The spike-timing-dependent plasticity of VIP interneurons in motor cortex.

The plasticity of inhibitory interneurons (INs) plays an important role in the organization and maintenance of cortical microcircuits. Given the many different IN types, there is an even greater diversity in synapse-type-specific plasticity learning rules at excitatory to excitatory (E→I), I→E, and I→I synapses. I→I synapses play a key disinhibitory role in cortical circuits. Because they typically target other INs, vasoactive intestinal peptide (VIP) INs are often featured in I→I→E disinhibition, which upregulates activity in nearby excitatory neurons. VIP IN dysregulation may thus lead to neuropathologies such as epilepsy. In spite of the important activity regulatory role of VIP INs, their long-term plasticity has not been described. Therefore, we characterized the phenomenology of spike-timing-dependent plasticity (STDP) at inputs and outputs of genetically defined VIP INs. Using a combination of whole-cell recording, 2-photon microscopy, and optogenetics, we explored I→I STDP at layer 2/3 (L2/3) VIP IN outputs onto L5 Martinotti cells (MCs) and basket cells (BCs). We found that VIP IN→MC synapses underwent causal long-term depression (LTD) that was presynaptically expressed. VIP IN→BC connections, however, did not undergo any detectable plasticity. Conversely, using extracellular stimulation, we explored E→I STDP at inputs to VIP INs which revealed long-term potentiation (LTP) for both causal and acausal timings. Taken together, our results demonstrate that VIP INs possess synapse-type-specific learning rules at their inputs and outputs. This suggests the possibility of harnessing VIP IN long-term plasticity to control activity-related neuropathologies such as epilepsy.

Self-harm presentations to hospital trauma centre emergency departments during the first year of the COVID-19 pandemic.

The COVID-19 pandemic raised concerns regarding increased suicide-related behaviours. We compared characteristics and counts of Emergency Department (ED) presentations for self-harm, an important suicide-related outcome, during versus prior to the pandemic's first year. We included patients presenting with self-harm to the ED of two trauma centres in Toronto, Canada. Time series models compared intra-pandemic (March 2020-February 2021) presentation counts to predictions from pre-pandemic data. The self-harm proportion of ED presentations was compared between the intra-pandemic period and preceding three years. A retrospective chart review of eligible patients seen from March 2019-February 2021 compared pre- vs. intra-pandemic patient and injury characteristics. While monthly intra-pandemic self-harm counts were largely within expected ranges, the self-harm proportion of total presentations increased. Being widowed (OR=9.46; 95 %CI=1.10-81.08), employment/financial stressors (OR=1.65, 95 %CI=1.06-2.58), job loss (OR=3.83; 95 %CI=1.36-10.76), and chest-stabbing self-harm (OR=2.50; 95 %CI=1.16-5.39) were associated with intra-pandemic presentations. Intra-pandemic self-harm was also associated with Intensive Care Unit (ICU) admission (OR=2.18, 95 %CI=1.41-3.38). In summary, while the number of self-harm presentations to these trauma centres did not increase during the early pandemic, their proportion was increased. The association of intra-pandemic self-harm with variables indicating medically severe injury, economic stressors, and being widowed may inform future suicide and self-harm prevention strategies.

Vision Transformer-based Decision Support for Neurosurgical Intervention in Acute Traumatic Brain Injury: Automated Surgical Intervention Support Tool.

Purpose To develop an automated triage tool to predict neurosurgical intervention for patients with traumatic brain injury (TBI). Materials and Methods A provincial trauma registry was reviewed to retrospectively identify patients with TBI from 2005 to 2022 treated at a specialized Canadian trauma center. Model training, validation, and testing were performed using head CT scans with binary reference standard patient-level labels corresponding to whether the patient received neurosurgical intervention. Performance and accuracy of the model, the Automated Surgical Intervention Support Tool for TBI (ASIST-TBI), were also assessed using a held-out consecutive test set of all patients with TBI presenting to the center between March 2021 and September 2022. Results Head CT scans from 2806 patients with TBI (mean age, 57 years ± 22 [SD]; 1955 [70%] men) were acquired between 2005 and 2021 and used for training, validation, and testing. Consecutive scans from an additional 612 patients (mean age, 61 years ± 22; 443 [72%] men) were used to assess the performance of ASIST-TBI. There was accurate prediction of neurosurgical intervention with an area under the receiver operating characteristic curve (AUC) of 0.92 (95% CI: 0.88, 0.94), accuracy of 87% (491 of 562), sensitivity of 87% (196 of 225), and specificity of 88% (295 of 337) on the test dataset. Performance on the held-out test dataset remained robust with an AUC of 0.89 (95% CI: 0.85, 0.91), accuracy of 84% (517 of 612), sensitivity of 85% (199 of 235), and specificity of 84% (318 of 377). Conclusion A novel deep learning model was developed that could accurately predict the requirement for neurosurgical intervention using acute TBI CT scans. Keywords: CT, Brain/Brain Stem, Surgery, Trauma, Prognosis, Classification, Application Domain, Traumatic Brain Injury, Triage, Machine Learning, Decision Support Supplemental material is available for this article. © RSNA, 2024 See also commentary by Haller in this issue.

