16 results on '"Teixeira, Pedro G. R."'
Search Results
2. Blunt thoracic aortic injuries: an autopsy study.
- Author
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Teixeira PG, Inaba K, Barmparas G, Georgiou C, Toms C, Noguchi TT, Rogers C, Sathyavagiswaran L, and Demetriades D
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- Abdominal Injuries etiology, Abdominal Injuries pathology, Accidents, Traffic, Adult, Aorta, Thoracic pathology, Autopsy, Female, Heart Injuries complications, Heart Injuries etiology, Heart Injuries pathology, Humans, Male, Middle Aged, Multiple Trauma etiology, Multiple Trauma pathology, Retrospective Studies, Risk Factors, Wounds, Nonpenetrating complications, Wounds, Nonpenetrating etiology, Aorta, Thoracic injuries, Wounds, Nonpenetrating pathology
- Abstract
Objective: The objective of this study was to identify the incidence and patterns of thoracic aortic injuries in a series of blunt traumatic deaths and describe their associated injuries., Methods: All autopsies performed by the Los Angeles County Department of Coroner for blunt traumatic deaths in 2005 were retrospectively reviewed. Patients who had a traumatic thoracic aortic (TTA) injury were compared with the victims who did not have this injury for differences in baseline characteristics and patterns of associated injuries., Results: During the study period, 304 (35%) of 881 fatal victims of blunt trauma received by the Los Angeles County Department of Coroner underwent a full autopsy and were included in the analysis. The patients were on average aged 43 years±21 years, 71% were men, and 39% had a positive blood alcohol screen. Motor vehicle collision was the most common mechanism of injury (50%), followed by pedestrian struck by auto (37%). A TTA injury was identified in 102 (34%) of the victims. The most common site of TTA injury was the isthmus and descending thoracic aorta, occurring in 67 fatalities (66% of the patients with TTA injuries). Patients with TTA injuries were significantly more likely to have other associated injuries: cardiac injury (44% vs. 25%, p=0.001), hemothorax (86% vs. 56%, p<0.001), rib fractures (86% vs. 72%, p=0.006), and intra-abdominal injury (74% vs. 49%, p<0.001) compared with patients without TTA injury. Patients with a TTA injury were significantly more likely to die at the scene (80% vs. 63%, p=0.002)., Conclusion: Thoracic aortic injuries occurred in fully one third of blunt traumatic fatalities, with the majority of deaths occurring at the scene. The risk for associated thoracic and intra-abdominal injuries is significantly increased in patients with thoracic aortic injuries.
- Published
- 2011
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3. Measurable outcomes of quality improvement using a daily quality rounds checklist: one-year analysis in a trauma intensive care unit with sustained ventilator-associated pneumonia reduction.
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Dubose J, Teixeira PG, Inaba K, Lam L, Talving P, Putty B, Plurad D, Green DJ, Demetriades D, and Belzberg H
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- Academic Medical Centers, Adolescent, Adult, Aged, California, Cross Infection mortality, Cross Infection prevention & control, Female, Guideline Adherence standards, Hospital Mortality, Humans, Male, Middle Aged, Prospective Studies, Quality Assurance, Health Care standards, Wounds and Injuries therapy, Young Adult, Checklist, Evidence-Based Medicine standards, Intensive Care Units standards, Pneumonia, Ventilator-Associated mortality, Pneumonia, Ventilator-Associated prevention & control, Quality Indicators, Health Care standards, Wounds and Injuries mortality
- Abstract
Background: We have previously demonstrated that the use of a daily "Quality Rounds Checklist" (QRC) can increase compliance with evidence-based prophylactic measures and decrease complications in a busy trauma intensive care unit (ICU) over a 3-month period. This study was designed to determine the sustainability of QRC use over 1 year and examine the relationship between compliance and outcome improvement., Methods: A prospective before-after design was used to examine the effectiveness of the QRC tool in documenting compliance with 16 prophylactic measures for ventilator-associated pneumonia (VAP), deep venous thrombosis, pulmonary embolism, catheter-related bloodstream infection, and other ICU complications. The QRC was implemented on a daily basis for a 1-year period by the ICU fellow on duty. Monthly compliance rates were assessed by a multidisciplinary team for development of strategies for real-time improvement. Compliance and outcomes were captured over 1 year of QRC use., Results: QRC use was associated with a sustained improvement of VAP bundle and other compliance measures over a year of use. After multivariable analysis adjusting for age (> 55), injury mechanism, Glasgow Coma Scale score (≤ 8), and Injury Severity Score (> 20), the rate of VAP was significantly lower after QRC use, with an adjusted mean difference of -6.65 (per 1,000 device days; 95% confidence interval, -9.27 to -4.04; p = 0.008). During the year of QRC use, 3% of patients developed a VAP if all four daily bundle measures were met for the duration of ICU stay versus 14% in those with partial compliance (p = 0.04). The overall VAP rate with full compliance was 5.29 versus 9.23 (per 1,000 device days) with partial compliance. Compared with the previous year, a 24% decrease in the number of pneumonias was recorded for the year of QRC use, representing an estimated cost savings of approximately $400,000., Conclusion: The use of a QRC facilitates sustainable improvement in compliance rates for clinically significant prophylactic measures in a busy Level I trauma ICU. The daily use of the QRC, requiring just a few minutes per patient to complete, equates to cost-effective improvement in patient outcomes.
