Michael D. Pasquale

Practice management guidelines for trauma from the Eastern Association for the Surgery of Trauma.

Clinical practice guidelines are being used as a means of reducing inappropriate care, controlling geographic variations in practice patterns, and making more effective use of health care resources. Developments at the national health policy level, as well as managed care imperatives, suggest that c

Trauma in the elderly: Intensive care unit resource use and outcome

BACKGROUND As the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly suffer more severe consequences from traumatic injuries compared with the young, presumably resulting in increased resource use. In this study, we sought to examine ICU resource use in trauma on the basis of age and injury severity. METHODS This study was a retrospective review of trauma registry data prospectively collected on 26,237 blunt trauma patients admitted to all trauma centers (n = 26) in one state over 24 months (January 1996-December 1997). Age-dependent and injury severity-dependent differences in mortality, ICU length of stay (LOS), and hospital LOS were evaluated by logistic regression analysis. RESULTS Elderly (age > or = 65 years, n = 7,117) patients had significantly higher mortality rates than younger (age < 65 years) trauma patients after stratification by Injury Severity Score (ISS), Revised Trauma Score, and other preexisting comorbidities. Age > 65 years was associated with a two- to threefold increased mortality risk in mild (ISS < 15, 3.2% vs. 0.4%; < 0.001), moderate (ISS 15-29, 19.7% vs. 5.4%; < 0.001), and severe traumatic injury (ISS > or = 30, 47.8% vs. 21.7%; < 0.001) compared with patients aged < 65 years. Logistic regression analysis confirmed that elderly patients had a nearly twofold increased mortality risk (odds ratio, 1.87; confidence interval, 1.60-2.18; < 0.001). Elderly patients also had significantly longer hospital LOS after stratifying for severity of injury by ISS (1.9 fewer days in the age 18-45 group, 0.89 fewer days in the age 46-64 group compared with the age > or = 65 group). Mortality rates were higher for men than for women only in the ISS < 15 (4.4% vs. 2.6%, < 0.001) and ISS 15 to 29 (21.7% vs. 17.6%, = 0.031) groups. ICU LOS was significantly decreased in elderly patients with ISS > or = 30. CONCLUSION Age is confirmed as an independent predictor of outcome (mortality) in trauma after stratification for injury severity in this largest study of elderly trauma patients to date. Elderly patients with severe injury (ISS > 30) have decreased ICU resource use secondary to associated increased mortality rates.

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.

American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank.

BACKGROUND This study attempts to validate the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for spleen, liver, and kidney injuries using the National Trauma Data Bank (NTDB). STUDY DESIGN All NTDB entries with Abbreviated Injury Scale codes for spleen, liver, and kidney were classified by OIS grade. Injuries were stratified either as an isolated intraabdominal organ injury or in combination with other abdominal injuries. Isolated abdominal solid organ injuries were additionally stratified by presence of severe head injury and survival past 24 hours. The patients in each grading category were analyzed for mortality, operative rate, hospital length of stay, ICU length of stay, and charges incurred. RESULTS There were 54,148 NTDB entries (2.7%) with Abbreviated Injury Scale-coded injuries to the spleen, liver, or kidney. In 35,897, this was an isolated abdominal solid organ injury. For patients in which the solid organ in question was not the sole abdominal injury, a statistically significant increase (p < or = 0.05) in mortality, organ-specific operative rate, and hospital charges was associated with increasing OIS grade; the exception was grade VI hepatic injuries. Hospital and ICU lengths of stay did not show substantial increase with increasing OIS grade. When isolated organ injuries were examined, there were statistically significant increases (p < or = 0.05) in all outcomes variables corresponding with increasing OIS grade. Severe head injury appears to influence mortality, but none of the other outcomes variables. Patients with other intraabdominal injuries had comparable quantitative outcomes results with the isolated abdominal organ injury groups for all OIS grades. CONCLUSIONS This study validates and quantifies outcomes reflective of increasing injury severity associated with increasing OIS grades for specific solid organ injuries alone, and in combination with other abdominal injuries.

Practice Parameters for Evaluating New Fever in Critically Ill Adult Patients. Task Force of the American College of Critical Care Medicine of the Society of Critical Care Medicine in Collaboration with the Infectious Disease Society of America.