Mechanical Ventilation after Traumatic Spinal Cord Injury-A Multicentric Cohort Study-based Prediction Model for Weaning Success: The BICYCLE Score.

Rationale: Limited information exists about the epidemiology, outcomes, and predictors of weaning from mechanical ventilation in patients with spinal cord injury. Objectives: Our aim was to investigate predictors of weaning outcomes for patients with traumatic spinal cord injury (tSCI) and develop and validate a prognostic model and score for weaning success. Methods: This was a registry-based, multicentric cohort study including all adult patients with tSCI requiring mechanical ventilation (MV) and admitted to one of the intensive care units (ICUs) of the Trauma Registry at St. Michael's Hospital (Toronto, ON, Canada) and the Canadian Rick Hansen Spinal Cord Injury Registry between 2005 and 2019. The primary outcome was weaning success from MV at ICU discharge. Secondary outcomes included weaning success at Days 14 and 28, time to liberation from MV accounting for competing risk of death, and ventilator-free days at 28 and 60 days. Associations between baseline characteristics and weaning success or time to liberation from MV were measured using multivariable logistic and competing risk regressions. A parsimonious model to predict weaning success and ICU discharge was developed and validated via bootstrap. A prediction score for weaning success at ICU discharge was derived, and its discriminative ability was assessed using receiver operating characteristic curve analysis and compared with the Injury Severity Score (ISS). Results: Of 459 patients analyzed, 246 (53.6%), 302 (65.8%), and 331 (72.1%) were alive and free of MV at Day 14, Day 28, and ICU discharge, respectively; 54 (11.8%) died in the ICU. Median time to liberation from MV was 12 days. Factors associated with weaning success were Blunt injury (odds ratio [OR], 2.96; P = 0.010), ISS (OR, 0.98; P = 0.025), Complete syndrome (OR, 0.53; P = 0.009), age in Years (OR, 0.98; P = 0.003), and Cervical LEsion (OR, 0.60; P = 0.045). The BICYCLE score showed a greater area under the curve than the ISS (0.689 [95% confidence interval (CI), 0.631-0.743] vs. 0.537 [95% CI, 0.479-0.595]; P < 0.0001). Factors predicting weaning success also predicted time to liberation. Conclusions: In a large multicentric cohort, 72% of patients with tSCI were weaned and discharged alive from the ICU. Readily available admission characteristics can reasonably predict weaning success and help prognostication.

The plasticitome of cortical interneurons.

Hebb postulated that, to store information in the brain, assemblies of excitatory neurons coding for a percept are bound together via associative long-term synaptic plasticity. In this view, it is unclear what role, if any, is carried out by inhibitory interneurons. Indeed, some have argued that inhibitory interneurons are not plastic. Yet numerous recent studies have demonstrated that, similar to excitatory neurons, inhibitory interneurons also undergo long-term plasticity. Here, we discuss the many diverse forms of long-term plasticity that are found at inputs to and outputs from several types of cortical inhibitory interneuron, including their plasticity of intrinsic excitability and their homeostatic plasticity. We explain key plasticity terminology, highlight key interneuron plasticity mechanisms, extract overarching principles and point out implications for healthy brain functionality as well as for neuropathology. We introduce the concept of the plasticitome - the synaptic plasticity counterpart to the genome or the connectome - as well as nomenclature and definitions for dealing with this rich diversity of plasticity. We argue that the great diversity of interneuron plasticity rules is best understood at the circuit level, for example as a way of elucidating how the credit-assignment problem is solved in deep biological neural networks.

Opioid prescribing practices in trauma patients at discharge: An exploratory retrospective chart analysis.

