Henry G. Cryer

Acute secondary adrenal insufficiency after traumatic brain injury: A prospective study

Objective:To determine the prevalence, time course, clinical characteristics, and effect of adrenal insufficiency (AI) after traumatic brain injury (TBI). Design:Prospective intensive care unit–based cohort study. Setting:Three level 1 trauma centers. Patients:A total of 80 patients with moderate or severe TBI (Glasgow Coma Scale score, 3–13) and 41 trauma patients without TBI (Injury Severity Score, >15) enrolled between June 2002 and November 2003. Measurements:Serum cortisol and adrenocorticotropic hormone levels were drawn twice daily for up to 9 days postinjury; AI was defined as two consecutive cortisols of ≤15 &mgr;g/dL (25th percentile for extracranial trauma patients) or one cortisol of <5 &mgr;g/dL. Principal outcome measures included: injury characteristics, hemodynamic data, usage of vasopressors, metabolic suppressive agents (high-dose pentobarbital and propofol), etomidate, and AI status. Main Results:AI occurred in 42 TBI patients (53%). Adrenocorticotropic hormone levels were lower at the time of AI (median, 18.9 vs. 36.1 pg/mL; p = .0001). Compared with patients without AI, those with AI were younger (p = .01), had higher injury severity (p = .02), had a higher frequency of early ischemic insults (hypotension, hypoxia, severe anemia) (p = .02), and were more likely to have received etomidate (p = .049). Over the acute postinjury period, patients with AI had lower trough mean arterial pressure (p = .001) and greater vasopressor use (p = .047). Mean arterial pressure was lower in the 8 hrs preceding a low (≤15 &mgr;g/dL) cortisol level (p = .003). There was an inverse relationship between cortisol levels and vasopressor use (p = .0005) and between cortisol levels within 24 hrs of injury and etomidate use (p = .002). Use of high-dose propofol and pentobarbital was strongly associated with lower cortisol levels (p < .0001). Conclusions:Approximately 50% of patients with moderate or severe TBI have at least transient AI. Younger age, greater injury severity, early ischemic insults, and the use of etomidate and metabolic suppressive agents are associated with AI. Because lower cortisol levels were associated with lower blood pressure and higher vasopressor use, consideration should be given to monitoring cortisol levels in intubated TBI patients, particularly those receiving high-dose pentobarbital or propofol. A randomized trial of stress-dose hydrocortisone in TBI patients with AI is underway.

Prehospital intubation in patients with severe head injury.

BACKGROUND Prehospital intubation and airway control is routinely performed by paramedics in critically injured patients. Despite the advantages provided by this procedure, numerous potential risks exist when this is performed in the field. We reviewed the outcome of patients with severe head injury, to determine whether prehospital intubation is associated with an improved outcome. METHODS A retrospective review of registry data of patients admitted to an urban trauma center with severe head injury (field Glasgow Coma Scale score of < or =8 and head Abbreviated Injury Scale score of > or =3) was performed. Patients were stratified by methods of airway control performed by prehospital personnel: not intubated, intubated, or unsuccessful intubation. Mortality was determined for each group. To control for significant variables between these populations, matching and multivariate analysis were performed. RESULTS Patients requiring prehospital intubation or in whom intubation was attempted had an increased mortality (81% and 77%, respectively) when compared with nonintubated patients (43%). The mortality for patients who had prehospital intubation performed did not demonstrate an improved survival using matching. In fact, intubated patients had a significantly higher relative risk (RR) of mortality when compared with nonintubation (RR = 1.74,p < 0.001) and unsuccessful intubation patients (RR = 1.53, p = 0.008) CONCLUSION For patients with severe head injury, prehospital intubation did not demonstrate an improvement in survival. Further prospective randomized trials are necessary to confirm these results.

