Jane E. McCormack

The Association Between Hypothermia, Prehospital Cooling, and Mortality in Burn Victims

OBJECTIVES Hypothermia is associated with increased morbidity and mortality in trauma victims. The prognostic value of hypothermia on emergency department (ED) presentation in burn victims is not well known. The objective of this study was to determine the incidence of hypothermia in burn victims and its association with mortality and hospital length of stay (LOS). The study also examined the potential causative role of prehospital cooling in hypothermic burn patients. METHODS This was a retrospective review of a county trauma registry. The county was both suburban and rural, with a population of 1.5 million and with one burn center. Burn patients between 1994 and 2007 who met trauma registry criteria were included. Demographic and clinical data including prehospital cooling, burn size and depth, and presence of inhalation injury were collected. Hypothermia was defined as a core body temperature of less than or equal to 35 degrees C. Data analysis consisted of univariate associations between patient characteristics and hypothermia. RESULTS There were 1,215 burn patients from 1994 to 2007. Mean age (+/-standard deviation [+/-SD]) was 29 (+/-24) years, 67% were male, 248 (26.7%) had full-thickness burns, and 24 (2.6%) had inhalation injury. Only 17 (1.8%) had a burn larger than 70% total body surface area (TBSA). A total of 929 (76%) patients had an initial ED temperature recorded. Only 15/929 (1.6%) burn patients had hypothermia on arrival, and all were mild (lowest temperature was 32.6 degrees C). There was no association between sex, year, and presence of inhalation injury with hypothermia. Hypothermic patients were older (44 years vs. 29 years, p = 0.01), and median Injury Severity Score (ISS) was higher (25 vs. 4, p = 0.002) than for nonhypothermic patients. Hypothermia was present in 6/17 (35%) patients with a TBSA of 70% or greater and in 8/869 (0.9%) patients with a TBSA of <70% (p < 0.001). Mortality was higher in hypothermic patients (60% vs. 3%, p < 0.001). None of the hypothermic patients received prehospital cooling. CONCLUSIONS Hypothermia on presentation to the ED was noted in 1.6% of all burn victims in this trauma registry. Hypothermia was more common in very large burns and was associated with high mortality. In this series, prehospital cooling did not appear to contribute to hypothermia.

Ventilator-associated pneumonia in pediatric trauma patients.

Background: Ventilator-associated pneumonia (VAP) is a significant cause of secondary morbidity and mortality in adult trauma patients. No study has characterized VAP in pediatric trauma patients. We determined the rates of and potential risk factors for VAP in pediatric trauma patients. Methods: A countywide trauma registry identified all pediatric trauma patients with potential VAP treated at a Regional Trauma Center. After a structured chart review, descriptive statistics were used to characterize the population. Results: One hundred fifty-eight trauma patients younger than 16 years requiring intubation and mechanical ventilation were identified in 3388 pediatric trauma admissions from the period 1995-2006. Drownings and poisonings were excluded. The registry identified 14 potential VAPs, of which, on detailed review, 7 were true cases. The VAP rate for pediatric trauma patients was 0.2% overall or 4.4% of those mechanically ventilated. In addition, ventilator days were available in the registry from 2003 forward and the rate in ventilator days was found to be 13.83/1000. Although higher than the overall pediatric intensive care unit VAP rate (5.93/1000 ventilator days), the pediatric trauma VAP rate was substantially lower than the VAP rate in adult trauma patients (58.25/1000 ventilator days). On chart review, six of the seven patients were male and older than 10 years (mean age, 11.9 years). All seven patients with VAP were blunt trauma victims with head injury (mean initial Glasgow Coma Score, 5.6) with Injury Severity Scores over 25 (mean, 32.1). Pulmonary contusion was present in four of the seven. Although the in-hospital mortality rate of ventilated pediatric trauma patients was 17.1%, there was no mortality in those with VAP. Conclusions: The rate of VAP in pediatric trauma patients is substantially lower than in similar adults. Age older than 10 years, blunt trauma, head injury, and Injury Severity Score >25 may be risk factors. VAP is not associated with increased mortality in pediatric trauma patients.

