Michael P. Ogilvie

First report on safety and efficacy of hetastarch solution for initial fluid resuscitation at a level 1 trauma center.

BACKGROUND For logistics, the US Army recommends Hextend (Hospira; 6% hetastarch in buffered electrolyte, HET) for battlefield resuscitation. To support this practice, there are laboratory data, but none in humans. To test the hypothesis that HET is safe and effective in trauma, we reviewed our first 6 months of use at a civilian level 1 trauma center. STUDY DESIGN From June 2008 to December 2008, trauma patients received standard of care (SOC) +/- 500 to 1,000 mL of HET within 2 hours of admission at surgeon discretion. Each case was reviewed, with waiver of consent. RESULTS There were 1,714 admissions; 805 received HET and 909 did not. With HET versus SOC, overall mortality was 5.2% versus 8.9% (p = 0.0035) by univariate analysis. Results were similar after penetrating injury only (p = 0.0016) and in those with severe injury, defined by Glasgow Coma Scale <9 (p = 0.0013) or Injury Severity Score >26 (p = 0.0142). After HET, more patients required ICU admission (40.9% vs. 34.5%; p = 0.0334) and transfusions of blood (34.4% vs. 20.2%; p = 0.0014) or plasma (20.7% vs. 12.2%; p = 0.0251), but there were no treatment-related differences in prothrombin time or partial thromboplastin time. The 24-hour urine outputs and requirements for blood, plasma, and other fluids were similar. However, increased early deaths with SOC implicate possible selection bias. If that factor was controlled for with multivariate analysis, the same trends were present, but the apparent treatment effects of HET were no longer statistically significant. CONCLUSIONS In the first trial to date in hemodynamically unstable trauma patients, and the largest trial to date in any population of surgical patients, initial resuscitation with HET was associated with reduced mortality and no obvious coagulopathy. A randomized blinded trial is necessary before these results can be accepted with confidence.

Heart rate variability is an independent predictor of morbidity and mortality in hemodynamically stable trauma patients.

BACKGROUND Reduced heart rate variability (HRV) reflects autonomic dysfunction and can triage patients better than routine trauma criteria or vital signs. However, there is questionable specificity and no consensus measurement technique. The purpose of this study was to analyze whether factors that alter autonomic function affect the specificity of HRV for assessing traumatic injury. METHODS We evaluated 216 hemodynamically stable adults (3:1 M:F; 97:3 blunt:penetrating; age 49 years ± 1 year, mean ± standard error) undergoing computed axial tomography (CT) scan to rule out traumatic brain injury (TBI). All were prospectively instrumented with a Mars Holter system (GE Healthcare, Milwaukee, WI). HRV was determined offline using time domain (standard deviation of normal-normal intervals, root-mean-square successive difference) and frequency domain (very low frequency [VLF], LF, wideband frequency, high frequency [HF], low to HF index ratio) calculations from 15-minute electrocardiogram and correlated with routine vital signs, mortality, TBI, morbidity, length of stay (LOS), and comorbidities. Significance (p ≤ 0.05) was determined using nonparametric analysis, Students t test, analysis of variance, or multiple logistic regression. RESULTS VLF alone predicted survival, severity of TBI, intensive care unit LOS, and hospital LOS (all p < 0.05). Beta-blockers or diabetes had no effect, whereas age, sedation, mechanical ventilation, spinal cord injury, and intoxication influenced one or more of the variables with age being the most powerful confounder (all p < 0.05). Except for the Glasgow Coma Scale, no other routine trauma or hemodynamic criteria correlated with any of these outcomes. CONCLUSIONS Decreased VLF is an independent predictor of mortality and morbidity in hemodynamically stable trauma patients. Other time and other frequency domain variables correlated with some, but not all, outcomes. All were heavily influenced by factors that alter autonomic function, especially patient age.

