Timothy Browder

Preventable or potentially preventable mortality at a mature trauma center.

OBJECTIVE The objective of this study was to analyze the preventable and potentially preventable deaths occurring at a mature Level I trauma center. METHODS All trauma patients that died during their initial hospital admission during an 8-year period (January, 1998 to December, 2005) were analyzed. The deaths were initially reviewed at a weekly Morbidity and Mortality (M&M) conference followed by a multidisciplinary (Trauma Surgery, Critical Care, Emergency Medicine, Neurosurgery, Nursing, and Coroner) Combined Trauma Death Review Committee, and were classified into nonpreventable, potentially preventable, and preventable deaths. All preventable and potentially preventable deaths were identified for the purpose of the study. Quality improvement death forms included data on epidemiology, vital signs, injury severity, type of injury, probability of survival with Trauma and Injury Severity Score methodology, preventability (nonpreventable, potentially preventable, and preventable deaths), errors in the evaluation and management of the patient, and classification of errors (system, judgment, knowledge). Additional injury details, clinical course, circumstances leading to the death and autopsy findings were abstracted from the trauma registry and individual chart review. RESULTS During the study period, 35,311 patients meeting trauma registry criteria were admitted and a total of 2,081 (5.9%) deaths occurred. Fifty-one deaths were classified as preventable or potentially preventable deaths (0.1% of admissions, 2.5% of deaths). Eleven of them (0.53% of deaths) were classified as preventable and 40 (1.92% of deaths) as potentially preventable deaths. Mean age was 40 years, 66.7% were men, mean Injury Severity Score was 27, 74.5% were blunt. The most common cause of death was bleeding (20, 39.2%) followed by multiple organ dysfunction syndrome (14, 27.5%) and cardiorespiratory arrest (8, 15.6%). This was caused by a delay in treatment (27, 52.9%), clinical judgment error (11, 21.6%), missed diagnosis (6, 11.8%), technical error (4, 7.8%), and other (3, 5.9%). The deaths peaked at two time periods: 26 (51.1%) during the first 24 hours and 16 (31.4%) after 7 days. Only one patient (2.0%) died in the first hour. The most common location of death was the intensive care unit (28, 54.9%), operating room (13, 25.5%), and emergency room (5, 9.8%). CONCLUSION Preventable or potentially preventable deaths are rare but do occur at an academic Level I trauma center. Delay in treatment and error in judgment are the leading causes of preventable and potentially preventable deaths.

Impact of plasma transfusion in massively transfused trauma patients.

OBJECTIVE The objective of this study was to determine the optimal use of fresh-frozen plasma (FFP) in trauma. Our hypothesis was that a higher FFP: packed red blood cells (PRBC) ratio is associated with improved survival. METHODS This is a 6-year retrospective trauma registry and blood bank database study in a level I trauma center. All massively transfused patients (> or =10 PRBC during 24 hours) were analyzed. Patients with severe head trauma (head Abbreviated Injury Severity score > or =3) were excluded from the analysis. Patients were classified into four groups according to the FFP:PRBC ratio received: low ratio (< or =1:8), medium ratio (>1:8 and < or =1:3), high ratio (>1:3 and < or =1:2), and highest ratio (>1:2). RESULTS Of 25,599 trauma patients, 4,241 (16.6%) received blood transfusion. Massive transfusion occurred in 484 (11.4%) of the transfused. After exclusion of 101 patients with severe head injury 383 patients were available for analysis. The mortality rate decreased significantly with increased FFP transfusion. However, there does not seem to be a survival advantage after a 1:3 FFP:PRBC ratio has been reached. Using the highest ratio group as a reference, the relative risk of death was 0.97 (p = 0.97) for the high ratio group, 1.90 (p < 0.01) for the medium ratio group, and 3.46 (p < 0.01) for the low ratio group. There was an increasing trend toward more FFP use during time with the mean units per patient increasing 83% from 6.3 +/- 4.6 in 2000 to 11.5 +/- 9.7 in 2005. CONCLUSION Higher FFP:PRBC ratio is an independent predictor of survival in massively transfused patients. Aggressive early use of FFP may improve outcome in massively transfused trauma patients.

Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective.

BACKGROUND Since the promulgation of emergency department (ED) thoracotomy>40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival. METHODS Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively. RESULTS During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15-64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was >25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge. CONCLUSION Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.

Beta-Blockers in Isolated Blunt Head Injury

BACKGROUND The purpose of this study was to evaluate the effect of beta-blockers on patients sustaining acute traumatic brain injury. Our hypothesis was that beta-blocker exposure is associated with improved survival. STUDY DESIGN The trauma registry and the surgical ICU databases of an academic Level I trauma center were used to identify all patients sustaining blunt head injury requiring ICU admission from July 1998 to December 2005. Patients sustaining major associated injuries (Abbreviated Injury Score > or = 4 in any body region other than the head) were excluded. Patient demographics, injury profile, Injury Severity Score, and beta-blocker exposure were abstracted. The primary outcomes measure evaluated was in-hospital mortality. RESULTS During the 90-month study period, 1,156 patients with isolated head injury were admitted to the ICU. Of these, 203 (18%) received beta-blockers and 953 (82%) did not. Patients receiving beta-blockers were older (50 +/- 21 years versus 38 +/- 20 years, p < 0.001), had more frequent severe (Abbreviated Injury Score > or = 4) head injury (54% versus 43%, p < 0.01), Glasgow Coma Scale < or = 8 less often (37% versus 47%, p = 0.01), more skull fractures (20% versus 12%, p < 0.01), and underwent craniectomy more frequently (23% versus 4%, p < 0.001). Stepwise logistic regression identified beta-blocker use as an independent protective factor for mortality (adjusted odds ratio: 0.54; 95% CI, 0.33 to 0.91; p = 0.01). On subgroup analysis, elderly patients (55 years or older) with severe head injury (Abbreviated Injury Score > or = 4) had a mortality of 28% on beta-blockers as compared with 60% when they did not receive them (odds ratio: 0.3; 96% CI, 0.1 to 0.6; p = 0.001). CONCLUSIONS Beta-blockade in patients with traumatic brain injury was independently associated with improved survival. Older patients with severe head injuries demonstrated the largest reduction in mortality with beta-blockade.

Abdominal injuries in pregnancy: a 155-month study at two level 1 trauma centers

INTRODUCTION Trauma in pregnancy is the leading cause of non-obstetrical maternal death and remains a major cause of fetal demise. The objective of this study was to examine the outcomes of pregnant patients sustaining abdominal injury. PATIENTS AND METHODS This is a retrospective analysis of all pregnant trauma patients admitted to two level 1 trauma centers from February 1, 1996 to December 31, 2008. Patient data abstracted included mechanism of injury, physiologic parameters on admission, Injury Severity Score (ISS), abdominal Abbreviated Injury Scale (AIS), gestational age, diagnostic and surgical procedures performed,complications, and maternal and fetal mortality. Univariate analysis and logistic regression analysis were used. RESULTS During the 155-month study period, 321 pregnant patients were included, of which 291 (91%)sustained a blunt injury, while 30 (9%) were victims of penetrating trauma. Of the penetrating injuries,22 (73%) were gunshot wounds, 7 (23%) stab wounds, and 1 (4%) shotgun injury. The overall maternal and fetal mortality was 3% (n = 9) and 16% (n = 45), respectively. Mean age was 22 6 year-old, and the mean ISS was 12 16. The overall mean abdominal AIS was 2 1.2. When adjusted for age, abdominal AIS,ISS, and diastolic blood pressure, the penetrating trauma group experienced higher maternal mortality [7%vs. 2% (adjusted OR: 7; 95% CI: 0.65–79), p = 0.090], significantly higher fetal mortality [73% vs. 10% (adjusted OR: 34; 95% CI: 11–124), p < 0.0001] and maternal morbidity [66% vs. 10% (adjusted OR: 25; 95% CI: 9–79)p < 0.0001]. CONCLUSIONS Fetal mortality and overall maternal morbidity remains exceedingly high, at 73% and 66%,respectively, following penetrating abdominal injury. Penetrating injury mechanism, severity of abdominal injury and maternal hypotension on admission were independently associated with an increased risk for fetal demise following traumatic insult during pregnancy.

