Dorraine D. Watts

Hypothermic coagulopathy in trauma : Effect of varying levels of hypothermia on enzyme speed, platelet function, and fibrinolytic activity

BACKGROUND The coagulopathy noted in hypothermic trauma patients has been variously theorized to be caused by either enzyme inhibition, platelet alteration, or fibrinolytic processes, but no study has examined the possibility that all three processes may simultaneously contribute to coagulopathy, but are perhaps triggered at different levels of hypothermia. The purpose of this study was to determine whether, at clinically common levels of hypothermia (33.0-36.9 degrees C), there are specific temperature levels at which coagulopathic alterations are seen in each of these processes. METHODS Of 232 consecutive adult trauma patients presenting to a Level I trauma center, 112 patients met the inclusion criteria of an Injury Severity Score of 9 or greater and time since injury of less than 2 hours. Of the included patients, 40 were normothermic and 72 were hypothermic (> or =37 degrees C, n = 40; 36.9-36 degrees C, n = 29; 35.9-35 degrees C, n = 20; 34.9-34 degrees C, n = 16; 33.9-33 degrees C, n = 7). Included patients were prospectively studied with thrombelastography adjusted to core body temperature. Additionally, PT, aPTT, platelets, CO2, hemoglobin, hematocrit, and Injury Severity Score were measured. RESULTS Analysis by multivariate analysis of variance of the relationship between coagulation and temperature demonstrated that in hypothermic trauma patients, 34 degrees C was the critical point at which enzyme activity slowed significantly (p < 0.0001), and at which significant alteration in platelet activity was seen (p < 0.001). Fibrinolysis was not significantly affected at any of the measured temperatures (p > 0.25). CONCLUSIONS Patients whose temperature was > or =34.0 degrees C actually demonstrated a significant hypercoagulability. Enzyme activity slowing and decreased platelet function individually contributed to hypothermic coagulopathy in patients with core temperatures below 34.0 degrees C. All the coagulation measures affected are part of the polymerization process of platelets and fibrin, and this process may be the mechanism by which the alteration in coagulation occurs.

Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death.

BACKGROUND Elderly patients suffer higher mortality rates after trauma than younger patients. This increased mortality is attributable to age, preexisting disease, and complications as well as injury severity. METHODS Records from 5,139 adult patients from a Level I trauma center were retrospectively reviewed. Injury Severity Score (ISS), Revised Trauma Score (RTS), early mortality (<24 hours), and late mortality (>24 hours) were determined for elderly (> or =65 years) and younger (16-64 years) patients. Preexisting diseases and complications were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis coding. RESULTS Mortality in elderly patients was twice that in younger patients despite equivalent injury severity (p < 0.001), and elderly patients were more likely to suffer later death than younger patients (p < 0.005). The prevalence of preexisting disease was greater in the elderly, as was the incidence of complications. Using logistic regression, ISS, RTS, preexisting cardiovascular or liver disease, the development of cardiac, renal, or infectious complications, and geriatric status were all independently predictive of late mortality (p < 0.05). CONCLUSION Elderly trauma patients more frequently suffer late mortality than younger patients because of the combination of injury and increased preexisting disease and complications after injury. Aggressive treatment of the elderly trauma patient is warranted; however, in the face of significant preexisting disease or complications, survival is less likely. Predictive models of survival can be developed, taking into account preexisting disease and complications as well as admission parameters such as age, ISS, and RTS, and specific risk of mortality quantitated.

Incidence of hollow viscus injury in blunt trauma: An analysis from 275,557 trauma admissions from the EAST multi-institutional trial

BACKGROUND Blunt hollow viscus injury (HVI) is uncommon. No sufficiently large series has studied the prevalence of these injuries in blunt trauma patients. This study defines the prevalence of blunt HVI, in addition to the associated morbidity and mortality rates for this diagnosis on the basis of a series of over 275,000 trauma admissions. METHODS Patients with blunt small bowel injury (SBI) were identified from the registries of 95 trauma centers for a 2-year period (1998-1999). Each HVI patient (case) was matched by age and Injury Severity Score with a blunt trauma patient receiving an abdominal workup who did not have HVI (control). Patient level data were abstracted by individual chart review. Institution level data were collected on total numbers for trauma admission demographics and on total diagnostic examinations performed. RESULTS From 275,557 trauma admissions, 227,972 blunt injury patients were identified. HVI was rare, with 2,632 patients identified from this group. Perforating small bowel injury accounted for less than 0.3% of blunt admissions. Mortality and morbidity were high for HVI. Controlling for injury severity, patients with HVI were usually at higher risk of death than non-HVI patients. CONCLUSION HVI is a rare but deadly phenomenon. The high mortality rates reflect the severity of the HVI and associated injuries. HVI patients should be carefully monitored for related injuries and complications.

Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: analysis from 275,557 trauma admissions from the EAST multi-institutional HVI trial.

OBJECTIVES Blunt SBI is infrequent and its diagnosis may be difficult, especially in the face of confounding variables. The purpose of this study was to evaluate methods for making the diagnosis of blunt SBI. METHODS Patients with blunt small bowel injury (SBI) were identified from the registries of 95 trauma centers for a 2-year period (1998-1999). Patients with SBI (cases) were matched by age and Injury Severity Score with a blunt trauma patient receiving an abdominal workup who did not have SBI (controls). RESULTS Logistic regression models were unable to differentiate SBI with perforation from SBI without perforation. Thirteen percent of patients with documented perforating SBI had normal abdominal computed tomographic scans preoperatively. CONCLUSION Alone or in combination, current diagnostic approaches lack sensitivity in the diagnosis of perforated SBI. Improvements in diagnostic methods and approaches are needed to ensure the prompt diagnosis of this uncommon but potentially devastating injury.

Percutaneous endoscopic gastrostomy: the preferred method of elective feeding tube placement in trauma patients.

PURPOSE The purpose of this study was to determine whether gastric feeding tubes placed by the percutaneous endoscopic route resulted in fewer and less severe complications than open surgical gastrostomy (SG). METHODS Charts for all trauma patients admitted 1/94 to 12/98, which had an electively placed feeding tube, were individually reviewed. All tube-related complications were recorded. Of 8119 patients screened, 158 (1.9%) met inclusion criteria. Percutaneous endoscopic gastrostomies (PEGs) were placed in 95 (60.1%) and surgical gastrostomies in 63 (39.9%). Most patients (79.1%) had AIS 3 or greater head or spinal cord injury as the primary diagnosis leading to tube placement. RESULTS Overall, SG patients were 5.4 times more likely than PEG patients to have a complication from their gastrostomy tube (95% CI, 2.1-13.8). They were 2.6 times more likely to have a major complication (internal leakage, dehiscence, peritonitis, and fistula), and 5.5 times more likely to have a minor complication (unplanned removal, dislodgment, external leak, skin infection, and nonfunction). The groups did not differ on ISS, ICU LOS, total LOS, or mortality (p > 0.05). Overall, a total of 39 individual complications related to tube placement were noted in 26 separate patients (PEG, 7; SG, 19). All four of the major complications requiring operative intervention were in the SG group. There were 31 minor complications, 8 in the PEG group and 27 in the SG group. Mean total charges for placement were also significantly lower in the PEG group than the SG group (

Colon Injury after Blunt abdominal trauma: Results of the EAST multi-institutional hollow Viscus Injury Study

1271 vs.

The utility of traditional prehospital interventions in maintaining thermostasis

2761, p < 0.001) CONCLUSION Gastrostomy tubes placed via the percutaneous endoscopic route had a significantly lower complication rate than surgically placed tubes. In addition, the charges incurred for their placement were also significantly less. Based on the findings of this study, PEG should be considered as the method of choice for gastric feeding tube placement for trauma patients who do not have specific contraindications to the procedure.

Insult after injury: pressure ulcers in trauma patients.