Microbiology of burn wound infections

One of the most complicated issues that surgeons face, in the care of burn patients, is infection. This includes both superficial and systemic infections. Systemic infection is the leading cause of death in this population. This article will look to review the microbiology of burn wound infections with particular emphasis on classification, host response to burn wound infections, antimicrobial agents, and modern treatment practices.

Predeployment Mass Casualty and Clinical Trauma Training for Us Army Forward Surgical Teams

Since the beginning of the program in 2002, 84 Forward Surgical Teams (FSTs) have rotated through the Army Trauma Training Center (ATTC) at the University of Miami/Ryder Trauma Center including all those deployed to Iraq and Afghanistan. The purpose of this study was to provide the latest updates of our experience with FSTs at the ATTC. Before deployment, each FST participates in a 2-week training rotation at the ATTC. The rotation is divided into 3 phases. Phase 1 is to refresh FST knowledge regarding the initial evaluation and management of the trauma patient. Phase 2 is the clinical phase and is conducted entirely at the Ryder Trauma Center. The training rotation culminates in phase 3, the Capstone exercise. During the Capstone portion of their training, the entire 20-person FST remains at the Ryder Trauma Center and is primarily responsible for the evaluation and resuscitation of all patients arriving over a 24-hour period. Subject awareness concerning their role within the team improved from 71% to 95%, indicating that functioning as a team in the context of the mass casualty training exercise along with clinical codes was beneficial. The clinical component of the rotation was considered by 47% to be the most valuable aspect of the training. Our experience strongly suggests that a multimodality approach is beneficial for preparing a team of individuals with minimal combat (or trauma) experience for the rigors of medical care and triage on the battlefield. The data provided by participants rotating through the ATTC show that through clinical exposure and simulation over a 2-week period, FST performance is optimized by defining provider roles and improving communication. The mass casualty training exercise is a vital component of predeployment training that participants feel is valuable in preparing them for the challenges that lay ahead.

Surgery does not adversely affect survival in primary gastrointestinal lymphoma

To evaluate the impact of surgery on gastrointestinal lymphoma.

Bispectral index to monitor propofol sedation in trauma patients

BACKGROUND This study tested the hypothesis that the bispectral index (BIS) is reliable relative to clinical judgment for estimating sedation level during daily propofol spontaneous awakening trials (SATs) in trauma patients. METHODS This was a prospective observational trial with waiver of consent conducted in the intensive care unit of Level I trauma center in 94 mechanically ventilated trauma patients sedated with propofol alone or in combination with midazolam. BIS, Richmond Agitation Sedation Scale (RASS), electromyography, and heart rate variability, as a test of autonomic function, were measured for 45 minutes during daily SATs. Data were evaluated with analysis of variance, linear regression, and nonparametric tests. RESULTS The BIS wave form coincided almost exactly with propofol on/off. Steady-state BIS correlated with RASS (p < 0.0001) and with propofol dose (p < 0.0001), but the strengths of association were relatively low (all r(2) < 0.5). BIS wave form was not altered by age, heart rate, or heart rate variability and was similar with propofol alone or propofol plus midazolam, but the presence of brain injury or the use of paralytics shifted the curve downward (both p < 0.001). The overall test characteristics for BIS versus RASS without neuromuscular blockade were sensitivity: 90% versus 77% (p = 0.034); specificity: 90% versus 75% (p = 0.021); positive predictive value: 90% versus 76% (p = 0.021), and negative predictive value: 90% versus 76% (p = 0.021). CONCLUSIONS In the first trial in trauma patients and largest trial in any surgical population, the (1) BIS was reliable and has advantages over RASS of being continuous and objective, at least during a propofol SAT; (2) BIS interpretation remains somewhat subjective in patients receiving paralytic agents or with traumatic brain injury.