Effect of Trauma Center Designation on Outcome in Patients With Severe Traumatic Brain Injury

OBJECTIVE To determine the association of the American College of Surgeons (ACS) designation with outcomes in patients, specifically those with severe traumatic brain injuries. DESIGN A retrospective review. Logistic regression was performed for mortality, complications, and progression of initial neurologic insult. SETTING Data from the National Trauma Data Bank. PATIENTS A total of 16,037 patients with isolated severe head injury (head acute injury score, > or =3 and other body region abbreviated injury score, <3) classified into 2 groups (level 1 and level 2) according to ACS designation. RESULTS Patients admitted to a level 2 center had higher mortality rates (13.9% vs 9.6%; P < .001), higher rates of complication (15.5% vs 10.6%; P < .001), and higher rates of progression of initial neurologic insult (2.0% vs 1.1%; P < .001). After adjustment for the factors that were different between the 2 groups, admission to a level 2 facility remained an independent predictor of mortality (adjusted odds ratio [OR], 1.57; 95% confidence interval [CI], 1.41-1.75; P < .001), complications (adjusted OR, 1.55; 95% CI, 1.40-1.71; P < .001), and progression of neurologic insult (adjusted OR, 1.78; 95% CI, 1.37-2.31; P < .001). Other independent risk factors for mortality were penetrating mechanism, age of 55 years or older, Injury Severity Score of 20 or higher, Glasgow Coma Scale score of 8 or lower, and hypotension (systolic blood pressure, <90 mm Hg). CONCLUSION Patients with severe traumatic brain injury treated in ACS-designated level 1 trauma centers have better survival rates and outcomes than those treated in ACS-designated level 2 centers.

Blunt cardiac rupture: A 5-year NTDB analysis

OBJECTIVE Because of its rarity and high rate of mortality, traumatic blunt cardiac rupture (BCR) has been poorly studied. The objective of this study was to use the National Trauma Data Bank to review the epidemiology and outcomes associated with traumatic BCR. METHODS After approved by the institutional review board, the National Trauma Data Bank (version 5.0) was queried for all BCR occurring between 2000 and 2005. Demographics, clinical injury data, interventions, and outcomes were abstracted for each patient. Statistical analysis was performed using an unpaired Students t test or Mann-Whitney U test to compare means and chi analysis to compare proportions. Stepwise logistic regression analysis was performed to identify independent predictors of inhospital mortality. RESULTS Of 811,531 blunt trauma patients, 366 (0.045%) had a BCR of which 334 were available for analysis, with the mean age of 45 years, 65% were men, and their mean Injury Severity Score was 58 +/- 19. The most common mechanism of injury was motor vehicle collision (73%), followed by pedestrian struck by auto (16%), and falls from height (8%). Twenty-one patients (6%) died on arrival and 140 (42%) died in the emergency room. The overall mortality for patients arriving alive to hospital was 89%. Of the patients surviving to operation, 42% survived >24 hours of which 87% were discharged. Survivors were significantly younger (39 vs. 46 years, p = 0.04), had a lower Injury Severity Score (47 vs. 56, p = 0.02), higher Glasgow Coma Scale (10 vs. 6, p < 0.001), and were more likely to present with an systolic blood pressure >or=90 mm Hg (p = 0.01). Nevertheless, none of these factors was found to be an independent risk factor for mortality. CONCLUSION BCR is an exceedingly rare injury, occurring in 1 of 2400 blunt trauma patients. In patients arriving alive to hospital, traumatic BCR is associated with a high mortality rate, however, is not uniformly fatal.

