Generating datasets for the project portfolio selection and scheduling problem.

The article presents two variants of the project portfolio selection and scheduling problem (PPSSP). The primary objective of the PPSSP is to maximise the total portfolio value through the selection and scheduling of a subset of projects subject to various operational constraints. This article describes two recently-proposed, generalised models of the PPSSP [1], [2] and proposes a set of synthetically generated problem instances for each. These datasets can be used by researchers to compare the performance of heuristic and meta-heuristic solution strategies. In addition, the Python program used to generate the problem instances is supplied, allowing researchers to generate new problem instances.

Blood pressure management in emergency department patients with spontaneous intracerebral hemorrhage.

INTRODUCTION: Despite the well documented importance of blood pressure management in patients with spontaneous intracerebral hemorrhage (sICH), little is known about whether emergency departments (EDs) are able to achieve close monitoring and precise management. Our study characterizes ED monitoring and management of blood pressure in sICH patients. METHODS: This is a retrospective study of adults with sICH and elevated intracranial pressure. Patients who were admitted from any referring ED to our CCRU from 1 August 2013 to 30 September 2015 were included. We graphically assessed the association between average minutes between blood pressure measurements and average minutes between administration of antihypertensives. We also performed logistic regression to evaluate factors associated with close blood pressure monitoring and the achievement of goal blood pressure in patients with sICH who presented with hypertension. RESULTS: Of 115 patients, 73 presented to the ED with SBP above 160 mmHg. Length of stay in the ED was significantly associated with a longer period between blood pressure measurements. Longer periods between blood pressure measurements were a significant determinant of failure to achieve blood pressure goal in sICH patients. Longer periods between blood pressure measurements were significantly associated with longer periods between administration of antihypertensives. CONCLUSION: Our study suggests that blood pressure monitoring is related to the frequency of blood pressure interventions and achievement of adequate blood pressure control in patients with sICH. There is significant variability in EDs' achievement of the recommended close blood pressure monitoring and management in patients with sICH.

Angiographic embolization for hemorrhage following pelvic fracture: Is it "time" for a paradigm shift?

INTRODUCTION: Major pelvic disruption with hemorrhage has a high rate of lethality. Angiographic embolization remains the mainstay of treatment. Delays to angiography have been shown to worsen outcomes in part because time spent awaiting mobilization of resources needed to perform angiography allows ongoing hemorrhage. Alternative techniques like pelvic preperitoneal packing and aortic balloon occlusion now exist. We hypothesized that time to angiographic embolization at our Level 1 trauma center would be longer than 90 minutes. METHODS: A retrospective review was performed of patients with pelvic fracture who underwent pelvic angiography at our trauma center over a 10-year period. The trauma registry was queried for age, sex, injury severity score, hemodynamic instability (HI) on presentation, and transfusion requirements within 24 hours. Charts were reviewed for time to angiography, embolization, and mortality. RESULTS: A total of 4712 patients were admitted with pelvic fractures during the study period, 344 (7.3%) underwent pelvic angiography. Median injury severity score was 29. Median 24-hour transfusion requirements were five units of red blood cells and six units of fresh frozen plasma. One hundred fifty-one patients (43.9%) presented with HI and 104 (30%) received massive transfusion (MT). Median time to angiography was 286 minutes (interquartile range, 210-378). Times were significantly shorter when stratified for HI (HI, 264 vs stable 309 minutes; p = 0.003), and MT (MT, 230 vs non-MT, 317 minutes; p < 0.001), but still took nearly 4 hours. Overall mortality was 18%. Hemorrhage (35.5%) and sepsis/multiple-organ failure (43.5%) accounted for most deaths. CONCLUSION: Pelvic fracture hemorrhage remains a management challenge. In this series, the median time to embolization was more than 5 hours. Nearly 80% of deaths could be attributed to early uncontrolled hemorrhage and linked to delays in hemostasis. Earlier intervention by Acute Care Surgeons with techniques like preperitoneal packing, aortic balloon occlusion, and use of hybrid operative suites may improve outcomes. LEVEL OF EVIDENCE: Therapeutic study, level V.

Dexmedetomidine as an adjunct for sedation in patients with traumatic brain injury.

