Laterality of deep venous thrombosis among trauma patients: are we screening our patients adequately?

OBJECTIVES: Major trauma represents a significant risk for development of deep venous thrombosis (DVT). Duplex ultrasonography is a noninvasive test to identify DVT and has been suggested for screening asymptomatic high-risk trauma patients. While some risk factors for DVT are well described, it remains unclear whether site of DVT development is associated with anatomical location of injury. An association between anatomical locations of injury would serve to highlight the importance of directed screening of those extremities at highest risk. Therefore, we hypothesize that location of DVT correlates with side of lower extremity injury. METHODS: We performed an 11-year (1995-2005) retrospective review from the prospectively collected trauma registry at an urban, university-based, level I trauma center. All trauma patients with lower extremity DVT were included. Lateralizing lower extremity injuries were defined as penetrating or blunt injuries affecting only one lower extremity. Fisher's exact test compared concordance between side of injury and side of DVT. RESULTS: A total of 6674 trauma patients were admitted, of whom 40 (0.6%) were diagnosed with lower extremity or pelvic DVT. Mean age of patients with DVT was 39 y, with 80% male, 80% African American, and 55% penetrating trauma. Fourteen patients (35%) with DVT sustained lateralizing lower extremity injuries (6 gunshot wounds, 5 tibia/fibula fractures, 2 femur fractures, and 1 calcaneus fracture). Twelve of these 14 patients (86%) developed DVT on the same side as their injury; (7/7 on right side and 5/7 on left side, P = 0.02). The 26 patients without lateralizing injuries had equal distribution of DVT (39% right, 42% left, and 19% bilateral). CONCLUSION: Patients who sustained lateralizing lower extremity injury and developed lower extremity DVT had a high likelihood of developing their DVT on the same side as their injury. A larger multi-institutional analysis is needed to assess the correlation between injury site and anatomical location of DVT before suggesting any changes in recommendations for duplex screening.     

Physiologic trauma triage criteria in adult trauma patients: are they effective in saving lives by transporting patients to trauma centers?

BACKGROUND: Trauma triage criteria have been in place for many years and were updated in 1999 by the American College of Surgeons. We are unaware of any studies that have directly examined the ability of these criteria to reduce short-term mortality by transporting patients to trauma centers rather than to noncenters. STUDY DESIGN: Retrospective observational cohort study of adult patients meeting physiologic triage criteria who were transported to 9 regional (Level I) trauma centers, 21 area (Level II) trauma centers, and 119 noncenters in New York in 1996 to 1998. For each triage criterion and for one or more of the criteria, odds ratios and their confidence intervals for mortality in regional and area trauma centers versus noncenters and odds ratios and their confidence intervals for mortality in regional centers versus area centers and noncenters were used to measure performance. RESULTS: Patients in regional trauma centers had considerably lower mortality than patients in area trauma centers and noncenters for two individual triage criteria and for patients with one or more triage criteria (odds ratio, 0.75; 95% CI, 0.63-0.90 for one or more criteria). Also, patients with head injuries who were treated in regional centers had notably lower mortality than patients in other hospitals (odds ratio, 0.67; 95% CI, 0.53-0.85). CONCLUSIONS: In New York, regional trauma centers exhibit considerably lower mortality than area trauma centers or noncenters for adult patients meeting specific physiologic triage criteria. It is important that population-based trauma systems with data from centers and noncenters be developed for the purpose of evaluating and redesigning trauma systems.     

Pelvic fractures in pediatric and adult trauma patients: are they different injuries?

