Toan T. Huynh

The hazard of scattered radiation in a trauma intensive care unit.

OBJECTIVEnPatients admitted to the trauma intensive care unit (TICU) often require bedside imaging procedures such as radiographs, fluoroscopic placement of enteral feeding tubes, and insertion of vena cava filters. The potential for scattered radiation exposure is a concern to healthcare workers. Our studys purpose was to measure the level of scattered ionizing radiation present in a TICU.nnnDESIGN AND SETTINGnThis prospective study was conducted over 3 months in an open-design, ten-bed TICU of a Level I trauma center.nnnINTERVENTIONS AND MEASUREMENTSnFifteen dosimeters were placed in selected areas of the TICU to measure the amount of scattered radiation present. Standard radiation protection precautions were used throughout the study period. At the end of each month, data from the dosimeters were sent to the manufacturer for analysis.nnnMAIN RESULTSnOne thousand seventy-four radiologic studies were performed at the bedside during the study period (803 portable chest radiographs, 103 abdominal radiographs, 303 extremity radiographs, 223 spine radiographs, and 15 fluoroscopic procedures). Dosimetry analysis showed <5 mrem (1/1000 roentgen equivalent in man) scattered radiation per month (<60 mrem/year) in each of the monitored areas. All monitored areas measured <2 mrem per week of scattered radiation when adjusted for occupancy.nnnCONCLUSIONSnThe level of scattered radiation in our TICU is less than the recommended allowable exposure of <100 mrem/year, indicating that radiation exposure is not a significant occupational hazard in our TICU, even in the setting of frequent use of bedside imaging studies.

The role of transesophageal echocardiography in optimizing resuscitation in acutely injured patients.

BACKGROUNDnThe goal of resuscitation is to correct the mismatch between oxygen delivery and that of cellular demands. The pulmonary artery catheter (PAC) is frequently used to gauge the adequacy of resuscitation and guide therapy based on ventricular filling pressures. Transesophageal echocardiography (TEE) has emerged as a potential tool in assessing adequacy of acute hemodynamic resuscitation. The purpose of this study was to evaluate the role of TEE in assessing preload during ongoing volume resuscitation in trauma patients.nnnMETHODSnA retrospective review was conducted of acutely injured patients undergoing TEE during resuscitation from hemorrhagic shock from January 2002 to 2004 at a Level I trauma center. The indication for TEE was persistent hemodynamic instability in the absence of ongoing surgical hemorrhage. Variables included hemodynamic and PAC parameters, pre-TEE resuscitation volume, and vasopressor requirements. The impact of TEE findings on therapeutic decisions was evaluated.nnnRESULTSnTwenty-five patients underwent TEE, 18 (72%) had an indwelling PAC with a mean pulmonary artery occlusion pressure of 19.3 mm Hg (range, 12-29 mm Hg) and mean cardiac index of 2.9 L/min/m2 (range, 1.6-4.6 L/min/m2). Twelve patients (48%) were receiving inotropes and/or vasopressors for hypotension at the time of TEE. Resuscitation volume within 6 hours before TEE included a mean of 6.5 L of crystalloid and 12.2 units of blood products (packed red blood cells, fresh frozen plasma, and platelets). TEE revealed left ventricular hypovolemia in 13 patients (52%) and altered therapy in 16 patients (64%), including additional volume (n = 13), addition of an inotrope (n = 4), and addition of a vasodilator (n = 1) in one patient with ventricular overdistention. Comparison of the abnormal and normal TEE groups revealed that only cardiac index was significantly different (2.6 L/min/m2 in the abnormal group vs. 3.9 L/min/m2 in the normal group; p = 0.005). Significant mitral valve regurgitation leading to valve replacement was identified in one patient. No clinically relevant pericardial effusion was identified.nnnCONCLUSIONnTEE altered resuscitation management in almost two thirds of patients. Many patients with acceptable pulmonary artery occlusion pressure parameters may in fact have inadequate left ventricular filling. In addition, TEE offers the advantage of direct assessment of cardiac valve competency, myocardial wall contractility, and pericardial fluid.

Optimal management strategy for incidental findings in trauma patients: an initiative for midlevel providers.

