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Background Deranged physiology in trauma complicates the clinical identification of sepsis, resulting in overscreening for bacteremia. No clinical signs or biomarkers accurately diagnose sepsis in this population. Our objective was to evaluate the accuracy of the current criteria used to prompt screening for bacteremia in trauma patients and determine independent predictors of bacteremia. Materials and Methods Adult trauma patients admitted to our level I academic trauma center who had blood cultures (BCs) drawn were identified. Those with positive BCs were compared to those with negative or false positive BCs. False positive was defined as a BC deemed contaminated and not treated at the discretion of the attending physician. Results Over a 2-year period, 366 trauma patients had BCs drawn. After excluding surveillance cultures (those drawn to demonstrate bacteremia clearance), 492 unique BC sets were evaluated; 104 (21.1%) BC sets were positive; 30 (28.8%) of these were falsely positive, resulting in a true-positive rate of 15% in the screened population. Univariate analysis suggested temperature and heart rate were associated with positive BC, while multivariable analysis found only the presence of a central line and lactic acid to be predictive. Procalcitonin (PCT) was poorly predictive, with a positive predictive value of 18% and a negative predictive value of 91%. Conclusion Current tools for identifying bacteremia in trauma patients result in overscreening. PCT may have a limited role as a negative predictor for bacteremia. Given that false-positive BCs have negative patient and economic consequences, future study should focus on development of alternative screening modalities.

Every trauma patient has a golden hour, and resuscitation efficiency within that hour has large implications for patients. We instituted simulation based trauma resuscitation training with the hypothesis that it would improve trauma team efficiency.Five simulation training sessions were conducted with immediate debriefing. Metrics collected in actual trauma resuscitations before and after simulation training included time of primary and secondary surveys and time to computed tomography (CT) scan. Study participants were from multidisciplinary specialties involved in trauma resuscitations as well as former trauma patients from the Trauma Survivors Network.Seventy-three patients undergoing trauma resuscitations were screened and 67 patients were included. Time to CT scan and secondary survey completion were significantly reduced in actual trauma patient activations following implementation of the curriculum (reduction of 23 to 16 minutes for CT scan p0.05, and reduction from 14 to 6 minutes for secondary survey, p0.05). Time to primary survey completion did not change (5 minutes).Multidisciplinary simulation training was associated with improved trauma team efficiency in the form of reduced assessment time. As emergency department length of stay is an independent predictor of hospital mortality following trauma activation, team-based simulation training has the potential to improve patient outcomes. Multidisciplinary involvement was a key factor, and Trauma Survivors Network involvement brought credibility from the patient perspective.

Background Elderly trauma patients are at risk for undertriage, resulting in substantial morbidity and mortality. The objective of this study was to determine whether implementation of geriatric-specific trauma team activation (TTA) protocols appropriately identified severely-injured elderly patients. Methods This single-center retrospective study evaluated all severely injured (injury severity score [ISS] >15), geriatric (≥65 years) patients admitted to our Level 1 tertiary-care hospital between January 2014 and September 2017. Undertriage was defined as the lack of TTA despite presence of severe injuries. The primary outcome was all-cause in-hospital mortality; secondary outcomes were mortality within 48 hours of admission and urgent hemorrhage control. A multivariable logistic regression analysis was performed to identify predictors of appropriate triage in this study. Results Out of 1039 severely injured geriatric patients, 628 (61%) did not undergo TTA. Undertriaged patients were significantly older and had more comorbidities. In-hospital mortality was 5% and 31% in the undertriaged and appropriately triaged groups, respectively ( P < .0001). One percent of undertriaged patients needed urgent hemorrhage control, compared to 6% of the appropriately triaged group ( P < .0001). One percent of undertriaged patients died within 48 hours compared to 19% in the appropriately triaged group ( P < .0001). Predictors of appropriate triage include GCS, heart rate, systolic blood pressure, lactic acid, ISS, shock, and absence of dementia, stroke, or alcoholism. Discussion Geriatric-specific TTA guidelines continue to undertriage elderly trauma patients when using ISS as a metric to measure undertriage. However, undertriaged patients have much lower morbidity and mortality, suggesting the geriatric-specific TTA guidelines identify those patients at highest risk for poor outcomes.

Summary: Complement pathway overactivation can lead to neuronal damage in various neurological diseases. Although Alzheimer’s disease (AD) is characterized by β-amyloid plaques and tau tangles, previous work examining complement has largely focused on amyloidosis models. We find that glial cells show increased expression of classical complement components and the central component C3 in mouse models of amyloidosis (PS2APP) and more extensively tauopathy (TauP301S). Blocking complement function by deleting C3 rescues plaque-associated synapse loss in PS2APP mice and ameliorates neuron loss and brain atrophy in TauP301S mice, improving neurophysiological and behavioral measurements. In addition, C3 protein is elevated in AD patient brains, including at synapses, and levels and processing of C3 are increased in AD patient CSF and correlate with tau. These results demonstrate that complement activation contributes to neurodegeneration caused by tau pathology and suggest that blocking C3 function might be protective in AD and other tauopathies. : Wu et al. show that loss of the central complement component C3, which is elevated and activated in brains and cerebrospinal fluid from AD patients, ameliorates synapse loss and neurodegeneration in amyloidosis and tauopathy AD mouse models despite ongoing glial activation. Keywords: Alzheimer’s disease, C3, complement, amyloidosis, tauopathy, synapse, neurodegeneration, neuroinflammation, astrocyte, microglia

Aging worsens outcome in traumatic brain injury (TBI), but available studies may not provide accurate outcomes predictions due to confounding associated injuries. Our goal was to develop a predictive tool using variables available at admission to predict outcomes related to severity of brain injury in aging patients.Characteristics and outcomes of blunt trauma patients, aged 50 or older, with isolated TBI, in the National Trauma Data Bank (NTDB), were evaluated. Equations predicting survival and independence at discharge (IDC) were developed and validated using patients from our trauma registry, comparing predicted with actual outcomes.Logistic regression for survival and IDC was performed in 57,588 patients using age, sex, Glasgow Coma Scale score (GCS), and Revised Trauma Score (RTS). All variables were independent predictors of outcome. Two models were developed using these data. The first included age, sex, and GCS. The second substituted RTS for GCS. C statistics from the models for survival and IDC were 0.90 and 0.82 in the GCS model. In the RTS model, C statistics were 0.80 and 0.67. The use of GCS provided better discrimination and was chosen for further examination. Using a predictive equation derived from the logistic regression model, outcome probabilities were calculated for 894 similar patients from our trauma registry (January 2012 to March 2016). The survival and IDC models both showed excellent discrimination (p0.0001). Survival and IDC generally decreased by decade: age 50 to 59 (80% IDC, 6.5% mortality), 60 to 69 (82% IDC, 7.0% mortality), 70 to 79 (76% IDC, 8.9% mortality), and 80 to 89 (67% IDC, 13.4% mortality).These models can assist in predicting the probability of survival and IDC for aging patients with TBI. This provides important data for loved ones of these patients when addressing goals of care.

BACKGROUND: : The early resuscitation occurs in the emergency department (ED) where intensive care unit protocols do not always extend and monitoring capabilities vary. Our hypothesis is that increased ED length of stay (LOS) leads to increased hospital mortality in patients not undergoing immediate surgical intervention. METHODS: : We examined all trauma activation admissions from January 2002 to July 2009 admitted to the Trauma Service (n = 3,973). Exclusion criteria were as follows: patients taken to the operating room within the first 2 hours of ED arrival, nonsurvivable brain injury, and ED deaths. Patients spending >5 hours in the ED were not included in the analysis because of significantly lower acuity and mortality. RESULTS: : Patients spent a mean of 3.2 hours ± 1 hour in the ED during their initial evaluation. Hospital mortality increases for each additional hour a patient spends in the ED, with 8.3% of the patients staying in the ED between 4 hours and 5 hours ultimately dying (p = 0.028). ED LOS measured in minutes is an independent predictor of mortality (odds ratio, 1.003; 95% confidence interval, 1.010-1.006; p = 0.014) when accounting for Injury Severity Score, Revised Trauma Score, and age. Linear regression showed that a longer ED LOS was associated with anatomic injury pattern rather than physiologic derangement. CONCLUSION: : In this patient population, a longer ED LOS is associated with an increased hospital mortality even when controlling for physiologic, demographic, and anatomic factors. This highlights the importance of rapid progression of patients through the initial evaluation process to facilitate placement in a location that allows implementation of early goal directed trauma resuscitation. Language: en

Hyperglycemia after severe injury has been associated with an increased risk of infection and death. Strict glycemic control has been found to be valuable in select surgical populations. Varying amounts of insulin by infusion are required to maintain blood glucose levels within normal limits. Little is known about how insulin requirements are affected by the presence of infection, and therefore, the purpose of this study was to characterize this relationship.Medical records of all intubated, injured patients admitted to the intensive care unit during a 16-month period were reviewed. Patients were included if they were managed with an insulin infusion, and they had a single bronchoalveolar lavage (BAL) culture performed for presumed pneumonia between 48 hours and 8 days. Mean hourly and 24-hour insulin requirements were analyzed before BAL was performed and then compared with values after cultures were obtained. This difference was then compared between patients with and without pneumonia.Eighty-two patients met inclusion criteria during the 16-month study period. The hourly and 24-hour insulin requirements significantly increased from before to after BAL was performed in patients with pneumonia (n = 54) and not in those without (n = 28) (p = 0.008). The 24-hour insulin requirement increased by 26.2 units from before to after BAL in the pneumonia group versus 7.6 units in the nonpneumonia group (p = 0.029). A mean hourly insulin requirement increase of 1.2 units more than the pre-BAL level demonstrated an 86% positive predictive value and 89% specificity for pneumonia.An increase in insulin requirements at the time of obtaining pulmonary cultures is associated with the presence of pneumonia and may represent a valuable tool for earlier recognition.

