Samir M. Fakhry

Injury in the aged: geriatric trauma care at the crossroads

In the 2010 US Census, the number of persons age 65 years and older constituted 13% of the population and is projected to constitute 22% of the population by 2020.1 As the US population ages, there is an increasing volume of GTPs; injury is now the seventh leading cause of death for those age 65 years.2 Geriatric trauma is increasing both in absolute number and as a proportion of annual volume presenting to trauma centers. Based on the National Trauma Data Bank, the proportion of trauma patients aged 65 years or older in Level I and II trauma centers increased from 23% in 2003 to 30% in 2009. This is likely a significant underestimate because most GTPs are treated at lower-level or nontrauma centers.3,4 In Washington State, for example, the annual number of GTPs in the state registry has increased from 4,266 in 2000 to 11,226 in 2012, an increase from 30% to 42% of the total trauma population. Clearly, the management of injury in geriatric patients will continue to be a major challenge for trauma care providers. In his presidential address to the AAST entitled “For the care of the undeserved,” Dr. Robert Mackersie identified the growing population of elderly injured patients as medically underserved in terms of limited trauma center access, age-related treatment biases, and as a result, deprived of many of the recent advances in modern trauma care.5 To specifically address these inequalities, he convened an Ad Hoc Geriatric Committee and charged it, “To advise the AAST regarding the problems, issues, and needs of the geriatric patient.” What follows is the work product of the Committee in responding to President Mackersie’s charge. The initial priority was to survey the membership of the AAST to better understand the current conditions under which hospitalized GTPs are receiving care. The second task of the Committee was to enumerate the major problems associated with the care of GTPs and to suggest potential solutions to the identified problems. While the Committee does not presume infallibility in its pronouncements, the material presented is intended to initiate discussion, stimulate research, and to ultimately result in evidence-based guidelines that will better serve this “underserved” segment of our population.

Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation

PURPOSE The goal of this study was to determine the impact of surgical rib fixation (SRF) in a treatment protocol for severe blunt chest trauma. MATERIALS AND METHODS Patients with flail chest admitted between September 2009 and June 2010 to our level I trauma center who failed traditional management and underwent SRF were matched with an historical group. Outcome variables evaluated include age, injury severity score, intensive care unit length of stay (LOS), hospital LOS, ventilator days, total number of rib fractures, and total number of segmental rib fractures. RESULTS The 2 groups were similar in age, injury severity score, intensive care unit LOS, hospital LOS, total number of rib fractures, and total segmental rib fractures. The operative group demonstrated a significant reduction in total ventilator days as compared with the nonsurgical group (4.5 [0-30] vs 16.0 [4-40]; P = .040). Patients with SRF were permanently liberated from the ventilator within a median of 1.5 days (0-8 days). CONCLUSIONS Surgical rib fixation resulted in a significant decrease in ventilator days and may represent a novel approach to decreasing morbidity in flail chest patients when used as a rescue therapy in patients with declining pulmonary status. Larger studies are required to further identify these benefits.

Safety and efficacy of heparin or enoxaparin prophylaxis in blunt trauma patients with a head abbreviated injury severity score >2

BACKGROUND Timing and type of chemoprophylaxis (CP) that should be used in patients with traumatic brain injury (TBI) remains unclear. We reviewed our institutions experience with low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) in TBI. METHODS The charts of all TBI patients with a head abbreviated injury severity score >2 (HAIS) and an intensive care unit length of stay >48 hours admitted during a 42-month period between 2006 and 2009 were reviewed. CP was initiated after intracranial hemorrhage was considered stable. We reviewed all operative notes and radiologic reports in these patients to analyze the rate of significant intracranial hemorrhagic complications, deep venous thrombosis, or pulmonary embolus. RESULTS A total of 386 patients with TBI were identified; 158 were treated with LMWH and 171 were treated with UFH. HAIS was significantly different between the LMWH (3.8 ± 0.7) and UFH (4.1 ± 0.7) groups; the time to initiation of CP was not. The UFH group had a significantly higher rate of deep venous thrombosis and pulmonary embolus. Progression of ICH that occurred after the initiation of CP was significantly higher in the UFH-treated patients (59%) when compared with those treated with LMWH (40%). Two patients in the UFH group required craniotomy after the initiation of CP. CONCLUSION LMWH is an effective method of CP in patients with TBI, providing a lower rate of venous thromboembolic and hemorrhagic complications when compared with UFH. A large, prospective, randomized study would better evaluate the safety and efficacy of LMWH in patients suffering blunt traumatic brain injury.

The utility of procalcitonin in critically ill trauma patients.

