Ernest L. Dunn

Continuous intercostal nerve blockade for rib fractures: ready for primetime?

BACKGROUND Providing analgesia for patients with rib fractures continues to be a management challenge. The objective of this study was to examine our experience with the use of a continuous intercostal nerve block (CINB). Although this technique is being used, little data have been published documenting its use and efficacy. We hypothesized that a CINB would provide excellent analgesia, improve pulmonary function, and decrease length of stay (LOS). METHODS Consecutive adult blunt trauma patients with three or more unilateral rib fractures were prospectively studied over 24 months. The catheters were placed at the bedside in the extrathoracic, paravertebral location, and 0.2% ropivacaine was infused. Respiratory rate, preplacement (PRE) numeric pain scale (NPS) scores, and sustained maximal inspiration (SMI) lung volumes were determined at rest and after coughing. Parameters were repeated 60 minutes after catheter placement (POST). Hospital LOS comparison was made with historical controls using epidural analgesia. RESULTS Over the study period, 102 patients met inclusion criteria. Mean age was 69 (21-96) years, mean injury severity score was 14 (9-16), and the mean number of rib fractures was 5.8 (3-10). Mean NPS improved significantly (PRE NPS at rest = 7.5 vs. POST NPS at rest = 2.6, p < 0.05, PRE NPS after cough = 9.4, POST after cough = 3.6, p < 0.05) which was associated with an increase in the SMI (PRE SMI = 0.4 L and POST SMI = 1.3 L, p < 0.05). Respiratory rate decreased significantly (p < 0.05) and only 2 of 102 required mechanical ventilation. Average LOS for the study population was 2.9 days compared with 5.9 days in the historical control. No procedural or drug-related complications occurred. CONCLUSION Utilization of CINB significantly improved pulmonary function, pain control, and shortens LOS in patients with rib fractures.

Geriatric trauma service: A one-year experience

Background: Trauma centers nationwide have been experiencing an increase in their elderly trauma patients because of an ever growing elderly population within the United States. Many studies have demonstrated the physiologic differences between an older trauma patient versus a younger trauma patient. Coupling these differences with their coexisting medical comorbidities, makes caring for this population extremely challenging. To meet these challenges, we organized a geriatric trauma unit specifically designed with a multidisciplinary approach to take a more aggressive stance to the care of the geriatric trauma patient. Methods: We created a geriatric trauma unit at our Level II trauma facility, called the G-60 unit. This unit opened for admission in August 2009. Inclusion criteria included all trauma patients older than 60 years. Data were abstracted from our G-60 unit from the period of August 2009 to July 2010. We compared these data to a similar patient population (control group) from January 2008 to December 2008. Results: Our Trauma Data Bank yielded 673 patients for the above queried time period. The G-60 group contained 393 patients, while the control group had 280 patients. A decrease was seen among the G-60 group in all categories: average emergency department length of stay (LOS), average emergency department to operating room time, average surgical intensive care unit LOS, and average hospital LOS. A 3.8% mortality rate was found in the G-60 group compared with a 5.7% mortality rate in the control group. Our analysis also showed rate of 0% pneumonia, 1.3% respiratory failure, and 1.5% urinary tract infection in the G-6O group, while the control group had a rate of 1.8% pneumonia, 6.8% respiratory failure, and 3.9% urinary tract infection. Conclusion: Our data from the 1-year experience of our G-60 unit show that addressing the specific needs of elderly trauma patients will lead to better outcomes. Level of Evidence: II.

Practice management education during surgical residency

BACKGROUND Surgical education has undergone radical changes in the past decade. The introductions of laparoscopic surgery and endovascular techniques have required program directors to alter surgical training. The 6 competencies are now in place. One issue that still needs to be addressed is the business aspect of surgical practice. Often residents complete their training with minimal or no knowledge on coding of charges or basic aspects on how to set up a practice. We present our program, which has been in place over the past 2 years and is designed to teach the residents practice management. METHODS The program begins with a series of 10 lectures given monthly beginning in August. Topics include an introduction to types of practices available, negotiating a contract, managed care, and marketing the practice. Both medical and surgical residents attend these conferences. In addition, the surgical residents meet monthly with the business office to discuss billing and coding issues. These are didactic sessions combined with in-house chart reviews of surgical coding. The third phase of the practice management plan has the coding team along with the program director attend the outpatient clinic to review in real time the evaluation and management coding of clinic visits. RESULTS Resident evaluations were completed for each of the practice management lectures. The responses were recorded on a Likert scale. The scores ranged from 4.1 to 4.8 (average, 4.3). Highest scores were given to lectures concerning negotiating employee agreements, recruiting contracts, malpractice insurance, and risk management. The medical education department has tracked resident coding compliance over the past 2 years. Surgical coding compliance increased from 36% to 88% over a 12-month period. The program director who participated in the educational process increased his accuracy from 50% to 90% over the same time period. CONCLUSIONS When residents finish their surgical training they need to be ready to enter the world of business. These needs will be present whether pursuing a career in academic medicine or the private sector. A program that focuses on the business aspect of surgery enables the residents to better navigate the future while helping to fulfill the systems-based practice competency.

