Matthew D. Tadlock

Re-evaluating the need for hospital admission and observation of pediatric traumatic brain injury after a normal head CT

There is no consensus on the optimal management of pediatric patients with suspected trauma brain injury and a normal head CT. This study characterizes the clinical outcomes of patients with a normal initial CT scan of the head. A retrospective chart review of pediatric blunt trauma patients who underwent head CT for closed head injury at two trauma centers was performed. Charts were reviewed for demographics, neurologic function, CT findings, and complications. 631 blunt pediatric trauma patients underwent a head CT. 63% had a negative CT, 7% had a non-displaced skull fracture, and 31% had an intracranial hemorrhage and/or displaced skull fracture. For patients without intracranial injury, the mean age was 8 years, mean ISS was 5, and 92% had a GCS of 13-15 on arrival. All patients with an initial GCS of 13-15 and no intracranial injury were eventually discharged to home with a normal neurologic exam and no patient required craniotomy. Not admitting those children with an initial GCS of 13-15, normal CT scan, and no other injuries would have saved 1.8 ± 1.5 hospital days per patient. Pediatric patients who have sustained head trauma, have a negative CT scan, and present with a GCS 13-15 can safely be discharged home without admission.

The origin of fatal pulmonary emboli: a postmortem analysis of 500 deaths from pulmonary embolism in trauma, surgical, and medical patients

BACKGROUND The traditional theory that pulmonary emboli (PE) originate from the lower extremity has been challenged. METHODS All autopsies performed in Los Angeles County between 2002 and 2010 where PE was the cause of death were reviewed. RESULTS Of the 491 PE deaths identified, 36% were surgical and 64% medical. Venous dissection for clots was performed in 380 patients; the PE source was the lower extremity (70.8%), pelvic veins (4.2 %), and upper extremity (1.1%). No source was identified in 22.6% of patients. Body mass index (adjusted odds ratio [AOR] 1.044, 95% confidence interval [CI] 1.011 to 1.078, P = .009) and age (AOR 1.018, 95% CI 1.001 to 1.036, P = .042) were independent predictors for identifying a PE source. Chronic obstructive pulmonary disease (AOR .173, 95% CI .046 to .646, P = .009) was predictive of not identifying a PE source. CONCLUSIONS Most medical and surgical patients with fatal PE had a lower extremity source found, but a significant number had no source identified. Age and body mass index were positively associated with PE source identification. However, a diagnosis of chronic obstructive pulmonary disease was associated with no PE source identification.

Credentialing and Privileging of Acute Care Nurse Practitioners to Do Invasive Procedures: A Statewide Survey

BACKGROUND Acute care nurse practitioners have been successfully integrated into inpatient settings. They perform invasive procedures in the intensive care unit and other acute care settings. Although their general scope of practice is regulated at the state level, local and regional scope of practice is governed by hospitals. OBJECTIVE To determine if credentialing and privileging of these nurses for invasive procedures varies depending on the institution. METHODS Personnel in medical staff offices of 329 hospitals were surveyed by telephone with 6 questions. Data collected included acute care nurse practitioner and hospital demographics, frequency and type of procedures performed, proctoring and credentialing process, and the presence of residents and fellows at the institution. RESULTS The response rate was 74.8% (246 hospitals). Among these, 48% (118) employed acute care nurse practitioners, of which 43.2% performed invasive procedures. Three hospitals were excluded from the final analysis. Of the hospitals that credentialed and granted privileges to the nurse practitioners for invasive procedures, 60.4% were teaching hospitals. A supervising physician was the proctor in 94% of the nonteaching hospitals and 100% of the teaching hospitals. The most common number of cases proctored was 4 to 7. CONCLUSION The majority of hospitals employ acute care nurse practitioners. The most common method of privileging for invasive procedures is proctoring by a supervising physician. However, the amount of proctoring required before privileges and independent practice are granted varies by procedure and institution.

Nutritional Support Using Enteral and Parenteral Methods

The purpose of this Clinical Practice Guideline is to provide an approach for optimal nutritional support in the postinjury period for those injured in combat. Indications and contraindications for enteral and parenteral nutrition are addressed. Timing of nutritional support, nutritional goals, energy requirements, and ideal formula selection for various types of traumatic injuries are addressed. Challenges encountered providing nutrional support for the traumatically injured in the deployed environment are also discussed.

