Keith F. O'Malley

Prospective Study of Blunt Aortic Injury: Multicenter Trial of the American Association for the Surgery of Trauma

BACKGROUND Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years. METHODS This study was a prospectively conducted multi-center trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma. RESULTS There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of > or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia. CONCLUSIONS Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.

Multicenter, randomized, prospective trial of early tracheostomy

OBJECTIVES Determine the effect of early (days 3-5) or late (days 10-14) tracheostomy on intensive care unit length of stay (ICU LOS), frequency of pneumonia, and mortality, and evidence of short-term or long-term pharyngeal, laryngeal, or tracheal injury in head trauma, non-head trauma, and critically ill nontrauma patients. STUDY DESIGN Randomized, prospective. SETTING Five Level I trauma centers. METHODS Data were obtained prospectively and included Acute Physiology and Chronic Health Evaluation III score (AIII), Glasgow Coma Scale score, Emergency Room Trauma Score, Injury Severity Score, Acute Injury Score, type of endotracheal tube or tracheostomy, level of positive end-expiratory pressure, and peak inspiratory pressure. Patients were to undergo laryngoscopy for detection of injury according to the Lindholm criteria at the time of endotracheal tube or tracheostomy removal and be reevaluated at 3 to 5 months after discharge. RESULTS One hundred fifty-seven patients were entered, 127 to early randomization (3-5 days) and 28 to late randomization (10-14 days); however, only 112 patients with early and 14 with late randomization had completed data forms for the primary study goals. An additional 22 patients from the early entry groups were rerandomized late. Early randomization data: the AIII score was higher (p < 0.05) in the head trauma tracheostomy (65 +/- 4) than in the nontracheostomy group (51 +/- 4) and in the nontrauma tracheostomy (92 +/- 6) than in the nontracheostomy group (68 +/- 7), but was equivalent in the non-head trauma group. Glasgow Coma Scale score, Emergency Room Trauma Score, Injury Severity Score, Acute Injury Score, positive end-expiratory pressure, and peak inspiratory pressure were not significantly different in any of the groups. There were no significant differences in ICU LOS, frequency of pneumonia, or death in any of the groups after either early or late tracheostomy compared with continued endotracheal intubation. Only 83 patients underwent postextubation laryngoscopy. There were no significant differences between the groups; however, there were trends to more vocal cord ulceration and subglottic inflammation in the continued intubation group. No patient was seen in this study with late vocal cord or laryngeal stenosis; there were no tracheal-innominate artery fistulae. Seven of the patients with abnormal findings at extubation had normal 3- to 5-month postextubation laryngoscopy. CONCLUSION Physician bias limited patient entry into the study. Although there were higher AIII scores in the head trauma early tracheostomy patients, there were no differences in the primary end points of ICU LOS, pneumonia, or death in any of the groups studied. Long-term endoscopic follow-up was poor, but no known late tracheal stenosis was seen.

Conservative management of duodenal trauma: a multicenter perspective.

The experience of eight trauma centers with duodenal injuries was analyzed to identify trends in operative management, sources of duodenal-related morbidity, and causes of mortality. During the 5-year period ending December 1988, 164 duodenal injuries were identified. Patient ages ranged from 5 to 78 years. There were 38 Class I, 70 Class II, 48 Class III, four Class IV, and four Class V injuries. Injury mechanism was penetrating in 102 (62%) patients and blunt in 62. Primary repair of the duodenal injury was performed in 117 (71%) patients, including 27 patients also managed with pyloric exclusion and 12 with tube duodenostomy. Duodenal resection with primary anastomosis was used in six (4%) patients and pancreatoduodenectomy was necessary in five (3%). There were 30 (18%) deaths. The cause of death was uncontrolled hemorrhage from severe hepatic or vascular injuries in 22 (73%) patients. In only two (1%) patients could death be attributed to the duodenal injury; each as the result of duodenal repair dehiscence and subsequent sepsis. Duodenal-related morbidity was documented in 29 (18%) patients, including 22 patients with intra-abdominal abscess, six with duodenal fistula, and five with frank duodenal dehiscence. In summary, this analysis demonstrated: 1) the great majority of duodenal injuries can be managed by simple repair; 2) tube duodenostomy is not a mandatory component of operative treatment; 3) pyloric exclusion is a useful adjunct for more complex injuries; 4) pancreatoduodenectomy is rarely necessary for civilian duodenal trauma; 5) morbidity following duodenal trauma is more dependent on associated intra-abdominal injuries than the extent of duodenal trauma; and 6) mortality following duodenal injuries is primarily related to associated vascular and hepatic trauma.

Efficacy of the Motor Component of the Glasgow Coma Scale in Trauma Triage

BACKGROUND National guidelines recommend that patients with Glasgow Coma Scale (GCS) scores of less than 14 be triaged to trauma centers. We hypothesized that the motor component of the GCS (GCSM) would be equally sensitive as the total GCS in head injury triage. METHODS A 2-year retrospective review of 3,235 injured adults transported directly to a Level I trauma center. RESULTS One thousand four hundred ten patients (44%) had prehospital GCS scores recorded. GCSM was found to have a sensitivity of 0.90 for Abbreviated Injury Scale (AIS) score = 5 head injury and 0.61 for AIS score > 3 injury, whereas the GCS had sensitivities of 0.92 and 0.62, respectively (p = not significant). Specificities were equal at 0.85 for AIS score = 5 and 0.89 for AIS score > 3. CONCLUSION GCSM is equivalent to GCS for prehospital triage, and in view of its simplicity it should replace the GCS in triage schemes.