CT guided percutaneous fixation of sacroiliac fractures in trauma patients

BACKGROUND Open reduction and internal fixation of unstable pelvic fractures has been advocated to minimize complications and avoid further injury. We have recently performed CT guided percutaneous fixation of sacroiliac joints as an alternative to open repair. METHODS From May 1, 1998 to April 30, 1999, our Level II trauma center admitted 76 patients with pelvic fractures, all due to blunt trauma. Twenty patients with unstable sacroiliac fracture-distractions underwent 22 percutaneous fixation procedures under general anesthesia in the radiology department by the third hospital day. Procedure times averaged 82 minutes. Localization with CT guidance was performed by the radiologist using 3-D images followed by percutaneous screw placement by the orthopaedic surgeon. RESULTS There was minimal procedural blood loss and no post-procedural wound complications. There was one operative delay due to respiratory difficulties and one postoperative death unrelated to the pelvic fracture. All patients were mobilized on the first post-procedural day. CONCLUSION CT guided fixation of unstable pelvic fractures minimizes blood loss during a short procedure with few subsequent complications and allows early mobilization of the patients.

Parathyroidectomy in chronic renal failure

BACKGROUND A subset of patients who are being maintained on dialysis for end-stage renal disease develop severely symptomatic secondary hyperparathyroidism that cannot be controlled medically. The relative merits of two alternative surgical approaches--subtotal parathyroidectomy versus total parathyroidectomy with autotransplantation--have not been clearly elucidated. METHODS The records of 77 patients who had renal failure and underwent parathyroid surgery between 1982 and 1993 were retrospectively reviewed. RESULTS Fifty-three patients (69%) underwent subtotal parathyroidectomy and 24 (31%) underwent total resection with auto-transplantation into forearm musculature. The incidences of postoperative hypocalcemia and tetany were similar in both groups, as was the recurrence rate (7%) of clinically significant hyperparathyroidism. CONCLUSIONS Subtotal parathyroidectomy can be performed without mortality or morbidity and provides good control of hyperparathyroidism secondary to chronic renal failure. Total parathyroidectomy with autotransplantation offers no additional advantage in this difficult patient population. Most patients will require postoperative intravenous calcium replacement. We observed a significant incidence of continued hyperparathyroidism following successful renal transplantation.

Platelet Abnormalities associated with Massive Autotransfusion

Although hemostatic defects have been reported with large-volume autotransfusion, the effect on platelet function has not been well defined. Twenty adult mongrel dogs underwent controlled intraperitoneal hemorrhage with collection and reinfusion using the Sorenson System. Each animal was autotransfused twice its E.B.V. over a 4-hour period. A.C.D., delivered at the sucker tip, served as the only anticoagulant. Mean arterial pressure and cardiac output remained stable during the study period with the additional volume support of 50 cc/kg Ringers lactate. A moderate consumptive coagulopathy ensued. The P.T., P.T.T., and T.C.T. were all significantly prolonged, with a decrease in fibrinogen at 4 hours compared to baseline. Platelet counts fell significantly to 71% of baseline. In addition, platelet aggregation response to A.D.P. and collagen was markedly depressed, with corresponding prolongation in bleeding times at 4 hours. Twenty-four hours following autotransfusion the P.T., P.T.T., T.C.T., and fibrinogen levels returned toward normal. In contrast, the platelet counts continued to fall and the aggregation response remained markedly impaired. Methylprednisolone (30 mg/kg), administered to 10 animals, had no statistically significant effect on the coagulation parameters.

Hemodynamic effects of aortic occlusion during hemorrhagic shock.