BACKGROUND: Many aspects of pediatric trauma are considerably different from adult trauma. Very few studies have performed comprehensive comparisons between pediatric and adult pelvic fractures. The purpose of this study was to compare the incidence of pelvic fracture, the epidemiologic characteristics, type of associated abdominal injuries, and outcomes between pediatric (age 16 years) patients. METHODS: This was a trauma registry study that included all blunt trauma admissions at a Level I trauma center during an 8-year period. The incidence and severity of pelvic fractures, associated abdominal injuries, need for blood transfusion, and mortality in the two age groups were compared with the two-sided Fisher's exact test. Stepwise logistic regression analysis was used to identify independent risk factors for associated abdominal injuries in pelvic fractures in the two age groups. RESULTS: The incidence of pelvic fractures was 10.0% (1,450 of 14,568) in the adult group and 4.6% (95 of 2,062) in the pediatric group (p < 0.0001). In motor vehicle and pedestrian injuries, adults were twice as likely and in falls from heights > 15 ft seven times as likely as children to suffer pelvic fractures. However, age group was not a significant predictor of the severity of pelvic fracture. Only 9.5% of pediatric fractures and 8.8% of adult fractures had a pelvis Abbreviated Injury Scale (AIS) score >/= 4. The incidence of associated abdominal injuries was high but similar in the two age groups (16.7% in adults and 13.7% in children, p = 0.48). Motor vehicle crash, pelvis AIS score >/= 4, and fall from height > 15 ft were significant predictors of associated abdominal injuries in the adult but not the pediatric group. The incidence of associated gastrointestinal injuries was similar in the two age groups (5.3% in children and 3.3% in adults, p = 0.37). The incidence of solid organ injuries was nearly identical in both groups (11.6% in children and 11.5% in adults). The need for blood transfusions and angiographic intervention was not significantly different between the two age groups. Exsanguination because of bleeding related to the pelvic fracture was responsible or possibly responsible in 42 deaths (2.9%) in the adult group and no deaths in the pediatric group. CONCLUSION: Pediatric trauma patients are significantly less likely than adults to suffer pelvic fractures, although the age group is not a significant risk factor for the severity of pelvic fracture. The incidence of associated abdominal injuries is high and similar in the two age groups. Motor vehicle crash, fall from a height, and pelvis AIS score >/= 4 were significant predictors of associated abdominal injuries in the adult but not the pediatric patients. The need for blood transfusion is similar in both groups irrespective of Injury Severity Score and pelvis AIS score. The mortality resulting from exsanguination related to pelvic fractures is very low, especially in pediatric patients.     

Management of pulseless and apneic trauma patients: are aggressive measures justified?

This study prospectively examined the care of trauma patients in extremis on presentation to a tertiary medical center between January 2000 and August 31, 2002. There were 144 patients who presented without a pulse or spontaneous respiration and required cardiopulmonary resuscitation (mean age, 41.5+/-2.3 years; male-to-female ratio, 105:39). Successfully resuscitated patients, who were either admitted to the surgical intensive care unit (SICU) or who were taken to the operating room for surgical exploration, had significantly shorter duration of cardiopulmonary resuscitation (14.55+/-1.64 minutes vs. 33.32+/-1.23 minutes; P < 0.001) and received less amounts of epinephrine than those who died in the emergency room (P < 0.05). One hundred sixteen patients died in the emergency room. Nineteen admitted patients died within 24 hours of presentation. Nine patients survived beyond 24 hours and all of them were admitted directly to the SICU for the management of brain injury. Six patients were taken to the operating room for surgical exploration to control the bleeding; all of them died in the operating room or shortly thereafter in the SICU. No patient in this study survived to be discharged. The financial cost of successfully resuscitated patients was significantly higher than that of patients who died in the emergency room (P < 0.001). Instead of insisting on aggressive measures to resuscitate trauma patients in extremis on presentation, the authors suggest we should redirect that fervor toward efforts made to promote trauma awareness and injury prevention programs.     

Multiple, simultaneous trauma patients: Are they worse off?