Abstract Objective: To develop practice parameters for the evaluation of adult patients who develop a new fever in the intensive care unit (ICU) for the purpose of guiding clinical practice. Participants: A task force of 13 experts in disciplines related to critical care medicine, infectious diseases, and surgery was convened from the membership of the Society of Critical Care Medicine, and the Infectious Disease Society of America. Evidence: The task force members provided the personal experience and determined the published literature (MEDLINE articles, textbooks, etc.) from which consensus would be sought. Published literature was reviewed and classified into one of four categories, according to study design and scientific value. Consensus Process: The task force met several times in person and twice monthly by teleconference over a 1‐yr period of time to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the experts’ opinions. Draft documents were composed and debated by the task force until consensus was reached by nominal group process. Conclusions: The panel concluded that, because fever can have many infectious and noninfectious etiologies, a new fever in a patient in the ICU should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests. A cost‐conscious approach to obtaining cultures and imaging studies should be undertaken if it is indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether or not infection is present, so additional testing can be avoided and therapeutic options can be made. (Crit Care Med 1998; 26:392‐408) In some intensive care units (ICUs), the measurement of a newly elevated temperature triggers an automatic order set which includes many tests that are time consuming, costly, and disruptive (Table 1). Moreover, the patient may experience discomfort, be exposed to unneeded radiation, or experience considerable blood loss due to this testing, which is often repeated several times within 24 hrs, and daily thereafter. In an era when utilization of hospital and patient resources is under intensive scrutiny, it is appropriate to assess how such fevers should be evaluated in a prudent and cost‐effective manner. Table 1. Typical costs associated with fever evaluation The American College of Critical Care Medicine of the Society of Critical Care Medicine and the Infectious Disease Society of America established a Task Force to provide practice parameters for the evaluation of a new fever in patients in an ICU with the goal of promoting the rational consumption of resources and promoting an efficient evaluation. These practice parameters presume that any unexplained temperature elevation merits a clinical assessment by a healthcare professional that includes a review of the patients history and a focused physical examination before any laboratory tests or imaging procedures are ordered. These practice parameters specifically address how to evaluate a new fever in an adult patient already in the ICU who has previously been afebrile and in whom the source of fever is not initially obvious. If the initial evaluation of history and physical examination reveals a consolidated lung, a purulent wound, or a phlebitic leg, then diagnosis and therapy of that infectious process should commence: such management is addressed by other practice parameters aimed specifically at pneumonia, catheter‐related infections, etc. Specific questions addressed in these practice parameters relate to the search for the underlying cause of fever and include: a) What temperature should elicit an evaluation? b) When are blood cultures warranted? c) When should intravascular catheters be cultured or removed? d) When are cultures of respiratory secretions, urine, stool, or cerebral spinal fluid warranted? e) When are radiographic studies warranted? These practice parameters do not address children, since children have different issues that merit discussion in a separate document. In addition, these practice parameters do not address an approach to persistent fever after the initial evaluation, or to localized infection once the anatomic source of fever has been identified. These issues are addressed in other monographs or practice parameters. The current document also does not address the desirability or selection of empiric vs. specific therapy since the need for therapy is so dependent on clinical evaluation and the underlying disease. It did not appear to this task force that useful therapeutic guidelines could easily be provided which took into account the acuity of illness, the underlying disease process, concurrent drugs (i.e., immunosuppressive agents, and antimicrobials), ability to tolerate toxicities, and geographic antibiotic susceptibility differences. Each ICU must establish its own policies for evaluating fever that take into account the type of ICU involved (e.g., medical ICU, surgical ICU, burn ICU, etc.), the specific patient population (e.g., immunosuppressed vs. immunocompetent, elderly vs. younger adults), recent epidemics (e.g., out‐breaks of Clostridium difficile diarrhea or vancomycin‐resistant Enterococcus), or endemic pathogens (e.g., methicillin‐resistant Staphylococcus aureus). It is hoped that these practice parameters will assist intensivists and consultants as a starting point for developing an effective and cost conscious approach appropriate for their patient populations. The specific recommendations are rated by the strength of evidence, using the published criteria of the Society of Critical Care Medicine (Table 2). Table 2. Society of Critical Care Medicines rating system for strength of recommendation and quality of evidence supporting the references

Outcome after decompressive craniectomy for the treatment of severe traumatic brain injury.

