Desirability of Outcome Ranking and Response Adjusted for Antibiotic Risk (DOOR/RADAR) Post Hoc Analysis Supports Equipoise for Antibiotic Initiation Strategies in Intensive Care Unit-Acquired Pneumonia.

Background: Pneumonia is the most common intensive care unit (ICU)-acquired infection and source of potential sepsis in ICU populations but can be difficult to diagnose in real-time. Despite limited data, rapid initiation of antibiotic agents is endorsed by society guidelines. We hypothesized that a post hoc analysis of a recent randomized pilot study would show no difference between two antibiotic initiation strategies. Patients and Methods: The recent Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP) was a pragmatic cluster-randomized pilot of antibiotic initiation strategies for patients with suspected ICU-acquired pneumonia. Participating ICUs were cluster-randomized to either an immediate initiation protocol or a specimen-initiated protocol where a gram stain was required for initiation of antibiotics. Patients in the study were divided into one of seven mutually exclusive outcome rankings (desirability of outcome ranking; DOOR): (1) Survival, No Pneumonia, No adverse events; (2) Survival, Pneumonia, No adverse events; (3) Survival, No Pneumonia, ventilator-free-alive days ≤14; (4) Survival, Pneumonia, ventilator-free-alive days ≤14; (5) Survival, No Pneumonia, Subsequent episode of suspected pneumonia; (6) Survival, Pneumonia, Subsequent episode of suspected pneumonia; and (7) Death. These rankings were further refined using the duration of antibiotics prescribed for pneumonia (response adjusted for antibiotic risk; RADAR). Results: There were 186 patients enrolled in the study. After applying the DOOR analysis, a randomly selected patient was equally likely to have a better outcome in specimen-initiated arm as in the immediate initiation arm (DOOR probability: 50.8%; 95% confidence interval [CI], 42.7%-58.9%). Outcome probabilities were similar after applying the RADAR analysis (52.5%; 95% CI, 44.2%-60.6%; p = 0.31). Conclusions: We found that patients for whom antibiotic agents were withheld until there was objective evidence (specimen-initiated group) had similar outcome rankings to patients for whom antibiotic agents were started immediately. This supports the findings of the TARPP pilot trial and provides further evidence for equipoise between these two treatment strategies.

Provider Perceptions of Antibiotic Initiation Strategies for Hospital-Acquired Pneumonia.

Background: The practice of rapidly initiating antibiotic therapy for patients with suspected infection has recently been criticized yet remains commonplace. Provider comfort level has been an understudied aspect of this practice. Hypothesis: We hypothesized that there would be no significant differences in provider comfort level between the two treatment groups. Methods: We prospectively surveyed critical care intensivists who provided care for patients enrolled in the Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP), which was a multicenter cluster-randomized crossover trial that evaluated an immediate antibiotic initiation protocol compared with a protocol of specimen-initiated antibiotic initiation in ventilated patients with suspected new-onset pneumonia. At the end of each enrollment arm, physicians at each center were surveyed regarding their overall comfort level with the recently completed treatment arm, and perception of adherence. Both a paired and unpaired analysis was performed. Results: We collected 51 survey responses from 31 unique participants. Providers perceived a higher rate of adherence to the immediate initiation arm than the specimen-initiated arm (Always Adherent: 37.5% vs. 11.1%; p = 0.045). Providers were less comfortable waiting for objective evidence of infection in the specimen-initiated arm than with starting antibiotic agents immediately (Very Comfortable: 83.3% vs. 40.7%; p = 0.004). For the smaller paired analysis, there was no longer a difference in comfort level. Conclusions: There may be differences in provider comfort levels and perceptions of adherence when considering two different antibiotic initiation strategies for suspected pneumonia in ventilated patients. These findings should be considered when planning future studies.

Type-O Blood Is Not Associated With Elevated Mortality After Trauma: A North American Cohort Study.

BACKGROUND: Recent studies have presented contradictory findings on the relationship between blood type and mortality in trauma patients. Using the largest population in a study of this type to date, we hypothesized that ABO genotype and Rhesus status would influence trauma-related mortality and morbidity given the relationship between blood type and hemostasis. METHODS: Data from all trauma patients admitted to level I and level II trauma centers in one city over a five-year period was retrospectively analyzed. Patients were stratified by ABO type. Patient demographics and outcomes were then assessed. Chi-squared and Fisher's exact tests were used to analyze categorical variables. Continuous variables were analyzed using ANOVA or Kruskal-Wallis tests as appropriate. Logistic regression was used to determine independent associations for 28-day mortality and complications. RESULTS: Of 5249 patients, severe injury (ISS >15) was present in 1469. Approximately one-quarter of patients with severe injury received blood products within the first 24 hours. There were no significant variations in demographics or complications between patients of different blood types. Univariate and multivariable regression analysis showed no association between blood type and mortality. However, penetrating injury, lower GCS, higher ISS, blood transfusion within 24 hours, and Asian descent were associated with higher overall mortality. CONCLUSIONS: In contrast to previous studies, we found no evidence of an association between blood type and mortality. However, our findings suggest that patients of Asian descent may be at higher risk for mortality following trauma. Further research is warranted to explore this observation.

