring hospital (20%), and Trauma Surgery (60%). DISCUSSION: Cricothyrotomy remains a vital tool in the successful management of emergent airway access. The most common complication observed was improper anatomical placement, which occurred in nearly half of patients. Trauma surgeons perform 75% of cricothyrotomies, with an anatomical accuracy rate of 66.7%.
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Cartilagem Cricoide , Intubação Intratraqueal , Humanos , Masculino , Adulto , Feminino , Intubação Intratraqueal/métodos , Estudos Retrospectivos , Cartilagem Cricoide/cirurgia , Manuseio das Vias Aéreas/métodos , Traqueostomia/métodosRESUMO
Geriatric patients who fall are among the most common mechanisms of injury presenting to trauma centers. We sought to quantify the impact of various comorbidities on length of stay (LOS) in these patients to identify areas for intervention. A level 1 trauma center's registry was queried for patients ≥65 years old with fall related injuries admitted with LOS greater than 2 days. Over 7 years, 3714 patients were included. Mean age was 80.9 ± 8.7 years. All patients fell from heights of 6 feet or less. Median total LOS was 5 days, interquartile range [3,8]. Overall mortality rate was 3.3%. The most common comorbidities were cardiovascular (57.1%), musculoskeletal (31.4%), and diabetes (20.8%). Multivariate linear regression modeling LOS identified diabetes, pulmonary, and psychiatric diseases associated with longer lengths of stay (P < .05). As trauma centers refine care for geriatric trauma patients, comorbidity management represents an opportunity for proactive intervention.
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Hospitalização , Centros de Traumatologia , Humanos , Idoso , Idoso de 80 Anos ou mais , Tempo de Internação , Comorbidade , Estudos Retrospectivos , Escala de Gravidade do FerimentoRESUMO
INTRODUCTION: Nonoperative management of hemodynamically stable patients with blunt splenic and/or hepatic injury has been widely accepted in the pediatric population. However, variability exists in the utilization and timing of repeat imaging to assess for delayed complications during index hospitalization. Recent level-IV evidence suggests that repeat imaging in children should be performed based on a patient's clinical status rather than on a routine basis. The aim of this study is to examine the rate of delayed complications and interventions in pediatric trauma patients with blunt splenic and/or hepatic injuries who undergo repeat imaging prompted either by a clinical change (CC) or non-clinical change (NCC). METHODS: A 9-year (2011-2019), retrospective, dual-institution study was performed of children (0-17 years) with blunt splenic and/or hepatic injuries. Patients were grouped based on reason for repeat imaging: CC or NCC. The rate of organ-specific delayed complications and interventions was examined by reason for scan. RESULTS: A total of 307 injuries were included in the study period (174 splenic, 113 hepatic, and 20 both). Of 194 splenic injuries, 30(15.5%) underwent repeat imaging (CC = 19; NCC = 11). Of 133 hepatic injuries, 27(20.3%) underwent repeat imaging (CC = 21; NCC = 6). There was no difference in the incidence of organ-specific delayed complications between the CC and NCC groups. Of the 4 patients with complications necessitating intervention, only one was identified based on NCC. CONCLUSIONS: Our data suggest routine repeat imaging is unnecessary in children with blunt splenic and/or hepatic injuries; therefore, practitioners may rely on a patient's clinical change.
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Traumatismos Abdominais , Ferimentos não Penetrantes , Humanos , Criança , Estudos Retrospectivos , Escala de Gravidade do Ferimento , Baço/diagnóstico por imagem , Baço/lesões , Fígado/diagnóstico por imagem , Fígado/lesões , Traumatismos Abdominais/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/cirurgiaRESUMO
BACKGROUND: Uncontrolled hemorrhage is the leading cause of preventable death in combat and civilian trauma. Efficacious hemostatic agents in junctional hemorrhage can quell blood loss and improve survival. We hypothesized that a novel hemostatic foam of starch and chitosan would improve hemostasis, and thereby increase survival in a swine femoral artery hemorrhage model when compared with CombatGauze (CG). METHODS: A novel hemostatic foam of starch and chitosan was created and modified during the study period. Thirty pigs (four excluded) were assigned to treatment using either foam version 1 (FV1, n = 9) or 2 (FV2, n = 8), or (n = 9) in a standard swine femoral artery hemorrhage model. Animals were observed for 150 minutes. Outcomes assessed included hemostasis, survival, posttreatment blood loss, IV fluid volume, and hemodynamic and laboratory trends. RESULTS: Hemostasis prior to 150 minutes was similar with 44.4%, 77.8%, and 50% of swine treated with CG, FV1 and FV2, respectively (Kaplan-Meyer and log-rank test [KM-LR] p > 0.05). Survival to 150 minutes was improved in swine treated with FV1 (100%) compared with CG (55.6%) (KM-LR p = 0.02). Survival was similar between FV1 and FV2 (75%) (KM-LR p > 0.05), and between CG and FV2 (KM-LR p > 0.05). Using mixed model for longitudinal data, mean arterial pressure decreased significantly in CG- and FV2-treated swine, while there was no significant change in mean arterial pressure in FV1-treated swine. Trends in lactic acid, hematocrit, platelets, INR, and thrombelastography were more favorable for FV1 compared with CG. CONCLUSION: In this preclinical study of junctional hemorrhage, survival was improved in swine treated with version 1 of a novel chitosan/starch foam compared with CG. Trends in hemodynamics and laboratory data were also more favorable in the FV1-treated swine. This novel hemostatic foam may be an effective alternative to current hemostatic agents.
