Jeanne Lee

A 21-Year History of All-Terrain Vehicle Injuries: Has Anything Changed?

BACKGROUND All-terrain vehicle (ATV)-related injuries have increased. The purpose of this study was to determine if the increase in injuries correlates with the expiration of government mandates. METHODS ATV-injured patients admitted to a level I trauma center were reviewed over the years 1985-1999 and 2000-2005. Several demographic variables and injuries sustained were analyzed. RESULTS There were a total of 433 injuries, which increased from 164 between 1985 and 1999, to 269 between 2000 and 2005. By comparing the time periods we observed a decrease in closed-head injury (53.6% vs 27.5%; P < .001), spinal cord injury (11.6% vs 5.2%; P < .05), and soft-tissue injury (62.8% vs 45.3%; P < .01), but an increase in long-bone fractures (18.9% vs 33.0%; P < .05). No differences were observed in other injuries. CONCLUSIONS The number of patients sustaining ATV-related injuries has increased and correlates with the expiration of government mandates. Even though ATVs remain dangerous, injury prevention strategies such as helmet laws may be having a positive impact.

A New Clopidogrel (Plavix) Point-of-Care Assay: Rapid Determination of Antiplatelet Activity in Trauma Patients

INTRODUCTION An increasing proportion of trauma patients are on anticoagulation or antiplatelet therapy. Unlike warfarin, where measuring international normalized ratio can help direct management, measuring platelet inhibition from clopidogrel (Plavix) is not standardized. We report the use of a new P2Y12 point-of-care assay (VerifyNow; Accumetrics, San Diego, CA) to determine the magnitude of platelet inhibition in trauma patients using clopidogrel. METHODS Trauma patients in 2009 were queried for clopidogrel use by prehospital personnel and the trauma team. Blood was obtained on admission for patients reportedly taking clopidogrel and was assayed for platelet inhibition using the VerfiyNow-P2Y12 device that measures P2Y12 reaction units and photometrically determines platelet inhibition percentage within 30 minutes. Patient demographics including age, Injury Severity Score, mechanism of injury, and complications from hemorrhage were also analyzed. RESULTS In the time studied, 46 patients taking clopidogrel were assayed for platelet inhibition. The mean age was 75.9 years±11.8 years, and the most common mechanism of injury was fall (86.9%). Platelet inhibition ranged from 0% to 89%. There were no deaths, and only two patients, from the 0% and>30% inhibition group, had hemorrhagic complications (increased intracranial hemorrhage). CONCLUSIONS The P2Y12 point-of-care assay determined that a large percentage of patients had undetectable or low platelet inhibition despite reportedly being on clopidogrel therapy. These patients may be clopidogrel nonresponders or noncompliant. It is unlikely that clopidogrel reversal therapies, such as platelet transfusions or Desmopressin, would be beneficial in this group. Further studies stratifying the percent platelet inhibition needed to increase bleeding complications is warranted to optimize management strategies.

Is bigger better? The effect of obesity on pelvic fractures after side impact motor vehicle crashes

BACKGROUND Previous research has identified nearside impacts, intrusion, gender, age, and body mass index (BMI) as associated with pelvic fractures in motor vehicle crashes. This study assesses the role of BMI in predicting pelvic fracture and whether BMI modifies the effect of other potential risk factors. METHODS The Crash Injury Research and Engineering Network data were queried to study occupant, vehicle, and crash factors predicting pelvic injury in occupants of nearside crashes. Occupants in different BMI categories were compared with assess odds of pelvic fracture during nearside impacts. Logistic regression was used to identify predictive variables for pelvic fracture controlling for age, gender, delta V, intrusion, side airbag deployment, seat position, vehicle curb weight, and safety belt use. RESULTS Two hundred forty-four (57.5%) occupants in nearside impacts sustained pelvic fractures. Occupants with a normal BMI were more likely (unadjusted odds ratio = 1.80, adjusted odds ratio = 1.98) to have a pelvis fracture compared with overweight and obese occupants. Door panel intrusion >15 cm, female gender, and delta V were associated with pelvic fracture in univariate analyses. BMI was a predictor of pelvic fracture when controlling for potential confounding factors. CONCLUSIONS BMI status influences other variables associated with pelvic fracture. Redesign of interior door panels, hardware, armrests, and the center console may be appropriate for motor vehicle manufacturers to consider in prevention of pelvic fracture during nearside impacts.

