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Pneumonia is the most common complication observed in patients with severe injuries. Although the average age of injured patients is 47 years, existing studies of the effect of injury on the susceptibility to infectious complications have focused on young animals, equivalent to a late adolescent human. We hypothesized that mature adult animals are more susceptible to infection after injury than younger counterparts. To test this hypothesis, we challenged 6 to 8-month-old mature mice to a polytrauma injury followed by Pseudomonas aeruginosa pneumonia and compared them to young (8-10-week-old) animals. We demonstrate that polytrauma injury increases mortality from pneumonia in mature animals (sham-pneumonia 21% vs. polytrauma-pneumonia 62%) but not younger counterparts. After polytrauma, pneumonia in mature mice is associated with higher bacterial burden in lung, increased incidence of bacteremia, and elevated levels of bacteria in the blood, demonstrating that injury decreases the ability to control the infectious challenge. We further find that polytrauma did not induce elevations in circulating cytokine levels (TNF-alpha, IL-6, KC, and IL-10) 24  h after injury. However, mature mice subjected to polytrauma demonstrated an exaggerated circulating inflammatory cytokine response to subsequent Pseudomonas pneumonia. Additionally, whereas prior injury increases LPS-stimulated IL-6 production by peripheral blood leukocytes from young (8-10-week-old) mice, injury does not prime IL-6 production by cell from mature adult mice. We conclude that in mature mice polytrauma results in increased susceptibility to Pseudomonas pneumonia while priming an exaggerated but ineffective inflammatory response.

Background: Biliary leak after severe hepatic trauma is a complex problem requiring multidisciplinary care. We report on our experience with endoscopic management of posttraumatic bile leaks and clarify the role of endoscopic retrograde cholangiopancreatography (ERCP)., Methods: A retrospective analysis was performed on all patients who sustained liver injury and underwent ERCP from September 2003 to September 2009. Patients who had associated biliary leak were identified. Patient demographics, injury characteristics, liver operations, endoscopic treatment, and success of endoscopic intervention were reviewed. Liver injury was managed in an interdisciplinary fashion, including immediate or delayed operation or angiography or both for primary or adjunctive hemostasis. ERCP with stenting and sphincterotomy was used to treat biliary fistulae. Sequelae of liver injury including biloma or other perihepatic fluid collection were also managed by computed tomography scan-guided or ultrasound-guided drainage., Results: A total of 26 patients underwent ERCP for the management of biliary fistula as a result of severe hepatic trauma. There were 14 (54%) blunt injuries. In every patient (100%), ERCP with stenting and sphincterotomy was successful in controlling bile leak. All patients eventually had removal of stents and drains, with resolution of leak. Two patients had concomitant treatment of associated pancreatic ductal injury., Conclusion: ERCP is useful as both a diagnostic and therapeutic tool for the safe treatment of biliary ductal injuries after severe liver trauma and should be part of a multidisciplinary treatment algorithm.

Background: We performed this study to evaluate the hemostatic efficacy of the FAST Dressing in treating a grade V liver injury in noncoagulopathic swine., Methods: Sixteen female splenectomized, noncoagulopathic swine underwent reproducible grade V liver injuries. The animals were blindly randomized to two treatment groups: (1) FAST Dressing (n = 8) or (2) IgG placebo dressing (n = 8). After 30 seconds of uncontrolled hemorrhage, dressings and manual compression were applied at 4-minute intervals. The number of dressings used, time to hemostasis, total blood loss, mean arterial pressure, blood chemistry, and total resuscitation fluid volume were monitored for 2 hours after injury., Results: The mean total blood loss was 412.5 mL (SD 201.3) for the FAST Dressing group compared with 2296.6 mL (SD 1076.0) in the placebo group (p < 0.001). All animals in the FAST Dressing group achieved hemostasis and survived for the duration of the experiment (2 hours) after injury, whereas none of the animals in the placebo group attained hemostasis or survived to 2 hours after injury (p < 0.001). The mean time to hemostasis was 6.6 minutes (SD 2.5). A median of five dressings (mean absolute deviation 1.0, p = 0.007) was sufficient to control hemorrhage in the FAST Dressing group., Conclusion: The FAST Dressing reduced blood loss and improved survival compared with placebo in a noncoagulopathic, grade V liver injury swine model.

