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Background: Platelets play a central role in hemostasis after trauma. However, the platelet count of most trauma patients does not fall below the normal range (100-450 × 10(9)/L), and as a result, admission platelet count has not been adequately investigated as a predictor of outcome. The purpose of this study was to examine the relationship between admission platelet count and outcomes after trauma., Methods: A retrospective cohort study of 389 massively transfused trauma patients. Regression methods and the Kruskal-Wallis test were used to test the association between admission platelet count and 24-hour mortality and units of packed red blood cells (PRBCs) transfused., Results: For every 50 × 10(9)/L increase in admission platelet count, the odds of death decreased 17% at 6 hours (p = 0.03; 95% confidence interval [CI], 0.70-0.99) and 14% at 24 hours (p = 0.02; 95% CI, 0.75-0.98). The probability of death at 24 hours decreased with increasing platelet count. For every 50 × 10(9)/L increase in platelet count, patients received 0.7 fewer units of blood within the first 6 hours (p = 0.01; 95% CI, -1.3 to -0.14) and one less unit of blood within the first 24 hours (p = 0.002; 95% CI, -1.6 to -0.36). The mean number of units of PRBCs transfused within the first 6 hours and 24 hours decreased with increasing platelet count., Conclusions: Admission platelet count was inversely correlated with 24-hour mortality and transfusion of PRBCs. A normal platelet count may be insufficient after severe trauma, and as a result, these patients may benefit from a lower platelet transfusion threshold. Future studies of platelet number and function after injury are needed.

Background: Current trauma resuscitation guidelines recommend giving an initial crystalloid bolus as first line for resuscitation. Recent studies have shown a survival benefit for trauma patients resuscitated with high ratios of fresh frozen plasma (FFP) to packed red blood cells (PRBC). Our aim was to determine whether the volume of crystalloid given during resuscitation correlated with differences in morbidity or mortality based on the ratio of FFP:PRBC given., Methods: This was a retrospective review of 2,473 transfused trauma patients at 23 Level I trauma centers from July 2005 to October 2007. Patients were separated based on the ratios of FFP:PRBC they received (<1:4, 1:4-1:1, and >1:1) and then analyzed for morbidity and mortality based on whether or not they received at least 1 L crystalloid for each unit of PRBC. Outcomes analyzed were 6-hour, 24-hour, and 30-day survival as well as intensive care unit (ICU)-free days, ventilator-free days, and hospital-free days., Results: Massive transfusion patients who received <1:4 ratios of FFP:PRBC had significantly improved 6-hour, 24-hour, and 30-day mortality and significantly more ventilator-free days if they received at least 1 L of crystalloid for each unit of PRBC. Nonmassive transfusion patients who received <1:4 ratios of FFP:PRBC had significantly improved 6-hour, 24-hour, and 30-day mortality and significantly more ICU-free days, ventilator-free days, and hospital-free days if they received at least 1 L crystalloid for each unit of PRBC. In both massive and nonmassive transfusion groups, the survival benefit and morbidity benefit was progressively less for the 1:4 to 1:1 FFP:PRBC groups and >1:1 FFP:PRBC groups., Conclusions: If high ratios of FFP:PRBC are unable to be given to trauma patients, resuscitation with at least 1 L of crystalloid per unit of PRBC is associated with improved overall mortality.

Background: Recent data suggest that massively transfused patients have lower mortality rates when high ratios (>1:2) of plasma or platelets to red blood cells (RBCs) are used. Blunt and penetrating trauma patients have different injury patterns and may respond differently to resuscitation. This study was performed to determine whether mortality after high product ratio massive transfusion is different in blunt and penetrating trauma patients., Methods: Patients receiving 10 or more units of RBCs in the first 24 hours after admission to one of 23 Level I trauma centers were analyzed. Baseline physiologic and biochemical data were obtained. Univariate and logistic regression analyses were performed. Adjusted mortality in patients receiving high (≥ 1:2) and low (<1:2) ratios of plasma or platelets to RBCs was calculated for blunt and penetrating trauma patients., Results: The cohort contained 703 patients. Blunt injury patients receiving a high ratio of plasma or platelets to RBCs had lower 24-hour mortality (22% vs. 31% for plasma, p = 0.007; 20% vs. 30% for platelets, p = 0.032), but there was no difference in 30-day mortality (40% vs. 44% for plasma, p = 0.085; 37% vs. 44% for platelets, p = 0.063). Patients with penetrating injuries receiving a high plasma:RBC ratio had lower 24-hour mortality (21% vs. 37%, p = 0.005) and 30-day mortality (29% vs. 45%, p = 0.005). High platelet:RBC ratios did not affect mortality in penetrating patients., Conclusion: Use of high plasma:RBC ratios during massive transfusion may benefit penetrating trauma patients to a greater degree than blunt trauma patients. High platelet:RBC ratios did not benefit either group.