This study examined the opioid prescribing patterns at discharge in the trauma center of a major Canadian hospital and compared them to the guidelines provided by the Illinois surgical quality improvement collaborative (ISQIC), a framework that has been recognized as being associated with reduced risk. This was a retrospective chart review of patient data from the trauma registry between January 1, 2018, and October 31, 2019. A total of 268 discharge charts of naïve opioid patients were included in the analysis. A Morphine Milligram Equivalents per day (MME/day) was computed for each patient who was prescribed opioids and compared with standard practice guidelines. About 75% of patients were prescribed opioids. More males (75%) than females (25%) were prescribed opioids to patients below 65 years old (91%). Best practice guidelines were followed in most cases. Only 16.6% of patients were prescribed over 50 mg MME/day, the majority (80.9%) were prescribed opioids for =<3 days and only 1% for >7 days. Only 7.5% were prescribed extended-release opioids and none were strong like fentanyl. Patients received a multimodal approach with alternatives to opioids in 88.9% of cases and 82.9% had a plan for opioid discontinuation. However, only 23.6% received an acute pain service referral. The majority of the prescriptions provided adhered to the best practice guidelines outlined by the ISQIC framework. These results are encouraging with respect to the feasibility of implementing opioid prescription guidelines effectively. However, routine monitoring is necessary to ensure that adherence is maintained.

A regional massive hemorrhage protocol developed through a modified Delphi technique.

BACKGROUND: A massive hemorrhage protocol (MHP) enables rapid delivery of blood components in a patient who is exsanguinating pending definitive hemorrhage control, but there is variability in MHP implementation rates, content and compliance owing to challenges presented by infrequent activation, variable team performance and patient acuity. The goal of this project was to identify the key evidence-based principles and quality indicators required to develop a standardized regional MHP. METHODS: A modified Delphi consensus technique was performed in the spring and summer of 2018. Panellists used survey links to independently review and rate (on a 7-point Likert scale) 43 statements and 8 quality indicators drafted by a steering committee composed of transfusion medicine specialists and technologists, and trauma physicians. External stakeholder input from all hospitals in Ontario was sought. RESULTS: Three rounds were held with 36 experts from diverse clinical backgrounds. Consensus was reached for 42 statements and 8 quality indicators. Additional modifications from external stakeholders were incorporated to form the foundation for the proposed MHP. INTERPRETATION: This MHP template will provide the basis for the design of an MHP toolkit, including specific recommendations for pediatric and obstetrical patients, and for hospitals with limited availability of blood components or means to achieve definitive hemorrhage control. We believe that harmonization of MHPs in our region will simplify training, increase uptake of evidence-based interventions, enhance communication, improve patient comfort and safety, and, ultimately, improve patient outcomes.

An Optogenetic Kindling Model of Neocortical Epilepsy.

Epileptogenesis is the gradual process by which the healthy brain develops epilepsy. However, the neuronal circuit changes that underlie epileptogenesis are not well understood. Unfortunately, current chemically or electrically induced epilepsy models suffer from lack of cell specificity, so it is seldom known which cells were activated during epileptogenesis. We therefore sought to develop an optogenetic variant of the classical kindling model of epilepsy in which activatable cells are both genetically defined and fluorescently tagged. We briefly optogenetically activated pyramidal cells (PCs) in awake behaving mice every two days and conducted a series of experiments to validate the effectiveness of the model. Although initially inert, brief optogenetic stimuli eventually elicited seizures that increased in number and severity with additional stimulation sessions. Seizures were associated with long-lasting plasticity, but not with tissue damage or astrocyte reactivity. Once optokindled, mice retained an elevated seizure susceptibility for several weeks in the absence of additional stimulation, indicating a form of long-term sensitization. We conclude that optokindling shares many features with classical kindling, with the added benefit that the role of specific neuronal populations in epileptogenesis can be studied. Links between long-term plasticity and epilepsy can thus be elucidated.

Exploring the effect of factor Xa inhibitors on rotational thromboelastometry: a case series of bleeding patients.

