Prioritizing Injury Prevention: Cause of Injury Text Analysis.

BACKGROUND: Motor vehicle (MVCs) and motorcycle crashes (MCCs) continue to be among the most prevalent mechanisms of trauma injury and mortality. We sought to identify specific populations and factors associated with MVCs and MCCs for local injury prevention efforts. A novel, yet easily performed, research method was utilized-a qualitative content analysis of text narratives describing each patient's cause of injury. OBJECTIVE: To determine target populations for local MVC and MCC injury prevention. METHODS: A retrospective descriptive analysis was performed using registry data from a Level I trauma center. The registry was queried for all trauma patients presenting with MVC or MCC injuries between June 8, 2014, and June 7, 2019. Cases were then reviewed via their respective text narratives of injury causation. Common themes were identified, coded by independent raters, and assessed for interrater reliability using Cohen's κ. Frequencies and proportions are reported for each preventable factor and patient characteristic. RESULTS: There were a total of 2,861 cases studied, of which 2,330 (81.4%) were MVC and 531 (18.6%) were MCC. Demographics varied by mechanism of injury. Driver drug or alcohol use was involved in 97 (3.4%), protective devices were not used in 776 (27.1%), distracted driving was involved in 30 (1%), excessive speeding was involved in 152 (5.3%), and driver sleeping/syncope/medical condition was present in 113 (3.9%) cases. CONCLUSIONS: Content analysis of cause of injury text narratives can detect target populations and preventable factors to direct injury prevention efforts specific to the local population.

Treatment of sepsis in the surgical intensive care unit.

Since the Surviving Sepsis Campaign Guidelines (SSG) were published in 2004, critical care physicians can readily access the evidence and current recommendations regarding management of patients with severe sepsis and septic shock. However, several issues including a potential conflict of interest in developing the guidelines were disclosed. There have also been dramatic changes in the management of sepsis, supported by high levels of evidence. SSG 2008 was developed to update the evidence using a new grading system. We reviewed select topics, routinely addressed by intensivists in the surgical intensive care unit, that have changed between SSG 2004 and SSG 2008: namely, glucose control, and administration of steroids, recombinant human activated protein C (rhAPC) and total parenteral nutrition.

Trauma team activation and the impact on mortality.

BACKGROUND: Trauma centers use injury mechanism, physiology, and anatomic criteria to determine the extent of trauma team activation (TTA). We examined whether physiologic variables in our three-tier TTA system stratified patients appropriately by injury severity and mortality. METHODS: The trauma registry at our Level I trauma center was retrospectively reviewed for full (level 1 or L1), partial (level 2 or L2), and limited (level 3) adult TTA. Data were collected on age, injury severity score (ISS), hospital length of stay, systolic blood pressure (SBP), heart rate, respiratory rate (RR), Glasgow coma score (GCS), and intubation status. Penetrating injuries, traumatic arrests, and interfacility transfers were excluded. Data are median (25%75%). Statistical analysis included hazard ratios (HzR), Kruskal-Wallis, chi, and survival analyses. The p value overall was <0.05, and pair wise was <0.05 versus L1. RESULTS: There were 494 adult TTAs for blunt injury from the scene out of 1,969 admissions. Variables associated with mortality (HzR; 95% confidence interval) by univariate analysis include SBP <90 (9.4; 4.2, 21.2), RR >29 or <10 (17.8; 4.8, 66.0), intubation status (4.5; 2.3, 8.9), and GCS <8 (9.7; 4.8, 19.9). When combined in a multivariate model to evaluate multiple predictors simultaneously, SBP <90 and GCS <8 appear to be the strongest predictors of mortality (RR and intubation were not significant in the presence of SBP and GCS). The three-tier system identified patients with increased ISS and early (< or =4 weeks) mortality risk. There was a statistically significant difference in survival between L1 and L2 at 38 days, but not for >38 days (p = 0.739). CONCLUSIONS: TTA criteria selected patients with greater ISS and early mortality, but impact on long-term survival may not be appreciated. Full TTA criteria for blunt injury may be limited to GCS <8, SBP <90, RR >29 or <10, and intubation status.

Do early ionized calcium levels really matter in trauma patients?

BACKGROUND: Age, injury severity, and base deficit are commonly used prognostic indicators in trauma. This study investigates the relationship between ionized calcium (iCa) levels drawn on arrival to the emergency department, with injury severity, acidosis, hypotension, and mortality. METHODS: Adult trauma team activations requiring the highest level of response were identified retrospectively from January 2000 to December 2002. Patients were stratified into two groups: iCa < or = 1 and iCa > 1 mmol/L. The relationship between iCa and injury severity (Trauma Injury Severity Score, Injury Severity Score [ISS], Revised Trauma Scale, Glasgow Coma Scale), age, sampling time, shock (systolic blood pressure [SBP] < 90 at the scene, transport, and admission; base deficit), resource utilization (hospital and intensive care unit length of stay, ventilator days) and mortality was examined. Statistical analysis included chi2 tests, Wilcoxon rank sum tests, p < 0.05 versus iCa > 1, median (25th-75th percentile), and odds ratio (OR). RESULTS: In all, 396 out of 2,367 patients were identified. Mortality was significantly increased in the iCa < or = 1 group (26.4% versus 16.7%, p < 0.05; OR 1.92). Time to death in iCa < or = 1 was significantly shorter, 0.50 (0-1) versus 1.0 (0-6) days. Mortality was predicted using iCa < or = 1 alone (p < 0.02, OR 3.28), iCa < or = 1 + base deficit (p < 0.02, OR 2.00), and base deficit alone (p = 0.06, OR 1.5). Low iCa was associated with SBP < 90 at the scene and transport (p < 0.01). The incidence of base deficit was higher in the iCa < or = 1 group (p < 0.05). CONCLUSIONS: Low iCa is associated with prehospital hypotension regardless of age, ISS, or sampling time and is a better predictor of mortality than base deficit. Since acidosis reduces calcium binding to serum protein and actually increases iCa, the association between base deficit and iCa in this study requires further investigation.