- Published
- 2010
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4. Motorcycle-related injuries: effect of age on type and severity of injuries and mortality.
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Talving P, Teixeira PG, Barmparas G, Dubose J, Preston C, Inaba K, and Demetriades D
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- Adolescent, Adult, Age Factors, Fractures, Bone epidemiology, Head Injuries, Closed epidemiology, Humans, Liver injuries, Los Angeles epidemiology, Middle Aged, Registries, Regression Analysis, Spleen injuries, Wounds, Nonpenetrating mortality, Young Adult, Accidents, Traffic statistics & numerical data, Motorcycles, Wounds, Nonpenetrating epidemiology
- Abstract
Background: The aim of this study was to evaluate the relationship of age to the injury types, distribution, and severity in motorcycle crash (MCC) victims admitted to Los Angeles County emergency hospitals in California., Methods: This Los Angeles countywide trauma registry study included all MCC victims admitted to the 13 trauma centers of the Los Angeles County between January 1995 and December 2007. Besides demographical data collected, the Injury Severity Score, body area (head, chest, abdomen, and extremities), Abbreviated Injury Scale score >or=3, specific organ injuries, and mortality were calculated according to age groups (
55 years). A stepwise logistic regression model was used to identify independent risk factors for death., Results: Among 6,530 admissions due to MCCs, there were 493 patients (7.5%) aged 18 years or younger, 5,627 patients (86%) aged 19 years to 55 years, and 398 patients (6.5%) older than 55 years. The incidences of severe injury (Injury Severity Score >15) in the three ascending age groups were 23.5%, 30.3%, and 36.2%, respectively (p < 0.05), and critical injuries (Injury Severity Score >25) occurred in 6.5%, 12.3%, and 13.8%, respectively (p < 0.05). Severe head injuries were significantly more likely in the population older than 55 year (odds ratio [OR] {95% confidence interval [CI] } = 1.45 {1.03-2.03}, p = 0.04). The risk of sustaining a severe chest injury (Abbreviated Injury Scale Chest Score >or=3) increased in a stepwise fashion with increasing age, with an OR (95% CI) = 1.86 (1.44-2.39) in the age group 19 years to 55 years and 2.81 (2.03-3.88) in the older than 55 years group, p < 0.001. Mortality was twofold higher in the 19-year- to 55-year-old group [OR (95% CI) = 2.30 (1.08-4.93), p = 0.03] and threefold higher in the older than 55 years group [OR (95% CI) = 3.28 (1.36-7.93), p = 0.05] compared with the - Published
- 2010
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5. Complications and death at the start of the new academic year: is there a July phenomenon?
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Inaba K, Recinos G, Teixeira PG, Barmparas G, Talving P, Salim A, Brown C, Rhee P, and Demetriades D
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- Adult, Clinical Competence, Female, Hospital Mortality, Humans, Male, Quality of Health Care, Risk Factors, Wounds and Injuries mortality, Wounds and Injuries therapy, Academic Medical Centers, Internship and Residency, Medical Errors statistics & numerical data, Trauma Centers, Traumatology education, Wounds and Injuries complications
- Abstract
Background: The "July Phenomenon" refers to the propensity for increased errors to occur with new housestaff, as they assume new responsibilities at the beginning of the academic year. The purpose of this study was to examine the impact of the new residents presenting in July at a high volume Level I Academic Trauma Center., Methods: The trauma registry at the Los Angeles County + University of Southern California Medical center was retrospectively reviewed to identify all injured patients admitted over a 5-year period ending in December 2006. All Morbidity and Mortality reports for the study period were reviewed to extract deaths and any complications classified as preventable or potentially preventable. Patients admitted in the first 2 months (July to August) of the academic year were compared with those treated at the end of the academic year (May to June). Baseline clinical and demographic characteristics were compared, and the rates of preventable and potentially preventable deaths and complications were determined for each of these groups., Results: During the 5-year study period, 24,302 injured patients were admitted. Of those, 8,151 were admitted during the period from May to August with 4,030 (49.4%) at the beginning of the academic year (July to August) and 4,121 (50.6%) at the end of the academic year (May to June). Overall, the average age was 35.1 +/- 17.7 years, 77% were men with an Injury Severity Score of 8.4 +/- 9.7 and 24.2% penetrating injury rate. When examining mortality, after adjustment for differences between the two groups, there was no difference between patients admitted at the beginning or at the end of the academic year (adjusted odds ratio [95% confidence interval]: 1.1 [0.8, 1.5], p = 0.52). However, when compared with the patients treated for their injuries in May to June, those treated at the beginning of the academic year had a significantly higher rate of preventable and potentially preventable complications (adjusted odds ratio [95% confidence interval]: 1.9 [1.1, 3.2], p = 0.013)., Conclusions: At an academic Level I trauma center, admission at the beginning of the academic year was associated with an increased risk of errors resulting in preventable and potentially preventable complications; however, these errors did not impact mortality. Specific errors associated with this increased rate of preventable complications warrant further investigation.