Trial of antibiotic restraint in presumed pneumonia: A Surgical Infection Society multicenter pilot.

BACKGROUND: Pneumonia is the most common intensive care unit-acquired infection in the trauma and emergency general surgery population. Despite guidelines urging rapid antibiotic use, data supporting immediate antibiotic initiation in cases of suspected infection are limited. Our hypothesis was that a protocol of specimen-initiated antibiotic initiation would have similar compliance and outcomes to an immediate initiation protocol. METHODS: We devised a pragmatic cluster-randomized crossover pilot trial. Four surgical and trauma intensive care units were randomized to either an immediate initiation or specimen-initiated antibiotic protocol for intubated patients with suspected pneumonia and bronchoscopically obtained cultures who did not require vasopressors. In the immediate initiation arm, antibiotics were started immediately after the culture regardless of patient status. In the specimen-initiated arm, antibiotics were delayed until objective Gram stain or culture results suggested infection. Each site participated in both arms after a washout period and crossover. Outcomes were protocol compliance, all-cause 30-day mortality, and ventilator-free alive days at 30 days. Standard statistical techniques were applied. RESULTS: A total of 186 patients had 244 total cultures, of which only the first was analyzed. Ninety-three patients (50%) were enrolled in each arm, and 94.6% were trauma patients (84.4% blunt trauma). The median age was 50.5 years, and 21% of the cohort was female. There were no differences in demographics, comorbidities, sequential organ failure assessment, Acute Physiology and Chronic Health Evaluation II, or Injury Severity Scores. Antibiotics were started significantly later in the specimen-initiated arm (0 vs. 9.3 hours; p < 0.0001) with 19.4% avoiding antibiotics completely for that episode. There were no differences in the rate of protocol adherence, 30-day mortality, or ventilator-free alive days at 30 days. CONCLUSION: In this cluster-randomized crossover trial, we found similar compliance rates between immediate and specimen-initiated antibiotic strategies. Specimen-initiated antibiotic protocol in patients with a suspected hospital-acquired pneumonia did not result in worse clinical outcomes compared with immediate initiation. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Burn patient decontamination outside of mass casualties.

OBJECTIVE: Decontamination protocols for victims of mass casualty events are well documented and emphasized to protect physicians, nurses and facilities. Decontamination practices outside of mass casualty events are unknown. This pilot study was undertaken to assess the current practices of burn patient decontamination outside of mass casualty events within level I and II trauma center emergency departments in the state of Michigan. METHODS: Using the Michigan Trauma Quality Improvement Project membership, a 10-question online survey was sent to trauma program managers at all level I and II trauma centers in Michigan. Survey questions focused on institutional decontamination protocols and consistency of use. RESULTS: Survey response was 50%. Of the responding facilities, 31% did not decontaminate burn patients. Of the centers who indicated that they did decontaminate burn patients, 31% did not follow a standardized protocol. Our survey revealed that 69% of facilities used a protocol for decontamination: 45% used the protocol consistently on all burns, and 55% at physician discretion. Products used most frequently to decontaminate burn patients included water (100%) followed by soap (44%). CONCLUSION: This pilot survey of level I and II trauma centers in the state of Michigan revealed variability in the use of burn patient decontamination protocols and consistency of use. Additional research is warranted to determine if our results are reflective of trauma centers nationally.

Ten Years of Equine-related Injuries: Severity and Implications for Emergency Physicians.

