Bruce Potenza

A prospective evaluation of abdominal ultrasound in blunt trauma: is it useful?

OBJECTIVE The purpose of this study is to evaluate the utility and feasibility of abdominal ultrasound (US) in blunt trauma patients. DESIGN This prospective study examined the operational issues and the diagnostic accuracy of US in selected blunt trauma patients triaged to a Level 1 trauma center. MATERIALS AND METHODS All patients were evaluated by an attending trauma surgeon and our usual criteria for objective evaluation of the abdomen were applied. US was performed by US technicians and interpreted by the trauma surgeon. We prospectively evaluated the availability (time to arrival), the ease with which the US could be integrated into the resuscitation (minutes to start after arrival), and the time required to perform the study. The US results were compared to diagnostic peritoneal lavage and computed tomography findings, clinical course, operative findings, and to repeat US examinations to determine sensitivity, specificity, and usefulness. MEASUREMENTS AND MAIN RESULTS A total of 800 US studies were performed over 15 months. In four cases (0.5%), the US was incomplete for technical reasons. The results in the remaining 796 studies were as follows: [table: see text] The average time to arrival of the US was 17.3 minutes (range 0-120) and the average minutes to start after arrival was 7.0 (range 1-49). The average time required to perform the study was 10.6 minutes (range 2-26). CONCLUSIONS This study demonstrates that US can be obtained rapidly, integrated into the resuscitation, and completed quickly. US provides a highly accurate, noninvasive method to evaluate the abdomen in the blunt trauma patient, and has supplanted the previously used methods at this institution.

Does sexual dimorphism influence outcome of traumatic brain Injury patients? The answer is no!

BACKGROUND The protective effect of female gender on posttraumatic mortality or acute complications after traumatic brain injury (TBI) has been postulated. This effect might be seen if TBIs were analyzed by severity. To assess potential gender effects, we performed a retrospective case-controlled study matching female patients to male counterparts for overall injury severity; hemodynamic status at admission; and head, chest, and abdomen Abbreviated Injury Scale score. METHODS All female patients sustaining TBI admitted over 6.5 years were reviewed. An overall comparison between women (n = 914) and their male matched counterparts (n = 916) was performed. Patients were then stratified according to the severity of head injury on the basis of admission Glasgow Coma Scale (GCS) score into three groups: group 1, GCS score of 13 to 15 (788 female patients, 769 male patients); group 2, GCS score of 9 to 12 (40 female patients, 42 male patients); and group 3, GCS score < 9 (63 female patients, 87 male patients). Cohorts were compared for mortality or the development of acute respiratory distress syndrome, pneumonia, and systemic sepsis using standard definitions. A subset analysis was performed excluding patients with age above 50 years (789 women, 811 men) to exclude the effects of menopause on the results. RESULTS There was no statistically significant difference in outcome overall or in subset analysis of mild (group 1), moderate (group 2), or severe (group 3) TBI. The exclusion of patients older than 50 years showed no protective effect of female gender on outcome. CONCLUSION Gender does not play a role in posttraumatic mortality or in the incidence of acute complications after any degree of TBI.

The epidemiology of serious and fatal injury in San Diego County over an 11-year period.

BACKGROUND Analysis of the mechanism and severity of injury over time may permit a more focused planning of acute care and trauma prevention programs. METHODS A retrospective, population-based study examining severe traumatic injury in a single county was undertaken. Three overlapping data sets were used to form a composite injury data set. RESULTS There were 55,664 patients included in the study. A total of 40,897 (73.5%) patients survived and 14,767 (26.5%) died. Of those patients who died, 8,910 (60.3%) died in the field and were not transported to a trauma center. There was an increase in the mean age of all trauma victims (3 years) and an increase of 5 years in fatally injured patients. The mean Injury Severity Score decreased from 14.7 to 11.6 (p < 0.01); however, Injury Severity Score for fatal patients remained constant (39.7). The overall injury rate remained unchanged (195 per 10(5)), whereas the fatal injury rate decreased by 22% (45.9 per 10(5)) over the 11-year study period. The leading cause of injury was motor vehicle crash, followed by assault. The leading cause of fatal injury was suicide, followed by homicide. CONCLUSION A combination of three independent injury data sources generated a composite data set of serious and fatal injury. This regional injury analysis was the most comprehensive overview of injury in our region. Important observations included the following: there has been no change in the overall incidence of severe injury within our county; the incidence of fatal traumatic injury has significantly decreased; the leading causes of nonfatal injury do not correlate with the rank order of fatal injury; intentional injury was the leading cause of injury deaths; and scene fatalities represent a poorly studied group of patients who may benefit from primary prevention and injury control research.