BACKGROUND: The simultaneous management of multiple severely injured patients has the potential to overwhelm trauma center resources. We hypothesize that trauma patients presenting in clusters of two or more patients within a short time period have worse outcomes. METHODS: From the registry at our urban Level I trauma center, we reviewed 4,619 "major" trauma patients admitted during a span of 5.5 years (January 1998 through June 2003). A multidisciplinary team led by an in-house trauma surgery attending evaluated all patients. Pairs of two patients presenting less than 10 minutes apart (PAIRS) and clusters of three patients presenting within 30 minutes (CLUSTERS) were compared with patients arriving alone presenting over 4 hours apart (ALONE) and to other patients that did not meet any of the above criteria (OTHER). Multivariate regression was performed to determine differences in likelihood of direct operating room admissions, hospital, and intensive care unit (ICU) length of stay, and mortality. RESULTS: PAIRS made up 8.9% (413) and CLUSTERS made up 2.7% (126) of patients; 42% (1,939) arrived ALONE; 48.3% (2,229) of patients were classified as OTHER. Multivariate regression showed no significant differences in ICU or hospital length of stay, or mortality for PAIRS or CLUSTERS compared with patients presenting ALONE. PAIR and CLUSTER patients were more likely to undergo immediate surgery than the ALONE group (odds ratio 1.37, 95% confidence interval 1.03-1.83 and 1.61, 95% CI 1.00-2.58, respectively). CONCLUSIONS: When PAIRS or CLUSTERS of seriously injured patients arrive in close time proximity, they are more likely to be directly admitted to the operating room than patients arriving ALONE. This difference in management does not appear to affect patient outcomes.     

Venous thromboembolic events in pediatric trauma patients: is prophylaxis necessary?

BACKGROUND: Venous thromboembolic events (VTE), such as deep vein thrombosis and pulmonary embolism, are major morbidities in adult trauma patients. Invasive and noninvasive prophylactic therapies are used to prevent VTE in trauma patients. The risk of VTE in pediatric patients is not well known. Is VTE prophylaxis necessary in the pediatric trauma population? METHODS: This is a retrospective study from the trauma registry of a Level I trauma center from January 1, 1994, through December 31, 2003. Three separate age groups were reviewed: Group I, age less than 13 years; group II, age 13 to 17 years; and group III, age greater than 17 years. Group I did not receive any VTE prophylaxis. All patients in group III received invasive and noninvasive prophylaxis if not contraindicated. In group II, VTE prophylaxis was administered at the preference of the attending surgeon. All patients were assigned an Injury Severity Score at discharge. RESULTS: A total of 13,880 patients were identified. Groups I, II, and III had 1,192; 1,021; and 10,568 patients, respectively. In group I, no patient developed a VTE. Two patients in group II developed VTE. Both had an Injury Severity Score of >24 and both had contraindication to invasive prophylaxis. In group III, 59 patients developed VTE. CONCLUSION: The risk of clinically significant thromboembolic event in trauma patients under age 13 is negligible. Therefore, VTE prophylaxis is unnecessary in pediatric patients with traumatic injury.     

Closed midshaft femur fractures: are they only for trauma centers?

Trauma centers are limited resources, particularly in rural areas, and availability of emergency care in some parts of the United States may be inadequate. The declining number of orthopedic surgeons willing to care for injured patients has limited access to fracture repair in some communities. We studied the management of closed midshaft femur fractures in both trauma centers (TCs) and nontrauma centers (NTCs) to evaluate outcome for this common orthopedic injury and determine if these issues have affected fracture care in Kentucky. All patients 16-years-old and older who suffered femur fractures in Kentucky from 2004 and 2005 were identified. There were 334 TC patients and 341 NTC patients with closed, midshaft femur fractures. The mean age of TC patients (33 ± 17 years) was significantly lower than that of NTC patients (59 ± 25 years). TC patients were more likely men (71% vs 44%), had more associated injuries (2.4 ± 2.1 vs 0.5 ± 1.2), and had longer lengths of stay (8.3 ± 9.8 vs 6.4 ± 7.1 days) (TCs vs NTCs, all P < 0.005). Although both groups ultimately underwent internal fixation (97% vs 99%, TCs vs NTCs), TC patients were more likely (2.7% vs 0.3%) to receive external fixation than the NTC patients (P < 0.05). There was no significant difference in the percentage of patients that received only a closed reduction. There was no significant difference in hospital mortality (0.3% vs 0.9%, TCs vs NTCs, P = 0.62). Although differences in patient populations exist between TCs and NTCs, both TCs and NTCs manage substantial numbers of patients with closed, midshaft femur fractures with low mortality in this state database.     