BACKGROUND Using decompressive craniectomy as part of the treatment regimen for severe traumatic brain injury (STBI) has become more common at our Level I trauma center. This study was designed to examine this practice with particular attention to long-term functional outcome. METHODS A retrospective review of prospectively collected data was performed for patients with STBI admitted from January 1, 2003 to December 31, 2005. Our institution manages patients using the Brain Trauma Foundation Guidelines. Data collected from patients undergoing decompressive craniectomy included: age, Injury Severity Score, admission and follow-up Glasgow Coma Score, timing of, and indication for decompressive craniectomy, and procedure-related complications. The Extended Glasgow Outcome Scale (GOSE) was performed by a experienced trauma clinical research coordinator using a structured phone interview to assess long-term outcome in the survivors. Students t test and chi2 were used to examine differences between groups. RESULTS Forty STBI patients were treated with decompressive craniectomy; 24 were performed primarily in conjunction with urgent evacuation of extra-axial hemorrhage and 16 were performed primarily in response to increased intracranial pressure with 4 of these after an initial craniotomy. Decompressive craniectomy was very effective at lowering intracranial pressure in these 16 patients (35.0 mm Hg +/- 13.5 mm Hg to 14.6 mm Hg +/- 8.7 mm Hg, p = 0.005). Twenty-two decompressive craniectomy patients did not survive to hospital discharge, whereas admission Glasgow Coma Score and admission pupil size and reactivity correlated with outcome, age, and Injury Severity Score did not. At a mean of 11 months (range, 3-26 months) after decompressive craniectomy, 6 survivors had a poor functional outcome (GOSE 1-4), whereas 12 survivors had a good outcome (GOSE 5-8). Therefore, 70% of these patients had an unfavorable outcome (death or severe disability), and 30% had a favorable long-term functional outcome. Fifteen of 18 survivors went on to cranioplasty, whereas 4 of 18 had cerebrospinal infection. CONCLUSION The majority of survivors after decompressive craniectomy have a good functional outcome as analyzed by GOSE. Overall, 30% of patients with STBI who underwent decompressive craniectomy had a favorable long-term outcome. Improving patient selection and optimizing timing of this procedure may further improve outcome in these very severely brain injured patients.

Establishing reliability and validity of the critical care family satisfaction survey.

ObjectiveTo develop and validate the Critical Care Family Satisfaction Survey as a proxy for patient satisfaction. DesignInstrument validation study. Setting and Time FrameThe Medical Intensive Care, Shock Trauma, Acute Coronary Care, Central Nervous System, Surgical Intensive Care, and Special Care units of Lehigh Valley Hospital (Allentown, PA), for the period December 1997 through September 1998. Patients/ParticipantsOne family member for each of 237 critical care patients. Intervention(s)Content and construct validity were examined on 37 items and 6 constructs thought to measure family satisfaction with the quality of critical care in hospitals. Initially, 14 items and 1 construct were removed from the questionnaire based on this analysis. It was then administered to 237 family members. Measurements and Main Results Factor analysis and confirmatory factor analysis using path models were performed. Internal consistency using Pearson correlations and Cronbach’s alpha, and discriminant validation were also calculated. Factor analysis yielded a single eigenvalue >1 (3.712), whereas confirmatory factor analysis led to the final instrument being reduced to 20 items and 5 subscale constructs. One subscale (“Comfort”) performed poorly, indicating the possible need for a four-factor model. Subsequently, internal consistency assessed by Cronbach’s alpha was 0.9101 for the five-factor model and 0.9327 for the four-factor model. Subscale correlations were no lower than 0.750 for the five-factor model and 0.856 for the four-factor model. ConclusionsThis study provides support that the Critical Care Family Satisfaction Survey—which yields five subscales, “Assurance,” “Information,” “Proximity,” “Support,” and “Comfort”—is reliable and valid. Using five constructs rather than four is recommended because of the following: a) the internal consistency loss of 0.0226 for the “Comfort” subscale is not enough to warrant its removal, b) a four-factor questionnaire can be administered and totaled independently of this subscale, c) the need for the fifth construct is indicated by this study’s results, and d) including the extra data may allow for more detailed analysis.

