Michael L. Hawkins

Serious traumatic brain injury: An evaluation of functional outcomes

OBJECTIVES Evaluate independent living, productivity, and social outcomes of patients with serious traumatic brain injury (TBI) after inpatient rehabilitation. METHODS Fifty-five adults with serious TBI (Abbreviated Injury Scale score > or = 3) were admitted to a Level I trauma center and subsequently transferred to a comprehensive inpatient rehabilitation hospital (Walton Rehabilitation Hospital). Functional Independence Measures were obtained at admission (Adm), discharge (D/C), and at 3- (n = 52) and 1-year (n = 51) follow-up. RESULTS At 1 year, 90% of the patients were living at home. Eight (16%) required full-time supervision, while 41 (82%) were independent of supervision throughout most of the day. Thirteen (25%) patients had returned to work, eight full time and five with reduced responsibility and fewer hours than before injury. Nineteen shared household duties, while eight (16%) had primary responsibility. Fourteen (27%) patients demonstrated socially inappropriate or disruptive behavior at least weekly. [table: see text] CONCLUSION Although cognitive skills were diminished for the majority of patients, many achieved a substantial reduction in disability within 18 months after TBI.

Deer stands: a significant cause of injury and mortality.

Deer hunting is a popular recreational activity in the United States. Although the risks associated with firearms are well known, the hazards related to deer stands are not widely appreciated. From September 1982 through December 1989, there were 19 patients admitted to the Medical College of Georgia Hospital and Clinics for injuries sustained from falls related to deer stands. One death occurred, and six of the 18 survivors remain paralyzed. Data from 18 of these patients showed that 83% of these falls (15/18) were associated with hunter-constructed stands. Structural failure accounted for 39% (7/18) of the accidents; other causes included carelessness, falling asleep, and medical events. Four of the 19 patients (21%) had elevated blood alcohol levels on admission. Fracture of the spine and long bones accounted for the majority of the injuries, and seven of the 18 survivors (39%) were hospitalized for more than 4 weeks. Eight of the survivors (44%) remain permanently disabled. Deer-stand-related falls may result in significant long-term disability, expensive and lengthy hospitalization, and even death. A preventive approach to these injuries is paramount, and published guidelines for safety while hunting from deer stands should be followed.

Percutaneous peritoneal lavage in blunt trauma patients: a safe and accurate diagnostic method.

We reviewed the records of 395 patients seen from January 1983 through May 1988, who after sustaining blunt thoracoabdominal trauma had diagnostic peritoneal lavage (DPL) performed percutaneously by the Seldinger wire technique of Lazarus and Nelson. The test was considered grossly positive if 10 cc of blood were aspirated from the catheter immediately after its insertion into the peritoneal cavity. Microscopic criteria for positivity included more than 100,000 RBC or 500 WBC/cc of lavage return, elevated amylase or bilirubin, or the presence of vegetable fibers or bacteria. Seventy-two (18%) of the patients were true positives and 315 (80%) were true negatives. There were four false positives (1.3%) and one false negative (0.2%), giving the test a sensitivity of 99% and a specificity of 98%. Complications occurred in three patients, for a rate of 0.8%, and included catheter insertion into a large ovarian dermoid cyst, needle perforation of the ileum, and needle perforation of the sigmoid colon. This technique of DPL can consistently be performed much more rapidly than the open method. Therefore we conclude that percutaneous DPL is as accurate as, as safe as, and quicker than open DPL for determining intra-abdominal injury in blunt trauma patients.

Pharmacokinetics of reconstituted human high-density lipoprotein in pigs after hemorrhagic shock with resuscitation