Background: There is little that can be done to treat or reverse the primary injury that occurs at the time of a traumatic brain injury (TBI). Initial management of the patient with severe TBI focuses on prevention of subsequent secondary insults, namely, intracranial hypertension (ICH) and cerebral hypoperfusion (CH). Currently, there is no reliable way to predict which patients will develop ICH and CH other than clinical acumen; therefore, indicators of impending secondary intracranial insults may be useful in predicting these events and allowing for prevention and early intervention. This study was undertaken to investigate the relationship of cytokine levels with intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients with severe TBI., Methods: Patients at the R Adams Cowley Shock Trauma Center were prospectively enrolled for a 6-month period. Inclusion criteria were older than 17 years, admission within the first 6 hours after injury, Glasgow Coma Scale<9 on admission, and placement of a clinically indicated ICP monitor. Serum and cerebrospinal fluid, when available, were collected on admission and twice daily for 7 days. Cytokine levels of interleukin (IL)-1β, IL-6, IL-8, IL-10, and tumor necrosis factor (TNF)-α were analyzed by multiplex bead array assays. Hourly values for ICP and CPP were recorded, and means, minimum (for CPP) or maximum (for ICP) values, percentage time ICP>20 mm Hg (%ICP20) and CPP<60 mm Hg (%CPP60), and cumulative Pressure Times Time Dose (PTD; mm Hg·h) for ICP>20 mm Hg (PTD ICP20) and CPP<60 mm Hg (PTD CPP60) were compared with the serum and cerebrospinal fluid levels that were drawn before 12-hour time periods (PRE) and after 12-hour time periods (POST) of monitoring., Results: Twenty-four patients were enrolled. In-hospital mortality was 12.5%, and good functional outcome was noted in 58%. Two hundred and seventy-five serum samples were taken and analyzed. IL-6 levels in the serum were found in the highest concentration of the cytokines measured. PTD ICP20 and PTD CPP60 were moderately correlated with increased PRE IL-8 levels (r=0.34, p<0.001; r=0.53, p<0.001). PTD ICP20 was also correlated with PRE TNF-α levels (r=0.27, p<0.001) as was PTD CPP60 (r=0.25, p<0.001). POST IL-8 levels were found to be correlated with PTD ICP20 (r=0.46, p<0.001) and PTD CPP60 (r=0.54, p<0.001). POST TNF-α was associated with PTD ICP20 (r=0.45, p<0.001). PTD CPP60 was also moderately correlated with POST TNF-α levels (r=0.26, p<0.001). When comparing patients with good versus poor outcome, median daily serum IL-8 levels were associated with poor outcome., Conclusions: IL-8 and, to a lesser extent, TNF-α demonstrated the most promise in this study to be candidate serum markers of impending ICH and CH. The clinical relevance of this is the suggestion that we may be able to predict impending secondary insults after TBI before the clinical manifestation of these events. Given the known morbidity of ICH and CH, early intervention and prevention may have a significant impact on outcome. This becomes even more important when decisions must be made about timing of interventions. Increased levels of IL-8 and TNF-α in the serum during episodes of ICH and CH imply there are significant systemic effects of these events. These serum biomarkers are promising as diagnostic targets. In addition, further study of the precise role of these molecules may have significant implications for inflammatory system manipulation in the management of severe TBI.

Objective(s): To evaluate whether acute glucose elevation (AGE) is predictive of infection and outcome in critically injured trauma patients during the first 14 days of ICU admission., Methods: A prospective study was conducted on 2200 patients admitted to the ICU over a 2 1/2 year period. The diagnosis of infection was made via a multidisciplinary fashion utilizing CDC criteria. After early glucose stabilization occurred (no significant change for 48 hours after admission) monitoring for AGE was performed utilizing a computational and graded algorithmic model. Iatrogenic causes of AGE were excluded. Stepwise regression models were performed controlling for age, gender, mechanism of injury, diabetes, injury severity, and APACHE 2 score. ROC curves were used to evaluate the positive predictive value of the test., Results: Seventy-seven percent of the patients in the cohort were males, and were admitted for blunt injuries (n = 1870 or 85%). The mean age, Injury Severity Score, and APACHE score were 44 ± 20 years, 29 ± 13, and 13 ± 7, respectively. The mean admission serum glucose value was 141 ± 36 mg/dL (range, 64-418 mg/dL). A total of 616 (28%) patients were diagnosed with an infection during the first 14 days of admission. AGE had a 91% positive predictive value for infection diagnosis. In addition, AGE was associated with a significant increase in ventilator, ICU, and hospital days as well as mortality even when adjusted for age, injury severity, APACHE score, and diabetes (P < 0.001)., Conclusions: AGE is a highly accurate predictor of infection and should stimulate clinicians to identify a new source of infection.

