C. Michael Dunham

Blunt splenic injury in adults: Multi-institutional study of the Eastern Association for the Surgery of Trauma

BACKGROUND Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The purpose of this multi-institutional study was to determine which factors predict successful observation of blunt splenic injury in adults. METHODS A total of 1,488 adults (>15 years of age) with blunt splenic injury from 27 trauma centers in 1997 were studied through the Multi-institutional Trials Committee of the Eastern Association for the Surgery of Trauma. Statistical analysis was performed with analysis of variance and extended chi2 test. Data are expressed as mean +/- SD; a value of p < 0.05 was considered significant. RESULTS A total of 38.5 % of patients went directly to the operating room (group I); 61.5% of patients were admitted with planned nonoperative management. Of the patients admitted with planned observation, 10.8% failed and required laparotomy; 82.1% of patients with an Injury Severity Score (ISS) < 15 and 46.6% of patients with ISS > 15 were successfully observed. Frequency of immediate operation correlated with American Association for the Surgery of Trauma (AAST) grades of splenic injury: I (23.9%), II (22.4%), III (38.1%), IV (73.7%), and V (94.9%) (p < 0.05). Of patients initially managed nonoperatively, the failure rate increased significantly by AAST grade of splenic injury: I (4.8%), II (9.5%), III (19.6%), IV (33.3%), and V (75.0%) (p < 0.05). A total of 60.9% of the patients failed nonoperative management within 24 hours of admission; 8% failed 9 days or later after injury. Laparotomy was ultimately performed in 19.9% of patients with small hemoperitoneum, 49.4% of patients with moderate hemoperitoneum, and 72.6% of patients with large hemoperitoneum. CONCLUSION In this multicenter study, 38.5% of adults with blunt splenic injury went directly to laparotomy. Ultimately, 54.8% of patients were successfully managed nonoperatively; the failure rate of planned observation was 10.8%, with 60.9% of failures occurring in the first 24 hours. Successful nonoperative management was associated with higher blood pressure and hematocrit, and less severe injury based on ISS, Glasgow Coma Scale, grade of splenic injury, and quantity of hemoperitoneum.

The impact of hyperglycemia on patients with severe brain injury.

BACKGROUND This study aimed to analyze the relation of hyperglycemia to outcome in cases of severe traumatic brain injury, and to examine factors that may be responsible for the hyperglycemic state. METHODS A retrospective analysis in an intensive care unit of a level 1 trauma center investigated 77 patients with severe traumatic brain injury. Patients with a Glasgow Coma Scale (GCS) of 8 or lower who survived more than 5 days were reviewed. Serum glucose, base deficit, GCS, use of steroids, and amounts of insulin and carbohydrates were recorded for 5 days, along with age. The Injury Severity Score (ISS) and the Abbreviated Injury Score (AIS) for the head, chest, and abdomen also were recorded. A hyperglycemia score (HS) was calculated as follows. A value of 1 was assigned each day the glucose exceeded 170 mg/dL (range, 0-5). A hyperglycemia score for days 3, 4, and 5 (HS day 3-5) also was calculated (range, 0-3). Outcomes included mortality, day 5 GCS, intensive care unit length of stay, and hospital length of stay. RESULTS Of the 77 patients, 24 (31.2%) died. Nonsurvivors had higher glucose levels each day. The HS was higher for those who died: 2.4 +/- 1.7 versus 1.5 +/- 1.4 (p = 0.02). Univariate analysis showed that only HS and ISS correlated with all four outcome variables studied. Coxs regression analysis showed that mortality was related to age and ISS. Head AIS and HS were independent predictors of lower day 5 GCS, whereas HS 3-5 and day 4 GCS were related to prolonged hospital length of stay. Older age, diabetes, and lower day 1 GCS were associated with higher HS, whereas carbohydrate infusion rate, ISS, head AIS, and steroid administration were not. CONCLUSIONS Early hyperglycemia is associated with poor outcomes for patients with severe traumatic brain injury. Tighter control of serum glucose without reduction of nutritional support may improve the prognosis for these critically ill patients.

Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and hypoperfusion.

