Hieu H. Ton-That

A clustering of injury behaviors.

BACKGROUND Alcohol is a well-known risk factor for injury. A number of other behaviors are also associated with injury risk. We hypothesized that risky drinking would be associated with other high risk behaviors, thereby delineating a need for behavioral interventions in addition to alcohol. METHODS A consecutive sample of trauma patients was interviewed for drinking and risky behaviors including seat belt use, helmet use, and driving behaviors. The Alcohol Use Disorders Identification Test was used to screen for risky drinking and risky behavior questions were taken from validated questionnaires. Behaviors were ranked on a Likert scale ranging from a low to a high likelihood of the behavior or assessed the frequency of behavior in the past 30 days. An Alcohol Use Disorders Identification Test score of 8 or more was considered risky drinking for adults age 21 to 64, and 4 or more for ages 16 to 20 and over 65. Risky and nonrisky drinkers were compared on behavior risk items. A p value of less than 0.05 was considered significant. RESULTS One hundred sixty patients (mean age, 36.8 years, 72% men,) were interviewed. Risky drinkers were more likely to drive after consuming alcohol, ride with drinking drivers, tailgate, weave in and out of traffic, and make angry gestures at other drivers (all p < 0.05). Risky drinkers were less likely to wear motorcycle helmets. However, risky drinkers were no more or less likely to talk on the cell phone while driving, to use seatbelts, or use turn signals. Although number of lifetime vehicle crashes were similar, risky drinkers were more likely to have been the party at fault for the crash (mean 1.09 vs. 0.64, p = 0.03). CONCLUSIONS Factors other than alcohol increase injury risk in problem drinkers. Injury prevention programs performing alcohol interventions should consider including behavioral interventions along with alcohol reduction strategies. New screening and intervention programs should be developed for injury behaviors that increase risk but are not alcohol related.

Cervical spine clearance when unable to be cleared clinically: a pooled analysis of combined computed tomography and magnetic resonance imaging

BACKGROUND The role of cervical spine magnetic resonance imaging (MRI) in the evaluation of clinically unevaluable blunt trauma patients has been called into question by several recent studies. METHODS A PubMed search was performed for all studies comparing computed tomography and MRI in the assessment of the cervical spine in patients who cannot be evaluated clinically. The radiologic findings and clinical outcomes from each study were collated for analysis. RESULTS Data for 1,714 patients were available. All patients had a negative computed tomography scan and then underwent an MRI. There were 271 (15.8%) patients who had a previously undocumented finding on MRI with the majority (98.2%) being a ligamentous injury. Only 5 injuries (1.8%) resulted in surgical intervention. CONCLUSIONS MRI identifies additional injuries; however, the vast majority are of minor clinical significance. Routine MRI after a negative computed tomography of the cervical spine is not supported by the current literature.

Re-evaluating the need for hospital admission and observation of pediatric traumatic brain injury after a normal head CT

There is no consensus on the optimal management of pediatric patients with suspected trauma brain injury and a normal head CT. This study characterizes the clinical outcomes of patients with a normal initial CT scan of the head. A retrospective chart review of pediatric blunt trauma patients who underwent head CT for closed head injury at two trauma centers was performed. Charts were reviewed for demographics, neurologic function, CT findings, and complications. 631 blunt pediatric trauma patients underwent a head CT. 63% had a negative CT, 7% had a non-displaced skull fracture, and 31% had an intracranial hemorrhage and/or displaced skull fracture. For patients without intracranial injury, the mean age was 8 years, mean ISS was 5, and 92% had a GCS of 13-15 on arrival. All patients with an initial GCS of 13-15 and no intracranial injury were eventually discharged to home with a normal neurologic exam and no patient required craniotomy. Not admitting those children with an initial GCS of 13-15, normal CT scan, and no other injuries would have saved 1.8 ± 1.5 hospital days per patient. Pediatric patients who have sustained head trauma, have a negative CT scan, and present with a GCS 13-15 can safely be discharged home without admission.