Toll-like receptors (TLRs) are critical components of innate immunity. This study was designed to evaluate differential expression of genes for TLR and associated signal transduction molecules in critically ill patients developing sepsis compared with those with sterile inflammation. Uninfected critically ill patients with systemic inflammatory response syndrome were prospectively followed daily for development of sepsis. They were divided into two groups and compared in a case-control manner: (a) preseptic patients (n = 45) who subsequently developed sepsis, and (b) uninfected systemic inflammatory response syndrome patients (n = 45) who remained uninfected. Whole blood RNA was collected (PAXGene tube) at study entry and 1, 2, and 3 days before clinical sepsis diagnosis (or time-matched uninfected control) and analyzed via Affymetrix Hg&#95;U133 Plus 2.0 microarrays. Genes were considered differentially expressed if they met univariate significance controlled for multiple comparisons at P < 0.005. Differentially expressed probes were uploaded into the Database for Annotation, Visualization and Integrated Discovery. The TLR pathway (Kyoto Encyclopedia of Genes and Genomes-KEGG) significance was determined via Expression Analysis Systematic Explorer (EASE) scoring. A total of 2,974 Affymetrix probes representing 2,190 unique genes were differentially expressed 1 day before sepsis diagnosis. Thirty-six probes representing 25 genes were annotated to the TLR pathway (KEGG) via the Database for Annotation, Visualization and Integrated Discovery with an EASE score at P < 0.0004. Notable TLR genes demonstrating increased expression include TLR-4 (median, 1.43-fold change), TLR-5 (2.08-fold change), and MAPK14 (1.90-fold change). An additional 11 unique genes were manually annotated into the TLR pathway based on known relevance such as TLR-8 (1.54-fold change). The total 36 genes contained 28 showing increased expression and 8 showing decreased expression. Differential gene expression was noted for TLR receptors (eight genes), TLR intracellular signal transduction cascade molecules (27 genes), and TLR-related effector molecules (one gene). The TLR and downstream signaling genes are differentially expressed in critically ill patients developing sepsis compared with those with sterile inflammation. These expression differences occur before phenotypic-based diagnosis of clinical sepsis.

Objectives: Recent data from Iraq supporting early aggressive use of fresh frozen plasma (FFP) in a 1:1 ratio to packed red blood cells (PRBCs) has led many civilian trauma centers to adopt this resource intensive strategy., Methods: Prospective data were collected on 806 consecutive trauma patients admitted to the intensive care unit over 2 years. Patients were stratified by PRBC:FFP transfusion ratio over the first 24 hours. Stepwise regression models were performed controlling for age, gender, mechanism of injury, injury severity, and acute physiology and chronic health evaluation (APACHE) 2 score to determine if early aggressive use of PRBC:FFP improved outcome., Results: Seventy-seven percent of patients were male (N = 617) and 85% sustained blunt injury (n = 680). Mean age, injury severity score (ISS), and APACHE score were 43 +/- 20 years, 29 +/- 13, and 13 +/- 7, respectively. Mean number of PRBCs and FFP transfused were 7.7 +/- 12 U, 6 U, and 5 +/- 12 U, respectively. Three hundred sixty-five (45%) patients were transfused in the first 24 hours. Sixty-eight percent (n = 250) of them received both PRBCs and FFP. Analyzing these patients by stepwise regression controlling for all significant variables, the PRBC:FFP ratio did not predict intensive care unit days, hospital days, or mortality even in patients who received massive transfusion (> or = 10 U). Furthermore, there was no significant difference in outcome when comparing patients who had a 1:1 PRBC:FFP ratio with those who did not receive any FFP., Conclusion: Early and aggressive use of FFP does not improve outcome after civilian injury. This may reflect inherent differences compared with military injury; however, this practice should be reevaluated.