BACKGROUND Traumatic brain injury (TBI) can be compounded by physiologic derangements that produce secondary brain injury. The purpose of this study is to elucidate the frequency with which physiologic factors that are associated with secondary brain injury occur in patients with severe closed head injuries and to determine the impact of these factors on outcome. METHODS The records of 81 adult blunt trauma patients with Glasgow Coma Scale scores < or = 8 and transport times < 2 hours to a Level I trauma center were retrospectively reviewed searching for the following 11 secondary brain injury factors (SBIFs) in the first 24 hours postinjury: hypotension, hypoxia, hypercapnia, hypocapnia, hypothermia, hyperthermia, metabolic acidosis, seizures, coagulopathy, hyperglycemia, and intracranial hypertension. We recorded the worst SBIF during six time periods: hours 1, 2, 3, 4, 5 to 14, and 16 to 24. Occurrence of each SBIF was then correlated with outcome. RESULTS Hypocapnia, hypotension, and acidosis occurred more frequently than other SBIFs (60-80%). Hypotension, hyperglycemia, and hypothermia were associated with increased mortality rate. Patients with episodes of hypocapnia, acidosis, and hypoxia had significantly longer intensive care unit length of stay (LOS). These three SBIFs and hyperglycemia related to longer hospital LOS as well. Hypotension and acidosis were associated with discharge to a rehabilitation facility rather than home. Finally, multivariate regression analysis revealed that hypotension, hypothermia, and Abbreviated Injury Scale score of the head were independently related to mortality, whereas other SBIFs, age, Injury Severity Score, and Glasgow Coma Scale score were not. Metabolic acidosis and hypoxia were related to longer intensive care unit and hospital LOS. CONCLUSION Our early management of head-injured patients stresses avoidance and correction of SBIFs at all costs. Nonetheless, SBIFs occur frequently in the first 24 hours after traumatic brain injury. Six of the 11 factors studied are associated with significantly worse outcomes. Hypotension and hypothermia are independently related to mortality. Because these SBIFs are potentially preventable, protocols could be developed to decrease their frequency.

Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee.

BACKGROUND Injury to the cervical spine (CS) is common after major trauma. The Eastern Association for the Surgery of Trauma first published its Practice Management Guidelines for the evaluation of CS injury in 1998. A subsequent revision was published in 2000. Since that time a large volume of literature has been published. As a result, the Practice Management Guidelines Committee set out to develop updated guidelines for the identification of CS injury. METHODS A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov). The search retrieved English language articles regarding the identification of CS injury from 1998 to 2007. The questions posed were: who needs CS imaging; what imaging should be obtained; when should computed tomography, magnetic resonance imaging, or flexion/extension radiographs be used; and how is significant ligamentous injury excluded in the comatose patient? RESULTS Seventy-eight articles were identified. From this group, 52 articles were selected to construct the guidelines. CONCLUSION There have been significant changes in practice since the previous CS injury guidelines. Most significantly, computed tomography has supplanted plain radiography as the primary screening modality in those who require imaging. Clinical clearance remains the standard in awake, alert patients with trauma without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion. Cervical collars should be removed as soon as feasible. Controversy persists regarding CS clearance in the obtunded patient without gross neurologic deficit.

Penetrating esophageal injuries: Multicenter study of the American Association for the Surgery of Trauma

OBJECTIVE The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay. METHODS This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fishers exact test, Students T test, and logistic regression analysis. RESULTS The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47). CONCLUSION Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

Practice management guidelines for the optimal timing of long-bone fracture stabilization in polytrauma patients : The EAST practice management guidelines work group

I. STATEMENT OF THE PROBLEM The optimal timing for long-bone stabilization in polytrauma patients has been debated for the last two decades. Much of the relevant literature focused on long-bone fracture as a femoral fracture; however, a substantial portion of published studies include various fractures (tibia, humerus, spine, and/or pelvis). Reported benefits of early long-bone stabilization in polytrauma patients include increased patient mobilization by eliminating the need for traction and decreased pulmonary morbidity (fat emboli syndrome, pneumonia, adult respiratory distress syndrome [ARDS]), late septic sequelae, hospital care costs, mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and ventilator days. Some authors suggest that early long-bone stabilization in polytrauma patients increases blood loss, fluid administration, and surgical stress, pulmonary morbidity, and mortality. However, others intimate that pulmonary morbidity (pulmonary shunt) is similar in those undergoing early or late stabilization (i.e., no worse, no better). There have been additional concerns regarding the timing of long-bone stabilization in patients with brain or chest injury. Problems with early fixation of long bones in patients with brain injury include secondary brain injury as a result of hypoxemia, hypotension, and/or complexity of controlling intracranial hypertension, increased mortality, and increased fluid administration, which might exacerbate cerebral edema. Other investigators suggest that early long-bone stabilization is not advised in patients with pulmonary contusion, multiple rib fractures, or hemopneumothorax, since there is increased pulmonary morbidity (ARDS, fat embolism syndrome), especially when intramedullary nailing and reaming are used. However, others indicate that chest injury patients with early intramedullary nailing have similar outcomes compared with later intramedullary nailing or other stabilization techniques (i.e., no worse or better). Other studies suggest that pulmonary contusion patients have similar pulmonary morbidity (PaO2/FIO2 and duration of mechanical ventilation) with early or late stabilization (i.e., no worse or better).