Is routine computed tomography scanning too expensive for mild head injury

OBJECTIVE To compare relative costs of treating mildly head-injured patients by routine admission or by using skull radiographs or cranial computed tomography (CT) scanning to screen patients for admission. DESIGN Retrospective record review, hypothetical costs based on actual patient course and requirements. SETTING Southern New Jersey Regional Trauma Center at Cooper Hospital/University Medical Center. PARTICIPANTS 658 consecutive mildly head-injured patients admitted from 1986 to 1988. All were given cranial CT scans. MEASUREMENTS Records were reviewed retrospectively and hypothetical costs were calculated based on actual length of hospitalization, surgical intervention, etc. These costs were compared for different treatment protocols. MAIN RESULTS The average cost if every patient had been admitted for observation given skull radiographs, with CT scans done on those exhibiting skull fracture or later deterioration, was

DRG reimbursement for trauma: the demise of the trauma center (the use of ISS grouping as an early predictor of total hospital cost).

1,207. If the CT scan had been used to identify patients with intracranial lesions and the others had been discharged, costs would have been almost 10% less. Had skull radiography been used to screen admissions, costs would have been 22% below those of routine CT scanning. However, these small savings are likely to be reduced by additional expenses related to missed intracranial lesions. CONCLUSIONS Every patient with loss of consciousness or post-traumatic amnesia should have routine CT scanning. If the scan is normal and there are no other reasons for admission, the patients can be discharged safely from the emergency department. This represents optimal care from a medical standpoint and is justified from a cost-effectiveness point of view.

Clinical predictors of unstable cervical spinal injury in multiply injured patients

All institutional reimbursement for inpatient care in the State of New Jersey is administered by the DRG methodology (Prospective Payment System). This system is essentially identical to federal Medicare. In 1983 our hospital was designated the Level I trauma center for southern New Jersey (population, 2.6 million). Prehospital triage guidelines based on anatomic injury were implemented, and, as a result, an annual 30% increase in severe trauma cases (ISS greater than 16) was realized. In late 1984 serious financial shortfalls were noticed, especially in the higher ISS cases. A 1-year study (1985) of all patients admitted through the Trauma Center to an intensive care unit was completed (523 patients; mean ISS, 15.16; ISS greater than 16, 37.8%). All patients were stratified to one of five ISS groups (A: ISS 1-8; B: ISS 9-15; C: ISS 16-24; D: ISS 25-40; E: ISS greater than 40). Average cost, reimbursement, ISS, LOS, and mortality were reviewed for the entire aggregate and each severity group. The system of ISS grouping was an accurate method of cost analysis, and prospectively, ISS grouping allowed prediction of length of stay and total hospital cost. In addition, these data allowed early fiscal management decisions and resource allocation. As a reimbursement system, DRG falls short of the cost of care for all ISS levels and groups. As severity of injury rose, costs increased in a linear manner, but reimbursement did not, resulting in a substantial financial loss. The net loss to the hospital in 1 year was

Continuous pulse oximetry and the diagnosis of pulmonary embolism in critically ill trauma patients

1.86 million.(ABSTRACT TRUNCATED AT 250 WORDS)

ABBREVIATED INJURY SCALING OF HEAD INJURY AS A PROGNOSTIC TOOL FOR FUNCTIONAL OUTCOME

All victims of major blunt trauma have been said to be at risk of cervical spinal injury. In a prospective study of 410 such patients at our institution, we identified 13 patients (6.12 per cent) with unstable cervical spines. Loss or defect of consciousness following injury (regardless of duration), neurological deficit consistent with cervical cord or nerve root injury and neck tenderness were significantly predictive of an unstable cervical spine. Immediate radiographic investigation of the cervical spine is mandatory in such patients, but may not be required in patients without these signs.

Peritoneal cavity lavage reduces the presence of mitochondrial damage associated molecular patterns in open abdomen patients

The diagnosis of pulmonary embolism (PE) may be difficult to establish in trauma patients, particularly those who are unresponsive or mechanically ventilated. Based on a prior retrospective study, we hypothesized that patients monitored by continuous pulse oximetry who experienced a 10% or greater sudden sustained drop in arterial oxygen saturation (SaO2) without a change in static lung compliance (Cst) were most likely to have had a PE. We followed SaO2 in 972 patients admitted to our trauma ICU during the 18-month period ending in December 1990. Forty-eight patients (5%) with SaO2 changes, but no Cst changes, were evaluated for suspected PE using pulmonary arteriography (PA). Of these, 21 (44%) had a positive PA study. All patients with a positive PA had either clear chest roentgenograms or no change in underlying pulmonary pathologic processes. Of the remainder, 26 had evidence of a new pathologic entity on chest roentgenograms and only one patient had a SaO2 decrease, no change in Cst, and a negative PA. All mechanically ventilated trauma patients should have SaO2 monitored continuously. Patients with a > 10% drop in Sao2 with no change in Cst and no new roentgenographic chest findings should undergo PA. Based on our experience, this approach would yield a sensitivity, specificity, and predictive value of 100%, 99.9%, and 95%, respectively, for the diagnosis of clinically significant PE.