Background: Glial fibrillary acidic protein (GFAP) is an intermediate filament protein found in the cytoskeleton of astroglia. Recent work has indicated that GFAP may serve as a serum marker of traumatic brain injury (TBI) that is released after central nervous system cell damage., Methods: Serum from 51 critically injured trauma patients was prospectively collected on admission and on hospital day 2. All patients underwent an admission head computed tomography (CT) scan as a part of their clinical evaluation. Patients with facial fractures in the absence of documented TBI and patients with spinal cord injury were excluded. Demographic and outcome data were collected prospectively. Serum GFAP was measured in duplicate using enzyme-linked immunosorbent assay techniques., Results: Thirty-nine (76%) of the 51 patients had CT-documented TBI. The study cohort was 72.5% men with a mean age of 43 years and mean Injury Severity Score (ISS) of 30.2. There were no statistically significant demographic differences between the two groups. At admission day, the mean GFAP level in non-TBI patients was 0.07 pg/mL compared with 6.77 pg/mL in TBI patients (p = 0.002). On day 2 the mean GFAP level was 0.02 in non-TBI patients compared with 2.17 in TBI patients (p = 0.003). Using regression analysis to control for age, sex, and ISS, the Head Abbreviated Injury Scale was predictive of the level of GFAP on both days 1 and 2 (p values 0.006 and 0.026, respectively). Although GFAP levels were not predictive of increased hospital length of stay, intensive care unit length of stay, or ventilator days, high GFAP levels on hospital day 2 were predictive of mortality when controlling for age, sex, and ISS (odds ratio 1.45, p value 0.028). The area under the receiver operating characteristic curve for GFAP was 0.90 for day 1 and 0.88 for day 2. A GFAP cutoff point of 1 pg/mL yielded 100% specificity and 50% to 60% sensitivity for TBI., Conclusions: GFAP is a serum marker of TBI, and persistent elevation on day 2 is predictive of increased mortality. Excellent specificity for CT-documented brain injury was found using a cutoff point of 1 pg/mL.

Background: The expression of the beta chemokine RANTES (regulated upon activation, normal T cell expressed, and secreted) has previously been shown to be elevated after traumatic brain injury (TBI) in animal models, but it was unknown whether the plasma level of RANTES was predictive of TBI in critically injured trauma patients., Methods: A prospective study was conducted on 108 critically ill trauma patients. Patients were stratified by radiologic diagnosis of TBI. Severe TBI was classified as the presence of diffuse axonal injury, midline shift, or herniation based on admission head computed tomography findings. Serum levels were evaluated at admission and hospital day 7. RANTES was measured using Luminex multiplex assays., Results: Fifty-four patients with and without TBI were compared. Severe TBI was diagnosed in 23 of the 54 TBI patients (43%) and mild/moderate TBI was found in 31 (57%) patients. The mean age of the study population was 43 +/- 20 years with a mean Injury Severity Score of 29 +/- 14. There was no significant difference between groups in age, sex, and Injury Severity Score. At admission, RANTES was significantly higher in patients with severe brain injury than in non-TBI patients (mean 1,339 pg/mL vs. 708 pg/mL, p = 0.046), and there was a trend toward significance when comparing patients with severe versus mild/moderate brain injury (mean 1,339 pg/mL vs. 752 pg/mL, p = 0.069). There was no statistically significant difference on day 7., Conclusions: RANTES was a significant early marker of severe TBI in critically injured trauma patients, consistent with animal models. Future research on the role of RANTES in the pathogenesis of human TBI is warranted.

Background: Our objectives were to determine whether persistent hyperglycemia when compared with normoglycemia was predictive of outcome in the later stages of hospitalization in critically injured trauma patients., Methods: A prospective study was conducted on 896 consecutive trauma patients admitted to the intensive care unit during a 2-year period. Patients were stratified by serum glucose level on day 1 to day 28 (low = 0-139 mg/dL, medium to high = 140-219 mg/dL, and high = >220 mg/dL), age, gender, race, insulin dependent diabetes, obesity, and Injury Severity Score (ISS). Patients were further stratified by pattern of glucose control (all low, all moderate, all high, improving, worsening, highly variable. Outcome was measured by ventilator days, infection, hospital and intensive care unit length of stay, and mortality. Multiple variable logistic and linear regression models were used to determine level of significance., Results: Eighty-three percent were victims of blunt trauma. The majority (74%) were male, with a mean ISS of 26 +/- 12. Hyperglycemia (moderate, worsening, and highly variable) in the first week was associated with significantly greater hospital and intensive care unit length of stay, ventilator time, infection, and mortality when controlling for age, race, gender, ISS, mechanism of injury, obesity, and insulin dependent diabetes (p < 0.03). However, hyperglycemia in later weeks was not associated with infection and only weakly associated with mortality when analyzed by the same model. When controlling for glucose levels in subsequent weeks, patients who were normoglycemic in the first week had a lower infection rate and were less likely to die even when controlling for age, ISS, and obesity (p < 0.05)., Conclusions: Early euglycemia is associated with improved outcome and appears to be protective regardless of glucose levels in subsequent weeks. Further studies are warranted to determine the etiology of this protective effect.

