Richard W. Virgilio

AN ANALYSIS OF ERRORS CAUSING MORBIDITY AND MORTALITY IN A TRAUMA SYSTEM: A GUIDE FOR QUALITY IMPROVEMENT

The purpose of auditing trauma care is to maintain quality assurance and to guide quality improvement. This study was conducted to identify the incidence, type, and setting of errors leading to morbidity and mortality in trauma patients. Determinations of the Medical Audit Committee of San Diego County were reviewed and classified by the authors for identification of preventable errors leading to morbidity or mortality. Errors were classified by type and categorized by phase of care. Errors were identified in the cases of 4% of all patients admitted for trauma care over a 4-year period. Of all trauma patient deaths, 5.9% were considered preventable or potentially preventable. The most common single error across all phases of care was failure to appropriately evaluate the abdomen. Although errors in the resuscitative and operative phases were more common, critical care errors had the greatest impact on preventable death. The detected error rate of 4% may represent the baseline error rate in a trauma system. While regionalized trauma care has dramatically reduced the incidence of preventable death after injury, efforts to further reduce preventable morbidity and mortality may be guided by an identification of common errors in a trauma system and their relationship to outcome.

The Effect of Prehospital Fluids on Survival in Trauma Patients

The effect of prehospital intravenous fluids upon survival was studied in 6,855 trauma patients. Mean prehospital time was 36 minutes in both the group of patients who received fluids and the group that did not. The volume of fluid administered was not significantly different in the group who survived compared to those who died. Eighty-five per cent of the patients had an Injury Severity Score (ISS) less than 25 and the mortality rate in the 56% of patients in this group who received fluids was similar to that of the patients who did not receive fluids (0.7% vs. 0.5%). Twelve per cent of the patients had an ISS between 25 and 50. Sixty per cent of these patients received fluids and the mortality rates were similar to the patients who received fluids compared to those who did not (23% vs. 22%). Three per cent of patients had an ISS of greater than 50 and the mortality rate was highest in this group but was not influenced by the administration of fluids (90% vs. 86%). Comparison of groups with similar probability of survival according to the TRISS methodology also failed to show an influence of fluid administration on survival. The mortality rate in patients with an initial systolic blood pressure (BP) of 90 torr or greater was compared to the rate in patients with an admission BP less than 90 torr. Although hypotension was associated with a significantly higher mortality rate, the administration of fluids had no influence on this rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Complications of the flow-directed pulmonary artery catheter: A prospective analysis in 219 patients.

In order to determine and analyze the complication rate of the insertion and maintenance of the balloontipped, flow-directed pulmonary artery catheter (PAC), the authors prospectively studied the use of 320 catheters in 219 critically ill patients. Mean patient age was 53 ± 1 years, and 36% had a history of cardiovascular disease. Mean duration of catheterization averaged 76 ± 3 h. Major complications occurred in 3% of catheterizations. These included six pneumothoraces; three arrhythmias requiring treatment, one of which was fatal; and one subclavian vein thrombosis. Site complications occurred more frequently in catheters maintained longer than 72 h. These findings suggest that, when indicated in the care of critically ill patients, the properly placed and maintained PAC has an acceptably low morbidity and mortality rate, particularly when used for 72 h or less.

Lymph and pulmonary response to isobaric reduction in plasma oncotic pressure in baboons.

Plasma colloid osmotic pressure was reduced by 76% (from 19.6 ± 0.6 to 4.7 ± 1.5 mm Hg) in five baboons while pulmonary capillary hydrostatic pressure was maintained at a normal level. This resulted in fluid retention, weight gain, peripheral edema and ascites, but no pulmonary edema. Thoracic duct lymph flow increased 6-fold and pulmonary lymph flow 7-fold. Thoracic duct lymph had a lower colloid osmotic pressure (2.0 ± 0.7 mm Hg) than plasma (4.7 ± 1.5 mm Hg), whereas the colloid osmotic pressure of pulmonary lymph (4.7 ± 0.7 mm Hg) was the same as that of plasma. The lymph-plasma ratio for albumin fell in thoracic duct lymph but remained unchanged in pulmonary lymph. The difference between plasma colloid osmotic pressure and pulmonary artery wedge pressure decreased from 15.3 ± 1.9 to −0.7 ± 2.9 mm Hg. Despite this increase in filtration force, the lungs were protected from edema formation by a decrease of 11 mm Hg in pulmonary interstitial colloid osmotic pressure and a 7-fold increase in lymph flow.