Selective Use of Computed Tomography Compared With Routine Whole Body Imaging in Patients With Blunt Trauma

STUDY OBJECTIVE Routine pan-computed tomography (CT, including of the head, neck, chest, abdomen/pelvis) has been advocated for evaluation of patients with blunt trauma based on the belief that early detection of clinically occult injuries will improve outcomes. We sought to determine whether selective imaging could decrease scan use without missing clinically important injuries. METHODS This was a prospective observational study of 701 patients with blunt trauma at an academic trauma center. Before scanning, the most senior emergency physician and trauma surgeon independently indicated which components of pan-CT were necessary. We calculated the proportion of scans deemed unnecessary that: (a) were abnormal and resulted in a pre-defined critical action or (b) were abnormal. RESULTS Pan-CT was performed in 600 of the patients; the remaining 101 underwent limited scanning. One or both physicians indicated a willingness to omit 35% of the individual scans. An abnormality was present in 18% of scans, including 22% of desired scans and 10% of undesired scans. Among the 95 patients who had one of the 102 undesired scans with abnormal results, 3 underwent a predefined critical action. There is disagreement among the authors about the clinical significance of the abnormalities found on the 99 undesired scans that did not lead to a critical action. CONCLUSION Selective scanning could reduce the number of scans, missing some injuries but few critical ones. The clinical importance of injuries missed on undesired scans was subject to individual interpretation, which varied substantially among authors. This difference of opinion serves as a microcosm of the larger debate on appropriate use of expensive medical technologies.

Multiple organ failure: By the time you predict it, it's already there

OBJECTIVE Validate an at-risk population to study multiple organ failure and to determine the importance of organ dysfunction 24 hours after injury in determining the ultimate severity of multiple organ failure. METHODS We evaluated 105 patients admitted to five academic trauma centers during a 1-year period who survived for more than 24 hours with Injury Severity Scores > or = 25 and who received 6 or more units of blood. Organ dysfunction was scored daily with a modified multiple organ failure scoring system made up of individual adult respiratory distress syndrome score, renal dysfunction, hepatic dysfunction, and cardiac dysfunction scores. Multiple organ failure (MOF) severity was quantitated using the maximum daily multiple organ failure score and the cumulative sum of daily multiple organ failure scores for the first 7 days (MOF 7) and 10 days (MOF 10). Independent variables included markers of tissue injury, shock, host factors, physiologic response, therapeutic factors, and organ dysfunction within the first 24 hours after admission. Data were subjected to a conditional stepwise multiple regression analysis, first excluding and then including 24-hour MOF as an independent variable. RESULTS Of the 105 high-risk patients, 69 (66%) developed a maximum daily multiple organ failure score > or = 1; 50 (72%) did so on day 1 one and 60 (87%) did so by day 2. In multiple regression models, the multiple correlation coefficient increased from 0.537 to 0.720 when maximum MOF was the dependent variable, from 0.449 to 0.719 when maximum daily MOF was the dependent variable, from 0.519 to 0.812 when MOF 7 was the dependent variable, and from 0.514 to 0.759 when MOF 10 was the dependent variable. CONCLUSION We have confirmed that the population of patients with Injury Severity Scores > or = 25 who received 6 or more units of blood represent a high-risk group for the development of multiple organ failure. Our data also indicate that multiple organ failure after trauma is established within 24 hours of injury in the majority of patients who develop it. It appears that multiple organ failure is already present at the time when most published models are trying to predict whether or not it will occur.

Adjunctive treatment of streptococcal toxic shock syndrome using intravenous immunoglobulin: case report and review.

Infections due to toxigenic strains of Streptococcus pyogenes have been associated with toxic shock syndrome. The portal of entry for streptococci is associated with skin, mucous membranes, or subcutaneous lesions, or occasionally, the upper or lower respiratory tract. The clinical spectrum of the streptococcal toxic shock syndrome (STSS) may range from mild illness characterized by local pain and fever to severe disease including hemodynamic instability, organ failure, and death. Clinical manifestations include local muscle pain, high fever, hypotension, and skin rash, which may rapidly progress to involve respiratory, renal, hepatic, and hematologic systems. Streptococcal pyrogenic exotoxin A (SPE A), a superantigen, has been implicated in the pathogenesis of this syndrome. SPE A is a inducer of the synthesis of cytokines, including tumor necrosis factor (TNF)alpha and beta; TNF is responsible for most of the clinical manifestations of STSS. The treatment of STSS is primarily supportive. Therapy is directed at removing the focus of streptococcal infection if feasible and eliminating any residual toxigenic streptococci with antibiotics in conjunction with correcting hemodynamic and organ dysfunction. Additional therapeutic modalities in the treatment of STSS would theoretically attempt to neutralize the toxins or the cytokines released as a consequence of the streptococcal toxins. Intravenous immunoglobulin (IVIG) has been reported to have beneficial effects in the management of STSS, – 9 and has been proposed as an agent to ameliorate these events. We describe a case of a patient with severe STSS, whose illness was lessened with conventional measures and adjunctive IVIG.