BACKGROUND: In patients with traumatic brain injury (TBI), optimizing sedation is challenging because maintaining a clinical examination is important in being able to detect neurological deterioration. Propofol (PROP) is frequently used as a sedative in TBI since it has been shown to reduce the cerebral metabolic rate, but it may lead to PROP-related infusion syndrome and hemodynamic compromise. Dexmedetomidine (DEX) is a sedative that produces minimal respiratory depression with opioid-sparing effects. The purpose of this study was to determine whether sedation with DEX would be safe in patients with severe TBI. METHODS: This prospective observational single-center study was conducted from 2011 to 2013. Patients with severe TBI were treated according to standard of care per the Brain Trauma Foundation guidelines. Sedative agents were titrated using the Richmond Agitation Sedation Scale (RASS) while maintaining intracranial pressure of less than 20 mm Hg and cerebral perfusion pressure of greater than 60 mm Hg. The primary outcome measure was the mean time in target RASS (0 = alert and calm to -2 = light sedation). RESULTS: A total of 198 patients were enrolled in the study. Patient-days (1,028 in total) were stratified into four groups: DEX only (n = 222), DEX + PROP (n = 148), PROP only (n = 599), and NEITHER (n = 59). Regression analyses indicated a significant difference in target RASS between sedative agents (p = 0.001). The DEX-only group had the highest adjusted mean daily estimate of 16.0 hours in target RASS. Hypotension was significantly higher in both the DEX only (p = 0.01) and DEX + PROP (p = 0.01) groups than in the PROP-only group. CONCLUSIONS: Dexmedetomidine was found to be associated with significantly more hypotension. Therefore, larger studies are needed to identify the role of DEX in TBI. LEVEL OF EVIDENCE: Therapeutic study, level III.

Cocaine-induced agitated delirium with associated hyperthermia: a case report.

BACKGROUND: "Cocaine-induced agitated delirium with associated hyperthermia" is a rare, almost uniformly fatal syndrome. The incidence of the disease is not known, however, it is believed to have markedly increased since the late 1980s with widespread popularity of crack cocaine. OBJECTIVE: Recent literature is lacking regarding this rare syndrome. Although almost uniformly fatal, we present a neurologically intact survivor due to a multidisciplinary team approach. CASE REPORT: We are reporting a 41-year-old African-American man who arrived at the trauma center with a rectal temperature of 42.6°C (108.6°F) and a toxicology screen positive for cocaine. The patient manifested many of the known complications of cocaine-induced agitated delirium with associated hyperthermia, including renal failure and coagulation panel abnormalities. With early application of cooling techniques, including ice pack, gastric lavage, and bilateral chest cavity lavage using multiple chest tubes, the patient's core temperature was quickly lowered. CONCLUSION: This case demonstrated how a multidisciplinary team approach, including emergency medicine and critical care specialists, and aggressive treatment of hyperthermia using bilateral tube thoracostomy and chest cavity lavage enabled our patient's core temperature to be effectively lowered. We were unable to find prior reports of using tube thoracostomy in this manner.

Blunt cerebrovascular injuries: does treatment always matter?

BACKGROUND: Blunt cerebrovascular injuries (BCVI) have become an increasingly recognized entity. Stroke as a result of these injuries can have devastating consequences. Optimal screening criteria, diagnostic imaging, and therapy for BCVIs have not been elucidated. Our institution began to apply liberal screening criteria using a whole-body scanning protocol with multidetector computed tomographic (WB-MDCT) scans to diagnose these injuries. The purpose of this study is to describe a single institution's large experience in patients with BCVI in an effort to provide insight into the diagnosis and management of these injuries. METHODS: All patients with a BCVI admitted to the R Adams Cowley Shock Trauma Center during a 30-month period were included in this study. Choice of diagnostic evaluation and treatment regimens were at the discretion of the treating attending physician. Review of medical records and all relevant radiographic studies were retrospectively performed for the purposes of this study. RESULTS: During the study period, there were 12,667 patients admitted to the R Adams Cowley Shock Trauma Center. There were 147 patients identified with 200 carotid or vertebral artery injuries. The incidence of BVCI was 1.2%. Mortality was 13%. Anatomic injury risk factors for BCVI (major facial fractures, skull base fractures, cervical spine fractures or spinal cord injury, or traumatic brain injury) were found in only 78%. Major thoracic injury was found in 63% of patients with carotid artery injuries and cervical spine fractures or spinal cord injury was found in 74% of patients with vertebral artery injuries. The initial screening test employed was a WB-MDCT in 96% of patients of which 84% detected a BCVI. Treatments included endovascular therapy (22%), antiplatelet medications (36%), anticoagulation (10%), and combination therapy with antiplatelet agents and anticoagulation (18%). Thirty percent received no therapy, primarily due to contraindications from concomitant injuries. There were 18 (12%) patients who had a stroke. Of these patients, 8 (44%) had evidence of infarction at admission, 6 were diagnosed within 72 hours, and 4 were diagnosed after 1 week. Stroke-related mortality was 50%, whereas clinical follow-up after hospital discharge demonstrated only one patient with disability as a result of infarction. Of 10 patients who did not have stroke at admission, 3 were fully treated, 5 had specific contraindications to therapy, and 2 had no or false-negative imaging before infarction. Stroke rates for untreated patients were 25.8% and patients treated with any therapy had a stroke rate of 3.9% (p = 0.0003). Radiographic follow-up >1 month after injury demonstrated improvement in over 50% of patients. CONCLUSIONS: BCVIs are not infrequent after blunt trauma. These injuries occur even in the absence of classically described risk factors. Liberal screening with WB-MDCT incorporates detection of these injuries into the initial diagnostic evaluation. Stroke occurs in a substantial number of patients and carries a very high mortality. However, nearly one third of patients with BCVI are not candidates for therapy. Treatment does reduce the risk of infarction in patients with BCVI, but strokes, when they occur, are not preventable.