- Published
- 2010
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6. Blunt cardiac trauma: lessons learned from the medical examiner.
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Teixeira PG, Georgiou C, Inaba K, Dubose J, Plurad D, Chan LS, Toms C, Noguchi TT, and Demetriades D
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- Adult, Autopsy, Cause of Death, Chi-Square Distribution, Female, Humans, Los Angeles epidemiology, Male, Multiple Trauma mortality, Risk Factors, Forensic Medicine, Heart Injuries diagnosis, Heart Injuries mortality, Wounds, Nonpenetrating diagnosis, Wounds, Nonpenetrating mortality
- Abstract
Objective: The objective of this study was to analyze autopsy findings after blunt traumatic deaths to identify the incidence of cardiac injuries and describe the patterns of associated injuries., Methods: All autopsies performed by the Los Angeles County Forensic Medicine Division for blunt traumatic deaths in 2005 were retrospectively reviewed. Only cases that underwent a full autopsy including internal examination were included in the analysis. The study population was divided into two groups according to the presence or absence of a cardiac injury and compared for differences in baseline characteristics and types of associated injuries., Results: Of the 881 fatal victims of blunt trauma received by the Los Angeles County Forensic Medicine Division, 304 (35%) underwent a full autopsy with internal examination and were included in the analysis. The mean age was 43 years +/- 21 years, patients were more often men (71%) and were intoxicated in 39% of the cases. The most common mechanism was motor vehicle collision (50%), followed by pedestrian struck by auto (37%), and 32% had a cardiac injury. Death at the scene was significantly more common in patients with a cardiac injury (78% vs. 65%, p = 0.02). The right chambers were the most frequently injured (30%, right atrium; 27%, right ventricle). Among the 96 patients with cardiac injuries, 64% had transmural rupture. Multiple chambers were ruptured in 26%, the right atrium in 25%, and the right ventricle in 20% of these patients. Patients with cardiac injuries were significantly more likely to have other associated injuries: thoracic aorta (47% vs. 27%, p = 0.001), hemothorax (81% vs. 59%, p < 0.001), rib fractures (91% vs. 71%, p < 0.001), sternum fracture (32% vs. 13%, p < 0.001), and intra-abdominal injury (77% vs. 48%, p < 0.001) compared with patients without cardiac injury. Of the 96 patients with a cardiac injury, 78% died at the scene of the crash and 22% died en route or at the hospital., Conclusion: Cardiac injury is a common autopsy finding after blunt traumatic fatalities, with the majority of deaths occurring at the scene. Patients with cardiac injuries are at significantly increased risk for associated thoracic and intra-abdominal injuries.
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- 2009
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7. Blunt cardiac rupture: a 5-year NTDB analysis.
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Teixeira PG, Inaba K, Oncel D, DuBose J, Chan L, Rhee P, Salim A, Browder T, Brown C, and Demetriades D
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- Adult, Aged, Female, Heart Rupture diagnosis, Heart Rupture mortality, Hospital Mortality, Humans, Male, Middle Aged, Registries, United States epidemiology, Heart Rupture epidemiology, Wounds, Nonpenetrating epidemiology
- Abstract
Objective: Because of its rarity and high rate of mortality, traumatic blunt cardiac rupture (BCR) has been poorly studied. The objective of this study was to use the National Trauma Data Bank to review the epidemiology and outcomes associated with traumatic BCR., Methods: After approved by the institutional review board, the National Trauma Data Bank (version 5.0) was queried for all BCR occurring between 2000 and 2005. Demographics, clinical injury data, interventions, and outcomes were abstracted for each patient. Statistical analysis was performed using an unpaired Student's t test or Mann-Whitney U test to compare means and chi analysis to compare proportions. Stepwise logistic regression analysis was performed to identify independent predictors of inhospital mortality., Results: Of 811,531 blunt trauma patients, 366 (0.045%) had a BCR of which 334 were available for analysis, with the mean age of 45 years, 65% were men, and their mean Injury Severity Score was 58 +/- 19. The most common mechanism of injury was motor vehicle collision (73%), followed by pedestrian struck by auto (16%), and falls from height (8%). Twenty-one patients (6%) died on arrival and 140 (42%) died in the emergency room. The overall mortality for patients arriving alive to hospital was 89%. Of the patients surviving to operation, 42% survived >24 hours of which 87% were discharged. Survivors were significantly younger (39 vs. 46 years, p = 0.04), had a lower Injury Severity Score (47 vs. 56, p = 0.02), higher Glasgow Coma Scale (10 vs. 6, p < 0.001), and were more likely to present with an systolic blood pressure >or=90 mm Hg (p = 0.01). Nevertheless, none of these factors was found to be an independent risk factor for mortality., Conclusion: BCR is an exceedingly rare injury, occurring in 1 of 2400 blunt trauma patients. In patients arriving alive to hospital, traumatic BCR is associated with a high mortality rate, however, is not uniformly fatal.
