Frank Kennedy

Prospective, randomized trial of survivor values of cardiac index, oxygen delivery, and oxygen consumption as resuscitation endpoints in severe trauma.

The objective was to test prospectively supranormal values of cardiac index (CI), oxygen delivery index (DO2I), and oxygen consumption index (VO2I) as resuscitation goals to improve outcome in severely traumatized patients. We included patients > or = 16 years of age who had either (1) an estimated blood loss > or = 2000 mL or (2) a pelvic fracture and/or two or more major long bone fractures with > or = four units of packed red cells given within six hours of admission. The protocol resuscitation goals were CI > or = 4.5 L/min/m2, DO2I > or = 670 mL/min/m2, and VO2I > or = 166 mL/min/m2 within 24 hours of admission. The control resuscitation goals were normal vital signs, urine output, and central venous pressure. The 50 protocol patients had a significantly lower mortality (9 of 50, 18% vs. 24 of 65, 37%) and fewer organ failures per patient (0.74 +/- 0.28 vs. 1.62 +/- 0.45) than did the 75 control patients. We conclude that increased CI, DO2I, and VO2I seen in survivors of severe trauma are primary compensations that have survival value; augmentation of these compensations compared to conventional therapy decreases mortality.

The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury.

BACKGROUND Although early intubation to prevent the mortality that accompanies hypoxia is considered the standard of care for severe traumatic brain injury (TBI), the efficacy of this approach remains unproven. METHODS Patients with moderate to severe TBI (Head/Neck Abbreviated Injury Scale [AIS] score 3+) were identified from our county trauma registry. Logistic regression was used to explore the impact of prehospital intubation on outcome, controlling for age, gender, mechanism, Glasgow Coma Scale score, Head/Neck AIS score, Injury Severity Score, and hypotension. Neural network analysis was performed to identify patients predicted to benefit from prehospital intubation. RESULTS A total of 13,625 patients from five trauma centers were included; overall mortality was 22.9%, and 19.3% underwent prehospital intubation. Logistic regression revealed an increase in mortality with prehospital intubation (odds ratio, 0.36; 95% confidence interval, 0.32-0.42; p < 0.001). This was true for all patients, for those with severe TBI (Head/Neck AIS score 4+ and/or Glasgow Coma Scale score of 3-8), and with exclusion of patients transported by aeromedical crews. Patients intubated in the field versus the emergency department had worse outcomes. Neural network analysis identified a subgroup of patients with more significant injuries as potentially benefiting from prehospital intubation. CONCLUSION Prehospital intubation is associated with a decrease in survival among patients with moderate-to-severe TBI. More critically injured patients may benefit from prehospital intubation but may be difficult to identify prospectively.

Early ventilation and outcome in patients with moderate to severe traumatic brain injury.

Objectives:An increase in mortality has been reported with early intubation in severe traumatic brain injury, possibly due to suboptimal ventilation. This analysis explores the impact of early ventilation on outcome in moderate to severe traumatic brain injury. Design:Retrospective, registry-based analysis. Setting:This study was conducted in a large county trauma system that includes urban, suburban, and rural jurisdictions. Patients:Nonarrest trauma victims with a Head Abbreviated Injury Score of ≥3 were identified from our county trauma registry. Interventions:Intubated patients were stratified into 5 mm Hg arrival Pco2 increments. Logistic regression was used to calculate odds ratios for each increment, adjusting for age, gender, mechanism of injury, year of injury, preadmission Glasgow Coma Scale score, hypotension, Head Abbreviated Injury Score, Injury Severity Score, Po2, and base deficit. Increments with the highest relative survival were used to define the optimal Pco2 range. Outcomes for patients with arrival Pco2 values inside and outside this optimal range were then explored for both intubated and nonintubated patients, adjusting for the same factors as defined previously. In addition, the independent outcome effect of hyperventilation and hypoventilation was assessed. Measurements and Main Results:A total of 890 intubated and 2,914 nonintubated patients were included. Improved survival was observed for the arrival Pco2 range 30–49 mm Hg. Patients with arrival Pco2 values inside this optimal range had improved survival and a higher incidence of good outcomes. Conversely, there was no improvement in outcomes for patients within this optimal Pco2 range for nonintubated patients after adjusting for all of the factors defined previously. Both hyperventilation and hypoventilation were associated with worse outcomes in intubated but not nonintubated patients. The proportion of arrival Pco2 values within the optimal range was lower for intubated vs. nonintubated patients. Conclusions:Arrival hypercapnia and hypocapnia are common and associated with worse outcomes in intubated but not spontaneously breathing patients with traumatic brain injury.

