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A retrospective study was conducted to determine the effects of a well-functioning rapid response team (RRT) within one facility. A well-functioning RRT was associated with fewer cardiac arrests outside critical care settings and decreased critical care length of stay.
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Parada Cardíaca/epidemiologia , Parada Cardíaca/prevenção & controle , Equipe de Respostas Rápidas de Hospitais , Centros Médicos Acadêmicos , Idoso , Cuidados Críticos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Texas/epidemiologiaRESUMO
INTRODUCTION: Major venous injury (MVI) affecting the lower extremity can result in subsequent amputation. The contribution of intraoperative resuscitation efforts on the need for amputation is not well defined. We hypothesized that intraoperative large volume crystalloid resuscitation (LVCR) increases the risk of amputation after MVI, while massive transfusion (MT) does not. METHODS: We performed a retrospective review of patients with infrarenal MVI from 2005 to 2015â¯at seven urban level I trauma centers. The outcome of interest was the need for secondary amputation. RESULTS: 478 patients were included. 31 (6.5%) patients with MVI required amputation. LVCR(pâ¯<â¯0.001), combined arterial/venous injury (pâ¯=â¯0.001), and associated fracture (pâ¯=â¯0.001) were significant risk factors for amputation. MT did not significantly increase amputation risk (pâ¯=â¯0.44). Multivariable logistic regression model demonstrated that patients receiving ≥5L LVCR(aOR (95% CI): 9.7 (2.9, 33.0); pâ¯<â¯0.001), with combined arterial/venous injury (aOR (95% CI):3.6 (1.5, 8.5); pâ¯=â¯0.004), and with an associated fracture (aOR (95% CI):3.2 (1.5, 7.1); pâ¯=â¯0.004) were more likely to require amputation. CONCLUSION: Patients with MVI who receive LVCR, have combined arterial/venous injuries and have associated fractures are more likely to require amputation. MT was not associated with delayed amputation.
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Amputação Cirúrgica/estatística & dados numéricos , Transfusão de Sangue , Soluções Cristaloides/uso terapêutico , Cuidados Intraoperatórios , Perna (Membro)/irrigação sanguínea , Ressuscitação/métodos , Veias/lesões , Veias/cirurgia , Adulto , Soluções Cristaloides/efeitos adversos , Feminino , Humanos , Escala de Gravidade do Ferimento , Cuidados Intraoperatórios/efeitos adversos , Masculino , Estudos Retrospectivos , Medição de Risco , Adulto JovemRESUMO
BACKGROUND: Trauma centers are receiving increasing numbers of older trauma patients. There is a lack of literature on the outcomes for elderly trauma patients who undergo damage control laparotomy (DCL). We hypothesized that trauma centers with geriatric protocols would have better outcomes in elderly patients after DCL. METHODS: A retrospective chart review of consecutive adult trauma patients with DCL at 8 level 1 trauma centers was conducted from 2012 to 2018. Patients aged 40 or older were included. Age ≥ 55 years was defined as elderly. Demographics, injury information, clinical outcomes, including mortality, and complications were recorded. Univariate and multivariate analyses were performed. RESULTS: A total of 379 patients with DCLs were identified with an average age of 54.8 ± 0.4 years with 39.3% (n = 149/379) of patients aged ≥ 55. Geriatric protocols or a consulting geriatric service was present at 37.5% (n = 3/8) of institutions. Age ≥ 55 was a significant risk factor for in-hospital mortality (OR 2, 95% CI 1.0-4.0, P = .04). Institutions without dedicated geriatric trauma protocols/services had higher overall in-hospital mortality on both univariate (57.9% vs 34.3%, P = .02) and multivariate analyses (OR 2.1, 95% CI 1.3-3.4, P < .001). CONCLUSIONS: Surgical management of older trauma patients remains a challenge. Geriatric protocols or dedicated services were found to be associated with improved outcomes. Future efforts should focus on standardizing the availability of these resources at trauma centers.