- Published
- 2009
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8. Risk factors for empyema after diaphragmatic injury: results of a National Trauma Databank analysis.
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Barmparas G, DuBose J, Teixeira PG, Recinos G, Inaba K, Plurad D, Green DJ, and Demetriades D
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- Adult, Databases as Topic, Empyema etiology, Empyema mortality, Female, Hospitals, Humans, Incidence, Intensive Care Units, Length of Stay, Male, Middle Aged, Risk Factors, United States, Young Adult, Diaphragm injuries, Empyema epidemiology
- Abstract
Background: Empyema is a rare, but morbid complication of diaphragmatic injury. The purpose of this study was to use the National Trauma Databank of the American College of Surgeons to determine (1) the incidence of empyema after diaphragmatic injury, (2) risk factors for development of empyema after these injuries, and (3) the effect of empyema on mortality, hospital, and intensive care unit (ICU) length of stay (LOS) after diaphragm injury., Methods: The National Trauma Databank (v. 5.0) was used to identify adult patients sustaining diaphragmatic injury and surviving for greater than 48 hours. Demographics, injury characteristics, associated abdominal injuries, thoracic procedures, and outcomes data were abstracted for comparison of patients who did and did not develop empyema after these injuries. Stepwise logistic regression analysis was used to identify independent risk factors for the development of empyema. Subsequent adjusted analysis was used to determine the effect of empyema on outcomes (hospital LOS, ICU LOS, mortality)., Results: Among 4,153 patients with diaphragmatic injury who survived more than 48 hours from admission, 57 (1.4%) developed empyema. Demographics did not differ significantly between the two groups. Empyema was associated with longer adjusted mean hospital (35.9 vs. 16.1, p < 0.001) and ICU (18.1 vs. 8.5, p < 0.001) LOS, but was not associated with increased mortality. Patients with empyema more commonly had associated hollow viscus (63.2% vs. 35.6%, p < 0.001), gastric (40.4% vs. 18.8%, p < 0.001), and splenic injuries (49.1% vs. 33.3%, p = 0.01). After multivariable analysis, two independent risk factors for the development of empyema after diaphragmatic injury were identified: gastric injury (adjusted odds ratio = 2.90; 95% confidence interval: 1.69-5.00; p < 0.001) and Injury Severity Score > or = 20 (adjusted odds ratio = 2.99; 95% confidence interval: 1.61-5.59; p = 0.001). Concomitant colonic injury did not significantly increase the risk of empyema in the study population., Conclusions: Empyema is an uncommon sequela of diaphragm injury that contributes to the need for prolonged hospital and ICU LOSs. Associated gastric trauma and Injury Severity Score > or = 20 were independently associated with empyema development after diaphragmatic injury.
- Published
- 2009
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9. Impact of plasma transfusion in massively transfused trauma patients.
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Teixeira PG, Inaba K, Shulman I, Salim A, Demetriades D, Brown C, Browder T, Green D, and Rhee P
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- Adolescent, Adult, California, Erythrocyte Transfusion, Female, Glasgow Coma Scale, Hospital Mortality, Humans, Injury Severity Score, Male, Middle Aged, Multiple Trauma blood, Multiple Trauma mortality, Multivariate Analysis, Registries, Retrospective Studies, Risk Factors, Shock, Hemorrhagic blood, Shock, Hemorrhagic mortality, Survival Analysis, Survival Rate, Trauma Centers, Young Adult, Multiple Trauma therapy, Plasma, Resuscitation methods, Shock, Hemorrhagic therapy
- Abstract
Objective: The objective of this study was to determine the optimal use of fresh-frozen plasma (FFP) in trauma. Our hypothesis was that a higher FFP: packed red blood cells (PRBC) ratio is associated with improved survival., Methods: This is a 6-year retrospective trauma registry and blood bank database study in a level I trauma center. All massively transfused patients (> or =10 PRBC during 24 hours) were analyzed. Patients with severe head trauma (head Abbreviated Injury Severity score > or =3) were excluded from the analysis. Patients were classified into four groups according to the FFP:PRBC ratio received: low ratio (< or =1:8), medium ratio (>1:8 and < or =1:3), high ratio (>1:3 and < or =1:2), and highest ratio (>1:2)., Results: Of 25,599 trauma patients, 4,241 (16.6%) received blood transfusion. Massive transfusion occurred in 484 (11.4%) of the transfused. After exclusion of 101 patients with severe head injury 383 patients were available for analysis. The mortality rate decreased significantly with increased FFP transfusion. However, there does not seem to be a survival advantage after a 1:3 FFP:PRBC ratio has been reached. Using the highest ratio group as a reference, the relative risk of death was 0.97 (p = 0.97) for the high ratio group, 1.90 (p < 0.01) for the medium ratio group, and 3.46 (p < 0.01) for the low ratio group. There was an increasing trend toward more FFP use during time with the mean units per patient increasing 83% from 6.3 +/- 4.6 in 2000 to 11.5 +/- 9.7 in 2005., Conclusion: Higher FFP:PRBC ratio is an independent predictor of survival in massively transfused patients. Aggressive early use of FFP may improve outcome in massively transfused trauma patients.