Prehospital Airway and Ventilation Management: A Trauma Score and Injury Severity Score-based Analysis

BACKGROUND Emergent endotracheal intubation (ETI) is considered the standard of care for patients with severe traumatic brain injury (TBI). However, recent evidence suggests that the procedure may be associated with increased mortality, possibly reflecting inadequate training, suboptimal patient selection, or inappropriate ventilation. OBJECTIVE To explore prehospital ETI in patients with severe TBI using a novel application of Trauma Score and Injury Severity Score methodology. METHODS Patients with moderate-to-severe TBI (head Abbreviated Injury Scale score 3+) were identified from our county trauma registry. Demographic information, pre-resuscitation vital signs, and injury severity scores were used to calculate a probability of survival for each patient. The relationship between outcome and prehospital ETI, provider type (air vs. ground), and ventilation status were explored using observed survival-predicted survival and the ratio of unexpected survivors/deaths. RESULTS A total of 11,000 patients were identified with complete data for this analysis. Observed and predicted survivals were similar for both intubated and nonintubated patients. The ratio of unexpected survivors/deaths increased and observed survival exceeded predicted survival for intubated patients with lower predicted survival values. Both intubated and nonintubated patients transported by air medical crews had better outcomes than those transported by ground. Both hypo- and hypercapnia were associated with worse outcomes in intubated but not in nonintubated patients. CONCLUSIONS Prehospital intubation seems to improve outcomes in more critically injured TBI patients. Air medical outcomes are better than predicted for both intubated and nonintubated TBI patients. Iatrogenic hyper- and hypoventilations are associated with worse outcomes.

The Glasgow Coma Scale and Prognosis in Gunshot Wounds to the Brain

To determine which factors predict survival in patients with gunshot wounds to the brain, 192 patients who had intracranial injury demonstrated on computed tomographic (CT) scanning were retrospectively reviewed. Glasgow Coma Scale (GCS) scores on admission seemed to be the most important factor in predicting survival. Age, the presence of extruded brain, and use of a shotgun could not be shown to be factors independent of admission GCS score. Findings on CT scans (single lobe vs. multilobe involvement) helped to predict survival only in patients with GCS scores 5-13. The mortality rate was 35%. Among survivors 18% had brain-related long-term disability, and an additional 27% had long-term disability related to associated eye injury.

The influence of vehicle damage on injury severity of drivers in head-on motor vehicle crashes

Data from crashes investigated through the Crash Injury Research and Engineering Network (CIREN) Program were used to assess differences in injury patterns, severity, and sources for drivers, protected by safety belts and deploying steering wheel air bags, in head-on frontal impacts. We studied whether exterior vehicle damage with a different distribution (wide vs. narrow) across the front vehicle plane influenced injury characteristics. Drivers from both impact types were similar on the basis of demographic characteristics (except age), restraint use, and vehicle characteristics. There were significant differences in the type of object contacted and intrusion into the passenger compartment at the drivers seat location. The mean delta V (based on the kilometers per hour change in velocity during the impact) was similar for drivers in both (wide vs. narrow) impact types. There were no significant differences in injury patterns and sources except that drivers in wide impacts were almost 4 times more likely (odds ratio (OR)=3.81, 95% confidence limits (CL) 1.26, 11.5) to have an abbreviated injury scale (AIS) 3 serious or greater severity head injury. Adjusted odds ratios showed that drivers in wide impacts were less likely (OR=0.54, 95% CI 0.37, 0.79) to have severe injury (based on injury severity score (ISS)>25) when controlling for intrusion, vehicle body type, vehicle curb weight, age, proper safety belt use, and delta V. Drivers with intrusion into their position or who were driving a passenger vehicle were almost twice more likely to have severe injury, regardless of whether the frontal plane damage distribution was wide or narrow. Our study supports that the type of damage distribution across the frontal plane may be an important crash characteristic to consider when studying drivers injured in head-on motor vehicle crashes.

