Factors associated with unintended perianesthesia hypothermia.

Background: Our hypothesis was that total intravenous anesthesia (TIVA) is associated with an increase in hypothermia. Methods: Inclusion criteria were patients from the National Anesthesia Clinical Outcomes Registry undergoing a general anesthetic during 2019. Data collected included patient age, sex, American Society of Anesthesiologists physical status classification system score (ASAPS), duration of anesthetic, use of TIVA, type of procedure, and hypothermia. Continuous variables were compared using Student's t test or Mann Whitney rank sum as appropriate. Mixed effects multiple logistic regression was performed to determine the association between independent variables and hypothermia. Results: There was a low incidence of hypothermia (1.2%). Patients who became hypothermic were older, had a higher median ASAPS, and had a higher rate of TIVA. TIVA patients had a significantly increased odds for hypothermia when controlling for covariates. Patients undergoing obstetrical, thoracic, or radiological procedures had increased odds for hypothermia. In a matched cohort subset, TIVA was associated with a greater rate and increased odds for hypothermia. Conclusions: The novel and noteworthy finding was the association between TIVA and perianesthesia hypothermia. Thoracic, radiologic, and obstetrical procedures were associated with greater rates of and odds for hypothermia. Other identified factors can help to stratify patients for risk for hypothermia.

Sugammadex and blood loss during cervical spine fusion surgery.

Background and Aims: Sugammadex (SUG) has been associated with changes in coagulation studies. Most reports have concluded a lack of clinical significance based on surgical blood loss with SUG use at the end of surgery. Previous reports have not measured its use intraoperatively during ongoing blood loss. Our hypothesis was that the use of SUG intraoperatively may increase bleeding. Material and Methods: This was a single site retrospective study. Inclusion criteria were patients undergoing a primary posterior cervical spine fusion, aged over 18 years, between July 2015 and June 2021. The primary outcomes compared were intraoperative estimated blood loss (EBL) and postoperative drain output (PDO) between patients receiving SUG, neostigmine (NEO) and no NMB reversal agent. The objective was to determine if there was a difference in primary endpoints between patients administered SUG, NEO or no paralytic reversal agent. Primary endpoints were compared using analysis of variance with a P value of 0.05 used to determine statistical significance. Groups were compared using the Chi-squared test, rank sum or student's t test. A logistic regression model was constructed to account for differences between the groups. Results: There was no difference in median EBL or PDO between groups. The use of SUG was not associated with an increase in odds for >500 milliliters (ml) of EBL. Increasing duration of surgery and chronic kidney disease were both associated with an increased risk for EBL >500 ml. Conclusion: Intraoperative use of SUG was not associated with increased bleeding. Any coagulation laboratory abnormalities previously noted did not appear to have an associated clinical significance.

Modern readmission rates after head trauma.

Background: A report on head trauma using the 2014 National Readmission Database described a significant readmission rate of 8.9%. This study was undertaken to reevaluate the rate based on more granular ICD10 codes and to identify any factors associated with readmission that may be targeted to reduce readmission. Methods: Patients were identified from the 2019 National Readmission Database with an ICD10 code for head trauma. Readmission was defined as occurring within 30 days of initial hospital admission. Comparisons were made using chi square, Mann Whitney rank sum, or multivariable logistic regression. Results: The readmission rate was 5.0%. The rate was higher among men (5.6% vs 4.3%, P < 0.001) and patients ≥65 years of age (5.8% vs 3.9%, P < 0.001). Multiple injuries, discharge against medical advice, and government insurance were associated with higher rates. The mortality rate among those readmitted was 4.34%. Among patients readmitted, the most common primary nontrauma diagnoses were seizure disorder (7.7%) and cerebrovascular disease (3.4%). Younger patients had a higher rate of readmission for seizures (10.3% vs 6.1%, P < 0.001) and a lower rate of cerebrovascular disease (2.3% vs 6.4%, P = 0.004). Discussion: The readmission rate was lower than previously described. Quality metrics used by hospitals should use the revised numbers. Based on the data, we suggest possible interventions to reduce readmission, including a trial among younger men of empirical antiepileptic medications and of prophylactic or continued antibiotics among elderly patients. These interventions should be evaluated to determine if they could reduce readmission, particularly among patients who leave against medical advice.