Objectives: Evaluate the impact of a tight glucose control (TGC) protocol during the first week of admission in critically injured trauma patients., Methods: A prospective quasi-experimental interrupted time-series design was used to evaluate the impact of TGC [24-month preintervention phase (no TGC) vs. 24-month postintervention phase]. Patients were stratified by serum glucose level on day 1 to 7 (low, 0-150 mg/dL; medium-high, 151-219 mg/dL; and high, >/=220 mg/dL), age, gender, and injury severity. Patients were further stratified by pattern of glucose control (all low, all medium high, all high, improving, worsening, highly variable). Outcome was measured by ventilator days, infection, hospital (HLOS) and ICU (ILOS) length of stay, and mortality., Results: One thousand twenty-one patients were evaluated in the preintervention phase as compared with 1108 patients in the postintervention phase. There was no significant difference in mechanism of injury (83% vs. 84% blunt), gender (74% vs. 73% male), age (44 vs. 43 years), and Injury Severity Score (ISS) (26 vs. 25). The TGC group was more likely to be in the all low and improving pattern of glucose control (P<0.001). The incidence of infection significantly decreased (over the first 2 weeks) from 29% to 21% in the TGC group (P<0.001). Ventilator days (OR=3.9, 1.8, 8.1), ILOS (OR=4.3, 2.1, 7.5), and HLOS (OR=5.5, 2.2, 11) and mortality (OR=1.4, 1.1, 10) were significantly higher in the non-TGC group when controlled for age, ISS, obesity, and diabetes (P<0.01)., Conclusion: The positive outcomes associated with the implementation of a TGC protocol necessitates further evaluation in a randomized prospective trial.

Introduction: The systemic inflammatory response syndrome (SIRS) occurs frequently in critically ill patients and presents similar clinical appearances despite diverse infectious and noninfectious etiologies. Despite similar phenotypic expression, these diverse SIRS etiologies may induce divergent genotypic expressions. We hypothesized that gene expression differences are present between sepsis and uninfected SIRS prior to the clinical appearance of sepsis., Methods: Critically ill uninfected SIRS patients were followed longitudinally for the development of sepsis. All patients had whole blood collected daily for gene expression analysis by Affymetrix Hg&#95;U133 2.0 Plus microarrays. SIRS patients developing sepsis were compared with those remaining uninfected for differences in gene expression at study entry and daily for 3 days prior to conversion to sepsis. Acceptance criteria for differentially expressed genes required: >1.2 median fold change between groups and significance on univariate and multivariate analysis. Differentially expressed genes were annotated to pathways using DAVID 2.0/EASE analysis., Results: A total of 12,782 (23.4%) gene probes were differentially expressed on univariate analysis 0 to 48 hours before clinical sepsis. 626 (1.1%) probes met acceptance criteria, corresponding to 459 unique genes, 65 (14.2%) down and 395 (85.8%) up expressed. These genes annotated to 10 pathways that functionally categorized to 4 themes involving innate immunity, cytokine receptors, T cell differentiation, and protein synthesis regulation., Conclusions: Sepsis has a unique gene expression profile that is different from uninfected inflammation and becomes apparent prior to expression of the clinical sepsis phenotype.