- Published
- 2009
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10. The impact of uncross-matched blood transfusion on the need for massive transfusion and mortality: analysis of 5,166 uncross-matched units.
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Inaba K, Teixeira PG, Shulman I, Nelson J, Lee J, Salim A, Brown C, Demetriades D, and Rhee P
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- ABO Blood-Group System, Abbreviated Injury Scale, Academic Medical Centers, Adult, Blood Group Incompatibility blood, Critical Care methods, Female, Glasgow Coma Scale, Hemorrhage blood, Hemorrhage mortality, Hospital Mortality, Humans, Injury Severity Score, Intubation, Intratracheal, Los Angeles, Male, Middle Aged, Multiple Trauma blood, Multiple Trauma mortality, Prognosis, Retrospective Studies, Risk Assessment, Survival Analysis, Young Adult, Blood Group Incompatibility mortality, Blood Grouping and Crossmatching, Erythrocyte Transfusion mortality, Hemorrhage therapy, Multiple Trauma therapy, Plasma, Platelet Transfusion mortality, Resuscitation
- Abstract
Background: The objective of this study was to analyze the outcomes associated with uncross-matched blood transfusion during trauma resuscitation. Our hypothesis was that uncross-matched blood transfusion is a predictor of the need for massive transfusion and mortality., Methods: All injured patients receiving packed red blood cell (PRBC) transfusion during a 6-year period ending December 2005 were identified from the blood bank database at a level I trauma center. Uncross-matched red blood cell (URBC) and cross-matched red blood cells, plasma and platelet utilization, and injury demographics were abstracted for each patient., Results: Of 25,599 trauma patients, 4,241 (16.6%) patients received 29,375 units of PRBC and 1,236 (29.1%) of the transfused patients received 5,166 units of URBC during their resuscitation. Patients requiring URBC had a higher mortality (39.6% vs. 11.9%, p < 0.001) and were more likely to require massive (> or = 10 PRBC during 12 hours) transfusion (29.3% vs. 1.8%, p < 0.001). There was a stepwise increase in mortality with increasing URBC transfusion. After adjusting for age, gender, mechanism, hypotension at admission, emergency department intubation, initial hemoglobin, Glasgow Coma Scale, Abbreviated Injury Scale, Injury Severity Score, and amount of blood products received; URBC remained an independent predictor of mortality (adjusted odds ratio 2.15; 95% confidence interval 1.58-2.94; p < 0.001) and massive transfusion (adjusted odds ratio, 11.87; 95% confidence interval, 8.43-16.7; p < 0.001). Patients receiving URBC also utilized more blood components (11.9 +/- 12.7 vs. 4.9 +/- 5.8 units of PRBC, p < 0.001; 5.1 +/- 8.9 vs. 2.0 +/- 4.8 units of plasma, p < 0.001; and 1.1 +/- 2.5 vs. 0.4 +/- 1.6 units of platelets, p < 0.001)., Conclusion: The requirement for uncross-matched blood during the acute resuscitation of trauma patients is an independent predictor of mortality and the need for massive transfusion. A URBC request during resuscitation should be considered by the blood bank as a potential trigger to prepare for massive transfusion.
- Published
- 2008
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11. Endovascular stenting for the treatment of traumatic internal carotid injuries: expanding experience.