In Vitro Analysis of Platelet Adhesion, Aggregation, and Surface GP1bα Expression in Stored Refrigerated Whole Blood: A Pilot Study.

BACKGROUND: Warm, fresh whole blood (WB) has been used by the US military to treat casualties in Iraq and Afghanistan. Based on data in that setting, cold-stored WB has been used to treat hemorrhagic shock and severe bleeding in civilian trauma patients in the United States. In an exploratory study, we performed serial measurements of WB's composition and platelet function during cold storage. Our hypothesis was that in vitro platelet adhesion and aggregation would decrease over time. METHODS: WB samples were analyzed on storage days 5, 12, and 19. Hemoglobin, platelet count, blood gas parameters (pH, Po2, Pco2, and Spo2), and lactate were measured at each timepoint. Platelet adhesion and aggregation under high shear were assessed with a platelet function analyzer. Platelet aggregation under low shear was assessed using a lumi-aggregometer. Platelet activation was assessed by measuring dense granule release in response to high-dose thrombin. Platelet GP1bα levels were measured with flow cytometry, as a surrogate for adhesive capacity. Results at the 3 study timepoints were compared using repeat measures analysis of variance and post hoc Tukey tests. RESULTS: Measurable platelet count decreased from a mean of (163 + 53) × 109 platelets per liter at timepoint 1 to (107 + 32) × 109 at timepoint 3 (P = .02). Mean closure time on the platelet function analyzer (PFA)-100 adenosine diphosphate (ADP)/collagen test increased from 208.7 + 91.5 seconds at timepoint 1 to 390.0 + 148.3 at timepoint 3 (P = .04). Mean peak granule release in response to thrombin decreased significantly from 0.7 + 0.3 nmol at timepoint 1 to 0.4 + 0.3 at timepoint 3 (P = .05). Mean GP1bα surface expression decreased from 232,552.8 + 32,887.0 relative fluorescence units at timepoint 1 to 95,133.3 + 20,759.2 at timepoint 3 (P < .001). CONCLUSIONS: Our study demonstrated significant decreases in measurable platelet count, platelet adhesion, and aggregation under high shear, platelet activation, and surface GP1bα expression between cold-storage days 5 and 19. Further studies are needed to understand the significance of our findings and to what degree in vivo platelet function recovers after WB transfusion.

Factors Associated With a Discharge Against Medical Advice From an Emergency Department in Adult Patients With Appendicitis.

BACKGROUND: Delays in care can lead to worsened outcomes with acute appendicitis. To get timely treatment, patients must consent. OBJECTIVE: To determine if there are racial and socioeconomic differences in discharge against medical advice (DAMA) rates from an emergency department after the diagnosis of acute appendicitis. METHODS: Patients were identified retrospectively from the 2019 National Emergency Department Sample. The inclusion criteria were patients 18 years of age or older with acute appendicitis. Rates were compared using chi-square or Fisher's exact test. Odds ratios were determined using multiple logistic regression. A p value of 0.05 was used to determine statistical significance. RESULTS: The overall rate of DAMA was low (0.37%). Black patients had the highest rate, and White patients had the lowest (0.72% and 0.28%, respectively, p < 0.001). When controlling for covariates, Black patients also had a higher odds ratio (OR) for DAMA (OR 1.96, 95% confidence interval [CI] 1.29-2.97). Male patients had a higher unadjusted rate (0.47% vs. 0.26% in females, p < 0.001) and were at increased risk (OR 1.78, 95% CI 1.32-2.41). Patients between 30 and 65 years old had an increased risk (OR 1.48, 95% CI 1.10-2.0). Patients with government insurance or no insurance had higher rates than private insurance (0.57% and 0.56% vs. 0.23% respectively, p < 0.001). CONCLUSION: Race, insurance status, age, and male sex were all associated with increase in DAMA. Risk stratifying patients can help to determine how to best employ mitigations strategies. Reducing DAMA may be the next area for improving reducing disparities in appendicitis care.