BACKGROUND: The size, speed, and unpredictable nature of horses present a significant risk for injury in all equine-related activities. OBJECTIVE: We sought to examine the mechanism, severity, frequency, body regions affected, surgical requirements, rehabilitation needs, safety equipment utilization, and outcomes of equine-related injured patients. METHODS: Records of inpatients who sustained an equine-related injury from 2002-2011 with International Classification of Diseases, Ninth Revision codes E828 and E906 were retrospectively reviewed for pertinent data. RESULTS: Ninety patients, 70% female, age (mean ± SD) 37.3 ± 19.4 years, length of stay 3.7 ± 4.5 days, Injury Severity Score 12.9 ± 8.4. Predominant mechanism of injury was fall from horse (46.7%). The chest (23%) was most frequently injured, followed by brain/head (21.5%). Thirty patients (33%) required 57 surgical procedures. Twenty percent of patients required occupational therapy and 33.3% required physical therapy while hospitalized. Only 3% required rehabilitation, with 90% discharged directly home. Safety equipment was not used in 91.9% of patients. One patient sustained a cord injury. Six patients expired, all from extensive head injuries. CONCLUSION: The majority of equine-related injuries occur while pursuing recreational activities and are due to falls. Our patients experienced more severe injuries to the trunk and head and required more surgical intervention for pelvic, facial, and brain injuries than previously reported. Failure to use safety equipment contributes to the risk of severe injury. Education and injury prevention is essential. The need for complex surgical intervention by multiple specialties supports transfer to Level I trauma centers.

Preparation for mass casualty incidents.

Mass casualty incidents are events where the number of injured patients exceeds the resources of the health care institution to the degree that care may not be available or may be limited for a portion of the casualties. Mass casualty incidents are increasing in frequency throughout the United States. Managing mass casualty incidents has not traditionally been part of the nursing curriculum; however, our changing world requires us to become educated and prepared to respond to these scenarios. This article focuses on intentional explosive disasters and the nursing and institutional response to these incidents. This information is of value to nursing professionals and other health care providers.

Resurgence of methamphetamine related burns and injuries: a follow-up study.

PURPOSE: Legislation enacted to curb methamphetamine production has only temporarily succeeded. Experiencing a recent increase in burns as a result of the new one-pot method, we compared methamphetamine related burn patients who utilized the previous anhydrous ammonia method of production to current patients who largely used the new one-pot method of production. BASIC PROCEDURES: Patients who were burned as a result of methamphetamine production were retrospectively reviewed. Comparisons were made including demographics, length of stay, injury severity score, hospital charges, total body surface area burned, inhalation injury, intubation, ventilator days, toxicology, fluid volumes, surgeries and complications. MAIN FINDINGS: Eighteen current study patients (88.9% male) were compared to twenty-nine (86.2% male) previous study patients. The groups were similar in age, pattern of burn injury and intubation. Total body surface area burned, injury severity score, inhalation injuries, and ventilator days were not significantly increased in the current study. Longer length of stay and greater hospital charges were incurred by the current group. Burn surgeries per patient were significantly increased in the current group. PRINCIPAL CONCLUSIONS: A new one-pot method has emerged despite legislative attempts to curtail methamphetamine production, and burns have also increased. The reason for more extensive burn surgeries in the current METH related burn patients remains enigmatic. Severity of injury and cost to society remain high.

Percutaneous tracheostomy: a new approach to the emergency airway.

BACKGROUND: Endotracheal intubation is the preferred method of airway control. Current surgical standard of care for the emergent airway when endotracheal intubation cannot be performed is cricothyroidotomy. Percutaneous tracheostomy (PT) is a widely accepted technique for elective long-term airway management in the critical care setting. We describe our experience with successful placement of PT for emergency airway control. METHODS: After institutional review board approval was obtained, patients were identified retrospectively from January 2003 to present that had emergency PT performed as identified by the DRG International Classification of Diseases--9th Rev. procedure code (31.1). Data included demographics, body mass index, admitting service, size of tracheostomy tube, reason for urgent airway access, duration PT was required, unit, time and hospital day performed, and complications. RESULTS: Eighteen patients underwent emergency PT; 61% were male, and age range was 21 years to 86 years. Indications for PT included respiratory failure associated with anaphylaxis, supraglottic edema, cardiac arrest, and blood or edema blocking the airway preventing intubation. PT was performed in various departments throughout the hospital. Admitting services included critical care intensivist (44.4%), trauma surgery (27.7%), cardiology (11.1%), medicine (11.1%), and neurology (5.5%). Most of the tracheostomy tube sizes were no. 8 (61.1%), followed by no. 7 (22.2%), no. 6 (5.5%), and no. 9 (5.5%). All PTs were successfully placed, and there were no complications. Ten of our patients had no airway in place at the time of procedure. Six patients had emergency esophageal-tracheal airways in place. Two patients had a cricothyroidotomy that was not functioning adequately. Nine patients had body mass indexes ranging from 30 kg/m² to 112 kg/m². CONCLUSION: PT provided a safe, effective emergency airway in adult patients who presented with a variety of indications, in varying locations throughout the hospital. PT performed by appropriately trained personnel may be a potential adjunct for emergent airway control in diverse settings.