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DuBose J, Recinos G, Teixeira PG, Inaba K, and Demetriades D
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- Adolescent, Adult, Aged, Aneurysm diagnostic imaging, Aneurysm surgery, Aneurysm, False diagnostic imaging, Aneurysm, False surgery, Anticoagulants administration & dosage, Arteriovenous Fistula diagnostic imaging, Arteriovenous Fistula surgery, Carotid Artery Diseases diagnostic imaging, Carotid Artery Diseases surgery, Carotid Artery Injuries diagnostic imaging, Carotid Artery, Internal, Dissection diagnostic imaging, Carotid Artery, Internal, Dissection surgery, Cerebral Angiography, Child, Female, Humans, Male, Middle Aged, Wounds, Nonpenetrating diagnostic imaging, Young Adult, Angioplasty, Balloon methods, Carotid Artery Injuries surgery, Carotid Artery, Internal diagnostic imaging, Carotid Artery, Internal surgery, Stents, Wounds, Nonpenetrating surgery
- Abstract
Background: The role of endovascular techniques in the treatment of traumatic vascular injuries, including injury to the internal carotid artery, continues to evolve. Despite growing experience with the usage of these techniques in the setting of artherosclerotic disease, published results in traumatic carotid injuries remain sporadic and confined to case reports and case series., Methods: We conducted a review of the medical literature from 1990 to the present date using the Pubmed and OVID Medline databases to search for all reports documenting the use of endovascular stenting for the treatment of carotid injuries. Thirty-one published reports were analyzed to abstract data regarding mechanism, location, and type of injury; use and type of anticoagulation used in conjunction with stenting; type and timing of radiographic and clinical follow-up; and radiographic and clinical outcomes., Results: The use of endovascular stenting for the treatment of internal carotid injuries was reported for only 113 patients from 1994 to the present date. Stenting was most commonly used after a blunt mechanism of injury (77.0%). The injury types treated by stenting included pseudoaneurysm (60.2%), arteriovenous fistula (16.8%), dissection (14.2%), partial transection (4.4%), occlusion (2.7%), intimal flap (0.9%), and aneurysm (0.9%). Initial endovascular stent placement was successful in 76.1% of patients. Radiographic and clinical follow-up periods ranging from 2 weeks to 2 years revealed a follow-up patency of 79.6%. No stent-related mortalities were reported. New neurologic deficits after stent placement occurred in 3.5%., Conclusion: Endovascular treatment of traumatic internal carotid artery injury continues to evolve. Early results are encouraging, but experience with this modality and data on late follow-up are still very limited. A large prospective randomized trial is warranted to further define the role of this treatment modality in the setting of trauma.
- Published
- 2008
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12. Evaluation of immediate endoscopic realignment as a treatment modality for traumatic urethral injuries.
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Hadjizacharia P, Inaba K, Teixeira PG, Kokorowski P, Demetriades D, and Best C
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- Abdominal Injuries diagnosis, Adolescent, Adult, Evaluation Studies as Topic, Female, Follow-Up Studies, Humans, Injury Severity Score, Male, Probability, Risk Assessment, Statistics, Nonparametric, Time Factors, Trauma Centers, Treatment Outcome, Urinary Catheterization methods, Abdominal Injuries therapy, Endoscopy methods, Urethra injuries
- Abstract
Background: Traumatic urethral injuries have been traditionally managed by suprapubic drainage with a delayed repair. Advances in endoscopic techniques have facilitated early realignment and transurethral catheterization of the injured segment as a new management option. The purpose of this study was to investigate the outcomes of patients undergoing immediate endoscopic realignment (IER) compared with delayed treatment (DT)., Methods: Trauma patients sustaining a traumatic urethral injury admitted to a level I trauma center were prospectively identified and followed through their course of treatment. Injury demographics and outcomes were compared for IER versus DT. The primary outcome measures were time to spontaneous voiding and urethral stricture rate., Results: Of 21 patients with acute urethral injuries, 14 (67%) had IER and 7 (33%) had DT (4 IER failures and 3 primary DT). The 4 IER failures represent 22% of the patients in the immediate realignment attempt group that failed and went on to delayed therapy. Mean follow-up was 7 months (range, 14 days to 1.7 years). IER and DT groups were similar with regards to age (30 +/- 16 vs. 24 +/- 6), mechanism of injury (blunt vs. penetrating), location of urethral injury (anterior vs. posterior), Glasgow Coma Scale score (13 +/- 3 vs. 12 +/- 6), ISS (14 +/- 11 vs. 20 +/- 6), and associated injuries (pelvic fractures and intra-abdominal injuries). Mean time to IER from admission was 32 +/- 80 hours (range, 1 hour-2.8 days). Patients undergoing IER had a significantly shorter time to spontaneous voiding (35 +/- 23 vs. 229 +/- 79 days, p = 0.001) and had a significantly decreased rate of stricture formation (14% vs. 100%, p < 0.0001). All DT patients required formal surgical urethroplasty whereas the 2 (14%) IER patients with strictures only required outpatient clinic dilatation., Conclusion: Compared with the traditional DT approach, IER results in a significantly reduced time to spontaneous voiding with less risk of urethral stricture, possibly avoiding the need for surgical urethroplasty and long-term suprapubic urinary diversion.
- Published
- 2008
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13. Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist.
