The effect of the COVID-19 pandemic on community violence in Connecticut.

INTRODUCTION: Natural disasters may lead to increases in community violence due to broad social disruption, economic hardship, and large-scale morbidity and mortality. The effect of the COVID-19 pandemic on community violence is unknown. METHODS: Using trauma registry data on all violence-related patient presentations in Connecticut from 2018 to 2021, we compared the pattern of violence-related trauma from pre-COVID and COVID pandemic using an interrupted time series linear regression model. RESULTS: There was a 55% increase in violence-related trauma in the COVID period compared with the pre-COVID period (IRR: 1.55; 95%CI: 1.34-1.80; p-value<0.001) driven largely by penetrating injuries. This increase disproportionately impacted Black/Latinx communities (IRR: 1.61; 95%CI: 1.36-1.90; p-value<0.001). CONCLUSION: Violence-related trauma increased during the COVID-19 pandemic. Increased community violence is a significant and underappreciated negative health and social consequence of the COVID-19 pandemic, and one that excessively burdens communities already at increased risk from systemic health and social inequities.

When to Admit to Observation: Predicting Length of Stay for Anticoagulated Elderly Fall Victims.

BACKGROUND: Geriatric patients who fall while taking an anticoagulant have a small but significant risk of delayed intracranial hemorrhage requiring observation for 24 h. However, the medical complexity associated with geriatric care may necessitate a longer stay in the hospital. Little is known about the factors associated with a successful observational status stay (<2 d) for this population. MATERIALS AND METHODS: Elderly patients who fell while taking an anticoagulant admitted from 2012 to 2017 at an ACS level II trauma center were included in a retrospective cohort study to determine what factors were associated with a stay consistent with observational status. INCLUSION CRITERIA: age> 65 y old, negative initial head CT, and one of the following: INR>3.5 if on warfarin, GCS<14, external signs of trauma, or focal neurological deficits. RESULTS: The cohort included 369 patients. Factors associated with decreased likelihood of successful observational status included the need for services after discharge such as an extended care facility (OR 0.06, 95% CI 0.02-0.19, P < 0.001) or visiting nurse agency services (OR 0.27, 95% CI 0.10-0.75, P < 0.001), a dementia diagnosis (OR 0.17, 95% CI 0.04-0.70, P = 0.014), increasing number of medications (OR 0.91, 95% CI 0.84-0.99, P = 0.031), and the use of coumadin (OR 0.28, 95% CI 0.12-0.70, P = 0.006). CONCLUSIONS: For trauma providers, knowing your patient's medication use and particularly type of anticoagulant, comorbidities including dementia, and likely need for services after discharge will help guide the decision to admit the patient for what may be a reasonably lengthy stay versus a brief observation in the hospital for elderly fall victims on anticoagulation.

The Impact of Interdisciplinary Care on Cost Reduction in a Geriatric Trauma Population.

The current growth of the geriatric population and increased burden on trauma services throughout the United States (US) has created a need for systems that can improve patient care and reduce hospital costs. We hypothesize that the multidisciplinary services provided through the Geriatric Injury Institute (GII) can reduce hospital costs, improve patient triage throughput, and decrease hospital length of stay (LOS). METHODS AND MATERIAL: We performed a single-center, retrospective chart review of our Level II trauma center registry and electronic medical records of patients ages 65 and older who satisfied trauma activation/code criteria between July 1, 2014, to June 30, 2016 (N = 663). Patients presenting from July 1, 2014, to June 30, 2015, were grouped as Pre-GII, while those presenting from July 1, 2015, to June 30, 2016, were grouped as Post-GII. Primary outcomes were emergency department (ED) triage time, overall LOS, and hospital costs. Secondary outcomes included patient disposition, mortality, and health assessments. Statistical comparisons were made using a one-way analysis of variance and Mann-Whitney U test. RESULTS: Pre-GII vs. Post-GII average ages and the Injury Severity Score (ISS) were not statistically different (p>0.05). The average LOS was similar between the Pre-GII and Post-GII groups (4.64 ± 4.42 days vs. 4.26 ± 5.58 days, p = 0.48). More patients were discharged earlier (≤ 4 days; 64% vs. 73%) as well as discharged to home (37% vs. 45%) in the Post-GII group. The total cost savings were $53,000 with a median savings of $1061 per patient ($8808 vs. $7747, p = 0.04). Savings were highest during the first two days of admission (p = 0.03). The reduction in ED triage time was not significant (310.7 minutes vs 219. 8 minutes, p > 0.05). CONCLUSION: With the increase in geriatric trauma, innovative models of care are needed. Our study suggests that the GII multidisciplinary approach to trauma services can lower overall hospital costs.