BACKGROUND Procalcitonin (PCT), the prohormone of calcitonin, has an early and highly specific increase in response to systemic bacterial infection. The objectives of this study were to determine the natural history of PCT for patients with critical illness and trauma, the utility of PCT as a marker of sepsis versus systemic inflammatory response syndrome (SIRS), and the association of PCT level with mortality. METHODS PCT assays were done on eligible patients with trauma admitted to the trauma intensive care unit (ICU) of a Level I trauma center from June 2009 to June 2010, at hours 0, 6, 12, 24, and daily until discharge from ICU or death. Patients were retrospectively diagnosed with SIRS or sepsis by researchers blinded to PCT results. RESULTS A total of 856 PCT levels from 102 patients were analyzed, with mean age of 49 years, 63% male, 89% blunt trauma, mean Injury Severity Score of 21, and hospital mortality of 13%. PCT concentration for patients with sepsis, SIRS, and neither were evaluated. Mean PCT levels were higher for patients with sepsis versus SIRS (p < 0.0001). Patients with a PCT concentration of 5 ng/mL or higher had an increased mortality when compared with those with a PCT of less than 5 ng/mL in a univariate analysis (odds ratio, 3.65; 95% confidence interval, 1.03–12.9; p = 0.04). In a multivariate logistic analysis, PCT was found to be the only significant predictor for sepsis (odds ratio, 2.37; 95% confidence interval,1.23–4.61, p = 0.01). CONCLUSION PCT levels are significantly higher in ICU patients with trauma and sepsis and may help differentiate sepsis from SIRS in critical illness. An elevated PCT level was associated with increased mortality. LEVEL OF EVIDENCE Prognostic study, level II.

Blunt abdominal aortic injury: A Western Trauma Association multicenter study

BACKGROUND Blunt abdominal aortic injury (BAAI) is a rare injury. The objective of the current study was to examine the presentation and management of BAAI at a multi-institutional level. METHODS The Western Trauma Association Multi-Center Trials conducted a study of BAAI from 1996 to 2011. Data collected included demographics, injury mechanism, associated injuries, interventions, and complications. RESULTS Of 392,315 blunt trauma patients, 113 (0.03%) presented with BAAI at 12 major trauma centers (67% male; median age, 38 years; range, 6–88; median Injury Severity Score [ISS], 34; range, 16–75). The leading cause of injury was motor vehicle collisions (60%). Hypotension was documented in 47% of the cases. The most commonly associated injuries were spine fractures (44%) and pneumothorax/hemothorax (42%). Solid organ, small bowel, and large bowel injuries occurred in 38%, 35%, and 28% respectively. BAAI presented as free aortic rupture (32%), pseudoaneurysm (16%), and injuries without aortic external contour abnormality on computed tomography such as large intimal flaps (34%) or intimal tears (18%). Open and endovascular repairs were undertaken as first-choice therapy in 43% and 15% of cases, respectively. Choice of management varied by type of BAAI: 89% of intimal tears were managed nonoperatively, and 96% of aortic ruptures were treated with open repair. Overall mortality was 39%, the majority (68%) occurring in the first 24 hours because of hemorrhage or cardiac arrest. The highest mortality was associated with Zone II aortic ruptures (92%). Follow-up was documented in 38% of live discharges. CONCLUSION This is the largest BAAI series reported to date. BAAI presents as a spectrum of injury ranging from minimal aortic injury to aortic rupture. Nonoperative management is successful in uncomplicated cases without external aortic contour abnormality on computed tomography. Highest mortality occurred in free aortic ruptures, suggesting that alternative measures of early noncompressible torso hemorrhage control are warranted. LEVEL OF EVIDENCE Epidemiologic study, level III; therapeutic study, level IV.

A mixed methods descriptive investigation of readiness to change in rural hospitals participating in a tele-critical care intervention

BackgroundTelemedicine technology can improve care to patients in rural and medically underserved communities yet adoption has been slow. The objective of this study was to study organizational readiness to participate in an academic-community hospital partnership including clinician education and telemedicine outreach focused on sepsis and trauma care in underserved, rural hospitals.MethodsThis is a multi-method, observational case study. Participants included staff from 4 participating rural South Carolina hospitals. Using a readiness-for-change model, we evaluated 5 general domains and the related factors or topics of organizational context via key informant interviews (n=23) with hospital leadership and staff, compared these to data from hospital staff surveys (n=86) and triangulated data with investigators’ observational reports. Survey items were grouped into 4 categories (based on content and fit with conceptual model) and scored, allowing regression analyses for inferential comparisons to assess factors related to receptivity toward the telemedicine innovation.ResultsGeneral agreement existed on the need for the intervention and feasibility of implementation. Previous experience with a telemedicine program appeared pivotal to enthusiasm. Perception of need, task demands and resource need explained nearly 50% of variation in receptivity. Little correlation emerged with hospital or ED leadership culture and support. However qualitative data and investigator observations about communication and differing support among disciplines and between staff and leadership could be important to actual implementation.ConclusionsA mixed methods approach proved useful in assessing organizational readiness for change in small organizations. Further research on variable operational definitions, potential influential factors, appropriate and feasible methods and valid instruments for such research are needed.

