Jameel Ali

Trauma outcome improves following the advanced trauma life support program in a developing country.

Trauma outcome variables before and after the institution of the Advanced Trauma Life Support (ATLS) program were compared for the largest hospital in Trinidad and Tobago from July 1981 through December 1985 (pre-ATLS) and from January 1986 to June 1990 (post-ATLS). A total of 199 physicians were ATLS trained by June 1990. Outcome data were analyzed for all dead or severely injured patients (ISS > or = 16; n = 413 pre-ATLS and n = 400 post-ATLS). Trauma mortality decreased post-ATLS (134 of 400 vs. 279 of 413) throughout the hospital, including the ICU (13.6% post-ATLS ICU mortality vs. 55.2% pre-ATLS). The odds of dying from trauma increased with age (1.02 for each year), ISS score (1.24 for each ISS increment), and blunt injury, both pre-ATLS and post-ATLS. Post-ATLS mortality was associated with a higher ISS (31.6 vs. 28.8). Although there was a higher percentage of blunt injury pre-ATLS (84.0%) versus post-ATLS (68.3%), the mortality rates for both blunt and penetrating injuries were higher in the pre-ATLS group (19.7% pre-ATLS vs. 6.3% post-ATLS for penetrating and 76.6% pre-ATLS versus 46.2% post-ATLS for blunt). For each ISS category, mortality was greater in the pre-ATLS group (ISS > or = 24 pre-ATLS mortality 47.9% vs. 16.7% post-ATLS; ISS 25-40 pre-ATLS mortality 91.0% vs. 71.0% post-ATLS). The overall ratio of observed to expected mortality based on the MTOS data base was lower for the post-ATLS period (pre-ATLS ratio 3.16; post-ATLS ratio 1.94).(ABSTRACT TRUNCATED AT 250 WORDS)

Consequences of postoperative alterations in respiratory mechanics.

Abstract In patients undergoing extrathoracic surgical procedures, upper abdominal operations led to the most significant reductions in vital capacity, tidal volume, and functional residual capacity. The degree of fall in vital capacity correlated with the development of a clinical pulmonary complication. After upper abdominal surgery there was a delay of sixteen hours prior to a fall in the functional residual capacity. Decrease in surfactant activity is the mechanism proposed for this volume change. In a series of seriously ill patients, changes in the functional residual capacity were related to the degree of arterial hypoxemia. Elevation in the functional residual capacity toward normal resulted in a decrease in the physiologic shunt. Failure to correlate hypoxemia with radiologic evidence of segmental atelectasis is consistent with peripheral alveolar collapse or decrease in alveolar ventilation because of small airway closure.

Evaluating the effectiveness of a 2-year curriculum in a surgical skills center

BACKGROUND This study was a formative evaluation of a 2-year Surgical Skills Center Curriculum (SSCC) using objective measures of surgical performance and self-reported process-oriented evaluations. METHODS Fifty postgraduate third-year (PGY-3) residents participated in an Objective Structured Assessment of Technical Skills (OSATS) examination. Nineteen residents underwent the SSCC and 31 residents did not. During the SSCC, self-reported student and faculty evaluations were completed after each session. RESULTS For the OSATS examination, scores were not significantly different between treatment and control groups, on either the checklist (66.4 +/- 6.1 versus 64.1 +/- 10.8) or global rating scale scores (66.9 +/- 6.9 versus 68.0 +/- 9.6). Further comparisons between groups on individual OSATS stations revealed no significant differences between groups. The majority of student and faculty evaluation remarks were highly positive. CONCLUSIONS The OSATS results failed to support our hypothesis that training on a core procedure in a single session during a SSCC would have an appreciable and sustained effect after 2 years. Self-reported process-oriented evaluations support the utility of our SSCC.

Predictors of fetal mortality in pregnant trauma patients.