Trauma morning report is the ideal environment to teach and evaluate resident communication and sign-outs in the 80 hour work week.

BACKGROUND: The 80h work week has raised concerns that complications may increase due to multiple sign-outs or poor communication. Trauma Surgery manages complex trauma and acute care surgical patients with rapidly changing physiology, clinical demands and a large volume of data that must be communicated to render safe, effective patient care. Trauma Morning Report format may offer the ideal situation to study and teach sign-outs and resident communication. MATERIALS AND METHODS: Surgery Residents were assessed on a 1-5 scale for their ability to communicate to their fellow residents. This consisted of 10 critical points of the presentation, treatment and workup from the previous night's trauma admissions. Scores were grouped into three areas. Each area was scored out of 15. Area 1 consisted of Initial patient presentation. Area 2 consisted of events in the trauma bay. Area 3 assessed clarity of language and ability to communicate to their fellow residents. The residents were assessed for inclusion of pertinent positive and negative findings, as well as overall clarity of communication. In phase 1, residents were unaware of the evaluation process. Phase 2 followed a series of resident education session about effective communication, sign-out techniques and delineation of evaluation criteria. Phase 3 was a resident-blinded phase which evaluated the sustainability of the improvements in resident communication. RESULTS: 50 patient presentations in phase 1, 200 in phase 2, and 50 presentations in phase 3 were evaluated. Comparisons were made between the Phase 1 and Phase 2 evaluations. Area 1 (initial events) improved from 6.18 to 12.4 out of 15 (p<0.0001). Area 2 (events in the trauma bay) improved from 9.78 to 16.53 (p<0.0077). Area 3 (communication and language) improved from 8.36 to 12.22 out of 15 (P<0.001). Phase 2 to Phase 3 evaluations were similar, showing no deterioration of skills. CONCLUSIONS: Trauma Surgery manages complex surgical patients, with rapidly changing physiologic and clinical demands. Trauma Morning Report, with diverse attendance including surgical attendings and residents in various training years, is the ideal venue for real-time teaching and evaluation of sign-outs and reinforcing good communication skills in residents.

Is Pre-Hospital CPR a Risk Factor for Early Death in Patients Transferred to an Adult Burn Center?

BACKGROUND: Burn patients who require CPR before admission to a burn center are anecdotally known to suffer higher mortality than those who do not require pre-hospital CPR. STUDY DESIGN: A retrospective chart review identified adult patients admitted to our burn center between 2013 and 2015. Included patients met 1 or both of the following criteria: 20% or more total body surface area burned and need for intubation before admission to our facility. We sought to identify predictors of early death, late death, and survival among burn patients who underwent CPR before admission. RESULTS: Of the 80 patients meeting inclusion criteria, 17.5% underwent CPR before arrival at our facility. Seventy-nine percent of these died, compared with 29% of the patients who did not require CPR (p = 0.0005). Seventy-one percent of CPR patients died within 48 hours of admission, compared with 8% of non-CPR patients (p < 0.0001). The major predictor of death vs survival after CPR was lower initial arterial pH. CONCLUSIONS: Patients who undergo CPR before transfer to a burn center are at high risk for early death. Predictors of death and early death after CPR may include elevated initial lactate and lower initial arterial pH.

Teaching leadership in trauma resuscitation: Immediate feedback from a real-time, competency-based evaluation tool shows long-term improvement in resident performance.