Objectives: Fluid therapy and/or acute lung injury may increase intra-abdominal pressure (IAP) and intrathoracic pressure, thereby increasing intracranial pressure (ICP) after traumatic brain injury (TBI). Further fluid administration to support cerebral perfusion or increasing ventilatory support to treat acute lung injury further increases ICP. This can create a cycle that ultimately produces multiple compartment syndrome (MCS). Both decompressive craniectomy (DC) and decompressive laparotomy (DL) decrease ICP. DL can also decrease IAP and ICP. We evaluated the serial application of DC and DL to treat MCS., Methods: Data were analyzed for 102 consecutive patients with severe TBI who underwent DC alone to decrease ICP or in combination with DL to treat MCS., Results: All 102 patients sustained blunt injury. Seventy percent were men with a mean age of 29.5 years, an Injury Severity Score of 34.4, and admission Glasgow Coma Scale score of 7.1. Fifty-one patients had diffuse brain injury and 51 had mass lesions. Seventy-eight patients (76%) underwent DC alone. Twenty-four (22%) had both therapies for MCS. Fifteen patients had DC before DL and nine had DL before DC. Mean time between DC and DL was 3.4 +/- 6 days. The mean IAP before DL was 28 +/- 5 mm Hg. Twenty-four-hour cumulative mean intrathoracic pressure decreased significantly after DL in the MCS group (p = 0.01). Mean ICP decreased significantly after both DC and DL (p < 0.05)., Conclusion: Increased ICP may be from primary TBI or MCS. Patients with MCS have a higher Injury Severity Score, ICP, and fluid requirements, but no increase in mortality. Both DC and DL reduce ICP and can be used in sequence. MCS should be considered in multiply injured patients with increased ICP that does not respond to therapy.

Background: To evaluate the impact of damage control laparotomy on long term morbidity and survival., Methods: Prospective data were collected on 56 consecutive trauma patients over a 20-month period (May 2000-January 2002). Patients were stratified by mechanism of injury, age, Injury Severity Score, and type of injury, temperature at admission, initial blood transfusion volume and pH. Initial outcome data included major complications, intensive care unit and hospital length of stay, and mortality. Readmission data including number of admissions, surgical procedures, and hospital length of stay were then analyzed over the subsequent follow-up years (2001-2003)., Results: The mean age of the study group was 31 +/- 11 years with a mean Injury Severity Score of 33 +/- 13. The majority of the patients were male (73%) with a relatively equal number of blunt (n = 30) and penetrating injuries (n = 26). Liver injuries (34 [61%]) were the most common solid organ injury followed by 22 bowel (39%), 19 spleen (34%), 11 major vessel (20%), and 7 pancreas (13%) injuries. The mean number of initial abdominal surgical procedures was 4.4 +/- 2.2 per patient. The overall mortality during the first admission was 27%. Time spent in the intensive care unit and hospital length of stay was 17 +/- 13 and 30 +/- 19 days, respectively. There were a total of 74 readmissions and 58 subsequent surgical procedures in the 41 patients who were readmitted. Thirty-one (76%) patients were re-admitted at least one time. Infection (n = 19) was the most common reason for readmission followed by ventral hernia repair (n = 17) and fistula management (n = 14). There was 0% mortality for patients who survived the preliminary hospitalization but required readmission., Conclusion: Although damage control laparotomy is associated with a significant complication and readmission rate, its long term survival and benefit is indisputable.

Background: Admission systemic inflammatory response syndrome (SIRS) score has been previously reported to be an accurate predictor of infection and outcome in trauma. However, the data were limited to the first 7 days of admission. Our objective in this follow-up study was to prospectively evaluate the utility of daily SIRS scores in the second and third week of admission as compared with the first week in prediction of nosocomial infection and outcome in high-risk trauma patients., Methods: Prospective data were collected on 1,277 consecutive trauma patients admitted during a 28-month period to the intensive care unit. SIRS scores were calculated daily for the first week and every other day for the following 2 weeks. Patients were categorized into SIRS occurring "early" (week 1), "middle" (week 2), and "late" (week 3). Centers for Disease Control and Prevention guidelines were used for the diagnosis of infection. Multivariate linear and logistic regression analyses were utilized for statistical analyses, controlling for the covariates of age, Injury Severity Score, and admission Glasgow Coma Scale score., Results: The trauma cohort included patients with blunt injuries (84%) and penetrating injuries (16%). The mean age was 43 +/- 21 years with an overall mortality of 14.7%. Nosocomial infection developed in 580 (45.4%) of the study patients (respiratory site most common) with a total of 1,001 infections (some patients with multiple infections). SIRS (defined as SIRS score >/=2) was common, with 92.4% of patients manifesting SIRS at admission. SIRS was most prevalent during the first week postinjury (91% of patients manifesting SIRS), decreasing to 69% and 50% during postinjury weeks 2 and 3. SIRS was more common in patients who acquired nosocomial infections compared with noninfected patients. Logistic regression analysis confirmed that patients with "middle" SIRS during week 2 (odds ratio [OR] 17.62, confidence interval [CI] 12.95-23.97, p < 0.0001, receiver operating characteristic [ROC] 0.83) and "late" SIRS during week 3 (OR18.12, CI 12.71-25.84, p < 0.0001, ROC 0.81) had significantly greater risk for nosocomial infection compared with patients with "early" SIRS during week 1 (OR 4.55, CI 2.57-8.06, p < 0.0001, ROC 0.65) postinjury., Conclusion: SIRS is predictive of nosocomial infection in trauma through postinjury day 21. Nosocomial infection should be considered as a treatable cause of SIRS in trauma patients, and early diagnostic interventions should be initiated to evaluate for potential causes.

