Dionne A. Skeete

Intrapleural tissue plasminogen activator for complicated pleural effusions.

BACKGROUND This study is aimed at evaluating the safety and efficacy of intrapleural tissue plasminogen activator (TPA) for complicated pleural effusions, including posttraumatic hemothorax. METHODS Data were retrospectively collected from hospitalized patients over a 4-year period (1999-2003) who were treated with intrapleural TPA after failing drainage by tube thoracostomy. Pre- and post-TPA imaging studies were reviewed and scored by a blinded radiologist. RESULTS Forty-one consecutive patients with 42 effusions were identified with the following indications: 6 traumatic hemothoraces (14%), 22 loculated pleural effusions (52%), 2 line-associated hemothoraces (5%), and 12 empyemas (29%). Nine patients (22%) required operative drainage including two with posttraumatic hemothoraces. All patients managed nonoperatively demonstrated radiographic improvement after TPA administration. One patient (2.4%) developed hematuria, requiring transfusion. No trauma patient required TPA-related blood transfusion and no deaths were attributable to TPA therapy. CONCLUSION Intrapleural TPA administration appears safe for use in complicated pleural effusions and may decrease the need for operative intervention.

Use of human acellular dermal matrix for abdominal wall reconstructions.

BACKGROUND Acellular dermal matrix (ADM) represents a promising new fascial substitute for repairing abdominal wall defects. METHODS We retrospectively studied 63 patients who underwent fascial reconstruction with ADM and analyzed risk factors for recurrence and infectious wound complications. RESULTS Postoperative wound infections, noninfectious wound complications, and recurrences developed in 35%, 44%, and 41% of patients, respectively. No patients required ADM removal. Long surgical times (> or =300 min), implants of 100 cm(2) or greater, and repairs using 3 or more ADM sheets were associated significantly with the development of a postoperative wound infection. The approximation of ADM directly to the fascial edge (P = .02), long surgical time (P < .01), implant size of 100 cm(2) or greater (P = .01), and the presence of a postoperative wound infection (P = .02) were associated significantly with recurrence. CONCLUSIONS Recurrences and complications after ADM fascial repairs may be higher than previously reported and associated with implant size and method of implantation. Postoperative infection, although not necessitating implant removal, is associated with more recurrences.

Long-term outcomes of patients with necrotizing fasciitis.

Context:Necrotizing fasciitis is an aggressive infection affecting the skin and soft tissue. It has a very high acute mortality. The long-term survival and cause of death of patients who survive an index hospitalization for necrotizing fasciitis are not known. Objective:To define the long-term survival of patients who survive an index admission for necrotizing fasciitis. We hypothesize that survivors will have a shorter life span than population controls. Design:Long-term follow-up of a registry of patients from 1989 to 2006 who survived a hospitalization for necrotizing fasciitis. Last date of follow-up was January 1, 2008. Settings:A university-based Burn and Trauma Center. Patients:A prospective registry of patients with necrotizing fasciitis has been collected from 1989 to 2006. This registry was linked to data from the Department of Health, Department of Motor Vehicles, and the University Hospital Medical Records Department in January 2008 to obtain follow-up and vital status data. Intervention:None. Main Outcome Measures:Date and cause of death were abstracted from death certificates. Date of last live follow-up was determined from the medical record and by the last drivers license renewal. The death rate of the cohort was standardized for age and sex against 2005 statewide mortality rates. Cause of death was collated into infectious and noninfectious and compared with the statewide causes of death. Statistical analysis included standardized mortality rates, Kaplan-Meier survival curves, and Aalens additive hazard model. Results:Three hundred forty-five patients of the 377 in the registry survived at least 30 days and were analyzed. Average age at presentation was 49 years (range, 1–86; median, 49). Patients were followed up an average of 3.3 years (range, 0.0–15.7; median, 2.4). Eighty-seven of these patients died (25%). Median survival was 10.0 years (95% confidence interval: 7.25–13.11). There was a trend toward higher mortality in women. Twelve of the 87 deaths were due to infectious causes. Using three different statistical analytic techniques, there was a statistically significant increase in the long-term death rate when compared with population-based controls. Infectious causes of death were statistically higher than controls as well. Conclusions:Patients who survive an episode of necrotizing fasciitis are at continued risk for premature death; many of these deaths were due to infectious causes such as pneumonia, cholecystitis, urinary tract infections, and sepsis. These patients should be counseled, followed, and immunized to minimize chances of death. Modification of other risk factors for death such as obesity, diabetes, smoking, and atherosclerotic disease should also be undertaken. The sex difference in long-term survival is intriguing and needs to be addressed in further studies.

A pediatric cervical spine clearance protocol to reduce radiation exposure in children

BACKGROUND To minimize radiation exposure in children and reduce resource use, we implemented an age-specific algorithm to evaluate cervical spine injuries at a Level 1 trauma center. The effects of protocol implementation on computed tomography (CT) use in children (≤ 10 y) were determined. METHODS With institutional review board approval, we conducted a retrospective review using the institutional trauma registry. All pediatric patients (≤ 10 y) (n = 324) between January 2007 and present were reviewed. We excluded cases in which no imaging or outside imaging was performed. Patients were evaluated by physical exam alone, with the aid of plain radiograms or with cervical spine CT. All patients who required head CT also had CT of cervical spine to C3. We analyzed demographic, injury, and outcome data using STATA to perform chi-square and t-test, and to determine P value. P < 0.05 was defined as significant. We used the WinDose program to calculate the radiation-effective dose used in cervical spine CT. RESULTS There were 123 and 124 patients in the pre-protocol and post-protocol groups, respectively. Demographics, GCS, and injury analysis, specifically head-neck and face Injury Severity Scores showed no significant difference between groups. There was a 60% (P < 0.001) decrease in the use of full CTs after protocol implementation. We estimated that the protocol reduced the exposed area by 50% and decreased the radiation dose to the thyroid by > 80%. We extrapolated the combined effect results in a threefold reduction in radiation exposure. CONCLUSIONS Implementation of a cervical spine protocol led to a significant reduction in radiation exposure among children.