Background: Administration of high transfusion ratios in patients not requiring massive transfusion might be harmful. We aimed to determine the effect of high ratios of fresh frozen plasma (FFP) and platelets (PLT) to packed red blood cells (PRBC) in nonmassively transfused patients., Methods: Records of 1,788 transfused trauma patients who received <10 units of PRBC in 24 hours at 23 United States Level I trauma centers were reviewed. The relationship between ratio category (low and high) and in-hospital mortality was assessed with propensity-adjusted multivariate proportional hazards models., Results: At baseline, patients transfused with a high FFP:PRBC ratio were younger, had a lower Glasgow Coma Scale score, and a higher Injury Severity Score. Those receiving a high PLT:PRBC ratio were older. The risk of in-hospital mortality did not vary significantly with FFP:PRBC ratio category. Intensive care unit (ICU)-free days, hospital-free days, and ventilator-free days did not vary significantly with FFP:PRBC ratio category. ICU-free days and ventilator-free days were significantly decreased among patients in the high (≥1:1) PLT:PRBC category, and hospital-free days did not vary significantly with PLT:PRBC ratio category. The analysis was repeated using 1:2 as the cutoff for high and low ratios. Using this cutoff, there was still no difference in mortality with either FFP:PRBC ratios or platelet:PRBC ratios. However, patients receiving a >1:2 ratio of FFP:PRBCs or a >1:2 ratio PLT:PRBCs had significantly decreased ICU-free days and ventilator-free days., Conclusions: FFP:PRBC and PLT:PRBC ratios were not associated with in-hospital mortality. Depending on the threshold analyzed, a high ratio of FFP:PRBC and PLT:PRBC transfusion was associated with fewer ICU-free days and fewer ventilator-free days, suggesting that the damage control infusion of FFP and PLT may cause increased morbidity in nonmassively transfused patients and should be rapidly terminated when it becomes clear that a massive transfusion will not be required.

Background: The Injury Severity Score (ISS) is widely used as a method for rating severity of injury. The ISS is the sum of the squares of the three worst Abbreviated Injury Scale (AIS) values from three body regions. Patients with penetrating injuries tend to have higher mortality rates for a given ISS than patients with blunt injuries. This is thought to be secondary to the increased prevalence of multiple severe injuries in the same body region in patients with penetrating injuries, which the ISS does not account for. We hypothesized that the mechanism-based difference in mortality could be attributed to certain ISS ranges and specific AIS values by body region., Methods: Outcome and injury scoring data were obtained from transfused patients admitted to 23 Level I trauma centers. ISS values were grouped into categories, and a logistic regression model was created. Mortality for each ISS category was determined and compared with the ISS 1 to 15 group. An interaction term was added to evaluate the effect of mechanism. Additional logistic regression models were created to examine each AIS category individually., Results: There were 2,292 patients in the cohort. An overall interaction between ISS and mechanism was observed (p = 0.049). Mortality rates between blunt and penetrating patients with an ISS between 25 and 40 were significantly different (23.6 vs. 36.1%; p = 0.022). Within this range, the magnitude of the difference in mortality was far higher for penetrating patients with head injuries (75% vs. 37% for blunt) than truncal injuries (26% vs. 17% for blunt). Penetrating trauma patients with an AIS head of 4 or 5, AIS abdomen of 3, or AIS extremity of 3 all had adjusted mortality rates higher than blunt trauma patients with those values., Conclusion: Significant differences in mortality between blunt and penetrating trauma patients exist at certain ISS and AIS category values. The mortality difference is greatest for head injured patients.

