Jonathan Marinaro

Family presence during brain death evaluation: a randomized controlled trial

Objective:To evaluate if a family presence educational intervention during brain death evaluation improves understanding of brain death without affecting psychological distress. Design:Randomized controlled trial. Setting:Four ICUs at an academic tertiary care center. Subjects:Immediate family members of patients suspected to have suffered brain death. Interventions:Subjects were group randomized to presence or absence at bedside throughout the brain death evaluation with a trained chaperone. All randomized subjects were administered a validated “understanding brain death” survey before and after the intervention. Subjects were assessed for psychological well-being between 30 and 90 days after the intervention. Measurements and Main Results:Follow-up assessment of psychological well-being was performed using the Impact of Event Scale and General Health Questionnaire. Brain death understanding, Impact of Event Scale, and General Health Questionnaire scores were analyzed using Wilcoxon nonparametric tests. Analyses were adjusted for within family correlation. Fifty-eight family members of 17 patients undergoing brain death evaluation were enrolled: 38 family members were present for 11 brain death evaluations and 20 family members were absent for six brain death evaluations. Baseline understanding scores were similar between groups (median 3.0 [presence group] vs 2.5 [control], p = 0.482). Scores increased by a median of 2 (interquartile range, 1–2) if present versus 0 (interquartile range, 0–0) if absent (p < 0.001). Sixty-six percent of those in the intervention group achieved perfect postintervention “understanding” scores, compared with 20% of subjects who were not present (p = 0.02). Median Impact of Event Scale and General Health Questionnaire scores were similar between groups at follow-up (Impact of Event Scale: present = 20.5, absent = 23.5, p = 0.211; General Health Questionnaire: present = 13.5, absent = 13.0, p = 0.250). Conclusions:Family presence during brain death evaluation improves understanding of brain death with no apparent adverse impact on psychological well-being. Family presence during brain death evaluation is feasible and safe.

HBOC-201 use in traumatic brain injury: case report and review of literature

BACKGROUND: The first use of HBOC‐201 in severe traumatic brain injury (TBI) is presented. The use of noninvasive cerebral oximetric devices to follow clinical progress in a patient infused with HBOC‐201 is reported and the literature of hemoglobin‐based oxygen carriers (HBOCs) in brain injury is reported.

Impact of positive pressure ventilation on thoracostomy tube removal.

BACKGROUND Little data exist examining the impact of positive pressure ventilation on safe thoracostomy tube removal. We sought to evaluate the impact of positive-pressure ventilation (PPV) on recurrent pneumothoraces (PTX) after removal of thoracostomy tubes (TT). METHODS A retrospective cohort analysis was performed evaluating all trauma patients requiring TT drainage of PTX or hemothoraces during a 3-year period. All chest radiographs before and after TT removal were reviewed to identify PTX recurrence. The principle outcome was recurrent PTX after TT removal. The 95% confidence intervals were calculated to assess for significance. RESULTS We studied 234 TT removals in 190 patients. One hundred thirty-six (58%) TTs were removed under PPV. PTX recurred in 15 (11%) and 6 (4%) required reinsertion. In 10 patients (7.4%), there was a radiographically stable small PTX before and after removal not requiring TT reinsertion. In comparison, 98 (42%) TTs were removed under spontaneous ventilation. PTX recurred in 16 (16%) and 3 (3%) required reinsertion. There were 25 (25.5%) stable small PTXs before and after removal. The overall recurrence rate difference was -5.3% (confidence interval: -14.8 to 3.5) and reinsertion rate difference was 1.35% (confidence interval: -4.7 to 6.6). CONCLUSIONS The rate of recurrent PTX or TT replacement after removal is not associated with PPV status. The slightly lower recurrence rate on PPV combined with the smaller proportion of patients with stable small PTX before removal may reflect more careful clinician selection of ideal patients or technique of TT removal among patients on PPV. Prospective data are needed to clarify these associations.