Emergent cricothyroidotomies for trauma: training considerations

BACKGROUND Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) physician training. We hypothesized that although most cricothyroidotomies for trauma occur in the emergency department (ED), they are usually performed by surgeons. METHODS We conducted a retrospective analysis of all emergent cricothyroidotomies for trauma presentations performed at 2 large level I trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of injury and patient demographics were examined. RESULTS Fifty-four cricothyroidotomies were analyzed. Patients had a mean age of 50 years, 80% were male, and 90% presented as a result of blunt trauma. The most common primary operator was a surgeon (n = 47, 87%), followed by an emergency medical services (EMS) provider (n = 6, 11%) and an EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared with in-hospital procedures (P < .0001). CONCLUSIONS (1) Prehospital cricothyroidotomy results in serious complications. (2) Despite the ubiquitous presence of EM physicians in the ED, all cricothyroidotomies were performed by a surgeon, which may present opportunities for training improvement.

Vasopressin for cerebral perfusion pressure management in patients with severe traumatic brain injury: preliminary results of a randomized controlled trial.

BACKGROUND After traumatic brain injury (TBI), catecholamines (CAs) may be needed to maintain adequate cerebral perfusion pressure (CPP), but there are no recommended alternative vasopressor therapies. This is an interim report of the first study to test the hypothesis that arginine vasopressin (AVP) is a safe and effective alternative to CAs for the management of CPP in patients with severe TBI. METHODS Since 2008, all TBI patients requiring intracranial pressure monitoring at this Level 1 trauma center have been eligible for a randomized trial to receive either CA or AVP if vasopressors were required to maintain CPP greater than 60 mm Hg. RESULTS To date, 96 patients have been consented and randomized. Demographics, vital signs, and laboratory values were similar. As treated, 60 required no vasopressors and were the least severely injured group with the best outcomes. Twenty-three patients received CA (70% levophed, 22% dopamine, 9% phenylephrine) and 12 patients received AVP. The two vasopressor groups had similar demographics, but Injury Severity Score (ISS) and fluid requirements on intensive care unit Day 1 were worse in the AVP versus the CA groups (all p < 0.05) before treatment. These differences indicate more severe injury with accompanying hemodynamic instability. Nevertheless, adverse events were not increased with AVP versus CA. Trends favored AVP versus CA, but no apparent differences were statistically significant at this interim point. There was no difference in mortality rates between CA and AVP. CONCLUSION These preliminary results suggest that AVP is a safe and effective alternative to CA for the management of CPP after TBI and support the continued investigation and use of AVP when vasopressors are required for CPP management in TBI patients. LEVEL OF EVIDENCE Therapeutic study, level II.

Hetastarch during initial resuscitation from trauma.

