C. William Schwab

Effects of an organized critical care service on outcomes and resource utilization: A cohort study

OBJECTIVE To determine whether the presence of an on-site, organized, supervised critical service improves care and decreases resource utilization. DESIGN The study compared two patient cohorts admitted to a surgical intensive care unit during the same period of time. The study cohort was cared for by an on-site critical care team supervised by an intensivist. The control cohort was cared for by a team with patient care responsibilities in multiple sites supervised by a general surgeon. The main outcome measures were duration of stay, resource utilization, and complication rate. SETTING Study patients were general surgical patients in an academic medical center. RESULTS Despite having higher Acute Physiology and Chronic Health Evaluation II scores, patients cared for by the critical care service spent less time in the surgical intensive care unit, used fewer resources, had fewer complications and had lower total hospital charges. The difference between the two cohorts was most evident in patients with the worst APACHE II score. CONCLUSIONS Critical care interventions are expensive and have a narrow safety margin. It is essential to develop structured and validated approaches to study the delivery of this resource. In this study, the critical care service model performed favorably both in terms of quality and cost.

Renal injury and operative management in the United States: results of a population-based study.

BACKGROUND To evaluate the extent to which nonoperative renal trauma management has been adopted, we determined the incidence of renal injury and the rate of operative management across the United States. METHODS International Classification of Diseases, Ninth Revision diagnosis and procedure codes identified patients with renal injuries in an 18-state administrative database representing 62% of the U.S. population. RESULTS Of 523,870 patients hospitalized for trauma in 1997 or 1998, 6,231 (1.2%) had renal injuries (4.89 per 100,000 population). Sixty-four percent of patients with injuries that were classified had contusions/hematomas, 26.3% had lacerations, 5.3% had parenchymal disruption, and 4% had vascular injuries. Eleven percent of renal trauma patients required surgical management of their kidney injuries, of whom 61%, or 7% of patients with renal injuries overall, underwent nephrectomy. Injury Severity Score, mechanism, and renal injury severity were independent predictors of nephrectomy. CONCLUSION The nephrectomy rate in community and academic centers reflects renal and global injury severity. Prospective trials are indicated to determine whether, in the traumatized patient with severe kidney injury, renal preservation could lead to improved outcomes compared with nephrectomy.

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.

Trauma in the Geriatric Patient

Elderly individuals are living longer, healthier, and more active lives, and, in the process, they are continually exposed to the risk of injury. Trauma is now the fifth most common cause of death in people over the age of 65 years, and the elderly suffer disproportionately high injury-related mortality rates compared with younger adults. They consume a vast portion of health care resources and their care precipitates some of the most difficult ethical and sociologic questions in modern medicine. Physiologically, the elderly present a unique and complex picture that requires an understanding of the process of aging and the concomitant effects of acquired diseases. As surgeons involved in the care of the injured, we find ourselves becoming more frequently involved with this national dilemma. This review provides some insights and guidelines for the care of the injured elderly, with the hope of improving our understanding and their outcome.

Urban firearm deaths: a five-year perspective

Firearm violence is an ever-increasing element in the lives of the U.S. urban population. This study examined the trends in firearm violence and victims during a 5-year period in the city of Philadelphia. Medical Examiner records of all deaths in Philadelphia County in 1985 and 1990 were reviewed. Demographic, autopsy, and criminal record information was analyzed. There were 145 firearm homicide victims in 1985 versus 324 in 1990, a 123% increase. This was primarily because of deaths among young (age 15-24 years), black male victims. Handguns were involved in at least 90% of firearm homicides in both study years. The use of semiautomatic handguns increased from 24% to 39% during the study period. In 1985, 42% of revolver homicides died at the scene, versus 18% in 1990. However, 5% of victims of semiautomatic weapons fire died at the scene in 1985 versus 34% in 1990. The decrease in survival of semiautomatic weapon victims occurred despite the implementation of six trauma centers within the county, and probably reflects a shift toward high-velocity, high-caliber ammunition. Antemortem drug use and criminal history was common. A total of 54% of victims were intoxicated in 1985 and 61% were in 1990. Cocaine became the most common intoxicant in 1990, with 39% of victims using it during the antemortem period. The percentage of victims with a criminal record increased from 44% to 67%. Although the duration of criminal history decreased from 14 to 6 years, the number of patients with previous drug offenses increased from 33% to 84%..(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid sequence induction for intubation by an aeromedical transport team: A critical analysis

Airway control is the initial priority in the management of the injured patient. The purpose of this investigation was to evaluate the experience of an aeromedical transport team in the utilization of rapid sequence induction (RSI) for endotracheal intubation in the prehospital setting. Records of a consecutive series of injured patients undergoing RSI between June 1988 and July 1992 by a university-based aeromedical transport team were reviewed for demographics, intubation mishaps, and pulmonary complications. The relationship between intubation mishaps and pulmonary complications was analyzed. Eighty-four patients were studied with a mean age of 30.8 +/- 15.3 years. The mean Revised Trauma Score was 11.3 +/- 2.4, and the mean Injury Severity Score (ISS) was 19.6 +/- 11.5. Intubation mishaps occurred in 15 patients (18%), and pulmonary complications developed in 22 (29%) of the 75 patients surviving longer than 24 hours. There was no relationship between intubation mishaps and pulmonary complications. Abbreviated Injury Scale (AIS) face score was significantly higher in patients with intubation mishaps, compared with patients without mishaps (1.1 +/- 1.2 and 0.5 +/- 0.9, respectively, P < .05, Wilcoxon rank-sum). ISS and AIS chest were higher in patients with pulmonary complications, compared with those without (25.7 +/- 12.6 and 17.4 +/- 10.3 and 2.2 +/- 1.8 and 1.0 +/- 1.5, ISS and AIS respectively; P < .05, Wilcoxon rank-sum). Eighty-one patients (96%) underwent successful RSI, 73 (87%) on the first attempt. Failure to intubate occurred in three patients (4%). Performed under strict protocol by appropriately trained aeromedical transport personnel, RSI is an effective means to facilitate endotracheal intubation in the injured patient requiring definitive airway control. Pulmonary complications were related to injury severity and not to intubation mishaps.

