Randall S. Friese

Selective Nonoperative Management of Blunt Splenic Injury: An Eastern Association for the Surgery of Trauma Practice Management Guideline

BACKGROUND During the last century, the management of blunt force trauma to the spleen has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the Practice Management Guidelines for Non-operative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the current EAST guideline. METHODS The National Library of Medicine and the National Institute of Health MEDLINE database was searched using Pub Med (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords splenic injury and blunt abdominal trauma. RESULTS One hundred seventy-six articles were reviewed, of which 125 were used to create the current practice management guideline for the selective nonoperative management of blunt splenic injury. CONCLUSION There has been a plethora of literature regarding nonoperative management of blunt splenic injuries published since the original EAST practice management guideline was written. Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and has an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries. Repeat imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography with embolization are increasingly important adjuncts to nonoperative management of splenic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt splenic injuries remain without conclusive answers in the literature.

Increasing trauma deaths in the United States

Objective:To determine the impact of the increasing aging population on trauma mortality relative to mortality from cancer and heart disease in the United States. Background:The population in the United States continues to increase as medical advancements allow people to live longer. The resulting changes in the leading causes of death have not yet been recognized. Methods:Data were obtained (2000–2010) from the Web-based Injury Statistics Query and Reporting System database of the Centers for Disease Control and Prevention. We defined trauma deaths as unintentional injuries, suicides, and homicides. Results:From 2000 to 2010, the US population increased by 9.7% and the number of trauma deaths increased by 22.8%. Trauma deaths and death rates deceased in individuals younger than 25 years but increased for those 25 years and older. During this period, death rates for cancer and heart disease decreased. The largest increases in trauma deaths were in individuals in their fifth and sixth decades of life. Since 2000, the largest proportional increase (118%) in crude trauma deaths occurred in 54-year-olds. Overall, in 2010, trauma was the leading cause of death in individuals 46 years and younger. Trauma remains the leading cause of years of life lost. Results:Trauma is now the leading cause of death for individuals 46 years and younger. The largest increase in the number of trauma deaths and the highest crude number of trauma deaths occurred in baby boomers. Policy makers allocating resources should be made aware of the larger impact of trauma on our aging and burgeoning US population.

Sleep and recovery from critical illness and injury: A review of theory, current practice, and future directions*

Objective:The objectives of this article were to describe the deleterious effects of sleep deprivation, characterize sleep in patients cared for in an intensive care unit (ICU) environment, and propose an integrated strategy to improve sleep in critical care units. Study Selection:Clinical trials and review articles assessing sleep deprivation, sleep in a critical care setting, and interventions to improve sleep in the critical care environment were identified through an in depth PubMed search. Conclusions:Sleep deprivation and disruption are particularly prevalent in patients cared for in the critical care environment. Although numerous observational studies during the past several decades have demonstrated that sleep in patients cared for in ICUs is highly abnormal, little is known about the effects of poor sleep quality on outcomes from critical illness or injury. Reasons for sleep deprivation during recovery from illness and injury in the ICU are multifactorial. Major contributing factors in this patient population are type and severity of underlying illness, the pathophysiology of acute illness/injury, pain from surgical procedures, and perhaps most importantly, the ICU environment itself. Sleep in ICU patients is characterized by prolonged sleep latencies, sleep fragmentation, decreased sleep efficiency, frequent arousals, a predominance of stage 1 and 2 nonrapid eye movement sleep, decreased or absent stage 3 and 4 nonrapid eye movement sleep, and decreased or absent rapid eye movement sleep. Optimizing patient comfort and ensuring that patients achieve adequate restorative sleep while cared for in the ICU is an arduous task. However, environmental alterations in the ICU may reliably improve sleep quality and subsequently alter outcomes during recovery from critical illness and injury.

Superiority of frailty over age in predicting outcomes among geriatric trauma patients: A prospective analysis

IMPORTANCE The Frailty Index (FI) is a known predictor of adverse outcomes in geriatric patients. The usefulness of the FI as an outcome measure in geriatric trauma patients is unknown. OBJECTIVE To assess the usefulness of the FI as an effective assessment tool in predicting adverse outcomes in geriatric trauma patients. DESIGN, SETTING, AND PARTICIPANTS A 2-year (June 2011 to February 2013) prospective cohort study at a level I trauma center at the University of Arizona. We prospectively measured frailty in all geriatric trauma patients. Geriatric patients were defined as those 65 years or older. The FI was calculated using 50 preadmission frailty variables. Frailty in patients was defined by an FI of 0.25 or higher. MAIN OUTCOMES AND MEASURES The primary outcome measure was in-hospital complications. The secondary outcome measure was adverse discharge disposition. In-hospital complications were defined as cardiac, pulmonary, infectious, hematologic, renal, and reoperation. Adverse discharge disposition was defined as discharge to a skilled nursing facility or in-hospital mortality. Multivariate logistic regression was used to assess the relationship between the FI and outcomes. RESULTS In total, 250 patients were enrolled, with a mean (SD) age of 77.9 (8.1) years, median Injury Severity Score of 15 (range, 9-18), median Glasgow Coma Scale score of 15 (range, 12-15), and mean (SD) FI of 0.21 (0.10). Forty-four percent (n = 110) of patients had frailty. Patients with frailty were more likely to have in-hospital complications (odds ratio, 2.5; 95% CI, 1.5-6.0; P = .001) and adverse discharge disposition (odds ratio, 1.6; 95% CI, 1.1-2.4; P = .001). The mortality rate was 2.0% (n = 5), and all patients who died had frailty. CONCLUSIONS AND RELEVANCE The FI is an independent predictor of in-hospital complications and adverse discharge disposition in geriatric trauma patients. This index should be used as a clinical tool for risk stratification in this patient group.

Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline

Background During the last century, the management of blunt force trauma to the liver has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma in the Practice Management Guidelines for Nonoperative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the previous Eastern Association for the Surgery of Trauma guideline. Methods The National Library of Medicine and the National Institutes of Health MEDLINE database were searched using PubMed (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords liver injury and blunt abdominal trauma. Results One hundred seventy-six articles were reviewed, of which 94 were used to create the current practice management guideline for the selective nonoperative management of blunt hepatic injury. Conclusion Most original hepatic guidelines remained valid and were incorporated into the greatly expanded current guidelines as appropriate. Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age. Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries. Repeated imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography, percutaneous drainage, endoscopy/endoscopic retrograde cholangiopancreatography and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature.

Pulmonary artery catheter use is associated with reduced mortality in severely injured patients: A National Trauma Data Bank analysis of 53,312 patients*

Objective:To evaluate the association between pulmonary artery catheter (PAC) use and mortality in a large cohort of injured patients. We hypothesized that PAC use is associated with improved survival in critically injured trauma patients. Design:Retrospective database analysis. Setting:A total of 268 level 1 trauma centers from across the United States. Patients:A total of 53,312 patients admitted to the intensive care units of the trauma centers participating in the National Trauma Data Bank maintained by the American College of Surgeons. Measurements and Main Results:The National Trauma Data Bank was queried to identify patients aged 16–90 yrs with complete data on base deficit, and Injury Severity Score (n = 53,312). Patients were initially divided into two groups: those managed with a PAC (n = 1,933) and those managed without a PAC (n = 51,379). Chi-square and Student’s t-test analysis were utilized to explore group differences in mortality. In a second analysis, groups were stratified by base deficit, Injury Severity Score, and age to further explore the influence of injury severity on PAC use and mortality. In addition, a logistic regression model was developed to assess the relationship between PAC use and mortality after adjusting for differences in age, mechanism, injury severity, injury pattern, and co-morbidities. Overall, patients managed with a PAC were older (45.8 ± 21.3 yrs), had higher Injury Severity Score (28.4 ± 13.5), worse base deficit (−5.2 ± 6.5), and increased mortality (PAC, 29.7%; no PAC, 9.8%; p < .001). However, after stratification for injury severity, PAC use was associated with a survival benefit in four subgroups of patients. Each of these groups had advanced age or increased injury severity. Specifically, patients aged 61–90 yrs, with arrival base deficit worse than −11 and Injury Severity Score of 25–75, had a decrease in the risk of death with PAC use (odds ratio, 0.33; 95% confidence interval, 0.17–0.62). Three additional groups had a similar decrease in the risk of death with PAC use: odds ratio, 0.60 (95% confidence interval, 0.43–0.83), 0.82 (95% confidence interval, 0.44–1.52), and 0.63 (95% confidence interval, 0.40–0.98). Logistic regression analysis demonstrated a decreased mortality when a PAC was used in the management of patients with the following severe injury characteristics: Injury Severity Score of 25–75, base deficit of less than −11, or age of 61–90 yrs (odds ratio, 0.593; 95% confidence interval, 0.437–0.805). Conclusions:Trauma patients managed with a PAC are more severely injured and have a higher mortality. However, severely injured patients (Injury Severity Score, 25–75) who arrive in severe shock, and older patients, have an associated survival benefit when managed with a PAC. This is the first study to demonstrate a benefit of PAC use in trauma patients.

Accuracy of cardiac function and volume status estimates using the bedside echocardiographic assessment in trauma/critical care.

BACKGROUND Critically ill patients often require invasive monitoring to evaluate and optimize cardiac function and preload. With questionable outcomes associated with pulmonary artery catheters (PACs), some have evaluated the role of less invasive monitors. We hypothesized that the Bedside Echocardiographic Assessment in Trauma (BEAT) examination would generate cardiac index (CI) and central venous pressure (CVP) estimates that correlate with that of a PAC. METHODS BEAT was performed on all SICU patients with a PAC in place. Prospective data included stroke volume and the inferior vena cava (IVC) diameter. The CI was calculated and correlated with that from the PAC. Each CI was then categorized as low, normal, or high. The IVC diameter was used to estimate the CVP. The association between the BEAT and PAC estimates of CI and CVP was evaluated using chi. RESULTS Eighty-five BEAT examinations were performed, 57% on trauma and 37% on general surgery patients. Fifty-nine percent of the CI examinations and 97% of the IVC examinations contained quality images. Of these, the overall correlation coefficient was 0.70 (p < 0.0001). When CI was categorized, there was a significant association between the BEAT and PAC (p = 0.021). There was a significant association between the CVP estimate from the BEAT examination and the PAC (p = 0.031). CONCLUSION Our data show a significant correlation between the CI and CVP estimates obtained from the BEAT examination and that from a PAC. BEAT provides a noninvasive method of evaluating cardiac function and volume status. Bedside echocardiography is teachable and should become a part of future critical care curricula.

Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma.

BACKGROUND Occult diaphragm injury after penetrating thoracoabdominal injury can be difficult to diagnose and can remain occult for months to years. Delayed diagnosis is associated with the risk of hernia formation, strangulation, and high morbidity and mortality. Although laparoscopy has been proposed as a means of evaluating the diaphragm in these patients, prior studies did not include a confirmatory procedure or did not report long-term follow-up. Thus, true sensitivity and specificity remain unknown. The purpose of this study was to determine the sensitivity and specificity of laparoscopy for the detection of diaphragm injury after penetrating thoracoabdominal trauma. We hypothesized that laparoscopy alone is sufficient to exclude diaphragm injury after penetrating thoracoabdominal trauma. METHODS We conducted a prospective case series of 34 hemodynamically normal asymptomatic patients with thoracoabdominal penetrating injuries. All patients underwent diagnostic laparoscopy to evaluate the diaphragm for the presence of injury. All patients then underwent confirmatory celiotomy (n = 30) or video-assisted thoracoscopy (n = 4). RESULTS All patients were men between the ages of 18 and 54 years. There were 37 stab wounds and 1 gunshot wound. The mean lowest preoperative systolic blood pressure recorded was 120 +/- 18 mm Hg. Penetrating injuries were stratified by anatomic location (anterior, 18; posterior, 8; flank, 9; not specified, 3). There were 7 true-positive, 30 true-negative, no false-positive, and 1 false-negative result. Specificity, sensitivity, and negative predictive value were 100%, 87.5%, and 96.8%, respectively. The single missed injury occurred in a patient with hemoperitoneum from associated splenic injury that obscured the diaphragm and warranted celiotomy. CONCLUSION In asymptomatic hemodynamically normal patients with penetrating thoracoabdominal injury, laparoscopy alone is sufficient to exclude diaphragmatic injury.

Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis.

BACKGROUND The rate of mortality and factors predicting worst outcomes in the geriatric population presenting with trauma are not well established. This study aimed to examine mortality rates in severe and extremely severe injured individuals 65 years or older and to identify the predictors of mortality based on available evidence in the literature. METHODS We performed a systematic literature search on studies reporting mortality and severity of injury in geriatric trauma patients using MEDLINE, PubMed, and Web of Science. RESULTS An overall mortality rate of 14.8% (95% confidence interval [CI], 9.8–21.7%) in geriatric trauma patients was observed. Increasing age and severity of injury were found to be associated with higher mortality rates in this patient population. Combined odds of dying in those older than 74 years was 1.67 (95% CI, 1.34–2.08) compared with the elderly population aged 65 years to 74 years. However, the odds of dying in patients 85 years and older compared with those of 75 years to 84 years was not different (odds ratio, 1.23; 95% CI, 0.99–1.52). A pooled mortality rate of 26.5% (95% CI, 23.4–29.8%) was observed in the severely injured (Injury Severity Score [ISS] ≥ 16) geriatric trauma patients. Compared with those with mild or moderate injury, the odds of mortality in severe and extremely severe injuries were 9.5 (95% CI, 6.3–14.5) and 52.3 (95% CI, 32.0–85.5; p ⩽ 0.0001), respectively. Low systolic blood pressure had a pooled odds of 2.16 (95% CI, 1.59–2.94) for mortality. CONCLUSION Overall mortality rate among the geriatric population presenting with trauma is higher than among the adult trauma population. Patients older than 74 years experiencing traumatic injuries are at a higher risk for mortality than the younger geriatric group. However, the trauma-related mortality sustains the same rate after the age of 74 years without any further increase. Moreover, severe and extremely severe injuries and low systolic blood pressure at the presentation among geriatric trauma patients are significant risk factors for mortality. LEVEL OF EVIDENCE Systematic review and meta-analysis, level IV.

Sleep in the Intensive Care Unit

Sleep is an important physiologic process, and lack of sleep is associated with a host of adverse outcomes. Basic and clinical research has documented the important role circadian rhythm plays in biologic function. Critical illness is a time of extreme vulnerability for patients, and the important role sleep may play in recovery for intensive care unit (ICU) patients is just beginning to be explored. This concise clinical review focuses on the current state of research examining sleep in critical illness. We discuss sleep and circadian rhythm abnormalities that occur in ICU patients and the challenges to measuring alterations in circadian rhythm in critical illness and review methods to measure sleep in the ICU, including polysomnography, actigraphy, and questionnaires. We discuss data on the impact of potentially modifiable disruptors to patient sleep, such as noise, light, and patient care activities, and report on potential methods to improve sleep in the setting of critical illness. Finally, we review the latest literature on sleep disturbances that persist or develop after critical illness.