Michael L. Foreman

Successful diagnosis of penetrating cardiac injury using surgeon-performed sonography

BACKGROUND Patients with penetrating cardiac injuries have a high mortality. The utilization of sonography in these patients may lead to earlier diagnosis and definitive surgical intervention. METHODS A retrospective review of all patients admitted to a level I trauma center were examined from March 1996 to March 2001 (17,241 patients). Patients were identified with penetrating thoracic injuries and were evaluated for mechanism of injury, sonographic findings (subxiphoid and parasternal windows), injury severity score, length of stay, and mortality. Surgeons performed all sonography. RESULTS There were 478 patients who underwent sonography for penetrating thoracic injuries. Twenty-three patients were identified with positive sonographic findings. Subsequently 20 patients had a cardiac injury at surgery. There were no missed injuries. The 3 patients with false positive findings had congestive heart failure (2 patients) and morbid obesity (1 patient). Mean time to operation was 13 minutes. Mean injury severity score was 33. Mean intensive care unit and hospital stay was 3.1 days and 7.2 days respectively. Sonography had a specificity of 99.3% and sensitivity of 100% for identifying penetrating cardiac injury and a positive predictive value of 87% and negative predictive value of 100%. There were no hospital deaths. CONCLUSIONS Early diagnosis and management using surgeon performed sonography may reduce the high mortality associated with penetrating cardiac injury.

Perceived injustice after traumatic injury: Associations with pain, psychological distress, and quality of life outcomes 12 months after injury.

OBJECTIVE There is growing recognition that individuals who experience traumatic injuries perceive themselves as victims of injustice and that elevated levels of perceived injustice are associated with problematic physical and psychological outcomes. To date, research regarding injustice perception and injury outcomes has been restricted to a small number of musculoskeletal pain conditions. No research to date has examined the potential impact of perceived injustice among individuals admitted for trauma care. METHOD As part of this cross-sectional study, individuals (n = 155) admitted to a Level-1 trauma center completed measures of perceived injustice, pain, depression, posttraumatic stress, and health related (physical and mental/emotional) quality of life (HRQoL) outcomes 12 months after trauma admission. RESULTS Bivariate analyses revealed significant associations between perceived injustice and demographic variables (education, income, race, and age) as well as injury-related variables (type of injury and length of hospital stay). Perceived injustice was correlated with greater pain intensity, depression, and PTSD symptoms, as well as poorer physical and mental HRQoL. Controlling for relevant demographic and injury-related variables, perceived injustice accounted for unique variance in pain intensity, depression severity, the presence and intensity of PTSD symptoms, mental HRQoL, and was marginally significant for physical HRQoL. CONCLUSIONS This is the first study to examine perceived injustice in a trauma sample. Results support the presence of injustice perception in this group and its associations with pain and quality of life outcomes. Additional research is suggested to explore the impact of perceived injustice on recovery outcomes among individuals who have sustained traumatic injury.

Changing management trends in penetrating colon trauma.

PURPOSE: Recent prospective studies have recommended primary repair for all penetrating colon injuries. We evaluated our management trends given these recommendations and assessed our results of primary repair. METHODS: A retrospective review was conducted of 145 patients with penetrating colon injuries received between January 1, 1991, and December 31, 1997. The patients were characterized according to demographics and severity of injury. Morbidity was defined as failure of a primary repair, abscess, fistula, wound dehiscence, fasciitis, sepsis, organ failure, or coagulopathy. The periods 1991 to 1993 (early period) and 1994 to 1997 (late period) were chosen for comparison. RESULTS: Primary repairs were performed in 53 of 75 patients (71 percent) during the early period and in 61 of 70 patients (87 percent) during the late period (P=0.03). No significant differences in demographics or injury severity were found to account for the increased rate of primary repairs. The number of suture repairs was nearly equal in both periods (59vs. 61 percent). The number of resections and anastomoses for destructive colon injuries was significantly higher in the late period (26 percent) compared with the early period (12 percent;P=0.05). Morbidity was equal (24 percent) in the two periods. There were no failures of resections and anastomoses and one failure of suture repair. CONCLUSIONS: Increased primary repair occurred because of more liberal use of resection and anastomosis for destructive injuries. Suture repair was performed for the amenable colonic injury throughout the study period. Risk factors for failure of resection and anastomosis cannot be defined from our study. Further investigation is needed to determine if resection and anastomosis is safe for the most severely injured patients.