BACKGROUND: Limited data exist on how to develop resident leadership and communication skills during actual trauma resuscitations. METHODS: An evaluation tool was developed to grade senior resident performance as the team leader during full-trauma-team activations. Thirty actions that demonstrated the Accreditation Council for Graduate Medical Education core competencies were graded on a Likert scale of 1 (poor) to 5 (exceptional). These actions were grouped by their respective core competencies on 5 × 7-inch index cards. In Phase 1, baseline performance scores were obtained. In Phase 2, trauma-focused communication in-services were conducted early in the academic year, and immediate, personalized feedback sessions were performed after resuscitations based on the evaluation tool. In Phase 3, residents received only evaluation-based feedback following resuscitations. RESULTS: In Phase 1 (October 2009 to April 2010), 27 evaluations were performed on 10 residents. In Phase 2 (April 2010 to October 2010), 28 evaluations were performed on nine residents. In Phase 3 (October 2010 to January 2012), 44 evaluations were performed on 13 residents. Total scores improved significantly between Phases 1 and 2 (p = 0.003) and remained elevated throughout Phase 3. When analyzing performance by competency, significant improvement between Phases 1 and 2 (p < 0.05) was seen in all competencies (patient care, knowledge, system-based practice, practice-based learning) with the exception of "communication and professionalism" (p = 0.56). Statistically similar scores were observed between Phases 2 and 3 in all competencies with the exception of "medical knowledge," which showed ongoing significant improvement (p = 0.003). CONCLUSIONS: Directed resident feedback sessions utilizing data from a real-time, competency-based evaluation tool have allowed us to improve our residents' abilities to lead trauma resuscitations over a 30-month period. Given pressures to maximize clinical educational opportunities among work-hour constraints, such a model may help decrease the need for costly simulation-based training. LEVEL OF EVIDENCE: Therapeutic study, level III.

A case of pyogenic liver abscesses in a previously healthy adolescent man.

An 18-year-old, previously healthy man admitted with abdominal pain, high-grade fevers, nausea and emesis was found to have multiple hepatic abscesses. Aspiration cultures grew Fusobacterium necrophorum, a rare bacterium causing potentially fatal liver abscesses in humans. Following sequential percutaneous drainages and narrowing of antibiotics, the patient was discharged on a 6-week antibiotic course and showed no signs of infection. A week after presentation it was discovered that he had experienced upper respiratory symptoms and sore throat prior to presentation. Because oropharyngeal infections are a potential source of bacteremia, they must be considered in the differential diagnosis of patients presenting with hepatic abscesses and no evidence of immunocompromise.

Empiric antibiotics pending bronchoalveolar lavage data in patients without pneumonia significantly alters the flora, but not the resistance profile, if a subsequent pneumonia develops.

INTRODUCTION: Ventilator-associated pneumonia (VAP) occurs in up to 25% of mechanically ventilated patients, with an associated mortality up to 50%. Early diagnosis and appropriate empiric antibiotic coverage of VAP are crucial. Given the multitude of noninfectious clinical and radiographic anomalies within trauma patients, microbiology from bronchioalveolar lavage (BAL) is often needed. Empiric antibiotics are administered while awaiting BAL culture data. Little is known about the effects of these empiric antibiotics on patients with negative BAL microbiology if a subsequent VAP occurs during the same hospital course. METHODS: This is a retrospective chart review of intubated trauma patients undergoing BAL for suspected pneumonia over a 3-y period at a Level 1 trauma center. All patients with suspected VAP undergoing a BAL receive empiric antibiotics. If microbiology data are negative at 72 h, all antibiotics are stopped; however, if the BAL returns with ≥10(5) colony-forming units per milliliter, the diagnosis of VAP is confirmed. We divided patients into three groups. Group 1 consisted of patients in whom the initial BAL was positive for VAP. Group 2 consisted of patients with an initial negative BAL, who subsequently developed VAP at a later point in the hospital course. Group 3 consisted of patients with negative BAL who did not develop a subsequent VAP. RESULTS: We obtained 499 BAL specimens in 185 patients over the 3-y period. A total of 14 patients with 23 BAL specimens initially negative for VAP subsequently developed VAP later during the same hospital stay. These patients did not have an increase in the hospital length of stay, intensive care unit days, ventilator days, or mortality compared with those who had a positive culture on the first suspicion of VAP. There was a significant increase in the percentage of Enterobacter (21% versus 8%) and Morganella (8% versus 0%) as the causative organism in these 14 patients when the VAP occurred. Furthermore, the profile of the top two organisms in each group changed. Enterobacter (21%) and Pseudomonas (17%) were the principal organisms in the initial BAL-negative group, whereas the two predominant strains in the initial positive BAL group were methicillin-sensitive Staphylococcus aureus (21%) and Haemophilus influenza (11%). Interestingly, methicillin-resistant S. aureus remained the third most common organism in both groups. Empiric antibiotics also did not seem to induce the growth of multidrug-resistant organisms, and there was no increased rate of secondary infections such as Clostridium difficile. CONCLUSIONS: Ventilator-associated pneumonia remains a significant cause of morbidity and mortality in mechanically ventilated trauma patients. The diagnosis and treatment of VAP continue to be challenging. Once clinically suspected, empiric coverage decreases morbidity and mortality. Our data demonstrate that patients who receive empiric coverage exhibit a significantly different microbiologic profile compared with those who had an initial positive BAL culture. Initial empiric antibiotics in BAL-negative patients were not associated with an increase in multidrug-resistant organisms, hospital, or intensive care unit length of stay, ventilator days, and mortality or secondary infections.

