William S. Hoff

Clinical practice guideline: red blood cell transfusion in adult trauma and critical care.

Objective: To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care. Design: Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members. Methods: This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM. Results: Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion. Conclusions: Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.

Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care*

STATEMENT OF THE PROBLEMRed blood cell (RBC) transfusion is common in critically ill and injured patients. Many studies1–6 have documented the widespread use of RBC transfusion in critically ill patients and the data from these studies from diverse locations in Western Europe, Canada, the United Kin

The Importance of the Command-physician in Trauma Resuscitation

OBJECTIVE Definitive trauma team leadership, although difficult to measure, has been shown to improve trauma resuscitation performance. The purpose of this study was to evaluate the effect of an identified command-physician on resuscitation performance. In addition, the leadership capability of four physician combinations functioning as command-physician was studied. DESIGN Retrospective review. METHODS Videotapes of trauma resuscitations performed at a Level I trauma center over a 25-month period were reviewed. The presence of an identified command-physician was determined by multidisciplinary consensus. Resuscitation performance was measured by compliance with three objective criteria: primary survey, secondary survey, and definitive plan; and two subjective criteria: orderliness, and adherence to Advanced Trauma Life Support protocol. Performance was then analyzed (1) as a function of the presence or absence of a command-physician, and (2) between four identified physician combinations: AF (attending surgeon + trauma fellow); F (trauma fellow); ASR (attending surgeon + senior surgical resident); SR (senior surgical resident). Chi square and the Mann-Whitney U tests were applied. RESULTS A total of 425 trauma resuscitations were reviewed. A command-physician was identified (CP[Pos]) in 365 resuscitations (85.7%); no command-physician was identified (CP[NEG]) in 60 (14.3%). Compliance with completion of secondary survey (81.4%) and formulation of a definitive plan (89.6%) was significantly higher in the CP(POS) group. Subjective scores for orderliness and adherence to Advanced Trauma Life Support protocol were significantly higher in the CP(POS) group. In the CP(POS) resuscitations, formulation of a definitive plan was lower in SR when compared with the other three physician combinations. CONCLUSIONS An identified command-physician enhances trauma resuscitation performance. Completion of the primary and secondary survey is not affected by the physician combination. Prompt formulation of a definitive plan is facilitated by the active involvement of an attending traumatologist or a properly mentored trauma fellow.

Blunt traumatic occult pneumothorax: is observation safe?--results of a prospective, AAST multicenter study.

BACKGROUND An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma patients. Indications for intervention remain controversial. We sought to determine which factors predicted failed observation in blunt trauma patients. METHODS A prospective, observational, multicenter study was undertaken to identify patients with OPTX. Successfully observed patients and patients who failed observation were compared. Multivariate logistic regression was used to identify predictors of failure of observation. OPTX size was calculated by measuring the largest air collection along a line perpendicular from the chest wall to the lung or mediastinum. RESULTS Sixteen trauma centers identified 588 OPTXs in 569 blunt trauma patients. One hundred twenty-one patients (21%) underwent immediate tube thoracostomy and 448 (79%) were observed. Twenty-seven patients (6%) failed observation and required tube thoracostomy for OPTX progression, respiratory distress, or subsequent hemothorax. Fourteen percent (10 of 73) failed observation during positive pressure ventilation. Hospital and intensive care unit lengths of stay, and ventilator days were longer in the failed observation group. OPTX progression and respiratory distress were significant predictors of failed observation. Most patient deaths were from traumatic brain injury. Fifteen percentage of patients in the failed observation group developed complications. No patient who failed observation developed a tension PTX, or experienced adverse events by delaying tube thoracostomy. CONCLUSION Most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy; however, OPTX progression and respiratory distress are independently associated with observation failure.