A Position Paper: The Convergence of Aging and Injury and the Need for a Geriatric Trauma Coalition (GeriTraC).

As the U.S. population ages and more adults live into their eighties and nineties, health care providers and hospitals are increasingly challenged to address a broad range of issues from injury prevention to acute care management and postacute transitions of care. Most geriatric trauma represents the confluence of aging-related decline, resulting in injury, and the body’s physiologic response to maintain homeostasis during and after hospitalization. Older patients suffer greater morbidity, mortality, and functional decline than similarly injured younger adults, and even seemingly minor, low-impact injuries are associated with considerable mortality. Challenges in the care and treatment of older trauma patients differ from younger counterparts because of their unique physiology, and medical and psychosocial needs. A recent survey of trauma surgeons and a growing recognition of the complexity of caring for geriatric trauma patients gave rise to the call for a focused effort and agenda to address this public health crisis. The American Association for the Surgery of Trauma (AAST) responded by funding and

Pharmacologic Stress Gastropathy Prophylaxis May Not Be Necessary in At-Risk Surgical Trauma ICU Patients Tolerating Enteral Nutrition.

Objective: Stress gastropathy is a rare complication of the intensive care unit stay with high morbidity and mortality. There are data that support the concept that patients tolerating enteral nutrition have sufficient gut blood flow to obviate the need for prophylaxis; however, no robust studies exist. This study assesses the incidence of clinically significant gastrointestinal bleeding in surgical trauma intensive care unit (STICU) patients at risk of stress gastropathy secondary to mechanical ventilation receiving enteral nutrition without pharmacologic prophylaxis. Design: A retrospective cohort study of records from 2008 to 2013. Setting: Adult patients in a single-center STICU were included. Patients: Patients were included if they received full enteral nutrition while on mechanical ventilation. Exclusion criteria were coagulopathy, glucocorticoid use, prior-to-admission acid-suppressive therapy use, direct trauma or surgery to the stomach, failure to tolerate goal enteral nutrition, orders to allow natural death, and deviation from the intervention. Intervention: Pharmacologic stress ulcer prophylaxis was discontinued once enteral nutrition was providing full caloric requirements for patients requiring mechanical ventilation. Measurements and Main Results: A total of 200 patients were included. The median age was 42 years, 83.0% were male, and 96.0% were trauma patients. The incidence of clinically significant gastrointestinal bleeding was 0.50%, with a subset analysis of traumatic brain injury patients yielding an incidence of 0.68%. Rates of ventilator-associated pneumonia and Clostridium difficile infection were low at 1.0 case/1000 ventilator days and 0.2 events/1000 patient days, respectively. Hospital all-cause mortality was 2.0%. Cost savings of US

The Association of Race, Socioeconomic Status, and Insurance on Trauma Mortality.

121/patient stay were realized. Conclusion: Stress gastropathy is rare in this population. Surgical and trauma patients at risk for stress gastropathy did not benefit from continued pharmacologic prophylaxis once they tolerated enteral nutrition. Pharmacologic prophylaxis may safely be discontinued in this patient population. Further investigation is warranted to determine whether continued prophylaxis after attaining enteral feeding goals is detrimental.

Fat embolism in pediatric patients: An autopsy evaluation of incidence and Etiology

Background:Although race, socioeconomic status, and insurance individually are associated with trauma mortality, their complex interactions remain ill defined. Methods:This retrospective cross-sectional study from a single Level I center in a racially diverse community was linked by socioeconomic status, insurance, and race from 2000 to 2009 for trauma patients aged 18–64 years with an injury severity score more than 9. The outcome measure was inpatient mortality. Multiple logistic regression analyses were performed to investigate confounding variables known to predict trauma mortality. Results:A total of 4,007 patients met inclusion criteria. Individually, race, socioeconomic status, and insurance were associated with increased mortality rate; however, in multivariate analysis, only insurance remained statistically significant and varied by insurance type with age. Odds of death were higher for Medicare (odds ratio [OR] = 3.63, p = .006) and other insurance (OR = 3.02, p = .007) than for Private Insurance. However, when grouped into ages 18–40 years versus 41–64 years, the insurance influences changed with Uninsured and Other insurance (driven by Tricare) predicting mortality in the younger age group, while Medicare remained predictive in the older age group. Conclusions:Insurance type, not race or socioeconomic status, is associated with trauma mortality and varies with age. Both Uninsured and Tricare insurance were associated with mortality in younger age trauma patients, whereas Medicare was associated with mortality in older age trauma patients. The lethality of the Tricare group warrants further investigation.