Compliance with Recommended Care at Trauma Centers: Association with Patient Outcomes

BACKGROUND State health departments and the American College of Surgeons focus on the availability of optimal resources to designate hospitals as trauma centers, with little emphasis on actual delivery of care. There is no systematic information on clinical practices at designated trauma centers. The objective of this study was to measure compliance with 22 commonly recommended clinical practices at trauma centers and its association with in-hospital mortality. STUDY DESIGN This retrospective observational study was conducted at 5 Level I trauma centers across the country. Participants were adult patients with moderate to severe injuries (n = 3,867). The association between compliance with 22 commonly recommended clinical practices and in-hospital mortality was measured after adjusting for patient demographics and injuries and their severity. RESULTS Compliance with individual clinical practices ranged from as low as 12% to as high as 94%. After adjusting for patient demographics and injury severity, each 10% increase in compliance with recommended care was associated with a 14% reduction in the risk of death. Patients who received all recommended care were 58% less likely to die (odds ratio = 0.42; 95% CI, 0.28-0.62) compared with those who did not. CONCLUSIONS Compliance with commonly recommended clinical practices remains suboptimal at designated trauma centers. Improved adoption of these practices can reduce mortality.

Posttraumatic stress disorder following traumatic injury at 6 months: associations with alcohol use and depression.

BACKGROUND Posttraumatic stress disorder (PTSD) is progressively recognized as a psychological morbidity in injured patients. Participants in a longitudinal study were identified as PTSD positive or PTSD negative at 6 months following injury. Risky alcohol use, depression, demographic, and injury-related variables were explored. METHODS This prospective cohort included patients 18 years or older, admitted to our Level I trauma center. Outcome measures included PTSD Checklist—Civilian Version (PCL-C), Alcohol Use Disorders Identification Test (AUDIT-C), and Patient Health Questionnaire (PHQ-8). Demographic and injury variables were collected. RESULTS A total of 211 participants enrolled in the study, and 118 participants completed measures at both baseline and 6 months. Of the participants, 25.4% (n = 30) screened positive for PTSD at 6 months. The entire sample showed a decline in risky alcohol use at 6 months (p = 0.0043). All PTSD-positive participants at 6 months were also positive for depression (p < 0.0001). For the entire sample, there was a 10% increase in depression from baseline to 6 months (p = 0.03). However, for those participants who were PTSD positive at 6 months, there was a 53% increase in depression from baseline (p = 0.0002) as compared with the group at 6 months without PTSD. Statistically significant differences were found between PTSD-positive and PTSD-negative participants regarding age (40.1 [15.9] vs. 50.9 [18.2], p = 0.0047), male (77% vs. 50%, p = 0.0109), penetrating injury (30% vs. 4%, p < 0.0001), PTSD history (17% vs. 4%, p = 0.0246), or other psychiatric condition (63% vs. 19%, p ⩽ 0.001). CONCLUSION PTSD was not associated with risky alcohol use at 6 months. Surprisingly, risky alcohol use declined in both groups. Incidence of PTSD (25.4%, n = 30) and risky alcohol use (25%, n = 29) were equal at 6 months. Although the American College of Surgeons’ Committee on Trauma requires brief screening and intervention for risky alcohol use owing to societal impact, reinjury rates, and cost effectiveness, our study suggests that screening for psychological conditions may be equally important. LEVEL OF EVIDENCE Prognostic study, level III.