Echographic Evaluation of Splenic Injury after Blunt Trauma

In a significant number of patients with blunt abdominal trauma, the diagnosis of ruptured spleen is not readily apparent. Is is in these cases that echographic evaluation appears to aid significantly in diagnosis. Seventy patients with blunt abdominal trauma were studied by echography. Results indicated 61 true negative cases, 1 false negative, 4 true positives, and 4 false positives. Criteria for splenic rutures are set forth. Ultrasound is considered to be an excellent screening procedure for suspected splenic rupture.

Effectiveness of peritoneal lavage in blunt abdominal trauma.

To analyze the effectiveness of peritoneal lavage and to define its limitations in the evaluation of patients who have sustained blunt abdominal trauma, a prospective study of 500 such patients was undertaken by the Trauma Service at the Naval Hospital, San Diego. Utilizing a qualitative colorometric method to evaluate the degree of hemoperitoneum, patients could rapidly be divided into three clinical groups: strongly positive, weakly positive, and negative. Using this method, patients with a strongly positive peritoneal lavage had a 94% incidence of significant intra-abdominal injuries. In 333 patients with a negative lavage, there was no documented incidence of significant intra-abdominal injuries. Visceral angiography and abdominal echography were utilized in this group of patients to identify those with significant intra-abdominal injuries. By utilizing this approach, there were only eight unnecessary celiotomies in the total group of 500 patients. It is concluded, therefore, that peritoneal lavage is a safe, rapid, and effective means of evaluating patients who have sustained blunt abdominal trauma.

The effect of vascular volume on positive end-expiratory pressure-induced cardiac output depression and wedge—left atrial pressure discrepancy

Abstract The effects of increasing levels of PEEP were studied in six baboons under conditions of normovolemia, acute hypervolemia, chronic hypervolemia, and functional hypervolemia. In normovolemic animals, PEEP caused a significant fall in cardiac output with a marked increase in pulmonary vascular resistance and the development of a discrepancy between wedge and left atrial pressures. Acute fluid loading prevented the wedge-left atrial pressure discrepancy, the rise in pulmonary vascular resistance, and the fall in cardiac output. Chronically hypervolemic animals were less susceptible to cardiac output depression than were normovolemic animals. Those with pulmonary edema benefited greatly from PEEP, while those with normal lungs derived no benefit. Hypovolemic animals sustained profound falls in cardiac output with PEEP.

Hemodynamic alterations with positive end-expiratory pressure: the contribution of the pulmonary vasculature.

The hemodynamic responses to positive end-expiratory pressure (PEEP) ventilation have been evaluated. A rise in pulmonary capillary wedge pressure which follows the use of PEEP may not reflect changes in left atrial pressure and may be associated with a fall in cardiac output. This increase in pulmonary capillary wedge pressure suggests that there is a high resistance to flow in the pulmonary circulation and that a lower level of PEEP should be used.

Evaluation of splenorrhaphy: a grading system for splenic trauma

Since April 1977, we have used splenorrhaphy as the procedure of choice for splenic trauma. To evaluate the efficacy of this procedure, we graded splenic injury based upon the extent of splenic repair in 77 patients with blunt abdominal trauma. This grading system is as follows: Grade 1-capsular treatment (five patients); Grade 2-capsular or parenchymal injuries requiring topical hemostatic agents (13 patients); Grade 3-parenchymal injuries requiring suture repair (nine patients); Grade 4-parenchymal injuries requiring partial splenic resection (seven patients); Grade 5-total splenic devascularization or uncontrollable bleeding from the splenic pedicle requiring splenectomy (43 patients). Twenty-nine patients had associated orthopedic injuries, and 42 patients had associated intra-abdominal or thoracic injuries. Mean operative time was 130 +/- 10 minutes. Operative time increased with severity of associated intra-abdominal injuries. Mean operative transfusion requirement was 500 +/- 100 cc of packed red blood cells. Transfusion requirements were not related to the severity of splenic injury. Twenty-three patients developed complications. Pancreatitis occurred in three patients, atelectasis of pneumonitis in eight patients, ten developed wound infections, and two patients required reoperation for small-bowel obstruction. Complication rates were not related to the degree of splenic injury. The grading system described herein provides a framework for sound clinical judgment and comparison of results in the management of splenic injuries.

Bilateral scapular fractures from accidental electric shock.

This report presents a patient with bilateral scapular fractures resulting from an accidental electric shock (440 volt, 60 cps current). This appears to be a previously unreported injury. A postulated mechanism of injury is discussed.