Socioeconomic Disparities in Method of Anesthesia for Knee Arthroplasties in the US.

INTRODUCTION: Knee arthroplasty (KA) can be performed using general anesthesia (GA), neuraxial anesthesia (NA) or regional anesthesia (RA). We believe proportion of types of anesthetics have changed but that there is a disparity based on socioeconomic factors. METHODS: Unadjusted rates and adjusted odds ratios for the use of RA or PNB were compared between groupings of patients based on socioeconomic status. RESULTS: General anesthesia is the most common (49.7%) while NA (39.4%) and RA (10.9%) were the second and third. University hospitals and patient home ZIP Code median income had the strongest association with RA as a (adjusted odds ratio (AOR) 26.3, 95% confidence interval (95%CI) 22.1-31.3, p<.01 and AOR 7.58, 95% CI 7.20-7.98, p<.01). CONCLUSION: General anesthesia is the most common but the rate of alternative forms of primary anesthesia type have changed over time. Disparities exist in anesthesia care which are associated with income levels.

Image Acquisition using Portable Sonography for Emergency Airway Management.

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of patients, but also to address the potential benefits of employing ultrasound in airway management. The benefits of point of care ultrasound (POCUS) include its portability, the speed at which it can be utilized, and its lack of invasiveness or exposure of the patient to radiation of other imaging modalities. Two primary indications for airway POCUS include confirmation of endotracheal intubation and identification of the cricothyroid membrane in the event a surgical airway is required. In this article, the technique of using ultrasound to confirm endotracheal intubation and the relevant anatomy is described, along with the associated ultrasonographic images. In addition, identification of the anatomy of the cricothyroid membrane and the ultrasonographic acquisition of appropriate images to perform this procedure are reviewed. Future advances include utilizing airway POCUS to identify patient characteristics that might indicate difficult airway management. Traditional bedside clinical exams have, at best, fair predictive values. The addition of ultrasonographic airway assessment has the potential to improve this predictive accuracy. This article describes the use of POCUS for airway management, and initial evidence suggests that this has improved the diagnostic accuracy of predicting a difficult airway. Given that one of the limitations of airway POCUS is that it requires a skilled sonographer, and image analysis can be operator dependent, this paper will provide recommendations to standardize the technical aspects of airway ultrasonography and promote further research utilizing sonography in airway management. The goal of this protocol is to educate researchers and medical health professionals and to advance the research in the field of airway POCUS.

Citrate does not change viscoelastic haemostatic assays after cardiopulmonary bypass.

Context: Viscoelastic hemostatic assays (VHA) are commonly used to identify specific cellular and humoral causes for bleeding in cardiac surgery patients. Cardiopulmonary bypass (CPB) alterations to coagulation are observable on VHA. Citrated VHA can approximate fresh whole blood VHA when kaolin is used as the activator in healthy volunteers. Some have suggested that noncitrated blood is more optimal than citrated blood for point-of-care analysis in some populations. Aims: To determine if storage of blood samples in citrate after CPB alters kaolin activated VHA results. Settings and Design: This was a prospective observational cohort study at a single tertiary care teaching hospital. Methods and Material: Blood samples were subjected to VHA immediately after collection and compared to samples drawn at the same time and stored in citrate for 30, 90, and 150 min prior to kaolin activated VHA both before and after CPB. Statistical Analysis Used: VHA results were compared using paired T-tests and Bland-Altman analysis. Results: Maximum clot strength and time to clot initiation were not considerably different before or after CPB using paired T-tests or Bland-Altman Analysis. Conclusions: Citrated samples appear to be a clinically reliable substitute for fresh samples for maximum clot strength and time to VHA clot initiation after CPB. Concerns about the role of citrate in altering the validity of the VHA samples in the cardiac surgery population seem unfounded.