Based on a large body of literature concerning the subject, trauma surgeons are becoming more comfortable with anastomosis rather than stoma creation in patients with destructive colon injuries requiring resection. This literature was largely generated before the widespread acceptance of the importance of damage control laparotomy (DCL). Thus, when such injuries occur in patients initially left in colonic discontinuity after DCL, the question of anastomosis versus stoma becomes more difficult, and there are no data to guide management decisions. The goal of this report is to describe the results of our early experience with delayed anastomosis (DA) after destructive colon injury in the setting of DCL. We reviewed the records of patients with destructive colon injuries at our Level I trauma center over a 5.5-year period for demographics, injury characteristics, and outcome. Studied outcomes included anastomotic leak, intra-abdominal abscess, and colon injury-related death. The decision to proceed with DA was based on individual surgeon opinion at the time of re-exploration. From January 1, 2000 to July 31, 2006, 92 patients sustained colon injury, 55 of which required resection (31 blunt mechanism and 24 penetrating). Twenty-two resections occurred in the setting of DCL. Six of these patients underwent stoma creation and 11 underwent DA. Three died before reoperation, and two had an anastomosis created during the initial DCL. The remaining 33 resections occurred during initial definitive operation, and 21 underwent anastomosis, whereas 12 had a stoma created. Comparing the 11 patients undergoing DA with the 21 undergoing immediate anastomosis, the anastomotic leak rate (0% vs 5%), abscess rate (36% vs 24%), and colon related-death rate (9% vs 0%; all P > 0.05) were similar. Six patients undergoing DA had a right hemicolectomy with ileocolonic anastomosis, four had a segmental left colon resection, and one had a near total abdominal colectomy with ileosigmoid anastomosis. Delayed anastomosis of colon injuries after DCL is safe in selected patients and has a similar complication rate as resection and anastomosis performed during initial definitive operation. DA avoids stoma creation in some patients who are not candidates for anastomosis during initial DCL. To our knowledge, this represents the first reported series of DA after DCL, an area in which further work is needed to carefully define indications for the safe application of this concept.

In patients with blunt splenic injury (BSI), patient selection, angiography, and embolization have contributed to low nonoperative management (NOM) failure rates. Despite these advances, some patients will fail NOM. We noted that a significant proportion of NOM failures had subcapsular hematomas (SCHs) identified on imaging. We sought to determine if there is a correlation between SCH and higher risk of NOM failure after BSI.Our institutional trauma registry was queried for all patients with BSI during a 2-year period. Charts were reviewed to determine grade, presence of SCH, and outcome of NOM. Under current institutional protocol, all stable patients with BSI Grades III to V and those with contrast blush on computed tomography are referred for angiography and embolization. Failure of NOM was declared if splenectomy was required for bleeding after an initial plan of nonoperation.From May 2012 to May 2014, 312 patients with BSI were identified. A total of 253 patients (81%) underwent NOM. Overall, 15 (5.9%) failed NOM. Of those undergoing NOM, 34 had SCH and 12 failed (35.3% vs. 1.5% without SCH, p = 0.0001). Failure rates in Grades 1 to 4 were 2.3%, 3.8%, 8.8%, and 19.2%, respectively. NOM failure rates in the subset with SCH for Grades I to IV were 20%, 25%, 30.8%, and 80%, respectively. These are significantly higher than patients without SCH in Grades II to IV (0%, p = 0.003; 2.3%, p = 0.008; and 4.8%, p = 0.016) and approach significance in Grade I (1.2%, p = 0.11). There were no SCHs and no failures of NOM in Grade V injuries.The NOM failure rate of BSI patients with SCH is significantly higher than those without SCH. Patients with BSI Grades I to III slated for NOM must be observed as the failure rate approaches 30%. Splenectomy should be considered in patients with Grade IV BSI with SCH, as NOM failure rate is 80%.Therapeutic study, level IV.

Background: Ventilator associated pneumonia (VAP) is common in trauma patients, and accurate diagnosis of VAP may improve survival. With the risk of development of bacterial resistance, we also strive to minimize the use of unnecessary antibiotics. Recent studies suggest that quantitative deep endotracheal aspirate (QDEA) is adequate in VAP diagnosis. We currently use bronchoalveolar lavage (BAL) diagnosis. The purpose of this study was to examine the accuracy of QDEA as compared with BAL in diagnosing VAP in trauma patients. Methods: We prospectively compared the results of BAL and QDEA in intubated patients suspected of having VAP during an 8-month period. Indication for BAL was pulmonary infiltrate, systemic inflammatory response syndrome, and C-reactive protein >17 mg/dL at ≥48 hours after admission. Study patients underwent QDEA immediately before BAL, and quantitative cultures were compared for both specimens. The techniques differ in that QDEA involves the direct culture of sputum suctioned from the distal trachea, whereas BAL involves lavage of the bronchoalveolar tree with sterile saline, which is then cultured. VAP was diagnosed on BAL if ≥10 5 cfu/mL was present on culture. The ability of QDEA to diagnose pneumonia was examined at cutoffs of ≥10 5 cfu/mL and ≥10 4 cfu/mL, as compared with BAL at ≥10 5 . Results: Sixty-one patients underwent BAL during this period, and 39 of these underwent both BAL and QDEA for the study. Of the 39 studied patients between March 16, 2002, and November 4, 2002, 20 (51%) were found to have VAP by BAL (≥10 5 cfu/mL). Using this cutoff for QDEA, 18 of 20 (90%) would have been correctly diagnosed. Using ≥10 4 cfu/mL for QDEA, the rate of correct diagnosis would increase to 19 of 20 (95%). However, of the 19 who did not have pneumonia according to BAL, 6 (31%) would have been incorrectly diagnosed with VAP using the QDEA cutoff of ≥10 5 cfu/mL. A QDEA cutoff of ≥10 4 cfu/mL would result in the even higher false-positive rate of 8 of 19 patients (42%). Conclusion: Whereas most patients with pneumonia by BAL would have been diagnosed by QDEA, use of QDEA in treatment decisions would have led to needless antibiotic administration in 31% of VAP-negative patients at a cutoff of ≥10 5 cfu/mL and 42% at ≥10 4 cfu/mL. The use of QDEA in VAP diagnosis is limited because of the rate of over-diagnosis. With the increasing problems associated with excess antibiotic use, we believe these results support the use of BAL over QDEA in the diagnosis of VAP in the ventilated trauma patient.

Severe injury and shock are frequently associated with abnormalities in patient body temperature. Substantial increases in mortality have been associated with profound hypothermia, especially below 35 degrees C. The purpose of this study was to further characterize the impact of hypothermia in a large dataset of trauma patients. This study was a retrospective analysis of the 2004 version of the National Trauma Data Bank (NTDB), which contains approximately 1.1 million patients from over 400 trauma centers. Admission temperature was analyzed with respect to mortality, injury severity score (ISS), base deficit (BD), Glasgow Coma Score (GCS), and hospital outcomes. The NTDB contained 701,491 patients with temperatures recorded upon trauma center admission. Of these, 11,026 patients had admission temperatures35 degrees C, and 802 had temperatures32 degrees C. Comparison of core temperature versus mortality revealed that as temperature decreased, the mortality rate increased, reaching approximately 39% at 32 degrees C, and remained constant at lower temperatures. Surprisingly, 477 patients (59.5%) survived with temperatures32 degrees C. Similarly, BD increased as hypothermia worsened until body temperature reached 31 degrees C, below which there was little further increase. Patients with admission temperatures less than 35 degrees C had significantly greater mortality (25.5% vs. 3.0%, P0.001) and BD (7.8 vs. 3.7, P0.001) when compared with patients with temperaturesor=35 degrees C. In survivors, average ventilator days and intensive care unit (ICU) days were 14.4 and 12.8, respectively, for patients with temperatures35 degrees C as opposed to more normothermic patients who demonstrated an average of 9.5 ventilator days and 9.1 ICU days (P0.001). When grouped by individual ISS, BD level, and GCS motor score, mortality was significantly greater when admission temperature was below 35 degrees C (ISS mean difference = 11.4%, BD mean difference = 22.8%, and GCS motor mean difference = 9.85%). Logistic regression revealed that hypothermia remains an independent determinant of mortality after correction for confounding variables (odds ratio = 1.54, 95% confidence interval 1.40-1.71). Admission hypothermia is associated with greater mortality, increased injury severity, more profound acidosis, and prolonged ICU/ventilator courses. However, although mortality at32 degrees C is high, patients with temperatures this low do survive. As temperatures drop below 32 degrees C, mortality rates remain constant, which may indicate a threshold below which physiologic mechanisms are unable to correct body temperature regardless of injury severity. Although shock severity is highly indicative of outcome, hypothermia independently contributes to the substantial mortality associated with severe injury.

