Thomas A. Santora

Video assessment of trauma response: Adherence to ATLS protocols

A novel strategy using videotape recordings of initial trauma resuscitations was incorporated into the quality assurance program at a level 1 trauma center. Described are the process of taping the resuscitations, the multidisciplinary nature of the resuscitation team, the security measures taken to assure patient confidentiality, and the review process involved. The videotape review process was incorporated into a multidisciplinary educational trauma conference. The videotapes were used to evaluate the adherence to Advanced Trauma Life Support (ATLS) resuscitation protocols. Resident performance in six aspects of the ATLS resuscitation process were specifically highlighted on each videotape and graded for adherence to preestablished standards. The videotape process allowed an unblased, indisputable accurate documentation of the sequential application of the protocols of evaluation and resuscitation espoused in the ATLS course. We found 23% overall deviation from ATLS resuscitation principles, with at least one aspect of the resuscitation deviating from expected ATLS performance in 64% of the patients. In addition to documenting adherence to ATLS principles, this study illustrated the impact of the videotape review process on the education of eight senior residents in surgery.

Start with a Subjective Assessment of Skin Temperature to Identify Hypoperfusion in Intensive Care Unit Patients

OBJECTIVE To determine whether physical examination alone or in combination with biochemical markers can accurately diagnose hypoperfusion. METHODS Data from 264 consecutive surgical intensive care unit patients were collected by two intensivists and included extremity temperature, vital signs, arterial lactate, arterial blood gases, hemoglobin, and pulmonary artery catheter values with derived indices. Days of data were divided into data collected from patients with cool extremities (cool skin temperature [CST] group) versus warm extremities (warm skin temperature [WST] group). Values are means +/- SD. Comparisons between groups were made by two-tailed unpaired t test; significance was assumed for p < or = 0.05. RESULTS There were 328 days of observations in the CST group versus 439 in the WST group. There were no differences (p > 0.05) between CST and WST data with regard to heart rate (107 +/- 14 vs. 99 +/- 19 beats/min), systolic blood pressure (118 +/- 24 vs. 127 +/- 28 mm Hg), diastolic blood pressure (57 +/- 14 vs. 62 +/- 15 mm Hg), pulmonary artery occlusion pressure (14 +/- 6 vs. 16 +/- 5 mm Hg), Fio2 (0.48 +/- 0.7 vs. 0.45 +/- 0.2), hemoglobin (8.8 +/- 1.6 vs. 9.3 +/- 1.3 g/dL), Pco2 (44.3 +/- 11.8 vs. 40.7 +/- 9.2 mm Hg), or Po2 (96.4 +/- 12.6 vs. 103.8 +/- 22.2 mm Hg). However, cardiac output (5.3 +/- 2.2 vs. 8.2 +/- 2.6 L/min), cardiac index (2.9 +/- 1.2 vs. 4.3 +/- 1.2 L/min/m2), pH (7.32 +/- 0.2 vs. 7.39 +/- 0.07), TCO2 (19.5 +/- 3.1 vs. 25.1 +/- 4.8 mEq/L), and Svo2 (60.2 +/- 4.4% vs. 68.2 +/- 7.8%) were all significantly lower (p < 0.05) in CST patients compared with WST patients. By comparison, lactate (4.7 +/- 1.5 vs. 2.2 +/- 1.6 mmol/L, p < 0.05) was significantly elevated in patients with cool extremities. CONCLUSION Combining physical examination with serum bicarbonate and arterial lactate identifies patients with hypoperfusion as defined by low Svo2 and cardiac index. Hypoperfusion may occur despite supranormal cardiac indices. Patients with cool extremities and elevated lactate levels may benefit from a pulmonary artery catheter to guide but not initiate therapy.

Emergency Department Thoracotomy: Still Useful After Abdominal Exsanguination?

BACKGROUND Although literature regarding emergency department thoracotomy (EDT) outcome after abdominal exsanguination is limited, numerous reports have documented poor EDT survival in patients with anatomic injuries other than cardiac wounds. As a result, many trauma surgeons consider prelaparotomy EDT futile for patients dying from intra-abdominal hemorrhage. Our primary study objective was to prove that prelaparotomy EDT is beneficial to patients with exsanguinating abdominal hemorrhage. METHODS A retrospective review of 237 consecutive EDTs for penetrating injury (2000-2006) revealed 50 patients who underwent EDT for abdominal exsanguination. Age, gender, injury mechanism and location, field and emergency department (ED) signs of life, prehospital time, initial ED cardiac rhythm, vital signs, Glasgow Coma Score, blood transfusion requirements, predicted mortality, primary abdominal injuries, and the need for temporary abdominal closure were analyzed. The primary study endpoint was neurologically intact hospital survival. RESULTS The 50 patients who underwent prelaparotomy EDT for abdominal exsanguination were largely young (mean, 27.3 +/- 8.2 years) males (94%) suffering firearm injuries (98%). Patients presented with field (84%) and ED signs of life (78%) after a mean prehospital time of 21.2 +/- 9.8 minutes. Initial ED cardiac rhythms were variable and Glasgow Coma Score was depressed (mean, 4.2 +/- 3.2). Eight (16%) patients survived hospitalization, neurologically intact. Of these eight, all were in hemorrhagic shock because of major abdominal vascular (75%) or severe liver injuries (25%) and all required massive blood transfusion (mean, 28.6 +/- 17.3 units) and extended intensive care unit length of stay (mean, 36.3 +/- 25.7 days). CONCLUSIONS Despite critical injuries, 16% survived hospitalization, neurologically intact, after EDT for abdominal exsanguination. Our results suggest that prelaparotomy EDT provides survival benefit to penetrating trauma victims dying from intra-abdominal hemorrhage.

