Alvaro I. Sanchez

Effect of the Modified Glasgow Coma Scale Score Criteria for Mild Traumatic Brain Injury on Mortality Prediction: Comparing Classic and Modified Glasgow Coma Scale Score Model Scores of 13

BACKGROUND The Glasgow Coma Scale (GCS) classifies traumatic brain injuries (TBIs) as mild (14-15), moderate (9-13), or severe (3-8). The Advanced Trauma Life Support modified this classification so that a GCS score of 13 is categorized as mild TBI. We investigated the effect of this modification on mortality prediction, comparing patients with a GCS score of 13 classified as moderate TBI (classic model) to patients with GCS score of 13 classified as mild TBI (modified model). METHODS We selected adult TBI patients from the Pennsylvania Outcome Study database. Logistic regressions adjusting for age, sex, cause, severity, trauma center level, comorbidities, and isolated TBI were performed. A second evaluation included the time trend of mortality. A third evaluation also included hypothermia, hypotension, mechanical ventilation, screening for drugs, and severity of TBI. Discrimination of the models was evaluated using the area under receiver operating characteristic curve (AUC). Calibration was evaluated using the Hosmer-Lemershow goodness of fit test. RESULTS In the first evaluation, the AUCs were 0.922 (95% CI, 0.917-0.926) and 0.908 (95% CI, 0.903-0.912) for classic and modified models, respectively. Both models showed poor calibration (p < 0.001). In the third evaluation, the AUCs were 0.946 (95% CI, 0.943-0.949) and 0.938 (95% CI, 0.934-0.940) for the classic and modified models, respectively, with improvements in calibration (p = 0.30 and p = 0.02 for the classic and modified models, respectively). CONCLUSION The lack of overlap between receiver operating characteristic curves of both models reveals a statistically significant difference in their ability to predict mortality. The classic model demonstrated better goodness of fit than the modified model. A GCS score of 13 classified as moderate TBI in a multivariate logistic regression model performed better than a GCS score of 13 classified as mild.

Safety of Performing a Delayed Anastomosis During Damage Control Laparotomy in Patients with Destructive Colon Injuries

BACKGROUND Recent studies report the safety and feasibility of performing delayed anastomosis (DA) in patients undergoing damage control laparotomy (DCL) for destructive colon injuries (DCIs). Despite accumulating experience in both civilian and military trauma, questions regarding how to best identify high-risk patients and minimize the number of anastomosis-associated complications remain. Our current practice is to perform a definitive closure of the colon during DCL, unless there is persistent acidosis, bowel wall edema, or evidence of intra-abdominal abscess. In this study, we evaluated the safety of this approach by comparing outcomes of patients with DCI who underwent definitive closure of the colon during DCL versus patients managed with colostomy with or without DCL. METHODS We performed a retrospective chart review of patients with penetrating DCI during 2003 to 2009. Severity of injury, surgical management, and clinical outcome were assessed. RESULTS Sixty patients with severe gunshot wounds and three patients with stab wounds were included in the analysis. DCL was required in 30 patients, all with gunshot wounds. Three patients died within the first 48 hours, three underwent colostomy, and 24 were managed with DA. Thirty-three patients were managed with standard laparotomy: 26 patients with primary anastomosis and 7 with colostomy. Overall mortality rate was 9.5%. Three late deaths occurred in the DCL group, and only one death was associated with an anastomotic leak. CONCLUSIONS Performing a DA in DCI during DCL is a reliable and feasible approach as long as severe acidosis, bowel wall edema, and/or persistent intra-abdominal infections are not present.

Solid organ transplant patients experience high rates of infection and other complications after total knee arthroplasty.

Survival after solid organ transplants in the United States is increasing, and there is a need to understand the complications in knee arthroplasty patients who underwent organ transplantation. A retrospective study was conducted from 1993-2008 on 19 patients (23 knee arthroplasties) with previous successful solid organ transplants. Eleven knee arthroplasties were performed after renal transplantation, and 12 after nonrenal solid organ transplant (seven liver, four heart, one lung). Complications occurred in 9/23 patients (39.1%) and infections occurred in 4/23 patients (17.3%). Of the infected knees, two had MRSA, one had MSSA, and one Escherichia coli. Noninfectious complications (5/24, 21.7%) include aseptic loosening, quadriceps rupture, femoral fracture, hemarthrosis, and arthrofibrosis. All patients with complications were on immunosuppressant medications at the time of arthroplasty. There was a significantly higher rate of infection in the renal group compared to the non-renal group (P = 0.022). There was also a higher overall complication rate in the renal group however this did not reach significance.