Recent randomized prospective data suggest that early hyperglycemia is associated with excess mortality in critically ill patients, and tight glucose control leads to improved outcome. This concept has not been carefully examined in trauma patients, and the relationship of early hyperglycemia to mortality from sepsis in this population is unclear. The objective of this study was to determine the relationship different levels of early blood glucose elevation to outcome in a trauma ICU population.The records of all patients admitted to the ICU over a 2-year period at a Level I trauma center were reviewed for age, injury severity scores (ISS), admission Glasgow Coma Scale (GCS) score, base deficit (BD), blood glucose, and mortality. Three possible cutoffs in defining hyperglycemia were examined (glucoseor =110 mg/dL,or =150 mg/dL,or =200 mg/dL) in relation to infection and mortality. Early hyperglycemia was defined as elevated blood glucose on hospital days 1 or 2. Those with diabetes mellitus were excluded.From 1/00-12/01, 516 eligible patients were admitted to the ICU after injury. Early hyperglycemia occurred in 483 at theor =110 mg/dL level, 311 at theor =150 mg/dL level, and 90 patients at theor =200 mg/dL level. Univariate logistic regression demonstrated a significant relationship between ISS and subsequent infection(p = 0.02) and a trend toward such a relationship in GCS score, glucoseor =150 mg/dL, and glucoseor =200 mg/dL (p = 0.06, 0.12, and 0.06). A similar analysis for the relationship of these variables to eventual mortality showed a significant correlation with all examined variables except glucoseor =110 mg/dL. Multiple logistic regression to control for the effect of age, ISS, GCS score, and BD found early glucoseor =200 mg/dL to be an independent predictor of both infection and mortality while no such relationship was found withor = 110 mg/dL oror =150 mg/dL.Early hyperglycemia as defined by glucoseor =200 mg/dL is associated with significantly higher infection and mortality rates in trauma patients independent of injury characteristics. This was not true at the cutoffs ofor =110 mg/dL oror =150 mg/dL. These data support the need for a prospective analysis of tight glucose control, keeping serum glucose200 mg/dL in critically ill trauma patients. However, aggressive maintenance of levels110 mg/dL as reported by others may not be necessary.

Background: The base deficit, an important indicator of physiologic derangement after severe injury in adults, has not been specifically examined in the pediatric trauma population. The purpose of this study was to assess the ability of the admission base deficit to predict injury severity and outcome in the pediatric trauma population. Methods: The study group included all patients in the National Trauma Data Bank over a 2-year period aged 0 to 12 years with a base deficit (0 to -30 mEq/L) recorded from the emergency department. Age, presence of a severe closed head injury, and base deficit were analyzed with respect to mortality and other indicators of injury severity. Results: A total of 515 patients constituted the study group. Base deficit less than -4 mEq/L (p < 0.001) and the presence of a closed head injury (odds ratio, 3.8; p < 0.05) were predictors of mortality. For the group, an admission base deficit of -8 mEq/L corresponded to a probability of mortality of 25%. Significant correlations were found between base deficit and emergency department systolic blood pressure, Injury Severity Score, and Revised Trauma Score. There was no relationship between age and mortality. Conclusion: In injured children, the admission base deficit reflects injury severity and predicts mortality. The probability of mortality increases precipitously in children with a base deficit less than -8 mEq/L, and should alert the clinician to the presence of potentially lethal injuries or uncompensated shock.

Objective: Maintaining left ventricular power output (LVP) > 320 mm Hg.L/ min/m 2 during resuscitation has been retrospectively associated with faster resolution of acidosis and survival after posttraumatic shock. The purpose of this prospective study was to evaluate the effects of maintaining LVP above this threshold during resuscitation on base deficit clearance, organ failure, and survival. Methods: This was a study of a consecutive series of critically injured patients (PWR) monitored with a pulmonary artery catheter during initial resuscitation. LVP, calculated as cardiac index.(mean arterial pressure-central venous pressure), was maintained >320 mm Hg.L/min/m 2 via a predefined protocol by using ventricular pressure-volume diagrams. Outcome was assessed by base deficit clearance (

Background: The gastric intramucosal pH (pHi) and gastric mucosal-arterial CO 2 gap (GAP) estimate visceral perfusion and predict outcome. Threshold values of these variables for use during resuscitation, however, remain poorly defined. The purpose of this study was to develop clinically derived cutoffs for both pHi and GAP for predicting death and multiple organ failure (MOF) in trauma patients. Methods: This was a cohort study of 114 consecutive trauma patients who had pHi determined at 24 hours after intensive care unit admission. The corresponding GAP for each of these values of pHi was obtained through chart review. Receiver operating characteristic curves were constructed for both pHi and GAP with respect to death and MOF. These curves were used to determine the value of each variable that maximized the sum of sensitivity and specificity in predicting outcome. X 2 tests and odds ratios were used to determine if significant differences in outcome occurred above and below these cutoff values. Results: Of 114 patients who had pHi determined at 24 hours after admission, 108 had corresponding GAP values available. The values of pHi and GAP that maximized sensitivity and specificity were 7.25 and 18 mm Hg, respectively. The odds ratio for pHi versus death was 4.6 and for pHi versus MOF was 4.3. The odds ratios for GAP versus death and MOF were 2.9 and 3.3, respectively. Conclusion: In trauma patients, the ability to predict death and MOF is maximized at values of pHi less than 7.25 and GAP greater than 18 mm Hg. These values represent clinically derived cutoffs that should be useful for evaluating the adequacy of intestinal perfusion during resuscitation.

In trauma patients, the admission value of arterial base deficit stratifies injury severity, predicts complications, and is correlated with arterial lactate concentration. In theory, elevated base deficit and lactate concentrations after shock are related to oxygen transport imbalance at the cellular level. The purpose of this study was to test the hypothesis that an elevated base deficit in trauma patients is indicative of impaired systemic oxygen utilization and portends poor outcomes.This study was a retrospective analysis of a prospectively collected database. The study population included all patients admitted to the trauma intensive care unit at a Level 1 trauma center during a 12-month period who were monitored with a pulmonary artery catheter and serial measurements of lactate and base deficit, and who achieved a normal arterial lactate concentration (2.2 mmol/L) with resuscitation. The patients were divided into those who maintained a persistently high base deficit (or = 4 mmol/L) and those who achieved a low base deficit (4 mmol/L) during resuscitation.One-hundred patients (mortality 20%) were monitored with a pulmonary artery catheter and achieved a normal arterial lactate concentration. The mean age+/-SD (SEM) of the group was 37+/-17 years and the Injury Severity Score was 25+/-11. Subgroup analysis revealed that patients with a persistently high base deficit (n=26) had higher rates of multiple organ failure (35% versus 5%, p0.001) and death (50% versus 9%, p0.00001) compared with patients who achieved a low base deficit. Patients with a persistently high base deficit also had lower oxygen consumption (126+/-40 mL/m2 versus 156+/-30 mL/m2, p=0.01 at 48 hours) and a lower oxygen utilization coefficient (0.20+/-0.05 versus 0.24+/-0.03, p=0.01 at 48 hours) compared with patients with a low base deficit. At 48 hours, both oxygen consumption (r=-0.44, [r, correlation coefficient] p=0.002) and oxygen utilization (r=-0.46, p=0.001) had a significant negative correlation with base deficit.In trauma patients, a persistently high arterial base deficit is associated with altered oxygen utilization and an increased risk of multiple organ failure and mortality. Serial monitoring of base deficit may be useful in assessing the adequacy of oxygen transport and resuscitation.

Inadequate splanchnic perfusion, detected as a low gastric intramucosal pH (pHi), in the face of normal systemic perfusion predicts an increased risk for multiple organ failure after trauma. Although the exact etiology of this low pHi is unknown, angiotensin II is thought to be an important regulator of gut perfusion during and after resuscitation from shock. The purpose of this study is to determine whether enalaprilat, an angiotensin-converting enzyme inhibitor, improves gut perfusion in critically injured patients. To test this hypothesis, 18 trauma patients monitored with a nasogastric tonometer and a pulmonary artery catheter were enrolled in a prospective study. A single dose of enalaprilat, .625 mg, was given as an i.v. bolus or a 4 h infusion following systemic resuscitation. Pre- and postdrug tonometric and hemodynamic data, including cardiac index, mean arterial pressure, right ventricular end-diastolic volume index, systemic vascular resistance index, and oxygen transport variables were compared using the paired t test. Results demonstrate that pHi was significantly improved after 4 h (7.13 +/- .04 to 7.19 +/- .03, p = .03) and after 24 h compared with baseline (7.14 +/- .04 to 7.25 +/- .04, p = .04). Overall, pHi increased in 12 of 18 patients. No significant differences were observed in any of the studied hemodynamic or systemic perfusion variables including mean arterial pressure (92 +/- 4 to 87 +/- 4, p = .24) and oxygen delivery (669 +/- 33 to 675 +/- 32, p = .82). In examining the determinants of pHi, the intramucosal-arterial PCO2 difference was improved after enalaprilat administration (27 +/- 6 to 17 +/- 3 mmHg, p = .04) while no difference was observed in arterial bicarbonate (19.5 +/- .7 to 19.7 +/- .8, p = .90). Additionally, the change in pHi observed with enalaprilat correlated with predrug intramucosal-arterial PCO2 difference (r = .74, r2 = .55, p = .0005). These results demonstrate that enalaprilat improves gut perfusion as measured by gastric tonometry in critically injured patients, and that this effect appears to be independent of changes in systemic perfusion.