BACKGROUND Fetal mortality after trauma is significant. This study was aimed at identifying factors responsible for this high fetal mortality. METHODS All pregnant trauma patients admitted to the two major Toronto trauma institutions during the period of November of 1991 to February of 1996 with an Injury Severity Score (ISS) > or = 12 were assessed. Data on age, gestation, hypotension, ISS, hemoglobin, blood transfusion, length of stay, disseminated intravascular coagulation (DIC), and specific maternal injury were analyzed retrospectively to determine predictors of fetal mortality by comparison of patients with and without fetal survival. RESULTS Twenty of a total of 68 pregnant trauma patients qualified for entry into the trauma registry by having an ISS > or = 12. Overall fetal mortality was 65% (13 of 20) for ISS > or = 12, and there was one maternal death (age, 29 years; ISS, 66). There were no statistically significant differences between the fetal death and fetal survival groups in age (29.2 +/- 6.2 vs. 30.4 +/- 3.9 years), gestation (25.3 +/- 10.5 vs. 24.1 +/- 9.2 weeks), lowest systolic blood pressure (98.3 +/- 33.8 vs. 112 +/- 18.0 mm Hg), head injury rate (3 of 13 vs. 1 of 7), extremity injury rate (8 of 13 vs. 2 of 7), abdominal injury rate (4 of 13 vs. 0 of 7), pelvic fracture rate (6 of 13 vs. 1 of 7), and chest injury rate (5 of 13 vs. 3 of 7). However, ISS (27.7 +/- 3.5 vs. 14.2 +/- 11.4), lowest hemoglobin level (78.8 +/- 17.0 vs. 101.9 +/- 17.1), blood transfusions (10.8 +/- 6.3 vs. 0.9 +/- 1.6 units), length of stay (20.9 +/- 16.7 vs. 8.2 +/- 4.9 days), and the incidence of DIC (8 of 13 vs. 0 of 7) were statistically significantly different between the two groups (p < 0.05). All eight patients with abruptio placentae had associated fetal mortality. CONCLUSIONS Apart from ISS, blood loss, and abruptio placentae; the presence of DIC was the most significant predictor of fetal mortality. This finding may represent stimulation of DIC by placental products entering the maternal circulation after significant intrauterine injury.

Trauma patient outcome after the Prehospital Trauma Life Support program.

BACKGROUND We have previously demonstrated a significant improvement in trauma patient outcome after the Advanced Trauma Life Support (ATLS) program in Trinidad and Tobago. In January of 1992, a Prehospital Trauma Life Support (PHTLS) program was also instituted. This study assessed trauma patient outcome after the PHTLS program. METHODS Morbidity (length of stay and degree of disability), mortality, injury severity score, mechanism of injury, age, and sex among all adult trauma patients transported by ambulance to the major trauma hospital were assessed between July of 1990 to December of 1991 (pre-PHTLS, n = 332) and January of 1994 to June of 1995 (post-PHTLS, n = 350). RESULTS Age, sex distribution, percentage blunt injury, and injury severity score were similar for both groups. Mortality pre-PHTLS (15.7%) was greater than post-PHTLS (10.6%). Length of stay and disability were statistically significantly decreased post-PHTLS. Age, injury severity score, and mechanism of injury were positively correlated with mortality in both periods. The previously reported post-ATLS mortality was similar to the pre-PHTLS mortality. CONCLUSIONS Post-PHTLS mortality and morbidity were significantly decreased, suggesting a positive impact of the PHTLS program on trauma patient outcome.

ADVANCED TRAUMA LIFE SUPPORT PROGRAM INCREASES EMERGENCY ROOM APPLICATION OF TRAUMA RESUSCITATIVE PROCEDURES IN A DEVELOPING COUNTRY

Over a 9-year period (July 1981-December 1985--pre-ATLS period; January 1986-June 1990--post-ATLS period), the hospital charts of 813 trauma patients with ISS > or = 16 were reviewed (n = 413, pre-ATLS and n = 400, post-ATLS) in order to assess the impact of the ATLS program. The frequency of endotracheal intubation (ET), nasogastric tube insertion (NG), intravenous access (i.v.), Foley catheterization of the bladder (Foley) and chest tube insertion (CT) were compared by Pearson Chi-square analysis. Overall, pre-ATLS vs. post-ATLS frequencies (%) were 83.5 vs. 65.3 for ET, 97.3 vs. 98.0 for i.v., 74.6 vs. 96.3 for Foley, 68.3 vs. 91.3 for NG, and 18.4 vs. 47.0 for CT. In the emergency room these frequencies (%) were 26.1 vs. 36.4 for ET, 98.8 vs. 98.7 for i.v., 11.0 vs. 97.1 for Foley, 3.2 vs. 95.9 for NG, and 3.9 vs. 95.2 for CT. The differences in the application of these life saving procedures between the pre-ATLS and post-ATLS periods were statistically significant (p < 0.05) except i.v. access, which showed no difference between the pre-ATLS and post-ATLS groups. Of the patients with severe chest injuries (AIS > or = 3) 87.7% had chest tubes post ATLS (94.4% in ER) compared with 48.1% pre ATLS (3.2% in ER). These differences were associated with significant improvement in trauma patient outcome post ATLS. We conclude that the frequency of lifesaving interventions, particularly in the ER, was increased post ATLS.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiinstitutional Experience With the Management of Superior Mesenteric Artery Injuries.

