Alicia N. Kieninger

Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: A national trauma data bank analysis

OBJECTIVE Prehospital intravenous (IV) fluid administration is common in trauma patients, although little evidence supports this practice. We hypothesized that trauma patients who received prehospital IV fluids have higher mortality than trauma patients who did not receive IV fluids in the prehospital setting. METHODS We performed a retrospective cohort study of patients from the National Trauma Data Bank. Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients with versus without prehospital IV fluid administration, using patient demographics, mechanism, physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was performed based on mechanism (blunt/penetrating), hypotension, immediate surgery, severe head injury, and injury severity score. RESULTS A total of 776,734 patients were studied. Approximately half (49.3%) received prehospital IV. Overall mortality was 4.6%. Unadjusted mortality was significantly higher in patients receiving prehospital IV fluids (4.8% vs. 4.5%, P < 0.001). Multivariable analysis demonstrated that patients receiving IV fluids were significantly more likely to die (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05–1.17). The association was identified in nearly all subsets of trauma patients. It is especially marked in patients with penetrating mechanism (OR 1.25, 95% CI 1.08–1.45), hypotension (OR 1.44, 95% CI1.29–1.59), severe head injury (OR 1.34, 95% CI 1.17–1.54), and patients undergoing immediate surgery (OR 1.35, 95% CI 1.22–1.50). CONCLUSIONS The harm associated with prehospital IV fluid administration is significant for victims of trauma. The routine use of prehospital IV fluid administration for all trauma patients should be discouraged.

Spine immobilization in penetrating trauma: more harm than good?

BACKGROUND Previous studies have suggested that prehospital spine immobilization provides minimal benefit to penetrating trauma patients but takes valuable time, potentially delaying definitive trauma care. We hypothesized that penetrating trauma patients who are spine immobilized before transport have higher mortality than nonimmobilized patients. METHODS We performed a retrospective analysis of penetrating trauma patients in the National Trauma Data Bank (version 6.2). Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients with versus without prehospital spine immobilization, using patient demographics, mechanism (stab vs. gunshot), physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was performed based on Injury Severity Score category, mechanism, and blood pressure. We calculated a number needed to treat and number needed to harm for spine immobilization. RESULTS In total, 45,284 penetrating trauma patients were studied; 4.3% of whom underwent spine immobilization. Overall mortality was 8.1%. Unadjusted mortality was twice as high in spine-immobilized patients (14.7% vs. 7.2%, p < 0.001). The odds ratio of death for spine-immobilized patients was 2.06 (95% CI: 1.35-3.13) compared with nonimmobilized patients. Subset analysis showed consistent trends in all populations. Only 30 (0.01%) patients had incomplete spinal cord injury and underwent operative spine fixation. The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66. CONCLUSIONS Prehospital spine immobilization is associated with higher mortality in penetrating trauma and should not be routinely used in every patient with penetrating trauma.

Females have fewer complications and lower mortality following trauma than similarly injured males: A risk adjusted analysis of adults in the National Trauma Data Bank

BACKGROUND Studies of sexual dimorphism in trauma outcomes suggest that women have a survival advantage compared to equivalently injured men. It is unknown if this gender disparity is mediated by potentially life-threatening complications. OBJECTIVE To determine (1) if there is a sex-based differences in the odds of developing inpatient complications after trauma, and (2) if are these complications associated with death among trauma patients. METHODS Review of adult trauma patients admitted to hospitals in the National Trauma Data Bank that report complications. Patient and injury severity covariates were adjusted using multiple logistic regression and the independent effect of sex on developing complications and associated mortality was determined. RESULTS A total of 681,730 adult patients met the inclusion criteria of hospital admission > or =3 days. Women demonstrated a 21% lower adjusted risk of death compared to males (OR 0.79, 95% CI 0.76-0.83). Females had decreased adjusted odds of developing life-threatening complications including pneumonia, acute respiratory distress syndrome, acute renal failure and pulmonary embolism. However, when compared to males with life-threatening complications, females with complications were found to be at greater risk of dying. CONCLUSION This study demonstrates that women are less likely than men to develop inpatient complications, suggesting that the survival advantage among women after traumatic injury may involve a reduced susceptibility to developing life-threatening complications.