Background: Improvements in trauma systems and resuscitation have increased survival in severely injured patients. Massive transfusion has been increasingly used in the civilian setting. Objective predictors of mortality have not been well described. This study examined data available in the early postinjury period to identify variables that are predictive of 24-hour- and 30-day mortality in massively transfused trauma patients., Methods: Massively transfused trauma patients from 23 Level I centers were studied. Variables available on patient arrival that were predictive of mortality at 24 hours were entered into a logistic regression model. A second model was created adding data available 6 hours after injury. A third model evaluated mortality at 30 days. Receiver operating characteristic curves and the Hosmer-Lemeshow test were used to assess model quality., Results: Seven hundred four massively transfused patients were analyzed. The model best able to predict 24-hour mortality included pH, Glasgow Coma Scale score, and heart rate, with an area under the receiver operating characteristic curve (AUROC) of 0.747. Addition of the 6-hour red blood cell requirement increased the AUROC to 0.769. The model best able to predict 30-day mortality included the above variables plus age and Injury Severity Score with an AUROC of 0.828., Conclusion: Glasgow Coma Scale score, pH, heart rate, age, Injury Severity Score, and 6-hour red blood cell transfusion requirement independently predict mortality in massively transfused trauma patients. Models incorporating these data have only a modest ability to predict mortality and should not be used to justify withholding massive transfusion in individual cases.

Background: Improvements in prehospital care and resuscitation have led to increases in the number of severely injured patients who are salvageable. Massive transfusion has been increasingly used. Patients often present with markedly abnormal physiologic and biochemical data. The purpose of this study was to identify objective data that can be used to identify clinical futility in massively transfused trauma patients to allow for early termination of resuscitative efforts., Methods: A multicenter database was used. Initial physiologic and biochemical data were obtained, and mortality was determined for patients in the 5th and 10th percentiles for each variable. Raw data from the extreme outliers for each variable were also examined to determine whether a point of excessive mortality could be identified. Injury scoring data were also analyzed. A classification tree model was used to look for variable combinations that predict clinical futility., Results: The cohort included 704 patients. Overall mortality was 40.2%. The highest mortality rates were seen in patients in the 10th percentile for lactate (77%) and pH (72%). Survivors at the extreme ends of the distribution curves for each variable were not uncommon. The classification tree analysis failed to identify any biochemical and physiologic variable combination predictive of >90% mortality. Patients older than 65 years with severe head injuries had 100% mortality., Conclusion: Consideration should be given to withholding massive transfusion for patients older than 65 years with severe head injuries. Otherwise we did not identify any objective variables that reliably predict clinical futility in individual cases. Significant survival rates can be expected even in patients with profoundly abnormal physiologic and biochemical data.

Background: Recent data suggest that patients undergoing massive transfusion have lower mortality rates when ratios of plasma and platelets to red blood cells (RBCs) of ≥ 1:2 are used. This has not been examined independently in women and men. A gender dichotomy in outcome after severe injury is known to exist. This study examined gender-related differences in mortality after high product ratio massive transfusion., Methods: A retrospective study was conducted using a database containing massively transfused trauma patients from 23 Level I trauma centers. Baseline demographic, physiologic, and biochemical data were obtained. Univariate and logistic regression analyses were performed. Adjusted mortality in patients receiving high (≥ 1:2) or low (<1:2) ratios of plasma or platelets to RBCs was compared in women and men independently., Results: Seven hundred four patients were analyzed. In males, mortality was lower for patients receiving a high plasma:RBC ratio at 24 hours (20.6% vs. 33.0% for low ratio, p = 0.005) and at 30 days (34.9% vs. 42.8%, p = 0.032). Males receiving a high platelet:RBC ratio also had lower 24-hour mortality (17.6% vs. 31.5%, p = 0.004) and 30-day mortality (32.1% vs. 42.2%, p = 0.045). Females receiving high ratios of plasma or platelets to RBCs had no improvement in 24-hour mortality (p = 0.119 and 0.329, respectively) or 30-day mortality (p = 0.199 and 0.911, respectively). Use of high product ratio transfusions did not affect 24-hour RBC requirements in males or females., Conclusion: Use of high plasma:RBC or platelet:RBC ratios in massive transfusion may benefit men more than women. This may be due to gender-related differences in coagulability. Further study is needed to determine whether separate protocols for women and men should be established.

Background: The effect of blood component ratios on the survival of patients with traumatic brain injury (TBI) has not been studied., Methods: A database of patients transfused in the first 24 hours after admission for injury from 22 Level I trauma centers over an 18-month period was queried to find patients who (1) met different definitions of massive transfusion (5 units red blood cell [RBC] in 6 hours vs. 10 units RBC in 24 hours), (2) received high or low ratios of platelets or plasma to RBC units (<1:2 vs. ≥ 1:2), and (3) had severe TBI (head abbreviated injury score ≥ 3) (TBI+)., Results: Of 2,312 total patients, 850 patients were transfused with ≥ 5 RBC units in 6 hours and 807 could be classified into TBI+ (n = 281) or TBI- (n = 526). Six hundred forty-three patients were transfused with ≥ 10 RBC units in 24 hours with 622 classified into TBI+ (n = 220) and TBI- (n = 402). For both high-risk populations, a high ratio of platelets:RBCs (not plasma) was independently associated with improved 30-day survival for patients with TBI+ and a high ratio of plasma:RBCs (not platelets) was independently associated with improved 30-day survival in TBI- patients., Conclusions: High platelet ratio was associated with improved survival in TBI+ patients while a high plasma ratio was associated with improved survival in TBI- patients. Prospective studies of blood product ratios should include TBI in the analysis for determination of optimal use of ratios on outcome in injured patients.

