Henry Cryer

Is the use of pan-computed tomography for blunt trauma justified? A prospective evaluation.

OBJECTIVE Many trauma centers use the pan-computed tomography (CT) scan (head, neck, chest, and abdomen/pelvis) for the evaluation of blunt trauma. This prospective observational study was undertaken to determine whether a more selective approach could be justified. METHODS We evaluated injuries in blunt trauma victims receiving a pan-CT scan at a level I trauma center. The primary outcome was injury needing immediate intervention. Secondary outcome was any injury. The perceived need for each scan was independently recorded by the emergency medicine and trauma surgery service before patients went to CT. A scan was unsupported if at least one of the physicians deemed it unnecessary. RESULTS Between July, 1, 2007, and December, 28, 2007, 284 blunt trauma patients (average Injury Severity Score = 11) underwent a pan-CT after the survey form was completed. A total of 311 CT scans were judged to be unnecessary in 143 patients (27%), including scans of the head (62), neck (50), chest (116), and abdomen/pelvis (83). Of the 284 patients, 48 (17%) had injuries on 52 unsupported CT scans. An immediate intervention was required in 2 of the 48 patients (4%). Injuries that would have been missed included 5 of 62 unsupported head scans (8%), 2 of 50 neck scans (4%), 33 of 116 chest scans (28%), and 12 of 83 abdominal scans (14%). These missed injuries represent 5 of the 61 patients with closed head injuries (8%) in the series, 2 of the 23 with C-spine injuries (9%), 33 of the 112 with chest injuries (29%), and 12 of the 86 with abdominal injuries (14%). In 19 patients, none of the four CT scans was supported; nine of these had an injury identified, and six were admitted to the hospital (1 to the intensive care unit). Injuries that would have been missed included intraventricular and intracerebral hemorrhage (4), subarachnoid hemorrhage (2), cerebral contusion (1), C1 fracture (1), spinous and transverse process fractures (3), vertebral fracture (6), lung lacerations (1), lung contusions (14), small pneumothoraces (7), grade II-III liver and splenic lacerations (6), and perinephric or mesenteric hematomas (2). CONCLUSIONS In this small sample, physicians were willing to omit 27% of scans. If this was done, two injuries requiring immediate actions would have been missed initially, and other potentially important injuries would have been missed in 17% of patients.

Trauma quality improvement using risk-adjusted outcomes.

PURPOSE The National Surgical Quality Improvement Program has improved the quality of surgical care by tracking risk-adjusted patient outcomes. Unlike the National Surgical Quality Improvement Program, the trauma center verification program of the American College of Surgeons (ACS) focuses on availability of optimal resources, not outcomes. We hypothesized that significant variations in outcomes exist across similar level ACS-verified trauma centers despite availability of similar resources. METHODS The National Trauma Data Bank was used to identify adult patients (age 16-99 years) who were treated at ACS-verified Level I trauma centers that submitted at least 1,000 patients during the 5-year study period (264,102 patients from 58 trauma centers, excluding dead upon arrival). Multivariate logistic regression was used to analyze expected survival for each patient, adjusted for age, gender, race, injury mechanism, transfer status, and injury severity. Observed-to-expected survival ratios (O/E ratios with 95% confidence intervals) were used to rank trauma centers as high performers (O/E ratio significantly larger than 1), low performers (O/E ratio significantly less than 1), or average performers (O/E ratio overlapping 1). RESULTS Almost half the centers performed significantly different from their risk-adjusted expectation. Fourteen were high performers, 11 were low performers, and 33 were average performers. CONCLUSIONS The trauma center verification process in its present form may not ensure optimal outcome across all verified centers. If further validated, these findings suggest significant room for trauma quality improvement by replicating structures and processes of high performing trauma centers.

Massive transfusion policies at trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program.

BACKGROUND Massive transfusion protocols (MTPs) have been developed to implement damage control resuscitation (DCR) principles. A survey of MTP policies from American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) participants was performed to establish which MTP activation, hemostatic resuscitation, and monitoring aspects of DCR are included in the MTP guidelines. METHODS On October 10, 2013, ACS-TQIP administration administered a cross-sectional electronic survey to 187 ACS-TQIP participants. RESULTS Seventy-one percent (132 of 187) of responses were analyzed, with 62% designated as Level I and 38% designated as Level II ACS-TQIP trauma centers. Sixty-nine percent of sites indicated that they have plasma immediately available for MTP activation. By policy, in the first group of blood products administered, 88% of sites target high (≥1:2) plasma–to–red blood cell (RBC) ratios and 10% target low ratios. Likewise, 79% of sites target high platelet-to-RBC ratios and 16% target low ratios. Eighteen percent of sites reported incorporating point-of-care thromboelastogram into MTP policies. The most common intravenous hemostatic adjunct incorporated into MTPs was tranexamic acid (49%). Thirty-four percent of sites reported that some or all of their emergency medical service agencies have the ability to administer blood products or hemostatic agents during prehospital transport. There were minimal differences in MTP policies or capabilities between Level I and II sites. CONCLUSION The majority of ACS-TQIP participants reported having MTPs that support the use of DCR principles including high plasma-to-RBC and platelet-to-RBC ratios. Immediate availability of plasma and product use by emergency medical services are becoming increasingly common, whereas the incorporation of point-of-care thromboelastogram into MTP policies remains low.

