Maureen McCunn

Glial fibrillary acidic protein is highly correlated with brain injury.

BACKGROUND Glial fibrillary acidic protein (GFAP) is an intermediate filament protein found in the cytoskeleton of astroglia. Recent work has indicated that GFAP may serve as a serum marker of traumatic brain injury (TBI) that is released after central nervous system cell damage. METHODS Serum from 51 critically injured trauma patients was prospectively collected on admission and on hospital day 2. All patients underwent an admission head computed tomography (CT) scan as a part of their clinical evaluation. Patients with facial fractures in the absence of documented TBI and patients with spinal cord injury were excluded. Demographic and outcome data were collected prospectively. Serum GFAP was measured in duplicate using enzyme-linked immunosorbent assay techniques. RESULTS Thirty-nine (76%) of the 51 patients had CT-documented TBI. The study cohort was 72.5% men with a mean age of 43 years and mean Injury Severity Score (ISS) of 30.2. There were no statistically significant demographic differences between the two groups. At admission day, the mean GFAP level in non-TBI patients was 0.07 pg/mL compared with 6.77 pg/mL in TBI patients (p = 0.002). On day 2 the mean GFAP level was 0.02 in non-TBI patients compared with 2.17 in TBI patients (p = 0.003). Using regression analysis to control for age, sex, and ISS, the Head Abbreviated Injury Scale was predictive of the level of GFAP on both days 1 and 2 (p values 0.006 and 0.026, respectively). Although GFAP levels were not predictive of increased hospital length of stay, intensive care unit length of stay, or ventilator days, high GFAP levels on hospital day 2 were predictive of mortality when controlling for age, sex, and ISS (odds ratio 1.45, p value 0.028). The area under the receiver operating characteristic curve for GFAP was 0.90 for day 1 and 0.88 for day 2. A GFAP cutoff point of 1 pg/mL yielded 100% specificity and 50% to 60% sensitivity for TBI. CONCLUSIONS GFAP is a serum marker of TBI, and persistent elevation on day 2 is predictive of increased mortality. Excellent specificity for CT-documented brain injury was found using a cutoff point of 1 pg/mL.

A Review of the Fundamental Principles and Evidence Base in the Use of Extracorporeal Membrane Oxygenation (ECMO) in Critically Ill Adult Patients

Extracorporeal membrane oxygenation (ECMO) comprises a commonly used method of extracorporeal life support. It has proven efficacy and is an accepted modality of care for isolated respiratory or cardiopulmonary failure in neonatal and pediatric populations. In adults, there are conflicting studies regarding its benefit, but it is possible that ECMO may be beneficial in certain adult populations beyond postcardiotomy heart failure. As such, all intensivists should be familiar with the evidence-base and principles of ECMO in adult population. The purpose of this article is to review the evidence and to describe the fundamental steps in initiating, adjusting, troubleshooting, and terminating ECMO so as to familiarize the intensivist with this modality.

Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND The ABCs of trauma resuscitation begin with the airway evaluation, and effective airway management is imperative in the care of a patient with critical injury. The Eastern Association for the Surgery of Trauma Practice Management Guidelines committee aimed to update the guidelines for emergency tracheal intubation (ETI) published in 2002. These guidelines were made to assist clinicians with decisions regarding airway management for patients immediately following traumatic injury. The goals of the work group were to develop evidence-based guidelines to (1) characterize patients in need of ETI and (2) delineate the most appropriate procedure for patients undergoing ETI. METHODS A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov). RESULTS The search retrieved English-language articles published from 2000 to 2012 involving patients who had sustained blunt trauma, penetrating trauma, or heat-related injury and had developed respiratory system insufficiency or required ETI in the immediate period after injury (first 2 hours after injury). Sixty-nine articles were used to construct this set of practice management guidelines. CONCLUSION The data supported the formation of six Level 1 recommendations, four Level 2 recommendations, and two Level 3 recommendations. In summary, the decision to intubate a patient following traumatic injury is based on multiple factors, including the need for oxygenation and ventilation, the extent and mechanism of injury, predicted operative need, or progression of disease. Rapid sequence intubation with direct laryngoscopy continues to be the recommended method for ETI, although the use of airway adjuncts such as blind insertion supraglottic devices and video laryngoscopy may be useful in facilitating successful ETI and may be preferred in certain patient populations. There is no pharmacologic induction agent of choice for ETI; however, succinylcholine is the neuromuscular blockade agent recommended for rapid sequence intubation.