Association of Early Aspirin Use With In-Hospital Mortality in Patients With Moderate COVID-19.

Importance: Prior observational studies suggest that aspirin use may be associated with reduced mortality in high-risk hospitalized patients with COVID-19, but aspirin's efficacy in patients with moderate COVID-19 is not well studied. Objective: To assess whether early aspirin use is associated with lower odds of in-hospital mortality in patients with moderate COVID-19. Design, Setting, and Participants: Observational cohort study of 112 269 hospitalized patients with moderate COVID-19, enrolled from January 1, 2020, through September 10, 2021, at 64 health systems in the United States participating in the National Institute of Health's National COVID Cohort Collaborative (N3C). Exposure: Aspirin use within the first day of hospitalization. Main Outcome and Measures: The primary outcome was 28-day in-hospital mortality, and secondary outcomes were pulmonary embolism and deep vein thrombosis. Odds of in-hospital mortality were calculated using marginal structural Cox and logistic regression models. Inverse probability of treatment weighting was used to reduce bias from confounding and balance characteristics between groups. Results: Among the 2 446 650 COVID-19-positive patients who were screened, 189 287 were hospitalized and 112 269 met study inclusion. For the full cohort, Median age was 63 years (IQR, 47-74 years); 16.1% of patients were African American, 3.8% were Asian, 52.7% were White, 5.0% were of other races and ethnicities, 22.4% were of unknown race and ethnicity. In-hospital mortality occurred in 10.9% of patients. After inverse probability treatment weighting, 28-day in-hospital mortality was significantly lower in those who received aspirin (10.2% vs 11.8%; odds ratio [OR], 0.85; 95% CI, 0.79-0.92; P < .001). The rate of pulmonary embolism, but not deep vein thrombosis, was also significantly lower in patients who received aspirin (1.0% vs 1.4%; OR, 0.71; 95% CI, 0.56-0.90; P = .004). Patients who received early aspirin did not have higher rates of gastrointestinal hemorrhage (0.8% aspirin vs 0.7% no aspirin; OR, 1.04; 95% CI, 0.82-1.33; P = .72), cerebral hemorrhage (0.6% aspirin vs 0.4% no aspirin; OR, 1.32; 95% CI, 0.92-1.88; P = .13), or blood transfusion (2.7% aspirin vs 2.3% no aspirin; OR, 1.14; 95% CI, 0.99-1.32; P = .06). The composite of hemorrhagic complications did not occur more often in those receiving aspirin (3.7% aspirin vs 3.2% no aspirin; OR, 1.13; 95% CI, 1.00-1.28; P = .054). Subgroups who appeared to benefit the most included patients older than 60 years (61-80 years: OR, 0.79; 95% CI, 0.72-0.87; P < .001; >80 years: OR, 0.79; 95% CI, 0.69-0.91; P < .001) and patients with comorbidities (1 comorbidity: 6.4% vs 9.2%; OR, 0.68; 95% CI, 0.55-0.83; P < .001; 2 comorbidities: 10.5% vs 12.8%; OR, 0.80; 95% CI, 0.69-0.93; P = .003; 3 comorbidities: 13.8% vs 17.0%, OR, 0.78; 95% CI, 0.68-0.89; P < .001; >3 comorbidities: 17.0% vs 21.6%; OR, 0.74; 95% CI, 0.66-0.84; P < .001). Conclusions and Relevance: In this cohort study of US adults hospitalized with moderate COVID-19, early aspirin use was associated with lower odds of 28-day in-hospital mortality. A randomized clinical trial that includes diverse patients with moderate COVID-19 is warranted to adequately evaluate aspirin's efficacy in patients with high-risk conditions.