Computed tomography alone for cervical spine clearance in the unreliable patient--are we there yet?

BACKGROUND: Injuries to the cervical spine (CS) occur in 2% to 6.6% of blunt trauma patients. Studies have suggested that computed tomography (CT) alone is sufficient for CS clearance in unreliable patients based on follow-up magnetic resonance (MR) imaging not altering management. We hypothesized that an admission cervical spine CT with no acute injury-using new CT technology-is not sufficient for CS clearance in an unreliable patient. METHODS: The trauma registry was used to identify all patients with blunt trauma who had CS imaging with a CT and MR between August 2004 and December 2005. During this time period, a clinical guideline was in place whereby patients who had persistently unreliable examinations had MR despite a normal admission CT. Medical records were reviewed for demographics, Glasgow Coma Scale (GCS) score at time of MR, and injury specific data. RESULTS: Seven hundred thirty-four patients in total were identified. Two hundred three patients without obvious neurologic deficits but unreliable clinical examination, defined by a GCS score of

Accuracy of computed tomography (CT) scan in the detection of penetrating diaphragm injury.

BACKGROUND: The use of computed tomography (CT) to identify injury after penetrating torso trauma has become routine in the hemodynamically stable patient. The diaphragm has been a historically difficult structure to evaluate, however, and missed injuries to the diaphragm may result in significant morbidity. With the increasing use of multidetector row CT (MDCT), we hypothesized that CT would be an accurate detection modality to identify patients with diaphragm injuries. METHODS: We retrospectively reviewed the admission CT of consecutive patients admitted for penetrating injury to the torso during a 4-year period. The CT scans were reviewed and classified into three categories: positive (P), negative (N), or equivocal (Eq). Data from the medical records of these patients were abstracted to identify demographics, injury-specific data, length of stay, length of follow-up (LOFU), and operative findings. RESULTS: There were 803 patients who met inclusion criteria. Mechanism of injury was gunshot wound in 36% and stab wound in 64%. Mean length of stay was 4 days (+/-6.6) and mean length of follow-up was 43 days (+/-184). CT was read as P in 57, N in 710, and Eq in 36 patients. Diaphragm injury was detected in 67 patients overall and was excluded in 736. For the entire study population, sensitivity and specificity were calculated as 94.0% (95% CI = 88.4-99.7) and 95.9% (94.5-97.4) with an overall accuracy of 95.8% (94.4-97.2) if the CT scan was used to exclude diaphragm injury ([P and Eq] vs. N). Sensitivity and specificity were 82.1% (72.9-91.3) and 99.7% (99.4-100) if CT was used to detect diaphragm injury (P vs. [N and Eq]). One hundred and forty-eight patients underwent operative procedures in which the diaphragm was evaluated. Diaphragm injury was identified in 50 (38 P, 4 N, 8 Eq) and was surgically excluded in 104 patients (2 P, 93 N, 9 Eq). Three hundred and eighty-four patients were lost to follow-up; including 348 who had negative finding on CT. There were no known missed diaphragm injuries during the study period or in follow-up. CONCLUSIONS: Injuries to the diaphragm occur commonly after penetrating torso trauma. MDCT scan is an accurate test to detect diaphragm injury. When MDCT is equivocal, further investigation is required to evaluate the diaphragm.

Follow-up abdominal CT is not necessary in low-grade splenic injury.