Effect of high product ratio massive transfusion on mortality in blunt and penetrating trauma patients.

BACKGROUND Recent data suggest that massively transfused patients have lower mortality rates when high ratios (>1:2) of plasma or platelets to red blood cells (RBCs) are used. Blunt and penetrating trauma patients have different injury patterns and may respond differently to resuscitation. This study was performed to determine whether mortality after high product ratio massive transfusion is different in blunt and penetrating trauma patients. METHODS Patients receiving 10 or more units of RBCs in the first 24 hours after admission to one of 23 Level I trauma centers were analyzed. Baseline physiologic and biochemical data were obtained. Univariate and logistic regression analyses were performed. Adjusted mortality in patients receiving high (≥ 1:2) and low (<1:2) ratios of plasma or platelets to RBCs was calculated for blunt and penetrating trauma patients. RESULTS The cohort contained 703 patients. Blunt injury patients receiving a high ratio of plasma or platelets to RBCs had lower 24-hour mortality (22% vs. 31% for plasma, p = 0.007; 20% vs. 30% for platelets, p = 0.032), but there was no difference in 30-day mortality (40% vs. 44% for plasma, p = 0.085; 37% vs. 44% for platelets, p = 0.063). Patients with penetrating injuries receiving a high plasma:RBC ratio had lower 24-hour mortality (21% vs. 37%, p = 0.005) and 30-day mortality (29% vs. 45%, p = 0.005). High platelet:RBC ratios did not affect mortality in penetrating patients. CONCLUSION Use of high plasma:RBC ratios during massive transfusion may benefit penetrating trauma patients to a greater degree than blunt trauma patients. High platelet:RBC ratios did not benefit either group.

The vulnerable elders survey-13 predicts hospital complications and mortality in older adults with traumatic injury: a pilot study.

OBJECTIVES: To determine whether the Vulnerable Elders Survey (VES)‐13, a survey based on functional status that has been validated in uninjured older populations, will predict complications and mortality in injured older adults.

Long-term Postinjury Functional Recovery: Outcomes of Geriatric Consultation

IMPORTANCE Functional recovery is an important outcome following injury. Functional impairment is persistent in the year following injury for older trauma patients. OBJECTIVE To measure the impact of routine geriatric consultation on functional outcomes in older trauma patients. DESIGN, SETTING, AND PARTICIPANTS In this pretest-posttest study, the pretest control group (n = 37) was retrospectively identified (December 2006-November 2007). The posttest geriatric consultation (GC) group (n = 85) was prospectively enrolled (December 2007-June 2010). We then followed up both groups for 1 year after enrollment. This study was conducted at an academic level 1 trauma center with adults 65 years of age and older admitted as an activated code trauma. INTERVENTION Routine GC. MAIN OUTCOMES AND MEASURES The Short Functional Status survey of 5 activities of daily living (ADLs) at hospital admission and 3, 6, and 12 months postinjury. RESULTS The unadjusted Short Functional Status score (GC group only) declined from 4.6 preinjury to 3.7 at 12 months postinjury, a decline of nearly 1 full ADL (P < .05). The ability to shop for personal items was the specific ADL more commonly retained by the GC group compared with the control group. The GC group had a better recovery of function in the year following injury than the GC group, controlling for age, sex, race/ethnicity, length of stay, comorbidity, injury severity, postdischarge rehabilitation, complication, and whether surgery was performed (P < .01), a difference of 0.67 ADL abilities retained by the GC group compared with the control group (95% CI, 0.06-1.4). CONCLUSIONS AND RELEVANCE Functional recovery for older adults following injury may be improved by GC. Early introduction of multidisciplinary care in geriatric trauma patients warrants further investigation.

Gender-based differences in mortality in response to high product ratio massive transfusion.

BACKGROUND Recent data suggest that patients undergoing massive transfusion have lower mortality rates when ratios of plasma and platelets to red blood cells (RBCs) of ≥ 1:2 are used. This has not been examined independently in women and men. A gender dichotomy in outcome after severe injury is known to exist. This study examined gender-related differences in mortality after high product ratio massive transfusion. METHODS A retrospective study was conducted using a database containing massively transfused trauma patients from 23 Level I trauma centers. Baseline demographic, physiologic, and biochemical data were obtained. Univariate and logistic regression analyses were performed. Adjusted mortality in patients receiving high (≥ 1:2) or low (<1:2) ratios of plasma or platelets to RBCs was compared in women and men independently. RESULTS Seven hundred four patients were analyzed. In males, mortality was lower for patients receiving a high plasma:RBC ratio at 24 hours (20.6% vs. 33.0% for low ratio, p = 0.005) and at 30 days (34.9% vs. 42.8%, p = 0.032). Males receiving a high platelet:RBC ratio also had lower 24-hour mortality (17.6% vs. 31.5%, p = 0.004) and 30-day mortality (32.1% vs. 42.2%, p = 0.045). Females receiving high ratios of plasma or platelets to RBCs had no improvement in 24-hour mortality (p = 0.119 and 0.329, respectively) or 30-day mortality (p = 0.199 and 0.911, respectively). Use of high product ratio transfusions did not affect 24-hour RBC requirements in males or females. CONCLUSION Use of high plasma:RBC or platelet:RBC ratios in massive transfusion may benefit men more than women. This may be due to gender-related differences in coagulability. Further study is needed to determine whether separate protocols for women and men should be established.

