Carl I. Schulman

Can near-infrared spectroscopy identify the severity of shock in trauma patients?

BACKGROUND Our recent experimental study showed that peripheral muscle tissue oxygen saturation (StO2), determined noninvasively by near-infrared spectroscopy (NIRS), was more reliable than systemic hemodynamics or invasive oxygenation variables as an index of traumatic shock. The purpose of this study was to establish the normal range of thenar muscle StO2 in humans and the relationship between shock state and StO2 in trauma patients. METHODS This was a prospective, nonrandomized, observational, descriptive study in normal human volunteers (n = 707) and patients admitted to the resuscitation area of our Level I trauma center (n = 150). To establish a normal StO2 range, an NIRS probe was applied to the thenar eminence of volunteers (normals). Subsequently, in a group of trauma patients, an NIRS probe was applied to the thenar eminence and data were collected and stored for offline analysis. StO2 monitoring was performed continuously and noninvasively, and values were recorded at 2-minute intervals. Five moribund trauma patients were excluded. Members of our trauma faculty, blinded to StO2 values, classified each patient into one of four groups (no shock, mild shock, moderate shock, and severe shock) using conventional physiologic parameters. RESULTS Mean +/- SD thenar StO2 values for each group were as follows: normals, 87 +/- 6% (n = 707); no shock, 83 +/- 10% (n = 85); mild shock, 83 +/- 10% (n = 19); moderate shock, 80 +/- 12% (n = 14); and severe shock, 45 +/- 26% (n = 14). The thenar StO2 values clearly discriminated the normals or no shock patients and the patients with severe shock (p < 0.05). CONCLUSION Decreased thenar muscle tissue oxygen saturation reflects the presence of severe hypoperfusion and near-infrared spectroscopy may be a novel method for rapidly and noninvasively assessing changes in tissue dysoxia.

Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND Aging patients constitute an increasing proportion of patients treated at trauma centers. Previous and existing guidelines addressing care of the injured elder have not adequately addressed emerging data regarding optimal means for undertaking triage decisions, correcting coagulopathy, and the limitations of supraphysiologic resuscitation. METHODS More than 400 MEDLINE citations published between the years 2000 and 2008 were identified and screened. A total of 90 references were selected for the evidentiary table followed by consensus-based discussions regarding the level of evidence and the strength of recommendations that could be derived from the related findings of the individual studies. RESULTS In general, a lower threshold for trauma activation should be used for injured patients aged 65 years or older who are evaluated at trauma centers. Furthermore, elderly patients with at least one body system with an AIS score of 3 or higher or a base deficit of −6 or less should be treated at trauma centers, preferably in intensive care units staffed by surgeon-intensivists. In addition, all elderly patients who receive daily therapeutic anticoagulation should have appropriate assessment of their coagulation profile and cross-sectional imaging of the brain as soon as possible after admission where appropriate. In patients aged 65 years or older with a Glasgow Coma Scale (GCS) score less than 8, if substantial improvement in GCS is not realized within 72 hours of injury, consideration should be given to limiting further aggressive therapeutic interventions. CONCLUSION Effective evidence-based care of aging patients necessitates aggressive triage, correction of coagulopathy, and limitation of care when clinical evidence points toward an overwhelming likelihood of poor long-term prognosis.

Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma.