The Acute Physiology and Chronic Health Evaluation II (APACHE II) score has never been validated to risk-adjust between critically ill trauma (TICU) and general surgical (SICU) intensive care unit patients, yet it is commonly used for such a purpose. To study this, we evaluated risk of death in TICU and SICU patients with pneumonia. We hypothesized that mortality for a given APACHE II would be significantly different and that using APACHE II to directly compare TICU and SICU patients would not be appropriate. We conducted a retrospective review of patients admitted to the TICU or SICU at a tertiary medical center over an 18-month period with pneumonia. Admission APACHE II scores, in-hospital mortality, demographics, and illness characteristics were recorded. One hundred eighty patients met inclusion criteria, 116 in the TICU and 64 in the SICU. Average APACHE II scores were not significantly different in the TICU versus SICU (25 vs 24; P = 0.4607), indicating similar disease severity; overall mortality rates, however, were significantly different (24 vs 50%; P = 0.0004). Components of APACHE II, which contributed to this mortality differential, were Glasgow Coma Score, age, presence of chronic health problems, and operative intervention. APACHE II fails to provide a valid metric to directly compare the severity of disease between TICU and SICU patients with pneumonia. These groups represent distinct populations and should be separated when benchmarking outcomes or creating performance metrics in ICU patients. Improved severity scoring systems are needed to conduct clinically relevant and methodologically valid comparisons between these unique groups.

Indications for hysterosalpingography (HSG) include evaluation of infertility, spontaneous abortions, postoperative evaluation of tubal ligation, pre-myomectomy evaluation, and more recently, evaluation of tubal occlusion after placement of the Essure Permanent Birth Control System. Here we report a case of venous intravasation during a routine post-Essure HSG, a phenomenon in which contrast transits from the uterine cavity, through the myometrium, and directly into draining pelvic veins. Venous intravasation is a potential pitfall in interpretation of HSGs.

The relative infrequency of blunt carotid artery trauma prompted a multicenter review to determine the spectrum of injuries, treatment strategies, and neurologic outcome. During a six-year period, 60 carotid artery injuries from blunt mechanisms in 49 patients were treated at 11 institutions. There were 11 bilateral injuries. Injury mechanisms were diverse but involved motor vehicles in 35 (72%) patients. In 14 (29%) patients, significant neurologic deficits developed more than 12 hours after a normal admission neurologic examination. The diagnosis was confirmed by angiography in 42 (86%). Duplex ultrasound accurately demonstrated the arterial injury in 12 (86%) of 14 patients. Documented injuries included arterial thrombosis in 20 arteries, arterial dissection alone in 19, dissection with pseudoaneurysm in six, pseudoaneurysm alone in five, frank arterial disruption in seven, and carotid-cavernous fistula in three. Arterial dissection was managed nonsurgically in 15 (79%) of 19 cases, the majority with systemic anticoagulation. Arterial thrombosis was managed with supportive therapy alone for 16 (80%) of 20 arteries; most associated with fixed neurologic deficits. Pseudoaneurysm repair was performed for six (55%) injuries. Carotid-cavernous fistulas were treated in all three instances with balloon occlusion. Overall mortality was 16 of 49 patients (43%). Good neurologic outcome was achieved in 22 (45%) patients. We conclude that: (1) Neurologic symptoms may develop in a delayed fashion; prior clinical suspicion and diagnostic testing are essential; (2) arterial dissection without complete occlusion may effectively be managed by anticoagulation; (3) pseudoaneurysms in accessible anatomic locations can be repaired with good results; and (4) injuries with complete arterial thrombosis are associated with high mortality and poor neurologic outcome in proportion to the initial degree of neurologic impairment.

Emergent operations are thought to carry higher morbidity and mortality than nonemergent cases. However, there is a lack of specific outcomes data for emergent general surgery procedures. The objective of our study was to assess and quantify postoperative morbidity and mortality for emergency versus nonemergency general surgery operations. All general surgery inpatients were identified in the American College of Surgeons National Surgical Quality Improvement Program 2008 database. Preoperative, intraoperative, and postoperative clinical metrics and occurrences were assessed. A total of 25,770 emergent and 98,867 nonemergent cases were identified. Postoperative morbidity was significantly worse in the emergent group, including ventilation more than 48 hours, bleeding requiring transfusion, deep vein thrombosis, renal failure, and need for reoperation. Overall, emergent cases had significantly more postoperative complications (22.8% vs 14.2%) and higher mortality rates (6.5% vs 1.4%). General surgery patients who undergo emergent operations have significantly poorer outcomes when compared with nonemergent patients; our analysis has quantified these differences. Emergent patients seem to manifest unique clinical, pathophysiologic, and inflammatory responses to their surgical disease. This data suggests that there is a need for improvement in both methods and systems of care for the emergent population.

In some populations, intensive care unit (ICU) mobility has been shown to be safe and beneficial. We gathered data on 50 nonintubated surgical patients in a 10-bed surgical ICU (SICU) who met physiologic inclusion criteria beginning in May 2008 (A group). In January 2009, we began mandatory entry of computerized mobility orders as part of a standardized ICU order set. We also created a mobility protocol for nurses in this ICU. We then collected data on 50 patients in this postintervention cohort (B group). Both groups had similar baseline characteristics. A group patients had some form of mobility orders entered in 29 patients (58%) versus 47 patients (82%) in the B group, P0.05. In the A group, 11 patients (22%) were mobilized; in the B group, 40 patients (80%) were mobilized, P0.05. In our SICU patient population, mandatory entry of computerized mobility orders as part of a standard SICU order set and establishment of an ICU mobility nursing protocol was associated with an increase in number of mobility orders entered as well as an increase in SICU patient activity. Further studies should focus on measurement of the effect of mobility interventions on patient outcomes.

Background: Reconstruction of the abdominal wall poses a problem common to many surgical specialties. Abdominal wall defects may be caused by trauma and/or prior surgery, with dehiscence or infection. Several options to repair the structural integrity of the abdominal wall exist, including primary closure, flaps, mesh, and skin grafts. Complications of these procedures include recurrent infection of the abdominal wall, infection of mesh, dehiscence, flap death, and poor skin graft take. Risk factors predisposing to these complications include tissue edema, preoperative tissue infection, and patient debilitation, with poor wound healing potential. Ideally, reconstruction should be performed on a nonedematous, clean tissue bed with bacterial levels less than 10 5 bacteria/cm 3 in a well-nourished patient. Methods: Vacuum-assisted closure was used in a series of patients in an attempt to prepare the abdominal wall for reconstruction and reduce the risk of complications. Charts were reviewed for 100 patients who underwent abdominal wall reconstruction after vacuum-assisted closure therapy. Their wound cause, reconstruction technique, complications, and number of days on the vacuum-assisted closure device are reported. Results: The ability of vacuum-assisted closure to reduce edema, increase blood flow, potentially decrease bacterial colonization, and reduce wound size greatly facilitated abdominal wall reconstruction. The vacuum-assisted closure device served as a temporary dressing with which to control dehiscence and to maintain abdominal wall integrity when bowel wall edema prevented abdominal closure. Conclusion: Vacuum-assisted closure therapy frequently shortened time to abdominal wall reconstruction and simplified the method of reconstruction.

Background: Resuscitation regimens based on stroke work index (SWI) and ventricular-arterial coupling (VAC) are controversial. The Signal Interpretation and Monitoring (SIMON) system continuously collects and stores physiologic intensive care unit (ICU) bedside data at 3- to 5-second intervals. The purpose of this study was to demonstrate the capabilities of a completely automated data management system by further evaluating SWI-based resuscitation. Methods: This study was a retrospective review of all severely injured patients requiring a pulmonary artery catheter (PAC) for acute postinjury resuscitation. Patients with a severe head injury were excluded. Hemodynamic (HD) data (21 million datapoints) were densely acquired and archived by SIMON. Mean values of HD variables were compared between survivors and nonsurvivors. Receiver operator characteristic (ROC) curves were constructed for HD variables. Threshold values which maximized sensitivity and specificity were determined. Results: Eighty-eight patients over a 19-month time period met criteria and were included in the analysis. SWI was significantly greater in survivors versus nonsurvivors (4421 ± 1278 versus 3163 ± 1066 mm Hg mL/m 2 , p = 0.0008). VAC was quantified by the ratio (RATIO) of afterload (E a ) to contractility (E es ). RATIO (E a /E es ) in survivors was significantly better than in nonsurvivors (1.9 ± 1.1 vs. 2.9 ± 1.0, p = 0.002). ROC curves identified threshold values of 3250 mm Hg · mL/m 2 for SWI and 2.1 for RATIO (AUC = 0.78 and 0.82, respectively). Conclusion: Previous work demonstrating the use of SWI and VAC as resuscitation guidelines was supported through the use of a powerful ICU data management system (SIMON). The emergence of these "new vital signs" may change the way injured patients are evaluated and resuscitated in the ICU.