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Traumatismos Abdominais/diagnóstico , Avaliação Geriátrica/métodos , Laparotomia/métodos , Centros de Traumatologia/estatística & dados numéricos , Traumatismos Abdominais/cirurgia , Fatores Etários , Idoso , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The technique of tube thoracostomy has been standardized for years without significant updates. Alternative procedural methods may be beneficial in certain prehospital and inpatient environments with limited resources. We sought to compare the efficacy of chest tube insertion using a novel, endoscopic device (The Reactor™) to standard, open tube thoracostomy. METHODS: Novice users were randomly assigned to pre-specified sequences of six chest tube insertions performed on a human cadaver model in a crossover design, alternating between the Reactor™ and standard technique. All subjects received standardized training in both procedures prior to randomization. Insertion site, which was randomly assigned within each cadaver's hemithorax, was marked by the investigators; study techniques began with skin incision and ended with tube insertion. Adequacy of tube placement (intrapleural, unkinked, not in fissure) and incision length were recorded by investigators blinded to procedural technique. Insertion time and user-rated difficulty were documented in an unblinded fashion. After completing the study, participants rated various aspects of use of the Reactor™ compared to the standard technique in a survey evaluation. RESULTS: Sixteen subjects were enrolled (7 medical students, 9 paramedics) and performed 92 chest tube insertions (n = 46 Reactor™, n = 46 standard). The Reactor™ was associated with less frequent appropriate tube positioning (41.3% vs. 73.9%, P = 0.0029), a faster median insertion time (47.3 s, interquartile range 38-63.1 vs. 76.9 s, interquartile range 55.3-106.9, P < 0.0001) and shorter median incision length (28 mm, interquartile range 23-30 vs. 32 mm, interquartile range 26-40, P = 0.0034) compared to the standard technique. Using a 10-point Likert scale (1-easiest, 10-hardest) participants rated the ease of use of the Reactor™ no different from the standard method (3.8 ± 1.9 vs. 4.7 ± 1.9, P = 0.024). The Reactor™ received generally favorable scores for all parameters on the post-participation survey. CONCLUSIONS: In this randomized, assessor-blinded, crossover human cadaver study, chest tube insertion using the Reactor™ device resulted in faster insertion time and shorter incision length, but less frequent appropriate tube placement compared with the standard technique. Additional studies are needed to evaluate the efficacy, safety and potential advantages of this novel device.
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Tubos Torácicos , Endoscopia/métodos , Toracostomia/métodos , Toracotomia/métodos , Adulto , Cadáver , Competência Clínica , Estudos Cross-Over , Feminino , Humanos , Masculino , Método Simples-CegoRESUMO
Care during mass casualty events (MCE) has improved during the last 15 years. Military and civilian collaboration has led to partnerships which augment the response to MCE. Much has been written about strategies to deliver care during an MCE, but there is little about how to transition back to normal operations after an event. A panel discussion entitled The Day(s) After: Lessons Learned from Trauma Team Management in the Aftermath of an Unexpected Mass Casualty Event at the 76th Annual American Association for the Surgery of Trauma meeting on September 13, 2017 brought together a cadre of military and civilian surgeons with experience in MCEs. The events described were the First Battle of Mogadishu (1993), the Second Battle of Fallujah (2004), the Bagram Detention Center Rocket Attack (2014), the Boston Marathon Bombing (2013), the Asiana Flight 214 Plane Crash (2013), the Baltimore Riots (2015), and the Orlando Pulse Night Club Shooting (2016). This article focuses on the lessons learned from military and civilian surgeons in the days after MCEs.
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BACKGROUND: Optimal airway management following repair of cervical tracheal injuries is unknown. This study aimed to determine the optimal airway strategy following cervical tracheal injury repair. METHODS: Patients with cervical tracheal injuries admitted from January 2000 to January 2014 at seven US Level I trauma centers were identified. Patients were grouped depending on postoperative airway management: immediate or early extubation (≤24 hours, EXT), prolonged intubation (>24 hours, INT), and immediate tracheostomy (TRACH). Following univariate analysis, a multivariate model was then developed to evaluate for surgical site infection (SSI) and intensive care unit-free and ventilator-free days, comparing INT and TRACH with EXT as the reference. RESULTS: A total of 120 cervical tracheal injuries were treated at seven Level I trauma centers. Ten patients were excluded for incomplete data, and seven died within 24 hours of admission, leaving 103 patients included in the study. Patients were grouped based on airway management: 40 (39%) in the EXT, 30 (29%) in the INT, and 33 (32%) in the TRACH group. There were no differences in demographics or injury mechanism. The INT and TRACH groups were more severely injured than the EXT group (median Injury Severity Score [ISS]: INT, 25; TRACH, 17 vs. EXT, 16; p < 0.01). Despite a higher SSI rate (TRACH, 21% vs. INT, 13% vs. EXT, 2%; p = 0.11), the TRACH group had a lower mortality rate (TRACH, 0% vs. INT, 13% vs. EXT, 0%, p < 0.01) and more ventilator-free days compared with the INT cohort. On multivariate analysis, tracheostomy was associated with an increased risk in the odds of SSI (odds ratio, 9.56; 95% confidence interval, 1.35-67.95) compared with both EXT and INT, while INT was associated with fewer ventilator-free days (correlation coefficient, -9.24; 95% confidence interval, -12.30 to -6.18) compared with both EXT and TRACH. CONCLUSION: In patients with a cervical tracheal injury, immediate or early extubation was common and safe. However, among those with more severe injuries, immediate tracheostomy versus prolonged intubation presents a risk-benefit decision. Immediate tracheostomy is associated with increased risk of SSI, while prolonged intubation is associated with higher risk of mortality and fewer ventilator-free days. LEVEL OF EVIDENCE: Therapeutic study, level IV.
