Motivation of trauma patients to stop smoking after admission to the emergency department.

Every smoker should be offered smoking cessation treatment when they present for clinical care. The Readiness to Change-Smokers (RTC-S) questionnaire and the Heidelberg Smoking History (HSH) are brief questionnaires that divide patients into three stages. The purpose of this study was to prospectively compare the performance of each questionnaire at identifying patients who will successfully quit smoking within one year of Emergency Department (ED) discharge. Out of 1292 injured ED patients nearly half (n = 599, 46.4%) were identified as current smokers. Both questionnaires were given to all 599 subjects, and used to divide patients into three stages. At 12-months postdischarge 306 patients (51.1%) were contacted to determine smoking status. Patients were similarly classified by both tests in only 36% of cases. Concordance between tests was poor (kappa = 0.33). The RTC-S classified fewer patients as ready to quit (A = 13% vs. 22.2%). At 12 month follow-up, 55 patients (17.9%) had stopped smoking. The HSH was more successful to predict quitters. Multivariate logistic regression with respect to smoking cessation resulted in significant impact of HSH (p = 0.024).

Trauma patients' desire for autonomy in medical decision making is impaired by smoking and hazardous alcohol consumption--a bi-national study.

This cross-sectional investigation studied the association between substance use and patients' desire for autonomy in medical decision making (MDM) in two trauma settings. A total of 102 patients (age 42.7 +/- 17.4 years, 70.6% male) admitted to an orthopaedic service in Warsaw, Poland, and 1009 injured patients (age 34.6 +/- 12.8 years, 62.3% male) treated in an emergency department in Berlin, Germany, were enrolled. Patients' desire for autonomy in MDM was evaluated with the Decision Making Preference Scale of the Autonomy Preference Index. Substance use (hazardous alcohol consumption and/or tobacco use) and educational level were measured. Linear regression techniques were used to determine the association between substance use and desire for autonomy in MDM. Substance use was found to be independently associated with a reduced desire by the patient for autonomy in medical decision making. No differences in patients' desire for autonomy were observed between the study sites. Empowerment strategies that encourage smokers or patients with hazardous alcohol consumption to participate in MDM may increase the effectiveness of health promotion and injury prevention efforts in this population.

Limiting computed tomography to patients with peritoneal lavage-positive results reduces cost and unnecessary celiotomies in blunt trauma.

OBJECTIVE: To determine if computed tomographic (CT) scanning can be used to identify patients with blunt trauma, positive results of diagnostic peritoneal lavage (DPL), and a stable hemodynamic status who could be managed safely and cost-effectively without celiotomy. DESIGN: Patients with blunt trauma who required an abdominal evaluation underwent DPL. Patients with a red blood cell count greater than 10(11)/L (10(5)/mm3) on lavage then underwent CT. Patients with solid organ injury alone, as detected on CT scan, were observed; those with evidence of hollow viscus injury underwent celiotomy. RESULTS: Sixty-seven hemodynamically stable patients had a red blood cell count greater than 10(11)/L on DPL; 38 patients underwent subsequent CT scanning, and 29 underwent immediate celiotomy in violation of the protocol. Eleven patients in the protocol group ultimately underwent celiotomy. Overall, there were significantly fewer nontherapeutic celiotomies performed in the protocol group (2/38 vs 9/29, P < .01). There were no deaths in either group. Because DPL is less expensive than CT, limiting CT to patients with DPL-positive results and hemodynamic stability reduced the charges associated with abdominal evaluation by $580,594 over a period of 2 years. CONCLUSION: Limiting CT to the evaluation of patients with DPL-positive results and hemodynamic stability is safe, reduces charges, and results in a lower rate of nontherapeutic celiotomies compared with DPL alone.

Reasons why trauma surgeons fail to screen for alcohol problems.