Incidence, severity, and patterns of intrathoracic and intra-abdominal injuries in motorcycle crashes

BACKGROUND Although severe head injuries have been reduced with helmet use, little has been done to address the severity of trauma to organs of the trunk in motorcycle crashes. We detail the frequency, severity, and pattern of intrathoracic and intra-abdominal injuries that may be helpful in the recognition and medical treatment of such injuries. METHODS Diagnostic and treatment information from emergency room, hospital, and coroner records from a cohort of motorcyclists injured from 1991 to 1992 were obtained from 28 hospitals and 11 coroners in California. RESULTS Multiple intrathoracic and intra-abdominal injuries were common, and the number and bilaterality of rib fractures were strongly associated with chances of injuries to the thoracic and abdominal organs. CONCLUSION Patients with severe injury in one anatomic region of the trunk are very likely to have severe injuries in the same or other anatomic regions. These patients are best treated in trauma centers, where rapid diagnosis and treatment are possible.

Hips Can Lie: Impact of Excluding Isolated Hip Fractures on External Benchmarking of Trauma Center Performance

BACKGROUND Trauma centers (TCs) vary in the inclusion of patients with isolated hip fractures (IHFs) in their registries. This inconsistent case ascertainment may have significant implications on the assessment of TC performance and external benchmarking efforts. METHODS Data were derived from the National Trauma Data Bank (2007-8.1). We included patients (aged 16 years or older) with Injury Severity Score value ≥ 9 who were admitted to Level I and II TCs. To ensure data quality, we limited the study to TC that routinely reported comorbidities and Abbreviated Injury Scale codes. IHF were defined as patients, aged 65 years or older, injured as a result of falls, with Abbreviated Injury Scale codes for hip fracture and without other significant injuries. TCs were stratified according to their reported inclusion of IHF in their registry. Observed-to-expected mortality ratios were used to rank TC performance first with and then, without the inclusion of patients with IHF. RESULTS In total, 91,152 patients in 132 TCs were identified; 5% (n = 4,448) were IHF. The proportion of IHF per TC varied significantly, ranging from 0% to 31%. When risk-adjusted mortality was evaluated, excluding patients with IHF had significant effects: 37% (n = 49) of TCs changed their performance rank by ≥ 3 (range, 1-25) and 12% of centers changed their performance quintile. The greatest change in rank performance was evident in centers that routinely include IHF in their registries. CONCLUSIONS Given the fact that IHFs in the elderly significantly influence risk-adjusted outcomes and are variably reported by TCs, these patients should be excluded from subsequent benchmarking efforts.

