Timing is everything: delayed intubation is associated with increased mortality in initially stable trauma patients.

BACKGROUND: The indications for immediate intubation in trauma are not controversial, but some patients who initially appear stable later deteriorate and require intubation. We postulated that initially stable, moderately injured trauma patients who experienced delayed intubation have higher mortality than those intubated earlier. METHODS: Medical records of trauma patients intubated within 3 h of arrival in the emergency department at our university-based trauma center were reviewed. Moderately injured patients were defined as an ISS < 20. Early intubation was defined as patients intubated from 10-24 min of arrival. Delayed intubation was defined as patients intubated ≥25 min after arrival. Patients requiring immediate intubation, within 10 min of arrival, were excluded. RESULTS: From February 2006 to December 2007, 279 trauma patients were intubated in the emergency department. In moderately injured patients, mortality was higher with delayed intubation than with early intubation, 11.8% versus 1.8% (P = 0.045). Patients with delayed intubations had greater frequency of rib fractures than their early intubation counterparts, 23.5% versus 3.6% (P = 0.004). Patients in the delayed intubation group had lower rates of cervical gunshot wounds than the early intubation group, 0% versus 10.7% (P = 0.048) and a trend toward fewer of skull fractures 2.9% versus 16.1%, (P = 0.054). CONCLUSIONS: These findings suggest that delayed intubation is associated with increased mortality in moderately injured patients who are initially stable but later require intubation and can be predicted by the presence of rib fractures.

Adolescent smokers show decreased brain responses to pleasurable food images compared with nonsmokers.

INTRODUCTION: Nicotine acts on the mesocorticolimbic circuits of the brain leading to the release of dopamine. Repeated elevations of dopamine in the brain may cause smokers to become less sensitive to "natural reinforcers." To test the theory that adolescents with low nicotine exposure may already have decreased activation when exposed to a natural reinforcer, we looked at the effect of visual cues representing "pleasurable" food on light adolescent smokers compared with nonsmokers. METHODS: Twelve adolescent light smokers (aged 13-17 years, smoked 1-5 cigarettes/day) and 12 nonsmokers (aged 13-17 years, never smoked a cigarette) from the San Francisco Bay Area underwent functional magnetic resonance imaging scanning. During scanning, they viewed blocks of photographic images representing pleasurable foods (sweet, high fat, and salty foods) and control cues. RESULTS: Smokers reported smoking a mean of 3.6 cigarettes/day. There was no difference in body mass index between groups (24.1 vs. 24.0, respectively, p = .99). Food images elicited greater activations in nonsmokers in multiple areas including the insula (T = 4.38, p < .001), inferior frontal region (T = 5.12, p < .001), and rolandic operculum (T = 6.18, p < .001). There were no regions where smokers demonstrated greater blood oxygenation level-dependent activations compared with nonsmokers when viewing food versus neutral images. CONCLUSIONS: The finding of decreased activation to pleasurable food among adolescent light smokers supports the theory that these adolescents are displaying decreased sensitivity to at least one natural reinforcer. This also supports the theory that nicotine may affect the brain early in the trajectory of smoking, thus underscoring the need for early intervention among adolescent smokers.

Smoking-related cue-induced brain activation in adolescent light smokers.

PURPOSE: To examine using functional magnetic resonance imaging whether adolescents with low levels of nicotine exposure (light smokers) display neural activation in areas shown to be involved with addiction in response to smoking-related stimuli. DESIGN/SETTING/PARTICIPANTS: A total of 12 adolescent light smokers (aged 13-17, who smoked 1-5 cigarettes per day) and 12 nonsmokers (ages 13-17, never smoked a cigarette) from the San Francisco Bay Area underwent functional magnetic resonance imaging scanning. During scanning, the adolescents were shown photographic blocks of smoking and control cues. Smoking cues comprised pictures of individuals smoking cigarettes and smoking-related objects such as lighters and ashtrays. Neutral cues comprised images of everyday objects and individuals engaged in daily activities. FINDINGS: For smokers, smoking cues elicited greater activation than neutral cues in the mesolimbic reward circuit (left anterior cingulate: t = 7.04, p < .001; right hippocampus: t = 6.37, p < .001). We found activation from smoking cues versus neutral cues within both the left and right frontal medial orbital regions (t = 5.09, p < .001 and t = 3.94, p = .001, respectively). Nonsmokers showed no significant difference in activation between smoking-related cues and neutral cues. CONCLUSION: Our finding that smoking cues produced activation in adolescent light smokers in brain regions, similar to that seen in adult and teenage heavy smokers, suggests that adolescents exhibit heightened reactivity to smoking cues even at low levels of smoking. This article adds to the existing published data by suggesting that nicotine dependence may begin with exposure to low levels of nicotine, thus underscoring the need for early intervention among adolescent smokers.