Background: Several recent military and civilian trauma studies demonstrate that improved outcomes are associated with early and increased use of plasma-based resuscitation strategies. However, outcomes associated with platelet transfusions are poorly characterized. We hypothesized that increased platelet:red blood cells (RBC) ratios would decrease hemorrhagic death and improve survival after massive transfusion (MT)., Methods: A transfusion database of patients transported from the scene to 22 Level I Trauma Centers over 12 months in 2005 to 2006 was reviewed. MT was defined as receiving ≥ 10 RBC units within 24 hours of admission. To mitigate survival bias, 25 patients who died within 60 minutes of arrival were excluded from analysis. Six random donor platelet units were considered equal to a single apheresis platelet unit. Admission and outcome data associated with the low (>1:20), medium (1:2), and high (1:1) platelet:RBC ratios were examined. These groups were based on the median value of the tertiles for the ratio of platelets:RBC units., Results: Two thousand three hundred twelve patients received at least one unit of blood and 643 received an MT. Admission vital signs, INR, temperature, pH, Glasgow Coma Scale, Injury Severity Score, and age were similar between platelet ratio groups. The average admission platelet counts were lower in the patients who received the high platelet:RBC ratio versus the low ratio (192 vs. 216, p = 0.03). Patients who received MT were severely injured, with a mean (± standard deviation) Injury Severity Score of 33 ± 16 and received 22 ± 15 RBCs and 11 ± 14 platelets within 24 hours of injury. Increased platelet ratios were associated with improved survival at 24 hours and 30 days (p < 0.001 for both). Truncal hemorrhage as a cause of death was decreased (low: 67%, medium: 60%, high: 47%, p = 0.04). Multiple organ failure mortality was increased (low: 7%, medium: 16%, high: 27%, p = 0.003), but overall 30-day survival was improved (low: 52%, medium: 57%, high: 70%) in the high ratio group (medium vs. high: p = 0.008; low vs. high: p = 0.007)., Conclusion: Similar to recently published military data, transfusion of platelet:RBC ratios of 1:1 was associated with improved early and late survival, decreased hemorrhagic death and a concomitant increase in multiple organ failure-related mortality. Based on this large retrospective study, increased and early use of platelets may be justified, pending the results of prospective randomized transfusion data.

Background: Coagulopathy is present in 25% to 38% of trauma patients on arrival to the hospital, and these patients are four times more likely to die than trauma patients without coagulopathy. Recently, a high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBCs) has been shown to decrease mortality in massively transfused trauma patients. Therefore, we hypothesized that patients with elevated International Normalized Ratio (INR) on arrival to the hospital may benefit more from transfusion with a high ratio of FFP:PRBC than those with a lower INR., Methods: Retrospective multicenter cohort study of 437 massively transfused trauma patients was conducted to determine whether the effect of the ratio of FFP:PRBC on death at 24 hours is modified by a patient's admission INR on arrival to the hospital. Contingency tables and logistic regression were used., Results: Trauma patients who arrived to the hospital with an elevated INR had a greater risk of death than those with a lower INR. However, as the ratio of FFP:PRBC transfused increased, mortality decreased similarly between the INR quartiles., Conclusions: The mortality benefit from a high FFP:PRBC ratio is similar for all massively transfused trauma patients. This is contrary to the current belief that only coagulopathic trauma patients benefit from a high FFP:PRBC ratio. Furthermore, it is unnecessary to determine whether INR is elevated before transfusing a high FFP:PRBC ratio. Future studies are needed to determine the mechanism by which a high FFP:PRBC ratio decreases mortality in all massively transfused trauma patients.