Let the surgeon sleep: trauma team activation for severe hypotension.

BACKGROUND Trauma centers must balance the need to bring the full resources of the trauma center to the sickest patients emphasizing a need for personnel resource allocation. Our level I academic trauma center changed the systolic blood pressure (SBP) requirement for trauma team activation (TTA) from 90 mm Hg to 80 mm Hg. This investigation was undertaken to determine the effects of such change. METHODS The hospitals trauma registry identified patients for two 18-month periods, pre and post the change in TTA criteria. Data elements included team activation level, emergency department length of stay, emergency department to operating room (OR) times, delay to OR, and Injury Severity Score. RESULTS Full TTA decreased as did the percentage of cases with TTA. Eleven patients were identified in the SBP <80 mm Hg group who would have had TTA before the change. All 11 had timely trauma surgery consults. No delays to OR were related to TTA. The percentage of cases with laparotomy occurring >2 hours after arrival was unchanged. One hundred ninety fewer TTA were called in an 18-month period. Inpatient mortality between the two groups was not significantly changed. CONCLUSIONS Changing criteria for TTA from SBP 90 mm Hg to <80 mm Hg preserves personnel without patient harm. Lowering the SBP for TTA is one method of preserving trauma surgery manpower.

Critical analysis of injuries sustained in the TWA flight 800 midair disaster.

BACKGROUND Previous reports of commercial airline disasters have reviewed incidents occurring at takeoff and landing. The purpose of the present study, which represents the first analysis of aviation injuries incurred during a midflight incident, was to examine the injuries sustained by the victims of the TWA Flight 800 disaster and to determine any correlation of injuries with structural damage and seat location. METHODS Complete autopsy records, toxicology screening, and forensic analysis were reviewed. Injuries were assessed by anatomic region and severity by using the Abbreviated Injury Scale. The National Transportation Safety Board report of the investigation was applied to correlate individual injuries with seat location and structural damage. A comparison was performed against injury data from takeoff and landing incidents. RESULTS All 230 passengers of TWA Flight 800 were recovered as fatalities. Head, thoracic, and abdominal injuries were multiple and severe, contributing to the mortality of the occupants. Analysis revealed that the severity of injury and anatomic injury pattern did not generally correlate with seating position or structural damage. A comparison of these injuries with those of takeoff and landing crashes showed differences in injury pattern and severity. CONCLUSION Passengers of Flight 800 sustained instantaneous fatal blunt force injury. Analysis of the data revealed no global correlation between seat position and pattern of injury. In contrast to injuries incurred during crashes at takeoff and landing, these midflight injuries were too extreme to warrant a reappraisal of current passenger protective safety measures or standards.

Outcomes following prolonged mechanical ventilation: analysis of a countywide trauma registry.