OBJECTIVES Reconstituted human high-density lipoprotein (HDL) can inhibit lipopolysaccharide effects in vivo. The major objectives of this study were to characterize the pharmacokinetics of reconstituted HDL in a stressed large-animal model and to provide preclinical tolerance information in support of use of reconstituted HDL in humans. DESIGN A randomized, blinded, placebo-controlled trial where each animal received either reconstituted human HDL at a dose of 100 mg/kg (apolipoprotein A-I) or placebo, immediately after hemorrhagic shock and resuscitation. SETTING Animal laboratory. SUBJECTS Twelve immature female swine (18 to 25 kg) were studied. INTERVENTIONS Six to 8 days before shock and study drug administration, animals were anesthesized and catheters were placed in the external jugular vein and abdominal aorta. These catheters were secured to the dorsal surface. On the day of shock, the animals were sedated (alpha-chloralose) and 50 mL/kg of arterial blood was removed over 0.5 hr. One half hour after blood removal, shed blood was infused, which was immediately followed by study drug (reconstituted HDL or placebo), and then by 1 L of lactated Ringers solution. MEASUREMENTS AND MAIN RESULTS Physiologic (arterial blood pressure, heart rate, respiratory rate) and laboratory (serum chemistries, hematologic and coagulation studies, and blood gases) measurements were determined intermittently for 96 hrs after the induction of shock. Blood was collected intermittently for 48 hrs after shock for assay of apolipoprotein A-I and phosphatidylcholine in plasma. Reconstituted HDL was well tolerated and did not appear to alter the physiologic responses to shock and resuscitation. HDL transient increase in aspartate aminotransferase concentration was noted in the reconstituted group but this increase normalized by 24 hrs after drug administration. Mean apolipoprotein A-I pharmacokinetic parameters were as follows: half-life 24.5+/-5.3 (SD) hrs; clearance 41.9+/-10 mL/hr; and volume of distribution 1.39+/-0.08 L. The apparent mean half-life of phosphatidylcholine was 5.4+/-0.8 hrs. CONCLUSIONS Reconstituted human HDL was well tolerated in animals that had undergone hemorrhagic shock with resuscitation. The apolipoprotein component of reconstituted HDL had a relatively long half-life, with distribution limited to the vascular space. These findings support the investigational use of this product in humans.

Demographic Differences in Systemic Inflammatory Response Syndrome Score After Trauma

BACKGROUND Demographic differences in health outcomes have been reported for chronic diseases, but few data exist on these differences in trauma (defined as acute, life-threatening injuries). OBJECTIVE To investigate the relationship between the systemic inflammatory response syndrome score after trauma and race/ethnicity and socioeconomic status. METHODS A retrospective chart review of 600 patients from a level I trauma center (1997-2007) was conducted. Inclusion criteria were age 18 to 44 years, Injury Severity Score 15 or greater, and admission to an intensive care unit. Exclusion criteria were use of transfusions, spinal cord injuries, comorbid conditions affecting the inflammatory response, use of nonsteroidal anti-inflammatory medications, and missing data (final sample, 246 charts/patients). Systemic inflammatory response syndrome was measured by using the systemic inflammatory response syndrome score. Race was self-reported. Socioeconomic status was defined by insurance and employment. Descriptive statistics, Wilcoxon rank sum, Kruskal-Wallis, and χ(2) tests were used for analysis. RESULTS Compared with whites, African Americans (n = 94) had fewer occurrences of the syndrome (P = .04) and a 14% lower white blood cell count on admission to the intensive care unit (mean, 15,200/μL; 95% CI, 14,400/μL to 16,000/μL vs mean 17,700/μL; 95% CI, 16,700/μL to 18,700/μL; P < .001). CONCLUSIONS Demographic differences exist in the systemic inflammatory response syndrome score after trauma. Additional studies in larger populations of patients are needed as well as basic science and translational research to determine potential mechanisms that may explain the differences.