Infections after trauma are associated with subsequent cardiac injury.

BACKGROUND: Trauma produces profound inflammatory and immune responses. A second hit such as an infection further disrupts the inflammatory cascade. Inflammatory responses, following traumatic injuries, infections, or both, are emerging as biologic mediators of cardiac disease including myocardial ischemia and infarction. Inflammation-induced and stress-related cardiac damage are increasingly recognized in patients with critical illness. It is believed that cardiac dysfunction is the result of alterations in the inflammatory and immune cascades. Urinary tract infections (UTIs) and ventilator-associated pneumonia (VAP) are associated with increased mortality in trauma patients. UTIs and VAPs induced inflammatory responses. We postulate that increased mortality seen in trauma patients with infections is caused by increased rates of cardiac injury. METHODS: This is a retrospective review of prospectively collected data. All trauma patients admitted to the intensive care unit at our Level I trauma center during 5 years were included in the analysis. Proportional hazard regression analysis was performed to predict suspicion of cardiac injury (troponin ordered), any cardiac injury (troponin > 0.15 ng/mL), or severe cardiac injury (troponin > 1 ng/mL) using age, sex, Injury Severity Score (ISS), pulmonary disease (chronic obstructive pulmonary disease), heart failure, hypertension, diabetes, and the presence of a UTI or VAP. A similar proportion hazard regression was performed to predict mortality. RESULTS: In the model to predict any cardiac injury, chronic obstructive pulmonary disease (hazards ratio [HR], 1.9; p = 0.02), ISS (HR, 1.01; p = 0.04), VAP (HR, 5.6; p < 0.01), and UTI (HR, 2.4; p = 0.03) were significant. Neither VAP nor UTI predicted severe cardiac injury. In the model to predict death, any cardiac injury was not associated with mortality, but severe cardiac injury and UTI were associated with mortality as age increased. CONCLUSION: Infectious complications have been associated with increased mortality in trauma patients. Our data demonstrate that development of VAP or UTI is associated with an increased risk of developing cardiac injury in trauma patients, which may contribute to subsequent increased mortality. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Undiagnosed medical comorbidities in the uninsured: a significant predictor of mortality following trauma.