Background: Significant differences in outcomes have been demonstrated between Level I trauma centers. Usually these differences are ascribed to regional or administrative differences, although the influence of variation in clinical practice is rarely considered. This study was undertaken to determine whether differences in early mortality of patients receiving a massive transfusion (MT, ≥ 10 units pf RBCs within 24 hours of admission) persist after adjustment for patient and transfusion practice differences. We hypothesized differences among centers in 24-hour mortality could predominantly be accounted for by differences in transfusion practices as well as patient characteristics., Methods: Data were retrospectively collected over a 1-year period from 15 Level I centers on patients receiving an MT. A purposeful variable selection strategy was used to build the final multivariable logistic model to assess differences between centers in 24-hour mortality. Adjusted odds ratios for each center were calculated., Results: : There were 550 patients evaluated, but only 443 patients had complete data for the set of variables included in the final model. Unadjusted mortality varied considerably across centers, ranging from 10% to 75%. Multivariable logistic regression identified injury severity score (ISS), abbreviated injury scale (AIS) of the chest, admission base deficit, admission heart rate, and total units of RBC transfused, as well as ratios of plasma:RBC and platelet:RBC to be associated with 24-hour mortality. After adjusting for severity of injury and transfusion, treatment variables between center differences were no longer significant., Conclusions: In the defined population of patients receiving an MT, between-center differences in 24-hour mortality may be accounted for by severity of injury as well as transfusion practices.

Objective: To determine risk factors of medical injury, defined as untoward injury from diagnostic or therapeutic healthcare interventions. Identifying risk factors for medical injuries could inform the development of preventive interventions., Methods: A hospital-based case-control study. Cases and controls were selected among patients discharged from a large Midwestern teaching hospital between 1 January 2003 and 31 December 2004. Cases (n=268) were selected in a three-step process. First, medical injuries in the discharge database were identified using the Wisconsin Medical Injury Prevention Programme Surveillance Criteria. Second, provisional cases were randomly chosen from patients flagged with a medical injury. Provisional controls were randomly selected from patients not flagged with a medical injury, matching for Diagnosis Related Group of the provisional cases. Third, a chart review determined ultimate case-control status. Severity of illness and risk of mortality were calculated using the All Patients Refined-Diagnosis Related Groups system. Zahn's comorbidity score was calculated. Conditional logistic regressions were run with injury status as the dependent variable., Results: Among the 268 cases, 47.8% were procedure-related injuries and 44.8% were medication-related injuries. Conditional logistic regressions found higher severity of illness and higher risks of mortality were related to risk of medical injury (OR 3.29 (95% CI 1.05 to 10.31) and OR 5.16 (95% CI 1.42 to 18.79), respectively). Additional regressions showed the Zahn comorbidity score related to the risk of medical injury (OR 1.63, 95% CI 1.31 to 2.02)., Conclusions: Patients with higher severity of illness, higher risk of inpatient mortality and multiple comorbidities are at increased risk for a medical injury.

The purpose of this study was to establish the feasibility of laparoscopy in embalmed cadavers to teach abdominal gross anatomy. One cadaver was selected based on body habitus and absence of previous abdominal operations. A standard trocar was used to enter the abdomen at the umbilicus. Two trocars were placed in the left upper quadrant. Pneumoperitoneum was achieved with continuous CO(2) pressure. Liver retraction was achieved percutaneously, exposing the porta hepatis and the gallbladder. The dissection was done with four first-year medical students using standard laparoscopic equipment. Following this, the demonstration was projected over multiple monitors so that all students could participate. Laparoscopic dissection in an embalmed cadaver is feasible and an excellent educational tool for both the medical student and the dissector. The dissector has the opportunity to manipulate laparoscopic tools in a human model closely paralleling operative experience, and the students have an opportunity to learn abdominal anatomy from a clinical perspective. Laparoscopic examination and dissection of fresh cadavers has been used for training surgeons on new procedures such as colon resection, antireflux procedures, and cholecystectomy. There is no report of this same technology used in embalmed cadavers to teach basic anatomy. This approach allows first-year medical students to learn the anatomy while exposing them to the technology currently used in surgical practice, and it affords surgical residents and students additional opportunities to practice laparoscopic skills., (Copyright 2001 Wiley-Liss, Inc.)

A case of a chest tube placed on the wrong side during a trauma resuscitation in the emergency department is presented as an example of medical injury. Two traditional models, the legal model and the managerial model, are described and their application to medical injury discussed. A new public health model is then applied to the case example as a more effective way to address medical injury. The public health model addresses the injury event rather than the error itself using Haddon's matrix as a framework. Pre-event, event, and post-event phases are examined to find the weakest link, where intervention has the highest likelihood of successfully preventing future injuries.