Cerebral Hypoxia in Severely Brain-Injured Patients Is Associated with Admission Glasgow Coma Scale Score, Computed Tomographic Severity, Cerebral Perfusion Pressure, and Survival

BACKGROUND The purpose of this study was to determine the relationship of cerebral hypoxia with admission Glasgow Coma Scale (GCS) score, brain computed tomographic (CT) severity, cerebral perfusion pressure (CPP), and survival in patients with severe brain injury. METHODS CPP and noninvasive transcranial oximetry (Stco2) were recorded hourly for 6 days in patients with a GCS score < or = 8 (3,722 observations). CT score was derived from midline shift (0/1) plus abnormal cisterns (0/1) plus subarachnoid hemorrhage (SAH) (0/1) (range, 0-3). RESULTS Brain CT results were as follows: shift, 10 (56%); abnormal cisterns, 14 (78%); SAH, 9 (50%); epidural hematoma, 2 (11%); subdural hematoma, 11 (61%); and contusion, 17 (94%). The incidences of Stco2 < 60 were: GCS score 3-4, 26.5%; GCS score 5-7, 12.4%; and GCS score 8, 2.8% (p < 0.0001); CT score 2/3, 26.4%; and CT score 0/1, 10.0% (p < 0.0001); nonsurvivors 36.1%; and survivors 16.3% (p < 0.0001). For incidence of CPP < 70, the results were as follows: Stco2 < 60%, 33% of observations; Stco2 > or = 60%, 10% of observations (odds ratio, 4.3; p < 0.01). Despite CPP > or = 70, Stco2 < 60 incidence was 16% of observations. CONCLUSION Cerebral hypoxia is common, even with CPP > or = 70, and is associated with GCS score, CT scan severity, and mortality. Cerebral hypoxia is related to cerebral hypoperfusion. Additional studies may prove that Stco2 monitoring will enhance the treatment of severe brain injury.

The rapid infusion system: a superior method for the resuscitation of hypovolemic trauma patients

The rapid infusion system (RIS), which can deliver fluids/blood products rapidly at precise rates and normothermic conditions, was compared with conventional fluid administration (CFA) in a randomized study of 36 hypovolemic trauma patients. Admission stratification criteria of the groups were similar relative to age, Glasgow Coma Score (GCS), Injury Severity Score (ISS) and plasma lactate. Despite the lack of difference in blood loss between the 24-h survivors of the two groups, the CFA group required greater total fluids (23.6/20.21), red blood cells (5.5/4.61), fresh frozen plasma (FFP) (2.8/1.91), platelets (523/204 ml), and crystalloids (12.9/10.61). Lactate levels were lower in the RIS group at virtually all times from hours 1 to 24 (4.3/5.3 mM/l, t-value = 3.3, DF = 279, P = 0.001). Post-admission hypothermia was greater in the CFA group at all times during the first 24 h (35.2/36.4 degrees C, t-value = 5.6, DF = 250, P = 0.001). The mean partial thromboplastin time was significantly higher in the CFA group (47.3/35.1 s, t-value = 3.1, DF = 279, P = 0.002). The PTT and PT were related to the degree of lactic acidosis (P = 0.0001) and hypothermia (P = 0.001) but not to the amount of FFP given (P = 0.14). The hospital costs, days in the ICU, and days on the ventilator were greater for the CFA group, as was the incidence of pneumonia (0/11 vs. 6/17; P = 0.03). Hypovolemic trauma patients resuscitated with the RIS needed fewer fluid/blood products and had less coagulopathy; more rapid resolution of hypoperfusion acidosis; better temperature preservation; and fewer hospital complications than those resuscitated with conventional methods of fluid/blood product administration.

