Jason B. Young

Saline versus Plasma-Lyte A in initial resuscitation of trauma patients: a randomized trial.

Objective:We sought to compare resuscitation with 0.9% NaCl versus Plasma-Lyte A, a calcium-free balanced crystalloid solution, hypothesizing that Plasma-Lyte A would better correct the base deficit 24 hours after injury. Background:Sodium chloride (0.9%) (0.9% NaCl), though often used for resuscitation of trauma patients, may exacerbate the metabolic acidosis that occurs with injury, and this acidosis may have detrimental clinical effects. Methods:We conducted a randomized, double-blind, parallel-group trial (NCT01270854) of adult trauma patients requiring blood transfusion, intubation, or operation within 60 minutes of arrival at the University of California Davis Medical Center. Based on a computer-generated, blocked sequence, subjects received either 0.9% NaCl or Plasma-Lyte A for resuscitation during the first 24 hours after injury. The primary outcome was mean change in base excess from 0 to 24 hours. Secondary outcomes included 24-hour arterial pH, serum electrolytes, fluid balance, resource utilization, and in-hospital mortality. Results:Of 46 evaluable subjects (among 65 randomized), 43% had penetrating injuries, injury severity score was 23 ± 16, 20% had admission systolic blood pressure less than 90 mm Hg, and 78% required an operation within 60 minutes of arrival. The baseline pH was 7.27 ± 0.11 and base excess −5.9 ± 5.0 mmol/L. The mean improvement in base excess from 0 to 24 hours was significantly greater with Plasma-Lyte A than with 0.9% NaCl {7.5 ± 4.7 vs 4.4 ± 3.9 mmol/L; difference: 3.1 [95% confidence interval (CI): 0.5–5.6]}. At 24 hours, arterial pH was greater [7.41 ± 0.06 vs 7.37 ± 0.07; difference: 0.05 (95% CI: 0.01–0.09)] and serum chloride was lower [104 ± 4 vs 111 ± 8 mEq/L; difference: −7 (95% CI: −10 to −3)] with Plasma-Lyte A than with 0.9% NaCl. Volumes of study fluid administered, 24-hour urine output, measures of resource utilization, and mortality did not significantly differ between the 2 arms. Conclusions:Compared with 0.9% NaCl, resuscitation of trauma patients with Plasma-Lyte A resulted in improved acid-base status and less hyperchloremia at 24 hours postinjury. Further studies are warranted to evaluate whether resuscitation with Plasma-Lyte A improves clinical outcomes. Randomized controlled trial, level I. (ClinicalTrials.gov Record UCDIRB-200917793.)

Use of ketorolac is associated with decreased pneumonia following rib fractures

BACKGROUND The effectiveness of the nonsteroidal anti-inflammatory drug ketorolac in reducing pulmonary morbidity after rib fractures remains largely unknown. METHODS A retrospective cohort study was conducted spanning January 2003 to June 2011 assessing pneumonia within 30 days and potential adverse effects of ketorolac among all patients with rib fractures who received ketorolac <4 days after injury compared with a random sample of those who did not. RESULTS Among 202 patients who received ketorolac and 417 who did not, ketorolac use was associated with decreased pneumonia (odds ratio, .14; 95% confidence interval, .04 to .46) and increased ventilator-free days (difference, 1.8 days; 95% confidence interval, 1.1 to 2.5) and intensive care unit-free days (difference, 2.1 days; 95% confidence interval, 1.3 to 3.0) within 30 days. The rates of acute kidney injury, gastrointestinal hemorrhage, and fracture nonunion were not different. CONCLUSIONS Early administration of ketorolac to patients with rib fractures is associated with a decreased likelihood of pneumonia, without apparent risks.

Does saline resuscitation affect mechanisms of coagulopathy in critically ill trauma patients? An exploratory analysis.

Metabolic acidosis has been implicated in the development of coagulopathy, although the specific mechanisms have not been well characterized. We sought to explore whether resuscitation of injured patients with a balanced crystalloid solution affects coagulation, as measured by endogenous thrombin potential (ETP) and thromboelastography (TEG). We performed an exploratory analysis of a subset of subjects enrolled in a randomized trial comparing the effect of resuscitation with isotonic saline versus Plasma-Lyte A (PLA) on acidosis and electrolyte abnormalities. We collected plasma at admission and 6 h later for subsequent ETP and TEG analysis and compared subjects receiving isotonic saline to those receiving PLA. Among 18 evaluated subjects, baseline characteristics, including ETP and TEG parameters, were similar between the two arms. At 6 h, subjects receiving isotonic saline were more acidemic. At 6 h, there were no differences in ETP parameters between groups; however, TEG results showed the time from initial clot formation to an amplitude of 20 mm (K) was shorter (3.8 ± 2.1 vs. 7.2 ± 2.8 s) and the rapidity of fibrin build-up and cross-linking (&agr; angle) was significantly greater (41 ± 8 vs. 24 ± 15 deg) for the PLA group than in the isotonic saline group. Relative to PLA, isotonic saline does not alter thrombin generation, but isotonic saline and PLA may differentially impact clotting factor availability. The shorter time to reach prespecified clot amplitude and the increased rate of fibrin generation imply faster amplification of clotting factors with PLA without effect on latency time or clot strength.