BACKGROUND: Lack of health care insurance has been correlated with increased mortality after trauma. Medical comorbidities significantly affect trauma outcomes. Access to health care and thereby being diagnosed with a pretrauma comorbidity is highly dependent on insurance status. The objective of this study was to determine whether rates of diagnosed or undiagnosed preexisting comorbidities significantly contribute to disparities in mortality rates observed between insured and uninsured trauma patients. METHODS: Review of trauma patients admitted to a Level I trauma center during a 5-year period. Data extracted from the registry included age, sex, Injury Severity Score (ISS), comorbidities, mortality, and insurance status. Multivariate logistic regression analysis was performed using age, sex, and insurance status to predict comorbidities and age, sex, ISS, and insurance status to predict mortality. RESULTS: Insured patients were older (54 years vs. 38, p < 0.001) and more likely female (41.3% vs. 22.5%, p < 0.001). When adjusting for age and sex, insured patients were more likely to have a pretrauma diagnosis of coronary artery disease (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.54-2.83), diabetes mellitus (OR, 2.09; 95% CI, 1.61-2.72), hypertension (OR, 1.97; 95% CI, 1.65-2.35), asthma/emphysema (OR, 1.64; 95% CI, 1.32-2.04), neurologic problems (OR, 1.79; 95% CI, 1.31-2.44), and gastroesophageal reflux disease (OR, 2.03; 95% CI, 1.33-3.11), compared with patients without insurance. In the analysis to predict mortality, having insurance was protective (OR, 0.57; 95% CI, 0.45-0.71). Among patients with no diagnosed comorbidities, insured patients had the lowest mortality risk (OR, 0.5; 95% CI, 0.38-0.67). When analyzing only patients with diagnosed comorbidities, insurance status had no impact on mortality risk (OR, 0.81; 95% CI, 0.53-1.22). CONCLUSION: Undiagnosed preexisting comorbidities play a crucial role in determining outcomes following trauma. Diagnosis of medical comorbidities may be a marker of access to health care and may be associated with treatment, which may explain the gap in mortality rates between insured and uninsured trauma patients. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Non-fatal suicide attempt by intentional stab wound: Clinical management, psychiatric assessment, and multidisciplinary considerations.

BACKGROUND: Suicide by means of self-inflicted stab wounds is relatively uncommon and little is known about this population and their management. MATERIALS AND METHODS: Retrospective review of adult trauma patients admitted to our Level-1 trauma center between January 2005 and October 2009 for management of non-fatal, self-inflicted stab wounds. RESULTS: Fifty-eight patients were evaluated with self-inflicted stab wounds. Four patients died due to their injuries (mortality, 7%). Of the non-fatal stab wounds, 78% were male ranging in age from 19-82 (mean: 45 years). The most common injury sites were the abdomen (46%), neck (33%), and chest (20%). In terms of operative interventions, 56% of abdominal operations were therapeutic, whereas 100% of neck and chest operations were therapeutic. When assessing for suicidal ideation, 44 patients (81%) admitted to suicidal intentions whereas 10 patients (19%) described accidental circumstances. Following psychiatric evaluation, 8 of the 10 patients with "accidental injuries" were found to be suicidal. Overall, 54 patients (98%) met criteria for a formal psychiatric diagnosis with 48 patients (89%) necessitating inpatient or outpatient psychiatric assistance at discharge. CONCLUSIONS: Compared to previous reports of stab wounds among trauma patients, patients with self- inflicted stab wounds may have a higher incidence of operative interventions and significant injuries depending on the stab location. When circumstances surrounding a self-inflicted stabbing are suspicious, additional interviews by psychiatric care providers may uncover a suicidal basis to the event. Given the increased incidence of psychiatric illness in this population, it is imperative to approach the suicidal patient in a multidisciplinary fashion.

The development of a urinary tract infection is associated with increased mortality in trauma patients.

BACKGROUND: In October 2008, Medicare and Medicaid stopped paying for care associated with catheter-related urinary tract infections (UTIs). Although most clinicians agree UTIs are detrimental, there are little data to support this belief. METHODS: This is a retrospective review of trauma registry data from a Level I trauma center between 2003 and 2008. Two proportional hazards regressions were used for analyses. The first predicted acquisition of UTI as a function of indwelling urinary catheter use, adjusting for age, diabetes, gender, and injury severity. The second predicted hospital mortality as a function of UTI, covarying for age, gender, chronic obstructive pulmonary disease, congestive heart failure, hypertension, diabetes, pneumonia, and injury severity. RESULTS: After excluding patients who stayed in the hospital <3 days and those with a UTI on arrival, 5,736 patients were included in the study. Of these patients, 680 (11.9%) met criteria for a UTI, with 487 (71.6%) indwelling urinary catheter-related infections. Predictors of UTI included the interaction between age and gender (p = 0.0018), Injury Severity Score (p = 0.0021), and indwelling urinary catheter use (p < 0.001). The development of a UTI predicted the risk of in-hospital death as a patient's age increased (p = 0.002). Similar results were seen when only catheter-associated UTIs are included in the analysis. CONCLUSIONS: Indwelling urinary catheter use is connected to the development of UTIs, and these infections are associated with a greater mortality as the age of a trauma patients increases.