The new relaxants: are they worth it?

Canadian Journal of Anesthesia/Journal canadien d'anesthésie - In the development of new neuromuscular blocking drugs the anesthesiologist is now provided with drugs that are almost free...     

Pulmonary embolism: which pediatric trauma patients are at risk?

Background/Purpose

Deep vein thrombosis and pulmonary embolism (DVT/PE) are rare in pediatric trauma patients, and guidelines for prophylaxis are scarce. The authors sought to identify subgroups of patients who may be at higher risk of developing DVT/PE.

Methods

Case-control study of pediatric trauma patients with DVT/PE. Odds ratios (ORs) and confidence intervals (CIs) were calculated for known risk factors of PE using matched trauma controls (χ² analysis).

Results

A total of 3637 pediatric trauma patients was admitted over the last 7 years. Three patients developed DVT/PE (overall incidence, 0.08%). There were 2 girls and 1 boy, aged 15, 15, and 9 years, respectively. All 3 had an Injury Severity Score (ISS) ≥25 and an initial Glasgow Coma Score (GCS) ≤8. None of the known and potential risk factors significantly increased the OR for developing DVT/PE: age 9 years or older (OR, 3.6; CI, 0.4-26), presence of head injury (OR, 2.9; CI, 0.3-22), female sex (OR, 1.2; CI, 0.15-9.1), GCS ≤8 (OR, 9.2; CI, 0.9-230), except ISS ≥25 (OR, 82; CI, 7.6-2058). The OR for a combination of age and GCS was 106, and the OR for the 3 risk factors (age, ISS, GCS) common to all 3 patients was 114 (CI, 10-5000; P < .001).

Conclusions

The overall incidence of DVT/PE in pediatric trauma patients is <0.1% and routine prophylaxis is not recommended. Children aged 9 years or older with an initial GCS ≤8 and patients with an estimated ISS ≥25 may constitute a high-risk group in which prophylaxis could be considered.     

The origin of information: are IUGA-specific patient information leaflets the answer?

Introduction  

In contemporary practice, patients should be partners in their care; unfortunately, we frequently find patients with unclear information regarding their conditions.     

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.     

Prepared endotracheal tubes: are they a potential source for pathogenic microorganisms?

Prepared endotracheal tubes (PETTs) are frequently used for unanticipated difficult intubation, but their storage time is highly variable and institution-dependent. We sought to determine first, if open, unused PETTs are a potential source of pathogenic microorganisms, and second, if PETTs can provide a medium for bacterial survival after deliberate contamination. A stylet was inserted into a 7-mm ETT, and this system was ethylene oxide sterilized. The PETTs were placed in 20 different locations and sampled 8 times in a 4-wk period. Growth was determined after 48-h incubation, and the microorganism was identified. In Phase 2, the PETT (n = 40) was swabbed with a fresh suspension of H. influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, Enterococcus faecium, or a negative control. Nonvirulent bacteria were cultured from 13 of 160 (8.1%) samples and from 15 of 320 (4.7%) samples in Phases 1 and 2, respectively. No PETT grew the same bacteria more than once. In Phase 2, after 24 h, only E. faecium was recovered. Based on this study, the pathogenic potential of PETTs is very small, and they can be safely used for up to 1 mo. This practice could translate to significant cost reduction for operating room budgets. IMPLICATIONS: Prepared endotracheal tubes (PETTs) are back-up airway equipment to be used in the case of a difficult intubation. A short PETT shelf life because of unknown safe storage time results in significant budget costs. This blinded, controlled study examined the pathogenic potential of PETTs in the operating room environment.     