Direct oral anticoagulants (DOACs) have become the standard for thromboembolic risk management. In cases of major bleeding, trauma, or urgent surgery, accurate monitoring of DOAC activity is desirable; however, there is often no rapid, readily available test. We therefore explored the degree to which DOAC activity correlated with two coagulation assays: rotational thromboelastometry (ROTEM) and a standard coagulation assay in bleeding patients. We conducted a retrospective review of patients who experienced bleeding while on DOAC therapy from 2015 to 2017 at a Level 1 trauma center. ROTEM (EXTEM-clotting time {CT} in seconds), activated partial thromboplastin time (aPTT) (in seconds), prothrombin time (PT) (in seconds), DOAC specific drug test (anti-Xa and Hemoclot in ng/mL), and relevant clinical parameters were recorded. Descriptive statistics (median, range) and Spearman correlation coefficients were estimated. Differences between correlations were tested using Williams' t test. Twelve cases were reviewed (13 separate bleeding episodes). Sixteen measurements of DOAC activity, EXTEM-CT, and PT were obtained. The correlations with rivaroxaban activity were 0.96 and 0.86 (p = 0.2062) for PT and EXTEM-CT, respectively. The correlations with apixaban activity were 0.63 and 0.56 (p = 0.7175) for PT and EXTEM-CT, respectively. Analyses were not conducted for dabigatran due to limited data. Although not statistically significant, PT appears to have a higher correlation with direct Xa inhibitor activity than EXTEM-CT. Further research with larger samples is necessary to clarify the differences between ROTEM and standard assays in detecting DOAC activity.

Canadian Study of Health and Aging Clinical Frailty Scale: Does It Predict Adverse Outcomes among Geriatric Trauma Patients?

BACKGROUND: The Canadian Study of Health and Aging Clinical Frailty Scale (CFS) and the laboratory Frailty Index (FI-lab) are validated tools based on clinical and laboratory data, respectively. Their utility as predictors of geriatric trauma outcomes is unknown. Our primary objective was to determine whether pre-admission CFS is associated with adverse discharge destination. Secondary objectives were to evaluate the relationships between CFS and in-hospital complications and between admission FI-lab and discharge destination. STUDY DESIGN: We performed a 4-year (2011 to 2014) retrospective cohort study with patients 65 years and older admitted to a level I trauma center. Admission FI-lab was calculated using 23 variables collected within 48 hours of presentation. The primary outcome was discharge destination, either adverse (death or discharge to a long-term, chronic, or acute care facility) or favorable (home or rehabilitation). The secondary outcome was in-hospital complications. Multivariable logistic regression was used to evaluate the relationship between CFS or FI-lab and outcomes. RESULTS: There were 266 patients included. Mean age was 76.5 ± 7.8 years and median Injury Severity Score was 17 (interquartile range 13 to 24). There were 260 patients and 221 patients who had sufficient data to determine CFS and FI-lab scores, respectively. Pre-admission frailty as per the CFS (CFS 6 or 7) was independently associated with adverse discharge destination (odds ratio 5.1; 95% CI 2.0 to 13.2; p < 0.001). Severe frailty on admission, as determined by the FI-lab (FI-lab > 0.4), was not associated with adverse outcomes. CONCLUSIONS: Pre-admission clinical frailty independently predicts adverse discharge destination in geriatric trauma patients. The CFS may be used to triage resources to mitigate adverse outcomes in this population. The FI-lab determined on admission for trauma may not be useful.

The Anticoagulated trauma patient in the age of the direct oral anticoagulants: a Canadian perspective.

BACKGROUND: The anticoagulated trauma patient presents a particular challenge to the critical care physician. Our understanding of these patients is defined and extrapolated by experience with patients on warfarin pre-injury. Today, many patients who would have been on warfarin are now prescribed the Direct Oral Anticoagulants (DOACs) a class of anticoagulants with entirely different mechanisms of action, effects on routine coagulation assays and approach to reversal. METHODS: Trauma registry data from Toronto's (Ontario, Canada) two Level 1 trauma centres were used to identify patients on oral anticoagulation pre-injury from June 1, 2014 to June 1, 2015. The trauma registry and medical records were reviewed and used to extract demographic and clinical data. RESULTS: We found 81 patients were on oral anticoagulants pre-injury representing 3.2% of the total trauma population and 33% of the orally anticoagulated patients were prescribed a DOAC prior to presentation. Comparison between the DOAC and warfarin groups showed similar age, mechanisms of injury, indications for anticoagulation, injury severity score and rate of intracranial hemorrhage. Patients on DOACs had higher initial mean hemoglobin vs warfarin (131 vs 120) and lower serum creatinine (94.8 vs 129.5). The percentage of patients receiving a blood transfusion in the trauma bay and total in-hospital transfusion was similar between the two groups however patients on DOACs were more likely to receive tranexamic acid vs patients on warfarin (32.1% vs 9.1%) and less likely to receive prothrombin concentrates (18.5% vs 60%). Patients on DOACs were found to have higher survival to discharge (92%) vs patients on warfarin (72%). CONCLUSION: Patients on DOACs pre-injury now represent a significant proportion of the anticoagulated trauma population. Although they share demographic and clinical similarities with patients on warfarin, patients on DOACs may have improved outcomes despite lack of established drug reversal protocols and challenging interpretation of coagulation assays. LEVEL OF EVIDENCE: III; Study Type: Retrospective Review.