Background: Thoracostomy for relief of pneumo- or hemothorax may be performed emergently at the bedside, in the emergency department or trauma area, often in nonideal circumstances. We hypothesized that ergonomic analysis of thoracostomy techniques can identify areas for potential improvement in patient and operator safety., Methods: Interviews with Subject Matter Experts (SME) provided steps in the task of thoracostomy; 44 thoracostomies (emergent and elective) were video-recorded and reviewed by SMEs. Ergonomic analyses evaluated surgical performance techniques using video clips., Results: Risks to the patient and operator included instrument-tray positioning and instrument content. Analyses of video records revealed that despite SME-survey consensus, operators inconsistently followed recommended techniques., Conclusions: Discrepancies between SME-recommended and observed practice are prevalent, with simple ergonomic problems impeding performance, and creating risks for patients and operators. Video-based ergonomic analysis is a rich source for identifying task performance problems and potential solutions.

Objectives: There is a paucity of data evaluating whether hyperglycemia at admission is associated with adverse outcome in trauma patients. Our objectives were to determine whether admission hyperglycemia was predictive of outcome in critically ill trauma patients., Methods: Prospective data were collected daily on 1,003 consecutive trauma patients admitted to the intensive care unit over a 2-year period. Diabetics were excluded. Patients were stratified by admission serum glucose level (<200 mg/dL vs. > or =200 mg/dL) age, gender, Injury Severity Score, and other preexisting risk factors. Outcome was measured by incidence of infection, ventilator days, hospital length of stay and intensive care unit length of stay, and mortality. Multiple linear regression models were used to determine level of significance., Results: Two hundred fifty-five of 1,003 (25%) patients were admitted with hyperglycemia over the study period. The majority (78%) of the admissions were caused by blunt injury. Male patients accounted for the majority of the study population (73%); however, female patients were more likely to be hyperglycemic at admission (p = 0.015). Patients with hyperglycemia had an overall greater infection rate and hospital length of stay. The hyperglycemic group had a 2.2-times greater risk of mortality when adjusted for age and Injury Severity Score., Conclusion: Hyperglycemia at admission is an independent predictor of outcome and infection in trauma patients. Future investigation on the effects of hyperglycemia are warranted.

Objectives: The purpose of this study was to examine the success rate of nonoperative management of blunt splenic injury in an institution using splenic embolization., Methods: We conducted a retrospective review of all patients admitted to a Level I trauma center with blunt splenic injury. Data review included patient demographics, computed tomographic (CT) scan results, management technique, and patient outcomes., Results: A total of 648 patients with blunt splenic injury were admitted, 280 of whom underwent immediate surgical management. Three hundred sixty-eight underwent planned nonoperative management, and 70 patients were treated with observation, serial abdominal examination, and follow-up abdominal CT scanning. All were hemodynamically stable, with a 100% salvage rate. One hundred sixty-six patients had a negative angiogram, with a nonoperative salvage rate of 94%, and 132 patients underwent embolization, with a nonoperative salvage rate of 90%. Overall salvage rates decreased with increasing injury grade; however, over 80% of grade 4 and 5 injuries were successfully managed nonoperatively. The salvage rate was similar for main coil embolization versus selective or combined embolization techniques. Admission abdominal CT scan correlated with splenic salvage rates. Significant hemoperitoneum, extravasation, and pseudoaneurysm had acceptable salvage rates, whereas arteriovenous fistula had a high failure rate, even after embolization., Conclusion: Splenic embolization is a valuable adjunct to splenic salvage in our experience, allowing for the increased use of nonoperative management and higher salvage rates for American Association for the Surgery of Trauma splenic injury grades when compared with prior studies. Main coil embolization has a similar salvage rate when compared with other angiographic techniques. An arteriovenous fistula as a CT finding was predictive of a 40% nonoperative failure rate.