Screening for At-Risk Drinking Behavior in Trauma Patients

CONTEXT A blood alcohol level above 0 g/dL is found in up to 50% of patients presenting with traumatic injuries. The presence of alcohol in the blood not only increases the risk of traumatic injury, but it is also associated with worse outcomes and trauma recidivism. In light of these risks, the American College of Surgeons Committee on Trauma advocates screening for at-risk drinking. Although many institutions use blood alcohol levels to determine at-risk drinking in trauma patients, the Alcohol Use Disorders Identification Test (AUDIT) offers a cheap and easy alternative. Few direct comparisons have been made between these 2 tests in trauma patients. OBJECTIVE To compare the utility of blood alcohol level and AUDIT score as indicators of at-risk drinking in trauma patients. METHODS Records for all trauma patients aged 18 years or older who were admitted to a level I trauma center from May 2013 through June 2014 were reviewed in this retrospective cohort study. Inclusion criteria required patients to have undergone both blood alcohol level testing and AUDIT on admission. A blood alcohol level greater than 0 g/dL and an AUDIT score equal to or above 8 were considered positive for at-risk drinking. Performance of both tests was indexed against the National Institute of Alcohol Abuse and Alcoholism (NIAAA) criteria for at-risk drinking. RESULTS Of 750 patients admitted for trauma, 222 records (30%) contained data on both blood alcohol level and AUDIT score. The patients were predominantly male (178 [80%]) and had a mean (SD) age of 40.1 (16.7) years. Most patients (178 [80%]) had sustained blunt trauma. Ninety-seven patients (44%) had a positive blood alcohol level, 70 (35%) had a positive AUDIT score, and 54 (24%) met NIAAA criteria for at-risk drinking. The sensitivity and specificity of having a positive blood alcohol level identify at-risk drinking were 61% and 62%, respectively. The sensitivity and specificity of having a positive AUDIT score identify at-risk drinking were 83% and 81%, respectively. CONCLUSION As a stand-alone indicator of at-risk drinking behavior in trauma patients, the AUDIT score was shown to be superior to blood alcohol level. The utility of obtaining routine blood alcohol levels in trauma patients as a screening tool for at-risk drinking should be reexamined.

Physiologic Response to HIPEC: Sifting Through Perturbation to Identify Markers of Complications

CONTEXT The postoperative physiologic response to hyperthermic intraperitoneal chemotherapy (HIPEC) has been poorly studied outside of the immediate perioperative time. OBJECTIVE To characterize the physiologic response during the first 5 days after HIPEC and identify variables associated with major complications. METHODS Patients undergoing HIPEC and cytoreductive surgery during a 14-month interval were retrospectively identified and their records reviewed for demographics, physiologic response, and major complications. Vital signs and laboratory results were recorded before the operation, immediately after the procedure, and for the first 5 postoperative days. RESULTS Thirty-three patients were included. The mean body temperature and heart rate were elevated on postoperative day 1 compared with baseline (preoperative) status (37.1°C vs 36.6°C and 103 vs 78 beats/min, respectively) and remained elevated through postoperative day 5. The mean arterial pressure was lower on postoperative day 1 (73 mm Hg) but returned to baseline on postoperative day 3 (93 mm Hg). Mean creatinine level increased on postoperative day 1 (0.96 mg/dL) but returned to baseline on postoperative day 2 (0.87 mg/dL). Fourteen patients (42%) had major complications. The strongest predictors of major complications were a prolonged operative time (519 vs 403 minutes) and extreme changes in body temperature and renal function. CONCLUSIONS Hyperthermic intraperitoneal chemotherapy results in a hypermetabolic response that partially returns to baseline around postoperative day 3. Elevated body temperature and impaired renal function are the best predictors of major complications.

Making the case for de-escalation therapy in ventilator-associated pneumonia once again.

