William Fallon

Trauma in the very elderly: A community-based study of outcomes at trauma and nontrauma centers

BACKGROUND Little research has examined trauma outcomes in the very elderly (>80 years), the fastest growing subset of our geriatric population. Our objective was to describe demographics, mechanism of injury and injury severity of very elderly trauma patients and examine the association between trauma center (TC) verification and hospital mortality in this age group. METHODS Retrospective cohort study. Database consisted of a 1996 countywide trauma registry. Subjects consisted of patients > 80 years of age. The setting consisted of Level I (TCI) and Level II (TCII) trauma centers, and acute care (AC) hospitals. The z score analysis was performed using the Major Trauma Outcome Study and a county-specific risk/outcome equation. In addition, a logistic regression model examined hospital mortality (outcome variable) using age, ISS, arrival GCS, and TC verification as predictor variables. Statistical analysis included descriptive statistics; ANOVA; and forward stepwise logistic regression model (OR; 95% CI). RESULTS Four hundred fifty-five patients with a mean age of 85.9 (+/-4.8) years (range 80-101). Overall mortality was 9.9%. Using z score analysis, survival at TCII performed as predicted (-1.59), while AC performed less than predicted (-3.41). In the regression model, GCS (OR 0.68; CI 0.57-0.79), ISS (OR 1.1; CI 1.05-1.2) and AC setting (OR 3.2; CI 1.1-9.5) predicted hospital mortality. TCs had significantly better outcomes than AC hospitals in a subset of severely injured patients (ISS 21-45) (56% v 8% survival; p < 0.01). CONCLUSION Risk-adjusted outcomes, in this population, differed between TC and AC settings. Head injury, injury severity, and lack of TC verification are associated with hospital mortality in very elderly trauma patients.

Injured Intoxicated Drivers: Citation, Conviction, Referral, and Recidivism Rates

STUDY OBJECTIVES Several studies have suggested that legally intoxicated drivers who are injured when involved in a motor vehicle crash are unlikely to be cited or prosecuted for driving under the influence (DUI). The purpose of this study was to determine (1) the rates of citation and prosecution of legally intoxicated drivers who are injured in a motor vehicle crash and hospitalized in a Level I trauma center, (2) the rates of previous and subsequent alcohol-related citation in this population, and (3) the rate of referral for treatment of alcohol-related problems made during the hospital stay. METHODS In a retrospective review of trauma registry and Cleveland Municipal Court records from January 1993 through April 1995, we examined the records of all drivers injured in a motor vehicle crash who were transported to a Level I urban trauma center, admitted to the trauma service, and determined to have a blood alcohol content (BAC) of .10 gm% or higher at the time of admission to the emergency department. RESULTS Seventy drivers admitted after a motor vehicle crash had a BAC of .10 gm% or higher. This represented 33% of the drivers older than 16 years of age who were admitted to the trauma service. Twenty-three drivers (32.8%) were cited for DUI, and 15 (21%) of the 70 were successfully prosecuted and convicted. Four of 23 cited drivers had previous citations; another 5 incurred subsequent citations during the study period. Eight of the 70 drivers who were admitted with a high BAC were referred for outpatient alcohol counseling after discharge. None were offered counseling as inpatients. CONCLUSION Citation and prosecution rates of legally intoxicated drivers injured in motor vehicle crashes and hospitalized in our trauma center were low. Recognition of alcoholism and inpatient counseling were rare. Multiple alcohol-related citations were common among drivers cited for DUI.

THE USE OF FOCUSED ASSESSMENT WITH SONOGRAPHY FOR TRAUMA (FAST) BY A PREHOSPITAL AIR MEDICAL TEAM IN THE TRAUMA ARREST PATIENT

Traumatic cardiac arrest can occur with catastrophic head injury, vascular injuries, and multisystem trauma. Because of the etiology of traumatic arrest, pulseless electrical activity (PEA) is a commonly found rhythm in this patient population.1 Pulseless electrical activity in the trauma arrest population is usually associated with hypovolemia, hypoxia, hypothermia, tension pneumothorax, or pericardial tamponade.2 Effective triage and treatment of traumatic arrest rely on the rapid identification and treatment of the underlying etiologic factors. Ultrasound examination has been used effectively for identifying traumatic injury in patients in the emergency department.3–15 We report a case of the use of ultrasound to differentiate and exclude several causes for the arrest and associated PEA, preventing indiscriminate use of modalities such as blood products or blind pericardiocentesis. Perhaps the most unique aspect of the exam was that it was performed by the prehospital air medical crew, using an ultrasound machine that is routinely carried and utilized on board a helicopter.