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Lesões do Pescoço/terapia , Respiração Artificial/métodos , Traqueia/lesões , Traqueostomia/métodos , Adolescente , Adulto , Manuseio das Vias Aéreas/métodos , Feminino , Seguimentos , Humanos , Intubação Intratraqueal/métodos , Masculino , Pessoa de Meia-Idade , Lesões do Pescoço/diagnóstico , Lesões do Pescoço/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Índices de Gravidade do Trauma , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Gender alone offers no survival advantage in humans following trauma. However, male gender does predict increased morbidity, specifically ventilator-associated pneumonia (VAP). Previous work has shown that despite lower incidence of VAP, females with VAP have increased mortality. The purposes of this study were to evaluate the impact of VAP and gender on outcome and to determine which characteristics of severe VAP predict mortality in trauma patients. METHODS: Patients with VAP (≥10 colony-forming units per milliliter in bronchoalveolar lavage) over 8 years were stratified by gender, age, severity of shock, and injury severity. Severe VAP factors were defined as multiple-episode, polymicrobial, multidrug-resistant, nosocomial VAP diagnosed within 7 days of admission (eNVAP), and multiple inadequate empiric antibiotic therapy episodes. Mortality and severe VAP factors were compared using χ analysis. Multivariable logistic regression (MLR) was performed to determine which VAP factors were independent predictors of mortality. RESULTS: A total of 854 patients were identified, 676 men (79%) and 178 women (21%). Despite a higher incidence of VAP among males (3.8% vs. 2.6%, p = 0.001), mortality was higher in females (24% vs. 15%, p = .009). All characteristics of severe VAP were increased in females except multiple episodes (p = 0.15). MLR identified eNVAP as an independent predictor of mortality in females with severe VAP after adjusting for age, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), admission base excess, and 24-hour transfusions (odds ratio, 9.97; p = 0.001). CONCLUSION: That females develop less VAP but experience increased mortality confirms previous studies. Characteristics of severe VAP are increased in females and may contribute to this observed mortality difference. MLR identified eNVAP as an independent predictor of mortality in females with severe VAP following trauma. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.
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Pneumonia Associada à Ventilação Mecânica/epidemiologia , Ferimentos e Lesões/complicações , Adulto , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Pneumonia Associada à Ventilação Mecânica/etiologia , Pneumonia Associada à Ventilação Mecânica/mortalidade , Prognóstico , Fatores de Risco , Fatores Sexuais , Ferimentos e Lesões/mortalidadeRESUMO
BACKGROUND: Pancreaticoduodenal artery (PDA) aneurysms are rare, representing only 2% of all visceral artery aneurysms. True PDA aneurysms associated with celiac stenosis or occlusion make up an even smaller subset of this group. No relationship between aneurysm size and the likelihood of rupture of PDA aneurysms is apparent. PDA aneurysm rupture is associated with a mortality rate upwards of 50%; therefore, accepted practice is treatment upon diagnosis. There is debate in the literature on whether the treatment of coexisting celiac axis stenosis is necessary for the prevention of recurrence. DATA SOURCES: Literature relating to PDA aneurysms associated with celiac stenosis or occlusion was identified by performing a PubMed keyword search. References from identified articles were also assessed for relevance. The current literature was then reviewed and summarized. CONCLUSIONS: Characteristics of this patient population are identified. Based on current evidence, our best practice recommendation for the treatment of coexisting celiac axis stenosis is provided.