Analysis of surgical participation in the Advanced Trauma Life Support course. What are the goals and are we meeting them?

Advanced Trauma Life Support (ATLS) course records spanning 4 years were examined and American College of Surgeons members in Washington State surveyed to gain further information on ATLS course participants, skills utilization, and hospital credentialing. Thirty-seven (9.7%) of 382 course participants were trained general surgeons, 56 (14.7%) were surgical residents, and 12 (3.1%) were surgical specialists. One hundred thirty-six (35.6%) of the participants were primary care physicians and 115 (30.1%) were emergency physicians. Surgical residents, primary care physicians, and emergency physicians tended to be overrepresented in ATLS courses in comparison with their general distribution. Fully trained surgeons and surgical specialists were underrepresented. Course participants represented 3.8% of all physicians involved in patient care in the state. Only 6.4% of all active general surgeons in the state were participants, while 39% of active emergency physicians participated. The successful completion rate was 94% (98% for surgeons and 92% for nonsurgical physicians). Thirty-one percent of all American College of Surgeons survey respondents (31% of urban practitioners and 21% of rural practitioners) reported current ATLS qualification. Advanced Trauma Life Support qualification was reported by 31% of respondents as a requirement for taking trauma/emergency department call. Surgeons with a preference not to treat patients with trauma were less likely to have ATLS qualification. More than half of those who reported ATLS qualification had not performed a tracheal intubation, cricothyroidotomy, pericardiocentesis, or emergency department thoracotomy in the previous year. Participation of surgeons in ATLS courses is low, particularly among rural practitioners. Impetus for participation appears related to requirements for hospital staff credentialing and preferences for treating patients with trauma. Performance of procedures taught in the course is rare. Strategies to increase participation need to be formulated and implemented.

Why surgeons prefer not to care for trauma patients.

A survey of the Washington State Chapter of the American College of Surgeons was undertaken to document the opinions of surgeons on trauma care issues. Thirty-nine percent of the total sample of surgeons who responded would prefer not to treat any trauma patients. These surgeons were more likely to be older, to practice in an urban setting, to feel that trauma call has a negative impact on elective practice, and to believe more strongly that reimbursement from trauma patients is not equal to that of nontrauma patients. They also agreed more strongly with the statements that these patients require a greater time commitment and pose an increased medicolegal risk. The most significant influence on preference not to treat trauma patients was exerted by the perception of a negative impact on practice, older age, and perception of increased medicolegal risk. Reimbursement issues and location of practice were less influential factors. This information can be used to target concerns and barriers to active, willing participation in a trauma care system and to tailor strategies to deal with them effectively.

Trauma during pregnancy. A review of 79 cases.

Few studies provide data on pregnant trauma patients that can be used to direct management decisions. Therefore, this retrospective study of 79 pregnant patients who were injured and admitted to a trauma center during a 9-year period was conducted to obtain such information. Maternal mortality for these pregnant patients was 10%, which was not different from that for nonpregnant females. Overall, rate of fetal loss was 34%. Rates of fetal loss were not different in patients with and without evidence of shock and/or hypoxia or in restrained and unrestrained automobile occupants. Diagnostic peritoneal lavage proved to be 95% accurate and safe. Based on these findings, we concluded the following: pregnancy does not increase maternal mortality from trauma. Blood pressure, pulse rate, and PO2 are unreliable indicators of adequate maternal resuscitation and fetal well-being. Assumption of maternal and fetal stability based solely on these usually standard criteria is unwise. Use of seat belts during pregnancy is advisable in the absence of evidence that restraints increase the rate of fetal loss.

Do prehospital trauma center triage criteria identify major trauma victims?