Impact of socioethnic factors on outcomes following traumatic brain injury.

BACKGROUND: Ethnic minorities and low income families tend to be in poorer health and have worse outcomes for a spectrum of diseases. Health care provider bias has been reported to potentially affect the distribution of care away from poorer communities, minorities, and patients with a history of substance abuse. Trauma is perceived as a disease of the poor and medically underserved. Minorities are overrepresented in low income populations and are also less likely to possess health insurance leading to a potential overlapping effect. Traumatic brain injury (TBI) is a predominant cause of mortality and long-term morbidity, which imposes a considerable social and financial burden. We therefore sought to determine the independent effect on outcome after TBI from race, insurance status, intoxication on presentation, and median income. METHODS: A 5-year retrospective chart review of admitted trauma patients aged 18 years and older to a Level I trauma center. Zip code of residency was a surrogate marker for socioeconomic status, because median income for each zip code is available from the US Census. Charts review included race, insurance status, mechanisms of trauma, and injuries sustained. Outcomes were placement of tracheostomy, hospital length of stay (HLOS), leaving Against Medical Advice (AMA), and discharge to home versus rehabilitation and mortality. RESULTS: A total of 3,101 TBI patients were included in the analyses. Multivariable logistic and proportional hazard regression analyses were undertaken adjusting for age, gender, Injury Severity Score, and mechanism. Rates of tracheostomy placement were unaffected by race, median income, or insurance status. Race and median income did not affect HLOS, but private insurance was associated with shorter HLOS and intoxication was associated with longer HLOS. Neither race nor intoxication affected rates of AMA, but higher income and private insurance was associated with lower rates of AMA. Non-Caucasian race and lack of insurance had significantly lower likelihood of placement in a rehabilitation center. Mortality was unaffected by race, increased in intoxicated patients, was variably affected by median income, and was lowest in patients with private insurance. CONCLUSIONS: An extremely complex interplay exists between socioethnic factors and outcomes after TBI. Few physicians would claim overt discrimination. Tracheostomy, the factor most directed by the surgeon, was unbiased by race, income, or insurance status. The likelihood of placement in a rehabilitation center was significantly impacted by both race and insurance status. Future prospective studies are needed to better address causation.

Peritoneal free air due to evacuation of pneumobilia in blunt abdominal trauma.

Pneumobilia is mostly observed on computed tomography (CT) following surgical biliary-enteric anastomosis and biliary manipulation through endoscopic procedures. Although pneumobilia can be seen in pathological conditions, post-surgical pneumobilia is typically not associated with morbidity. In the present article, we report a case in which blunt abdominal trauma led to the evacuation of pre-existing pneumobilia causing pneumoperitoneum. Given that the subsequent laparotomy proved to be non-therapeutic, this report adds to the few cases of intra-peritoneal free air not helped by surgical intervention.

Normal presenting vital signs are unreliable in geriatric blunt trauma victims.

BACKGROUND: Normal vital signs are typically associated with improved outcomes in trauma patients. Whether this association is true for geriatric patients is unclear. METHODS: A Level 1 trauma center retrospective chart review of vital signs on presentation (heart rate [HR] and blood pressure) in young (aged 17-35 years) and geriatric (aged 65 years or older) blunt trauma victims from September 2003 to September 2008 was preformed. Generalized nonlinear using piecewise regression for the linear portion of standard logistic models was used to model risk of mortality as a function of HR and blood pressure. Independent models were selected for elderly and young trauma patients based on blood pressure and HR. Models of the same complexity were then fit within each gender and age. RESULTS: There were 2,194 geriatric and 2,081 young patients. Two hundred fifty-one (11.4%) geriatric and 49 (2.4%) young patients died. At all points of "normality," the mortality of the geriatric patients was higher than the young group. Mortality increases considerably in the elderly patients for HRs >90 beats per minute (bpm), an association not seen until HR of 130 bpm in the young group. Mortality significantly increases with systolic blood pressure (SBP) <110 mm Hg in the geriatric patients but not until a SBP of 95 mm Hg in the young patients. HR and mortality association was most variable in the male geriatric patients. CONCLUSIONS: Vital signs on presentation are less predictive of mortality in geriatric blunt trauma victims. Geriatric blunt trauma patients warrant increased vigilance despite normal vital signs on presentation. New trauma triage set points of HR >90 or SBP <110 mm Hg should be considered in the geriatric blunt trauma patients.