Contribution of age and gender to outcome of blunt splenic injury in adults: Multicenter study of the eastern association for the surgery of trauma

BACKGROUND The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults. METHODS Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively. RESULTS Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05). CONCLUSION Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.

Practice management guidelines for the management of mild traumatic brain injury: the EAST practice management guidelines work group.

I. STATEMENT OF THE PROBLEM Mild traumatic brain injury (MTBI), or concussion, is a common cause for admission at trauma centers, particularly those centers admitting primarily blunt trauma victims. Represented by ICD-9-CM codes 850.0–850.9, MTBI may be generally defined as an injury caused by blunt acceleration/ deceleration forces which produce a period of unconsciousness for 20 minutes or less and/or brief retrograde amnesia, a Glasgow Coma Scale (GCS) score of 13 to 15, no focal neurologic deficit, no intracranial complications (e.g., seizure activity), and normal computed tomography (CT) findings.1–3 This brief loss of consciousness and/or retrograde amnesia has to be referred to as a transient disturbance of neurologic function and is a sine qua non to the diagnosis of MTBI. Focal neurologic deficits as well as seizure activity fall outside the definition of MTBI in this guideline. Despite the frequency of MTBI, there is no uniform agreement regarding the nature of the illness, the role of a variety of diagnostic tests, or the necessity of acute hospitalization. Neurotrauma textbooks and a large number of review articles have addressed the definition, epidemiology, and clinical characteristics of MTBI.1–8 Similarly, a number of studies have examined the role of CT9–31 and neuropsychological testing32–46 in the diagnosis and management of MTBI. Several studies, mostly retrospective, suggest which patients might be best served by hospital admission versus evaluation and discharge to home.9,47–53 Additional studies exist regarding management strategies in MTBI from the neurosurgeon’s perspective.17,28,31,54–64 Finally, the complicated and poorly understood issues surrounding posttraumatic and emotional symptoms in patients with MTBI are discussed in several publications.65–69 From this core of knowledge, recommendations can be made to facilitate a safe, more uniform, and cost-effective approach to the understanding and management of MTBI.9,15,70–72

Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation.

BACKGROUND The purpose of this study was to determine the predictive value of an endotracheal tube cuff leak for the development of postextubation stridor and the need for reintubation. STUDY DESIGN Consecutive trauma patients who required intubation at a level I trauma center from July 1997 to July 1998 were studied prospectively. Pediatric patients and those who did not meet the standard weaning protocol criteria established by the Division of Trauma and Surgical Critical Care were excluded. Injury Severity Score, endotracheal tube size, reason for intubation, and the number of days intubated before the initial extubation attempt were recorded. At the time of extubation, the difference in exhaled tidal volume from before to after endotracheal tube cuff deflation was calculated. This number was then divided by the exhaled tidal volume before cuff deflation and was recorded as the percent cuff leak. Patients were followed for 24 hours after extubation for the development of stridor or need for reintubation. Statistical analysis to compare subgroups of patients was performed using ANOVA with Scheffé post hoc analysis. RESULTS Among the 110 patients analyzed, the most common reason for intubation was closed-head injury. Seven patients (6.4%) developed stridor alone and had a mean cuff leak of 5 8 mL (8.4% of tidal volume before cuff deflation). Six patients (5.5%) experienced stridor that required reintubation and had a mean cuff leak of 68 mL (9.2% of tidal volume before cuff deflation). Patients who developed stridor or needed reintubation had been intubated for a significantly greater length of time than those not developing stridor or requiring reintubation (2.6 versus 3.0 days, p < 0.001). There were no differences in Injury Severity Score, endotracheal tube size, or reason for intubation between these groups. CONCLUSIONS A cuff leak of less than 10% of tidal volume before cuff deflation is useful in identifying patients at risk for stridor or reintubation (96% specificity). It appears that the amount of cuff leak decreases after intubation for more than 3 days, increasing the risk of stridor and need for reintubation. This information may be helpful in identifying those patients who need treatment for laryngotracheal edema, ie, use of steroids or anesthesia during extubation, the efficacy of which remains to be determined.