OBJECTIVE: To evaluate anatomic, physiologic, and mechanism-of-injury prehospital triage criteria as well as the subjective criterion of provider "gut feeling." DESIGN: Prospective analysis. SETTING: A state without a trauma system or official trauma center designation. PATIENTS: Patients treated by emergency medical services personnel statewide over a 1-year period who were injured and met at least one prehospital triage criterion for treatment at a trauma center. MAIN OUTCOME MEASURES: Outcome was analyzed for injury severity using the Injury Severity Score and mortality rates. A major trauma victim (MTV) was defined as a patient having an Injury Severity Score of 16 or greater. The yield of MTV and mortality associated with each criterion was determined. RESULTS: Of 5028 patients entered into the study, 3006 exhibited a singular entry criterion. Triage criteria tended to stratify into high-, intermediate-, and low-yield groups for MTV identification. Physiologic criteria were high yield and anatomic criteria were intermediate yield. Provider gut feeling alone was a low-yield criterion but served to enhance the yield of mechanism of injury criteria when the two criteria were applied in the same patient. CONCLUSIONS: A limited set of high-yield prehospital criteria are acceptable indicators of MTV. Isolated low- and intermediate-yield criteria may not be useful for initiating trauma center triage or full activation of hospital trauma teams.

Resuscitative thoracotomy performed in the operating room.

The efficacy of resuscitative thoracotomy in the trauma patient has been questioned. Survival rates are variable, but a review of resuscitative thoracotomy in the emergency department of our institution documented an overall survival rate of only 1.8%. Higher survival rates may be anticipated in patients initially presenting with signs of life who can be transported directly to the operating room prior to the need for resuscitative thoracotomy. To test this hypothesis, the clinical course of all injured patients undergoing urgent or exigent thoracotomy in the operating room between July 1983 and June 1989 was reviewed. There were 34 patients undergoing exigent/resuscitative thoracotomy, 8 with penetrating injuries, 25 with blunt trauma to multiple systems, and 1 with isolated blunt chest trauma. Eight median sternotomies were performed and 26 left or bilateral thoracotomies. Twenty-six patients underwent concurrent exploratory celiotomy. The overall survival rate was 9% (3 of 34). The survival rate for patients with penetrating injuries was 37.5% (3 of 8) and 0% (0 of 26) for those with blunt trauma. Fifty-four patients underwent urgent/nonresuscitative thoracotomy with an overall survival rate of 74% (40 of 54). Combined group survival rates were 49% overall, 77% for patients with penetrating wounds, and 22% for patients with blunt trauma. These data underscore the futility of resuscitative thoracotomy in patients with blunt trauma who have deteriorated to the point of being in extremis. The relatively high salvage rates in patients with penetrating injuries support continued use of resuscitative thoracotomy when vital signs are lost, particularly if the injury is to the thorax. Variability in reported survival rates may be primarily due to the mix of patients with blunt trauma and penetrating injuries and disagreement as to what constitutes a resuscitative thoracotomy.

Human immunodeficiency virus and infectious considerations.

In summary, HIV is a retrovirus with devastating consequences for those infected. Primary modes of transmission are through sexual contact and parenteral exposure to infected blood and body fluids. Prevalence of the virus among trauma patients, risk of exposure, and infection of health care workers are variable and to a large extent not known. Existing HIV infection and AIDS have both direct and indirect effects on care and outcome of trauma patients. Caring for these patients presents many challenges. Manifestations and complications of each condition may mask, mimic, or compound the other. Optimal care and outcome depend on knowledge of both diseases, and the specific nuances of their management. As with all trauma patients, a team approach coordinated by an identified team leader is indicated. Finally, to protect both the patient and the care giver, policies that effectively reduce exposure must be formulated, promulgated, and practiced.

Trauma during pregnancy.

The appearance of a pregnant trauma patient is rare even in the busiest of trauma centers. Management of these cases can present difficult challenges. A successful outcome for both mother and child is dependent on an immediate team approach and response involving physician, nursing, and ancillary staff. The disciplines of emergency medicine, trauma surgery, obstetrics, and perinatology must be involved primarily in a timely and appropriate fashion. Other consultants required for the optimal treatment of injuries and pregnancy must also play a timely role. An aggressive rather than timid approach to resuscitation, diagnosis, and treatment of these patients must be taken. Knowledge of the normal physiologic changes occurring during pregnancy, special attention to prevention and early recognition of occult maternal hypoxia and hypovolemia, as well as a high index of suspicion for injuries to mother and fetus likely to occur during pregnancy should guide and temper management strategies. Care providers should resist emotional distractions and the urge to focus on the fetus before the mother is properly stabilized and evaluated. They should be cognizant of the fact that an apparently stable mother may be compensating at the expense of the fetus. Finally, the tenet of what benefits the mother will ultimately benefit the fetus should be adhered to. When these points are kept in mind, the potential for successful outcome and satisfying results is greatest for all parties involved.