Prevention of Deep Venous Thromboembolism

The nature of many combat wounds puts patients at a high risk of developing deep venous thrombosis (DVT) and pulmonary embolism (PE), which fall under the broader disease category of venous thromboembolism (VTE). In addition to the hypercoagulable state induced by trauma, massive injuries to the extremities, prolonged immobility, and long fixed wing transport times to higher echelons of care are unique risk factors for venous thromboembolism in the combat-injured patient. These risk factors mandate aggressive prophylaxis for DVT and PE that can effectively be achieved by the use of lower extremity sequential compression devices and low dose unfractionated heparin or low molecular weight heparin. In addition, inferior vena cava filters are often used for PE prophylaxis when chemical DVT prophylaxis fails or is contraindicated. The following Department of Defense (DoD) Joint Trauma System (JTS) Clinical Practice Guideline (CPG) discusses the current recommendations for the prevention of DVT and PE including the use of inferior vena cava filters (IVCFs).

The Initial Impact of Tele-Critical Care on the Surgical Services of a Community Military Hospital

Introduction Mortality is reduced in hospitals staffed with intensivists, however, many smaller military hospitals lack intensivist support. Naval Hospital Camp Pendleton (NHCP) is a Military Treatment Facility (MTF) that operates a 6-bed Intensive Care Unit (ICU) north of its referral center, Naval Medical Center San Diego (NMCSD). To address a gap in NHCP on-site intensivist coverage, a comprehensive Tele-Critical Care (TCC) support system was established between NHCP and NMCSD. To examine the initial impact of telemedicine on surgical ICU patients, we compare NHCP surgical ICU admissions before and after TCC implementation. Materials and methods Patient care by remote intensivist was achieved utilizing video teleconferencing technology, and remote access to electronic medical records. Standardization was promoted by adopting protocols and mandatory intensivist involvement in all ICU admissions. Surgical ICU admissions prior to TCC implementation (pre-TCC) were compared to those following TCC implementation (post-TCC). Results Of 828 ICU admissions, 21% were surgical. TCC provided coverage during 35% of the intervention period. Comparing pre-TCC and post-TCC periods, there was a significant increase in the percentage of surgical ICU admissions [15.3 % vs 24.6%, p = 0.01] and the average monthly APACHE II score [4.1vs 6.5, p = 0.03]. The total number of surgical admissions per month also increased [3.9 vs 6.3, p = 0.009]. No adverse outcomes were identified. Conclusion Implementation of TCC was associated with an increase in the scope and complexity of surgical admissions with no adverse outcomes. Surgeons were able to safely expand the surgical services offered requiring perioperative ICU care to patients who previously may have been transferred. Caring for these types of patients not only maintains the operational readiness of deployable caregivers but patient experience is also enhanced by minimizing transfers away from family. Further exploration of TCC on surgical case volume and complexity is warranted.

Treatment algorithm and management of retrohepatic vena cava injuries

Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint providership of the American College of Surgeons and the American Association for the Surgery of Trauma. The American College Surgeons is accredited by the ACCME to provide continuing medical education for physicians. AMA PRA Category 1 CreditsTM The American College of Surgeons designates this journal-based CME activity for a maximum of 1 AMA PRACategory 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Of the AMA PRACategory 1 CreditTM listed above, a maximum of 1 credit meets the requirements for self-assessment.

105: HOW ARE ACNPS CREDENTIALED TO PERFORM CRITICAL CARE PROCEDURES? A SURVEY OF STATE HOSPITALS

Introduction: Recent literature suggests that Acute Care Nurse Practitioners (ACNP) have been integrated successfully into the inpatient setting throughout the United States, with teaching hospitals having the highest utilization. While the general scope of practice for ACNPs is regulated by individ

4: CREDENTIALING ACNPs IN INVASIVE CRITICAL CARE PROCEDURES UTILIZING PERFUSED (BLEEDING) CADAVERS

Introduction: Emerging data suggests that Acute Care Nurse Practioners (ACNP) have successfully been integrated into Intensive Care Units (ICU) across the United States. While the ACNP scope of practice and how to bill for procedures has been described, the ideal method to train and credential ACNPs to perform invasive procedures has not. We describe our initial experience training ACNPs to perform invasive critical care procedures utilizing our Fresh Tissue Dissection Lab (FTDL) and simulation program. Methods: Seven ACNP were given a self-directed didactic followed by a four-hour practicum utilizing perfused fresh tissue cadavers. The cadavers were perfused via femoral artery and vein cannulation with colored pressurized fluids simulating arterial and venous blood. Procedures performed included central venous landmark guided subclavian (SC) and ultrasound (US) guided internal jugular (IJ) vein catheter insertion, orotracheal intubation, tube thoracostomy, thoracentesis, and paracentesis. Pretest and posttest knowledge assessments were administered. Overall and specific procedural confidence was evaluated utilizing a retrospective pre-practicum and post-practicum analysis with a 5-point Likert scale (1, least confident and 5, most confident). Results: The mean years of clinical experience for the group was 4.1 years (range 4 months to 13 years). Each ACNP scored a 100% on both the pretest and posttest knowledge assessment. The overall procedural confidence for all procedures improved by 1.44, from 2.53 (SD± 0.629) to 3.97 (SD± 0.320) (p