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Quitosana , Hemostáticos , Suínos , Animais , Hemostáticos/farmacologia , Hemostáticos/uso terapêutico , Artéria Femoral/lesões , Polieletrólitos , Hemorragia/etiologia , Hemostasia , AmidoRESUMO
INTRODUCTION: Trauma transfers are a common occurrence in rural areas, where critical access and lower-level trauma centers routinely transfer to tertiary care centers for specialized care. Transfers are non-therapeutic (NTT) when no specialist intervention occurs, leading to transfer that were futile (FT) or secondary overtriage (SOT). This study aimed to evaluate the prevalence of NTT among four trauma centers providing care to rural Appalachia. METHODS: This retrospective review was performed at four, ACS verified, Level 1 trauma centers. All adult trauma patients, transferred during 2018 were included for analysis. Transfers were considered futile if in <48 h the patient died or was discharged to hospice, without operative intervention. SOT transfers were discharged in <48 h, without major intervention, with an ISS< 15. Cost analysis was performed to describe the impact of NTT on EMS use. RESULTS: 4,189 patients were analyzed during the study period. 105 (2.5%) met criteria for futility. Futile patients had a median ISS of 25 (IQR 9-26), and 48% had an AIS head ≥4. These were significantly greater (p<0.001) than non-futile transfers, median ISS 5 (IQR 2-9), 3% severe head injury. SOT occurred in 1371 (33%), median ISS of 5, and lower AIS scores by region. Isolated facial injuries resulted in 165 transfers. 13% of FT+SOT were admitted to the ICU. Only 22% of FT+SOT came from a trauma center. 68% were transported by ALS and 13% transported by air transport. FT+SOT traveled on average 70 miles from their home to receive care. CONCLUSIONS: Non-therapeutic transfers account for more than 1/3 of transfers in this rural environment. There was a significant use of advanced life support and aeromedical transport. The utility of these transfers should be questioned. With the recent increases in telehealth there is an opportunity for trauma systems to improve regional care and decrease transfers for futile cases.
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Transferência de Pacientes , Ferimentos e Lesões , Adulto , Humanos , Hospitalização , Centros de Traumatologia , Alta do Paciente , Centros de Atenção Terciária , Estudos Retrospectivos , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/terapia , Escala de Gravidade do Ferimento , Triagem/métodosRESUMO
BACKGROUND: Shock index (SI) predicts outcomes after trauma. Prior single-center work demonstrated that emergency medical services (EMSs) initial SI was the most accurate predictor of hospital outcomes in a rural environment. This study aimed to evaluate the predictive ability of SI in multiple rural trauma systems with prolonged transport times to a definitive care facility. METHODS: This retrospective review was performed at four American College of Surgeons-verified level 1 trauma centers with large rural catchment basins. Adult trauma patients who were transferred and arrived >60 minutes from scene during 2018 were included. Patients who sustained blunt chest or abdominal trauma were analyzed. Subjects with missing data or severe head trauma (Abbreviated Injury Scale score, >2) were excluded. Poisson and binomial logistic regression were used to study the effect of SI and delta shock index (∆SI) on outcomes. RESULTS: After applying the criteria, 789 patients were considered for analysis (502 scene patients and 287 transfers). The mean Injury Severity Score was 8 (interquartile range, 6) for scene and 8.9 (interquartile range, 5) for transfers. Initial EMSs SI was a significant predictor of the need for blood transfusion and intensive care unit care in both scene and transferred patients. An increase in ∆SI was predictive of the need for operative intervention ( p < 0.05). There were increased odds for mortality for every 0.1 change in EMSs SI; those changes were not deemed significant among both scene and transfer patients ( p < 0.1). CONCLUSION: Providers must maintain a high level of clinical suspicion for patients who had an initially elevated SI. Emergency medical services SI is a significant predictor for use of blood and intensive care unit care, as well as mortality for scene patients. This highlights the importance of SI and ∆SI in rural trauma care. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.