Pediatric Thoracic Trauma Mortality in Iraq and Afghanistan Compared to the United States National Trauma Data Bank.

INTRODUCTION: The authors compared pediatric thoracic patients in the Joint Theatre Trauma Registry (JTTR) to those in the National Trauma Data Bank (NTDB) to assess differences in patient mortality rates and mortality risk accounting for age, injury patterns, and injury severity. MATERIALS AND METHODS: Patients less than 19 years of age with thoracic trauma were identified in both the JTTR and NTDB. Multiple logistic regression, χ2, Student's t-test, or Mann-Whitney U test were used as indicated to compare the two groups. RESULTS: Pediatric thoracic trauma patients seen in Iraq and Afghanistan (n = 955) had a significantly higher mortality rate (15.1 vs. 6.0%, P <.01) than those in the NTDB (n = 9085). After controlling for covariates between the JTTR and the NTDB, there was no difference in mortality (odds ratio for mortality for U.S. patients was 0.74, 95% CI 0.52-1.06, P = .10). The patients seen in Iraq or Afghanistan were significantly younger (8 years old, interquartile ratio (IQR) 2-13 vs. 15, IQR 10-17, P <.01) had greater severity of injuries (injury severity score 17, IQR 12-26 vs. 12, IQR 8-22, P <.01), had significantly more head injuries (29 vs. 14%, P <.01), and over half were exposed to a blast. DISCUSSION: Pediatric patients with thoracic trauma in Iraq and Afghanistan in the JTTR had similar mortality rates compared to the civilian population in the NTDB after accounting for confounding covariates. These findings indicate that deployed military medical professionals are providing comparable quality of care in extremely challenging circumstances. This information has important implications for military preparedness, medical training, and casualty care.

Racial disparities in catheter related urinary tract infections among elderly trauma patients in the US.

BACKGROUND: Catheter associated urinary tract infections (CAUTIs) have become a focus for reducing healthcare costs. Reimbursement may be reduced to hospitals with higher rates. The implementation of bundles or other efforts to reduce infection numbers may not be as robust at hospitals caring for more diverse patient populations. This may lead to a disparity in hospital-associated infections rates that may lead to lower reimbursement and a downward spiral of quality of care and racial disparities. METHODS: We analyzed patients in the National Trauma Data Bank from 2016 to 2017. The final analysis included patients 65 years or older with one or more day of mechanical ventilation. This was the population had the highest rate of CAUTI. We compared white patients to non-whites using students t test, Mann Whitney U test, or chi-square as appropriate. Logistic regression with odds ratios (ORs) and 95% confidence intervals (CI) was computed to identify risk factors for of CAUTI. RESULTS: Risk factors for developing a CAUTI were race (OR 1.44, 95% confidence interval (95%CI) 1.23-1.71), injury severity score (OR 1.10 per increase of one, 95% CI 1.01-1.02), care at a teaching hospital (OR 1.17, 95%CI 1.02-1.35), private insurance (OR 1.28, 95%CI 1.09-1.51), hypertension (OR 1.18, 95%CI 1.02-1.37), female gender (OR 1.54, 95%CI 1.33-1.77). Non-white patients received care at teaching hospitals more often and had a higher rate of government insurance or no insurance. DISCUSSION: The Center for Medicare and Medicaid Services (CMS) has put in place a reimbursement modification 87 plan based on the rates of hospital-associated infections including CAUTIs. We have demonstrated non-white 88 patients have higher odds for developing a CAUTI. CONCLUSION: CMS may potentially worsen the racial disparity by further cutting reimbursement to hospitals who care for higher proportions of non-whites.

Association of prehospital antiplatelet therapy with survival in patients hospitalized with COVID-19: A propensity score-matched analysis.