Practice management guidelines for timing of tracheostomy: The EAST practice management guidelines work group

STATEMENT OF THE PROBLEM The ideal time for performing a tracheostomy has not been clearly established. Periods ranging from 3 days to 3 weeks have been suggested in the literature. With current operative methods, it has been established that tracheostomy can be performed with a low rate of complications. In a review of 281 tracheostomies, as well as another 2,862 cases in the literature, Zeitouni and Kost1 reported 0% mortality in their series and 0.3% mortality in the other series since 1973. The risks of prolonged endotracheal intubation—such as patient discomfort, necessitating increased sedation; sinusitis; inadvertent extubation; and laryngeal injury—have become increasingly apparent. Selection of patients who might benefit from conversion of a translaryngeal tube to a tracheostomy tube is a complex medical decision. Furthermore, different subgroups may benefit from tracheostomy at different times in their hospital course. Management of patients with a single organ failure (head injury or respiratory failure) may differ from that of the multiple injury trauma patient. With the lack of clear guidelines for selecting patients for tracheostomy, considerable variability exists in the timing of the procedure, with local practice preferences guiding care, rather than patient considerations. We initiated our review by converting the need for information about optimal timing of tracheostomy into several answerable questions: 1. Does performance of an “early” tracheostomy provide a survival benefit for the recipients? 2. What patient populations benefit from an “early” tracheostomy? 3. Does “early” tracheostomy reduce the number of days on mechanical ventilation and intensive care unit length of stay (ICU LOS)? 4. Does “early” tracheostomy influence the rate of ventilatorassociated pneumonia?

Practice management guidelines for the diagnosis and management of injury in the pregnant patient: the EAST Practice Management Guidelines Work Group.

Trauma during pregnancy has presented very unique challenges over the centuries. From the first report of Ambrose Pare of a gunshot wound to the uterus in the 1600s to the present, there have existed controversies and inconsistencies in diagnosis, management, prognostics, and outcome. Anxiety is heightened by the addition of another, smaller patient. Trauma affects 7% of all pregnancies and requires admission in 4 of 1000 pregnancies. The incidence increases with advancing gestational age. Just over half of trauma during pregnancy occurs in the third trimester. Motor vehicle crashes comprise 50% of these traumas, and falls and assaults account for 22% each. These data were considered to be underestimates because many injured pregnant patients are not seen at trauma centers. Trauma during pregnancy is the leading cause of nonobstetric death and has an overall 6% to 7% maternal mortality. Fetal mortality has been quoted as high as 61% in major trauma and 80% if maternal shock is present. The anatomy and physiology of pregnancy make diagnosis and treatment difficult.

Barrier precautions in trauma resuscitation: Real-time analysis utilizing videotape review

Blood-borne pathogens threaten all individuals involved in emergency health care. Despite recommendations by the Centers for Disease Control and the American College of Emergency Physicians, documented compliance with universal precautions in trauma resuscitation has been poor. The purpose of this study was to determine the factors that predispose to noncompliance with barrier precautions at a level I trauma center. Videotapes of trauma resuscitations performed during 1 month (n = 66) were reviewed. Full compliance with barrier precautions was documented in 89.1% of health care workers. Of the noncompliant health care workers, 50.7% were emergency department personnel and 47.8% were first responders to the trauma resuscitation area. Barrier precaution compliance improved from 62.5% to 91.8% with prenotification of patient arrival. Immediate access to barrier equipment is essential for all potential in-hospital first responders. Prehospital communication systems should be optimized to ensure prenotification.

Compliance with Recommended Care at Trauma Centers: Association with Patient Outcomes

BACKGROUND State health departments and the American College of Surgeons focus on the availability of optimal resources to designate hospitals as trauma centers, with little emphasis on actual delivery of care. There is no systematic information on clinical practices at designated trauma centers. The objective of this study was to measure compliance with 22 commonly recommended clinical practices at trauma centers and its association with in-hospital mortality. STUDY DESIGN This retrospective observational study was conducted at 5 Level I trauma centers across the country. Participants were adult patients with moderate to severe injuries (n = 3,867). The association between compliance with 22 commonly recommended clinical practices and in-hospital mortality was measured after adjusting for patient demographics and injuries and their severity. RESULTS Compliance with individual clinical practices ranged from as low as 12% to as high as 94%. After adjusting for patient demographics and injury severity, each 10% increase in compliance with recommended care was associated with a 14% reduction in the risk of death. Patients who received all recommended care were 58% less likely to die (odds ratio = 0.42; 95% CI, 0.28-0.62) compared with those who did not. CONCLUSIONS Compliance with commonly recommended clinical practices remains suboptimal at designated trauma centers. Improved adoption of these practices can reduce mortality.