Comparative study of decompressive craniectomy after mass lesion evacuation in severe head injury.

OBJECTIVEThis study was conducted to evaluate outcome after decompressive craniectomy (DC) in the setting of mass evacuation with or without intracranial pressure (ICP) monitoring. METHODSOver a 48-month period (March 2000 to March 2004), 54 of 967 consecutive head injury patients underwent DC for evacuation of a mass lesion. DC was performed without ICP monitoring in 27 patients who required urgent decompression (group A) and in 27 patients who did not require urgent surgery and who had their ICP monitored for 1 to 14 days before surgery (group B). RESULTSIn group A, the mean Glasgow Coma Scale score was 6.0; 80% had computed tomographic evidence of a shift greater than 5 mm; and 25 patients underwent DC immediately after resuscitation. In group B, the mean Glasgow Coma Scale score was 7.3; 40% had computed tomographic evidence of shift; and 75% underwent DC 24 hours or longer after presentation. Overall, 22 patients died (12 in group A and 10 in group B), 11 remained vegetative or severely disabled (3 in group A and 8 in group B), and 19 had good recovery (11 in group A and 8 in group B). Two patients were lost to follow-up. In 18 group B patients with ICP greater than 20 mm Hg before mass evacuation, ICP dropped an average of 13 mm Hg (P < 0.001). A mass lesion greater than 50 mL (odds ratio [OR], 2.86; 95% confidence interval [CI], 1.04–7.89) and evidence of low attenuation on computed tomography before (OR, 3.3; 95% CI, 1.1–10.3) or after (OR, 2.92; 95% CI, 1.02–8.34) DC were predictors of death. A good outcome occurred in 42% of patients with and in 63% of patients without delayed traumatic injury (OR, 0.3; 95% CI, 0.1–1.1). Outcome was favorable in 78.6% of patients who had no ICP monitoring before DC versus 47.1% of patients with ICP monitoring (OR, 0.2; 95% CI, 0.1–1.2). CONCLUSIONIn this study, mortality after DC for mass lesion was greater than expected, and outcome did not differ between patients with or without ICP monitoring.

Acute lung injury and the acute respiratory distress syndrome in the injured patient

Acute lung injury and acute respiratory distress syndrome are clinical entities of multi-factorial origin frequently seen in traumatically injured patients requiring intensive care. We performed an unsystematic search using PubMed and the Cochrane Database of Systematic Reviews up to January 2012. The purpose of this article is to review recent evidence for the pathophysiology and the management of acute lung injury/acute respiratory distress syndrome in the critically injured patient. Lung protective ventilation remains the most beneficial therapy. Future trials should compare intervention groups to controls receiving lung protective ventilation, and focus on relevant outcome measures such as duration of mechanical ventilation, length of intensive care unit stay, and mortality.

Extracorporeal support in an adult with severe carbon monoxide poisoning and shock following smoke inhalation: a case report