We investigated cardiac dynamics following temporary aortic occlusion during profound hypovolemia and abdominal distention. Control animals (N = 10) were bled from a femoral artery catheter to a systolic blood pressure of 60 mm Hg, while simultaneous abdominal distention was effected with intraperitoneal infusion of saline. After one hour of shock, thoracic aortic occlusion and immediate laparotomy were performed. The aorta was clamped for 20 minutes and then released over 5 minutes. The second group (N = 10) underwent the same procedure but received methylprednisolone sodium succinate intravenously at the time of aortic occlusion. During hypotension, mean arterial pressure, cardiac output, stroke volume, and stroke work decreased, while systemic vascular resistance increased. Aortic occlusion improved cardiac hemodynamics in the control group; in the steroid group these changes were even more pronounced. Measurement of dp/dt demonstrated ventricular contractility impaired during hypotension and improved during the period of aortic occlusion. Temporary thoracic aortic occlusion in the face of profound hypotension and massive abdominal distention improved cardiac function. The resulting increased afterload in this hypovolemic state was without deleterious effects. Furthermore, steroids appeared to enhance the cardiac response to aortic cross-clamping.

Should age be a factor to change from a level II to a level I trauma activation

BACKGROUND Elderly trauma patients have a higher incidence of medical comorbidities when compared with their younger cohorts. Currently, the minimally accepted criteria established by the Committee on Trauma for the highest level of trauma activation (Level I) does not include age as a factor. Should patients older than 60 years with multiple injuries and/or a significant mechanism of injury be considered as part of the criteria for Level I activation? Would these patients benefit from a higher level of activation? METHODS The National Trauma Data Bank was queried for the period of January 1, 1999, to December 31, 2008, for all trauma patients and associated injury severity score (ISS). The data abstracted were based on age and ISS. RESULTS The National Trauma Data Bank contained 802,211 trauma patients. Seventy-nine percent were younger than 60 years, and 21% were older than 60 years. Our analysis shows that in all levels of injury, patients older than 60 years have an increased risk for morbidity and mortality. We found a threefold increase in morbidity and a fivefold increase in mortality among the older (age >60 years) population with a minor ISS. Elderly patients with a major ISS demonstrated a twofold increase in morbidity and a fourfold increase in mortality. CONCLUSION Patients with an ISS between 0 and 15 are often triaged to Level II activation. Our data would suggest that patients older than 60 years should be a criterion for the highest level of trauma activation.

COMPUTED TOMOGRAPHY OF THE PELVIS IN PATIENTS WITH MULTIPLE INJURIES

The extent of osseous pelvic injury in patients suffering multiple organ trauma is difficult to assess. However, accurate information is essential in order to determine an acceptable treatment regimen, either operative (external or internal fixation), or nonoperative (bed rest and early ambulation). Twenty consecutive patients were treated for pelvic fractures from January 1981 through February 1982. All patients had multiple organ injuries, (average = 3.5 organ systems per patient). Each patient had an A-P X-ray projection of the pelvis in the emergency department (E.D.) as a part of the initial evaluation. Three patients (15%) required immediate laparotomy for associated abdominal injuries. Six patients (30%) required prolonged ventilatory support for pulmonary injuries. Computed tomography (CT) of the pelvis was performed on all patients within 4 days of admission. In seven patients, CT examination confirmed the findings of the routine X-rays obtained in the E.D. In 13 patients the CT examination demonstrated significant additional fractures of the pelvis which were not initially demonstrated in the E.D. A consistent pattern of either sacral fracture or injury to the sacroiliac joint which was not appreciated on the initial E.D. X-rays was demonstrated in these 13 patients. Six patients underwent operative intervention, four with Hoffmann frames (external fixation), and two with reduction and internal fixation. CT examination of the pelvis provides a rapid and thorough evaluation which is extremely useful in demonstrating all the fractures of the pelvis on the single examination, thereby allowing the early determination of the best treatment plan for patients with such major injuries.

Coagulation changes after albumin resuscitation.

The administration of albumin in the initial resuscitation of shock remains highly controversial. Impaired coagulation in the critically injured patient has recently been added as an argument against the use of supplemental albumin. This study investigated the hemostatic effects of albumin therapy after hemor-rhagic shock. Twenty mongrel dogs were bled to a systolic pressure of 60 mm Hg for 1 h. After the return of shed blood, the animals received either lactated Ringers solution or 5% serum albumin (25 ml/kg) daily for the 3 days. Coagulation parameters were measured before bleeding, immediately after resuscitation, and on days 2, 3, and 4. The changes in platelet count, platelet function, and serum fibrinogen were similar in the albumin treated and control animals. Although the prothrombin time and partial thromboplastin time were more prolonged in the albumin group, the changes were not sufficient to produce clinical bleeding.