BACKGROUND: Alcohol screening and intervention have been recommended as routine components of trauma care but are rarely performed. HYPOTHESIS: An association exists between current screening and counseling practices and the trauma surgeon's knowledge, attitude, and perceived role and responsibility toward alcohol problems. PARTICIPANTS: Random-sample survey (n = 241) of members of the American Association for the Surgery of Trauma. MAIN OUTCOME MEASURES: Reported screening and counseling practices. RESULTS: Fifty-four percent of respondents screened 25% or fewer patients, while only 29% screened most patients. The most common reason for not screening was "lack of time." Most (76%) were not familiar with the most common clinically used screening questionnaires, and 83% reported no training in alcohol screening. Screening was more likely if attending physicians perceived a major responsibility for screening (P<.001). Nonscreeners were twice as likely to state screening was "not what I was trained to do" and more frequently believed screening offends patients (P =.001). Independent predictors of screening were perceived major role responsibility (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.38-4.01) and confidence in screening ability (OR, 1.96; 95% CI, 1.05-3.67) and counseling ability (OR, 2.27; 95% CI, 1.34-3.85). Eighty-eight percent of respondents would be willing to devote time to training if shown that counseling is effective. CONCLUSIONS: Lack of screening and counseling appears to be due to cognitive factors, not lack of motivation. Skills on how to screen and counsel for alcohol abuse should be taught to trauma surgeons, because a strong correlation exists between screening and confidence in skills. There is a need for education regarding results of effective intervention trials in medical settings.

Major injury as a unique opportunity to initiate treatment in the alcoholic.

A prospective study was performed on the use of a standard outpatient intervention technique to induce inpatient alcoholic trauma patients into accepting alcoholism treatment. Interventions were performed on 17 trauma patients. All patients who underwent intervention accepted treatment and were immediately transferred to a 28-day inpatient treatment facility. Alcoholic trauma patients are highly susceptible to intervention for their disease. We found that intervention performed upon discharge from the trauma service successfully initiates alcoholism treatment.

Advances in the management of hypothermia.

Many believe that the consequence of hypothermia is an orderly decrease in metabolism. However, oxygen consumption is increased, except when anesthetics and neuromuscular blocking agents are used to block the thermoregulatory response. This may be detrimental in patients with a bleeding diathesis as a result of the impairment of platelet function, activation of the fibrinolytic cascade, and inhibition of clotting enzyme kinetics that are associated with cooling of the blood. To date, a potential benefit of hypothermia in trauma patients has not been identified. Based on current data, every attempt should be made to prevent heat loss from occurring and to aggressively treat hypothermia once it has occurred.

Trauma critical care.

The surgical approach to the most injured patients has changed in recent years. Many patients arrive in the intensive care unit with problems that in the past would have been definitively addressed in the operating room, or led to the patient's demise due to continued attempts to complete all surgical procedures, despite deteriorating physiology. As a result, the triad of hypothermia, acidosis, and coagulopathy, along with the frequent complication of abdominal compartment syndrome, are critical factors that require correction in the intensive care unit. Prompt correction is necessary not only to allow expeditious completion of required surgical procedures, but because this triad, unless interrupted, invariably leads to death during resuscitation.

Continuous arteriovenous rewarming: report of a new technique for treating hypothermia.

Survival is rare after major trauma if core temperature falls below 32 degrees C. Available rewarming methods are often ineffective. We utilized arterial and venous catheters to create a circulatory fistula through the heating mechanism of a modified commercially available counter-current fluid warmer to achieve simple, rapid extracorporeal rewarming.

Treatment of hypothermia in trauma victims: thermodynamic considerations.

The relatively high specific heat of the human body makes hypothermia very difficult to treat. Although there are many treatment methods available, most evaluations of rewarming techniques are based on clinically observed rewarming rates, and they do not take into account initial core temperature, ambient temperature, the patient's own heat production, the effects of anesthesia, paralytic agents, and other variables. A heat transfer model is proposed that simulates the flow of heat through the body of a hypothermic patient. The model uses first principles involved in heat transfer and thermodynamics to describe the effects of currently available rewarming techniques. A commercially available routine is used to solve the equations, which also include any heat exchange between the patient's body and the environment, as well as metabolic heat generation as a function of time and core temperature. This thermodynamic analysis of rewarming, based on computer modeling of heat transfer, provides a scientific basis on which to establish guidelines for appropriate selection of treatment strategies for hypothermia, and it indicates that direct blood warming or infusion of warm intravenous fluids are the most effective rewarming techniques.

Practical guidelines for performing alcohol interventions in trauma centers.