Physician roles in tactical emergency medical support: the first 20 years.

BACKGROUND The benefits of Tactical Emergency Medical Support (TEMS) elements are providing injury prevention, immediate care of injuries, and medical augmentation of the success of dangerous law enforcement operations. TEMS is recognized by civilian Special Weapons and Tactics (SWAT) and various other law enforcement agencies around the country as a vital addition to such SWAT teams. The integration of specially trained TEMS personnel has become a key component of law enforcement special operations. OBJECTIVE Our aim was to review the published literature to identify if there is a role for physicians within TEMS elements with regard to its establishment and progression, and to characterize the level of physician-specific support provided in the tactical environment for civilian tactical law enforcement teams. DISCUSSION Physician presence as part of TEMS elements is increasing in number and popularity as the realization of the benefits provided by such physicians has become more apparent. The inclusion of physicians as active and participating members of TEMS elements is a critical measure to be taken for tactical law enforcement units. Physicians provide an added level of medical expertise to TEMS elements in rural and urban settings compared with law enforcement personnel with medic training. CONCLUSIONS Physician involvement is an essential element of a successful TEMS program. There is a need for more physicians to become involved as TEMS personnel for specialized tactical teams to spread the time commitment and increase their availability to tactical units on a daily basis.

The effect on problematic drinking behavior of a brief motivational interview shortly after a first arrest for driving under the influence of alcohol: A randomized trial

BACKGROUND In medical settings, motivational interviewing-based “brief intervention” (BI) counseling reduces alcohol-related risk-taking behavior and harm in high-risk populations. Individuals arrested for driving under the influence of alcohol (DUI) are another at-risk population. We sought to determine whether a BI administered shortly after a first DUI arrest might decrease problematic drinking behavior. METHODS We conducted a single-center, parallel-group, double-blinded superiority randomized trial (NCT01270217), enrolling first-time DUI arrestees at a county jail from December 2010 through April 2011. Before their release, we randomized participants by computer-generated sequence to either a single BI or no discussion. We assessed 90-day change in Alcohol Use Disorders Identification Test (AUDIT) scores (range 0–40, higher values indicating more problematic drinking) as the primary outcome. RESULTS We enrolled 200 subjects (100 to each arm), and 181 (90.5%, 86 control and 95 BI) completed the 90-day follow-up. Mean (SD) age was 30 (10) years, and 50% were men. Mean (SD) blood alcohol concentration upon arrest was 0.14% (0.04%). Mean (SD) baseline AUDIT scores were 8.8 (5.8) among control subjects and 7.7 (6.3) among BI subjects. At 90 days, AUDIT scores decreased by a mean (SD) 4.7 (5.1) units among control subjects and 3.4 (5.0) among BI subjects (difference, −1.3; 95% confidence interval [CI], −2.8 to +0.1). The likelihood of subsequent binge drinking [relative risk (RR) 1.6; 95% CI, 0.8–3.0; BI vs. control], abstinence (RR, 0.9; 95% CI, 0.4–2.1), alcohol-related injury to self or others (RR, 0.4; 95% CI, 0.1–2.4), and seeking treatment (RR, 1.2; 95% CI, 0.8–1.7) did not differ. CONCLUSION A single BI counseling session shortly after first-time DUI arrest does not reduce 90-day self-reported drinking behavior or increase seeking treatment for drinking beyond that which occurs without such a discussion. LEVEL OF EVIDENCE Therapeutic study, level III.

Multiple Complex Penetrating Cardiac Injuries: Role of Civilian Trauma in the Education of the Combat General Surgeon

OBJECTIVES To use a case report of a complex cardiac injury case to illustrate how civilian trauma can be used to train combat general surgeons. CASE REPORT We report the case of a 23-year-old man who suffered three penetrating injuries to the left ventricle (LV) after multiple stab wounds to left chest. On hospital arrival he was conversant, hemodynamically stable, oxygenating well, and without signs of cardiac tamponade. He deteriorated and required an urgent exploratory thoracotomy. Intraoperatively, 2-, 3.5-, and 5-cm stellate lacerations were discovered in the LV near the aortic root, of which, two were full thickness. A simple pledgeted horizontal mattress suture was not sufficient to repair the injuries. The repair ultimately required a running polypropylene suture to control the hemorrhage. The patient was awake on postoperative day 0 and discharged on postoperative day 12 without significant complication. CONCLUSIONS This case illustrates several points for the combat surgeon. First, young men are able to tolerate catastrophic injuries, presenting with normal hemodynamics. Second, there are a variety of techniques to use when treating uncommon injuries. Finally, the surgeon needs the ability to improvise quickly and to apply surgical techniques to treat complex traumatic injuries successfully.