Hemorrhage is More Prevalent than Brain Injury in Early Trauma Deaths: The Golden Six Hours

Introduction:Under the trimodal distribution, most trauma deaths occur within the first hour. Determination of cause of death without autopsy review is inaccurate. The goal of this study is to determine cause of death, in hourly intervals, in trauma patients who died in the first 24 h, as determined by autopsy.Materials and Methods:Trauma deaths that occurred within 24 h at a Level I trauma center were reviewed over a six-year period ending December 2005. Timing of death was separated into 0–1, 1–3, 3–6, 6–12 and 12–24 h intervals. Cause of death was determined by clinical course and AIS scores, and was confirmed by autopsy results.Results:Overall, 9,388 trauma patients were admitted, of which 185 deaths occurred within 24 h, with 167 available autopsies. Blunt and penetrating were the injury mechanisms in 122 (73%) and 45 (27%) patients, respectively. Of 167 deaths, 73 (43.7%) occurred within the first hour. Brain injury, when compared to other body areas, was the most likely cause of death in all hourly intervals, but hemorrhage was as or more important than brain injury as the cause of death during the first 3 h and up to 6 h. No deaths were attributable to hemorrhage after 12 h.Conclusions:The temporal distribution of the cause of death varies in the first 24 h after admission. Hemorrhage should not be overlooked as the cause of death, even after survival beyond 1 h. Understanding the temporal relationship of causes of early death can aid in the targeting of management and surgical training to optimize patient outcome.

Combat versus civilian open tibia fractures: The effect of blast mechanism on limb salvage

BACKGROUND This study compares open tibia fractures in US Navy and US Marine Corps casualties from the current conflicts with those from a civilian Level I trauma center to analyze the effect of blast mechanism on limb-salvage rates. METHODS Data from the 28,646 records in the University of California San Diego Trauma Registry from 1985 to 2006 was compared with 2,282 records from the US Navy and US Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database for the period of March 2004 to August 2007. Injuries were categorized by Gustilo-Anderson (G-A) open fracture classification. Independent variables included age, gender, mechanism of injury including blast mechanisms, shock, blood loss, prehospital time, procedures, Injury Severity Score, length of stay, and Mangled Extremity Severity Score (MESS). Dependent variables included early or late amputation and mortality. RESULTS The civilian group had 850 open tibia fractures with 45 amputations; the military group had 21 amputation patients (3 bilateral) in 115 open tibia fractures. Military group patients were more severely injured, more likely have hypotension, and had a higher amputation rate for G-A IIIB and IIIC fractures then civilian group patients. Blast mechanism was seen in the majority of military group patients and was rare in the civilian group. MESS scores had poor sensitivity (0.46, 95% confidence interval: 0.29-0.64) in predicting the need for amputation in the civilian group; in the military group sensitivity was better (0.67, 95% confidence interval: 0.43-0.85), but successful limb salvage was still possible in most cases with an MESS score of ≥7 when attempted. CONCLUSION Despite current therapy, limb salvage for G-A IIIB and IIIC grades are significantly worse for open tibia fractures as a result of blast injury when compared with typical civilian mechanisms. MESS scores do not adequately predict likelihood of limb salvage in combat or civilian open tibia fractures.

Real-time analysis of the kinetics of angiogenesis and vascular permeability in an animal model of wound healing

The use of engineered tissue for the treatment of a variety of acute to chronic wounds has become a clinical standard, and a better understanding of the cellular mechanisms of re-vascularization and barrier integrity could enhance clinical outcomes. Here, we focus on the characterization of the re-vascularization of acellular grafts such as Integra in an animal model to better understand the physiological properties of blood vessels growing in the collagen-glycosaminoglycan matrix vs. wound margins. While Integra has been extensively studied in pre-clinical models, the re-modeling mechanisms of the capillary bed under these matrices are not well understood. Therefore, our first objective was to quantify the kinetics of re-vascularization. The second objective was to assess changes in vascular permeability (VP) of the wound bed compared to normal adjacent skin. The third objective was to establish a non-invasive and quantitative assay for the measurement of VP to facilitate the rapid and reproducible characterization of vascular integrity. Using an excisional wound model in mice, we characterize the appearance, growth, and maturation of blood vessels in an Integra graft over 28 days after surgery. Initial appearance of blood vessels in the graft was observed at 7 days, with angiogenesis peaking between 7 and 14 days. The onset of VP coincided with the increase in re-vascularization of the wound bed and there was a sustained elevation of VP that declined to baseline by 28 days. We propose a non-invasive strategy to assess VP of the wound capillary bed will facilitate a better understanding of the cell and molecular basis of angiogenesis in wound healing.

Synopsis of the 2013 annual report of the national burn repository.