Nearly 50% of trauma patients are injured while under the influence of alcohol; however, addressing alcohol problems is not considered a routine component of trauma care. A public health approach to trauma prevention should include attention to underlying risk factors in the same way that advice regarding smoking cessation is offered in adult respiratory medicine clinics, and blood pressure, cholesterol, dietary, and exercise advice is provided in coronary care units. The Department of Health and Human Services, in its recent report to Congress, stated that efforts to reduce death and disability from injuries must be combined with efforts to reduce alcohol abuse, and called for an increase in the use of alcohol interventions in trauma patients. According to the National Academy of Sciences, the responsibility to provide counseling for patients with uncomplicated cases of mild to moderate alcohol abuse lies not with specialized alcohol treatment centers, but with physicians and other health care staff in general hospital settings trained to provide brief interventions. This paper provides practical guidelines for the administration of alcohol interventions that are suitable for trauma center use, and that have documented efficacy in reducing alcohol consumption.

Near-infrared spectroscopy: continuous measurement of cytochrome oxidation during hemorrhagic shock.

OBJECTIVE: Mitochondrial cytochrome a,a3 redox shifts can be determined by near-infrared wavelength reflection. Since near-infrared wavelengths penetrate skin and bone, a potential exists to noninvasively measure mitochondrial oxidation using this phenomenon. The purpose of this study was to compare conventional parameters of resuscitation with regional measurements of spectroscopically derived cytochrome redox state in a hemorrhagic shock model. DESIGN: Prospective, controlled laboratory investigation. SETTING: Animal research laboratory of a university medical center. SUBJECTS: New Zealand white rabbits (n = 23), weighing 2 to 3 kg. INTERVENTIONS: After anesthesia and instrumentation, the subjects underwent laparotomy with placement of near-infrared spectroscopy probes on the stomach, liver, kidney, and hamstring muscle. Baseline measurements were obtained, and phlebotomy was used to reduce cardiac output by 60% for 30 mins. Animals were resuscitated with shed autologous blood and crystalloid to reach baseline cardiac output (0.9%), and were monitored for an additional 60 mins. MEASUREMENTS AND MAIN RESULTS: Significant correlations between mitochondrial cytochrome a,a3 redox state, cardiac output, and oxygen delivery were observed throughout shock and resuscitation. However, gastric cytochrome oxidation did not recover after shock, despite systemic evidence of adequate resuscitation (p < .05). CONCLUSIONS: Resuscitation from severe hemorrhagic shock may not uniformly restore cellular oxygenation, despite normalization of traditional parameters of resuscitation. Direct monitoring of cytochrome oxidation may be useful in identifying regional areas of dysoxia.

Near-infrared spectroscopy: a potential method for continuous, transcutaneous monitoring for compartmental syndrome in critically injured patients.

BACKGROUND: Near-infrared spectroscopy (NIRS) noninvasively measures tissue O2 saturation (StO2), and has been proposed as a means of monitoring for compartmental syndrome (CS). However, its specificity in hypoxemic, hypotensive patients with severely reduced systemic oxygen delivery has not been tested. We hypothesized that NIRS can differentiate muscle ischemia caused by shock from ischemia caused by CS. METHODS: Nine swine were anesthetized and an NIRS probe placed over the anterolateral compartment of the hind leg. Compartment pressure was also measured. A nerve stimulator was placed over the peroneal nerve, and CS was defined as loss of dorsiflexion twitch. At 30-minute sequential intervals, mean arterial blood pressure was reduced to 60% of baseline (phlebotomy), fraction of inspired oxygen was reduced to 0.15, and compartment pressure was increased in one limb by interstitial albumin infusion until CS occurred. RESULTS: Hypotension combined with hypoxemia reduced StO2 from 82+/-4% to 66+/-10%. CS further reduced StO2 to 16+/-12% (p<0.0001). During hypotension + hypoxemia + CS, control limb StO2 was 70+/-15% (p = 0.0002 vs. experimental limb). CONCLUSION: NIRS detects muscle ischemia caused by CS despite severe hypotension and hypoxemia, making it potentially useful in critically injured, unstable patients.

The intravascular oxygenator (IVOX): preliminary results of a new means of performing extrapulmonary gas exchange.