The impact of variation in trauma care times: urban versus rural.

STUDY OBJECTIVES: To document the existence and nature of variation in times to trauma care between urban and rural locations; to assess the impact of identified variations on outcome. DESIGN: Retrospective case review. SETTING: Washington state, 1986. PARTICIPANTS: Motor-vehicle-collision fatalities. METHODS: Previously unreported definitions of urban and rural location and possibly preventable death were used to conduct a comparative analysis of urban and rural fatalities. Trauma care times in the prehospital and the emergency department (ED) phases of care were abstracted. Their relationships to corresponding crude death rates and possibly preventable death rates also were examined. RESULTS: Prehospital times averaged two times longer in rural locations than in urban areas. Fist-physician contact in the ED averaged six times longer in rural locations than in urban settings. Concomitantly, the crude death rate in rural settings was three times that of the urban areas. The overall possibly preventable death rate was double the urban rates in rural incidents. When stratified by phase of care, rate of possibly preventable death showed no urban/rural variation for the prehospital phase, but was three times greater for the ED phase in rural areas than in urban ones. CONCLUSIONS: Trauma care times and adverse outcome appear to be associated. Allocation of resources to decrease length of and geographic variation in time to definitive care, particularly in the ED phase, seems appropriate.

Traumatic lumbar hernia: case report and literature review.

Lumbar hernia is an uncommon abdominal wall hernia. Acute abdominal wall hernias, particularly lumbar hernias, are a rare complication of trauma. We present a case of acute lumbar hernia as a direct effect of blunt abdominal trauma. Double-contrast CT scan detected herniation of bowel through an 8-cm right flank defect, which was surgically repaired with a prosthetic patch and omentopexy. In cases of acute traumatic lumbar hernia, immediate exploratory laparotomy with primary repair (when feasible) is recommended.

Appendicitis after laparoscopic appendectomy: a warning.

Surgical options for appendicitis have increased, just as they have with cholecystitis. The laparoscope can now be utilized in place of the standard open operation for treatment of appendicitis. Like laparoscopic cholecystectomy, laparoscopic appendectomy can be associated with increased morbidities, not usually seen with open surgery. We present a case of the unusual complication of recurrent appendicitis in a generous appendiceal remnant after laparoscopic appendectomy.

State trauma system evaluation: a unique and comprehensive approach.

We detail the unique and comprehensive approach to evaluation taken by the state of Washington before development and legislation of a statewide trauma system plan. The various types of data collected and the rationale for collecting them are discussed. In addition, the advantages, disadvantages, and limitations of individual study methods are elucidated. These data-gathering approaches may serve as a guide for other states or regions contemplating comprehensive trauma system development.

Evaluation of blunt abdominal trauma occurring during pregnancy.

Evaluation of abdominal trauma in pregnant patients presents a number of dilemmas. Few series compare the various modalities available in this situation. The present review characterizes various techniques and their results. The charts of all patients with a secondary diagnosis of pregnancy admitted to a Level I trauma center over a 7 1/2-year period were reviewed. Forty were considered to have sustained possible blunt abdominal trauma: 30 were occupants in motor vehicle collisions, five were pedestrians, four sustained falls, and one was riding a motorcycle. Immediate laparotomy for emergency caesarean section or other indications was performed in three cases (7%). In 13 cases (32%) evaluation was accomplished by diagnostic peritoneal lavage (DPL). Three patients (7%) underwent computerized tomography of the abdomen. The remaining 22 patients (55%) were observed with serial physical exams, and hematocrits. The group that was observed had a mean ISS of 5.9. The mean Glasgow Coma Score (GCS) was 14.9. No patients had to undergo exploratory laparotomy for abdominal injury during hospitalization. In the 13 patients undergoing DPL, the mean ISS was 34.6, and the mean GCS was 10.6. Overall accuracy was 92% with no major complications. Pregnant patients sustaining minor injuries and blunt abdominal trauma may be safely observed. Those with major injuries, shock, altered mental status, or neurologic deficit require further studies to rule out intra-abdominal injury. Diagnostic peritoneal lavage proved to be safe and accurate in these patients. Diagnostic peritoneal lavage proved to be safe and accurate in these patients. CT scan and ultrasonography are other modalities which merit further assessment as a primary diagnostic technique in abdominal trauma occurring during pregnancy.