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Serviços Médicos de Emergência , Traumatismo Múltiplo , Ferimentos e Lesões , Adulto , Humanos , Centros de Traumatologia , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Mortalidade Hospitalar , Estudos Retrospectivos , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Vascular access in hypotensive trauma patients is challenging. Little evidence exists on the time required and success rates of vascular access types. We hypothesized that intraosseous (IO) access would be faster and more successful than peripheral intravenous (PIV) and central venous catheter (CVC) access in hypotensive patients. METHODS: An EAST prospective multicenter trial was performed; 19 centers provided data. Trauma video review was used to evaluate the resuscitations of hypotensive (systolic blood pressure ≤90 mm Hg) trauma patients. Highly granular data from video recordings were abstracted. Data collected included vascular access attempt type, location, success rate, and procedural time. Demographic and injury-specific variables were obtained from the medical record. Success rates, procedural durations, and time to resuscitation were compared among access strategies (IO vs. PIV vs. CVC). RESULTS: There were 1,410 access attempts that occurred in 581 patients with a median age of 40 years (27-59 years) and an Injury Severity Score of 22 [10-34]. Nine hundred thirty-two PIV, 204 IO, and 249 CVC were attempted. Seventy percent of access attempts were successful but were significantly less likely to be successful in females (64% vs. 71%, p = 0.01). Median time to any access was 5.0 minutes (3.2-8.0 minutes). Intraosseous had higher success rates than PIV or CVC (93% vs. 67% vs. 59%, p < 0.001) and remained higher after subsequent failures (second attempt, 85% vs. 59% vs. 69%, p = 0.08; third attempt, 100% vs. 33% vs. 67%, p = 0.002). Duration varied by access type (IO, 36 [23-60] seconds; PIV, 44 [31-61] seconds; CVC 171 [105-298]seconds) and was significantly different between IO versus CVC ( p < 0.001) and PIV versus CVC ( p < 0.001) but not PIV versus IO. Time to resuscitation initiation was shorter in patients whose initial access attempt was IO, 5.8 minutes versus 6.7 minutes ( p = 0.015). This was more pronounced in patients arriving to the hospital with no established access (5.7 minutes vs. 7.5 minutes, p = 0.001). CONCLUSION: Intraosseous is as fast as PIV and more likely to be successful compared with other access strategies in hypotensive trauma patients. Patients whose initial access attempt was IO were resuscitated more expeditiously. Intraosseous access should be considered a first line therapy in hypotensive trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.
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Cateteres Venosos Centrais , Serviços Médicos de Emergência , Feminino , Humanos , Adulto , Estudos Prospectivos , Ressuscitação , Infusões Intravenosas , Injeções Intravenosas , Infusões IntraósseasRESUMO
Acute care surgery has evolved to encompass the advanced management of complex nonhealing wounds. Biodebridement has the potential to improve the care of chronic wounds for acute care surgery patients, particularly for patients in the surgical intensive care unit (SICU) with hospital-acquired pressure injuries. A case report of biodebridement using larval maggot therapy in the SICU is presented to illustrate real-world application and progression in wound healing. A review of current research involving biodebridement was conducted. A septuagenarian gentleman sustained a fall resulting in cervical spine fractures with neurological deficits. The patient had a prolonged hospital course in the SICU, complicated by myocardial infarction, respiratory failure requiring tracheostomy, and development of a Stage IV sacral pressure ulcer. The wound base was sharply debrided several times and became refractory to conventional mechanical/chemical debridement techniques. The patient had a prohibitively high risk for the operating room but remained too sensate for further effective bedside debridement. Biodebridement was utilized to create a viable wound base, with improved appearance noted within 2 weeks. A review of the current literature shows biodebridement has numerous benefits in the management of chronic wounds. Biodebridement is a unique therapy that possesses great value for select patients in the SICU. In particular, patients who are too high risk for further operative intervention, but too sensate for ongoing bedside debridement and dressing changes, benefit significantly from this underutilized approach. Further research is needed to solidify the place of biodebridement in the surgical management of chronic nonhealing wounds.
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Úlcera por Pressão , Cicatrização , Animais , Cuidados Críticos , Desbridamento/métodos , Humanos , LarvaRESUMO
BACKGROUND: Patients with obesity are also at risk for sarcopenia, which is difficult to recognize in this population. Our study examines whether sarcopenic-obesity (SO) is independently associated with mortality in trauma. METHODS: Using a retrospective database, we performed logistic regression analysis. . Admission CT scans were used to identify SO by calculating the visceral fat to skeletal muscle ratio >3.2. RESULTS: Of 883 patients, the prevalence of SO was 38% (333). Patients with SO were more likely to be male (79% versus 43%, p < 0.001), older (mean 66.5 years versus 46.3 years, p < 0.001), and less likely to have an injury severity score (ISS) ≥ 24 (43% versus 55%, p = 0.0003). Using multivariable logistic regression analysis, SO was independently associated with mortality (OR 2.8; 95% CI 1.6-4.8, p < 0.001). Causal mediation analysis found admission hyperglycemia as a mediator for mortality. CONCLUSIONS: Sarcopenic obesity is an independent predictor of mortality in major trauma.