INTRODUCTION Approximately one third of stable patients with significant intra-abdominal injury do not have significant intraperitoneal blood evident on admission. We hypothesized that a delayed, repeat ultrasound study (Secondary Ultrasound--SUS) will reveal additional intra-abdominal injuries and hemoperitoneum. METHODS We performed a prospective observational study of trauma patients at our Level I trauma center from April 2003 to December 2003. Patients underwent an initial ultrasound (US), followed by a SUS examination within 24 hours of admission. Patients not eligible for a SUS because of early discharge, operative intervention or death were excluded. All US and SUS exams were performed and evaluated by surgical/emergency medicine house staff or surgical attendings. RESULTS Five hundred forty-seven patients had both an initial US and a SUS examination. The sensitivity of the initial US in this patient population was 31.1% and increased to 72.1% on SUS (p < 0.001) for intra-abdominal injury or intra-abdominal fluid. The specificity for the initial US was 99.8% and 99.8% for SUS. The negative predictive value was 92.0% for the initial US and increased to 96.6% for SUS (p = 0.002). The accuracy of the initial ultrasound was 92.1% and increased to 96.7% on the SUS (p < 0.002). No patient with a negative SUS after 4 hours developed clinically significant hemoperitoneum. CONCLUSION A secondary ultrasound of the abdomen significantly increases the sensitivity of ultrasound to detect intra-abdominal injury.

Impact of age of transfused blood in the trauma patient.

To the Editor:Impact of Age of Transfused Blood in the Trauma PatientApproximately 40% of 11 million units of blood transfused in the United States each year are utilized for emergency resuscitation, and two thirds of all transfusions occur perioperatively. The FDA requires that a unit of packed red

Integrating emergency general surgery with a trauma service: impact on the care of injured patients.

BACKGROUND There has been considerable discussion on the national level on the future of trauma surgery as a specialty. One of the leading directions for the field is the integration of emergency general surgery as a wider and more attractive scope of practice. However, there is currently no information on how the addition of an emergency general surgery practice will affect the care of injured patients. We hypothesized that the care of trauma patients would be negatively affected by adding emergency general surgery responsibilities to a trauma service. METHODS Our institution underwent a system change in August 2001, where an emergency general surgery (ES) practice was added to an established trauma service. The ES practice included emergency department and in-house consultations for all urgent surgical problems except thoracic and vascular diseases. There were no trauma staff changes during the study period. Trauma registry data (demographics, injuries, injury severity, and procedures) and performance improvement data (peer-review judgments for all identified errors, denied days, audit filters, and deaths) were abstracted for two 15-month periods surrounding this system change. Chi-square, Fishers exact, and t tests provided between-group comparisons. RESULTS The trauma staff evaluated a total of 5,874 patients during the 30-month study. There were 1,400 (51%) trauma admissions in the pre-ES group and 1,504 (48%) in the post-ES group, of which 1,278 and 1,434, respectively, met severity criteria for report to our statewide database (Pennsylvania Trauma Outcome Study [PTOS]). There were 163 (12.7% of PTOS) deaths in the pre-ES group compared with 171 (11.9% PTOS) deaths in the post-ES group (p = not significant [NS]). There was one death determined to be preventable by the peer review process for the pre-ES group, and none in the post-ES group. Both groups had 10 potentially preventable deaths, with the remaining mortalities being categorized as nonpreventable (p = NS). Unexpected deaths by TRISS methodology were 36 (2.8%) and 41 (2.9%) for the two groups, respectively (p = NS). There was no difference in the number of provider-specific complications between the groups (23, [1.8%] vs. 19 [1.3%], p = NS). The addition of emergency surgery has resulted in an additional average daily workload of 1.3 cases and 1.2 admissions. CONCLUSION Despite an increase in trauma volume over the study period, the addition of emergency surgery to a trauma service did not affect the care of injured patients. The concept of adding emergency surgery responsibilities to trauma surgeons appears to be a valid way to increase operative experience without compromising care of the injured patient.

