Trista Reid

Burn mortality in patients with preexisting cardiovascular disease

INTRODUCTION Burn shock, a complex process, which develops following burn leads to severe and unique derangement of cardiovascular function. Patients with preexisting comorbidities such as cardiovascular diseases may be more susceptible. We therefore sought to examine the impact of preexisting cardiovascular disease on burn outcomes. METHODS A retrospective analysis of patients admitted to a regional burn center from 2002 to 2012. Independent variables analyzed included basic demographics, burn mechanism, presence of inhalation injury, TBSA, pre-existing comorbidities, and length of ICU/hospital stay. Bivariate analysis was performed and Poisson regression modeling was utilized to estimate the incidence of being in the ICU and mortality. RESULTS There were a total of 5332 adult patients admitted over the study period. 6% (n=428) had a preexisting cardiovascular disease. Cardiovascular disease patients had a higher mortality rate (16%) compared to those without cardiovascular disease (3%, p<0.001). The adjusted Poisson regression model to estimate incidence risk of being in intensive care unit in patients with cardiovascular disease was 33% higher compared to those without cardiovascular disease (IRR=1.33, 95% CI=1.22-1.47). The risk for mortality is 42% higher (IRR=1.42, 95% CI=1.10-1.84) for patients with pre-existing cardiovascular disease compared to those without cardiovascular disease after controlling for other covariates. CONCLUSION Preexisting cardiovascular disease significantly increases the risk of intensive care unit admission and mortality in burn patients. Given the increasing number of Americans with cardiovascular diseases, there will likely be a greater number of individuals at risk for worse outcomes following burn. This knowledge can help with burn prognostication.

Anatomic Location and Mechanism of Injury Correlating with Prehospital Deaths in Sub-Saharan Africa

IntroductionTrauma is a large contributor to morbidity and mortality in developing countries. We sought to determine which anatomic injury locations and mechanisms of injury predispose to prehospital mortality in Malawi to help target preventive and therapeutic interventions. We hypothesized that head injury would result in the highest prehospital mortality.MethodsThis was a retrospective analysis of all trauma patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, from 2008 to 2015. Independent variables included baseline characteristics, anatomic location of primary injury, mechanism of injury, and severity of secondary injuries. Multivariable logistic regression was used to assess the effect of primary injury location and injury mechanism on prehospital death, after adjusting for confounders. Effect measure modification of the primary injury site/prehospital death relationship by injury mechanism (stratified into intentional and unintentional injury) was assessed.ResultsOf 85,806 patients, 701 died in transit (0.8%). Five hundred and five (72%) of these patients sustained a primary head injury. After adjustment, head injury was the anatomic location most associated with prehospital death (OR 11.81 (95% CI 6.96–20.06, p < 0.0001). The mechanisms of injury most associated with prehospital death were gunshot wounds (OR 38.23, 95% CI 17.66–87.78, p < 0.0001) and pedestrian hit by vehicle (OR 2.62, 95% CI 1.92–3.55, p < 0.0001). Among head injury patients, the odds of prehospital mortality were higher with unintentional injuries.ConclusionsHead injuries are the most common causes of prehospital death in Malawi, while pedestrians hit by vehicles are the most common mechanisms. In a resource-poor setting, preventive measures are critical in averting mortality.

Veno-venous Extracorporeal Membrane Oxygenation and Pulmonary Resection for Necrotizing Pneumonia

We describe the case of a 35-year-old man who presented in respiratory failure after influenza B infection requiring initiation of venovenous extracorporeal membrane oxygenation and eventual pulmonary resection for necrotizing pneumonia. Following a successful wean off venovenous extracorporeal membrane oxygenation, and once hemodynamically stable, he was taken to the operating room for decortication and left pulmonary resection. Recovery was complicated by persistent airleak requiring placement of endobronchial valves, but otherwise he recovered very well. This case demonstrates the benefits of lung resection for necrotizing pneumonia.

Acute Respiratory Distress Syndrome (ARDS)

Acute respiratory distress syndrome (ARDS) remains a challenging condition faced by clinicians. Characterized by a partial pressure of oxygen to fraction of inspired oxygen ratio of less than or equal to 300, the syndrome is exemplified by diffuse alveolar damage and hypoxic respiratory failure. The causes can be either direct lung injury or indirect systemic factors, and diagnosis is based on clinical assessment, laboratory, and radiographic evidence. This chapter will discuss the definition, causes, and diagnosis of ARDS and then will delineate evidence-based management strategies, including low tidal volume ventilation, discussions of PEEP and driving pressure, ventilator modes, and useful adjuncts in therapy.