Comparison of Helicopter Emergency Medical Services Transport Types and Delays on Patient Outcomes at Two Level I Trauma Centers.

BACKGROUND: Helicopter emergency medical services (HEMS) have become an engrained component of trauma systems. In Ontario, transportation for trauma patients is through one of three ways: scene call, modified scene call, or interfacility transfer. We hypothesize that differences exist between these types of transports in both patient demographics and patient outcomes. This study compares the characteristics of patients transported by each of these methods to two level 1 trauma centers and assesses for any impact on morbidity or mortality. As a secondary outcome reasons for delay were identified. METHODS: A local trauma registry was used to identify and abstract data for all patients transported to two trauma centers by HEMS over a 36-month period. Further chart abstraction using the HEMS patient care reports was done to identify causes of delay during HEMS transport. RESULTS: During the study period HEMS transferred a total of 911 patients of which 139 were scene calls, 333 were modified scene calls and 439 were interfacility transfers. Scene calls had more patients with an ISS of less than 15 and had more patients discharged home from the ED. Modified scene calls had more patients with an ISS greater than 25. The most common delays that were considered modifiable included the sending physician doing a procedure, waiting to meet a land EMS crew, delays for diagnostic imaging and confirming disposition or destination. CONCLUSIONS: Differences exist between the types of transports done by HEMS for trauma patients. Many identified reasons for delay to HEMS transport are modifiable and have practical solutions. Future research should focus on solutions to identified delays to HEMS transport. Key words: helicopter emergency medical services; trauma; prehospital care; delays.

Sustainability of a proactive geriatric trauma consultation service.

BACKGROUND: Proactive geriatric trauma consultation service (GTCS) models have been associated with better delivery of geriatric care and functional outcomes. Whether such collaborative models can be improved and sustained remains uncertain. We describe the sustainability and process improvements of an inpatient GTCS. METHODS: We assessed workflow using interviews and surveys to identify opportunities to optimize the referral process for the GTCS. Sustainability of the service was assessed via a prospective case series (July 2012-December 2013). Study data were derived from a review of the medical record and trauma registry database. Metrics to determine sustainability included volume of cases, staffing levels, rate of adherence to recommendations, geriatric-specific clinical outcomes, trauma quality indicators, consultation requests and discharge destination. RESULTS: Through process changes, we were able to ensure every eligible patient was referred for a comprehensive geriatric assessment. Compared with the implementation phase, volume of assessments increased and recommendation adherence rates were maintained. Delirium and/or dementia were the most common geriatric issue addressed. The rate of adherence to recommendations made by the GTCS team was 88.2%. Only 1.4% of patients were discharged to a nursing home. CONCLUSION: Workflow assessment is a useful means to optimize the referral process for comprehensive geriatric assessment. Sustainability of a GTCS was shown by volume, staffing and recommendation adherence.

Les modèles de services de consultation proactifs en traumatologie gériatrique ont été associés à une amélioration des soins gériatriques et des capacités fonctionnelles. Toutefois, on ignore toujours s'il est possible de perfectionner et de maintenir ces modèles collaboratifs. Nous décrivons donc ici la viabilité et l'amélioration des procédures d'un service de consultation en traumatologie gériatrique en milieu hospitalier.

Application and Evaluation of Knowledge Retention Related to Advanced Trauma Care for Nurses (ATCN) Course Content: A Preliminary Study.