Improved emergency department efficiency with a three-tier trauma triage system

This pilot study was carried out to determine whether converting from a two-tier to a three-tier in-hospital trauma triage system improves the efficiency of emergency department (ED) care and minimizes inappropriate triage. Patients at an urban, Level 1 trauma centre were triaged using either a two-tier (months 1-3; n = 197) or three-tier (months 4-6; n = 240) trauma response system. Patients were assessed for triage type, age, sex, injury severity score, Glasgow coma score, post-ED disposition, total ED time, survival, complication rate, probability of survival and unexpected death. Comparisons were made by ANOVA table analysis; significance was assumed for p < 0.05. Two-tier (n = 197) and three-tier patients (n = 240) were matched with respect to mean age, sex, mean injury severity score, mean Glasgow coma score, post-ED disposition, survival and probability of survival. Two-tier patients were triaged to give 20% alerts [criteria = physiological derangement (PD) and/or injury mechanism (MOI)] and 80% consults; three-tier patients were triaged as 20% category I (criteria = PD), 18% category II (criteria = MOI) and 62% consults. Total ED time decreased from two-tier (3.98 +/- 2.81 h) to three-tier triage (3.53 +/- 2.14 h, p = 0.001). There was no difference between two-tier alert and three-tier category I times (2.09 +/- 1.64 vs. 1.95 +/- 1.75 h; p = 0.72). Category II patients (3.28 +/- 1.98 h; p = 0.009) spent less time in the ED than did two-tier consults (4.36 +/- 2.65 h). The mean ED three-tier consult time significantly decreased as well (3.95 +/- 2.42 h, p = 0.008 vs. two-tier consult). Complications per patient were unchanged from two-tier to three-tier triage (0.17 +/- 0.52 vs. 0.12 +/- 0.48; p = 0.15). Under-triage (5%) and over-triage (7.5%) were minimal under three-tier triage. It is concluded that using a three-tier triage system results in an increase in the early involvement of the trauma service while decreasing emergency department time and minimizing over-triage.

Thoracic compartment syndrome

Presented is a case of a thoracic gunshot wound resulting in descending thoracic aortic and biventricular cardiac injuries. Successful management of these wounds allowed the development of an unusual and previously undescribed complication of thoracic trauma--thoracic compartment syndrome. The clinical features, therapy, and potential sequelae of thoracic compartment syndrome are presented with a review of the literature.