Management of the most severely injured spleen: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT).

OBJECTIVE: To determine the rate and predictors of failure of nonoperative management (NOM) in grade IV and V blunt splenic injuries (BSI). DESIGN: Retrospective case series. SETTING: Fourteen trauma centers in New England. PATIENTS: A total of 388 adult patients with a grade IV or V BSI who were admitted between January 1, 2001, and August 31, 2008. MAIN OUTCOME MEASURES: Failure of NOM (f-NOM). RESULTS: A total of 164 patients (42%) were operated on immediately. Of the remaining 224 who were offered a trial of NOM, the treatment failed in 85 patients (38%). At the end, 64% of patients required surgery. Multivariate analysis identified 2 independent predictors of f-NOM: grade V BSI and the presence of a brain injury. The likelihood of f-NOM was 32% if no predictor was present, 56% if 1 was present, and 100% if both were present. The mortality of patients for whom NOM failed was almost 7-fold higher than those with successful NOM (4.7% vs 0.7%; P = .07). CONCLUSIONS: Nearly two-thirds of patients with grade IV or V BSI require surgery. A grade V BSI and brain injury predict failure of NOM. This data must be taken into account when generalizations are made about the overall high success rates of NOM, which do not represent severe BSI.

The multiply injured trauma patient: resuscitation, rehabilitation, recovery.

The care of the acutely injured patient requires a multidisciplinary approach from the moment of injury through rehabilitation and reintegration into society. In addition to the doctors and nurses providing many aspects of the acute and chronic medical care, the rehabilitation component is delivered by several skilled specialists focused on maximizing functional outcomes.

Ultrasound-guided peripheral intravenous access in the intensive care unit.

PURPOSE: Central venous catheters continue to be a popular means of maintaining vascular access in surgical intensive care units despite well-described complications. With edema, obesity, and difficult to visualize veins potentially affecting the surgically ill, inability to obtain peripheral intravenous (PIV) access may hinder the clinician's ability to avoid the use of central lines. With ultrasound gaining increased popularity for obtaining vascular access, we evaluated its utility in ultrasonagraphically placing PIV catheters for the purposes of either avoiding central venous access or removing central venous catheters. MATERIALS AND METHODS: We performed a retrospective cohort review of our requests for ultrasound-guided PIV access in the intensive care unit between September 2007 and February 2008. RESULTS: Over a 6-month period, 77 requests for ultrasound-guided PIV access were made for 59 surgical, trauma, and cardiothoracic intensive care unit patients. Reasons for inability to obtain PIVs through standard means included edema (95%), obesity (42%), IV drug abuse history (8%), and emergency access (4%). Of the 148 PIV lines that were requested, 147 PIV catheters were successfully placed (99%). Of these, 105 PIV catheters were placed on the first attempt (71%). Complications of PIVs included IV infiltration (3.4%), inadvertent removal (2.7%), and phlebitis/cellulitis (0.7%). As a result of placing these PIV catheters, 40 central lines were discontinued and 34 central lines were avoided. The average number of line days at the time of central venous catheter removal was 11 ± 11 days. CONCLUSION(S): In intensive care unit patients who do not require central venous lines, ultrasound-guided PIV access can have a high placement success rate and can result in fewer central line days and/or less reliance on central venous catheters for access-only purposes.

The evolution of the Rhode Island trauma system: where do we stand?

The Rhode Island Trauma System today has been shown to demonstrate several positive attributes in the delivery of patient care; however, ongoing efforts need to continue in the realms of field and inter-facility communication, efficiency in inter-hospital transfer, and rehabilitation services. Through ongoing dialogue and the fundamental desire to improve, it remains our goal to provide patients the best care possible during one of the most stressful times of their lives.