Hepatic angiography in patients undergoing damage control laparotomy.

OBJECTIVE Patients undergoing damage control (DC) laparotomy require intensive and aggressive resuscitation, and may require additional maneuvers to control parenchymal bleeding. Those patients suffering significant liver injury are at high risk for arterial bleeding deep within the liver, and many require hepatic angiography in addition to hepatic packing. We reviewed our experience with hepatic angiography, and sought to determine its safety in the DC population of penetrating and blunt trauma patients. METHODS A 3-year (June 1997-May 2000) retrospective review generated 37 DC patients. Patients sustaining hepatic trauma constituted the study group. Patients undergoing angiography in addition to DC laparotomy were compared with the group of patients not undergoing angiography. Data regarding mechanism of injury, patient demographics, extent of hepatic injury, and presence of associated injuries were collected. Physiologic parameters including vital signs at admission, lowest pH and base excess in the operating room, and lactate levels in the intensive care unit, as well as volumes of fluid resuscitation throughout all phases of DC were examined. Complications including death, intra-abdominal processes, acute respiratory distress syndrome and/or multiple organ dysfunction syndrome, and acute renal failure were reviewed. RESULTS Nineteen patients (51%) had hepatic trauma and underwent perihepatic packing as a part of DC laparotomy. Eleven had sustained penetrating injury and 8 had blunt injury. There was 1 American Association for the Surgery of Trauma grade I, 5 grade II, 3 grade III, and 10 grade IV injuries. Nine patients in the study population underwent angiography, and eight of these were hepatic artery angiograms. One hepatic angiogram was obtained before operation and seven were obtained in the immediate postoperative period. Six underwent embolization of bleeding hepatic vessels, for a therapeutic liver angiography rate of 75%. There was no statistical difference in physiologic parameters or fluid requirements between the patients who underwent angiography and those who did not. There were no mishaps or complications from angiography or while in the angiography suite. CONCLUSION Hepatic angiography is a safe adjunct to the principles of damage control. It has a high therapeutic ratio, with no significant untoward effect in this small study population.

Urban–Rural Shifts in Intentional Firearm Death: Different Causes, Same Results

OBJECTIVES We analyzed urban-rural differences in intentional firearm death. METHODS We analyzed 584629 deaths from 1989 to 1999 assigned to 3141 US counties, using negative binomial regressions and an 11-category urban-rural variable. RESULTS The most urban counties had 1.03 (95% confidence interval [CI]=0.87, 1.20) times the adjusted firearm death rate of the most rural counties. The most rural counties experienced 1.54 (95% CI=1.29, 1.83) times the adjusted firearm suicide rate of the most urban. The most urban counties experienced 1.90 (95% CI=1.50, 2.40) times the adjusted firearm homicide rate of the most rural. Similar opposing trends were not found for nonfirearm suicide or homicide. CONCLUSIONS Firearm suicide in rural counties is as important a public health problem as firearm homicide in urban counties. Policymakers should become aware that intentional firearm deaths affect all types of communities in the United States.

Comorbidity and the elderly trauma patient.

Abstract. The elderly are forming an increasingly larger proportion of the population in developed countries with increasingly active life styles. The injured elderly patient has a combination of decreased physiologic reserve and a high incidence of preexisting medical conditions that cause comparably worse outcome, complications, longer hospital stay, and high costs. Although the management of specific injuries is similar in the elderly, many benefit from an overall more aggressive approach to early resuscitation and optimization of cardiopulmonary dynamics. An awareness of the importance of preexisting medical conditions and a coordinated, directed approach to the management of the injuries and the concomitant diseases leads to the most effective care. Upon recovery from injury there is often a change of functional level that precipitates a change in social circumstance. Ethical dilemmas, both at individual and community levels, may arise more frequently in the older trauma patient population. Increased triage to a trauma center, particularly when concomitant disease is present, is justified on the basis of improving outcomes.

Delayed identification of skeletal injury in multisystem trauma: the 'missed' fracture.

Delay in diagnosis of musculoskeletal injury in multiply injured patients may potentially lead to functional or cosmetic disability in survivors. In an 18-month prospective study to determine the incidence and spectrum of delayed recognition of skeletal injury at our Level I trauma center, delayed diagnosis of 39 fractures was made in 26 of 1,006 consecutive blunt trauma patients. The delay in recognition ranged from 1-91 days. Twenty-one (55%) of the fractures were not X-rayed at the time of admission, but nine (23%) fractures were clearly visible on admission films. Four (10%) fractures were missed because of technically inadequate X-rays, and five (13%) had adequate X-rays but could not be identified on admission films. In only two instances was a second anesthetic exposure required for operative therapy. For the patients in this series, the delay of fracture identification was not felt to contribute to additional long-term cosmetic, functional, or neurologic problems. Continued clinical and radiologic surveillance is required in multiply injured patients to prevent musculoskeletal diagnostic failure.