Hospital-Acquired Pneumonia: Pathophysiology, Diagnosis, and Treatment

Hospital-acquired pneumonia (HAP) is one of the most common causes of nosocomial infection, morbidity, and mortality in hospitalized patients. Many patient- and disease-specific factors contribute to the pathophysiology of HAP, particularly in the surgical population. Risk-factor modification and inpatient prevention strategies can have a significant impact on the incidence of HAP. While the best diagnostic strategy remains a subject of some debate, prompt and appropriate antimicrobial therapy in patients suspected of having HAP has been shown to significantly decrease mortality. Because the pathogens responsible for HAP are frequently more virulent and have greater resistance to commonly used antimicrobials than other pathogens, clinicians must have knowledge of the resistance patterns at their institutions to choose appropriate therapy.

Video Review Using a Reliable Evaluation Metric Improves Team Function in High-Fidelity Simulated Trauma Resuscitation

OBJECTIVE To demonstrate that instruction of proper team function can occur using high-fidelity simulated trauma resuscitation with video-assisted debriefing and that this process can be integrated rapidly into a standard general surgery curriculum. DESIGN The rater reliability of our team metric was assessed by having physicians and nonphysicians rate the same video-recorded trauma simulations at intervals in time. To assess the effectiveness of video debriefing, subjects participated in a 3-week trauma team training course that consisted of 2 video-recorded simulation sessions, each approximately 2 hours in length separated by a 90-minute debriefing session. To assess the impact of the debriefing session, video recordings of participants performing resuscitations before and after the debriefing were reviewed by a panel of blinded traumatologists and graded using our team evaluation instrument. SETTING The study took place at the high-fidelity simulation center at a large, urban academic training hospital. PARTICIPANTS All 11 PGY-2 general surgery and combined general surgery and plastic surgery residents at our institution. RESULTS Our instrument was found to have high interrater correlation (interclass correlation coefficient [ICC], 0.926; 95% confidence interval, 0.893-0.953). Initially, residents were either unsure as to their competency to serve as team leader (70%) or felt they were not competent to serve as team leader (30%). Ninety percent of residents found the video debriefing very to extremely helpful in improving team function and clinical competency. All participants felt more competent as both team leaders and team members because of the video debriefing. The mean team function score improved significantly after video debriefing (4.39 [±0.3] vs 5.45 [±0.4] prevideo vs postvideo review, p < 0.05). CONCLUSIONS Video review with debriefing is an effective means of teaching team competencies and improving team function in simulated trauma resuscitation. This strategy can be integrated readily into the surgical curriculum analogous to other applications of simulation technology.

Reply to letter: "prehospital intravenous fluid administration is associated with higher mortality in trauma patients

W e appreciate Dr Champion’s insightful comments in his critical review of our article.1 Dr Champion pioneered the field of trauma outcomes research as a driver for the Major Trauma Outcomes Study2 and continues to be instrumental in developing, evaluating, and revising injury severity scoring systems, such as the Revised Trauma Score.3 In his letter to the editor, Dr Champion points to what he feels are fundamental flaws in our methodology. Although we agree our study is imperfect due to some inherent limitations of the National Trauma Data Bank (NTDB), we respectfully disagree that these are fatal flaws and that our conclusions are not valid. As Dr Champion notes, patients with an intravenous (IV) catheter and those who received IV fluids were combined into the IV group.1 Although it is not ideal to lump these patients, data specificity in the NTDB forced us to make this decision, because the risks of misclassification and worse risk for bias would have been higher if we had tried to break the groups down further. He goes on to state the Eastern Association for the Surgery of Trauma (EAST) guidelines differentiate between IV placement and IV fluid administration. The EAST guidelines propose separate recommendations, not because of a wealth of data distinguished them, but in an effort to 1) recognize that having a large bore IV in place during transport was clinically sound and 2) clarify that fluids not be routinely administered (especially in large volumes) to all trauma patients.4 Dr Champion brings up the potential for severity bias within our study because patients in the IV group may be sicker than those in the no-IV group. We agree that many variables influence the performance of IV placement and/or IV fluid administration in the prehospital setting. The patients in the 2 groups in our study are clearly different in terms of demographics, baseline injury characteristics and severity, and mortality.1 We used a mul-

Penetrating Trauma to the Larynx and the Cervical Trachea

Penetrating neck trauma with laryngotracheal injury carries high mortality secondary to the loss of the airway. While many patients die from these injuries prior to reaching the hospital, improved prehospital care has increased the number of patients seeking surgical evaluation for penetrating neck trauma. As many as 50 % of patients presenting with gunshot wounds and 10–20 % of patients with stab wounds will have significant injuries. Injuries to multiple structures in the neck are common given the close proximity of major vascular, aerodigestive, nervous, and endocrine structures (Fig. 31.1). Important aspects of initial care include both hemorrhage control and airway control along with early and thorough diagnosis of all injuries.