Development of practice-based learning (PBL) is one of the core competencies required for resident education by the Accreditation Council for Graduate Medical Education, and specialty organizations including the American College of Surgeons have formed task forces to understand and disseminate information on this important concept. However, translating this concept into daily practice may be difficult. Our goal was to describe the successful application of PBL to patient care improvement with development of an algorithm for the empiric therapy of ventilator-associated pneumonia (VAP).The algorithm development occurred in two phases. In phase 1, the microbiology and timing of VAP as diagnosed by bronchoalveolar lavage was reviewed over a 2-year period to allow for recognition of patterns of infection. In phase 2, based on these data, an algorithm for empiric antibiotic coverage that would ensure that the large majority of patients with VAP received adequate initial empiric therapy was developed and put into practice. The period of algorithm use was then examined to determine rate of adequate coverage and outcome.: In Phase 1, from January 1, 2000 to December 31 2001, 110 patients were diagnosed with VAP. Analysis of microbiology revealed a sharp increase in the recovery of nosocomial pathogens on postinjury day 7 (19%day 7 versus 47%or = day 7, p = 0.003). Adequate initial antibiotic coverage was seen in 74%. In Phase 2, an algorithm employing ampicillin- sulbactam for coverage of community- acquired pathogens before day 7 and cefipime for nosocomial coverageor =day 7 was then employed from January 1, 2002 to December 31, 2003. Evaluation of 186 VAP cases during this interval revealed a similar distribution of nosocomial cases (13%day 7 versus 64%or = day 7, p0.0001). Empiric antibiotic therapy was adequate in 82% of casesday 7 and 85% of casesor =day 7: overall accuracy improved to 83% (p = 0.05). Mortality from phase 1 to phase 2 trended toward a decrease (21% versus 13%, p = 0.1).Application of the concept of PBL allowed for identification of local patterns of infection and development of an institution specific treatment algorithm that resulted in80% adequate initial empiric coverage for VAP with a trend toward decreased mortality. PBL allows for alteration in practice based on local patterns and outcomes and has the potential to improve patient care.

Introduction Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in the injured patient. Identification of those with VAP is important both in immediate clinical decision making as well as for the epidemiologic evaluation of the disease and benchmarking of rates across institutions with variable practice patterns. Despite this, controversy exists over the optimal method of VAP diagnosis. Many centers currently use invasive culture methods such as bronchoalveolar lavage (BAL) for diagnosis. Another diagnostic method, and the most common epidemiologic tool used to track VAP, is the definition employed by the National Nosocomial Infections Surveillance (NNIS) system. This relies on a combination of clinical and culture data. Our goal was to evaluate the accuracy of the NNIS definition as compared with BAL diagnosis in trauma patients. Methods Records of all ventilated patients admitted to the trauma intensive care unit at a Level I center who were evaluated for the presence of pneumonia over a 2.5-year period were reviewed. VAP diagnosis was established if > or =10 cfu/mL were cultured on BAL. VAP rates and time of onset were compared with the hospital infection control database, which defines VAP by NNIS criteria. Assuming BAL to be correct, sensitivity, specificity, and positive and negative predictive values were calculated for NNIS VAP. Results From September 1, 2001, through December 31, 2003, 292 patients underwent BAL for suspected pneumonia. The pneumonia rate in this group was 34 per 1,000 ventilator days. The NNIS definition showed excellent overall agreement, with a rate of 36 per 1,000 ventilator days. The use of the NNIS definition for bedside decision making, however, is less accurate. Sensitivity and positive predictive value were reasonably good (84% and 83%, respectively), whereas specificity and negative predictive value suffer (69% and 69%, respectively). Most importantly, the use of NNIS would have led to no treatment in 16% of patients diagnosed with VAP by BAL. Conclusions Compared with strict bacteriologic criteria for VAP, the NNIS definition has good overall agreement and seems to have utility as an epidemiologic benchmarking tool in trauma patients. However, the NNIS definition has less utility as a bedside decision-making tool in this population, leading to under-treatment in a significant number of patients.

Background: Fracture of the thoracolumbar (TL) spine is reported in 8 to 15% of victims of blunt trauma. Current screening of these patients is done with conventional radiography. This may require repeated sets of films and take hours to days. It is imperative that these patients get timely, accurate evaluation to allow for treatment planning and early mobilization; alternatives to plain films would aid in this. The objective of this study is to determine whether the data obtained from admission chest/abdomen/pelvis (CAP) computed tomography (CT) scans after blunt trauma has utility in thoracolumbar spine evaluation Methods: The records of all patients admitted to a Level I trauma center over a 2-month period who underwent CAP CT were reviewed for the presence of TL spine fracture, time to completion of plain film evaluation, and clinical course. Admission CT scans were reviewed by an attending radiologist who was blinded to any previously diagnosed spine fractures. The two tests were compared for diagnostic accuracy and their discriminatory ability was compared using receiver operating characteristic (ROC) curves. Significance was defined as p < 0.05. Results: In all, 103 patients were admitted from January 1, 2003 to February 28, 2003 and underwent CAP CT scan as part of their initial trauma evaluation. Of these, 26 (25%) had thoracolumbar fractures. Seven (27%) thoracolumbar fractures were not seen on plain radiographs taken during the trauma evaluation. Average time until plain film completion in this group was 8 hours (range, 44 minutes to 38 hours). All 26 (100%) patients with fractures, however, were diagnosed on CT scan performed shortly after admission. Of the remaining 77 patients, two (2.6%) were falsely read as positive for fracture on CT. Sensitivity and specificity of CT scan for thoracolumbar fracture were excellent at 100% and 97%, respectively, with a negative predictive value of 100%. Plain radiographs were 73% sensitive, 100% specific, and had a negative predictive value of 92%. Area under the ROC curve for CT was 0.98, but for plain film was 0.86 (p < 0.02). Conclusion: Admission CAP CT obtained as part of the routine trauma evaluation in these high-risk patients is more sensitive than plain radiographs for evaluation of the TL spine after blunt trauma. In addition, CAP CT can be performed faster. Omission of plain radiographs will expedite accurate evaluation allowing earlier treatment and mobilization.

Cardiovascular dysfunction associated with the systemic inflammatory response syndrome (SIRS) is caused by a combination of decreased myocardial contractility and low vascular resistance. The contribution of each of these components can be determined at the bedside, and directed therapy can be appropriately initiated. Over an 8-month period of time, 23 consecutive patients who experienced posttraumatic SIRS while still being monitored with a volumetric pulmonary artery catheter (PAC) were prospectively evaluated. Ventricular pressure-volume diagrams were constructed to quantify myocardial contractility and afterload. In a resuscitation protocol, dobutamine was administered to patients with an isolated decrease in contractility, and dopamine or epinephrine was instituted for the combination of reduced contractility and afterload. Variables describing cardiovascular function were measured at the time of resolution of initial shock resuscitation (BASE), at the onset of SIRS (ONSET), and after administration of inotropic or vasoactive agents (TREAT). ONSET was associated with a significant decrease in left ventricular power (LVP) (362 +/- 96 to 235 +/- 55 mmHg.L/min/m(2), P0.00001) and stroke work index (SWI) (4670 +/- 1213 to 3060 +/- 848 mmHg.mL/m, P0.00001) from BASE. Sixteen patients (70%) demonstrated predominantly decreased contractility, which returned to near BASE values after the administration of dobutamine. The remaining seven patients (30%) had both decreased contractility and afterload, which was treated with dopamine or epinephrine. LVP and SWI significantly increased (235 +/- 55 to 328 +/- 77 mmHg.L/min/m(2), P0.00001, and 3060 +/- 848 to 4554 +/- 1423 mmHg.mL/m(2), P0.00001, respectively) on the initiation of directed therapy. Specific cardiovascular abnormalities can be identified at the bedside, and this information can guide pharmacologic management. Directed therapy improves cardiovascular function.

Pulmonary complications remain one of the leading causes of mortality in patients with burns. We report two cases of adult patients with thermal and inhalation injuries who were placed on extracorporeal membrane oxygenation (ECMO) and survived. Patient 1 was a 42-year-old male who suffered 15% TBSA and a severe inhalation injury requiring intubation upon arrival to the emergency department. Patient 2 was a 24-year-old female in a house fire who received 20%TBSA and was noted to be in respiratory distress and intubated on the scene by the paramedic team. Three days after admission, patient 1 developed severe respiratory failure. He decompensated, despite maximum conventional management, and was placed on ECMO. After 300 hours of ECMO, his pulmonary function had improved, and he was decannulated. Patient 2 also developed severe refractory respiratory failure and was placed on ECMO. She was decannulated 288 hours later. Both patients were discharged home shortly afterwards and have managed well. ECMO should be considered when patients are facing a respiratory death from inhalation injury on conventional mechanical ventilation.