At the end of the 20th century, the Institute of Medicine reviewed the state of the art for combat casualty and civilian trauma care. Intravenous saline (or crystalloid) solutions were typically the first-line therapy for hypovolemic shock patients to compensate for acute blood loss before transfusions could be safely administered.1 In the first decade of the 21st century, little has changed; isotonic crystalloids remain the standard of care. There are promising data on the salutary actions of several different colloid or hypertonic solutions relative to isotonic crystalloids2–6; but to date, virtually no randomized controlled trial has reported a significant survival benefit of these novel solutions. As of 2006, there were at least 32 randomized controlled trials comparing albumin to crystalloid solutions in 8,452 critically ill patients with hypovolemia or burns, and there was no evidence that albumin reduced mortality when compared with cheaper alternatives.7 As of 2007, there were at least 55 randomized controlled trials of colloids compared with crystalloids, and there was no evidence that colloids reduced the risk of death compared with crystalloids in 7,754 patients with trauma or burns or after surgery.8 As of 2008, a review of 70 trials in 4,375 patients found no evidence that any one colloid solution is safer or more effective than any other.9 Because colloids are not associated with an improvement in survival and because they are more expensive than crystalloids, some thought that leaders, especially in the civilian sector, are convinced that continued use of colloids in trauma patients cannot be justified outside the context of randomized controlled trials.8 For the military, on the other hand, colloids and other low-volume resuscitation solutions are attractive alternatives, because they have unique advantages in austere environments where supplies are limited and evacuation times can be delayed. For these logistic reasons because of its reduced weight and size relative to saline solutions, Hextend (HEX, 6% hetastarch in lactated electrolyte buffer; www.hospira.com) was recommended for fluid resuscitation of combat casualties.10,11 HEX is a colloid approved by the US Food and Drug Administration that is indicated for use in hypovolemia during elective surgery.12 Despite these recommendations, saline solutions are still commonly used on the battlefield. Furthermore, many civilian or military clinicians avoid any artificial colloid solutions after trauma because of generalized concerns about anaphylaxis,1 coagulopathy,13 and/or catastrophic bleeding.14 In fact, the few studies that have addressed the coagulation profile of HEX have been inconclusive15–18; and there are no data on the safety and efficacy of HEX at the doses typically used for initial trauma resuscitation, except for several previous studies in various animal models.19–23 Ogilvie et al.24 attempted to fill this gap by examining the safety and efficacy of HEX at a Level I trauma center, with particular focus on the risk of coagulopathy. From June to December 2008, HEX was available as a therapeutic option for all nonburn patients. At the discretion of the admitting surgeon, 500 mL to 1,000 mL of HEX was administered during initial fluid resuscitation. Apart from this initial bolus of HEX, care was otherwise identical in all patients and in exact accordance with advanced trauma life support guidelines. Fluids, blood products, vasopressors, and/or any other drugs were administered as needed. Review of pharmacy records and nursing notes was approved by the Institutional Review Board of the University of Miami and by the Clinical Trials Office of Jackson Memorial Hospital with waiver of informed consent. This study was registered as NCT00527098 on www.clinicaltrials.gov. There were 1,714 admissions; 805 received HEX and 909 did not. The characteristics and demographics were identical between the two groups in terms of age, gender, hemodynamics, laboratory values, Glasgow coma scale score, and Injury Severity Score at the scene and on admission to the trauma resuscitation unit. With standard of care, the population was primarily male (78.9%) with blunt injury (72.8%); with standard of care HEX, the distribution was similar for gender (80.9%) and type of trauma (74.7%). These values are typical for any large, mostly urban, trauma population.24 With HEX versus standard of care, there were reduced early deaths (p 0.0001) and overall mortality (5.2% vs. 8.9%; p 0.0035) by univariate analysis. Results were similar after penetrating injury only (p 0.0016) and in those with severe injury, defined by the Glasgow coma scale score 9 (p 0.0013) or Injury Severity Score 26 (p 0.0142). Consistent with early salvage of otherwise lethal injury, after HEX, more required admission to the intensive care unit (40.9% vs. 34.5%; p 0.0334) and transfusions of blood (34.4% vs. 20.2%; p 0.0014) or plasma (20.7% vs. 12.2%; p 0.0251). Consistent with safety, in the intensive care unit Submitted for publication February 11, 2011. Accepted for publication March 14, 2011. Copyright

Pediatric Facial Trauma: A Review of Guidelines for Assessment, Evaluation, and Management in the Emergency Department

Approximately 22 million children in the United States sustain traumatic injuries every year, the etiologies of which vary with age as well as social and environmental factors. If not managed properly, these injuries can have a significant impact on future growth and development. Evaluation of facial injuries presents a unique diagnostic challenge in this population, as differences from adult anatomy and physiology can result in vastly different injury profiles. The increased ratio of the cranial mass relative to the body leaves younger patients more vulnerable to craniofacial trauma. It is essential that the treating physician be aware of these variations to properly assess and treat this susceptible and fragile patient population and ensure optimal outcomes. This article reviews the proper emergency department assessment and treatment of facial fractures in the pediatric population as well as any associated injuries, with particular emphasis on initial patient stabilization, radiological evaluation, and therapeutic options.