Nonoperative management of splenic injury has become the standard of care in the hemodynamically stable patient. The time period of observation and the utility of follow-up scanning remain an area of debate. This study examined the utility of follow-up abdominal CT for detection of delayed vascular injury in patients with low-grade splenic injury. A retrospective review of all patients with low-grade splenic injuries undergoing nonoperative management from June 2000 to June 2004 was performed. Patients underwent follow-up abdominal CT 48 to 72 hours after admission to rule out delayed vascular injury and were discharged if the results were negative. Charts were reviewed for demographic data, abdominal CT results, and splenic salvage. A total of 472 patients underwent nonoperative management for splenic injury, with 140 patients treated with simple observation during this protocol. All patients were successfully managed with simple observation with no nonoperative failures; there were two instances of delayed vascular injury on follow-up CT. Both patients with progression of injury had decreasing hematocrit levels during admission prior to follow-up abdominal CT scan. Overall, the injury severity score was 22 points and the American Association for the Surgery of Trauma (AAST) splenic injury severity score was 1.8 points. Length of hospital stay was 2.8 days for patients with predominately splenic injury and 10 days for the overall cohort. Follow-up abdominal CT confers no benefit in patients with low-grade splenic injury, and a stable hematocrit level and abdominal exam.

Operative management and outcome of iliac vessel injury: a ten-year experience.

The purpose of this study is to review demographics and examine and stratify risk factors related to the outcome of operatively treated iliac vascular injuries. We conducted a retrospective review of 78 cases of iliac vessel injury. Patients with blunt and penetrating injury had statistically similar length of hospital stay and intensive care unit stay, incidence of shock, and mortality. Shock on admission and bleeding hematoma are linked, and shock increased mortality with an odds ratio of 5.2 (P = 0.002). A review of operative technique and outcome demonstrated a low mortality of 25 per cent in arterial bypass of an isolated arterial injury versus a mortality of 83 per cent in the combined injury group. Patients treated with primary repair of venous injuries had a lower incidence of shock and mortality compared with patients treated with venous ligation. We conclude that, if matched for severity of injury and physiologic instability, the mechanism of injury does not affect mortality. Shock is the most significant prognostic factor for mortality. Operative management must be based on presence of shock.

Sublingual capnometry: an alternative to gastric tonometry for the management of shock resuscitation.

Normal vital signs do not reflect the physiologic aberrations after blood loss. Recognition of hypoperfusion during resuscitation can avoid the development of multiple organ failure. Advances in technology enable the clinician to monitor changes, potentially identifying tissue hypoxia much earlier than previously was possible. Gastric tonometry can be quite helpful in the intensive care unit in identifying gastric hypoperfusion, but has considerable drawbacks. The ability to monitor P(SI)CO(2) via sublingual capnometers overcomes some limitations of gastric tonometry and may be a valuable aid in the prehospital phase, the emergency department, and the intensive care unit in identifying end points of resuscitation.

The geriatric heart: nurses need to be aware of how aging and disease affect the myocardium...

Improved treatment for diabetes and cardiovascular disease have made it possible for elderly patients to remain active as well as mobile, but with a greater chance of sustaining traumatic injury.

Pelvic fracture in geriatric patients: a distinct clinical entity.

BACKGROUND: The purpose of this study was to describe differences in demographics, injury pattern, transfusion needs, and outcome of pelvic fractures in older versus younger patients. METHODS: This was a retrospective registry review of all patients with pelvic fractures admitted directly from the scene between January 1998 and December 1999. RESULTS: We cared for 234 patients with pelvic fractures during the study period. Mean age was 37.2 years, 51% were men, and mean Injury Severity Score (ISS) was 19. Overall mortality was 9%. Eighty-three percent were under the age of 55 years and 17% were older than 55 years. Severe pelvic fractures (AP3, LC3) were more common in young patients (p < 0.05). Admitting systolic blood pressure was lower and heart rate higher, although ISS was not different between the two age groups. Older patients were 2.8 times as likely to undergo transfusion (p < 0.005), and those undergoing transfusion required more blood (median, 7.5 units vs. 5 units). Older patients underwent angiography more frequently and were significantly more likely to die in the hospital even after adjusting for ISS (p < 0.005). This was most marked with ISS 15 to 25. Lateral compression (LC) fractures occurred 4.6 times more frequently in older patients than anteroposterior (AP) compression, and 8.2 times more frequently in those older patients undergoing transfusion as compared with AP compression. Ninety-eight percent of LC fractures in older patients were minor (LC1,2). However, older patients with LC fractures were nearly four times as likely to require blood compared with younger patients. CONCLUSION: In older patients, pelvic fractures are more likely to produce hemorrhage and require angiography. Fracture patterns differ in older patients, with LC fractures occurring more frequently, and commonly causing significant blood loss. The outcome of older patients with pelvic fractures is significantly worse than younger patients, particularly with higher injury severity. Recognition of these differences should help clinicians to identify patients at high risk for bleeding and death early, and to refine diagnostic and resuscitation strategies.