Risk Factors for Recurrence After Repair of Enterocutaneous Fistula

OBJECTIVES To assess outcomes after repair of enterocutaneous fistulae (ECF) and identify factors that predict mortality and recurrence. DESIGN Retrospective study. SETTING University hospital. PATIENTS One hundred thirty-five patients undergoing ECF repair between 1989 and 2005. MAIN OUTCOME MEASURES Mortality and recurrence of ECF. RESULTS Definitive operation for ECF was attempted in 135 patients. Mortality was 8%, recurrence was 17%, and 84% of patients eventually survived with a closed fistula. The primary determinant of mortality was ECF recurrence (odds ratio [OR], 6.7; 95% confidence interval [CI], 1.9-23.4). Factors independently associated with ECF recurrence by multivariate logistic regression included the presence of inflammatory bowel disease (OR, 4.9; 95% CI, 1.5-16.1), interval between diagnosis and operation of 36 weeks or longer (OR, 5.4; 95% CI, 1.8-16.4), location of fistulae in the small intestine (OR, 9.8; 95% CI, 1.7-57.6), and resection with stapled anastomosis (OR, 4.1; 95% CI, 1.3-13.2). Recurrence of ECF was 35% with resection and stapled anastomosis, 22% with simple oversew, and 11% with resection and hand-sewn anastomosis. Recurrence of ECF was 12% when operation was performed prior to 36 weeks from diagnosis, compared with 36% if performed at or beyond 36 weeks. CONCLUSIONS The primary determinant of mortality after ECF repair is a failed operation leading to recurrence of the fistula. Risk factors for ECF recurrence include inflammatory bowel disease, fistula located in the small intestine, an interval of 36 weeks or longer between diagnosis and operation, and resection with stapled anastomosis.

Disparity in management and long-term outcomes of pediatric splenic injury in California.

Objective:To determine the impact of evidence-based guidelines on the disparities in management of pediatric splenic injuries (PSI). Summary of Background Data:Several studies have highlighted a disparity in the utilization of nonoperative management (NOM) for PSI based on hospital and surgeon characteristics. Whether evidence-based guidelines had an impact on mitigating this disparity is uncertain. Methods:From 1999 to 2006, children ≤18 years with PSI were extracted from Californias Patient Discharge Database (n = 5089). Patient demographics, injury grade, immediate and delayed operations, readmissions, and complications were analyzed. Results:The overall rates of immediate operative management (IOM) decreased significantly from 23% in 1999 to 15% in 2006 (P < 0.001). This decline was attributed entirely to reduction of IOM at non-childrens hospitals (NCH) (29% to 20%, P < 0.001). In contrast, IOM rates were low and unchanged at childrens hospital (CH) (9%, P = NS). Failed NOM (3.3%), readmissions for complications (0.6%), and operations (0.3%) were rare and unaffected by NOM increase. NCH had increased risk of IOM compared to CH in multivariate analysis (OR: 2.00, 99% CI: 1.09–3.57). The rate of delayed splenic rupture was 0.2%. There were no differences when comparing the rates of readmissions (1.0% vs. 0.4%, P = NS) and readmit operations (0.3% vs. 0.3%, P = NS) between IOM versus NOM. Conclusion:A steady increase in the utilization of NOM for PSI in California over time was attributed entirely to changing practices at NCH. Increasing NOM has occurred without a concurrent increase in complications. Delayed splenic ruptures were rare. Although IOM rates at NCH decreased over time, disparity in NOM utilization still exists between NCH and CH.

A comparison of rural versus urban trauma care

Objective: We compared the survival of trauma patients in urban versus rural settings after the implementation of a novel rural non-trauma center alternative care model called the Model Rural Trauma Project (MRTP). Materials and Methods: We conducted an observational cohort study of all trauma patients brought to eight rural northern California hospitals and two southern California urban trauma centers over a one-year period (1995-1996). Trauma patients with an injury severity score (ISS) of >10 were included in the study. We used logistic regression to assess disparities in odds of survival while controlling for Trauma and Injury Severity Score (TRISS) parameters. Results: A total of 1,122 trauma patients met criteria for this study, with 336 (30%) from the rural setting. The urban population was more seriously injured with a higher median ISS (17 urban and 14 rural) and a lower Glasgow Coma Scale (GCS) (GCS 14 urban and 15 rural). Patients in urban trauma centers were more likely to suffer penetrating trauma (25% urban versus 9% rural). After correcting for differences in patient population, the mortality associated with being treated in a rural hospital (OR 0.73; 95% CI 0.39 to 1.39) was not significantly different than an urban trauma center. Conclusion: This study demonstrates that rural and urban trauma patients are inherently different. The rural system utilized in this study, with low volume and high blunt trauma rates, can effectively care for its population of trauma patients with an enhanced, committed trauma system, which allows for expeditious movement of patients toward definitive care.