Background: The use of quantitative cultures of the bronchoalveolar lavage (BAL) effluent to distinguish between posttraumatic inflammatory response and ventilator-associated pneumonia (VAP) is becoming more common. However, the diagnostic threshold of either 10 4 or 10 5 colonies/mL remains debatable. Because mortality from VAP is related to treatment delay, some have chosen a lower diagnostic threshold (≥10 4 colonies/mL). This may result in unnecessary antibiotic use with its sequelae: increased resistant organisms, antibiotic-related complications, and increased costs. The purpose of this study is to determine the optimal diagnostic threshold for VAP diagnosis using quantitative cultures of the BAL effluent. Methods: Data on patients with fiberoptic bronchoscopy with BAL are maintained in a prospectively collected database at our Level I trauma center. This database was reviewed for timing and frequency of BAL and the colony counts of each organism identified. Indication for bronchoscopy was clinical evidence of VAP. VAP was defined as ≥10 5 colonies/mL in the BAL effluent. A false-negative BAL was defined as any patient who had < 105 colonies/mL and developed VAP with the same organism up to 7 days after the previous culture. Results: Over a 46-month period, 526 patients underwent 1,372 fiberoptic bronchoscopy procedures with BAL. Of these, 72% were male patients, 91% followed blunt injury, and mean age and Injury Severity Score were 43 years and 30, respectively. Overall mortality was 14%. There were 1,898 organisms identified (42% were gram-positive and 58% were gram-negative). VAP was diagnosed in 38% of BAL. Overall, there were 43 episodes in 38 patients defined as false-negative (3%). The false-negative rate was 9% in patients with 10 4 organisms. The most common false-negative organisms were Pseudomonas and Acinetobacter species. Conclusion: The VAP diagnostic threshold for quantitative BAL in trauma patients should be ≥10 5 colonies/mL. One may consider a threshold of ≥10 4 colonies/mL in severely injured patients with Pseudomonas or Acinetobacter species.

Background: Identification of ventilator-associated pneumonia (VAP) with invasive methods such as bronchoalveolar lavage (BAL) paired with treatment is associated with improved mortality. Inappropriate antibiotic use, however, is known to increase bacterial resistance, making future treatment problematic. Thus, the diagnostic threshold for VAP in BAL must yield adequate sensitivity while limiting exposure of patients to unnecessary antibiotics. Our institution uses a cutoff of ≥ 10 5 colony-forming units (CFUs)/mL, but the optimal cutoff remains an area of debate. In this project, the effects of lower diagnostic cutoffs on VAP diagnosis and unnecessary antibiotic use are examined. Methods: Records of all patients admitted to the trauma intensive care unit over a 2-year period requiring > 48 hours of mechanical ventilation were reviewed. Number of BALs, quantity of organism on each BAL, and presence of VAP (≥ 10 5 CFUs/mL) were noted. Indication for BAL was pulmonary infiltrate, sepsis syndrome, and C-reactive protein > 17 μg/dL at ≥ 48 hours after admission. Results: From January 1, 2000, to December 31, 2001, 563 patients were admitted to the trauma intensive care unit. Two hundred fifty-seven required > 48 hours of mechanical ventilation, and 257 BALs were performed in 168 (65%) of these patients. One hundred thirty-nine episodes of VAP occurred in 109 (42%) patients. Subdiagnostic quantities of bacteria (≥ 10 2 but < 10 5 CFUs/mL) were seen in 98 BALs. Of these, only 16 (16%) episodes of VAP with the same organism were seen later during hospitalization. At a threshold of ≥ 10 4 CFUs/mL, 4 of 28 (14%) patients went on to develop pneumonia. A similar pattern was seen at diagnostic thresholds of ≥ 10 3 CFUs/mL (10 of 72 [14%]) and ≥ 10 2 CFUs/mL (16 of 98 [16%]). Conclusion: A threshold of ≥ 10 5 CFUs/mL for VAP diagnosis carries a low false-negative rate. Over 80% of additional patients who would have been treated had a threshold of ≥ 10 4 CFUs/mL been used recovered without treatment and thus would have undergone unnecessary antibiotic exposure. A similar pattern is seen at all lower thresholds. Lower diagnostic thresholds would lead to marginal increase in sensitivity, and many would receive unnecessary VAP treatment with potential for increasing bacterial resistance.

Background: Bleeding pelvic fractures (BPF) carry mortality as high as 60%, yet controversy remains over optimal initial management. Some base initial intervention on fracture pattern, with immediate external fixation (EX FIX) in amenable fractures aimed at controlling venous bleeding. Others feel ongoing hemodynamic instability indicates arterial bleeding, and prefer early angiography (ANGIO) before EX-FIX. Our aim was to evaluate markers of arterial bleeding in patients with BPF, thus identifying patients requiring early ANGIO regardless of fracture pattern. Methods: Patients with pelvis fracture were identified from a Level I trauma center registry over a 7-year period and records reviewed. From this group, two subsets were analyzed: those with initial hypotension related to pelvic fracture, and those without hypotension who underwent pelvic ANGIO. Data included hemodynamics, response to resuscitation, presence of contrast blush on CT, fracture treatment and outcome. Adequate response to initial resuscitation (R) was defined as a sustained (>2 hours) improvement of systolic blood pressure to >90 mm Hg systolic after the administration of ≤2 units packed red blood cells. Those with repeated episodes of hypotension despite resuscitation were classified as non-responders (NR) Results: From 1/94-1/01, 1171 patients were admitted with pelvic ring fracture. Thirty-five (0.3%) had hypotension attributable to pelvis fracture. 28 fell into the NR group, and 26 of these underwent ANGIO. Nineteen (73%) showed arterial bleeding while 3 resuscitation response patients underwent ANGIO with none demonstrating bleeding (p = 0.03). Sensitivity and specificity of inadequate response to initial resuscitation for predicting the presence of arterial bleeding on ANGIO were 100% and 30% respectively while negative and positive predictive value were 100% and 73%. In patients with fractures amenable to external fixation (n = 16), 44% had arterial bleeding on ANGIO, and all were in the NR group. An additional 17 patients without hypotension also underwent ANGIO. Contrast blush on admission CT was seen in 4, 3 of which had arterial bleeding seen on ANGIO (75%). Sensitivity and specificity for contrast blush in predicting bleeding on ANGIO were 60% and 92% with positive and negative predictive value being 75% and 85%. Conclusions: In patients with hypotension and pelvic fracture, therapy selection based on initial response to resuscitation in BPF yields a 73% positive ANGIO rate in NR patients. Delay in ANGIO for EX FIX in patients with amenable fractures would have delayed embolization in the face of ongoing arterial bleeding in 44% of patients. In stable patients with pelvic fracture, contrast blush also indicates a high likelihood of arterial injury and ANGIO is indicated. Optimal therapy in the face of BPF requires early determination of the presence of arterial bleeding so that ANGIO can be rapidly obtained, and response to initial resuscitation as well as the presence of contrast blush aid in this decision.

Background: The use of open abdomen techniques in damage control laparotomy and abdominal compartment syndrome has led to development of several methods of temporary abdominal closure. All of these methods require creation of a planned hernia with later reconstruction in patients unable to undergo fascial closure in the early postoperative period. We review a method of late primary fascial closure, thus eliminating the need for delayed reconstruction in some patients. Methods: The records of all patients managed with open abdomens over a 5-year period at a Level I trauma center were reviewed for injury characteristics, operative treatment, final abdominal closure type and timing, and outcome. Patients requiring open abdomen who were unable to undergo fascial closure in the early postoperative period were managed with a vacuum-assisted fascial closure (VAFC) technique. This allows for constant tension on the wound edges and facilitates late fascial closure. Patients managed with planned hernia (HERNIA group) were compared with those undergoing fascial closure ≥ 9 days after initial laparotomy (LATE group) for injury severity, fistula rate, and mortality. All patients in the LATE group underwent VAFC. Results: From September 1996 to October 2001, 148 patients required management with an open abdomen. Fifty-nine underwent fascial closure, 37 of these before postoperative day 9 and 22 on or after day 9. Mean time to closure in the LATE group was 21 days (range, 9-49 days). Injury Severity Scores were similar in the HERNIA and LATE groups (26 vs. 30, p = 0.28), as were admission base deficit (-8.8 vs. -9.5, p = 0.71), number of fistulas (1 vs. 0, p = 0.99), and mortality (17% vs. 14%, p = 0.99). Conclusion: VAFC enables late fascial closure in open abdomen patients up to a month after initial laparotomy. Complication rates do not differ from patients with planned hernia, and the need for future abdominal wall reconstruction is avoided

Background: Efficacy of circulation depends on interactions between the heart and the vascular system. Ventricular-arterial coupling (VAC) has been described as an important determinant of cardiovascular function during resuscitation from shock. However, no prospective studies examining VAC and systemic perfusion have been performed. VAC is measured by the ratio of afterload (aortic input impedance [E a ]) to contractility (end-systolic elastance [E es ]). Lowering E a /E es is associated with better VAC and improved myocardial work efficiency. Our hypothesis was that optimizing VAC during resuscitation results in improved myocardial work efficiency while simultaneously improving systemic perfusion. Methods: This was a prospective study in a consecutive series of critically injured patients. Hemodynamic variables, including E a , E es , and myocardial work efficiency were evaluated by constructing ventricular pressure-volume loops at the bedside during resuscitation. After pulmonary artery catheterization and adequate fluid resuscitation, left ventricular power output and E a /E es were optimized with inotropic agents and/or afterload reduction. Efficiency was calculated as stroke work/total left ventricular energy expenditure. Tissue perfusion was estimated by calculating base deficit clearance per hour. Results: Twenty-three patients were studied over a 9-month period. Fifteen patients required inotropic support or afterload reduction. Improvements were seen in E a /E es (from 1.0 ± 0.4 to 0.6 ± 0.2 mm Hg/mL/m 2 , p = 0.0004), and left ventricular power output (from 280 ± 77 to 350 ± 81 L/min/m 2 . mm Hg, p = 0.003) with resuscitation. A concomitant improvement in myocardial efficiency (from 70% ± 8.0% to 77% ± 5.0%, p = 0.0001) and base deficit clearance (from 0.1 ± 0.4 to -0.2 ± 0.1 mEq/L/h, p = 0.006) was seen. Conclusion: Improved ventricular-arterial coupling during resuscitation is associated with improved myocardial efficiency and systemic tissue perfusion. Perfusion can be improved at lower energy cost to the heart by focusing on thermodynamic principles during resuscitation.