Objective: To evaluate risk factors for snowmobile injury and patterns of injury., Methods: We performed a retrospective analysis of patients with snowmobile injury at three trauma centers. Data were collected from trauma databases and patients charts from January 1988 through April 1996; we obtained statistics from the Minnesota Department of Natural Resources for comparison purposes., Results: There were 274 patients identified. The average age was 29 years (SD 12, range 1.6-77). The male:female ratio was 6.6:1. Helmets were used in 35%, not used in 10%, and not reported in 55%. Ethanol consumption was reported in 44% of patients. The average speed of the snowmobile at the time of the accident, when reported, was 47 mph/75 kph (n = 103, range 10-100 mph/16-166 kph). Of these patients, 26% (n = 27) reported a speed in excess of the legal limit (55 mph/88 kph). Accidents were more common in the afternoon and evening hours, and most accidents were caused by the snowmobile striking terrain or man-made objects. Mortality rate was 3.6% for this patient group (10 of 274). The average injury severity score (ISS) was 15 (SD 11). The average Glasgow Coma Score (GCS) was 14. The average number of patients who went to the intensive care unit and the total lengths of stay were 2 +/- 5 and 8 +/- 9 days, respectively. Neither GCS nor ISS correlated with reported speed. The frequencies of different types of injuries are as follows: fractures of upper and lower extremities (n = 184), serious head injury (n = 92), facial fractures or soft tissue injury to head or neck (n = 88), thoracic injury (n = 80), spine injuries (n = 50), intraabdominal injuries (n = 41), and pelvic fractures (n = 31)., Conclusions: Snowmobile injuries are related to ethanol use and the high speed attained by the newer generation of snowmobiles. Extremity fractures were a common component of snowmobile injury in this series, and rates of such injuries are similar to rates injuries in motorcycle accidents in states with helmet laws. Efforts at prevention of snowmobile injuries should be targeted at rider education and enforcement of alcohol restrictions.

Background: Occult pneumothoraces (OPTXs) are seen on abdominal computed tomographic (CT) scans but not on routine chest x-ray films. Optimal treatment for blunt trauma OPTXs has not been defined. We hypothesized that OPTXs could be safely observed without need for a chest tube (CT)., Methods: A prospective trial randomized blunt trauma patients with OPTXs to CT scan or observation. Patients were not excluded for positive pressure ventilation. Primary outcome measures were respiratory distress and pneumothoraces progression., Results: Thirty-nine patients with 44 pneumothoraces were enrolled. Eighteen patients received a CT scan, and 21 patients were observed. Nine patients in each group received positive pressure ventilation. There was no difference in overall complication rate. No patient had respiratory distress related to the OPTX or required emergent CT scan., Conclusions: Observation of OPTX is not associated with an increased incidence of pneumothorax progression or respiratory distress. These pneumothoraces can be safely observed in patients with blunt trauma injury regardless of the need for positive pressure ventilation.

Background: Management of penetrating colon injuries in the presence of multiple associated risk factors is controversial. Issues not considered in previous management strategies are patient perception of quality of life with a colostomy and the true cost of each therapeutic option, which includes colostomy supplies and costs of colostomy takedown. To evaluate these issues, we performed a cost-utility analysis., Methods: We constructed a decision tree with 3 options: primary repair, resection and anastomosis, and colostomy. Chance and decision nodes on each decision branch represent injury severity, complications, colostomy takedown, and death. Chance node frequencies and utility assignments were taken from published data. We obtained actual costs for all components of perioperative care. The outcomes reported are cost and quality of life., Results: Colostomy has the least quality of life and the greatest cost. Primary repair and resection each dominate colostomy in the baseline analysis. No variable significantly altered these conclusions in sensitivity analyses., Conclusions: Simple suture or resection and anastomosis at the time of initial exploration is the dominant management method for penetrating colon trauma. It also demonstrates the trade-off between cost and life expectancy of the 3 management options.

Background: A dedicated operating room (OR) for urgent trauma cases is suggested by the American College of Surgeons Committee on Trauma as a necessary component of a Level I or II trauma center. We describe a cost analysis of this recommendation., Methods: Two models for staffing urgent trauma cases were constructed. Urgent trauma cases were defined as those taken to the OR within 30 minutes of arrival. In one model the OR was available 24 hours a day with in-hospital personnel. The second model used an out-of-hospital call schedule, assuming a patient-ready OR in 30 minutes. Costs and revenue per urgent case were calculated. A break-even analysis shows the number of cases required for costs to equal revenue., Results: In the 24-hour model, the cost/urgent case is $14,288; in the call-schedule model $3,243. The number of cases to break even in the 24-hour model is 1210; in the call-schedule model 375., Conclusions: A call-schedule model is the least costly way to staff an OR for urgent trauma cases.