Formalized radiology rounds: the final component of the tertiary survey.

BACKGROUND An important objective of organized trauma care is to minimize delayed diagnoses and missed injuries. Discrepant interpretations of radiographs initially read by trauma surgeons represent a unique source of delayed diagnoses. The purpose of this study was to evaluate the efficacy of formalized radiology rounds as a component of the tertiary survey. METHODS Over an 18-month period, 432 consecutive patients admitted to the trauma service at a Level II trauma center were studied prospectively. Radiographs obtained as part of the initial evaluation were initially interpreted by an attending trauma surgeon. All radiographs from the previous 24-hour admissions were reviewed by the trauma team with an attending radiologist at radiology rounds. New diagnoses (NDx) were defined as radiographic findings identified at radiology rounds that were not recorded by the trauma surgeon at the time of initial evaluation. The clinical significance of any NDx was described as follows: level 1, NDx resulted in significant morbidity/mortality; level 2, NDx resulted in alteration in care/no morbidity; level 3, NDx resulted in no alteration in care; level 4, NDx was an incidental finding by the radiologist; level 5, NDx by radiologist not definite. RESULTS Forty-seven NDx were identified in 42 patients (9.7%). Of the 47 NDx, 19 (40.4%) were level 3 and 28 (59.6%) were level 2. No level 1 NDx were identified. Forty-four changes in clinical management were documented in the level 2 group. Eight new consults were ordered in seven patients (16.7%): orthopedic surgery (n = 6), neurosurgery (n = 1), and physical therapy (n = 1). Seventeen additional diagnostic procedures were required in 16 patients (38.1%): plain radiographs (n = 11) and computed tomographic scans (n = 6). Nineteen therapeutic changes were required in 16 patients (38.1%): splint/immobilization device (n = 7), modified level of activity (n = 6), surgical procedures (n = 4), transfer (n = 1), and home equipment (n = 1). CONCLUSION A small number of radiographic findings are not detected by trauma surgeons during the initial evaluation. Although these findings are not of major clinical significance, the majority required some alteration in care plan. Formalized radiology rounds promotes clinical efficiency through early identification of these injuries, which facilitates any necessary alteration in the care plan.

Distracted driving and implications for injury prevention in adults

Distracted driving, a significant public safety issue, is typically categorized as cell phone use and texting. The increase of distracted driving behavior (DDB) has resulted in an increase in injury and death. The purpose of this study was to identify the frequency and perception of DDB in adults. A 7-question SurveyMonkey questionnaire was distributed to a convenience sample of adults. Standard demographics included age, gender, and highest levels of education. Primary outcome questions were related to frequency of DDB, and overall perceptions specific to distracted driving. Results were compared on the basis of demographics. Chi-square testing and the Kruskal-Wallis analysis of variance were applied, with statistical significance defined as P ⩽ .05. There were 1857 respondents to the survey: 1721 were aged 23–64 years (93%); 1511 were women (81%); 1461 had high school education or greater (79%). A total of 168 respondents (9%) reported being involved in a car accident while distracted. The highest reported frequency of DDB included cell phone use (69%), eating/drinking (67%), and reaching for an object in the care (49%). Younger age (18–34 years) and higher level of education (bachelors degree or greater) were statistically associated with these DDB; gender demonstrated no statistical significance. Text messaging was reported by 538 respondents (29%), with a statistically significant association with age (18–34 years), higher education (bachelors degree or greater), and gender (males). A total of 1143 respondents (63%) believed that they could drive safely while distracted. This study demonstrates that DDB in adults is not restricted to reading and sending text messages. Moreover, these results indicated that people fail to perceive the dangers inherent in distracted driving. Prevention and outreach education should not be limited to texting and cell phone use but should target all forms of DDB. The age group 18-34 years should be the primary target in the adult population.