BACKGROUNDnIncreasing patient volume and residents work hour restrictions have increased the workload at trauma centers. Further, comprehensive tertiary surveys after initial stabilization and appropriate follow-up plans for incidental findings are time consuming. Midlevel providers (MLP) can help streamline this process. We initiated a care plan in which MLPs conducted all tertiary surveys and coordinated follow-ups for incidental findings.nnnMETHODSnFrom November 2005 through May 2006, we implemented a MLP-driven initiative aimed at performing tertiary surveys within 48 hours of admission on all trauma patients admitted to our Level-1 trauma center. Tertiary surveys consisted of a complete history and physical, radiographic evaluations and appropriate consultations. Incidental findings were recorded and communicated to the trauma attending. A follow-up plan was devised, and the course of action was documented. Patients or family members were informed, and their acknowledgments were filed. Data are presented as mean +/- SE.nnnRESULTSnThere were 1,027 patients admitted during the study period. Blunt mechanisms accounted for 81% of the injuries (primarily motor vehicle crashes and falls). Seventy-six patients had 87 incidental findings (7.4%); 53 were men. The mean age was 51.8 years +/- 2.1 years and mean injury severity score was 18.5 +/- 1.4. Incidental findings of clinical significance included 18 pulmonary nodules or neoplasms, 9 adrenal masses (>4 mm), 7 patients with lymphadenopathy, 5 benign cystic lesions, and 3 renal masses. Other neoplastic lesions included bladder (2), thyroid (2), ovary (1), breast (1), and rectum (1).nnnCONCLUSIONSnWith prevalent medicolegal pressure and restricted residents work hours, a MLP-initiative to streamline the tertiary survey effectively addresses incidental findings. This MLP-driven care plan can help reduce residents workload, provides appropriate follow-up, and minimizes legal risks inherent to incidental findings on the trauma service.

An initiative by midlevel providers to conduct tertiary surveys at a level I trauma center.

INTRODUCTIONnIncreased patient volume and residents work hour restrictions have escalated the workload at trauma centers. Because tertiary surveys (TSs) are integral to care, midlevel providers (MLPs) can help streamline this time-consuming process. In this study, we implemented a care plan in which MLPs conduct all TSs, initiate appropriate consultations, and offload residents work hours.nnnMETHODSnFrom January 2007 to December 2008, we conducted a prospective evaluation of an initiative in which MLPs performed all TSs within 48 hours of admission. A TS consisted of a complete history and physical examination, follow-up of radiologic interpretations, and appropriate consultations. Data included patient demographics, incidence of additional diagnoses noted during TSs and reduction in residents work hours. Data are presented as mean +/- standard error.nnnRESULTSnDuring the 2-year period, there were 5,143 patients admitted to the trauma service. The mean age was 36 years +/- 4.8 years, and mean Injury Severity Score (ISS) was 14.2 +/- 4.2. Overall mortality was 5%. Blunt mechanisms accounted for 85%, and penetrating mechanisms resulted in 14% of injuries. MLPs conducted TSs in 56% of patients during the first year and 76% in the second year. In 80 patients (mean age of 44 years +/- 7.1 years, mean Injury Severity Score 21.7 +/- 2.8; p < 0.05 vs. entire cohort), TSs revealed additional injuries, for an incidence of 1.5%. The majority of these diagnoses were of minor fractures, half requiring consultations, and 9% necessitating operative intervention. Residents workload was reduced by 1,802 hours.nnnCONCLUSIONSnImplementation of a MLP initiative to conduct TSs in trauma patients can achieve a consistent and comprehensive workup while offsetting residents workload and helping to ensure compliance with the 80-hour resident work policy.

Comparison of procedural complications between resident physicians and advanced clinical providers.