The Model for End-stage Liver Disease Score An Independent Prognostic Factor of Mortality in Injured Cirrhotic Patients

OBJECTIVE To examine the ability of the model for end-stage liver disease (MELD) score to predict the risk of mortality in trauma patients with cirrhosis. Although cirrhosis is associated with poor outcomes after injury, the relative effect of the severity of the cirrhosis on outcomes is unclear. The MELD score is a prospectively developed and validated scoring system, which is associated with increasing severity of hepatic dysfunction and risk of death in patients with chronic liver disease. DESIGN Retrospective review. The MELD score for each patient was calculated from the international normalized ratio, the serum creatinine level, and the serum total bilirubin level obtained from the patient at admission to the level 1 trauma center. The association of MELD score with mortality was assessed using logistic regression analysis. SETTING Level 1 trauma center. PATIENTS Cirrhotic patients with trauma admitted to the level 1 trauma center during the period from January 2003 to December 2009. MAIN OUTCOME MEASURE Mortality. RESULTS During the 7-year study period, 285 injured cirrhotic patients were admitted. The mean (SD) age was 50.0 (10.5) years, and the mean (SD) MELD score was 11.7 (4.8) (range, 6-28). Overall, patients who died had a significantly higher mean (SD) MELD score than did survivors (14.1 [5.4] vs 11.2 [4.6]; P < .001). The MELD score and the injury severity score were statistically significant risk factors that were independently associated with mortality in this group of patients (the area under the curve for the model was 0.944; cumulative R(2) = 0.545). Each unit increase in the MELD score was associated with an 18% increase in the odds for mortality (adjusted odds ratio, 1.18 [95% confidence interval, 1.08-1.29]; P < .001). CONCLUSION The MELD score is a simple objective tool for risk stratification in cirrhotic patients who have sustained injury.

Analysis of 178 Penetrating Stomach and Small Bowel Injuries

Surgical site infections (SSIs), such as wound infection, fascial dehiscence, and intraabdominal abscess, commonly occur following penetrating abdominal trauma. However, most of the literature involves penetrating colon injuries. There are few reports describing complications following penetrating stomach and small bowel injuries. Based on the hypothesis that SSIs are commonly found following penetrating stomach and small bowel trauma, a prospective observational study was performed at an academic Level I trauma center from March 1, 2004 until August 31, 2006. The subjects were patients who had sustained a penetrating injury to the stomach or small bowel. Patients were followed for the development of an SSI, defined as wound infection, fascial dehiscence, or intraabdominal abscess. A total of 178 patients were admitted with penetrating stomach or small bowel injuries over the 29-month period. There were 121 (68%) gunshot injuries and 57 (32%) stab wounds. Associated intraabdominal injuries occurred in 74% of patients. Overall, SSIs occurred in 20% of cases. Risk factors for SSI included associated duodenal or colon injury, whereas time to operating room, blood loss, and type and duration of antibiotic use were not. When associated colon injuries were excluded, SSIs occurred in 16% of patients with gastric injuries and 13% of those with small bowel injuries. SSIs commonly follow penetrating stomach and small bowel trauma. Risk factors for SSI include associated duodenal or colon injury. Delay to operating room, blood loss, and type and length of antibiotic prophylaxis were not associated with an increased risk of SSI.

Preventable morbidity at a mature trauma center

OBJECTIVE To analyze the preventable and potentially preventable complications occurring at a mature level I trauma center. DESIGN Retrospective review. SETTING Academic level I trauma center. PATIENTS The study included 35 311 trauma registry patients. MAIN OUTCOME MEASURES The cause, effect on outcome, preventability (preventable, potentially preventable, or nonpreventable), and loop closure recommendations for all preventable and potentially preventable complications, and clinical data related to each complication retrieved from the trauma registry and individual medical records. RESULTS Over the 8-year study, 35 311 trauma registry patients experienced 2560 complications. Three hundred fifty-one patients (0.99% of all patients) had 403 preventable or potentially preventable complications. The most common preventable or potentially preventable complications were unintended extubation (63 patients [17% of complications]), surgical technical failures (61 patients [15% of complications]), missed injuries (58 patients [14% of complications]), and intravascular catheter-related complications (48 patients [12% of complications]). These complications were clinically relevant; 258 (64% of complications) resulted in a change in management, including 61 laparotomies, 52 reintubations, 41 chest tube insertions, and 19 vascular interventions. CONCLUSIONS The incidence of preventable or potentially preventable complications at an academic level I trauma center is low. These complications often require a change in management and cluster in 4 major categories (ie, unintended extubation, surgical technical failures, missed injuries, and intravascular catheter-related complications) that must be recognized as critical areas for quality improvement initiatives.