Sheldon Brotman

Risk, cost, and benefit of transporting ICU patients for special studies.

Prospective evaluation of 103 consecutive transports for diagnostic studies of 56 patients out of the Shock Trauma Unit over a 3-month period was done to document physiologic changes, the cost of each transport, and to assess whether the information gained was utilized to change patient management. Of the 56 patients, 36 (65%) were males and 20 (35%) were females with an age range of 14-82 years (mean, 48 years). The Apache II score ranged from 3-49 (mean, 19.4). There were seven types of diagnostic studies: CT of the head (28), CT of abdomen (35), CT of chest (four), angiography (nine), ventilation/perfusion scan (three), tomography (seven) and miscellaneous studies (15). The average trip time was 81 minutes, a range of 15-210, requiring an average of 3.3 personnel per trip. Ninety-four transported patients had ventilatory support, 26 had PA lines, and 26 transports required three or more IV infusion pumps. Sixty-eight per cent of all transports experienced serious physiologic changes of 5 minutes duration defined as BP systolic or diastolic +/- 20 mm Hg (40%), pulse +/- 20 beats/minute (21%), ventilatory rate +/- 5/minute (20%), O2 saturation decrease by 5% or more (17%). There was a total of 113 serious changes requiring an increase in support of the patient during the transport. There were no significant differences when comparing diagnosis of patient or types of studies to the number of changes in the physiologic parameters, nor were there significant differences within a physiologic parameter when comparing patient types or diagnostic studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Rural interhospital helicopter transport of motor vehicle trauma victims: Causes for delays and recommendations

One hundred twenty-six consecutive ACS Category I motor vehicle trauma patients transported by helicopter from 25 hospitals to a regional trauma center in rural Pennsylvania during a 14-month period were reviewed retrospectively. The overall mortality was 13%. Average round-trip distance was 79 miles. Interventions by the medical flight team (emergency physician/nurse) included endotracheal intubation, tube thoracostomy, and/or central venous access in 42 patients (33%) prior to lift-off. Ground time at the referring facility, from landing to lift-off, when no interventions were required of the flight team, averaged 31.2 minutes (baseline). Ground time when major therapeutic interventions were required (principally airway management), however, averaged 57.4 minutes, an 84% increase over baseline (P less than .01). A major cause of the excessive ground times was the lack of standardized diagnostic workup and stabilization of patients prior to arrival of the flight team. Recommendations for standardized emergency department preparation of trauma victims requiring aeromedical evacuation are made.

Injury from silage wagon accident complicated by mucormycosis

Infection due to farm machinery injuries may be caused by microorganisms found in soil or decaying vegetable material. A case of injury due to entrapment of a young boy in a silage wagon is reported here. His injuries were complicated by infection with Aspergillus species, Absidia species, Rhizopus species (the latter two are members of the Mucorales order), and Pseudomonas maltophilia. Successful treatment of his infection followed aggressive surgical debridement of the anterior abdominal wall, amphotericin B, hyperbaric oxygen therapy, and surgical closure utilizing delayed placement of split-thickness skin grafts.

Traumatic rupture of the stomach secondary to Heimlich maneuver

The case of a 93-year-old man who received a Heimlich maneuver while choking is reported. After the procedure, the patient presented with abdominal pain and ultimately was found to have developed a gastric rupture. He was hospitalized for 66 days. Review of the literature showed that only four gastric perforations related to the Heimlich maneuver have been documented. Other complications have occurred. It is reasonable to perform the procedure as an alternative to asphyxiation, but emergency physicians must be aware of the fact that life-threatening complications may ensue.

Psychological consequences of blunt head trauma and relation to other indices of severity of injury

To investigate the relationship between APACHE II, Injury Severity Score (ISS), Glasgow Coma Score (GCS), and behavioral outcome, a group of 39 patients who had been admitted on an emergency basis with a traumatic head injury were selected from the Neuropsychology Registry for study. Except for subtle personality and cognitive changes, all of the patients were making good neurological recoveries. The Halstead-Reitan Neuropsychological Test Battery, which has been shown to be accurate in identifying brain-damaged patients, was used as the measure of outcome. The age of the patients ranged from 16 to 49 years (mean, 25.6; SD, 9.3). The patients educational levels ranged from elementary school to college (mean, 11.6 years of education; SD, 1.5). Halstead Impairment Indexes (HII) ranged from 0.0 to 1.0 (mean, 0.6; SD, 0.26). APACHE II scores were calculated using the worst values, obtained during the first 24 hours. These scores ranged from 5 to 35 (mean, 16; SD, 7). APACHE II was found to not significantly correlate with HII (r = 0.21, P greater than .05). ISS was calculated for each patient and ranged from 5 to 70 (mean, 27; SD, 13). ISS was found to significantly correlate with HII (r = 0.38, P less than .01). GCS ranged from 3 to 15 (mean, 9.3; SD, 3.4). Of all the correlations, GCS was the most strongly correlated with outcome as measured by the HII (r = -0.44, P less than .01). Our data emphasize that head-injured patients have subtle cognitive dysfunction even when apparently recovering well and demonstrate the need for formal psychological evaluation in all patients with injury significant enough to warrant hospitalization.

