The insertion of a chest tube is a common procedure in trauma care, and the Advanced Trauma Life Support program teaches the insertion of chest tubes as an essential and life-saving skill. It is also ...recognized that the insertion of chest tubes is not without risks or complications. The purpose of this study was to evaluate complications of chest tube placement in a level 1 trauma center compared with those placed in surrounding referral hospitals.
A retrospective matched cohort study of trauma patients was performed between those who underwent chest tube placement at the level 1 trauma center and those with a chest tube placed before transfer to the level 1 center between 2004 and 2013. Conditional logistic regression was used to compare the likelihood of complications and death between chest tube placement groups.
Four thousand two hundred and sixteen trauma patients had a chest tube placed at the level 1 center, and 364 patients had a chest tube placed at an outside hospital before transfer. Two hundred and eighty-one patients were matched. Patients with a chest tube placed outside the trauma center had an increased likelihood of malposition (OR 7.2, 95% CI 3.6-14.6), residual hemothorax (OR 6.3, 95% CI 3.4-11.6), residual pneumothorax (OR 6.7, 95% CI 3.9-11.4), and having a second chest tube placed (OR 3.77, 95% CI 2.37-6.01). However, the patients with a chest tube placed outside of the trauma center were also less likely to develop pneumonia (OR 0.32, 95% CI 0.14-0.73). There were no differences in the odds of developing an empyema, the need for video-assisted thoracoscopic surgery, thoracotomy, or death.
There are opportunities for improving the care of patients who require chest tubes at both referring hospitals and the receiving trauma center. Improving the care of patients who require intercostal drainage requires a systems-based approach, focusing on training and quality improvement.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Often the clinician is faced with a diagnostic and therapeutic dilemma in patients with concomitant traumatic brain injury (TBI) and hemorrhagic shock (HS), as rapid deterioration from either can be ...fatal. Knowledge about outcomes after concomitant TBI and HS may help prioritize the emergent management of these patients. We hypothesized that patients with concomitant TBI and HS (TBI + HS) had worse outcomes and required more intensive care compared with patients with only one of these injuries.
This is a post hoc analysis of the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial. TBI was defined by a head Abbreviated Injury Scale score greater than 2. HS was defined as a base excess of -4 or less and/or shock index of 0.9 or greater. The primary outcome for this analysis was mortality at 30 days. Logistic regression, using generalized estimating equations, was used to model categorical outcomes.
Six hundred seventy patients were included. Patients with TBI + HS had significantly higher lactate (median, 6.3; interquartile range, 4.7-9.2) compared with the TBI group (median, 3.3; interquartile range, 2.3-4). TBI + HS patients had higher activated prothrombin times and lower platelet counts. Unadjusted mortality was higher in the TBI + HS (51.6%) and TBI (50%) groups compared with the HS (17.5%) and neither group (7.7%). Adjusted odds of death in the TBI and TBI + HS groups were 8.2 (95% confidence interval, 3.4-19.5) and 10.6 (95% confidence interval, 4.8-23.2) times higher, respectively. Ventilator, intensive care unit-free and hospital-free days were lower in the TBI and TBI + HS groups compared with the other groups. Patients with TBI + HS or TBI had significantly greater odds of developing a respiratory complication compared with the neither group.
The addition of TBI to HS is associated with worse coagulopathy before resuscitation and increased mortality. When controlling for multiple known confounders, the diagnosis of TBI alone or TBI+HS was associated with significantly greater odds of developing respiratory complications.
Prognostic study, level II.
The management of penetrating rectal trauma invokes a complex decision tree that advocates the principles of proximal diversion (diversion) of the fecal stream, irrigation of stool from the distal ...rectum, and presacral drainage based on data from World War II and the Vietnam War. This guideline seeks to define the initial operative management principles for nondestructive extraperitoneal rectal injuries.
A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding penetrating rectal trauma from January 1900 to July 2014. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included the management principles of diversion, irrigation of stool from the distal rectum, and presacral drainage using the GRADE methodology.
A total of 306 articles were screened leading to a full-text review of 56 articles. Eighteen articles were used to formulate the recommendations of this guideline.
This guideline consists of three conditional evidence-based recommendations. First, we conditionally recommend proximal diversion for management of these injuries. Second, we conditionally recommend the avoidance of routine presacral drains and distal rectal washout in the management of these injuries.