Assuntos
Sarcopenia , Feminino , Humanos , Gordura Intra-Abdominal/diagnóstico por imagem , Masculino , Músculo Esquelético , Obesidade/epidemiologia , Estudos Retrospectivos , Sarcopenia/complicações , Sarcopenia/diagnóstico por imagem , Sarcopenia/epidemiologiaRESUMO
INTRODUCTION: Early video-assisted thorascopic surgery (VATS) is the recommended intervention for retained hemothorax in trauma patients. Alternative options, such as lytic therapy, to avoid surgery remain controversial. The purpose of this decision analysis was to assess expected costs associated with treatment strategies. METHODS: A decision tree analysis estimated the expected costs of three initial treatment strategies: 1) VATS, 2) intrapleural tissue plasminogen activator (TPA) lytic therapy, and 3) intrapleural non-TPA lytic therapy. Probability parameters were estimated from published literature. Costs were based on National Inpatient Sample data and published estimates. Our model compared overall expected costs of admission for each strategy. Sensitivity analyses were conducted to explore the impact of parameter uncertainty on the optimal strategy. RESULTS: In the base case analysis, using TPA as the initial approach had the lowest total cost (U.S. $37,007) compared to VATS ($38,588). TPA remained the optimal initial approach regardless of the probability of complications after VATS. TPA was an optimal initial approach if TPA success rate was >83% regardless of the failure rate with VATS. VATS was the optimal initial strategy if its total cost of admission was <$33,900. CONCLUSION: Lower treatment costs with lytic therapy does not imply significantly lower total cost of trauma admission. However, an initial approach with TPA lytic therapy may be preferred for retained traumatic hemothorax to lower the total cost of admission given its high probability of avoiding the operating room with its resultant increased costs. Future studies should identify differences in quality of life after recovery from competing interventions.
Assuntos
Hemotórax , Traumatismos Torácicos , Técnicas de Apoio para a Decisão , Hemotórax/etiologia , Hemotórax/cirurgia , Humanos , Qualidade de Vida , Traumatismos Torácicos/complicações , Traumatismos Torácicos/cirurgia , Cirurgia Torácica Vídeoassistida/efeitos adversos , Ativador de Plasminogênio TecidualRESUMO
OBJECTIVES: Describe the epidemiology of a large cohort of older adults with isolated traumatic brain injury (TBI) and identify predictors of mortality, palliative interventions, and discharge to preinjury residence in those presenting with moderate/severe TBI. DESIGN: Prospective observational study of geriatric patients with TBI enrolled across 45 trauma centers. SETTING AND PARTICIPANTS: Inclusion criteria were age ≥40 years, and computed tomography (CT)-verified TBI. Exclusion criteria were any other body region abbreviated injury scale score >2 and presentation at enrolling center >24 hours after injury. METHODS: The analysis was restricted to individuals aged ≥65 and stratified into 3 age groups: young-old (65-74), middle-old (75-84), and oldest-old (≥85). Demographic, clinical, and injury data were collected. Predictors of mortality, palliative interventions, and discharge to preinjury residence in the moderate/severe TBI group were identified using Classification and Regression Tree and Generalized Linear Mixed Models. RESULTS: Of the 3081 subjects enrolled in the study, 2028 were ≥65 years old. Overall, 339 (16.7%) presented with a moderate/severe TBI and experienced a 64% mortality rate. A Glasgow Coma Scale (GCS) score <9 was the main predictor of mortality, CT worsening (odds ratio [OR] = 1.7, P < .04), cerebral edema (OR = 2.4, P < .04), GCS <9, and age ≥75 (OR = 2.1, P = .007) were predictors for palliative interventions, and an injury severity score ≤24 (OR = 0.087, P = .002) was associated with increased likelihood of discharge to preinjury residence in the moderate/severe TBI group. CONCLUSION AND IMPLICATIONS: In this prospective study of a large cohort of older adults with isolated TBI, comparisons across the older age groups with moderate/severe TBI revealed that survival and favorable discharge disposition were influenced more by severity of injury rather than age itself. Indicating that chronological age alone maybe insufficient to accurately predict outcomes, and increased representation of older adults in TBI research to develop better diagnostic and prognostic tools is warranted.