Objective: To determine the incidence and significance of free fluid on abdominal CT in blunt trauma., Design: Retrospective chart review., Methods: All blunt trauma patients with an abdominal computed tomographic scan from August of 1993 to December of 1995 were identified from the trauma registry at a Level 1 trauma center. A total of 1,159 computed tomographic scans were performed; records of 18 patients were excluded for incomplete records. Official reports of computed tomographic scans were reviewed for free fluid, solid organ injury, bladder injury, and pelvic fracture., Results: Free fluid without solid organ injury was found in 3% (34 of 1141). Laparotomy was performed because of free fluid in 13 patients. There were six small bowel injuries and one diaphragm injury for a therapeutic laparotomy rate of 54%. Ten patients had trace free fluid and did not undergo laparotomy; none had a missed small bowel injury., Conclusions: The presence of more than trace amounts of free fluid without solid organ injury in patients with blunt trauma is a strong indication for exploratory laparotomy. Patients with isolated trace amounts of free fluid can be safely observed.

Background: Cold restraint stress increases the force of gastric contractions and produces gastric mucosal injury in rats. The aim of our study was to determine whether enteral glucose or hyperglycemia alone would alter the stress-induced gastric motility pattern and ameliorate the associated gastric mucosal injury., Methods: Adult male rats underwent surgical placement of gastric catheters, jugular venous catheters, and gastric strain gauge transducers 5 days before cold restraint. Three groups of rats received different substances during the same cold restraint stress protocol. Group 1 received 0.9% NaCl, 2 mL/h infused both intravenously (i.v.) and intragastrically (i.g.); group 2 received 0.9% NaCl, 2 mL/h i.g. plus 25% glucose, 2 mL/h i.v.; and group 3 received 0.9% NaCl, 2 mL/h i.v. plus 25% glucose i.g. Following baseline gastric motility measurements, all rats were restrained for 2 hours at 20 degrees C followed by 2 hours at 4 degrees C., Results: Restraint even at room temperature increased the force of gastric contractions; the cold environment gradually prolonged gastric contractions. Enteral glucose blunted the effects of stress on gastric motility, increased gastric residual volume, decreased gastric acidity, and prevented gastric mucosal injury. Parenteral glucose had little effect on any gastric parameters., Conclusions: Enteral glucose prevents the abnormal gastric motility pattern that is necessary to produce the gastric mucosal injury associated with cold restraint stress, but hyperglycemia alone has little effect on the pathophysiology of cold restraint.

Background: Changing methods of evaluating blunt abdominal trauma and expanding selection criteria for nonoperative management (NOM) of splenic injury can increase the number of patients managed nonoperatively without affecting success rates., Methods: The charts of 164 patients with blunt splenic injuries from July 1, 1991, to June 30, 1996, were reviewed. Thirty-eight patients were excluded because of immediate laparotomy without adjunctive tests or expiration in the resuscitative period. Injuries were graded according to the Organ Injury Scale., Results: Overall, successful NOM occurred in 84% of patients (73 of 87). NOM was successful in 5 of 7 patients > 55 years old and in 14 of 15 patients with Glasgow Coma Scale scores < 13., Conclusion: Use of computed tomography increased NOM of splenic trauma from 11 to 71% during the 5-year period for injuries of equivalent severity. Age > 55 years or abnormal neurologic status should not preclude NOM, because success was related only to injury grade.

Objective: To define the cost-effectiveness of screening ultrasound (US) and prophylactic inferior vena cava filters (VCF), approaches aimed at reducing the incidence of pulmonary embolus (PE) in high-risk trauma patients., Design: Cost-effective analysis., Materials and Methods: We constructed a decision tree with three approaches for PE prevention: no intervention, US, and VCF. Probabilities in each subtree were taken from published data. Sensitivity analyses evaluated all assumptions, probabilities, and outcomes for effects on baseline conclusions., Results: US is more cost-effective than VCF, with a cost/PE prevented of $46,300 compared with $93,700. The strategies become equally cost-effective only when VCF are placed in the radiology suite and length of stay is > or = 2 weeks., Conclusions: US is the most cost-effective approach for PE prevention in high-risk trauma patients. VCF should be reserved for patients with an anticipated length of stay > or = 2 weeks who can safely have a filter placed in the radiology suite.