Most burn centers maintain some record or registry of the patients they treat. These registries typically include information on the clinical characteristics of the patients and their injuries, the care and treatment they received, and the clinical outcome. These records document the burn center’s work and experience. They can be used to estimate the resources—supplies, personnel, space—required to provide care. They can be reviewed by the clinicians working there to discern imperfections in their systems of providing care and to identify opportunities to improve the structure, processes, and outcomes of those systems. They may also, in part, describe the characteristics of burn injury in the community served by the burn center. More than 40 years ago, burn clinicians envisioned the creation of a larger database of burn-injured patients. Such a database would be composed of data from several individual facility registries. It could provide a much broader view of burn injury and burn care in a larger geopolitical region than a single community. It could serve as the basis for burn research, burn prevention, public health, health planning, and advocacy at a regional, state, and even national level. This database then would benefit victims of burn injury, providers of burn care, state and national policy makers, and the public. Such a database was started at the University of Michigan in the early 1970s. It included a handful of burn centers. Over the years, that database was transferred to other entities, and in 2001, the American Burn Association (ABA) assumed responsibility for it, almost three decades after it was begun. By then, it had become national in scope and was known as the National Burn Repository (NBR). An NBR Committee was formed by the ABA, and it began preparing annual summaries of the database in 2006. These reports summarized cases treated by contributing centers during a 10-year period. They were made available not only to members of the ABA but also to the public. Two of these reports were summarized for publication in this Journal,1,2 the most recent of which was a summary of the 2007 annual report published in 2008. As the result of efforts of both the NBR Committee and the Burn Registry Committee of the ABA to improve the quality of the data in the NBR in the intervening years, the annual NBR report prepared in 2013 was based on data that were of a much higher quality than those that existed before. The purpose of this current article is to summarize and review highlights from that 2013 NBR Report.

Lessons learned from the institution of the Surgical Care Improvement Project at a teaching medical center

BACKGROUND The Surgical Care Improvement Project (SCIP) was designed to reduce perioperative complications. We describe our institutional experience in 6 major areas: surgical site infection, venous thromboembolism prevention, use of perioperative beta-blockade, serum glucose level greater than 200 mg/dL, normothermia, and the use of electric razors for hair removal. METHODS This was a retrospective review of surgical cases. Evidence-based training and standardization of system and process were undertaken. Compliance with SCIP guidelines was determined. RESULTS Overall SCIP compliance improved from 80% to 94% over a 2-year period. Standardized antibiotic dosing times improved compliance to more than 90%. Appropriate preoperative antibiotic choice improved to 100%. Cessation of antibiotics postoperatively within 24 hours remains a difficult task. Venous thromboembolism prophylaxis has been difficult to achieve because of postoperative bleeding concerns. Administration of beta-blockers has remained one of the most difficult problems to correct because of the multiplicity of avenues by which a patient may arrive to the operating suite. CONCLUSIONS Achievement of the SCIP goals is a formidable, but achievable, process requiring individual, cultural, systems, and institutional changes to achieve success.

A 21-Year History of All-Terrain Vehicle Injuries: Has Anything Changed?

BACKGROUND All-terrain vehicle (ATV)-related injuries have increased. The purpose of this study was to determine if the increase in injuries correlates with the expiration of government mandates. METHODS ATV-injured patients admitted to a level I trauma center were reviewed over the years 1985-1999 and 2000-2005. Several demographic variables and injuries sustained were analyzed. RESULTS There were a total of 433 injuries, which increased from 164 between 1985 and 1999, to 269 between 2000 and 2005. By comparing the time periods we observed a decrease in closed-head injury (53.6% vs 27.5%; P < .001), spinal cord injury (11.6% vs 5.2%; P < .05), and soft-tissue injury (62.8% vs 45.3%; P < .01), but an increase in long-bone fractures (18.9% vs 33.0%; P < .05). No differences were observed in other injuries. CONCLUSIONS The number of patients sustaining ATV-related injuries has increased and correlates with the expiration of government mandates. Even though ATVs remain dangerous, injury prevention strategies such as helmet laws may be having a positive impact.

A New Clopidogrel (Plavix) Point-of-Care Assay: Rapid Determination of Antiplatelet Activity in Trauma Patients

INTRODUCTION An increasing proportion of trauma patients are on anticoagulation or antiplatelet therapy. Unlike warfarin, where measuring international normalized ratio can help direct management, measuring platelet inhibition from clopidogrel (Plavix) is not standardized. We report the use of a new P2Y12 point-of-care assay (VerifyNow; Accumetrics, San Diego, CA) to determine the magnitude of platelet inhibition in trauma patients using clopidogrel. METHODS Trauma patients in 2009 were queried for clopidogrel use by prehospital personnel and the trauma team. Blood was obtained on admission for patients reportedly taking clopidogrel and was assayed for platelet inhibition using the VerfiyNow-P2Y12 device that measures P2Y12 reaction units and photometrically determines platelet inhibition percentage within 30 minutes. Patient demographics including age, Injury Severity Score, mechanism of injury, and complications from hemorrhage were also analyzed. RESULTS In the time studied, 46 patients taking clopidogrel were assayed for platelet inhibition. The mean age was 75.9 years±11.8 years, and the most common mechanism of injury was fall (86.9%). Platelet inhibition ranged from 0% to 89%. There were no deaths, and only two patients, from the 0% and>30% inhibition group, had hemorrhagic complications (increased intracranial hemorrhage). CONCLUSIONS The P2Y12 point-of-care assay determined that a large percentage of patients had undetectable or low platelet inhibition despite reportedly being on clopidogrel therapy. These patients may be clopidogrel nonresponders or noncompliant. It is unlikely that clopidogrel reversal therapies, such as platelet transfusions or Desmopressin, would be beneficial in this group. Further studies stratifying the percent platelet inhibition needed to increase bleeding complications is warranted to optimize management strategies.