Physiologic amputation prevents myoglobinuria from lower extremity myonecrosis

Myoglobinuria secondary to myonecrosis is a proven cause of renal failure, especially in critically ill patients. Physiologic amputation or cryoamputation has been used at our institution for the past two decades as a safe and effective treatment for lower extremity infection, intractable rest pain, and irreversible myonecrosis. We retrospectively studied five critically ill patients with myonecrosis of lower extremities associated with myoglobinuria. The etiology of myonecrosis included preexisting peripheral vascular disease or crush injury to the lower extremities. It was determined that all five patients were too ill to undergo emergency amputation. Myoglobinuria was documented in all five patients and cleared within 24 hours of physiologic amputation in four patients. All five patients had elevated creatine phosphokinase levels (mean 20,270 mU/mL, range 12,090 to 43,164 mU/mL) that significantly decreased within 48 hours of physiologic amputation (mean 6,488 mU/mL, range 2,250 to 13,580 mU/mL). Mechanical ventilation and cardiovascular support were required in four patients. All patients had transient episodes of renal insufficiency with two progressing to anuric renal failure and requiring dialysis. One patients renal failure resolved after 56 days, but the other patient died of a cerebrovascular accident 22 days after initiation of physiologic amputation. The mean duration of physiologic amputation was 15.6 days (range 5 to 32 days) with no significant complication due to physiologic amputation. All five patients had surgical amputation successfully. Three patients survived. The two deaths in the study were due to a cerebrovascular accident in one patient and a cardiopulmonary arrest in another. Physiologic amputation is a treatment option that halts myonecrosis, prevents myoglobinuria, and lessens the risk of associated acute renal failure. Physiologic amputation may be appropriately used in patients with myoglobinuria due to extremity myonecrosis who are deemed too critically ill to survive emergency amputation.

It takes a village to raise research productivity: Impact of a Trauma Interdisciplinary Group for Research (TIGR) at an urban, Level 1 trauma center.

BACKGROUND Few interdisciplinary research groups include basic scientists, pharmacists, therapists, nutritionists, laboratory technicians, as well as trauma patients and families, in addition to clinicians. Increasing interprofessional diversity within scientific teams working to improve trauma care is a goal of national organizations and federal funding agencies such as the National Institutes of Health (NIH). This article describes the design, implementation, and outcomes of a Trauma Interdisciplinary Group for Research (TIGR) at a Level 1 trauma center as it relates to increasing research productivity, with specific examples excerpted from an ongoing NIH-funded study. METHODS We used a pretest/posttest design with objectives aimed at measuring increases in research productivity following a targeted intervention. A SWOT (strengths, weaknesses, opportunities, and threats) analysis was used to develop the intervention, which included research skill-building activities, accomplished by adding multidisciplinary investigators to an existing NIH-funded project. The NIH project aimed to test the hypothesis that accelerated biologic aging from chronic stress increases baseline inflammation and reduces inflammatory response to trauma (projected n = 150). Pre-TIGR/post-TIGR data related to participant screening, recruitment, consent, and research processes were compared. Research productivity was measured through abstracts, publications, and investigator-initiated projects. RESULTS Research products increased from 12 to 42 (approximately 400%). Research proposals for federal funding increased from 0 to 3, with success rate of 66%. Participant screenings for the NIH-funded study increased from 40 to 313. Consents increased from 14 to 70. Laboratory service fees were reduced from

Systemic Inflammatory Response Syndrome Score and Race As Predictors of Length of Stay in the Intensive Care Unit

300 per participant to

Diagnostic peritoneal lavage in blunt trauma

5 per participant. CONCLUSION Adding diversity to our scientific team via TIGR was exponentially successful in (1) improving research productivity, (2) reducing research costs, and (3) increasing research products and mentoring activities that the team before TIGR had not entertained. The team is now well positioned to apply for more federally funded projects, and more trauma clinicians are considering research careers than before.

Ultrarapid diagnostic peritoneal lavage

BACKGROUND Identifying predictors of length of stay in the intensive care unit can help critical care clinicians prioritize care in patients with acute, life-threatening injuries. OBJECTIVE To determine if systemic inflammatory response syndrome scores are predictive of length of stay in the intensive care unit in patients with acute, life-threatening injuries. METHODS Retrospective chart reviews were completed on patients with acute, life-threatening injuries admitted to the intensive care unit at a level I trauma center in the southeastern United States. All 246 eligible charts from the trauma registry database from 1998 to 2007 were included. Systemic inflammatory response syndrome scores measured on admission were correlated with length of stay in the intensive care unit. Data on race, sex, age, smoking status, and injury severity score also were collected. Univariate and multivariate regression modeling was used to analyze data. RESULTS Severe systemic inflammatory response syndrome scores on admission to the intensive care unit were predictive of length of stay in the unit (F=15.83; P<.001), as was white race (F=9.7; P=.002), and injury severity score (F=20.23; P<.001). CONCLUSIONS Systemic inflammatory response syndrome scores can be measured quickly and easily at the bedside. Data support use of the score to predict length of stay in the intensive care unit.