BACKGROUND Blunt injury to the colon is rare. Few studies of adequate size and design exist to allow clinically useful conclusions. The Eastern Association for the Surgery of Trauma Multi-institutional Hollow Viscus Injury (HVI) Study presents a unique opportunity to definitively study these injuries. METHODS Patients with blunt HVI were identified from the registries of 95 trauma centers over 2 years (1998-1999). Patients with colon injuries (cases) were compared with blunt trauma patient undergoing a negative laparotomy (controls). Data were abstracted by chart review. RESULTS Of the 227,972 patients represented, 2,632 (1.0%) had an HVI and 798 had a colonic/rectal injury (0.3%). Of patients diagnosed with HVI, 30.2% had a colon injury. No physical findings or imaging modalities were able to discriminate colonic injury. Logistic regression modeling yielded no clinically useful combination of findings that would reliably predict colonic injury. In patients undergoing laparotomy, presence of colon injury was associated with a higher risk of some complications but not mortality. Colon injury was associated with increased hospital (17.4 vs. 13.1, p < 0.001) and intensive care unit (9.7 vs. 6.9, p = 0.003) length of stay. Almost all colon patients (92.0%) underwent laparotomy within 24 hours of injury. CONCLUSION Colonic injury after blunt trauma is rare and difficult to diagnose. No diagnostic test or combination of findings reliably excluded blunt colonic injury. Despite the inadequacy of current diagnostic tests, almost all patients with colonic injury were taken to the operating room within 24 hours. Even with relatively prompt surgery, patients with colon injury were at significantly higher risk for serious complications and increased length of stay. In contrast to small bowel perforation, delay in operative intervention appears to be less common but is still associated with serious morbidity.

Windows 99: a source of suburban pediatric trauma

OBJECTIVE Hypothermia can have a negative effect on the metabolic and hemostatic functions of patients with traumatic injuries. Multiple methods of rewarming are currently used in the prehospital arena, but little objective evidence for their effectiveness in this setting exists. The purpose of this study was to assess the relative effectiveness of traditional prehospital measures in maintaining thermostasis in trauma patients. METHODS Participating helicopter and ground ambulance ALS units were prospectively randomized to provide either routine care only (passive or no warming) or routine care (passive warming) in conjunction with active warming (either reflective blankets, hot pack rewarming, or warmed IV fluids). A total of 174 trauma code patients, aged >14 years, who met inclusion criteria were prospectively enrolled by prehospital providers. Patients who received a non-assigned intervention or who had incomplete temperature data were dropped from the analysis. A total of 134 patients were included in the final analysis. RESULTS Patients who received hot pack rewarming showed a mean increase in body temperature during transport (+1.36 degrees F/0.74 degrees C), while all other groups (no intervention, passive rewarming, reflective blankets, warmed IV fluids, warmed IV fluid plus reflective blanket) showed a mean decrease in temperature during transport [-0.34 to -0.61 degrees F (-0.2 to -0.4 degrees C); p<0.01]. In addition, the hot pack group was consistent, with every patient who received hot pack warming showing an increase in body temperature during transport, while in all other groups there were patients who had both increases and decreases in temperature. The intervention groups did not differ significantly on exposure to precipitation, transport unit temperature, total prehospital time, initial vital signs, amount of fluid administered, Injury Severity Score, or Glasgow Coma Score. CONCLUSIONS Most traditional methods of maintaining trauma patient temperature during prehospital transport appear to be inadequate. Aggressive use of hot packs, a simple, inexpensive intervention to maintain thermostasis, deserves further study as a potential basic intervention for trauma patients.

Effect of a bicycle safety program and free bicycle helmet distribution on the use of bicycle helmets by elementary school children

DESIGN Nonexperimental-Descriptive. SAMPLE The inclusion criteria were trauma patients, ages 15 and older, who were hospitalized for > 2 days, and who did not have preexisting skin breakdown. A total of 148 consecutive trauma patients admitted to the study institution meeting the inclusion criteria were prospectively enrolled. METHODS Patients were assessed every 3 days for skin breakdown. Information on the patients bed type, therapies, medical devices, and nutrition was collected. The Braden Scale for predicting pressure ulcer risk was completed at each assessment. FINDINGS Of the 148 patients enrolled, 30 developed at least one area of skin breakdown for a prevalence of 20.3% in patients hospitalized more than 2 days. The most common cause of breakdown was positional pressure (47.4%). Cervical collars were the second leading cause at 23.7%, followed by tracheostomy/endotracheal tubes at 10.5%. The mobility subscale of the Braden Pressure Ulcer Risk Assessment tool was significantly predictive of skin breakdown (p < .001). IMPLICATIONS FOR NURSING RESEARCH Skin breakdown is a significant problem in trauma patients who are hospitalized for more than 2 days. Aggressive protocols on positioning, cervical collar use, and airway adjuncts, as well as additional active nursing interventions for immobile patients, may be ways to decrease the skin breakdown prevalence in this population.