The objective of this study was to discuss the case of a patient with severe smoke inhalation-related respiratory failure treated with extracorporeal support. The study was set in a 12-bed multi-trauma intensive care unit at a level one trauma center and hyperbaric medicine center. The patient under investigation had carbon monoxide poisoning, and developed acute respiratory distress syndrome and cardiovascular collapse following smoke inhalation. Rapid initiation of extracorporeal support, extreme inverse-ratio ventilation and intermittent prone positioning therapy were carried out. Admission and serial carboxyhemoglobin levels, blood gases, and computerized tomography of the chest were obtained. The patient developed severe hypoxia and progressed to cardiovascular collapse resistant to resuscitation and vasoactive infusions. Veno-venous extracorporeal support was initiated. Cardiovascular parameters of blood pressure, cardiac output, and oxygen delivery were maximized; oxygenation and ventilation were supported via the extracorporeal circuit. Airway pressure release ventilation and intermittent prone positioning therapy were instituted. Following 7 days of extracorporeal support, the patient was decannulated and subsequently discharged to a transitional care facility, neurologically intact. Smoke inhalation and carbon monoxide poisoning may lead to life-threatening hypoxemia associated with resultant cardiovascular instability. When oxygenation and ventilation cannot be achieved via maximal ventilatory management, extracorporeal support may prevent death if initiated rapidly.

Physician utilization of a portable computed tomography scanner in the intensive care unit.

ObjectiveTo determine the utilization of a portable computed tomography (CT) scanner for critically ill adult patients in an intensive care unit (ICU). DesignSurvey study and retrospective review. SubjectsCritical care attending staff and fellows and neurosurgery residents. SettingA university hospital and Level I trauma center with a multitrauma ICU, a neurotrauma ICU, and a neurosurgical ICU. InterventionsWe surveyed all physicians who ordered portable CT scans from December 1996 through June 1998. Ordering physicians included critical care attending staff and fellows (anesthesiology, surgery, internal medicine) and neurosurgery residents. Physicians who no longer worked at the institution were contacted by mail or fax. Radiology records were reviewed to determine the actual number and type of scans performed. Measurements and Main ResultsThe survey response was 100%. Most physicians reported ordering portable head CT scans (97%), followed by chest CT (88%), abdominal CT (78%), and pelvic CT (34%) scans. Analysis of the actual number of scans performed correlated with these reports (511 head, 115 chest, 88 abdomen, and 87 pelvis). The indication for portable CT scans (as opposed to a “fixed” or “stationary” scans) cited most often was patient severity of illness (77%). Patients on extracorporeal support (93%), those with cardiovascular instability (70%), followed by those with respiratory instability (57%) and neurologic instability (40%) were deemed too ill to transport. If the portable CT scanner was unavailable, however, most physicians (67%) ordered a fixed helical CT scan and the patient was transported to the radiology suite, regardless of medical condition. ConclusionsAccess to a portable CT scanner impacts the physician ordering patterns for ICU patients. We found that 100% of surveyed physicians used the portable CT scanner for critically ill patients when the patient was unstable. If the diagnostic study was deemed medically necessary, and the portable scanner was unavailable, most surveyed physicians ordered a “fixed” helical scan and the patient was transported by an experienced transport team for the study. The portable CT offered an alternative and potentially safer means of obtaining diagnostic studies.

Increased Rates of Mild Traumatic Brain Injury Among Older Adults in US Emergency Departments, 2009-2010.

Objective:To estimate rates of emergency department (ED) visits for mild traumatic brain injury (TBI) among older adults. We defined possible mild TBI cases to assess underdiagnoses. Design:Cross-sectional. Setting:National sample of ED visits in 2009-2010 captured by the National Hospital Ambulatory Medical Care Survey. Participants:Aged 65 years and older. Measurements:Mild TBI defined by International Classification of Diseases, Ninth Revision, Clinical Modification, codes (800.0x-801.9x, 803.xx, 804.xx, 850.xx-854.1x, 950.1x-950.3x, 959.01) and a Glasgow Coma Scale score of 14 or more or missing, excluding those admitted to the hospital. Possible mild TBI was defined similarly among those without mild TBI and with a fall or motor vehicle collision as cause of injury. We calculated rates of mild TBI and examined factors associated with a diagnosis of mild TBI. Results:Rates of ED visits for mild TBI were 386 per 100 000 among those aged 65 to 74 years, 777 per 100 000 among those aged 75 to 84 years, and 1205 per 100 000 among those older than 84 years. Rates for women (706/100 000) were higher than for men (516/100 000). Compared with a possible mild TBI, a diagnosis of mild TBI was more likely in the West (odds ratio = 2.31; 95% confidence interval, 1.02-5.24) and less likely in the South/Midwest (odds ratio = 0.52; 95% confidence interval, 0.29-0.96) than in the Northeast. Conclusions:This study highlights an upward trend in rates of ED visits for mild TBI among older adults.