Current diagnosis and management of blunt traumatic rupture of the thoracic aorta

O diagnostico e tratamento das lesoes traumaticas da aorta toracica vem gradualmente melhorando. Historicamente, as lesoes traumaticas da aorta toracica eram causa frequente de exanguinacao, apresentando altas taxas de mortalidade. Por outro lado, apos o desenvolvimento de sistemas modernos de atendimento as vitimas de traumatismos, com protocolos avancados de reanimacao volemica e rapida avaliacao radiologica, o diagnostico de lesoes da aorta toracica tem melhorado significativamente. A enfase atual esta centrada na prevencao da progressao das lesoes intimais menores e pseudo-aneurismas ate a disseccao franca ou ruptura aortica. As modalidades diagnosticas sofreram alteracoes, bem como o paradigma de intervencao cirurgica imediata. A evolucao de proteses endovasculares podera desempenhar um importante papel no tratamento definitivo.

Computerized insulin infusion programs are safe and effective in the burn intensive care unit.

Glucose control has repeatedly been shown to influence favorable outcomes in the surgical intensive care unit (ICU). Intensive insulin therapy has recently been associated with reduced infections complications in burn patients. However, traditional protocols are associated with rates of severe hypoglycemia as high as 19%. Two commercial computer glucose control programs have reported rates of severe hypoglycemia (glucose <50 mg/dl) of 0.6 and 0.4%. Recently, the authors’ burn ICU adopted an intensive insulin computer-based protocol created at their institution and already successfully in use in their surgical ICU. The authors hypothesized that their protocol can be used effectively in the burn patient population without an increase risk of severe hypoglycemia. All patients admitted to the burn ICU have blood glucose (BG) values checked routinely. With two consecutive hyperglycemic values >200 mg/dl, patients are placed on a computer-based protocol intravenous insulin drip. Once initiated, BGs are tested hourly with adjustments made according to the computer protocol. Values recorded from January to December 2008 were abstracted from the database and analyzed. Thirty-one patients were treated using the computer glucose control protocol and 12,699 measurements were performed. There were eight measurements <50 mg/dl (0.07%). Seventy-six percent of values were within the target range of 90 to 150 mg/dl. Few patients had severe hyperglycemia with BG >300 mg/dl (0.2%). There were no adverse events associated with the hypoglycemic episode. The computer-based protocol is more effective than those previously used at the institution and provides safe, reliable results in the burn patients.

Gastric Trichobezoar Causing Intermittent Small Bowel Obstruction: Report of a Case and Review of the Literature

We report the unusual case of a 45-year-old woman who presented with multiple episodes of small bowel obstruction. Initial exploratory lap-roscopy did not reveal an etiology of the obstruction. Subsequent upper endoscopy identified a non-obstructing gastric trichobezoar which could not be removed endoscopically but was not thought to be responsible for the small bowel obstruction given its location. One week postoperatively, the patient experienced recurrence of small bowel obstruction. Repeat endoscopy disclosed that the trichobezoar was no longer located in the stomach and upon repeat laparotomy was extracted from the mid-jejunum. In the following 8 months, the patient had no further episodes of small bowel obstruction. Consequently, gastric bezoars should be included in the differential diagnosis of recurrent small bowel obstruction.