Enhancing Patient Safety in the Trauma/surgical Intensive Care Unit

BACKGROUND Preventable deaths due to errors in trauma patients with otherwise survivable injuries account for up to 10% of fatalities in Level I trauma centers, 50% of these errors occur in the intensive care unit (ICU). The root cause of 67% of the Joint Commission sentinel events is communication errors. The objective is (1) to study how critical information degrades and how it is lost over 24 hours and (2) to determine whether a structured checklist for ICU handoffs prevents information loss. METHODS Prospective cohort study of trauma and surgical ICU teams observed with and without use of the checklist. An observational period (control group) was followed by a didactic session on the science and use of a checklist (study group), which was used for patient management and handoffs. Information was tracked for a 24-hour period and all handoffs. Comparisons use chi or Fishers exact test and a p value <0.05 was defined as significant. RESULTS Three hundred and thirty-two patient ICU days were observed (119 control, 213 study) and 689 patient care items (303 control, 386 study) were followed. Seventy-five (10.9%) items were lost over 24 hours; 61 of 303 (20.1%) without checklist and 14 of 386 (3.6%) with checklist (p < 0.0001). Critical laboratory values and test results were the most frequent lost items (36.1% control vs. 4.5% study p < 0.0001). Six of 75 (8.1%) items were correctly ordered but not carried out by ICU nursing staff--all caught and corrected with checklist use. CONCLUSION Critical information is degraded over 24 hours in the ICU. A structured checklist significantly reduces patient errors due to lost information and communication lapses between trauma ICU team members at handoffs of care.

Outcomes of Acinetobacter baumannii infection in critically ill burned patients

The objective of this study was to determine the incidence of drug resistance among isolates of Acinetobacter baumannii from our Burn Intensive Care Unit (BICU), the rate of clinical cure, and the mortality rate. We undertook a retrospective review of all cases of infection from the BICU between January 2004 and November 2005. The group consisted of 24 men (80%) and 6 women with a mean age of 43 years (range, 17–76 years, ±14.5 years). Mean TBSA burned was 43% (range, 9–75%, ±19%). Mean BICU length of stay was 49 days (range, 5–118 days, ±30 days). Patients developed their first infection after a mean of 16 days (5–73 days, ±14 days). The initial site of infection was bronchoalveolar lavage in 21 (70%), blood in 6 (20%), central venous catheter tip in 2 (7%), and urine in 1 (3%). The isolates displayed resistance to imipenem in 87% of cases. No organism displayed resistance to colistin (polymixin E). Patients were treated with colistin in 20 cases (67%), with amikacin in 8 cases (27%), and with imipenem in 2 cases (7%). A total of 10 patients (33%) died, 1 from gastrointestinal bleeding and 9 from active infection, giving an infection related mortality of 30%. In 21 cases (70%), a cure was achieved with a mean duration of treatment of 16 days (range, 4–30 days, ±7 days). The majority of A. baumannii isolates were multidrug resistant; however, no isolate displayed resistance to colistin. Cure rate was 70% and infection-related mortality reached 30%. More investigation is warranted to improve prevention and to assess new therapeutic agents.

First report on safety and efficacy of hetastarch solution for initial fluid resuscitation at a level 1 trauma center.

BACKGROUND For logistics, the US Army recommends Hextend (Hospira; 6% hetastarch in buffered electrolyte, HET) for battlefield resuscitation. To support this practice, there are laboratory data, but none in humans. To test the hypothesis that HET is safe and effective in trauma, we reviewed our first 6 months of use at a civilian level 1 trauma center. STUDY DESIGN From June 2008 to December 2008, trauma patients received standard of care (SOC) +/- 500 to 1,000 mL of HET within 2 hours of admission at surgeon discretion. Each case was reviewed, with waiver of consent. RESULTS There were 1,714 admissions; 805 received HET and 909 did not. With HET versus SOC, overall mortality was 5.2% versus 8.9% (p = 0.0035) by univariate analysis. Results were similar after penetrating injury only (p = 0.0016) and in those with severe injury, defined by Glasgow Coma Scale <9 (p = 0.0013) or Injury Severity Score >26 (p = 0.0142). After HET, more patients required ICU admission (40.9% vs. 34.5%; p = 0.0334) and transfusions of blood (34.4% vs. 20.2%; p = 0.0014) or plasma (20.7% vs. 12.2%; p = 0.0251), but there were no treatment-related differences in prothrombin time or partial thromboplastin time. The 24-hour urine outputs and requirements for blood, plasma, and other fluids were similar. However, increased early deaths with SOC implicate possible selection bias. If that factor was controlled for with multivariate analysis, the same trends were present, but the apparent treatment effects of HET were no longer statistically significant. CONCLUSIONS In the first trial to date in hemodynamically unstable trauma patients, and the largest trial to date in any population of surgical patients, initial resuscitation with HET was associated with reduced mortality and no obvious coagulopathy. A randomized blinded trial is necessary before these results can be accepted with confidence.