Global health outreach during anesthesiology residency in the United States: a survey of interest, barriers to participation, and proposed solutions ☆

STUDY OBJECTIVE To assess the interest in and barriers to pursuing global health outreach (GHO) experiences for anesthesiology residents in the United States. DESIGN Survey instrument. SETTING Academic department of anesthesiology. SUBJECTS Anesthesiology residents who were members of the American Society of Anesthesiologists (ASA). MEASUREMENTS An online survey was administered to residents in anesthesiology via the ASA membership database. Descriptive statistics, including means, frequencies, and percentages were calculated. MAIN RESULTS 91% of participants indicated an interest in GHO, of whom fewer than half (44%) had done a GHO medical mission. Seventy-nine percent reported that GHO affected their current practice or education; 33% commented they were now less wasteful with supplies and resources. Permission from work or obtaining work coverage were the primary barriers for both those with and without previous GHO participation. Of all respondents, 78% agreed that the availability of a GHO residency track would influence their ranking of that program for training, and 71% would pursue a GHO fellowship if available. CONCLUSIONS Anesthesiology residents have an interest in residency and fellowship GHO programs. Formalization of GHO programs during training may reduce work-related barriers associated with GHO participation and broaden academic program recruitment.

An organized, comprehensive, and security-enabled strategic response to the haiti earthquake: A description of pre-deployment readiness preparation and preliminary experience from an academic anesthesiology department with no preexisting international disaster response program

BACKGROUND: On Tuesday, January 12, 2010 at 16:53 local time, a magnitude 7.0 Mw earthquake struck Haiti. The global humanitarian attempt to respond was swift, but poor infrastructure and emergency preparedness limited many efforts. Rapid, successful deployment of emergency medical care teams was accomplished by organizations with experience in mass disaster casualty response. Well-intentioned, but unprepared, medical teams also responded. In this report, we describe the preparation and planning process used at an academic university department of anesthesiology with no preexisting international disaster response program, after a call from an American-based nongovernmental organization operating in Haiti requested medical support. The focus of this article is the pre-deployment readiness process, and is not a post-deployment report describing the medical care provided in Haiti. METHODS: A real-time qualitative assessment and systematic review of the Hospital of the University of Pennsylvanias communications and actions relevant to the Haiti earthquake were performed. Team meetings, conference calls, and electronic mail communication pertaining to planning, decision support, equipment procurement, and actions and steps up to the day of deployment were reviewed and abstracted. Timing of key events was compiled and a response timeline for this process was developed. Interviews with returning anesthesiology members were conducted. RESULTS: Four days after the Haiti earthquake, Partners in Health, a nonprofit, nongovernmental organization based in Boston, Massachusetts, with >20 years of experience providing medical care in Haiti contacted the University of Pennsylvania Health System to request medical team support. The departments of anesthesiology, surgery, orthopedics, and nursing responded to this request with a volunteer selection process, vaccination program, and systematic development of equipment lists. World Health Organization and Centers for Disease Control guidelines, the American Society of Anesthesiology Committee on Trauma and Emergency Preparedness, published articles, and in-country contacts were used to guide the preparatory process. CONCLUSION: An organized strategic response to medical needs after an international natural disaster emergency can be accomplished safely and effectively within 6 to 12 days by an academic anesthesiology department, with medical system support, in a center with no previously established response system. The value and timeliness of this response will be determined with further study. Institutions with limited experience in putting an emergency medical team into the field may be able to quickly do so when such efforts are executed in a systematic manner in coordination with a health care organization that already has support infrastructure at the site of the disaster.