Healthcare reform is a topic consuming the time and energy of many healthcare professionals, administrators, and politicians. One goal of reform is to improve value--better quality health care for less cost. Unfortunately, much of the current debate proceeds without clear definitions of quality or cost. To have profitable discussion, we must have precise definitions. With these definitions in hand, the technique of decision analysis provides a unique opportunity to evaluate quality and costs of healthcare decisions simultaneously. We believe it is imperative for physicians to become familiar with this important and powerful tool.

Background: The influence of patient preference and treatment costs has not been considered in previous analyses of wound management decisions for contaminated right lower quadrant incisions., Study Design: We performed a decision and cost-utility analysis, conducting a MEDLINE search of the postappendectomy wound infection literature to establish assumptions and assign baseline probability estimates. Institution-specific cost data were obtained, and utility assignments were made by the authors. Studies used to assign baseline probabilities fulfilled the following criteria: perforated appendix or gangrenous appendicitis, use of perioperative antibiotics active against aerobic and anaerobic bacteria, and data stratified by wound management, operative findings, and infection rate., Results: We constructed a decision tree comparing three methods of wound management for contaminated right lower quadrant incisions: primary closure, delayed primary closure, and secondary closure. Utility (a quality of life measure) was assigned to ultimate health states to incorporate patient preference. We calculated the cost-utility for each method of wound management and found that primary closure was of optimum cost-utility compared with delayed primary closure and secondary closure. To gain one quality-adjusted life year treating a population of patients with contaminated incisions, primary closure saves $22,635 over delayed primary closure and another $22,340 over secondary closure. This decision, tested by two-way sensitivity analyses, was sensitive only to high primary closure infection rates., Conclusions: Challenging traditional surgical dogma, cost-utility analysis shows that primary closure is the favored method of management for contaminated right lower quadrant incisions. This analysis is specific to right lower quadrant incisions and the conclusion is valid for all estimated primary infection rates less than 0.27.

Background: One of the most difficult problems in blunt trauma is evaluation for potential intraabdominal injury. Admission for serial abdominal exams remains the standard of care after intraabdominal injury has been initially excluded. We hypothesized a normal abdominal computed tomography (CT) scan in a subgroup of minimally injured patients would obviate admission for serial abdominal examinations, allowing safe discharge from the emergency department (ED)., Methods: We reviewed our blunt trauma experience with patients admitted solely for serial abdominal examinations after a normal CT. Patients were identified from the trauma registry at a Level 1 trauma center from July 1991 through June 1995. Patients with abnormal CTs, extra-abdominal injuries necessitating admission, hemodynamic abnormalities, a Glasgow Coma Scale less than 13, or injury severity scores (ISSs) greater than 15 were excluded. Records of 238 patients remained; we reviewed them to determine the presence of missed abdominal injury., Results: None of the 238 patients had a missed abdominal injury. Average ISS of these patients was 3.2 (range, 0 to 10). Discharging these patients from the ED would result in a yearly cost savings of $32,874 to our medical system., Conclusions: Abdominal CT scan is a safe and cost-effective screening tool in patients with blunt trauma. A normal CT scan in minimally injured patients allows safe discharge from the ED.

Objective: To evaluate the influences of patient preference and treatment costs on the diagnostic approach to blunt aortic trauma., Methods: Decision and cost-utility analysis., Data Sources: A MEDLINE search of all literature dealing with the diagnosis and management of blunt aortic injury was used to establish assumptions and assign baseline probability estimates. Utility assignments were made from published data and our own assignments. We obtained institution-specific cost data., Study Selection: Only randomized, prospective trials that used aortography as the gold standard test were used to assign baseline accuracy of transesophageal echocardiography and dynamic chest computed tomography. Other baseline estimates were taken from class II and class III published data., Data Synthesis: A decision tree compared 4 diagnostic approaches for blunt chest trauma after an initial normal chest radiograph: observation with follow-up chest radiography, aortography, transesophageal echocardiography, and dynamic chest computed tomography. Utility (a quality-of-life measure) was assigned to ultimate health states to incorporate patient preference. Chest radiography and aortography had similar utility. Aortography gained 1 quality-adjusted life year for minimal cost. Transesophageal echocardiography and dynamic chest computed tomography lose quality-adjusted life-years at increased cost. No variable changed the relative cost-utility of the screening methods in 2-way sensitivity analyses., Conclusions: Aortography gains additional quality life at minimal cost when used as a screening method for all patients with blunt chest trauma regardless of the results of the initial chest radiograph. With a normal initial chest radiograph, transesophageal echocardiography and dynamic chest computed tomography are associated with increased cost and loss of quality-adjusted life.