BACKGROUND Superior mesenteric artery (SMA) injuries are rare and often lethal injuries incurring very high morbidity and mortality. The purposes of this study are to review a multiinstitutional experience with these injuries; to analyze Fullens classification based on anatomic zone and ischemia grade for its predictive value; to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality; and to identify independent risk factors predictive of mortality, describing current trends for the management of this injury in America. DESIGN We performed a retrospective multiinstitutional study of patients sustaining SMA injuries involving 34 trauma centers in the US over 10 years. Outcomes variables, both continuous and dichotomous, were analyzed initially with univariate methods. For the subsequent multivariate analysis, stepwise logistic regression was used to identify a set of risk factors significantly associated with mortality. RESULTS There were 250 patients enrolled, with a mean Revised Trauma Score (RTS) of 6.44 and a mean Injury Severity Score (ISS) of 25. Surgical management consisted of ligation in 175 of 244 patients (72%), primary [corrected] repair in 53 of 244 patients (22%), autogenous grafts were used in 10 of 244 (4%), and prosthetic grafts of PTFE in 6 of 244 patients (2%). Overall mortality was 97 of 250 patients (39%). Mortality versus Fullens zones: zone I, 39 of 51 (76.5%); zone II, 15 of 34 (44.1%); zone III, 11 of 40 (27.5%); and zone IV, 25 of 108 (23.1%). Mortality versus Fullens ischemia grade: grade 1, 22 of 34 (64.7%). Mortality versus AAST-OIS for abdominal vascular injury: grade I, 9 of 55 (16.4%); grade II, 13 of 51 (25.5%); grade III, 8 of 20 (40%); grade IV, 37 of 69 (53.6%); and grade V, 17 of 19 (89.5%). Logistic regression analysis identified as independent risk factors for mortality the following: transfusion of greater than 10 units of packed RBCs, intraoperative acidosis, dysrhythmias, injury to Fullens zone I or II, and multisystem organ failure. CONCLUSION SMA injuries are highly lethal. Fullens anatomic zones, ischemia grade, and AAST-OIS abdominal vascular injuries correlate well with mortality. Injuries to Fullens zones I and II, Fullens maximal ischemia grade, and AAST-OIS injury grades IV and V, high-intraoperative transfusion requirements, and presence of acidosis and disrhythmias are significant predictors of mortality. All of these predictive factors for mortality must be taken into account in the surgical management of these injuries.

Attrition of Cognitive and Trauma Management Skills after the Advanced Trauma Life Support (ATLS) Course

OBJECTIVE To test the attrition of cognitive and trauma management skills among practising physicians after the Advanced Trauma Life Support (ATLS) course. DESIGN, MATERIALS, AND METHODS Sixty practising physicians who completed the ATLS course had comparative assessment of cognitive skills (with multiple choice questions, MCQ) pre-ATLS, immediately post-ATLS, at 6 months (group A), 2 years (group B), 4 years (group C), and 6 years (group D) after the course. Trauma management skills were also compared using eight Objective Structured Clinical Examination (OSCE) trauma stations completed by the four groups of physicians. MEASUREMENTS AND MAIN RESULTS Pre-ATLS MCQ scores (54.2 +/- 4.2 to 59.8 +/- 5.3%) and immediately post-ATLS MCQ scores (85.9 +/- 5.1 to 87.7 +/- 5.3%) were similar in all four groups. Follow-up MCQ scores were 77.8 +/- 3.6% at 6 months 70.6. +/- 1.9% at 2 years, 69.4 +/- 1.7% at 4 years, and 68.9 +/- 2.0% at 6 years. OSCE scores out of a maximum of 20 were 16.8 +/- 0.3 at 6 months, 13.9 +/- 0.1 at 2 years, 12.0 +/- 0.1 at 4 years, and 11.9 +/- 0.1 at 6 years. Adherence-to-priorities scores (maximum, 7) were 6.6 +/- 0.2 at 6 months, 6.8 +/- 0.1 at 2 years, 6.6 +/- 0.1 at 4 years, and 6.6 +/- 0.1 at 6 years. Organized-approach scores (maximum, 5) were 4.8 +/- 0.1 at 6 months, 4.6 +/- 0.2 at 2 years, 4.7 +/- 0.2 at 4 years, and 4.6 +/- 0.2 at 6 years. Using the MCQ 80% pass mark criterion, at least 50% of physicians fail by 6 months and all fail this cognitive test thereafter. CONCLUSIONS Whereas cognitive and trauma management skills decline after the ATLS, these skills are maintained at similar levels between 4 and 6 years after ATLS. A 50% failure rate occurs within 6 months and maximum attrition of cognitive skills occurs within 2 years of ATLS completion. Major principles of adherence to priorities and maintenance of an organized approach to trauma care are preserved for at least 6 years after ATLS.