Blunt Cerebrovascular Injuries: Advances in Screening, Imaging, and Management Trends

SUMMARY: Blunt cerebrovascular injury is a relatively uncommon but sometimes life-threatening injury, particularly in patients presenting with ischemic symptoms in that vascular territory. The decision to pursue vascular imaging (generally CT angiography) is based on clinical and imaging findings. Several grading scales or screening criteria have been developed to guide the decision to pursue vascular imaging, as well as to recommend different treatment options for various injuries. The data supporting many of these guidelines and options are limited however. The purpose of this article is to review and compare these scales and criteria and the data supporting clinical efficacy and to make recommendations for future research in this area.

Not just an urban phenomenon: uninsured rural trauma patients at increased risk for mortality

Introduction National studies of largely urban populations showed increased risk of traumatic death among uninsured patients, as compared to those insured. No similar studies have been done for major trauma centers serving rural states. Methods We performed retrospective analyses using trauma registry records from adult, non-burn patients admitted to a single American College of Surgeons-certified Level 1 trauma center in a rural state (2003–2010, n=13,680) and National Trauma Data Bank (NTDB) registry records (2002–2008, n=380,182). Risk of traumatic death was estimated using multivariable logistic regression analysis. Results We found that 9% of trauma center patients and 27% of NTDB patients were uninsured. Overall mortality was similar for both (~4.5%). After controlling for covariates, uninsured trauma center patients were almost five times more likely to die and uninsured NTDB patients were 75% more likely to die than commercially insured patients. The risk of death among Medicaid patients was not significantly different from the commercially insured for either dataset. Conclusion Our results suggest that even with an inclusive statewide trauma system and an emergency department that does not triage by payer status, uninsured patients presenting to the trauma center were at increased risk of traumatic death relative to patients with commercial insurance.

Duration of prehospital intubation is not a risk factor for development of early ventilator-associated pneumonia☆

PURPOSE Ventilator-associated pneumonia (VAP) is a significant cause of morbidity and mortality among critically ill patients with trauma. Few VAP prevention strategies have been studied in the prehospital environment. The objectives of this study are to measure the association between duration of prehospital intubation and intubation location with subsequent incidence of early (within 5 days) VAP. MATERIALS AND METHODS Single-center retrospective cohort study of all intubated adult (age≥18 years) patients with trauma presenting to a 711-bed Midwestern Level I trauma center between January 2005 and December 2011 (n=860). RESULTS Thirty-five patients (6.4%) were diagnosed as having early VAP during the study period. Using multivariable logistic regression to adjust for age, injury severity score, and year (corresponding to VAP bundle implementation), the duration of intubation prior to hospital admission was not associated with subsequent diagnosis of VAP (adjusted odds ratio, 0.90 per hour; 95% confidence interval, 0.70-1.15). Location of intubation was similarly not associated with VAP. CONCLUSIONS Duration of prehospital intubation and intubation location were not different in patients with trauma who developed early VAP. Further prospective analyses should be conducted to better elucidate the effect of prehospital management on the development of traditionally in-hospital complications.

Safety and effectiveness of Factor Eight Inhibitor Bypassing Activity for direct oral anticoagulant-related hemorrhage reversal

Background: The incidence of patients who present with life‐threatening bleeding complications has been increasing as the use of direct oral anticoagulation (DOAC) has increased. Therefore, effective reversal agents are urgently needed. Current guidelines recommend the use of prothrombin complex concentrates (PCCs) and activated PCCs (aPCC) for reversal of DOAC anticoagulant activity in the setting of traumatic and non‐traumatic intracranial hemorrhage (ICH). However, little data is available. Objective: Herein, we investigated the safety and effectiveness of Factor Eight Inhibitor Bypassing Activity [FEIBA (an aPCC)] in a population of patients who required emergent reversal of DOAC for hemorrhage or urgent surgical interventions. Methods: This is a case series study. Medical records from patients who required emergent reversal of DOAC for life threatening hemorrhage or urgent surgical interventions were collected from February 1, 2014, to April 1, 2017 and reviewed. Data, including demographics as well as safety, outcomes, and dosing of FEIBA for reversal of DOAC effects were collected and descriptive statistics were obtained. Results: Forty‐two patients who received FEIBA were included in the study. The rates of thrombotic events (10%), hemorrhage progression (10%), and observed mortality (29%) were similar to rates previously published in the limited literature evaluating aPCC use in this population. Conclusion: This case series suggests that FEIBA administration is relatively safe and effective to reverse DOACs in the setting of hemorrhage or need for urgent surgical procedures. Until target‐specific reversal agents are available, future studies are warranted to evaluate the effectiveness of aPCC administration for DOAC‐associated hemorrhagic complications.