The Advanced Trauma Care for Nurses (ATCN) course was designed to help nurses increase their knowledge in management of the multiple trauma patient. To determine whether the trauma-related knowledge of ATCN course takers differed from nontakers, assess the factors associated with ATCN content knowledge among course takers, and explore the extent to which the ATCN content was used by course takers in their clinical practice. A cross-sectional online survey of 78 ATCN takers (nurses who had successfully completed the ATCN course within the previous 3 years) and 58 ATCN nontakers (a control group of nurses who had not taken the course but who worked in comparable clinical settings) was conducted. The survey consisted of demographic questions and a 15-item knowledge test spanning the ATCN course content. ATCN takers were also asked about the frequency with which a specific ATCN content had been used in their practice since taking the course. ATCN takers had a significantly higher (mean ± SD = 10.6 ± 2.2) total score on the study test than the ATCN nontakers (mean ± SD = 6.4 ± 2.6); t(134) = -10.0, p < .001. A shorter time since course completion was associated with higher knowledge scores. ATCN takers rated the clinical relevance and applicability of the course content as high. The findings suggest that completing the ATCN course increases knowledge levels of trauma patient management and that the ATCN course content is clinically relevant to the nurses. However, higher knowledge scores were observed for the most recent study participants, suggesting that booster sessions for ATCN course participants may be warranted.

Lost information during the handover of critically injured trauma patients: a mixed-methods study.

BACKGROUND: Clinical information may be lost during the transfer of critically injured trauma patients from the emergency department (ED) to the intensive care unit (ICU). The aim of this study was to investigate the causes and frequency of information discrepancies with handover and to explore solutions to improving information transfer. METHODS: A mixed-methods research approach was used at our level I trauma centre. Information discrepancies between the ED and the ICU were measured using chart audits. Descriptive, parametric and non-parametric statistics were applied, as appropriate. Six focus groups of 46 ED and ICU nurses and nine individual interviews of trauma team leaders were conducted to explore solutions to improve information transfer using thematic analysis. RESULTS: Chart audits demonstrated that injuries were missed in 24% of patients. Clinical information discrepancies occurred in 48% of patients. Patients with these discrepancies were more likely to have unknown medical histories (p<0.001) requiring information rescue (p<0.005). Close to one in three patients with information rescue had a change in clinical management (p<0.01). Participants identified challenges according to their disciplines, with some overlap. Physicians, in contrast to nurses, were perceived as less aware of interdisciplinary stress and their role regarding variability in handover. Standardising handover, increasing non-technical physician training and understanding unit cultures were proposed as solutions, with nurses as drivers of a culture of safety. CONCLUSION: Trauma patient information was lost during handover from the ED to the ICU for multiple reasons. An interprofessional approach was proposed to improve handover through cross-unit familiarisation and use of communication tools is proposed. Going beyond traditional geographical and temporal boundaries was deemed important for improving patient safety during the ED to ICU handover.

Validation and evaluation of two observational pain assessment tools in a trauma and neurosurgical intensive care unit.

BACKGROUND: Studies have demonstrated that patients in the intensive care unit experience high levels of pain. While many of these patients are nonverbal at some point during their stay, there are few valid tools available to assess pain in this group. OBJECTIVES: To evaluate the validity and clinical utility of two pain assessment tools, the revised Adult Non-Verbal Pain Scale (NVPS-R) and the Critical Care Pain Observation Tool (CPOT), in a trauma and neurosurgical patient population. METHODS: Patients were assessed using the NVPS-R and CPOT by trained intensive care unit nurses (n=23) and research assistants before, during and after two procedures: turning of the patient (nociceptive procedure) and noninvasive blood pressure cuff inflation (non-nociceptive procedure). Communicative patients were also asked to report their level of pain during each assessment. RESULTS: A total of 66 patients (34 communicative, 32 noncommunicative) were included in the study. CPOT and NVPS-R scores increased significantly when participants were exposed to turning, but not during noninvasive blood pressure measurement (repeated measures ANOVA: CPOT, F=5.81, P=0.019; NVPS-R, F=5.32, P=0.025) supporting discriminant validity. CPOT and NVPS-R scores were significantly higher during the turning procedure for patients who had indicated that they were in pain versus those who were not, indicating criterion validity. Inter-rater reliability was generally higher for the CPOT than NVPS-R. Nurses rated the feasibility of the two tools as comparable but provided higher ratings of acceptability for the CPOT. CONCLUSIONS: While the present study supports the use of the CPOT and the NVPS-R with critically ill trauma and neurosurgical patients, further research should explore the role of vital signs in pain.

Venous and arterial base deficits: do these agree in occult shock and in the elderly? A Bland-Altman analysis.