Trauma in pregnancy: normal Revised Trauma Score in relation to other markers of maternofetal status--a preliminary study.

OBJECTIVE: Our goal was to examine whether a correlation exists between the Revised Trauma Score assigned on admission and pregnancy outcome, as well as whether the Revised Trauma Score has any predictive value for optimal duration of cardiotocographic monitoring necessary to detect immediate adverse pregnancy outcome. STUDY DESIGN: A retrospective chart review was performed of 30 pregnant trauma patients admitted during a 1-year period. Evaluation of cardiotocographic data for either contractions or decelerations or both was performed without knowledge of Revised Trauma Score or maternofetal outcome at discharge. RESULTS: Review of uterine activity and fetal decelerations did not detect useful predictive patterns unless the tracing was immediately ominous, although uterine activity did initially decrease over time. CONCLUSIONS: The Revised Trauma Score lacks predictive value for both risk of adverse pregnancy outcome and need for prolonged cardiotocographic monitoring. A larger patient population needs to be studied for an accurate determination of whether the Revised Trauma Score has potential as a predictive tool.

Blunt trauma during pregnancy: factors affecting fetal outcome.

During a 9 1/2-year period, 76 pregnant women who sustained blunt trauma were admitted to a level-I trauma center. Fetal outcome was ascertained in 59 patients (78%). Successful delivery was noted in 35 patients (46%). Eight patients (11%) elected to undergo abortion for nonmedical reasons. Sixteen patients (21%) sustained fetal loss, and 17 patients (22%) were lost to follow-up. The 51 patients who either delivered successfully or experienced a fetal loss were studied to determine the factors that affected fetal outcome. Variables analyzed included gestational age and maternal age, Glasgow Coma Scale score, serum bicarbonate level, pH, PCO2, PO2, blood pressure, heart rate, Injury Severity Score, and performance of surgery or diagnostic peritoneal lavage. Logistic regression analysis revealed that ISS (p less than 0.01) and admission serum bicarbonate level (p less than 0.02) have the most significant correlation with fetal outcome. No other variable exhibited a statistically significant influence on fetal outcome. This information documents that fetal demise is related to severity of maternal injury as characterized by ISS. A low serum bicarbonate level corresponds to maternal hypoperfusion and hypoxia, which may be otherwise unrecognized because of the normal physiologic changes occurring during pregnancy. Based on these findings, routine serum bicarbonate determination in all pregnant patients being evaluated for trauma is advocated. Performance of DPL and surgery do not have a significant association with fetal loss and therefore should not be withheld when indicated in a pregnant patient.

General surgeons and the Advanced Trauma Life Support course: is it time to refocus?

OBJECTIVE: The aim of this study was to assess Advanced Trauma Life Support (ATLS) training status of general surgeons, its perceived utility, and its relation to clinical trauma practice. METHODS: A national sample of 1300 general surgeons was surveyed by mail about trauma training, ATLS status, trauma call, and confidence in clinical trauma care abilities. RESULTS: Response rate was 61%. Respondents most commonly (67%) felt they learned a great deal about trauma care in residency training; 13% responded similarly regarding ATLS. Course participation within 4 years of the survey was reported by 33% of respondents. Nearly 75% of those not taking the course cited primary reasons related to relevance (30%), redundancy (29%), and credentialing (15%). Inaccessibility, inconvenience, and cost were lesser factors. Of those expressing extreme confidence with trauma resuscitation, 40% had taken ATLS; 15% of those expressing a lesser degree of confidence had taken ATLS. CONCLUSIONS: The ATLS course represents a standard of initial trauma care education in which only one-third of surgeons report current participation. Many view ATLS as not relevant or useful, yet take trauma call. To ensure standard education and patient care, an ATLS course curriculum specifically geared to the general surgeon should be developed and made a mandatory component of residency training or a requirement for board certification and trauma call credentialing.

Analysis of preventable trauma deaths and inappropriate trauma care in a rural state.