A prospective, randomized comparison between open and closed peritoneal lavage techniques.

We randomized 327 blunt trauma patients to compare the open peritoneal lavage technique with the percutaneous (Seldinger wire) technique. The open and closed lavage groups were similar with respect to accuracy and safety. There were one complication in the percutaneous group and two in patients treated by the open method. The incidence of positive lavage was similar in each group. There was one false positive in the percutaneous group and none in the open method group. False negative results did not occur by either method. The percutaneous lavage method required less time for performance, had better patient tolerance, and only required one surgeon to perform the procedure. Percutaneous diagnostic peritoneal lavage (DPL), in the hands of trauma surgeons, is a safe and acceptable alternative to the open DPL method and actually had several advantages as mentioned above.

Approaches to the management of shotgun injuries.

Shotgun wounds present specific challenges for the surgeon. Multiple penetrating wounds frequently involve large anatomic areas with potential multi-system injury. Experience with 121 patients sustaining shotgun wounds over the 5-year period ending 31 December 1981 was reviewed to assess results and evaluate treatment protocols. Sixty-six patients had chest wounds with pleural penetration. Twenty-four wounds were minor and were observed. Each had less than five pellets penetrating the pleura. Twenty-two patients had close-range injuries. Fourteen of these required chest tube drainage alone and eight patients required thoracotomy for control of bleeding. Eleven patients died, six as a direct result of the chest injury. In 55 patients with abdominal-retroperitoneal wounds exploratory operations were done if more than four pellets were thought to be lodged intraperitoneally or if signs of peritonitis were present, while lesser wounds without peritoneal findings were observed. In the 15 patients who did not have exploratory operations, there were no deaths or major complications. Thirty-five patients had exploratory operations. Two patients had five intraperitoneal missiles and no clinical evidence of peritonitis but were found to have significant intestinal perforations. Four patients died. Eighty-three patients with extremity wounds were classified according to location of injury. Forty-five had upper extremity wounds, with nine vascular injuries. Two patients died and one limb was amputated because of soft tissue infection. Thirty-eight patients had lower extremity wounds. Five had major vascular injuries. Preoperative arteriography was obtained in 13 patients with extremity injuries; the results of one of these were falsely negative. There were no deaths or amputations.(ABSTRACT TRUNCATED AT 250 WORDS)

Quality of Care Delivered Before vs After a Quality-Improvement Intervention for Acute Geriatric Trauma

BACKGROUND Older trauma-injury patients had improved recovery after we implemented routine geriatric consultation for patients aged 65 years and older admitted to the trauma service of a Level I academic trauma center. The intervention aimed to improve quality of geriatric care. However, the specific care processes that improved are unknown. STUDY DESIGN We conducted a prospective observation comparing medical care after (December 2007 to November 2009) vs before (December 2006 to November 2007) implementation of the geriatric consult-based intervention. To measure quality of care (QOC), we used 33 previously validated care-process quality indicators (QIs) from the Assessing the Care of Vulnerable Elders (ACOVE) study, measured by review of medical records for 76 geriatric consult (GC) vs 71 control group patients. As prespecified subgroup analyses, we aggregated QIs by type: geriatric (eg, delirium screening) vs nongeriatric condition-based care (eg, thrombosis prophylaxis) and compared QI scores by type of care. Last, we aggregated QI scores into overall, geriatric, and nongeriatric QOC scores for each patient (number of QIs passed/number of QIs eligible), and compared patient-level QOC for the GC vs control group, adjusting for age, sex, ethnicity, comorbidity, and injury severity. RESULTS Sixty-three percent of the GC patients vs 11% of the control group patients received a geriatric consultation. We evaluated 2,505 QIs overall (1,664 geriatric type and 841 nongeriatric QIs). In general, fewer geriatric-type QIs were passed than nongeriatric QIs (71% vs 81%; p < 0.001). We provided better overall QOC to the GC (77%) than control group patients (73%; p < 0.05). However, the difference was not statistically significant after multivariable adjustment (p = 0.08). We improved geriatric QOC for the GC (74%) compared with the control group (68%; p < 0.01), a difference that was significant after multivariable adjustment (p = 0.01). CONCLUSIONS Geriatricians and surgeons can collaboratively improve geriatric QOC for older trauma patients.