PURPOSE: Coronavirus disease 2019 (COVID-19) is associated with hypercoagulability and increased thrombotic risk. The impact of prehospital antiplatelet therapy on in-hospital mortality is uncertain. METHODS: This was an observational cohort study of 34 675 patients ≥50 years old from 90 health systems in the United States. Patients were hospitalized with laboratory-confirmed COVID-19 between February 2020 and September 2020. For all patients, the propensity to receive prehospital antiplatelet therapy was calculated using demographics and comorbidities. Patients were matched based on propensity scores, and in-hospital mortality was compared between the antiplatelet and non-antiplatelet groups. RESULTS: The propensity score-matched cohort of 17 347 patients comprised of 6781 and 10 566 patients in the antiplatelet and non-antiplatelet therapy groups, respectively. In-hospital mortality was significantly lower in patients receiving prehospital antiplatelet therapy (18.9% vs. 21.5%, p < .001), resulting in a 2.6% absolute reduction in mortality (HR: 0.81, 95% CI: 0.76-0.87, p < .005). On average, 39 patients needed to be treated to prevent one in-hospital death. In the antiplatelet therapy group, there was a significantly lower rate of pulmonary embolism (2.2% vs. 3.0%, p = .002) and higher rate of epistaxis (0.9% vs. 0.4%, p < .001). There was no difference in the rate of other hemorrhagic or thrombotic complications. CONCLUSIONS: In the largest observational study to date of prehospital antiplatelet therapy in patients with COVID-19, there was an association with significantly lower in-hospital mortality. Randomized controlled trials in diverse patient populations with high rates of baseline comorbidities are needed to determine the ultimate utility of antiplatelet therapy in COVID-19.

Medical planning for disaster response: Identifying risk factors for developing adult respiratory distress syndrome among trauma patients.

INTRODUCTION: Adult respiratory distress syndrome (ARDS) is a well-described complication of critical illness. We hy-pothesized that rates of comorbid diseases in a population may influence the risk for developing ARDS in trauma pa-tients. This can help plan medical responses. METHODS: Patients from the 2017 National Trauma Databank were analyzed. Inclusion criteria were an injury sever-ity score (ISS) of ≥ 2 and 1 or more documented days of mechanical ventilation. Data were analyzed using χ2, Student's t test, Mann-Whitney U test, or logistic regression as indicated. RESULTS: Diabetes (odds ratio [OR] 1.33, 95 percent confidence interval [CI] 1.17-1.52), smoking (OR 1.26, 95 per-cent CI 1.13-1.40), transfusion (OR 1.20, 95 percent CI 1.09-1.32), ISS (OR 1.02, 95 percent CI 1.02-1.03), male gen-der (OR 1.22, 95 percent CI 1.10-1.35), decreasing Glasgow coma score (OR 1.04, 95 percent CI 1.03-1.05), and in-creasing abbreviated injury score of the thorax (OR 1.12, 95 percent CI 1.09-1.16) were associated with an increase in risk for developing ARDS. CONCLUSION: Diabetes and smoking are risk factors for developing ARDS after trauma. Medical response planning in countries with high rates of diabetes mellitus or smoking should take into account a greater need for intensive care and longer patient admissions to field hospitals.

Making Ventilator Associated Pneumonia Rate a Meaningful Quality Marker.

INTRODUCTION: Ventilator associated pneumonia (VAP) rate has been tracked as a comparable quality measure but there is significant variation between types of ICUs. We sought to understand variability and improve its utility as a marker of quality. METHODS: The National Trauma Database was surveyed to identify risk factors for VAP. Logistic regression, χ2, Student's T-test or Mann-Whitney U test were used. RESULTS: Risk factors associated with developing VAP were: injury severity score (ISS) (OR 1.03, 95% CI 1.03 -1.04), prehospital assisted respiration (PHAR) (OR 1.10, 1.03 -1.17), thoracic injuries (OR 2.28, 1.69-3.08), diabetes (OR 1.32, 1.20 -1.46), male gender (OR 1.38, 1.28 -1.60), care at a teaching hospital (OR 1.40, 1.29 -1.47) and unplanned intubation (OR 2.76, 2.52-3.03). DISCUSSION: ISS, PHAR, diabetes, male gender, care at a teaching hospital and unplanned intubation are risk factors for the development of VAP. These factors should be accounted for in order to make VAP an effective quality marker.