Placental abruption (PA) is a common cause of fetal demise in pregnant trauma patients. Diagnosis of PA may be difficult, and multiple diagnostic clues are currently used including uterine/abdominal pain and tenderness, bleeding, maternal hemodynamic instability, and evidence of PA by ultrasonography or other fetal monitoring. Although diagnosis may be problematic fetal and maternal survival are dependent on early diagnosis and intervention. The purpose of this study is to determine predictive factors present at admission associated with PA in trauma victims. Records of all pregnant trauma patients admitted to Wake Forest University Baptist Medical Center over a 5-year period were reviewed for injury characteristics and outcome. Inclusion criteria included a confirmed pregnancy and fetal disposition. Specific admission parameters evaluated included temperature, heart rate, systolic blood pressure, partial pressure of CO2 in arterial blood, total white blood cell count (WBC) and differential, hematocrit, base deficit, and lactic acid. PA is defined as a spontaneous abortion in the first trimester or abruptio placenta in the second or third trimester. Between April 1, 1996 and October 30, 2000, 30 patients met study criteria. Six of 30 patients were found to have PA (20%). Of the studied parameters WBC was significantly elevated in PA patients (27 +/- 4.6 vs 17 +/- 7.8 WBC x 10(3)/mm3; P = 0.005) as was band count (10 +/- 6.6% vs 4 +/- 6.1%; P = 0.03). Hematocrit was lower in the PA group (27 +/- 4.3% vs 32 +/- 5.4%; P = 0.04). Within this group of variables which differed on univariate analysis, WBC was the best discriminator between patients with and without PA (sensitivity 100%, specificity 79%, negative predictive value 100%, and positive predictive value 54%). In pregnant trauma patients WBC20,000/mm3 on admission should raise suspicion of the possibility of PA, and close monitoring is warranted. Conversely WBC20,000/mm3 rules out PA in the pregnant trauma patient (negative predictive value of 100%).

Increased intra-abdominal pressure (IAP) is an adverse complication seen in critically ill, injured, and postoperative patients. IAP is estimated via the measurement of bladder pressure. Few studies have been performed to establish the actual relationship between IAP and bladder pressure. The purpose of this study was to confirm the association between intravesicular pressure and IAP and to determine the bladder volume that best approximates IAP.Thirty-seven patients undergoing laparoscopy had intravesicular pressures measured with bladder volumes of 0, 50, 100, 150, and 200 mL at directly measured intra-abdominal pressures of 0, 5, 10, 15, 20, and 25 mm Hg. Correlation coefficients and differences were then determined.Across the IAP range of 0 to 25 mm Hg using all of the tested bladder volumes, the difference between IAP and intravesicular pressures (bias) was -3.8 +/- 0.29 mm Hg (95% confidence interval) and measurements were well correlated (R2 = 0.68). Assessing all IAPs tested, a bladder volume of 0 mL demonstrated the lowest bias (-0.79 +/- 0.73 mm Hg). When considering only elevated IAPs (25 mm Hg), a bladder volume of 50 mL revealed the lowest bias (-1.5 +/- 1.36 mm Hg). A bladder volume of 50 mL in patients with elevated IAP resulted in an intravesicular pressure 1 to 3 mm Hg higher than IAP (95% confidence interval).Intravesicular pressure closely approximates IAP. Instillation of 50 mL of liquid into the bladder improves the accuracy of the intravesicular pressure in measuring elevated IAPs.

Background: Systemic inflammatory response syndrome (SIRS) is common in trauma patients, and infection represents an important and treatable source of SIRS. C-Reactive protein (CRP), an acute phase protein, is elevated in infection and discriminates between infected and uninfected patients in other patient populations. Our goal was to examine the ability of CRP and other commonly used markers of infection (maximum temperature [Tmax], and white blood cell count [WBC]) to distinguish between infectious and noninfectious causes of SIRS. Methods: This was a prospective study of consecutive series of trauma patients who spent greater than 48 hours in the intensive care unit. Studied variables included CRP, Tmax, WBC, and culture-proven infection compared with standard definitions of infection and the presence of SIRS. The ability of these variables to correctly classify patients as infected (INF) or not infected was examined by using receiver operating characteristic curves. Values on the day of infection diagnosis in the INF group and on postadmission day 5 (the mean day of onset of infection in the INF group) in the not infected group were used. Multivariate discriminant analysis was used to examine the relative contributions of Tmax and CRP in predicting infection. Significance was defined as p < 0.05. Results: Fifty-nine patients were admitted over a 4-month period. Of these, 35 patients (59%) had SIRS at the time of comparison (29 INF, 6 not infected). Thirty-three patients (56%) developed an infection. Both CRP and Tmax discriminated between patients with and without infection whereas WBC did not (areas under receiver operating characteristic curve: 0.86, 0.81, and 0.47, respectively). In patients with SIRS, cutoff values of 17 mg/dL for CRP (specificity 100%) and 102°F for Tmax (specificity 83%) were identified. CRP added significant discriminatory power to Tmax in determining presence of infection in patients with SIRS (p = 0.003). Conclusion: Infection must be presumed to be the source of SIRS in patients with CRP more than 17 mg/dL and Tmax more than 102°F after postinjury day 4. WBC is not useful in determining the presence of infection.

Objectives: (1) To compare left ventricular stroke work index (SW) and left ventricular power output (LVP), hemodynamic variables that encompass blood pressure as well as blood flow, with the purely flow-derived hemodynamic and oxygen transport variables as markers of perfusion and outcome in critically injured patients during resuscitation. (2) To use the ventricular pressure-volume diagram to define characteristic hemodynamic patterns in the determinants of SW and LVP that are associated with survival. Methods: This was a cohort study at a university Level I trauma center during the course of I year. A consecutive series of patients was monitored with a volumetric pulmonary artery catheter during the initial 48 hours of resuscitation. Heart rate, SW, LVP, cardiac index, and oxygen delivery and consumption during resuscitation were compared using multivariate logistic regression analysis with regard to the ability to clear lactate in less than 24 hours and survival. Receiver operating characteristic curves were constructed to determine threshold values for SW and LVP. Ventricular pressure-volume diagrams were used to describe characteristic patterns in the determinants of SW and LVP in survivors and nonsurvivors. Preload was expressed as left ventricular end-diastolic volume index, afterload as aortic input impedance (E a ), and contractility as ventricular end-systolic elastance (E es ). The ratio of E a /E es (RATIO) was used as a measure of ventricular-arterial coupling, which describes the efficacy of energy transfer from the heart to the vascular system. Results: One hundred eleven patients (87 survivors, 24 nonsurvivors) met study criteria. Survivors had a significantly higher SW (4,510 ± 1,070 vs. 3,440 ± 980 mm Hg.mL.m -2 ; p < 0.0001) and LVP (370 ± 94 vs. 270 ± 81 mm Hg.L.min -1 .m -2 ; p < 0.0001) than nonsurvivors. Heart rate, SW, and LVP were the only studied variables that were significantly related to lactate clearance and survival by logistic regression. Threshold values determined by the receiver operating characteristic curves were 4,000 mm Hg.mL.m -2 for SW and 320 mm Hg.L.min -1 .m -2 for LVP. Survivors had better ventricular-arterial coupling than nonsurvivors, indicated by a lower RATIO (0.32 ± 0.22 vs. 0.54 ± 0.38; p = 0.003). This lower RATIO was attributable to lower levels of E a (2.7 ± 0.7 vs. 3.4 ± 0.8 mm Hg.mL -1 .m -2 ; p = 0.0003) and a trend toward higher levels of E es (13 ± 11 vs. 9.9 ± 7.3 mm Hg.mL -1 .m -2 ; p = 0.12). Conclusion: Thermodynamic perfusion variables that encompass both pressure and flow, such as SW and LVP, are more closely related to perfusion and outcome than the purely flow-derived variables. The higher SW and LVP in survivors is related to better ventricular-arterial coupling, and therefore more efficient cardiac function. Cutoff values for LVP of 320 mm Hg.L.min -1 .m -2 and for SW of 4,000 mm Hg.mL.m -2 may be useful thresholds for evaluating hemodynamic performance during resuscitation.