Do all trauma patients benefit from tranexamic acid

BACKGROUND This study tested the hypothesis that early routine use of tranexamic acid (TXA) reduces mortality in a subset of the most critically injured trauma intensive care unit patients. METHODS Consecutive trauma patients (n = 1,217) who required emergency surgery (OR) and/or transfusions from August 2009 to January 2013 were reviewed. At surgeon discretion, TXA was administered at a median of 97 minutes (1-g bolus then 1-g over 8 hours) to 150 patients deemed high risk for hemorrhagic death. With the use of propensity scores based on age, sex, traumatic brain injury (TBI), mechanism of injury, systolic blood pressure, transfusion requirements, and Injury Severity Score (ISS), these patients were matched to 150 non-TXA patients. RESULTS The study population was 43 years old, 86% male, 54% penetrating mechanism of injury, 25% TBI, 28 ISS, with 22% mortality. OR was required in 78% at 86 minutes, transfusion was required in 97% at 36 minutes, and 75% received both. For TXA versus no TXA, more packed red blood cells and total fluid were required, and mortality was 27% versus 17% (all p < 0.05). The effects of TXA were similar in those with or without TBI, although ISS, fluid, and mortality were all higher in the TBI group. Mortality associated with TXA was influenced by the timing of administration (p < 0.05), but any benefit was eliminated in those who required more than 2,000-mL packed red blood cells, who presented with systolic blood pressure of less than 120 mm Hg or who required OR (all p < 0.05). CONCLUSION For the highest injury acuity patients, TXA was associated with increased, rather than reduced, mortality, no matter what time it was administered. This lack of benefit can probably be attributed to the rapid availability of fluids and emergency OR at this trauma center. Prospective studies are needed to further identify conditions that may override the benefits from TXA. LEVEL OF EVIDENCE Therapeutic study, level IV.

Pediatric FAST and Elevated Liver Transaminases: An Effective Screening Tool in Blunt Abdominal Trauma

BACKGROUND The current standard for the evaluation of children with blunt abdominal trauma (BAT) consists of physical examination, screening lab values, and computed tomography (CT) scan. We sought to determine if the focused assessment with sonography for trauma (FAST) combined with elevated liver transaminases (AST/ALT) could be used as a screening tool for intra-abdominal injury (IAI) in pediatric patients with BAT. METHODS Registry data at a level 1 trauma center was retrospectively reviewed from 1991-2007. Data collected on BAT patients under the age of 16 y included demographics, injury mechanism, ISS, GCS, imaging studies, serum ALT and AST levels, and disposition. AST and ALT were considered positive if either one was >100 IU/L. RESULTS Overall, 3171 cases were identified. A total of 1008 (31.8%) patients received CT scan, 1148 (36.2%) had FAST, and 497 (15.7%) patients received both. Of the 497 patients, 400 (87.1%) also had AST and ALT measured. FAST was 50% sensitive, 91% specific, with a positive predictive value (PPV) of 68%, negative predictive value (NPV) of 83%, and accuracy of 80%. Combining FAST with elevated AST or ALT resulted in a statistically significant increase in all measures (sensitivity 88%, specificity 98%, PPV 94%, NPV 96%, accuracy 96%). CONCLUSIONS FAST combined with AST or ALT > 100 IU/L is an effective screening tool for IAI in children following BAT. Pediatric patients with a negative FAST and liver transaminases < 100 IU/L should be observed rather than subjected to the radiation risk of CT.