Occupational exposure is an important consideration during emergency department thoracotomy (EDT). While human immunodeficiency virus/hepatitis prevalence in trauma patients (0-16.8%) and ...occupational exposure rates during operative trauma procedures (1.9-18.0%) have been reported, exposure risk during EDT is unknown. We hypothesized that occupational exposure risk during EDT would be greater than other operative trauma procedures.
A prospective, observational study at 16 US trauma centers was performed (2015-2016). All bedside EDT resuscitation providers were surveyed with a standardized data collection tool and risk factors analyzed with respect to the primary end point, EDT occupational exposure (percutaneous injury, mucous membrane, open wound, or eye splash). Provider and patient variables and outcomes were evaluated with single and multivariable logistic regression analyses.
One thousand three hundred sixty participants (23% attending, 59% trainee, 11% nurse, 7% other) were surveyed after 305 EDTs (gunshot wound, 68%; prehospital cardiopulmonary resuscitation, 57%; emergency department signs of life, 37%), of which 15 patients survived (13 neurologically intact) their hospitalization. Overall, 22 occupational exposures were documented, resulting in an exposure rate of 7.2% (95% confidence interval CI, 4.7-10.5%) per EDT and 1.6% (95% CI, 1.0-2.4%) per participant. No differences in trauma center level, number of participants, or hours worked were identified. Providers with exposures were primarily trainees (68%) with percutaneous injuries (86%) during the thoracotomy (73%). Full precautions were utilized in only 46% of exposed providers, while multiple variable logistic regression determined that each personal protective equipment item utilized during EDT correlated with a 34% decreased risk of occupational exposure (odds ratio, 0.66; 95% CI, 0.48-0.91; p = 0.010).
Our results suggest that the risk of occupational exposure should not deter providers from performing EDT. Despite the small risk of viral transmission, our data revealed practices that may place health care providers at unnecessary risk of occupational exposure. Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with personal protective equipment is paramount and would further minimize occupational exposure risks during EDT.
Therapeutic/care management study, level III.
Abstract Background We hypothesized that arterial embolization for bleeding after pelvic fracture is used relatively infrequently. We sought to identify the true need for arterial embolization and ...define injury patterns associated with successful therapeutic angiographic embolization. Methods A retrospective review identified patients admitted to our urban, Level 1 trauma center with pelvic fractures from 2001 to 2009. Patients requiring pelvic arterial angiogram and embolization of pelvic bleeding were reviewed for pelvic fracture pattern and pelvic injury mechanism. Results There were 819 patients diagnosed with pelvic fractures, with only 31 patients (3.8%) undergoing diagnostic pelvic angiography. Of those, 18 patients (58.1%) had active bleeding requiring arterial embolization. Complex pelvic fracture patterns were common in patients undergoing angiogram. Patients undergoing pelvic angiography with an anteroposterior compression mechanism were more likely to have negative findings on angiogram. Conclusions The actual need for angiography and therapeutic embolization is quite small in patients sustaining pelvic fracture. Although factors associated with the need for pelvic angiography frequently are debated, we may discuss angiography for pelvic fractures more often than it actually is performed.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Single institution studies have shown that clinical examination of the cervical spine (c-spine) is sensitive for clearance of the c-spine in blunt trauma patients with distracting injuries. Despite ...an unclear definition, most trauma centers still adhere to the notion that distracting injuries adversely affect the sensitivity of c-spine clinical examination. A prospective AAST multi-institutional trial was performed to assess the sensitivity of clinical examination screening of the c-spine in awake and alert blunt trauma patients with distracting injuries.
During the 42-month study period, blunt trauma patients 18 years and older were prospectively evaluated with a standard c-spine examination protocol at 8 Level 1 trauma centers. Clinical examination was performed regardless of the presence of distracting injuries. Patients without complaints of neck pain, tenderness or pain on range of motion were considered to have a negative c-spine clinical examination. All patients with positive or negative c-spine clinical examination underwent computed tomography (CT) scan of the entire c-spine. Clinical examination findings were documented prior to the CT scan.
During the study period, 2929 patients were entered. At least one distracting injury was diagnosed in 70% of the patients. A c-spine injury was found on CT scan in 7.6% of the patients. There was no difference in the rate of missed injury when comparing patients with a distracting injury to those without a distracting injury (10.4% vs. 12.6%, p = 0.601). Only one injury missed by clinical examination underwent surgical intervention and none had a neurological complication.
Negative clinical examination may be sufficient to clear the cervical spine in awake and alert blunt trauma patients, even in the presence of a distracting injury. These findings suggest a potential source for improvement in resource utilization.