BACKGROUND The care of mechanically ventilated patients at high-volume centers in select nontrauma populations has variable effects on outcomes. We evaluated outcomes for trauma patients requiring prolonged mechanical ventilation (PMV). We further hypothesized that the higher mechanical ventilator volume trauma center would have better outcomes. METHODS A retrospective review of a county’s trauma registry was performed for trauma patients who were at least 18 years old admitted from 2006 to 2010. Eleven hospitals serve this suburban county, with a population of approximately 1.5 million people. The state has designated them as nontrauma centers (n = 6), area trauma centers (ATCs, n = 4), or regional trauma center (RTC, n = 1), where the last one provides the highest echelon of care. Patients requiring mechanical ventilation for at least 96 hours following injury were evaluated. RESULTS A total of 3,382 trauma patients were admitted to the RTC, and 5,870 were admitted to the other 10 hospitals in the county. Seven hundred seventy-one received mechanical ventilation at the RTC, and 687 at the other 10 hospitals combined. Of these patients, 407 at the RTC and 308 at the remaining facilities (291 at ATCs and 17 at nontrauma centers) required PMV. Median (interquartile range [IQR]) Injury Severity Score (ISS) at the RTC was higher (29 [21–41] vs. 22 [16–29] p < 0.001) than that at ATCs. Hospital length of stay (in days) was comparable between the RTC and ATCs (28 [18–45] vs. 26 [16–44.7]). With regard to complications, rates of renal failure, sepsis, and myocardial infarction were similar. The RTC had higher pneumonia rates (59% vs. 45.4%, p < 0.001) and venous thromboembolic disease rates (20.4% vs. 10.4%, p < 0.001) than did ATCs. In-hospital mortality was 17% at the RTC and 34.4% at ATCs (p < 0.001). CONCLUSION A mortality benefit but higher VTE and pneumonia rate for PMV patients at the RTC was noted. Collaborative practice initiatives are warranted to reduce morbidity and mortality across the region. LEVEL OF EVIDENCE Epidemiologic study, level IV.

The effect of adding a second helicopter on trauma-related mortality in a county-based trauma system.

Objectives. Despite conflicting evidence regarding its efficacy, helicopter transportation of trauma victims is widespread. We determined the effect of adding a second helicopter to a countywide emergency medicine system on trauma-related mortality. Methods. A before-and-after trial design was used to compare hospital mortality before and after introducing a second helicopter to the eastern end of Suffolk County, New York, in 2001 aimed at reducing transport times to the regional trauma center. Outcomes before and after introducing the second helicopter were compared with parametric or nonparametric tests as appropriate. Results. A total of 1,551 trauma patients were included in this study from June 1996 to May 2006, with 705 in the single-helicopter period and 846 in the two-helicopter period. Mean ages, gender distributions, and mean Injury Severity Scores (ISSs) were similar between groups. Total mortality significantly decreased after the addition of the second helicopter (16.2% before vs. 11.9% after; p = 0.02). Conclusions. Introduction of a second helicopter to the east end of Long Island was associated with a significant reduction in the total trauma mortality.

Spinal Fractures in Older Adult Patients Admitted After Low-Level Falls: 10-Year Incidence and Outcomes.

To evaluate the incidence of spinal fractures and their outcomes in the elderly who fall from low‐levels in a suburban county.

Unplanned intensive care unit admission following trauma

BACKGROUND The prevalence and outcomes of trauma patients requiring an unplanned return to the intensive care unit (ICU) and those initially admitted to a step-down unit or floor and subsequently upgraded to the ICU, collectively termed unplanned ICU (UP-ICU) admission, are largely unknown. METHODS A retrospective review of the trauma registry of a suburban regional trauma center was conducted for adult patients who were admitted between 2007 and 2013, focusing on patients requiring ICU admission. Prehospital or emergency department intubations and patients undergoing surgery immediately after emergency room evaluation were excluded. RESULTS Of 5411 admissions, there were 212 UP-ICU admissions, 541 planned ICU (PL-ICU) admissions, and 4658 that were never admitted to the ICU (NO-ICU). Of the 212 UP-ICU admits, 19.8% were unplanned readmissions to the ICU. Injury Severity Score was significantly different between PL-ICU (16), UP-ICU (13), and NO-ICU (9) admits. UP-ICU patients had significantly more often major (Abbreviated Injury Score ≥ 3) head/neck injury (46.7%) and abdominal injury (9.0%) than the NO-ICU group (22.5%, 3.4%), but significantly less often head/neck (59.5%) and abdominal injuries (17.9%) than PL-ICU patients. Major chest injury in the UP-ICU group (27.8%) occurred at a statistically comparable rate to PL-ICU group (31.6%) but more often than the NO-ICU group (14.7%). UP-ICU patients also significantly more often underwent major neurosurgical (10.4% vs 0.7%), thoracic (0.9% vs 0.1%), and abdominal surgery (8.5% vs 0.4%) than NO-ICU patients. Meanwhile, the PL-ICU group had statistically comparable rates of neurosurgical (6.8%) and thoracic surgical (0.9%) procedures but lower major abdominal surgery rate (2.0%) than the UP-ICU group. UP-ICU admission occurred at a median of 2 days following admission. UP-ICU median hospital LOS (15 days), need for mechanical ventilation (50.9%), and in-hospital mortality (18.4%) were significantly higher than those in the PL-ICU (9 days, 13.9%, 5.4%) and NO-ICU (5 days, 0%, 0.5%) groups. CONCLUSIONS UP-ICU admission, although infrequent, was associated with significantly greater hospital length of stay, rate of major abdominal surgery, need for mechanical ventilation, and mortality rates than PL-ICU and NO-ICU admission groups.