Risks associated with magnetic resonance imaging and cervical collar in comatose, blunt trauma patients with negative comprehensive cervical spine computed tomography and no apparent spinal deficit

IntroductionIn blunt trauma, comatose patients (Glasgow Coma Scale score 3 to 8) with a negative comprehensive cervical spine (CS) computed tomography assessment and no apparent spinal deficit, CS clearance strategies (magnetic resonance imaging [MRI] and prolonged cervical collar use) are controversial.MethodsWe conducted a literature review to delineate risks for coma, CS instability, prolonged cervical collar use, and CS MRI.ResultsBased on our search of the literature, the numbers of functional survivor patients among those who had sustained blunt trauma were as follows: 350 per 1,000 comatose unstable patients (increased intracranial pressure [ICP], hypotension, hypoxia, or early ventilator-associated pneumonia); 150 per 1,000 comatose high-risk patients (age > 45 years or Glasgow Coma Scale score 3 to 5); and 600 per 1,000 comatose stable patients (not unstable or high risk). Risk probabilities for adverse events among unstable, high-risk, and stable patients were as follows: 2.5% for CS instability; 26.2% for increased intensive care unit complications with prolonged cervical collar use; 9.3% to 14.6% for secondary brain injury with MRI transportation; and 20.6% for aspiration during MRI scanning (supine position). Additional risk probabilities for adverse events among unstable patients were as follows: 35.8% for increased ICP with cervical collar; and 72.1% for increased ICP during MRI scan (supine position).ConclusionBlunt trauma coma functional survivor (independent living) rates are alarming. When a comprehensive CS computed tomography evaluation is negative and there is no apparent spinal deficit, CS instability is unlikely (2.5%). Secondary brain injury from the cervical collar or MRI is more probable than CS instability and jeopardizes cerebral recovery. Brain injury severity, probability of CS instability, cervical collar risk, and MRI risk assessments are essential when deciding whether CS MRI is appropriate and for determining the timing of cervical collar removal.

Inflammatory markers: superior predictors of adverse outcome in blunt trauma patients?

ObjectiveTo assess whether variables reflective of early metabolic responses to injury are predictors of outcome in critically ill trauma patients. DesignClinical inception cohort study comparing conventional measures of injury severity with early host response markers for the correlation of each with outcome. These data are prospectively collected in a group of patients being evaluated in a nutritional support investigation. SettingIntensive care unit (ICU) of a major Level I trauma center. PatientsSeventeen blunt trauma patients, aged 18 to 60 yrs with an Injury Severity Score of 2:15, requiring early mechanical ventilation. InterventionsBlood and urine samples were routinely obtained from patients undergoing nutritional support by one of three routes. Measurements and Main ResultsConventional assessment was consistent with moderate severity and variation: Injury Severity Score, 41 pL 15; Glasgow Coma Score, 11 pL 4; admission circulating lactate concentration, 4.8 pL 2.2 mmol/L; and first 24-hr transfusion requirement, 3.1 pL 2.9 L. The mean concentrations of inflammatory marker during the first week were: cholesterol, 2.67 pL 0.80 mmol/L (103.2 pL 31 mg/dL); C-reactive protein, 23 pL 11 mg/dL; transferrin, 1.44 pL 0.47 g/L; glucose, 9.21 pL 2.27 mmol/L (166 pL 41 mg/dL); albumin, 26 pL 5 g/L; and nitrogen loss, 24 pL 9 g/d. Hospital outcome variables were: ventilator days, 17 pL 7; ICU days, 26 pL 10; hospital days, 38 pL 15; occurrence rate of adult respiratory distress syndrome (ARDS), 35%; infections, 82%; multiple organ failure, 71%; and total of hospital plus professional charges, 125,000 pL 56,000. A significant (p < .05), but weak, correlation existed between all seven outcome variables and the inflammatory markers: ventilator days with cholesterol and C-reactive protein; ICU days with transferrin; total stay with cholesterol; ARDS with C-reactive protein; infections with glucose, cholesterol, and nitrogen loss; multiple organ failure with albumin and C-reactive protein; and financial charges with glucose. However, a significant correlation existed between only two of seven outcome variables and conventional measures of severity: multiple organ failure with lactate and financial charges with transfusion requirement. ConclusionReadily obtainable inflammatory marker measurements may better reflect the summation effects of the early perfusion deficit and tissue injury in the blunt trauma patient compared with conventional measures of injury severity. (Crit Care Med 1994; 22:667–672)