Computer-generated trauma management plans: Comparison with actual care

TraumAID is a computer-based decision aid that uses decision rules and logical deduction to generate management plans for the initial definitive management of injured patients; its use is currently confined to assessing penetrating thoracoabdominal injuries in nonpregnant adults. These management plans were compared to trauma center care in an American urban medical school hospital. The TraumAID program was available to trauma chief residents for patient care during the “golden hour.” Resulting changes in plans were documented by the residents. For 15 months the management plans for all applicable patients were documented serially, as were computer plans and outcomes. The sequential care and computer-generated care plans were then blinded and judged by three other trauma surgeons as to acceptability and preference. A consecutive series of 97 patients was evaluated. The residents used the computer for 40 cases during patient care. In 5 of the 40 cases, they altered their evaluation, diagnosis, or treatment; in none of these 5 was the alteration judged an error. Of the 97 patients, 10 had adverse outcomes, 2 of which were judged potentially avoidable, with unacceptable errors in management. TraumAID’s plans were acceptable for both. In 31 cases previously managed by the judges themselves, the TraumAID plans were preferred by the judge to the care he or she had provided, by a ratio of 25:6 (p<0.01). In a preliminary assessment, computer-generated, patient-specific protocols for the acute management of injuries were preferred to actual care previously given by the judges themselves and were associated with improved care and potential improvement in outcome.Résumé«TraumAID» est une aide aux décisions informatisée, utilisant des règles décisionnelles et de déduction logique pour générer un plan thérapeutique initial, définitif, pour les blessés thoraco-abdominaux (adultes sans grossesse uniquement). Ces plans thérapeutiques ont été comparés aux soins prodigués par un trauma center dans un hôpital urbain Américain, rattaché à une école de médecine. Le programme «TraumAID» était disponible aux résidents chefs pour le traitement pendant la première, «golden», heure post-accident. La modification thérapeutique induite par «TraumAID» a été documentée par les résidents. Pendant 15 mois, on a documenté les actions thérapeutiques réalisées, les propositions informatiques et les évolutions, de façon consécutive. Les séquences thérapeutiques réelles et informatiques ont ensuite été «aveuglées» et jugées par trois autres chirurgiens rompus à la traumatologie d’urgence quant à leur acceptabilité et les préférences de chacun. On a évalué une série consécutive de 97 patients. Les résidents ont utilisé le programme dans 40 cas. Dans cinq des 40 cas, ils ont changé leur évaluation, leur diagnostic ou leur schéma thérapeutique; dans aucun cas ce changement n’a été considéré comme une erreur. Des 97 patients, 10 avaient une évolution néfaste; deux ont été jugées comme potentiellement évitables, avec des erreurs inacceptables au plan thérapeutique. La séquence élaborée par «TraumAID» était acceptable dans les deux cas. Dans 31 cas pris en charge par les juges eux-mêmes, la séquence proposée par «TraumAID» a été préférée par rapport aux plans thérapeutiques choisis dans un rapport de 25:6 (p<0.01). En ce qui concerne l’évaluation préliminaire, les protocoles générés par l’informatique, patient-spécifique, ont été préférés pour la prise en charge des traumatismes aigus par rapport aux plans élaborés auparavant par les juges eux-mêmes. Ils étaient associés à une amélioration des soins avec une amélioration potentielle de l’évolution.ResumenTraumaAID es un programa de decisión asistida por computador que utiliza reglas de decisión y lógica deductiva para generar planes para el manejo de pacientes traumatizados, el cual por lo pronto se limita a las lesiones penetrantes tóraco-abdominales en adultas no embarazadas. Estos planes de manejo fueron comparados con la atención del trauma en centros hospitalarios norteamericanos urbanos y conectados con facultades de medicina. El programa TraumaAID estuvo disponible para los residentes jefes en servicios de trauma en la atención del paciente durante la “hora dorada” (“golden hour”). Los mismos residentes comprobaron los cambios en el manejo resultante del uso del programa. En un periodo de 15 meses se documentaron en forma seriada los planes de manejo reales aplicables a los pacientes, asÍ como los planes computadorizados y sus resultados. El cuidado real secuencial y los planes generados por computador fueron luego calificados a ciegas por tres cirujanos de trauma en cuanto a aceptabilidad y preferencia. Se hizo la evaluación de una serie consecutiva de 97 pacientes. Los residentes usaron el computador en 40 casos en el curso de la atención médica. En 5 de los 40, modificaron su evaluación, diagnóstico o tratamiento; en ninguno de los 5 el cambio fue posteriormente calificado como un error. De los 97 pacientes, 10 tuvieron resultados adversos; en dos casos se estimó que ello fue potencialmente evitable, con errores inaceptables de manejo. Los planes del traumaAID fueron aceptables en ambos casos. En 31 casos previamente manejados por los mismos árbitros, los planes del TraumaAID les merecieron preferencia en cuanto a la atención que había brindado en una proporción de 25:6 (p<0.01). En una evaluación preliminar, los protocolos de cuidado agudo generados por computador y especÍficos para cada pacient e, fueron preferidos sobre el cuidado real que habían dado los árbitros, y se asociaron con una mejor atención y con una potencial superación de los resultados.

Life after near death: Long-term outcomes of emergency department thoracotomy survivors

BACKGROUND: Predictors of hospital survival after emergency department thoracotomy (EDT) are well established, but little is known of long‐term outcomes after hospital survival. Our primary study objective was to analyze the long‐term social, cognitive, functional, and psychological outcomes in EDT survivors. METHODS: Review of our Level I trauma center registry (2000–2010) revealed that 37 of 448 patients survived hospitalization after EDT. Demographics and clinical characteristics were analyzed. After attempts to contact survivors, 21 patients or caretakers were invited to an outpatient study evaluation; 16 were unreachable (none of whom were present in the Social Security Death Index). Study evaluation included demographic and social data and an outpatient multidisciplinary assessment with validated scoring instruments (Mini‐Mental Status Exam, Glasgow Outcome Scores, Timed Get‐Up and Go Test, Functional Independence Measure Scoring, SF‐36 Health Survey, and civilian posttraumatic stress disorder checklist). RESULTS: After extended hospitalization (43 ± 41 days), disposition varied (home, 62%; rehabilitation, 32%; skilled nursing facility, 6%), but readmission was common (33%) in the 37 EDT hospital survivors. Of the 21 contacted, 16 completed the study evaluation, 2 had died, 1 remained in a comatose state, and 2 were available by telephone only. While unemployment (75%), daily alcohol (50%), and drug use (38%) were common, of the 16 patients who underwent the comprehensive, multidisciplinary outpatient assessment after a median of 59 months following EDT, 75% had normal cognition and returned to normal activities, 81% were freely mobile and functional, and 75% had no evidence of posttraumatic stress disorder upon outpatient screening. CONCLUSION: Despite the common belief that EDT survivors often live with severe neurologic or functional impairment, we have found that most of our sampled EDT survivors had no evidence of long‐term impairment. It is our hope that these results are considered by physicians making life or death decisions regarding the “futility” of EDT in our most severely injured patients. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