Predictors of PTSD symptoms in adults admitted to a Level I trauma center: a prospective analysis

Trauma centers are an ideal point of intervention in efforts to prevent posttraumatic stress disorder (PTSD). In order to assist in the development of prevention efforts, this study sought to identify early predictors of PTSD symptoms among adults admitted to a Level I trauma center using a novel analytic strategy (Fournier et al., 2009). Upon admission, participants (N=327) were screened for PTSD symptoms and provided information on potential predictor variables. Their PTSD symptoms were assessed again 3 months later (N=227). Participants were classified as symptomatic (positive PTSD screen) or asymptomatic (negative PTSD screen) at the follow-up assessment. Multinomial logistic regression showed that age, depression, number of premorbid psychiatric disorders, gunshot wound, auto vs. pedestrian injury, and alcohol use predicted who had PTSD symptoms at FU with 76.3% accuracy. However, when controlling for PTSD severity at baseline, only age, number of premorbid psychiatric disorders, and gunshot wounds predicted PTSD symptoms at FU but with 78.5% accuracy. These findings suggest that psychological prevention efforts in trauma centers may be best directed toward adults who are young, have premorbid psychiatric disorders, and those admitted with gunshot wounds.

A multisite randomized controlled trial of brief intervention to reduce drinking in the trauma care setting: How brief is brief?

Objective:Determine the efficacy of 3 brief intervention strategies that address heavy drinking among injured patients. Background:The content or structure of brief interventions most effective at reducing alcohol misuse after traumatic injury is not known. Methods:Injured patients from 3 trauma centers were screened for heavy drinking and randomly assigned to brief advice (n = 200), brief motivational intervention (BMI) (n = 203), or BMI plus a telephone booster using personalized feedback or BMI + B (n = 193). Among those randomly assigned, 57% met criteria for moderate to severe alcohol problems. The primary drinking outcomes were assessed at 3, 6, and 12 months. Results:Compared with brief advice and BMI, BMI + B showed significant reductions in the number of standard drinks consumed per week at 3 (&Dgr; adjusted means: −1.22, 95% confidence interval [CI]: −0.99, approximately −1.49, P = 0.01) and 6 months (&Dgr; adjusted means: −1.42, 95% CI: −1.14, approximately −1.76, P = 0.02), percent days of heavy drinking at 6 months (&Dgr; adjusted means: −5.90, 95% CI: −11.40, approximately −0.40, P = 0.04), maximum number of standard drinks consumed in 1 day at 3 (&Dgr; adjusted means: −1.38, 95% CI: −1.18, approximately −1.62, P = 0.003) and 12 months (&Dgr; adjusted means: −1.71, 95% CI: −1.47, approximately −1.99, P = 0.02), and number of standard drinks consumed per drinking day at 3 (&Dgr; adjusted means: −1.49, 95% CI: −1.35, approximately −1.65, P = 0.002) and 6 months (&Dgr; adjusted means: −1.28, 95% CI: −1.17, approximately −1.40, P = 0.01). Conclusions:Brief interventions based on motivational interviewing with a telephone booster using personalized feedback were most effective at achieving reductions in alcohol intake across the 3 trauma centers.

Mild traumatic brain injury increases risk for the development of posttraumatic stress disorder.

BACKGROUND Traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) occur in individuals who sustain physical injury and share a significant overlap in symptoms. PTSD rates in the civilian injury population range from 20% to 40%. The current study examined the presence of PTSD symptoms at multiple time points (3 months and 6 months after injury) among individuals with and without TBI after admission to a Level I trauma center. METHODS This prospective cohort study included patients 18 years and older admitted to a Level I trauma center for 24 hours or greater. Demographic and injury-related data were gathered in addition to assessments of PTSD during initial hospitalization after injury, as well as 3 months and 6 months later. The Primary Care PTSD Screen and PTSD Checklist–Civilian version were used to determine probable PTSD. International Classification of Diseases, 9th Rev. codes were used to determine mild TBI (MTBI). RESULTS A total of 494 patients were enrolled at baseline, 311 (63%) completed 3-month follow-up, and 231 (47%) completed 6-month follow-up at the time of analysis. Preinjury PTSD was reported by 7% of the participants. At 3 months, patients with MTBI evidenced a probable PTSD rate of 18%, compared with a rate of 9% for patients with no MTBI (p = 0.04), although this relationship became a nonsignificant trend (p = 0.06) when demographics were included. At 6 months, patients with MTBI evidenced a probable PTSD rate of 26%, compared with a rate of 15% for patients with no MTBI (p = 0.04), and this relationship remained significant when demographics were included. Preinjury history of TBI did not predict PTSD, but incidence of TBI for the injury in which they were hospitalized did predict PTSD. CONCLUSION TBI at time of injury demonstrated a nonsignificant trend toward higher rates of PTSD at 3 months and significantly predicted PTSD at 6 months after injury. This important finding may help clinicians identify patients at high risk for PTSD after injury and target these patients for screening, intervention, and referral for treatment. LEVEL OF EVIDENCE Prognostic study, level III.

