Robert Marley

Preinjury Warfarin and Geriatric Orthopedic Trauma Patients: A Case-matched Study

BACKGROUND This study examined the hypothesis that patients on warfarin before sustaining orthopedic injuries will have increased morbidity and mortality compared with matched control patients not on warfarin. METHODS Records of consecutive trauma patients on warfarin with orthopedic fractures who presented from January 1997 to June 2002 to a Level I trauma center were retrospectively analyzed. Data were evaluated using the chi and Students t tests and nonparametric tests when appropriate; values of p < 0.05 were considered significant. RESULTS A study group of 53 patients was available for review. In comparison with the control group, significant differences were found in time delay from admission to surgery (p = 0.005), hospital length of stay (p = 0.03), total units of blood transfused (p = 0.03), and discharge disposition (p < 0.0003). No difference was found in number of intensive care unit days, complications, or mortality. CONCLUSION Preinjury warfarin impacts outcomes of geriatric trauma patients sustaining orthopedic injuries.

Hospital outcomes and disposition of trauma patients who are intubated because of combativeness

BACKGROUND The purpose of this study was to determine whether trauma patients who are intubated because of combativeness, and not because of medical necessity, have more complications resulting in longer lengths of stay. METHODS Data were retrospectively collected from 2001 through 2004 on trauma patients who were intubated because of combative behavior before hospital admission (group 1, N = 34). Cases were matched 1:2 by age, sex, injury severity score (ISS), and injury to controls each who were not intubated (group 2, N = 68). Additionally, there were 187 patients identified who were intubated because of medical necessity before hospital admission; these represented unmatched intubated controls and were divided based on ISS <15 (group 3, N = 58) and ISS >15 (group 4, N = 129). RESULTS There were no significant differences between groups 1, 2, and 3 with regard to age, sex, or ISS. There was no significant difference between the groups 1 and 2 in frequency of head injuries as demonstrated by positive computed tomography (50 vs. 37%, p = 0.28); however, there was a significant difference in frequency of neurologic deficit at discharge (33 vs. 6%, p = 0.006). There was a significant difference in the frequency of head injuries between groups 1 and 3 (50 vs. 22%, p = 0.006); however, there was no significant difference in neurologic deficit at discharge (33 vs. 22%, p = 0.24). There was a significant difference in hospital length of stay between groups 1 and 2 (7.4 +/- 5.9 vs. 4.3 +/- 4.5 days, p = 0.0009). The incidence of pneumonia was significantly greater in group 1 than in group 2 (29 vs. 0%, p < 0.0001). The amount of lorazepam in average mg per day was also significantly greater in group 1 versus group 2 (4.4 +/- 11.5 vs. 0.4 +/- 1.6, p < 0.0001). There was also a difference in the discharge status, with significantly fewer group 1 cases being discharged home compared with group 2 (56 vs. 91%, p < 0.0001). There was no significant difference between groups 1 and 3 with regard to length of stay, ventilator days, pneumonia, or discharge status. There was a significant difference between groups 1 and 3 in the amount of lorazepam per day (4.4 +/- 11.5 vs. 0.4 +/- 1.6, p = 0.002). CONCLUSION The results from this study indicate that trauma patients who are intubated because of combativeness, and not because of medical necessity, have longer lengths of stay, increased incidence of pneumonia, and poorer discharge status when compared with matched controls. The outcomes of this group are similar to that of patients who are intubated because of medical necessity.

Predictors of New Findings on Repeat Head CT Scan in Blunt Trauma Patients with an Initially Negative Head CT Scan

BACKGROUND Our goal was to determine the need for a repeat head CT scan when the initial CT was negative. STUDY DESIGN Data were collected from January 1, 2002 to December 31, 2008. There were 281 patients admitted to the trauma center with an initial negative head CT, who had a repeat CT during the same hospitalization. Repeat CTs were categorized into negative/negative (NNG) and negative/positive (NPG) groups. RESULTS There were 281 patients who underwent a repeat head CT for changes in neurologic status, persistent symptoms, follow-up, decreased mental status, or suspected bleed. Of these, 241 patients remained negative (NNG) and new abnormal findings were noted in 40 patients (NPG). There were no differences in sex (NNG, 63% males vs NPG, 75% females; p = 0.14) or average age (NNG, 51.6 ± 22.5 years vs NPG, 45.2 ± 24.6 years; p = 0.07). There was no difference in positive toxicology (NNG, 29% vs NPG, 30%; p = 0.94) or mechanism of injury (NNG, 51% motor vehicle crash [MVC] vs NPG, 62% MVC; p = 0.18). There was a significant difference in Injury Severity Score (ISS) (NNG, 10.7 ± 8.1 vs NPG, 17.9 ± 11.0; p = 0.0002) and initial Glasgow Coma Scale (GCS) (NNG, 12.7 ± 3.5 vs NPG, 10.9 ± 4.2; p = 0.006). Patients with an ISS > 15 and who were intubated were associated with an increased odds of having a positive repeat CT scan (odds ratio [OR] 2.6; 95%CI 1.2, 5.5 and OR 3.5; 95% CI, 1.7, 7.3, respectively). CONCLUSIONS Patients with a high ISS score and/or those who are intubated have significantly higher odds of having a positive repeat head CT when repeated for follow-up or when clinically warranted.

