Michael F. Oswanski

Practice management guidelines for nutritional support of the trauma patient.

Nutritional support is an integral, though often neglected, component of the care of the critically injured patient. Our understanding of the metabolic changes associated with starvation, stress, and sepsis has deepened over the past 20 to 30 years, and along with this has come a greater appreciation for the importance of the timing, composition, and route of administration of nutritional support to the trauma patient. Although supportive data exist for many of our current nutritional practices, the trauma surgeon cannot assume that interventions that are successful in laboratory animals or even in the critically ill nontrauma patient will produce the same results in critically ill trauma patients. Stanley J. Dudrick, MD, one of the forefathers of surgical nutrition in this country, put it this way: “. . .we do get ourselves into an awful lot of trouble and lack of consensus as a result of mixing in animal data together with normal, starved man data when we are talking about trauma, especially in burns.” For this reason, the recommendations provided in this guideline are based, when at all possible, on studies using trauma or burn patients. Nevertheless, a brief discussion of some of the basic science principles of nutritional support is provided in the following section as a backdrop for the clinical studies presented in this guideline. This practice management guideline is a compilation of six separate guidelines; each addresses a specific aspect of the nutritional support of the trauma patient. These topics are presented in the following order: A. Route of nutritional support (total parenteral nutrition vs. total enteral nutrition). B. Timing of nutritional support (early vs. late). C. Site of nutritional support (gastric vs. jejunal). D. Macronutrient formulation (how many calories and what proportion of protein, carbohydrate, and fat?). E. Monitoring of nutritional support (which tests and how often?). F. Type of nutritional support (standard vs. enhanced). Each subguideline is a separate and free-standing document, with its own recommendations, evidentiary tables, and references. Where possible, we have attempted to eliminate redundancy and ensure consistency among the guidelines. Yet, because of substantial differences in both the quantity as well as the quality of supporting scientific data for each topic, and the fact that certain clinical circumstances are not conducive to a single guideline, concise and consistent recommendations were not always possible. Even when Class I (prospective, randomized, controlled) studies were available, limited patient numbers and inconsistent definitions rendered study conclusions less authoritative that they might have otherwise been. Recognizing the need to incorporate the major recommendations from the subguidelines into a logical overall approach to the nutritional support of the trauma patient, a summary algorithm is provided at the conclusion of the guideline (Fig. 1). Because of the scope of this document, many of the recommendations from the subguidelines could not be included in the algorithm. In addition, distinguishing between the various levels of recommendations (I, II, and III) within the algorithm was not practical. Nevertheless, the algorithm provides a safe, reasonable, and literature-supported approach to nutritional support and, we hope, will provoke constructive discussion and stimulate further investigation.

Evaluation of two assessment tools in predicting driving ability of senior drivers.

Oswanski MF, Sharma OP, Raj SS, Vassar LA, Woods KL, Sargent WM, Pitock RJ: Evaluation of two assessment tools in predicting driving ability of senior drivers. Am J Phys Med Rehabil 2007;86:190–199. Objective: To evaluate Motor Free Visual Perceptual Test (MVPT) and Clock Drawing Task (clock test) as quick assessment tools in predicting driving capability of senior drivers for an on-road driving test. Design: Senior drivers (≥55 yrs) referred for evaluation and recommendation for license renewal were given the MVPT, clock test, and an on-road driving test. Receiving operating characteristic (ROC) analysis and stepwise multivariate logistic regression (SMLR) were used to develop a probability model to differentiate between capable and incapable senior drivers. Results: Data for 232 seniors who had completed all written tests and the on-road driving test were analyzed. Of the 232 seniors, 131 (56%) were classified as capable and 101 (44%) as incapable drivers on the road test. Mean scores for capable and incapable drivers were MVPT 32.0 ± 4.0 vs. 28.4 ± 4.6 and mean clock test score 3.5 ± 0.8 vs. 2.7 ± 1.2, and mean processing time was 7.1 + 6.5 vs. 10.6 + 5.5. The means of the three measurements were significantly different between the two groups (P value <0.001). ROC curve analysis revealed an optimal cut point of ≥32 for MVPT score with 60% sensitivity and 83% specificity. The optimal cut point for clock test scores is ≥3 with 70% sensitivity and 65% specificity. The optimal cut point for processing times is ≤6.27 secs with 60% sensitivity and 80% specificity. SMLR showed that the most significant predictor of seniors’ driving capabilities are the MVPT test scores and clock test scores. Conclusion: MVPT and clock test tools are significant predictors of driving capability on an on-road driving test.

Prehospital Pain Assessment in Pediatric Trauma

Objective. Investigators implemented the current study to analyze the documentation of pain assessments andinterventions for injured children in prehospital settings. Methods. For this institutional review board–approved retrospective study, 696 Lucas County Emergency Medical Services trauma charts (46% of the countys total runs) from 2002 to 2004 were reviewed, anddescriptive statistics of frequency were used to analyze pain-assessment documentation andinterventions. Results. Pain was noted in 64.1% (446/696) of subjects, a statement of “no pain” was noted in 17.2% (120/696) of subjects, andpain was undocumented in 18.7%. Only one trauma chart (1/696, 0.2%) indicated the appropriate use of a validated pain assessment tool (Verbal Rating Scale). There were no documented pain interventions provided to 86.6% (603/696) of all subjects, including 85.0% (379/446) with documented pain. Of all subjects, 13.4% (93/696) received pain interventions. Pharmacological interventions were used for 2.2% (15/696) of all subjects and16.1% (15/93) of subjects with documented pain interventions. Nonpharmacologic interventions were used in 12.4% of cases (86/696), in which traction andsplinting were the most common interventions (36/93, 38.7%), followed by saline flush with dressing (15/93, 16.1%). Diversion anddistraction techniques were documented in five charts in which a pain intervention was documented (5/93, 5.4%). Conclusions. These results identify a void in the documentation of pain assessment andimplementation of pain-control interventions for injured pediatric patients. Education for prehospital providers is recommended, emphasizing the importance of pain assessment anddocumentation of pain-control care for pediatric trauma patients.

Injuries to the colon from blast effect of penetrating extra-peritoneal thoraco-abdominal trauma

Although rare, blast injury to the intestine can result from penetrating thoraco-abdominal extra-peritoneal gunshot (and shotgun) wounds despite the absence of injury to the diaphragm or to the peritoneum. Injuries of the spleen, small intestine and the mesentery by this mechanism have been previously reported in the world literature. This paper reports the first two cases of non-penetrating ballistic trauma to the colon.

Hydroblast intra-abdominal organ trauma

Hydroblast injuries of the extremities are not uncommon. Hydroblast injuries involving intra-abdominal organs are more unusual. Usually there are subtle findings on the abdominal wall with severe intra-abdominal trauma and undue delay in appropriate treatment may occur, resulting in increased morbidity. In addition to a review of the literature, this article presents a case of intestinal perforation due to hydroblast trauma.

Role of non-operative management of spleen injury in patients with hemophilia: Report of two patients with review of literature

The non-operative management (NOM) of hemodynamically stable patients with splenic trauma is currently well accepted, yet non-operative therapy has rarely been attempted in coagulopathic patients. Two cases of successful NOM of splenic trauma in patients with hemophilia are presented with a review of the English medical literature.