Outcomes of Blunt Thoracic Aortic Injury in Adolescents

BACKGROUND Blunt traumatic aortic injury (BTAI) is of very rare occurrence in adolescents. The purpose of our study was to assess the clinical presentation and treatment outcomes of BTAI in this subset of patients. METHODS We reviewed prospective data of 18 patients who were 20 years or younger with BTAI among 28,000 trauma patients from January 1993 to December 2011. Outcomes of interest were the trends on the type of repair (nonoperative [NOP], open repair [OR], or endovascular treatment [ET]) and the impact of concomitant injuries using the Injury Severity Score (ISS) on early morbidity and mortality. RESULTS Thirteen (72%) patients with BTAI were male with a cohort median age of 16 ± 3 years. The mechanism of trauma was car accident in 12 patients, pedestrian struck by car in 5, and motorcycle crash in 1. The total ISS was 46.2 ± 15.3 being the highest score of the thoracic component (4.6 ± 0.6) followed by the head score (4 ± 1.2). Two (11%) patients were pronounced dead in the emergency department and other 2 succumbed within 24 hr from admission. Of those 14 (78%) patients who survived longer than 24 hr, the ISS was significantly lower compared with those pronounced dead earlier (37.8 ± 10.7 vs. 59.6 ± 11.6; P = 0.0009). Ten patients (71%) underwent OR, 3 (17%) ET, and other 2 (28%) patients were treated nonoperatively. The ISS was similar among all 3 treatment groups (OR: 33 ± 8 vs. ET: 53 ± 9 vs. NOP: 51 ± 6; P = nonsignificant). No paraplegia or renal failure was noted in either ET or OR group. In-hospital and overall mortality were 21% and 39%. Of those who survived hospitalization, 8 (73%) patients were discharged home and 3 (27%) to a rehabilitation center. CONCLUSIONS The incidence of BTAI is very low in adolescents. Mortality rate is considerable even in young patients and it is associated with high ISS and degree of aortic wall disruption. Young patients with BTAI who survive hospitalization have a lower ISS and are often discharged home rather than to a rehabilitation facility.

Trends in Clinical Presentation, Management, and Mortality of Blunt Aortic Traumatic Injury Over an 18-Year Period

Background: The purpose of our study was to assess whether the trends in management of blunt thoracic aortic injury (BTAI) have changed its outcomes over the years. Methods: We reviewed data of 88 (0.3%) adult patients with BTAI from January 1993 to December 2010. Primary end points were trends in presentation and time to repair and early morbidity and mortality. Results: Of all, 63 (72%) patients with BTAI were male (age, 38 ± 17). The yearly distribution of cases and severity of associated injuries remain stable. Of all, 16 (21%) patients had no intervention, 47 (63%) underwent open repair, and 12 (16%) underwent endovascular treatment. The postoperative mortality has decreased from 29% to 9% and the time from presentation to repair has increased from 6 to 14 hours during the study period. Conclusions: The incidence of BTAI remains stable with a reduction in postoperative mortality rate and an increasing number of delayed interventions over the past 18 years.