Efficacy of 24-Hour Shifts: Prepared or Impaired? A Prospective Study

BACKGROUND The effect of duty duration on performances is unknown. In a prospective cohort study model using repeated measures, we evaluated the effect of shift length on a battery of neuropsychologic performance indicators using our flight program as the test site. METHODS Flight nurses completing 24- and 12-hour shifts were tested on memory, attention, reasoning, motor, and speed measures. Ratings of stress, fatigue, sleep quality, and logged amount of work and sleep were evaluated from personal journals kept for this purpose. Data were analyzed by linear regression and repeated measures multivariate analysis of variance (MANOVA) and analysis of variance (ANOVA). Clinical significance was set at P < 0.05. RESULTS Fifteen subjects completed the testing and evaluation process. Neuropsychologic testing demonstrated that performance was not predicted by shift length, time of shift (day versus night), amount or quality of sleep before or during shift, or fatigue ratings. Age, gender, and education did not mediate shift length/test performance relationships. Uninterrupted sleep, stress ratings, and number of flights per shift modestly reduced some test scores. Predictably, repeated testings resulted in practice effects that reduced analysis power. We found that 24-hour shifts per se do not result in a cognitive decline compared with 12-hour shifts. Inconsistent sleep, number of flights, and the stressfulness of flights may have greater impact.

Trauma triage: do AAMS transport guidelines do it effectively?

PURPOSE Appropriateness of helicopter transport for trauma patient transfer is under closer scrutiny with the development of regionalized trauma systems and managed care. This study was conducted to determine the effectiveness of the 14 Association of Air Medical Services (AAMS) guidelines in triaging trauma patients. METHODS The application of the trauma transport guidelines for 511 patients flown to our trauma center with hospital stays of fewer than 3 days were analyzed to ensure high sensitivity to overtriage. Injury severity score (ISS), revised trauma score (RTS), Glasgow coma scale (GCS), and mortality rates associated with each of the guidelines were analyzed. RESULTS Each guideline was associated with mortality greater than or equal to 20%, except motor vehicle, falls, amputation, and degloving. All guidelines had significant ISS (> 14), RTS (< 10), and GCS (< 12), except falls (ISS-6.7, RTS-11, GCS-13.3) and amputations (ISS-6.3, RTS-11, GCS-13.5). Degloving, motor vehicle, spinal cord, airway, and extrication also had a significantly higher RTS (> 12). CONCLUSION The AAMS transport guidelines for trauma patients accurately predict the potential for serious or life-threatening injury, with the exception of falls and amputations. The rapid access to highly skilled reimplantation teams required by patients with amputations justifies helicopter transport. However, falls greater than 20 feet do not appear to identify potential for life-threatening injury.

General Surgical Casualties: Abdominal Wounds, Urogenital Trauma, and Soft-Tissue Injuries

In addition to knowing what injuries their patients have sustained, the aeromedical transport crew must also know what therapies have been rendered in an attempt to stabilize the patient. This is in particular true in the trauma patient. The crew must understand modern techniques for surgical correction because they are likely to impact therapies needed for aeromedical transport. The evolution of aeromedical transport has allowed surgical facilities and definitive care to be moved farther from the front. In essence, advances in aeromedical transport and surgical techniques have extended the reach of advanced medical care from the tertiary-care centers to the field. This has placed a greater burden on the flight crew to be skilled and adept at critical care. Treatments and modalities previously rendered in hospitals are now routine for in-flight care. Patients previously thought to be unstable for transport are pushing the envelope and boundaries of conventional care, and military budget restraints are not allowing the massive medical units of the past. This is necessitating aeromedical crews to provide care farther, faster, and to more critical patients than they have ever done before.