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DuBose JJ, Inaba K, Shiflett A, Trankiem C, Teixeira PG, Salim A, Rhee P, Demetriades D, and Belzberg H
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- Catheterization, Central Venous standards, Cross Infection prevention & control, Humans, Intensive Care Units organization & administration, Organizational Case Studies, Pneumonia, Ventilator-Associated prevention & control, Prospective Studies, Intensive Care Units standards, Total Quality Management, Trauma Centers standards
- Abstract
Objective: The use of "care bundles" in the prevention of ventilator-associated pneumonia (VAP) and other intensive care unit (ICU) complications have been increasingly used in critical care practice. However, the effective implementation of these strategies represents a challenge in a busy Level I trauma ICU. We devised a daily "Quality Rounds Checklist" (QRC) tool for use in the ICU to increase compliance with these prophylactic measures and identify areas for improvement in quality of care., Methods: A prospective before-after design was used to examine the effectiveness of the QRC tool in promoting compliance with 16 prophylactic measures for VAP, deep venous thrombosis or pulmonary embolism, central line infection and other ICU complications. Compliance was assessed for 1 month before institution of the QRC. On daily analysis, the QRC was then applied by the ICU fellow to assess compliance. Any deficiencies were actively corrected in real time. Compliance was assessed by a multidisciplinary team for the next 3 months and compared with the pre-QRC compliance rates., Results: Implementation of the QRC tool facilitated improvement of all measures not already at >95% compliance. Compliance with VAP prevention measures of head of bed elevation >30 degrees (35.2% vs. 84.5%), sedation holiday (78.0% vs. 86.0%), and prophylaxis for both peptic ulcer disease (76.2% vs. 92.3%) and deep venous thrombosis (91.4% vs. 92.8%) were all increased. A decrease in central line duration >72 hours (62.4% vs. 52.8%) and ventilator duration >72 hours (74.0% vs. 61.7%) was also noted. Additionally, a decrease in mean monthly rates per 1,000 device days of VAP (16.3 vs. 8.9), central line infection (11.3 vs. 5.8) and self-extubation (7.8 vs. 2.2) was demonstrated., Conclusion: Introducing a daily QRC tool facilitated improved compliance rates for 16 clinically significant prophylactic measures in a busy Level I trauma ICU. The daily use of this tool, requiring just a few minutes per patient to complete, results in a sustainable improvement in patient outcomes.
- Published
- 2008
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14. Significance of troponin elevation after severe traumatic brain injury.
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Salim A, Hadjizacharia P, Brown C, Inaba K, Teixeira PG, Chan L, Rhee P, and Demetriades D
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- Accidents, Traffic mortality, Adult, Analysis of Variance, Brain Injuries classification, Brain Injuries drug therapy, Brain Injuries mortality, Female, Humans, Logistic Models, Male, Middle Aged, Prognosis, Retrospective Studies, Risk Factors, Trauma Severity Indices, Wounds, Nonpenetrating blood, Wounds, Nonpenetrating classification, Wounds, Nonpenetrating mortality, Adrenergic beta-Antagonists therapeutic use, Brain Injuries blood, Troponin blood
- Abstract
Introduction: Elevation of serum troponin (cTnI) after nontraumatic cerebral insult has been associated with an adverse prognosis. This association has not been well documented in traumatic brain injury (TBI)., Objective: To evaluate the association and prognostic significance of cTnI elevation in severe TBI. To evaluate the role of beta-blocker (BB) therapy in TBI patients with elevated cTnI., Methods: Retrospective review of all blunt trauma patients with severe TBI (head Abbreviated Injury Scale score [AIS] >/=3) admitted to the intensive care unit (ICU) with serial TnI measurements at a Level I trauma center from January 1998 to December 2005. Patients with AIS score >/=3 to other body regions were excluded. Univariate and multivariate logistic regression was performed to determine prognostic significance of TnI elevation., Results: There were 420 severe blunt TBI patients who had serial cTnI measurements during the study period. One hundred twenty-five (29.8%) had an elevated admission cTnI. TBI patients with an elevated cTnI had a lower admission Glasgow Coma Scale (GCS) score (7.5 vs. 8.7, p < 0.05), higher Injury Severity Score (27.4 vs. 24.8, p < 0.01), and increased hospital mortality (44% vs. 29%, p < 0.05), compared with TBI patients with a normal cTnI. Increasing severity of head injury was associated with an increasing cTnI (TnI level 0.8 mug/L for head AIS score = 3 vs. TnI Level I 0.3 mug/L for head AIS score = 4, 5, p = 0.09). After adjusting for injury severity, elevated cTnI was an independent predictor for mortality (Odds ratio [OR[: 8.5; 95% confidence interval [CI]: 3.46, 22.15, p < 0.0001). BB therapy was associated with a significant survival advantage (OR: 0.38; 95% CI: 0.15, 0.87, p = 0.03) in TBI patients with any elevation of cTnI., Conclusion: Elevated TnI is frequently observed after severe TBI. The level of TnI correlates with the severity of head injury and is an independent predictor of adverse outcomes. BB therapy is associated with a survival advantage in TBI patients with elevated cTnI.