OBJECTIVE: The goal of this study was to determine the rate of preventable mortality and inappropriate care in cases of traumatic death occurring in a rural state. DESIGN: This is a retrospective case review. MATERIALS AND METHODS: Deaths attributed to mechanical trauma throughout the state and occurring between October 1, 1990 and September 30, 1991 were examined. All cases meeting inclusion criteria were reviewed by a multidisciplinary panel of physicians and nonphysicians representing the prehospital as well as hospital phases of care. Deaths were judged frankly preventable, possibly preventable, or nonpreventable. The care rendered in both preventable and nonpreventable cases was evaluated for appropriateness according to nationally accepted guidelines. MEASUREMENTS AND MAIN RESULTS: The overall preventable death rate was 13%. Among those patients treated at a hospital, the preventable death rate was 27%. The rate of inappropriate care was 33% overall and 60% in-hospital. The majority of inappropriate care occurred in the emergency department phase and was rendered by one or more members of the resuscitation team, including primary contact physicians and surgeons. Deficiencies were predominantly related to the management of the airway and chest injuries. CONCLUSIONS: The rural preventable death rate from trauma is not dissimilar to that found in urban areas before the implementation of a trauma care system. Inappropriate care rendered in the emergency department related to airway and chest injury management occurs at a high rate. This seems to be the major contributor to preventable trauma deaths in rural locations. Education of emergency department primary care providers in basic principles of stabilization and initial treatment may be the most cost-effective method of reducing preventable deaths in the rural setting.

A statewide profile of general surgery trauma practice.

This study profiles the practices, experience, and viewpoints of general surgeons treating trauma patients throughout a state. A mail survey of the American College of Surgeons State Chapter membership was conducted. Response rate of general surgeons was 65%. Typically, the trauma surgeon is between 30 and 50 years old, having received formal trauma experience through residency training only. Thirty-nine per cent report current ATLS certification. Practices are most commonly based at a community hospital in an urban setting. Half of surgeons treating trauma operate at more than one hospital and nearly a third take call at more than one hospital simultaneously. Eighty-seven per cent of respondents reported trauma patients comprise less than one quarter of their practice. Most (68%) admitted fewer than 25 trauma patients to their service in the year before the survey and 78% reported performing less than ten trauma laparotomies in the prior year. Fifty-eight per cent disagree that every general surgeon should routinely manage major trauma and 83% feel that traumatology entails a specific body of knowledge and expertise. Of the various components of trauma care, the role of the surgeon in trauma prevention and administrative duties was ranked at least important. The areas of surgeon availability, uniformity of basic experience and adequate maintenance of skills need further analysis.

Changing epidemiology of injury-related pediatric mortality in a rural state: implications for injury control.

STUDY OBJECTIVE: To document the current epidemiology of pediatric injury-related deaths in a rural state and evaluate changes over time. DESIGN: Retrospective review of injury-related deaths in children less than 15 years of age. Data were obtained from death certificates and coroner, autopsy, prehospital, and hospital records. Analysis was done of the mechanism of injury, age, sex, race, location of incident, toxicology, and safety device use. Comparisons with analogous data collected from an earlier time period were made. SETTING: The state of Montana, from October 1989 to September 1992. MEASUREMENTS: Deaths per 100,000 population, intentionality of injury, mechanism of injury, use of protective devices, and comparisons with previous data (1980-1985) collected by Baker and Waller (Childhood injury: State by state mortality facts. Baltimore: Johns Hopkins Injury Prevention Center, 1989;148-152). RESULTS: Of 121 patients reviewed, 56% were male and 44% were female. Mean age was 7.0 years (median, 8.0). Eighty-one percent of patients were Caucasian, and 16% were Native American. The leading cause of injury was motor vehicle crashes, which was followed by drowning, unintentional firearm injuries, deaths related to house fires, homicides, and suicides. Overall, 87% of injuries were unintentional and 13% were intentional, with 62% of these suicides and 38% homicides. When considered independently of intent, firearm-related injuries ranked second. Earlier data showed motor vehicle crashes ranking second, unintentional firearm injuries seventh, and homicide fourth. Comparison of death rates per 100,000 people for the two time periods showed increases in suicide deaths (3.2 vs 0.8) and unintentional firearm injury deaths (2.3 vs 0.6). CONCLUSION: The epidemiology of rural pediatric injury-related deaths has changed. Deaths related to suicide and firearms have increased. Violent deaths related to injuries caused by firearms are at a magnitude approaching all other causes. These findings have implications for public health education and injury control strategies in rural areas.