HIV and hepatitis in an urban penetrating trauma population: unrecognized and untreated.

BACKGROUND Despite limited prospective data, it is commonly believed that human immunodeficiency virus (HIV) and hepatitis infections are widespread in the penetrating trauma population, placing healthcare workers at risk for occupational exposure. Our primary study objective was to measure the prevalence of HIV (anti-HIV), hepatitis B (HB surface antigen [HBsAg]), and hepatitis C virus (anti-HCV) in our penetrating trauma population. METHODS We prospectively analyzed penetrating trauma patients admitted to Temple University Hospital between August 2008 and February 2010. Patients (n = 341) were tested with an oral swab for anti-HIV and serum evaluated for HBsAg and anti-HCV. Positives were confirmed with western blot, neutralization immunoassay, and reverse transcription polymerase chain reaction, respectively. Demographics, risk factors, and clinical characteristics were analyzed. RESULTS Of 341 patients, 4 patients (1.2%) tested positive for anti-HIV and 2 had a positive HBsAg (0.6%). Hepatitis C was the most prevalent measured infection as anti-HCV was detected in 26 (7.6%) patients. Overall, 32 (9.4%) patients were tested positive for anti-HIV, HBsAg, or anti-HCV. Twenty-eight (75%) of these patients who tested positive were undiagnosed before study enrollment. When potential risk factors were analyzed, age (odds ratio, 1.07, p = 0.031) and intravenous drug use (odds ratio 14.4, p < 0.001) independently increased the likelihood of anti-HIV, HBsAg, or anti-HCV-positive markers. CONCLUSIONS Greater than 9% of our penetrating trauma study population tested positive for anti-HIV, HBsAg, or anti-HCV although patients were infrequently aware of their seropositive status. As penetrating trauma victims frequently require expedient, invasive procedures, universal precautions are essential. The prevalence of undiagnosed HIV and hepatitis in penetrating trauma victims provides an important opportunity for education, screening, and earlier treatment of this high-risk population.

Percutaneous drainage of recurrent pneumothoraces and pneumatoceles.

Thoracic trauma victims commonly sustain visceral pleural injury with resultant pneumothorax. These injuries usually respond to standard tube thoracostomy decompression and drainage. However, a subset of these patients develop recurrent and/or loculated pneumothoraces or pneumatoceles that are not readily accessible by tube thoracostomy. Percutaneous catheter drainage of these collections provides a safe and reliable method of management in critically ill patients.

Noncardiac surgery in patients on mechanical circulatory support.

This study examined outcomes in patients with left ventricular assist device (LVAD) and extracorporeal membrane oxygenation (ECMO) requiring noncardiac surgical procedures and identified factors that influence outcomes. All patients with mechanical circulatory support (MCS) devices at our institution from 2002 to 2013 undergoing noncardiac surgical procedures were reviewed. There were 148 patients requiring MCS during the study period, with 40 (27.0%) requiring 62 noncardiac surgical procedures. Of these, 29 (72.5%) had implantable LVAD and 11 (27.5%) were supported with ECMO. The two groups were evenly matched with regard to age (53.6 vs. 54.5 years, p = 0.87), male sex (71.4 vs. 45.5%, p = 0.16), and baseline creatinine (1.55 vs. 1.43 mg/dl, p = 0.76). Patients on ECMO had greater demand for postoperative blood products (0.8 vs. 2.8 units of packed red blood cells, p = 0.002) and greater postoperative increase in creatinine (0.07 vs. 0.44 mg/dl, p = 0.047). Median survival was markedly worse in ECMO patients. Factors associated with mortality included ECMO support, history of biventricular assist device, and postoperative blood transfusion. Preoperative aspirin was associated with survival. These findings demonstrate the importance of careful surgical hemostasis and minimizing perioperative blood transfusions in patients on MCS undergoing noncardiac surgical procedures. In addition, low-dose antiplatelet therapy should be continued perioperatively.