Background: The purpose of this study was to identify risk factors that predict the need for operative management (OM) of severe blunt liver injury. We also sought to determine the impact of interventional angiography (Ang) in the treatment and outcomes of these patients., Methods: Patients with blunt liver injuries of grade IV or higher were retrospectively reviewed for their demographics, hemodynamics, blood product requirements, laboratory and radiologic data, hospital course, and outcomes., Results: Forty-four patients underwent OM. They had a significantly higher Injury Severity Score (ISS) and lower Glasgow Coma Scale score (p = 0.004), a lower systolic blood pressure (p = 0.002) and a higher heart rate (p = 0.02), and higher fluid and transfusion requirements (p < 0.001) than those treated without OM. Their mortality rate was 66%; 59% of deaths were from uncontrolled bleeding. Initial platelet count and fluid requirements at 4 hours were independent predictors of the need for OM. Ang was performed in 48 patients. Patients who were treated without Ang required more fluids (p = 0.03) and more packed red blood cells (p = 0.02) at 4 hours. Patients requiring both OM and Ang had a higher complication rate (p = 0.02) and longer intensive care unit and hospital length of stay (p < 0.001) than those who had OM alone, but mortality was the same (p = 0.1). Patients treated nonoperatively had longer intensive care unit (p = 0.006) and hospital stays (p < 0.05) if they required Ang, but mortality was the same. The only survival advantage to the use of Ang was when Ang alone was compared with OM alone., Conclusion: Select high-grade injuries can be successfully managed nonoperatively. Initial platelet count and crystalloid fluid use at 4 hours predict the need for OM. Patients requiring OM are less stable and have substantial mortality but often do not die as a result of uncontrolled bleeding. Ang has a role in stable patients who do not require OM initially but does not improve outcome in patients who require OM.

Background: Appropriate and timely antibiotic therapy to treat pneumonia in trauma patients is extremely important. We evaluated the incidence and microbiology of pneumonia stratified by days postadmission and risk factors., Methods: Prospective data were collected on 714 trauma patients admitted to the intensive care unit over a 1-year period. Pneumonia was classified as community acquired (CAP) (< or = 3 days), early nosocomial (ENP) (4-6 days), or late nosocomial (LNP) (> or = 7 days). In addition, pneumonia was classified as CAP only, nosocomial only (NI), or combination (CAP and NI, or ENP and LNP) pneumonia. Strict institutional guidelines were followed for diagnosis., Results: One hundred eighty-two patients (25%) were diagnosed with 204 pneumonias over the study period. One hundred twenty-five (61%) of these pneumonias were ventilator associated. Staphylococcus aureus and Haemophilus influenzae were the most common pathogens isolated. Twenty-one percent of patients with CAP acquired an LNP (p < 0.025), in which Pseudomonas was the most common organism. Haemophilus caused LNP in 12% of patients. Cancer (p < 0.01), liver failure (p < 0.05), and age (p < 0.01) were predictive of nontypical pathogens in patients with CAP and ENP (p < 0.05). Obesity was most predictive of increased ventilator days (p < 0.001) and intensive care unit length of stay (p < 0.001). Increased age, alcohol abuse, and field airway were most predictive of mortality., Conclusion: Unanticipated pathogens were isolated in each class of pneumonia. The clinician must be aware of significant risk factors that may predispose patients to pathogens that are not ordinarily covered with standard antibiotic therapy.

The incidence of community-acquired infections (CAs) and their relationship to the incidence of nosocomial infections (NI), to our knowledge, is unknown in elderly trauma patients. We prospectively collected data on 380 patients > or =65 years of age who were admitted >48 h to our trauma center over a 2-year period. One hundred seventy-seven patients (47%) developed an infection. A total of 147 (39%) patients were diagnosed with an NI, and 67 (18%) were diagnosed with a CA. Of the 67 patients with CA, 37 (55%) went on to develop an NI. Patients with the combination of CA and NI had the greatest mean ICU (28.6 days) and hospital length of stay (38.2 days). Mortality was increased significantly in patients with the combination of CA and NI (27%). Respiratory and genitourinary infections were the most common CA. Patients with respiratory CAs accounted for the greatest proportion of NIs. Thus, community-acquired and nosocomial infections significantly increase morbidity and mortality in elderly patients post-injury. Patients who present with a CA are at increased risk of acquiring an NI, which is associated with the most significant increase in length of stay and mortality.