1810 www.ccmjournal.org July 2013 • Volume 41 • Number 7 Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection among patients receiving mechanical ventilation. VAP is associated with attributable costs of

Alcohol Withdrawal Syndrome in Trauma Patients: A Prospective Cohort Study

25,000–

Comparison of Objective Screening and Self-Report for Alcohol and Drug Use in Traumatically Injured Patients

32,140 per episode, an average of 7–12.5 added days of hospitalization, and case fatality rates of 12% to 24% (1–3). As the prevalence of multidrug resistant bacteria increases, intensivists are faced with the need to prescribe initial broad-spectrum antibiotic therapy in patients with suspected VAP to avoid inappropriate treatment associated with greater mortality (1, 3–5); however, competing with the need to provide initial adequate therapy is the need to prevent additional antibiotic resistance. To this end, one of the simplest and most effective methods for preventing the emergence of antibiotic-resistant bacteria is the avoidance of unnecessary antibiotic use (6). In this issue of Critical Care Medicine, Raman et al (7) provide another study suggesting that early discontinuation of antibiotics is both safe and advantageous in the right setting. The authors conducted a retrospective, observational review evaluating the relationship between early antibiotic discontinuation after negative quantitative bronchoalveolar lavage cultures and mortality in patients with clinically suspected VAP across several ICU settings. Eighty-nine patients with clinically suspected VAP and quantitative culture results below the threshold of 10colony-forming units/mL were analyzed over a 38-month period. Patients were divided into 40 patients whose antibiotics were discontinued within a day of final culture results (early discontinuation) and 49 patients whose antibiotics were stopped more than a day after final culture results (late discontinuation). The hospital did not have a protocol for antibiotic discontinuation using culture results or resolution of clinical signs of VAP. There were some notable demographic and procedural differences between the two groups, including differences in neurologic and cardiovascular diseases, use of minibronchoalveolar lavage versus bronchoscopy, and immunosuppression. However, baseline Acute Physiology and Chronic Health Evaluation II scores were similar between the two groups, and the authors attempt to account for these differences in a multivariate analysis to assess the effect of early discontinuation on mortality. The authors were unable to demonstrate a difference in the primary outcome of mortality, as the sample size was too small to detect a significant difference. However, supporting the position that antibiotics should be discontinued when the final culture results show no significant organism, their results demonstrated that early antibiotic discontinuation was found to have significantly fewer superinfections (22.5% vs 42.9%, p = 0.008), respiratory superinfections (10.0% vs 28.6%, p = 0.036), and multidrug resistant superinfections (7.5% vs 35.7%, p = 0.003), with no significant difference in mortality (25.0% vs 30.6%, p = 0.642). In doing so, the authors build on and compare their findings with those of Singh et al (8) and Kollef and Kollef (9). Although each study demonstrates safety in a shorter antibiotic duration, there are some notable differences across studies. In the study by Singh et al, patients with a new-onset pulmonary infiltrate and a clinical pulmonary infection score of less than 6 were randomized to either standard therapy or ciprofloxacin monotherapy for 3 days coupled with discontinuation if the clinical pulmonary infection score remained of less than 6. Patients had been in the ICU for a mean of 9 days prior to enrollment, with only 58% receiving mechanical ventilation, suggesting that patients were more accurately being treated for late-onset hospital-associated pneumonia. In both their prospective observational study and prospective, randomized controlled trials, Kollef and colleagues used an antibiotic discontinuation guideline based on resolution of signs and symptoms of infection or identification of a noninfectious etiology of the pulmonary infiltrate, rather than culture 13. Delisle S, Ouellet P, Bellemare P, et al: Sleep quality in mechanically ventilated patients: Comparison between NAVA and PSV modes. Ann Intensive Care 2011; 1:42 14 Roche-Campo F, Thille AW, Drouot X, et al: Comparison of Sleep Quality With Mechanical Versus Spontaneous Ventilation During Weaning of Critically Іll Traceotomized Patients. Crit Care Med 2013; 41: 1637–1644 15. Trompeo AC, Vidi Y, Locane MD, et al: Sleep disturbances in the critically ill patients: Role of delirium and sedative agents. Minerva Anestesiol 2011; 77:604–612 16 Jubran A, Grant BJ, Duffner LA, et al: Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: A randomized trial. JAMA 2013; 22:1–7