Hemodynamic and pulmonary fluid status in the trauma patient: are we slipping?

Recent reports point to problems in the clinical assessment of the cardiopulmonary system in hemodynamically unstable patients, especially with the decreasing usage of pulmonary artery catheters. Our purpose was to evaluate the hypothesis that clinical judgment alone is inadequate for a reliable estimate of cardiopulmonary status in critically ill patients. Physician assessments (high, normal, or low) of cardiac index (CI) and thoracic fluid content (TFC) were made in 68 acute trauma cases and compared to the results obtained with impedance cardiography (ICG). Physician assessment using clinical judgment alone was correct only 42 per cent and 57 per cent, respectively, for CI and TFC. There was very little difference in heart rate (HR), blood pressure (BP), Glasgow Coma Score (GCS), and the number of injured systems between the incorrect and correct assessments of CI. However, the mean Injury Severity Score (ISS) was markedly higher for the incorrect than the correct CI values (18.8 +/- 9.3 vs 14.2 +/- 9.8, P = 0.0589). Thus, there is a need for an objective measurement of CI and TFC especially in the more severely injured patient. The inaccuracy of the clinical exam strongly suggests the need for a supplemental measurement, which the new and improved ICG monitor could provide.     

Pre-operative labs: Wasted dollars or predictors of post-operative cardiac and septic events in orthopaedic trauma patients?

PurposeAs US healthcare expenditures continue to rise, there is significant pressure to reduce the cost of inpatient medical services. Studies have estimated that over 70% of routine labs may not yield clinical benefits while adding over $300 in costs per day for every inpatient. Although orthopaedic trauma patients tend to have longer inpatient stays and hip fractures have been associated with significant morbidity, there is a dearth of data examining pre-operative labs in predicting post-operative adverse events in these populations. The purpose of this study was to assess whether pre-operative labs significantly predict post-operative cardiac and septic complications in orthopaedic trauma and hip fracture patients.MethodsBetween 2006 and 2013, 56,336 (15.6%) orthopaedic trauma patients were identified and 27,441 patients (7.6%) were diagnosed with hip fractures. Pre-operative labs included sodium, BUN, creatinine, albumin, bilirubin, SGOT, alkaline phosphatase, white count, hematocrit, platelet count, prothrombin time, INR, and partial thromboplastin time. For each of these labs, patients were deemed to have normal or abnormal values. Patients were noted to have developed cardiac or septic complications if they sustained (1) myocardial infarction (MI), (2) cardiac arrest, or (3) septic shock within 30 days after surgery. Separate regressions incorporating over 40 patient characteristics including age, gender, pre-operative comorbidities, and labs were performed for orthopaedic trauma patients in order to determine whether pre-operative labs predicted adverse cardiac or septic outcomes.Results749 (1.3%) orthopaedic trauma patients developed cardiac complications and 311 (0.6%) developed septic shock. Multivariate regression demonstrated that abnormal pre-operative platelet values were significantly predictive of post-operative cardiac arrest (OR: 11.107, p = 0.036), and abnormal bilirubin levels were predictive (OR: 8.487, p = 0.008) of the development of septic shock in trauma patients. In the hip fracture cohort, abnormal partial thromboplastin time was significantly associated with post-operative myocardial infarction (OR: 15.083, p = 0.046), and abnormal bilirubin (OR: 58.674, p = 0.002) significantly predicted the onset of septic shock.ConclusionsThis is the first study to demonstrate the utility of pre-operative labs in predicting perioperative cardiac and septic adverse events in orthopaedic trauma and hip fracture patients. Particular attention should be paid to haematologic/coagulation labs (platelets, PTT) and bilirubin values.Level of evidencePrognostic Level II.