Trauma in Obstetrical Patients.

INTRODUCTION: Pregnant trauma patients are an underdescribed cohort in the medical literature. Noting injury patterns and contributors to mortality may lead to improved care. METHODS: Female patients between 14 and 49 years of age were identified among entries in the 2017 National Trauma Data Bank. Data points were compared using Chi-square test, Fisher's exact test, Student's t-test, Mann-Whitney rank-sum, or multiple logistic regression as appropriate. P < 0.05 was used to determine the findings of significance. RESULTS: There were 569 pregnant trauma patients identified, which was 0.54% of the 105,507 women identified. Overall, mortality was low among all women and not different between groups (1.2% for pregnant women vs. 2.2% for nonpregnant, P = 0.12). Pregnant women with head injuries had a higher mortality rate than pregnant women without (4.2% vs. 0.47%, P < 0.01). Head injuries (Abbreviated Injury Severity Score [AIS] head >1) were associated with an increased risk for mortality (odds ratio: 3.33, 95% confidence interval: 3.0-3.7, P < 0.01). CONCLUSION: There was no increase in mortality for trauma patients who are pregnant when controlling for covariates. Factors such as head injuries, the need for blood, and comorbid diseases appear to have a more significant contribution to mortality. We also report the prevalence of head, cervical spine, and extremity injuries in pregnant trauma patients. Multidisciplinary simulation, jointly crafted protocols, and expanding training in regional anesthesia may be the next steps to improving care for pregnant trauma patients.

Pediatric Thoracic Trauma in Iraq and Afghanistan.

Introduction: The objective of this study is to review available data on pediatric thoracic trauma seen at U.S. military treatment facilities in Iraq and Afghanistan and describe the scope of injuries, patterns seen, and associated mortality. The results were compared with adults injured in Iraq and Afghanistan and other reports of pediatric thoracic trauma in the literature. Materials and Methods: The investigators received approval from the Uniformed Services University of the Health Sciences' institutional review board before the study. The Joint Theatre Trauma Registry was queried for all patients with an ICD-9 code for thoracic trauma. Two-tailed Student's t-test, Mann-Whitney rank sum, χ2, ANOVA, or multiple logistic regression was used as indicated. Results: There were 955 patients under the age of 18 yr, just over 12% of all thoracic trauma. Penetrating injuries were common (73.6%), including gunshot wounds. The most common pediatric diagnoses were contusions (45%), pneumothorax (40%), and rib and/or sternal fractures (18%). The overall mortality for children was 15.2% compared with 13.8% and 9% for civilian adults and Coalition members with thoracic trauma, respectively. Mortality was inversely related to age among pediatric patients. Children under 2 yr of age had the highest mortality (25.1%). Patients under 12 yr of age were more likely to die than those between 12 and 18 (OR 2.02, 95% CI 1.27-3.22) yr. Thoracic vascular injuries and cardiac injuries resulted in the highest mortality among pediatric patients. The presence of a hemothorax was independently associated with an increased risk for mortality (OR 1.78, 95% CI 1.06-2.99) as was a concomitant head injury (OR 2.17, 95% CI 1.33-3.54). There was a 2.7% incidence of burns among pediatric patients with a high associated mortality (46.2%). Nearly one-half of all the children identified required a transfusion (47%). Conclusion: Penetrating injuries predominated and these children commonly required a transfusion. Mortality was inversely related to age. Children with a hemothorax or a concomitant head injury had significant increases in mortality. Children with thoracic injury as the result of a burn suffered the highest mortality.

Vital Signs and Physiologic Derangement in Patients With Thoracic Trauma in Iraq and Afghanistan.