Therapeutic/care management, level IV.
Abstract
Objectives
To investigate the utilization of CBC and CBC with differential (CBC w/diff) tests at University of Alabama at Birmingham Hospital, and to determine if a reduction in CBC w/diff ...tests could be achieved without negatively impacting patient care.
Methods
The quantity of testing and distribution of repeated tests before, during, and after an educational intervention were compared.
Results
CBC w/diff tests were ordered 10-fold more frequently than CBC tests. The trauma burn intensive care unit ordered the most CBC w/diff tests, with repeat tests done every 4 or 12 hours. The educational intervention reduced the number of CBC w/diff tests ordered and tests repeated every 12 hours.
Conclusions
The educational intervention changed the ordering practices of CBC w/diff and CBC tests. This was sustained after the intervention and no negative effects on patient care were noted. Similar interventions may lead to optimization of ordering practices of other laboratory tests.
There is an established association between the presence of SIH and worse morbidity and mortality after trauma. However, given the limitations of existing data, no definitive statements can be made ...as to whether aggressive treatment of hyperglycemia actually benefits outcome. Although early studies seemed to show a clear benefit in surgical ICU patients, subsequent studies have not duplicated these results. In addition, severe hypoglycemic episodes associated with glycemic control protocols have provided further concern, because they have been associated with higher rates of mortality. These disparate outcomes in prospective, randomized trials have not allowed definitive conclusions to be drawn regarding the exact glucose levels that should be maintained. Regardless, some postinjury control of glucose levels is likely necessary. Without data to support the practice, tight glycemic control keeping glucose levels below 110 mg/dL is likely not necessary and probably detrimental to patient outcome. It seems that a more moderate level of glycemic control, aimed at providing stabilization of glucose levels while reducing hyperglycemic and hypoglycemic events, is being practiced in most institutions. Performance of prospective, randomized trials in the trauma population along with further advancement and refinement of techniques to more precisely reduce glucose variability will further clarify the level of glucose control associated with improved outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
PURPOSE:To present information about a study of risk factors for development of pressure ulcers (PrUs) in trauma patients.
TARGET AUDIENCE:This continuing education activity is intended for ...physicians and nurses with an interest in skin and wound care.
OBJECTIVES/OUTCOMES:After participating in this educational activity, the participant should be better able to:1. Describe the previous PrU research, scope of the problem, and methodology of the study.2. Explain the results of the study identifying PrU risk factors for trauma patients.
ABSTRACT OBJECTIVE:Pressure ulceration prevention has been emphasized over the past several years in inpatient hospital settings with subsequent decreases in the development of pressure ulcers (PrUs). However, there remains a subset of trauma and burn patients that develop PrUs despite standard screening methodology and prophylaxis. This study determines the conditions that predict development of pressure ulcers (PrUs) despite conventional prophylaxis and screening. METHODSDemographic and PrU data were collected over a 5-year period from June 2008 to May 2013. Patients diagnosed with PrUs upon arrival in the trauma bay were excluded from analysis. An ordinal logistic regression of PrU stage was used to estimate odds ratios (ORs) and associated 95% confidence intervals (CIs) for the association between characteristics of interest and odds of a PrU. A backward selection process was used to select the most parsimonious model. RESULTSDuring the study period, 14,616 trauma patients were admitted and had available data. A total of 124 patients (0.85%) that met inclusion criteria went on to develop PrUs during their hospital course. Factors associated with the development of PrUs included spine Abbreviated Injury Scale (AIS) >3 (OR, 5.72; CI, 3.63–9.01), mechanical ventilation (OR, 1.95; CI, 1.23–3.10) and age 40 to 64 (OR, 2.09; CI, 1.24–3.52) and age ≥ 65 (OR, 4.48; CI, 2.52–7.95). Interestingly, head injury AIS >3 was protective from the development of PrUs (OR, 0.56; CI, 0.32–0.96). Hypotension and shock defined as systolic BP <90 mm Hg and base deficit less than –6 were not associated with the development of PrUs. In addition, body mass index was not associated with PrU development. CONCLUSIONSSpinal injuries, older than age 40, and mechanical ventilation predict the development of PrUs for a subset of patients, despite conventional prophylaxis and screening. Advanced prevention methods, such as low-air-loss mattresses for these patient subgroups should be considered immediately upon identification of these risk factors during the hospital course.
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