- Published
- 2008
- Full Text
- View/download PDF
15. Preventable or potentially preventable mortality at a mature trauma center.
- Author
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Teixeira PG, Inaba K, Hadjizacharia P, Brown C, Salim A, Rhee P, Browder T, Noguchi TT, and Demetriades D
- Subjects
- Adult, Diagnostic Errors, Female, Humans, Injury Severity Score, Los Angeles, Male, Registries, Time Factors, Wounds, Nonpenetrating classification, Wounds, Nonpenetrating therapy, Cause of Death, Quality Assurance, Health Care, Trauma Centers statistics & numerical data, Wounds, Nonpenetrating mortality
- Abstract
Objective: The objective of this study was to analyze the preventable and potentially preventable deaths occurring at a mature Level I trauma center., Methods: All trauma patients that died during their initial hospital admission during an 8-year period (January, 1998 to December, 2005) were analyzed. The deaths were initially reviewed at a weekly Morbidity and Mortality (M&M) conference followed by a multidisciplinary (Trauma Surgery, Critical Care, Emergency Medicine, Neurosurgery, Nursing, and Coroner) Combined Trauma Death Review Committee, and were classified into nonpreventable, potentially preventable, and preventable deaths. All preventable and potentially preventable deaths were identified for the purpose of the study. Quality improvement death forms included data on epidemiology, vital signs, injury severity, type of injury, probability of survival with Trauma and Injury Severity Score methodology, preventability (nonpreventable, potentially preventable, and preventable deaths), errors in the evaluation and management of the patient, and classification of errors (system, judgment, knowledge). Additional injury details, clinical course, circumstances leading to the death and autopsy findings were abstracted from the trauma registry and individual chart review., Results: During the study period, 35,311 patients meeting trauma registry criteria were admitted and a total of 2,081 (5.9%) deaths occurred. Fifty-one deaths were classified as preventable or potentially preventable deaths (0.1% of admissions, 2.5% of deaths). Eleven of them (0.53% of deaths) were classified as preventable and 40 (1.92% of deaths) as potentially preventable deaths. Mean age was 40 years, 66.7% were men, mean Injury Severity Score was 27, 74.5% were blunt. The most common cause of death was bleeding (20, 39.2%) followed by multiple organ dysfunction syndrome (14, 27.5%) and cardiorespiratory arrest (8, 15.6%). This was caused by a delay in treatment (27, 52.9%), clinical judgment error (11, 21.6%), missed diagnosis (6, 11.8%), technical error (4, 7.8%), and other (3, 5.9%). The deaths peaked at two time periods: 26 (51.1%) during the first 24 hours and 16 (31.4%) after 7 days. Only one patient (2.0%) died in the first hour. The most common location of death was the intensive care unit (28, 54.9%), operating room (13, 25.5%), and emergency room (5, 9.8%)., Conclusion: Preventable or potentially preventable deaths are rare but do occur at an academic Level I trauma center. Delay in treatment and error in judgment are the leading causes of preventable and potentially preventable deaths.
- Published
- 2007
- Full Text
- View/download PDF
16. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients.
- Author
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Mathen R, Inaba K, Munera F, Teixeira PG, Rivas L, McKenney M, Lopez P, and Ledezma CJ
- Subjects
- Adult, Algorithms, Female, Humans, Joint Dislocations diagnostic imaging, Ligaments diagnostic imaging, Ligaments injuries, Male, Mass Screening, Prospective Studies, Wounds and Injuries complications, Cervical Vertebrae diagnostic imaging, Cervical Vertebrae injuries, Spinal Fractures diagnostic imaging, Tomography, X-Ray Computed
- Abstract
Background: The objective of this study was to compare the utility of plain radiographs to multislice computed tomography (MCT) for cervical spine (c-spine) evaluation. We hypothesized that plain radiographs add no clinically relevant diagnostic information to MCT in the screening evaluation of the c-spine of trauma patients., Methods: This was a prospective, unblinded, consecutive series of injured patients requiring c-spine evaluation that were imaged with three-view plain films and MCT (occiput to T1 with 3-dimensional reconstruction). The final discharge diagnosis based on all prospectively collected clinical data, MCT, and plain films was utilized as the gold standard for the sensitivity calculation., Results: From October 2004 to February 2005, 667 trauma patients requiring c-spine evaluation were enrolled. Average age was 35.4 years and 70% were male. The mechanism of injury was blunt in 99% and 48.7% occurred as a result of motor vehicle collision. Sixty of 667 (9%) sustained acute c-spine injuries. MCT had a sensitivity of 100% and specificity of 99.5%. Plain films had a sensitivity of 45% and specificity of 97.4%. Plain radiography missed 15 of 27 (55.5%) clinically significant c-spine injuries., Conclusion: MCT outperformed plain radiography as a screening modality for the identification of acute c-spine injury in trauma patients. All clinically significant injuries were detected by MCT. Plain films failed to identify 55.5% of clinically significant fractures identified by MCT and added no clinically relevant information.
- Published
- 2007
- Full Text
- View/download PDF
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