BACKGROUND: Triage is the act of stratifying the need for medical attention. Effective triage must account for injury patterns and severity. Personnel making triage decisions must also consider the patients' physiologic states. Vital signs can possibly be used to assess for the presence of physiological derangements such as coagulopathy, acidosis, or a significant base deficit. Providers could use this knowledge to assist with triage at casualty collection points where laboratory studies or point of care testing may not be available. METHODS: With institutional approval, data were extracted from the Joint Theater Trauma Registry for all patients with thoracic trauma between 2002 and 2012. Patients were identified by International Statistical Classification of Diseases and Related Health Problems, 9th Revision (ICD-9) codes. Heart rate (HR), systolic blood pressure (SBP), and pulse pressure were correlated with coagulopathy (international normalization ratio ≥ 1.5), acidosis (pH < 7.2) or an elevated base deficit (>6) on admission. Sensitivity, specificity, positive predictive values, negative predictive values, and odds ratios were calculated. FINDINGS: HR > 100, SBP < 90, or pulse pressure <30 were associated with an increased risk for acidosis (odds ratio 3.06 [95% confidence interval 2.48-3.78], 4.72 [3.85-5.78], and 2.73 [2.15-3.48], respectively), coagulopathy (2.21 [1.72-2.83], 4.55 [3.57-5.80], and 2.73 [2.15-3.48], respectively), and base deficit >6 (2.17 [1.88-2.50], 3.48 [2.87-4.22], and 2.22 [1.78-2.77], respectively). HR was a moderately sensitive marker (0.74), whereas SBP was a specific marker (0.93). DISCUSSION: SBP < 90 is an effective marker for ruling in physiologic derangement after thoracic trauma. HR > 100 was associated with over twice the odds for physiologic derangement. Vital signs can be used to assess for physiologic derangement in the population studied and may help in triage.

Warm fresh whole blood and thoracic traumain iraq and afghanistan.

BACKGROUND: Thoracic trauma occurred in 10% of the patients seen at US military treatment facilities in Iraq and Afghanistan and 52% of those patients were transfused. Among those transfused, 281 patients received warm fresh whole blood. A previous report documented improved survival with warm fresh whole blood in patients injured in combat without stratification by injury pattern. A later report described an increase in acute lung injuries after its administration. Survivorship and warm fresh whole blood have never been analyzed in a subpopulation at highest risk for lung injuries, such as patients with thoracic trauma. There may be a heterogeneous relationship between whole blood and survival based on likelihood of a concomitant pulmonary injury. In this report, the relationship between warm fresh whole blood and survivorship was analyzed among patients at highest risk for concomitant pulmonary injuries. MATERIALS AND METHODS: Patients with thoracic trauma who received a transfusion were identified in the Joint Theater Trauma Registry. Gross mortality rates were compared between whole blood recipients and patients transfused with component therapy only. The association between each blood component and mortality was determined in a regression model. The overall mortality risk was compared between warm fresh whole blood recipients and non-recipients. RESULTS: Patients transfused with warm fresh whole blood in addition to component therapy had a higher mortality rate than patients transfused only separated blood components (21.3% vs. 12.8%, P < 0.001). When controlling for covariates, transfusion of warm fresh whole blood in addition to component therapy was not associated with increased mortality risk compared with the transfusion of component therapy only (OR 1.247 [95% CI 0.760-2.048], P = 0.382). CONCLUSION: Patients with combat related thoracic trauma transfused with warm fresh whole blood were not at increased risk for mortality compared to those who received component therapy alone when controlling for covariates.

Horner's syndrome and trigeminal nerve palsy following epidural analgesia for labor.

Epidural analgesia is a widely used method of pain control in the labor and delivery setting but is not without risks. We present a case of Horner's syndrome and trigeminal nerve palsy as a rare complication of epidural analgesia in an obstetric patient. Although reported in few instances in the anesthesia literature, awareness among providers in obstetrics is critical because this could be the first sign of a high sympathetic blockade resulting in potential maternal-fetal morbidity.