Conventional management of adult respiratory distress syndrome (ARDS) with high minute ventilation, positive end-expiratory pressure (PEEP), and increased fractional inspired oxygen (FIO2) concentrations may worsen pulmonary injury. The intravascular oxygenator (IVOX) is a device made up of several hundred gas permeable hollow fibers that are inserted into the vena cava by femoral venous cutdown. Flow of gas through each fiber adds O2 and removes CO2 from the bloodstream. The purpose of this study was to determine if the IVOX significantly reduces the level of mechanical ventilatory support in ARDS patients. The IVOX was inserted in nine patients, and aborted in one because of technical complications. The IVOX increased PaO2 and reduced PaCO2, but the quantity of gas transfer was not sufficient to allow a reduction in PEEP, FIO2, or minute ventilation. Insertion of the IVOX decreased cardiac index and systemic oxygen delivery despite maximum fluid and inotropic support. Mortality was 80%. Although some gas exchange occurs, the current device does not allow a significant reduction in the level of mechanical ventilatory support and adversely affects systemic oxygen transport.

The impact of hypothermia on dilutional coagulopathy.

UNLABELLED: The control of hemorrhage in hypothermic patients with platelet and clotting factor depletion is often impossible. Determining the cause of coagulopathic bleeding (CB) will enable physicians to appropriately focus on rewarming, clotting factor repletion, or both. OBJECTIVE: To determine the contribution of hypothermia in producing CB and ascertain if simultaneous hypothermia and dilutional coagulopathy (DC) interact synergistically. METHOD: Prothrombin time, partial thromboplastin time, and platelet function were determined at assay temperatures of 29 degrees to 37 degrees C on normal and critically ill, noncoagulopathic (NC) individuals. Dilutional coagulopathy was created using buffered saline and the assays repeated. RESULTS: Hypothermic assay at < or = 35 degrees C significantly prolonged coagulation times. The effect of hypothermia on NC and DC samples was not different. CONCLUSION: Assays performed at 37 degrees C underestimate coagulopathy in hypothermic patients. The effect of hypothermia on NC and DC is not different, indicating the lack of a synergistic effect. Normalization of clotting requires both rewarming and clotting factor repletion.

Near-infrared spectroscopy versus compartment pressure for the diagnosis of lower extremity compartmental syndrome using electromyography-determined measurements of neuromuscular function.

BACKGROUND: Compartmental syndrome (CS) is difficult to diagnose in intensive care unit patients. Compartment perfusion pressure (CPP) is an invasive, indirect measure of ischemia. Near-infrared spectroscopy is noninvasive, and directly measures ischemia by transmitting light through tissues at wavelengths that react with hemoglobin to provide percent tissue oxygen saturation (Sto(2)). Animal studies demonstrate that Sto(2) is superior to CPP for detecting CS. However, there are no studies in humans comparing Sto(2) with CPP. We hypothesized that Sto(2) can reliably detect CS, and is superior to CPP. METHODS: CS was induced in 15 human volunteers using a standard calf compression model. At 30-minute intervals, compression was increased to reduce Sto(2) from baseline (86% +/- 4%) to 60%, 40%, 20%, and < 10%, with simultaneous recording of CPP. Outcome variables included deep peroneal nerve conduction assessed by electromyography, cutaneous peroneal nerve sensitivity using Semmes-Weinstein monofilaments, and pain (visual analog scale). RESULTS: Both Sto(2) and CPP significantly correlated with all ischemia outcome variables (p < 0.001). Receiver operating characteristic curves of deep peroneal nerve conduction demonstrated that Sto(2) had higher sensitivity than CPP for detecting > 50% block. For example, when specificity was 83% for Sto(2) and 84% for CPP, sensitivity was 85% versus 56%, respectively (p = 0.02). When specificity for both was 72%, sensitivity was 94% for Sto(2) versus 76% for CPP (p = 0.04). CONCLUSION: In intensive care unit patients who cannot alert physicians to symptoms, near-infrared spectroscopy may help clinicians to avoid delayed or unnecessary prophylactic fasciotomy, and provides the benefits of a continuous, noninvasive monitoring technique.

Nutritional assessment using a pulmonary artery catheter.