Ultrasonographic Determination of Pubic Symphyseal Widening in Trauma: The FAST-PS Study

BACKGROUND The focused abdominal sonography in trauma (FAST) examination is a routine component of the initial work-up of trauma patients. However, it does not identify patients with retroperitoneal hemorrhage associated with significant pelvic trauma. A wide pubic symphysis (PS) is indicative of an open book pelvic fracture and a high risk of retroperitoneal bleeding. STUDY OBJECTIVES We hypothesized that an ultrasound image of the PS as part of the FAST examination (FAST-PS) would be an accurate method to determine if pubic symphysis diastasis was present. METHODS This is a comparative study of a diagnostic test on a convenience sample of 23 trauma patients at a Level 1 Trauma Center. The PS was measured sonographically in the Emergency Department (ED) and post-mortem (PM) at the State Medical Examiner. The ultrasound (US) measurements were then compared with PS width on anterior-posterior pelvis radiograph. RESULTS Twenty-three trauma patients were evaluated with both plain radiographs and US (11 PM, 12 ED). Four patients had radiographic PS widening (3 PM, 1 ED) and 19 patients had radiographically normal PS width; all were correctly identified with US. US measurements were compared with plain X-ray study by Bland-Altman plot. With one exception, US measurements were within 2 standard deviations of the radiographic measurements and, therefore, have excellent agreement. The only exception was a patient with pubic symphysis wider than the US probe. CONCLUSION Bedside ultrasound examination may be able to identify pubic symphysis widening in trauma patients. This potentially could lead to faster application of a pelvic binder and tamponade of bleeding.

Oral albuterol to treat symptomatic bradycardia in acute spinal cord injury

Cardiovascular disturbances remain a leading cause of morbidity and mortality in patients with acute spinal cord injury (ASCI) [1]. This is particularly true for those with cervical and high thoracic spinal cord injuries. One series of 28,239 ASCI patients finds cardiac dysfunction responsible for 23 % of deaths within the first year of injury [2]. For patients with severe cervical spinal cord injury, persistent bradycardia is nearly universal and cardiac arrest is not uncommon [3]. The most common dysrhythmia, and the most worrisome, is symptomatic bradycardia because this rhythm disturbance often precedes cardiac arrest [1, 4]. Bradycardia affects as many as 35–71 % of patients with incomplete motor spinal cord injury [1]. These cardiovascular disturbances usually develop within 3–5 days following injury, and typically resolve in 6–8 weeks [5–7]. Although bradycardia associated with ASCI may resolve within 6–8 weeks after injury, medical management is important to prevent further symptomatic bradycardic episodes or cardiac arrest. The medical management options in this patient population are limited. Current medical management includes the use of methylxanthines (aminophylline and theophylline), dopamine infusions, or propantheline to avoid or to provide a safe bridge to pacemaker placement [6]. Atropine remains the drug of choice to treat an acute episode of bradycardia or cardiac arrest secondary to marked bradycardia [7]. Other medications that may be used to treat bradycardic episodes include epinephrine, pseudoephedrine and isoproterenol. Placement of a pacemaker is traditionally reserved for patients who are refractory to pharmacologic management, but Moerman et al. advocate for early pacemaker placement given the frequency of bradycardia and arrest in this patient population [8]. However, the natural history of ASCI-associated bradycardia is usually self-limited, and it may be possible to avoid pacemaker placement altogether if these individuals can be managed with medical treatment (Table 1). At our institution, a common practice has been to use oral albuterol elixir to treat patients with acute spinal cord injury and symptomatic bradycardia. When a patient is bradycardic during the initial resuscitation phase, it is our practice to use vasopressors or inotropic continuous infusions. Once a patient is considered to be resuscitated, if they remain bradycardic or develop symptomatic bradycardia that is believed to be secondary to their acute spinal cord injury, oral albuterol is started. The initial dose is usually 4 mg every 6 h. If this is found to be insufficient & Amber Rollstin arollstin@salud.unm.edu

Eye and Head Injuries

Ocular injuries caused by CEWs are rare occurrences. Some 30 years after its introduction, two case reports have documented the sight threatening potential of these weapons [1,2]. In discussing the impact of ocular injuries by CEWs, understanding pertinent ocular and adnexal anatomy as well as the terminology of ocular injuries is useful in effectively managing individuals requiring extrication of an embedded probe. In addition to ocular injuries, there have been two case reports of penetrating skull trauma. The case reports, evaluation, and management patients with intracranial penetration are presented in the final portion of this chapter.