The effect of admission spontaneous hypothermia on patients with severe traumatic brain injury

INTRODUCTION Recent information has emerged regarding the harmful effects of spontaneous hypothermia at time of admission in trauma patients. However the volume of evidence regarding the role of spontaneous hypothermia in TBI patients is inadequate. METHODS We performed secondary data analysis of 10 years of the Pennsylvania trauma outcome study (PTOS) database. Unadjusted comparisons of the association of admission spontaneous hypothermia with mortality were performed. In addition, full assessment of the association of hypothermia with mortality was conducted using multivariable logistic regressions reporting the odds ratios (OR) with the 95% confidence intervals (CI) and P-values. RESULTS There were 11,033 patients identified from the PTOS with severe TBI. There were 4839 deaths (43.9%). The proportion of deaths in hypothermic patients was higher than the proportion of deaths in normothermic patients (53.9% vs. 37.4% respectively; P value<0.001). In a multivariable logistic regression model adjusted for demographics, injury characteristics, and information at admission to the trauma centre, the odds of death among patients with hypothermia were 1.70 times the odds of death among patients with normothermia (OR 1.70, 95% CI 1.50-1.93), indicating that the probability of death was significantly higher when patients arrived hypothermic at the trauma centre. CONCLUSION The presence of spontaneous hypothermia at hospital admission is associated with a significant increase in the risk of mortality in patients with severe TBI. The benefit of maintaining normothermia in severe TBI patients, the impact of prolonged re-warming in patients with established hypothermia and the introduction of prophylactic measures to complications of hypothermia are key points that require further investigation.

Computed tomography in hemodynamically unstable severely injured blunt and penetrating trauma patients.

BACKGROUND Dynamic and efficient resuscitation strategies are now being implemented in severely injured hemodynamically unstable (HU) patients as blood products become readily and more immediately available in the trauma room. Our ability to maintain aggressive resuscitation schemes in HU patients allows us to complete diagnostic imaging studies before rushing patients to the operating room (OR). As the criteria for performing computed tomography (CT) scans in HU patients continue to evolve, we decided to compare the outcomes of immediate CT versus direct admission to the OR and/or angio suite in a retrospective study at a government-designated regional Level I trauma center in Cali, Colombia. METHODS During a 2-year period (2012–2013), blunt and penetrating trauma patients (≥15 years) with an Injury Severity Score (ISS) greater than 15 who met criteria of hemodynamic instability (systolic blood pressure [SBP] <100 mm Hg and/or heart rate >100 beats/min and/or ≥4 U of packed red blood cells transfused in the trauma bay) were included. Isolated head trauma and patients who experienced a prehospital cardiac arrest were excluded. The main study outcome was mortality. RESULTS We reviewed 171 patients. CT scans were performed in 80 HU patients (47%) immediately upon arrival (CT group); the remaining 91 patients (53%) went directly to the OR (63 laparotomies, 20 thoracotomies) and/or 8 (9%) to the angio suite (OA group). Of the CT group, 43 (54%) were managed nonoperatively, 37 (46%) underwent surgery (15 laparotomies, 3 thoracotomies), and 2 (5%) underwent angiography (CT OA subgroup). None of the mortalities in the CT group occurred in the CT suite or during their intrahospital transfers. CONCLUSION There was no difference in mortality between the CT and OA groups in HU patients. CT scan was attainable in 47% of HU patients and avoided surgery in 54% of the cases. Furthermore, CT scan was helpful in deciding definitive/specific surgical management in 46% scanned HU patients who necessitated surgery after CT. LEVEL OF EVIDENCE Therapy/care management study, level IV.

Bayesian semi-parametric analysis of Poisson change-point regression models: application to policy making in Cali, Colombia

A Poisson regression model with an offset assumes a constant baseline rate after accounting for measured covariates, which may lead to biased estimates of coefficients in an inhomogeneous Poisson process. To correctly estimate the effect of time-dependent covariates, we propose a Poisson change-point regression model with an offset that allows a time-varying baseline rate. When the non-constant pattern of a log baseline rate is modeled with a non-parametric step function, the resulting semi-parametric model involves a model component of varying dimensions and thus requires a sophisticated varying-dimensional inference to obtain the correct estimates of model parameters of a fixed dimension. To fit the proposed varying-dimensional model, we devise a state-of-the-art Markov chain Monte Carlo-type algorithm based on partial collapse. The proposed model and methods are used to investigate the association between the daily homicide rates in Cali, Colombia, and the policies that restrict the hours during which the legal sale of alcoholic beverages is permitted. While simultaneously identifying the latent changes in the baseline homicide rate which correspond to the incidence of sociopolitical events, we explore the effect of policies governing the sale of alcohol on homicide rates and seek a policy that balances the economic and cultural dependencies on alcohol sales to the health of the public.