To determine if oxygen consumption (VO2) derived from the Fick equation (FE) can be used to determine energy expenditure (EE), 29 paired indirect calorimetry (IC) and FE VO2 determinations were obtained. The Weir equation was used to calculate EE from the FE VO2 value. There was a strong correlation between the methods (r = 0.82, p less than 0.001). Mean EE by IC and FE was 2460 +/- 539 and 2372 +/- 787 kcal/day, respectively, a difference of 88 +/- 467 kcal/day. A single IC determination is often used to guide nutrition for several days. To evaluate this practice, FE and IC determinations were repeated in 8 patients. There was a 19% difference in EE between initial and follow-up IC, which was identical to the mean difference between paired FE and IC measurements. FE can be used to estimate EE, and is as accurate as using a single IC reading to predict EE on subsequent days.

Screening trauma patients for alcohol problems: are insurance companies barriers?

BACKGROUND: Impairment caused by alcohol is the leading risk factor for trauma. However, many physicians do not screen for alcohol use because of concerns about confidentiality and denial of insurance coverage. The purpose of this study was to examine objectively the confidentiality issues and insurance statutes affecting alcohol screening in trauma centers. METHODS: We conducted a survey of insurance commissioners in all 50 states to determine the prevalence of statutes allowing denial of coverage for injuries sustained while impaired due to alcohol, reviewed state insurance laws, and reviewed federal regulations protecting the confidentiality of alcohol information in patients seeking alcohol treatment. RESULTS: Special federal regulations protecting confidentiality of alcohol screening data depend on how such information is acquired and do not routinely cover trauma patients. Concerns about screening on insurance coverage are valid in 38 states. CONCLUSION: Segregating information about alcohol use in the medical record and assigning designated chemical dependency counselors to screen all trauma patients would provide confidentiality of alcohol information under current federal regulations, allowing denial of release of such information, except under subpoena.

Alcohol interventions in trauma centers. Current practice and future directions.

Nearly half of all trauma beds are occupied by patients who were injured while under the influence of alcohol. Alcoholism plays such a significant role in trauma that efforts to reduce injury recurrence are unlikely to be successful if it remains untreated. An injury requiring hospitalization creates a unique opportunity to intervene and to motivate patients to alter their drinking behavior, thereby making trauma centers ideal sites to implement an alcohol screening, intervention, and referral program. However, despite emphasis on injury control and prevention, little has been done to incorporate alcohol intervention programs into care of the injured patient. Effective means of intervention exist that are consistent with the time, financial, and staffing constraints of trauma centers, and they should be implemented.

Permissive hypercapnia in trauma patients.

The use of a normal tidal volume in patients with progressive loss of alveolar airspace may increase inspiratory pressure and overdistend remaining functional alveoli. Permissive hypercapnia (PH) is a ventilator management technique that emphasizes control of alveolar pressure, rather than PCO2. The purpose of this study was to determine if the use of PH is associated with an improved outcome from adult respiratory distress syndrome (ARDS). Over a 2-year period, 39 trauma patients were treated for ARDS. Permissive hypercapnia was used in 11, and the remaining patients were treated conventionally. Demographics and risk factors were well matched in PH patients and controls. The duration of mechanical ventilation was greater in PH patients [49.2 +/- 15.2 vs. 20.8 +/- 10 days (p < 0.01)]. Survival was also greater in the PH group [91% vs. 48% (p < 0.01)]. A reduction in intensity of mechanical ventilation is associated with a prolongation of ventilatory support and an improved outcome from ARDS.

Imprecision in lower "inflection point" estimation from static pressure-volume curves in patients at risk for acute respiratory distress syndrome.

BACKGROUND: Static pressure-volume (PV) curves have been promoted as a tool for selecting positive end-expiratory pressure (PEEP) by identifying a lower "inflection point" (Pflex) from these curves. Their visual interpretation is subjective and difficult, however, particularly with subtle changes in the slope of the curves. This study was designed to examine the physician-to-physician variability in estimating the lower Pflex from these curves. METHODS: Static PV curves for eight patients were obtained within 24 hours of admission. Five intensivists and one respiratory therapist independently estimated the lower Pflex from these curves. RESULTS: Pflex estimates for individual patients were highly variable, ranging from 5 to 9 cm H2O. This variability was not attributable to a single discordant estimate, nor was a single physician responsible for consistently high or low estimates. CONCLUSION: Static PV curve interpretation with current methods imprecisely estimates the lower inflection point and is of limited usefulness in PEEP selection.