Cognitive And Attitudinal Impact Of The Advanced Trauma Life Support Program In A Developing Country

Improvement in trauma patient outcome has been reported after Advanced Training Life Support training (ATLS) in the developing country of Trinidad and Tobago (T & T). The cognitive impact of ATLS training was assessed from pre-ATLS and post-ATLS performance of T & T physicians in multiple choice question tests and comparison with post-ATLS test performance among Nebraska physicians. Overall, improvement between the pre-test and post-test among the T & T physicians was 22.0% +/- 2.0%. All physicians including failures (199 out of 212 passed) improved in their post-test scores. Individual item analysis of the post-test, including the KR-20 determination, varied but the overall performance was similar for both physician groups with the T & T physicians performing slightly better in test 2 (6 of 16 vs. 25 of 100 failures, p < 0.05). Attitudinal impact was assessed through 87 questionnaires from 50 physicians (92% response) and 37 nurses (89% response). Physicians (97.8% compared with 69.7%) were more aware of the ATLS training, and both groups (physicians, 77.3%; nurses, 69.6%) differentiated ATLS-trained physicians based on better resuscitation, more timely and appropriate consultation, greater confidence in trauma management, and improvement in trauma mortality and morbidity; all respondents recommended ATLS training for all emergency room physicians. The demonstrated positive cognitive and attitudinal effects very likely contributed to the improved post-ATLS trauma patient outcome.

Effect of the Prehospital Trauma Life Support Program (PHTLS) on prehospital trauma care

BACKGROUND Improvement in trauma patient outcome has been demonstrated after the implementation of the Prehospital Trauma Life Support (PHTLS) program in Trinidad and Tobago. This study was aimed at identifying prehospital care factors that may explain this improvement. METHODS All patients transferred by ambulance to the major trauma referral hospital had assessment of airway control, oxygen use, cervical (C)-spine control, and hemorrhage control, as well as splinting of extremities during pre-PHTLS (July of 1990 to December of 1991; n = 332) and post-PHTLS periods (January of 1994 to June of 1995; n = 350). Pre-PHTLS data were compared with post-PHTLS data by chi 2 analysis with a p value < or = 0.05 being considered statistically significant. RESULTS The frequency (%) increased in the post-PHTLS period for airway control (10 vs. 99.7%), C-spine control (2.1 vs. 89.4%), splinting of extremities (22 vs. 60.6%), hemorrhage control (16 vs. 96.9%), and oxygen use (6.6 vs. 89.5%) when no specific problem was identified. When a specific problem was identified in these areas, the post-PHTLS percentage also increased for airway control (16.2 vs. 100%), C-spine control (25 vs. 100%), splinting of extremities (33.9 vs. 100%), hemorrhage control (18 vs. 100%), and oxygen use (43.2 vs. 98.9%). CONCLUSIONS Prehospital trauma care has changed after the introduction of the PHTLS program as indicated by more frequent airway control, use of oxygen, control of cervical (C)-spine and hemorrhage, as well as splinting of fractures. This finding was evident not only as a routine but particularly when a specific related problem was identified. This change in prehospital care could be responsible for the improved trauma patient outcome after PHTLS.