Increased intra-abdominal pressure (IAP) compromises cardiopulmonary function and visceral perfusion. Our goal was to characterize acute changes in these subsystems associated with operative abdominal decompression.A series of 11 consecutive injured patients monitored with a pulmonary artery catheter and nasogastric tonometer in whom operative decompression was performed. Indications for decompression included oliguria or progressive acidosis despite aggressive resuscitation in the presence of elevated IAP (25 mm Hg).Studied hemodynamic variables included pulmonary artery occlusion pressure (PAOP), right ventricular end-diastolic volume index (RVEDVI), and cardiac index (CI). Pulmonary variables included shunt fraction (Qs/Qt) and dynamic compliance (Cdyn). Visceral perfusion was assessed using hourly urine output 4 hours before and after decompression (UOP) and gastric intramucosal pH (pHi). Mean values before and after decompression were compared using the paired t test. Linear regression and Fisher's z transformation were used to evaluate the relationships between RVEDVI, PAOP, CI, and IAP. IAP was transduced via bladder pressures. Significance was defined as p0.05. Data are expressed as means+/-SD.IAP decreased with decompression (49+/-11 to 19+/-6.8 mm Hg; p0.0001). RVEDVI improved independent of CI and correlated better (p0.01) with CI (r =0.49, p=0.04) than PAOP did (r=-0.36, p=0.09). PAOP correlated significantly with IAP (r=0.45, p=0.04). Decompression resulted in significant improvements in Qs/Qt, Cdyn, UOP, and pHi.Abdominal decompression in patients with increased IAP improves preload, pulmonary function, and visceral perfusion. Elevated IAP has important effects on PAOP, which makes the PAOP an unreliable index of preload in these patients.

Assessment of splanchnic perfusion by gastric intramucosal pH (pHi) adds to the information provided by systemic indicators of oxygen transport.University Hospital level I trauma center.Prospective study in 20 critically ill trauma patients comparing pHi with base deficit, lactate, oxygen delivery, and oxygen consumption (indexed to body surface area), mixed venous oxygen saturation (Svo2), oxygen utilization coefficient, and arterial pH. All measurements were obtained at admission, 1, 2, 4, 8, 16, and 24 hours, or at death.Correlation of pHi with the measured systemic variables, prediction of organ dysfunction, development of multiple organ dysfunction syndrome, and mortality.There was a poor correlation between pHi and the systemic hemodynamic and oxygen transport variables. Patients with a low pHi (7.32) on admission who did not correct within the initial 24 hours had a higher mortality (50% vs. 0.0%, p = 0.03) and incidence of organ dysfunction (2.6 organs/patient vs. 0.62 organs/patient, p = 0.02) than those who did. Using logistic regression analysis, only pHi, base deficit, and Svo2 were significantly associated with mortality during the study period. At 24 hours, only pHi was different between patients who developed multiple organ dysfunction syndrome and those who did not. There was a threshold value for pHi (7.10) which identified those patients who would go on to develop multiple organ dysfunction syndrome.Uncorrected splanchnic malperfusion is associated with a higher incidence of organ dysfunction and mortality. Gastric tonometry supplements information provided by systemic indicators of oxygen transport during resuscitation of critically ill trauma patients.

Delta-9-tetrahydrocannabinol ((-)delta 9 THC), the primary psychoactive cannabinoid in marihuana, reduces the fertilizing capacity of sea urchin sperm by blocking the acrosome reaction that normally is stimulated by a specific ligand in the egg's jelly coat. The bicyclic synthetic cannabinoid [3H]CP-55,940 has been used as a ligand to demonstrate the presence of a cannabinoid receptor in mammalian brain. We now report that [3H]CP-55,940 binds to live sea urchin (Strongylocentrotus purpuratus) sperm in a concentration, sperm density, and time-dependent manner. Specific binding of [3H]CP-55,940 to sperm, defined as total binding displaced by (-)delta 9THC, was saturable: KD 5.16 +/- 1.02 nM; Hill coefficient 0.98 +/- 0.004. This suggests a single class of receptor sites and the absence of significant cooperative interactions. Sea urchin sperm contain 712 +/- 122 cannabinoid receptors per cell. Binding of [3H]CP-55,940 to sperm was reduced in a dose-dependent manner by increasing concentrations of CP-55,940, (-)delta 9THC, and (+)delta 9THC. The rank order of potency to inhibit binding of [3H]CP-55,940 to sperm and to block the egg jelly stimulated acrosome reaction was: CP-55,940 > (-)delta 9THC > (+)delta 9THC. These findings show that sea urchin sperm contain a stereospecific cannabinoid receptor that may play a role in inhibition of the acrosome reaction. The radioligand binding data obtained with live sea urchin sperm are remarkably similar to those previously published by other investigators using [3H]CP-55,940 on mammalian brain and nonneural tissues. The cannabinoid binding properties of this receptor appear to have been highly conserved during evolution. We postulate that the cannabinoid receptor may modulate cellular responses to stimulation.

Delta-9-tetrahydrocannabinol (THC), cannabidiol (CBD), and cannabinol (CBN) inhibit fertilization in the sea urchin Strongylocentrotus purpuratus by reducing the fertilizing capacity of the sperm. Sperm fertility depends upon their motility, and their capacity to undergo the acrosome reaction upon encountering a specific ligand derived from the egg's jelly coat. The acrosome reaction involves exocytosis of the acrosomal granule at the apex of the sperm head and elongation of the acrosomal filament. This process exposes the sperm membrane that will attach to and fuse with the egg. Pretreatment of sperm with THC prevents the triggering of the acrosome reaction by solubilized egg jelly in a dose and time dependent manner. Motility of THC-treated sperm is not reduced compared to control sperm in sea water or vehicle dissolved in sea water. The adverse effects of THC on the acrosome reaction and sperm-fertilizing capacity are reversible. Studies with ionophores suggest that THC blocks the acrosome reaction by affecting event(s) in the stimulation-secretion coupling mechanism in the sperm preceding the opening of ion channels. Ultrastructural studies show that THC, CBD and CBN block the membrane fusion reaction between the sperm's plasma membrane and the acrosomal membrane that normally is elicited in response to stimulation by egg jelly to initiate the acrosome reaction. However, lipid deposits are found in the subacrosomal and centriolar fossae of cannabinoid treated sperm. The nuclear envelope is fragmented in close proximity to the lipid deposits within the subacrosomal fossa. These morphological observations suggest that cannabinoids may activate phospholipase(s) within the sperm. Biochemical studies show that THC activates phospholipase A2 activity in sperm homogenates.(ABSTRACT TRUNCATED AT 250 WORDS)

Δ9-Tetrahydrocannabinol (THC) and two other major cannabinoids derived from marihuana–cannabidiol (CBD) and cannabinol (CBN)–inhibit fertilization in the sea urchin Strongylocentrotus purpuratus by reducing the fertilizing capacity of sperm (Schuel et al., 1987). Sperm fertility depends on their motility and on their ability to undergo the acrosome reaction upon encountering the egg's jelly coat. Pretreatment of S. purpuratus sperm with THC prevents triggering of the acrosome reaction by solubilized egg jelly in a dose (0.1–100 μM) and time (0–5 min)-dependent manner. Induction of the acrosome reaction is inhibited in 88.9±2.3% of sperm pretreated with 100 μM THC for 5 min, while motility of THC-treated sperm is not reduced compared to solvent (vehicle) and seawater-treated controls. The acrosome reaction is inhibited 50% by pretreatment with 6.6 μM THC for 5 min and with 100 μM THC after 20.8 sec. CBN and CBD at comparable concentrations inhibit the acrosome reaction by egg jelly in a manner similar to THC. THC does not inhibit the acrosome reaction artificially induced by ionomycin, which promotes Ca2+ influx, and nigericin, which promotes K+ efflux. THC partially inhibits (20–30%) the acrosome reaction induced by A23187, which promotes Ca2+ influx, and NH4OH, which raises the internal pH of the sperm. Addition of monensin, which promotes Na+ influx to egg jelly or to A23187, does not overcome the THC inhibition. Inhibition of the egg jelly-induced acrosome reaction by THC produces a corresponding reduction in the fertilizing capacity of the sperm. The adverse effects of THC on the acrosome reaction and sperm fertility are reversible. These findings show that cannabinoids reduce the fertilizing capacity of sea urchin sperm by inhibiting the induction of the acrosome reaction by egg jelly. THC may affect events in the stimulus–secretion coupling mechanism before the opening of ion channels.

To evaluate the utility of the right ventricular end-diastolic volume index (RVEDVI) as a method of preload assessment in trauma patients during large-volume shock resuscitation, and to compare the RVEDVI with the pulmonary artery occlusion pressure (PAOP) as a predictor of preload in this patient population.Retrospective study of a consecutive series of 46 trauma patients, admitted between June 1, 1992, and June 1, 1993, who received a volumetric oximetry pulmonary artery catheter and greater than 10 L of fluid in 24 hours.University level 1 trauma center.Correlations of the RVEDVI and PAOP with the cardiac index (CI) during the defined study period.Three hundred fourteen measurements of the RVEDVI, PAOP, CI, and other hemodynamic variables were evaluated. Patients received a mean +/- SD of 22.1 +/- 13.3 L of blood and fluid during the 24 hours. The RVEDVI correlated better (P.001) with the CI (r = 0.39) than did the PAOP (R = 0.05). Furthermore, there was a better correlation (P.04) between the RVEDVI and CI when the RVEDVI was 130 mL/m2 or less (r = 0.54) than when it was greater than 130 mL/m2 (r = 0.30).The RVEDVI is a better predictor of preload than the PAOP in trauma patients during large-volume shock resuscitation. When the RVEDVI is 130 mL/m2 or less, volume administration will likely increase the CI.