Imaging utilization during explosive multiple casualty incidents.

BACKGROUND: Emergency radiology is a vital tool in the evaluation of victims of explosive multiple casualty incidents (MCIs). Prior reports estimate that approximately 50% of explosive MCI patients required imaging, including 7% to 22% who required computed tomography (CT) studies. This report describes the contemporary utilization of emergency radiology during the evaluation of explosive MCI victims in a modern US military trauma hospital in Iraq. We hypothesized that a much higher number of patients received imaging than has been reported previously in the literature. METHODS: We performed a retrospective chart review of records from 3 MCIs managed at the US Air Force Theater Hospital, Balad AB, Iraq between February and April 2008. All three incidents were the result of improvised explosive devices. RESULTS: Overall, 50 patients had a mean Injury Severity Score of 19 and a mortality of 8%. Ninety-two percent received imaging during their emergency department evaluation, including 90% who received CT, 70% who received X-rays, and 38% who received extended focused abdominal sonography for trauma ultrasound examinations. Overall, patients had a mean of 3.5 CTs and 1.9 X-rays during their initial assessment. Of the CTs, 93% were part of a trauma pan-scan, and 49% of the CT results were clinically significant. CONCLUSION: These results are significantly different from previous reports and indicate that victims of explosive MCIs will require more imaging, especially CT, than previously anticipated. These data will allow improved integration of radiology staffing and resource allocation into disaster management plans designed to prepare for future explosive MCIs.

Surgical response to multiple casualty incidents following single explosive events.

BACKGROUND: Modern publications on response to single explosive events are from non-US hospitals, predate current resuscitation guidelines and lack detail on surgical and intensive care unit (ICU) requirements. The objective of this study is to provide a contemporary account of surge response to multiple casualty incidences following explosive events managed at a US trauma hospital in Iraq. METHODS: Observational study and retrospective chart review of 72-hour transfusion, operating room, and ICU resource utilization from 3 multiple casualty incidences managed at the US Air Force Theater Hospital, Balad AB, Iraq between February and April 2008. RESULTS: Fifty patients were treated with a mean injury severity score of 19. Forty-eight percent (n = 24) of casualties required blood transfusion with 4 patients receiving 43% (N = 74 units) of the packed red blood cells (pRBC). An average of 3.5 and 3.8 units of pRBC and plasma, respectively, was transfused per casualty (pRBC:plasma ratio of 1:1.1). Seventy-six percent (n = 38) of patients required immediate operation upon initial presentation. A total of 191 procedures were performed in parallel during 75 operations (3.8 procedures per casualty). Fifty percent (n = 25) of patients required ICU admission with nearly the same number (n = 24) requiring mechanical ventilator support beyond that required for operation. All cause, in-hospital mortality was 8% (n = 4). CONCLUSIONS: Results from this study provide a contemporary assessment of transfusion, surgical, and intensive care resource requirements after a single explosive event. Data from this experience may translate into useful guidelines for emergency planners worldwide.

Methamphetamine production is hazardous to your health.

BACKGROUND: To describe the thermal injuries related to methamphetamine (METH) production, characterize patients' courses, and compare patients with matched controls and to the previously published series. METHODS: Trauma registry data from January 2001 to November 2005 was retrospectively reviewed. METH patients were compared with other burn patients of similar age and total body surface area burn size for toxicology, injury extent, therapies, hospital course, outcomes, and hospital charges. The METH group was compared with the other published series of METH-related burn patients. RESULTS: Twenty-nine patients (86.2% male) had METH-related burns. METH and control groups were similar in age, gender, predicted resuscitation fluid volume, and total body surface area. Mortality, mean length of stay, surgical procedures, and mean hospital charges did not differ significantly between the groups. Endotracheal intubation was required more frequently in METH patients (55.2% vs. 24.1%, p = 0.020). METH patients mean resuscitation volume was greater than controls (9,638 mL vs. 6,633 mL, p = 0.011), but neither group exceeded the volume predicted by the Parkland formula. More METH patients had inhalation injury (41.4% vs. 13.8%, p = 0.019). A METH patient was more likely to have a complication than his matched control (p = 0.049), and pneumonia was more frequent in the METH group (p = 0.005). Private insurance was less common in METH patients (10.3% vs. 58.6%, p < 0.001). CONCLUSIONS: METH patients suffer more frequent inhalation injuries, need greater initial fluid resuscitation volume, require endotracheal intubation more frequently, and are more likely to have complications than matched controls. This does not translate to greater mortality, longer length of stay, more surgical procedures, or significantly greater hospital charges. Few METH patients hold private insurance.