Preinjury factors and 3-month outcomes following emergency department diagnosis of mild traumatic brain injury.

ObjectiveTo investigate the sequelae of mild traumatic brain injury (MTBI) by comparing selected outcomes of emergency department–diagnosed patients with mild head injuries to those with non–head injuries. SettingFive emergency departments in southern California. ParticipantsTwo cohorts, one with MTBI (n = 689 at initial assessment) and another with non–head injuries (n = 1318). Main MeasuresRivermead Post-Concussion Symptoms Questionnaire and Pittsburgh Sleep Quality Index at 3 months postinjury. ResultsPostconcussion symptom rates and summary Rivermead Post-Concussion Symptoms Questionnaire scores were significantly higher for persons with MTBI than for the comparison cohort. Women reported significantly more symptoms than men. Complaints about sleep quality overall (and also sleep latency and daytime dysfunction subcomponents) were significantly more frequent among those with MTBI. ConclusionPatients with MTBI have significantly more negative outcomes than patients in the comparison cohort and should be clinically managed with these prevalent outcomes in mind. Further study of follow-up medical management and the development of treatment guidelines for this group of patients are both warranted.

Personal watercraft injuries: 62 patients admitted to the San Diego County trauma services.

Objective To determine the types and patterns of injuries seen in personal watercraft (PWC) accidents. Design A retrospective review of medical records and imaging studies. Setting Level 1 and 2 trauma centers in San Diego County, California. Patients/Participants Trauma patients treated for PWC-related injuries between 1984 and 1997. Main Outcome Measurements Evaluation of injury patterns via chart review and imaging studies. Intervention None. Results A total of 62 patients were identified. The average age was 23 years (range 2–59 years). There were 41 males and 21 females. A total of 35 injuries (56%) involved another PWC. Of patients, 24 had loss of consciousness, with 8 closed head injuries. There were 17 chest injuries, with 10 pneumothoraces, and 16 lower extremity fractures (9 femur, 3 hip, 3 tibia-fibula, and 1 patella). Conclusions Injuries related to PWC have increased dramatically over the past several years, becoming one of the leading causes of recreational water-sport injuries. This study supports a high level of awareness for significant blunt trauma to the chest and lower extremities in patients involved in PWC accidents.

Aortoesophageal fistulae due to gunshot wounds: report of two cases with one survivor.

We report the cases of two patients who developed aortoesophageal fistulae after sustaining gunshot wounds to the chest. One suddenly exsanguinated 5 hours postinjury while in the angiography suite. The other manifested 4 weeks postinjury while in a rehabilitation hospital for associated spinal cord injury. The diagnosis and management were complicated, but the patient lived. He is the only survivor of aortoesophageal fistula due to gunshot wound that we could find in the literature.

Limb salvage after complex repairs of extremity arterial injuries is independent of surgical specialty training

BACKGROUND Major peripheral vascular trauma is managed by several surgical specialties. The impact of surgical specialty training and certification on outcome has not been evaluated. We hypothesized that general surgeons without specialty training in vascular surgery would have outcomes equivalent to surgeons with vascular training in the management of extremity arterial injuries requiring interposition grafting. METHODS We performed a multicenter, retrospective study of patients undergoing interposition grafting for peripheral vascular injury between 1995 and 2010. Specialty was defined by training and certification. Outcomes were recorded at the time of discharge from the index hospitalization. Factors affecting limb salvage were determined using logistic regression. RESULTS From the 11 participating centers, 615 patients were identified. General surgeons performed 69.9%, cardiac/vascular surgeons performed 27.3%, and surgeons of other specialties performed 2.8% of the grafts. There were 32 amputations (5.2%). Outcomes did not differ by institution. Factors associated with amputation were blunt mechanism, older age, female sex, hospital length of stay, and Injury Severity Score (ISS). There was no significant difference in limb salvage among specialty groups (general surgeons, 94%; cardiac/vascular, 95%; other, 100%). CONCLUSION Limb salvage following major peripheral vascular injury is independent of surgeon specialty training. The majority of complex repairs are performed by general surgeons. LEVEL OF EVIDENCE Therapeutic/care management, level III.