Emergency medicine and surgery resident roles on the trauma team: A difference of opinion

Although many emergency medicine residency programs are located in major trauma centers, trauma often is managed by a multispecialty team. In order to define the role of the emergency medicine resident at such centers, we sent surveys to the directors of all 64 approved emergency medicine residency programs. Of the 54 programs (84%) responding, 39 (72%) had trauma teams. Trauma team composition varied widely. Only 54% included general surgery staff physicians, and 38% included an anesthesiologist. Ninety percent of the teams included an emergency medicine resident. Overall emergency medicine residents serve as trauma captains 50% of the time and share the role with a general surgery resident 23% of the time. With the exceptions of peritoneal lavage and intubation, resuscitation procedures were shared between the general surgery and emergency medicine residents. Thirty-one percent of the respondents had air ambulances, 70% of which were staffed by emergency physicians. We conclude that emergency medicine residents are active trauma team leaders and providers.

Behavioral consequences of trauma.

A group of 65 head-injured patients, making an apparent good recovery, were studied with the Halstead-Reitan neuropsychological test battery because of personality or cognitive difficulty. A significant relationship was identified between outcome as measured by the Halstead Impairment Index and both Injury Severity Score and Glasgow Coma Scale score. A significant relationship was also found to exist between the Halstead Impairment Index and employment status of the study group. Patients were placed in three groups, depending on their impairment index. Of the complications identified, spinal fracture, pupillary dysfunction, and intracranial pressure elevation were consistently associated with an impaired performance on the neuropsychological testing. These findings suggest that there is a relationship between head injury complications and neuropsychological potential which can cause lingering problems and influence the patients rehabilitation process.

Massive degloving injury of the trunk

A case of massive degloving injury of the perineum, thigh, and buttocks is presented. Hemostasis was achieved with a pneumatic anti-shock garment (PASG), followed by direct suturing of bleeding areas. A colostomy was performed. Initial conservative debridement was followed in ten days by multiple skin grafts. The patient was treated with sodium bicarbonate and mannitol to preclude myoglobinuric renal failure. Intravenous hyperalimentation was also utilized.

INTESTINAL EVISCERATION RESULTING FROM A MOTOR VEHICLE ACCIDENT

Presented is the case of a motor vehicle accident (MVA) victim with hypotension and evisceration of small intestine. Vigorous resuscitation in the emergency department was required, after which a portion of small bowel was resected at laparotomy. Evisceration secondary to trauma in an MVA is a rare injury. Significant blood loss occurs. Although abdominal sepsis did not occur in our case, this is a complication for which the patient must be monitored closely.

IQ levels following trauma.

One hundred fifteen consecutive trauma patients who experienced a head injury and were administered a Wechsler Intelligence Scale as outpatients were selected for study from the Neuropsychology Registry. These patients ranged in age from 4 to 61 years. At the time of examination, all were living at home with their families. Dividing this group of patients on the basis of a Glasgow Coma Score (GCS) of 10 revealed significant differences in group mean post-traumatic IQs. The more severely injured group of patients had a mean post-traumatic IQ of 93.6; the less severely injured patients had a mean IQ of 103.5. The difference between these two groups is significant (p less than 0.005). When divided on the basis of a GCS of 13, the more severely injured group of patients had a mean post-traumatic IQ of 94.2 and the less severely injured group of patients had a mean post-traumatic IQ of 104.2. The difference between these two groups is also statistically significant (p less than 0.0005). There was no statistically significant (p greater than 0.05) difference in the mean post-traumatic IQs of these patients divided on the basis of an Injury Severity Score (ISS) of 15. However, there was a significant difference (p less than 0.05) when the patients were divided at ISS of 17. The less severely injured patients had a mean post-traumatic IQ of 101.2 and the more severely injured patients had a mean post-traumatic IQ of 95.8. The difference between these two groups is statistically significant (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)