Does caring for trauma patients lead to psychological stress in surgeons

BACKGROUND Symptoms identical to posttraumatic stress disorder (PTSD) have been shown to occur in caregivers of trauma patients. Secondary traumatic stress (STS) characterizes those who exhibit PTSD symptoms related to indirect exposure to a stressor. We hypothesized that caring for trauma patients is associated with symptoms of PTSD/STS. METHODS Surgeons in various specialties (n = 133) were surveyed from January to May 2012 at two regional surgical conferences. Symptoms of PTSD were identified using the Secondary Traumatic Stress Scale (STSS) using specific diagnostic criteria to measure the psychological impact of exposure to trauma patients. Resilience was measured using the Connor-Davidson Resilience Scale 10 items. The amount of time caring for trauma patients was used as a measure of risk exposure. The relationship between STSS, resilience, and exposure to trauma patients was measured with p < 0.05 considered significant. RESULTS Twenty-eight surgeons (22%) met diagnostic symptom criteria for PTSD as measured by the STSS. Approximately two thirds of the surgeons (86 of 133, 65%) exhibited at least one symptom of STS. However, the magnitude of exposure to trauma patients was similar between surgeons with and without PTSD symptoms (p = 0.2177). Higher resilience scores were associated with lower STS scores (r = −0.369, p < 0.0001). Most importantly, surgeons who met symptom criteria for PTSD exhibited significantly lower resilience scores (31 [3.4] vs. 34 [3.9], p < 0.0001). CONCLUSION Symptoms of PTSD as measured by the STSS were reported in two thirds of study participants but did not correlate with time spent for caring for trauma patients. One in five reported symptoms consistent with a PTSD. Lower resilience scores correlated with risk of symptoms and may be used to identify those surgeons most at risk. Efforts to better identify, address, and moderate these psychological consequences of surgical care may improve both the emotional well-being and the vocational performance of surgeons. LEVEL OF EVIDENCE Epidemiologic study, level IV.

Trauma patient readmissions: Why do they come back for more?

BACKGROUND Hospital readmissions are a frequent challenge. Speculation exists that rates of readmission following traumatic injury will be publicly disclosed. The primary aim of this study was to characterize and model 1-year readmission patterns to multiple institutions among patients originally admitted to a single, urban Level I trauma center. Additional analyses within the superutilizers subgroup identified predictors of 30-day readmissions as well as patient loyalty for readmission to their index hospital. We hypothesized that hospital readmission among trauma patients would be associated with socioeconomic, demographic, and clinical features and superutilizers would be identifiable during initial hospitalization. METHODS Data were retrospectively gathered for 2,411 unique trauma patients admitted to a Level I American College of Surgeons–certified trauma center over 1 year, with readmissions identified 1 year after index admission. A regional hospital database was queried for readmissions. Outcomes of all readmission encounters were analyzed using a binary logistic regression model including demographic, diagnoses, Injury Severity Score (ISS), procedures, Elixhauser comorbidities, insurance, and disposition data. Subset analysis of superutilizers was also performed to examine patterns among superutilizers. RESULTS A total of 434 patients (21%) were readmitted during the study period, accounting for 720 readmission encounters. Sixty-three patients accounting for 269 encounters were identified as superutilizers (3+ readmissions). A total of 136 patients (6%) were readmitted within 30 days of initial discharge. Fifty-seven percent of readmissions returned to the originating hospital. CONCLUSION Complications including comorbid disease (diabetes and congestive heart failure), septicemia, weight loss, and trauma recidivism distinguish the superutilizer trauma patient. Having Medicaid funding increased the odds of readmission by 274%. It is imperative that interventions be developed and targeted toward those at high risk of superutilization of health care resources to curb spending. These results strongly support continuation of longitudinal readmission research in trauma patients conducted in multicenter settings. LEVEL OF EVIDENCE Epidemiologic study, level III.