Superusers: Drivers of health care resource utilization in the national trauma population

Introduction: Trauma patients with a positive blood alcohol concentration (BAC) are often believed to be at high risk for the alcohol withdrawal syndrome (AWS). Therefore some centers prophylaxis all BAC positive patients. This study prospectively measures the incidence of AWS among trauma patients admitted to the hospital who have consumed alcohol and determines their risk factors for AWS. Methods: A cohort of trauma patients admitted to a non-ICU hospital setting was prospectively monitored for the development of AWS during the first 10 days of hospitalization. The 10-item Alcohol Use Disorders Identification Test (AUDIT) and questions about alcohol withdrawal history were administered on the first day and the revised Clinical Institute for Withdrawal of Alcohol Scale (CIWA-Ar) was administered daily. Results: 113 patients were followed through discharge or for the first 10 days of hospitalization. 74.3% (n = 84) reported drinking alcohol. Of the 89 patients with a measured BAC, 25 (28%) were positive. Mean BAC for positive patients was 187.7 mg/dl. No person who denied drinking had a measurable BAC or developed AWS. Among the 84 drinkers, 3 were diagnosed with AWS by CIWA-Ar (3.6% risk), giving an incidence rate of 1.4 episodes per 100 patient days. All patients developing AWS admitted to a previous history of AWS symptoms upon stopping drinking. All AWS patients drank at least 2-3 times per week compared to only 37% of drinkers who did not develop AWS (p = .05). Positive response to dependence items from the AUDIT were highly associated with AWS risk (67% AWS vs 16% non-AWS, p = .005). Implementation of a prophylaxis protocol for all positive BAC would have resulted in 88% (22/25) of BAC positive patients receiving unwarranted medication. Conclusion: AWS has a low incidence rate among intoxicated trauma patients admitted to a non-ICU setting. It is associated with frequent drinking and is found in patients who report dependence symptoms. Patients can reliably tell physicians whether they are at risk for AWS. Routine prophylaxis for positive BAC patients will likely result in substantial excess medication use.

Penetrating Major Vein Injury Predicts VTE: A Propensity Matched Analysis

Alcohol and drug use is prevalent in trauma patients. Concerns over the validity of self-reporting drug use could make nonlaboratory screening problematic. This study sought to validate patient self-report of substance use against objective screening to determine the reliability of self-report in trauma patients. Patients admitted to either the Trauma or Burn services who were at least age 18 were screened for alcohol and drug use with validated screening tools. Exclusion criteria were altered mental status, non English speaking, inability to answer questions for other reasons, under police custody, or admission for <24 hours. Results from admission blood alcohol concentration (BAC) and urine drug screen (UDS) were also collected and compared to self-reported use to determine its reliability. Alcohol use was queried in 128 patients, 101 of whom had a BAC drawn. Of those 101, 34 (33.7%) had a BAC ≥ 0 mg%. Alcohol Use Disorder Identification Test creening revealed 13 (12.9%) patients who were self-reported non drinkers, none of which had a BAC > 0 mg%. Drug use was queried in 133 patients, 93 of whom had a UDS. A positive was found in 26 (28.0%) of the patients, only 12 (46.2%) of whom reported drug use in the past year. Although substance use in trauma patients is prevalent, self-report screening techniques for drugs may be inadequate at determining those patients whom could benefit from brief interventions while in the hospital. Further investigation is needed to determine the discrepancy between alcohol and drug use screening in trauma patients and more acceptable means of drug use discussion.