The relationship between psychiatric medication and course of hospital stay among intoxicated trauma patients

Introduction The purpose of this study was to determine whether trauma patients requiring psychiatric medication who were admitted with positive alcohol or drug screen require more pain medications or sedation resulting in longer length of stay. Methods Data were retrospectively collected from 1997 through 2003 on patients with positive alcohol or drug screen who also received psychiatric medication during their hospital stay in a trauma center. Patients were matched by age, injury severity score, and injury to controls who had negative alcohol and toxicology screens and no psychiatric medication. An additional group consisted of positive alcohol or drug-screen trauma patients without psychiatric medication during hospitalization. Each group had 25 patients. Results No significant differences between the three groups regarding comorbidities or pain-medication doses given per day were found. The patients with positive alcohol and with psychiatric medication were more likely to have respiratory complications such as pneumonia or respiratory failure requiring ventilator support (36 versus 4%, P=0.005), to develop other infections (8 versus 0%), or other complications (26 versus 4%, P=0.0007) compared with the controls. A significant difference in hospital length of stay between the group with positive toxicity and psychiatric medication and that with negative toxicity and psychiatric medication (mean: 12.8 and 5.5 days, respectively; P=0.01) was found. Conclusion Psychiatric medication and positive drug or alcohol screens are associated with longer length of stay and increased respiratory complications. Factors influencing these outcomes need more clarification and prospective studies.

Effect of Hospital Length of Stay on Functional Independence Measure Score in Trauma Patients.

ObjectiveThe purpose of this study was to determine whether prolonged hospital length of stay (HLOS) and rehabilitation facility length of stay (RLOS) lead to poor functional outcomes, defined as a Functional Independence Measure (FIM) score of less than 76 (LFIM) at rehabilitation facility (RF) discharge. DesignThis study analyzed retrospective data collected between 2002 and 2009 on 326 patients in a trauma center and affiliated RF. Factors predicting LFIM at RF discharge were determined using multivariate logistic regression, &khgr;2 tests, and t tests. ResultsSignificant multivariate predictors of LFIM included age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02–1.07; P < 0.0001), spinal cord injury (OR, 7.22; 95% CI, 2.73–19.02; P = 0.000), female sex (OR, 2.34; 95% CI, 1.17–4.65; P = 0.01), and RF admission FIM (OR, 0.93; 95% CI, 0.91–0.95; P < 0.001). An increased risk of LFIM (OR, 2.21; 95% CI, 1.41–3.45; P = 0.001) was observed with an increased ratio of HLOS/RLOS after adjusting for injury severity score. ConclusionAn increased ratio of HLOS/RLOS increases the risk of LFIM more than 2-fold after adjusting for injury severity score, spinal cord injury, and FIM upon RF admission. Delays in transfer to an RF negatively affect patient functional outcomes. Studies to identify factors affecting delays in transfer from hospitals to RF should be conducted.

1058: THC IS MORE PREDICTIVE OF A GREATER INJURY SEVERITY SCORE THAN ALCOHOL FOR TRAUMA PATIENTS OVER 30

was < 0.2 IU/ml (0.38[0.32:0.42] mg/kg sc q12h vs. 0.45[0.39:0.48] mg/kg sc q12h, p=0.003). 4 VTE events occurred, all in the anti-FXaA < 0.2 IU/ml group. CrCl was 137[105:172] ml/min <0.2 IU/ml vs. 101[87:137] ml/min ≥ 0.2 IU/ ml (p=0.06). 37 TP achieved target peak anti-FXaA. Dose increases were needed in 23 TP. ENOX dose to achieve target anti-FXaA was 0.49 [0.44:0.54] mg/kg sc q12h. Conclusions: NWBD of ENOX does not achieve target peak anti-FXaA in most TP. Weight based ENOX dosing (i.e. 0.5 mg/kg sc q12h) would better achieve target peak anti-FXaA.