BACKGROUND In the era of resident work hour restrictions, many trauma centers across the country have incorporated advanced clinical providers (ACPs) as integral partners in the care of critically ill patients. In addition to providing daily care, ACPs have also begun performing invasive procedures. Few studies have addressed ACPs procedural complications. The purpose of this study was to compare the complication rates from surgical procedures performed by resident physicians (RPs) and ACPs in the critical care setting. METHODS We conducted a retrospective review of all procedures performed from January to December of 2011 in our trauma and surgical intensive care units. Under attending supervision, ACPs performed procedures for surgical critical care patients and RPs for trauma patients. Procedures consisted of arterial lines, central venous lines, bronchoalveolar lavage, thoracostomy tubes, percutaneous endoscopic gastrostomy, and tracheostomies. Data included demographics, Acute Physiology and Chronic Health Evaluation III scores, complications, and outcomes and were divided into RP versus ACP groups. Complications were assessed by postprocedure radiography, operative notes, and postprocedure notes. Dichotomous data were compared using &khgr;2 and continuous variables by Student’s t tests. RESULTS There were a total of 1,404 patients; the mean ± SE Acute Physiology and Chronic Health Evaluation III score for patients in the RP group was 40.8 ± 0.9 compared with ACP group at 47.7 ± 0.7 (p < 0.05). Our RPs performed 1,020 procedures, and 21 complications were noted (complication rate, 2%). The ACPs completed 555 procedures; 11 complications were incurred (complication rate, 2%). There were no difference in the mean ± SE intensive care unit (RP, 3.9 ± 0.2 days vs. ACP, 3.7± 0.1 days) and hospital (RP, 12.2 ± 0.4 days vs. ACP, 13.3 ± 0.3 days) length of stay. Mortality rates were also comparable between the two groups (RP, 11% vs. ACP, 9.7%). CONCLUSION In critically ill patients, ACPs can competently perform invasive procedures safely. Our ACPs’ responsibilities can be expanded to include invasive procedures in the critical care setting with appropriate supervision. LEVEL OF EVIDENCE Therapeutic study, level IV.

Mopeds: The legal Loophole for Repeat Driving While Intoxicated Offenders

BACKGROUNDnMopeds have less stringent licensing laws than automobiles. Moped operators in motorized vehicle collisions (MVCs) exhibit significantly higher rates of driving while intoxicated (DWI) and higher blood alcohol levels than automobile or motorcycle operators. This study evaluates the public safety issue of DWI recidivism among moped operators.nnnMETHODSnMoped operators evaluated after MVCs were identified from 2007 to 2009. Demographics, hospital data, and Department of Motor Vehicles records were reviewed.nnnRESULTSnSixty-five moped operators were evaluated. Thirty-two (49%) had a positive blood alcohol level, 29 (45%) had a previous DWI, and 21 (72%) of those were repeat offenders. Twenty-five (38%) had a revoked license at the time of injury. Of these, 19 (76%) incurred multiple revocations. Twenty-two (34%) showed prior charges of driving with a revoked license (DWRL), with 15 (68%) incurring multiple DWRL charges.nnnCONCLUSIONSnMoped operators are often intoxicated at the time of injury and represent a public safety hazard. The majority are recidivists with multiple alcohol-related traffic charges. Current laws allow repeat offenders the sustained opportunity to operate motorized vehicles. Re-evaluation of current moped laws is needed to keep habitual offenders off the road.

Removal of erythropoietin from anaemia trauma practice guideline does not increase red blood cell transfusions and decreases hospital utilization costs.

INTRODUCTIONnWe previously demonstrated that utilization of erythropoietin (r-EPO) did not significantly reduce blood utilization in trauma patients. We undertook this study to analyze blood utilization 1 year after r-EPO removal from our trauma service anaemia practice management guideline.nnnMETHODSnElectronic records of patients admitted to the trauma service were retrospectively reviewed for units of packed red blood cells (pRBCs) transfused and for units of r-EPO administered 12 months before the initiation of an anaemia practice guideline (PRE), 12 months during the use of an anaemia guideline (GUIDE), and 12 months following removal of r-EPO from the guideline (POST). Hospital acquisition cost was also reviewed for the respective time periods. Nominal data were analyzed using chi-squared or Fishers exact tests, and interval data were compared using ANOVA followed by Tukeys test where appropriate. Results were considered significant for P<0.05.nnnRESULTSnOver the 3-year study period, 4881 patients were admitted to the trauma service and included in this study. The hospital length of stay, intensive care unit length of stay, and units of pRBC transfused were similar among all three groups. Group I (PRE) received a total of 228 doses of r-EPO at a cost of

Does history of substance use disorder predict acute traumatic brain injury rehabilitation outcomes

102,600. Group II (GUIDE) received a total of 410 doses at a cost of

Venous air embolism from central venous catheterization: under-recognized or over-diagnosed?

184,500. Group III (POST) received 28 doses of r-EPO at a cost of

Delays in transfer of elderly less-injured trauma patients can have deadly consequences.

12,600.nnnCONCLUSIONnRemoval of erythropoietin from our trauma service anaemia practice management guideline did not result in increased blood utilization. However, it yielded a hospital acquisition cost savings of