Trends in Survival and Early Functional Outcomes From Hospitalized Severe Adult Traumatic Brain Injuries, Pennsylvania, 1998 to 2007

Objective:To determine trends for in-hospital survival and functional outcomes at acute care hospital discharge for patients with severe adult traumatic brain injury (SATBI) in Pennsylvania, during 1998 to 2007. Methods:Secondary analysis of the Pennsylvania trauma outcome study database. Main Outcome Measures:Survival and functional status scores of 5 domains (feeding, locomotion, expression, transfer mobility, and social interaction) fitted into logistic regression models adjusted for age, sex, race, comorbidities, injury mechanism, extracranial injuries, severity scores, hospital stay, trauma center, and hospital level. Sensitivity analyses for functional outcomes were performed. Results:There were 26 234 SATBI patients. Annual numbers of SATBI increased from 1757 to 3808 during 1998 to 2007. Falls accounted for 47.7% of all SATBI. Survival increased significantly from 72.5% to 82.7% (odds ratio [OR] = 1.10, 95% CI: 1.08–1.11, P < .001). In sensitivity analyses, trends of complete independence in functional outcomes increased significantly for expression (OR = 1.01, 95% CI: 1.00–1.02, P = .011) and social interaction (OR = 1.01, 95% CI: 1.00–1.03, P = .002). There were no significant variations over time for feeding, locomotion, and transfer mobility. Conclusions:Trends for SATBI served by Pennsylvanias established trauma system showed increases in rates but substantial reductions in mortality and significant improvements in functional outcomes at discharge for expression and social interaction.

Trauma Care Training for National Police Nurses in Colombia

Abstract Introduction. In response to a requirement for advanced trauma care nurses to provide combat tactical medical support, the antinarcotics arm of the Colombian National Police (CNP) requested the Colombian National Prehospital Care Association to develop a Combat Tactical Medicine Course (MEDTAC course). Objective. To evaluate the effectiveness of this course in imparting knowledge and skills to the students. Methods. We trained 374 combat nurses using the novel MEDTAC course. We evaluated students using pre- and postcourse performance with a 45-question examination. Field simulations and live tissue exercises were evaluated by instructors using a Likert scale with possible choices of 1 to 4. Interval estimation of proportions was calculated with a 95% confidence interval (95% CI). Differences in didactic test scores were assessed using a t-test at 0.05 level of statistical significance. Results. Between March 2006 and July 2007, 374 combat nursing students of the CNP were trained. The difference between examination scores before and after the didactic part of the course was statistically significant (p < 0.01). After the practical session of the course, all participants (100%) demonstrated competency on final evaluation. Conclusions. The MEDTAC course is an effective option improving the knowledge and skills of combat nurses serving in the CNP. MEDTAC represents a customized approach for military trauma care training in Colombia. This course is an example of specialized training available for groups that operate in austere environments with limited resources.

Could resuscitative endovascular balloon occlusion of the aorta improve survival among severely injured patients with post-intubation hypotension?

Current literature shows the association of post-intubation hypotension and increased odds of mortality in critically ill non-trauma and trauma populations. However, there is a lack of research on potential interventions that can prevent or ameliorate the consequences of endotracheal intubation and thus improve the prognosis of trauma patients with post-intubation hypotension. This review paper hypothesizes that the deployment of REBOA among trauma patients with PIH, by its physiologic effects, will reduce the odds of mortality in this population. The objective of this paper is to review the current literature on REBOA and post-intubation hypotension, and, furthermore, to provide a rational hypothesis on the potential role of REBOA in severely injured patients with post-intubation hypotension.

Drugs, Violence, and Trauma in Mexico and the USA

The impact of illicit drug markets on the occurrence of violence varies tremendously depending on many factors. Over the last years, Mexico and the USA have increased security border issues that included many aspects of drug-related trade and criminal activities. Mexico experienced only a small reduction in trauma deaths after the enforcement of severe crime reinforcement policies. This strategy in the war on drugs is shifting the drug market to other Central American countries. This phenomenon is called the ballooning effect, whereby the pressure to control illicit drug-related activities in one particular area forces a shift to other more vulnerable areas that leads to an increase in crime and violence. A human rights crisis characterized by suffering, injury, and death related to drug trafficking continues to expand, resulting in the exorbitant loss of lives and cost in productivity across the continent. The current climate of social violence in Central America and the illegal immigration to the USA may be partially related to this phenomenon of drug trafficking, gang violence, and crime. A health care initiative as an alternative to the current war approach may be one of the interventions needed to reduce this crisis.