The unrecognized danger of a new transportation mechanism of injury - Pedicabs

OBJECTIVE Pedicabs are a new and controversial transportation innovation for tourists in congested areas in several U.S. cities. Scant literature on this trauma mechanism exists. The purpose of this study is to identify the incidence, demographics, morbidity, mortality, and potential for injury prevention of pedicab incidents amongst major trauma admissions at an urban, academic Level I Trauma Center. PATIENTS & METHODS Researchers conducted a retrospective review of the Trauma Registry from 2000 to 2009. All patients identified as being injured in a pedicab incident were reviewed. Demographics, diagnoses, toxicology, treatments, and injury severity scale (ISS) were collected. Outcomes included mortality, ICU, and hospital length of stay (LOS), discharge disposition, and hospital charges. A photographic survey of 50 local pedicabs was examined for the presence and use of safety equipment. RESULTS During the period of January 2000 to July 2009 there were 15 major trauma victims from identified pedicab incidents. Falling from the pedicab was the mechanism of injury in 14 of 15 cases. There were two fatalities in victims following severe traumatic brain injury. Traumatic brain injury, skull fracture, or loss of consciousness was seen in 11/15 victims. Ethanol ingestion was detected in blood tests of 10 of the 14 adult victims. Median charges of hospitalization due to a pedicab related injury was US

Survey of surgical infections currently known (SOSICK): A multicenter examination of antimicrobial use from the Surgical Infection Society Scientific Studies Committee

29,956 ± 77,482. A photographic survey of 50 local pedicabs reveals very limited use of safety belts by passengers despite existing city ordinances. CONCLUSIONS Major trauma victims of pedicab incidents in the United States suffer significant injuries and death. Most cases occurred in passengers falling from the pedicab at night after alcohol ingestion. There is an opportunity for implementation of strategies toward improved injury prevention with this new form of transport.

A Novel Solution to Securing Nasogastric Feeding Tubes in Pediatric Burn Patients

PURPOSE The Scientific Studies Committee of the Surgical Infection Society undertook the present study to examine the prevalence of and indications for antimicrobial use in intensive care units where members of the Society practice. METHODS Information and data collection sheets were posted on the Internet for download by members interested in participating. All centers were required to obtain approval from their local human subjects research office or equivalent. A one-week time was set during which the center could collect information on any one day, at the centers convenience. Data collection sheets were then sent to the lead author for analysis. Seventeen centers reported data for 371 patients in 22 intensive care units. RESULTS Trauma and general surgical patients comprised 224 of the patients (60%). The indications for anti-infective agents were prophylactic (22%), empiric (27%), therapeutic with known pathogen (41%), therapeutic without known pathogen (e.g., cellulitis) (4%), insistence of influential practitioner (4%), or non-anti-infective purposes (e.g., erythromycin for gastric motility) (2%). Only 44%, 29%, and 54% of the orders for prophylactic, empiric, and therapeutic antibiotics, respectively, had date-certain stop dates. The antimicrobial drugs most commonly used were vancomycin, piperacillin-tazobactam, and fluconazole. CONCLUSION Most patients were receiving antimicrobial agents. Polypharmacy was common. Most patients did not have a date-certain stop date. This study sets the benchmark for future study regarding antibiotic prescribing behavior in surgical intensive care units.

Redefining Renal Dysfunction in Trauma: Implementation of the Acute Kidney Injury Network Staging System

Aims: To present a novel method of securing nasogastric (NGT) feeding tubes in pediatric burn patients. Presentation of Case: We have developed an arrangement of tube, twill tie and suture, to secure a feeding tube in position, in which a twill tie is secured around the patient’s head and interwoven into the burn dressing. The NGT is secured to the twill tie via a locking suture. Discussion: Nasogastric feeding tubes are important in pediatric burn patients to facilitate the healing process by meeting their increased metabolic demand for protein and calories. These tubes are typically secured via tape to the face, but in patients with facial burns tape may not adequately anchor the feeding tube, allowing for unintended dislodgement of the NGT. Inadvertent removal of nasogastric tubes places patients at risk for complications including prolonged healing time and aspiration, as well as the need for replacement of the NGT.