BACKGROUND: Trauma centers are increasingly advocating the replacement of arterial blood gas measurements with venous blood gas measurements for simplification of base deficit (BD) determination. These values have never been demonstrated to agree in important trauma populations, such as for patients in occult shock (OS) or the elderly. The goal of this study was to investigate the level of agreement between venous and arterial BDs from blood gases in critically ill or injured patients, specifically in OS and the elderly. METHODS: This is a retrospective, consecutive, cohort study using matched pairs of venous and arterial blood gases from patients admitted to the Trauma and Neurosurgery Intensive Care Unit in a Level I trauma center in Toronto, Ontario, Canada. Agreement between near simultaneous arterial and venous BD was calculated using the Bland-Altman method. McNemar's test was used for differences in BDs in the presence or absence of OS and in elderly patients. RESULTS: BDs for 466 arterial and venous samples from 72 patients were compared pairwise. There was no significant difference between samples (p = 0.88). Ninety-eight percent of samples were within 3.0 mmol/L of each other. No significant differences were detected between venous and arterial BD in the presence of OS or in the elderly (p = 0.72 and p = 0.25, respectively). CONCLUSION: Arterial and venous BDs agree, including in the presence of OS and in the elderly. Consideration may be given to venous sampling both in the intensive care unit or in other areas of care, such as the trauma bay. LEVEL OF EVIDENCE: Diagnostic study, level III.

An evaluation of a proactive geriatric trauma consultation service.

OBJECTIVE: To describe and evaluate an inpatient geriatric trauma consultation service (GTCS). BACKGROUND: Delays in recognizing the special needs of older trauma patients may result in suboptimal care. The GTCS is a proactive geriatric consultation model aimed at preventing and managing age-specific complications and discharge planning for all patients 60 years or older admitted to the St Michael's Hospital Trauma Service. METHODS: This was a before and after case series of patients admitted pre-GTCS (March 2005-August 2007) and post-GTCS (September 2007-March 2010). Study data were derived from a review of the medical records and from the St Michael's Hospital trauma registry. Abstracted data included demographics, type of geriatric issues addressed, rate of adherence to recommendations made by the GTCS, geriatric-specific clinical outcomes, trauma quality indicators, consultation requests, and discharge destinations. RESULTS: A total of 238 pre-GTCS patients and 248 post-GTCS patients were identified. The rate of adherence to recommendations made by the GTCS team was 93.2%. There were fewer consultation requests made to Internal Medicine and Psychiatry in the post-GTCS group (N = 31 vs N = 18, P = 0.04; and N = 33 vs N = 18, P = 0.02; respectively). There were no differences in any of the prespecified complications except delirium (50.5% pre-GTCS vs 40.9% post- GTCS, P = 0.05). Among patients admitted from home, fewer were discharged to long-term care facilities among the post-GTCS group (6.5% pre-GTCS vs 1.7% post-GTCS, P = 0.03). CONCLUSIONS: A proactive geriatric consultation model for elderly trauma patients may decrease delirium and discharges to long-term care facilities. Future studies should include a multicenter randomized trial of this model of care.

Patient satisfaction and documentation of pain assessments and management after implementing the adult nonverbal pain scale.

BACKGROUND: Accurate assessment and management of pain in critically ill patients who are nonverbal or cognitively impaired is challenging. No widely accepted assessment tool is currently in place for assessing pain in these patients. OBJECTIVES: To evaluate the effect of implementing a new pain assessment tool in a trauma/neurosurgery intensive care unit. METHODS: Staff and patient satisfaction questionnaires and retrospective chart reviews were used before and after implementation of the Nonverbal Pain Scale. The questionnaire responses, frequency of pain documentation, and amount of pain medication given were compared from before to after implementation. RESULTS: Most staff (78%) ranked the tool as easy to use. Implementation of the tool increased staff confidence in assessing pain in nonverbal, sedated patients (57% before vs 81% after implementation, P = .02) and increased the number of pain assessments documented by the nursing staff for noncommunicative patients per day in the intensive care unit (2.2 before vs 3.4 after, P = .02). Patients reported decreased retrospective pain ratings (8.5 before vs 7.2 after, P = .04) and a trend toward a decrease in the time required to receive pain medication (38% before vs 10% after requiring >5 minutes to receive medication, P = .06). CONCLUSIONS: Implementation of the Nonverbal Pain Scale in a critical care setting improved patients' ratings of their pain experience, improved documentation by nurses, and increased nurses' confidence in assessing pain in nonverbal patients.