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Objectives: This study assessed whether Georgia Senate Bill 360, a statewide law passed in August, 2010, that prohibits text messaging while driving, resulted in a decrease in this behavior among emergency medicine (EM) and general surgery (GS) healthcare providers. Methods: SurveyMonkey was used to create a web-based survey containing up to 28 multiple choice and free-text questions about driving behaviors. EM and GS healthcare providers at a southeastern medical school and its affiliate county hospital received an email inviting them to complete this survey in February, 2011. All analyses were conducted in SPSS (version 19.0, Chicago, IL, 2010), using chi-squared tests and logistic regression models. The primary outcome of interest was a change in participant texting or emailing while driving after passage of the texting ban in Georgia.Results: Two hundred and twenty-six providers completed the entire survey (response rate 46.8%). Participants ranged in age from 23 to 71 years, with an average age of 38 (SD=10.2; median=35).Only three-quarters of providers (n=173, 76.6%) were aware of a texting ban in the state. Out of these, 60 providers (36.6%) reported never or rarely sending texts while driving (0 to 2 times per year), and 30 engaged in this behavior almost daily (18.9%). Almost two-thirds of this group reported no change in texting while driving following passage of the texting ban (n=110, 68%), while 53 respondents texted less (31.8%).Respondents younger than 40 were more than twice as likely to report no change in texting post-ban compared to older participants (OR=2.31, p=0.014). Providers who had been pulled over for speeding in the previous five years were about 2.5 times as likely to not change their texting while driving behavior following legislation passage compared to those without a history of police stops for speeding (OR=2.55, p=0.011). Each additional ticket received in the past 5 years for a moving violation lessened the odds of reporting a decrease in texting by 45%. (OR=0.553, p=0.007). Conclusion: EM and GS providers, particularly those who are younger, have received more tickets for moving violations, and with a history of police stops for speeding, exhibit limited compliance with distracted driving laws, despite first-hand exposure to the motor vehicle crashes caused by distracted driving.

Military logisticians have long recognized the efficiency of using decision support tools to streamline logistical systems. In the 1970s, the U.S. military began using automated linear-programing software to better stock [...]

Background: Massive transfusion protocols (MTPs) using high plasma and platelet ratios for exsanguinating trauma patients are increasingly popular. Major liver injuries often require massive resuscitations and immediate hemorrhage control. Current published literature describes outcomes among patients with mixed patterns of injury. We sought to identify the effects of an MTP on patients with major liver trauma. Methods: Patients with grade 3, 4 or 5 liver injuries who required a massive blood component transfusion were analyzed. We compared patients with high plasma:red blood cell:platelet ratio (1:1:1) transfusions (2007-2009) with patients injured before the creation of an institutional MTP (2005-2007). Results: Among 60 patients with major hepatic injuries, 35 (58%) underwent resuscitation after the implementation of an MTP. Patient and injury characteristics were similar between cohorts. Implementation of the MTP significantly improved plasma: red blood cell:platelet ratios and decreased crystalloid fluid resuscitation (p = 0.026). Rapid improvement in early acidosis and coagulopathy was superior with an MTP (p = 0.009). More patients in the MTP group also underwent primary abdominal fascial closure during their hospital stay (p = 0.021). This was most evident with grade 4 injuries (89% vs. 14%). The mean time to fascial closure was 4.2 days. The overall survival rate for all major liver injuries was not affected by an MTP (p = 0.61). Conclusion: The implementation of a formal MTP using high plasma and platelet ratios resulted in a substantial increase in abdominal wall approximation. This occurred concurrently to a decrease in the delivered volume of crystalloid fluid. Contexte: Les protocoles de transfusion massive (PTM) impliquant des rapports plasma:plaquettes eleves sont de plus en plus populaires pour traiter les patients atteints d'un traumatisme hemorragique. Les chirurgies majeures du foie requierent souvent le declenchement de protocoles de transfusion massive et une maitrise immediate de l'hemorragie. La litterature actuelle decrit les resultats chez des patients victimes de divers types de traumatismes. Nous avons voulu mesurer les effets d'un PTM sur les patients ayant subi un traumatisme majeur au foie. Methodes: Nous avons analyse les dossiers de patients ayant subi des blessures au foie de grade 3, 4 ou 5 qui ont necessite des transfusions massives de composants sanguins. Nous avons compare les patients ayant necessite des transfusions importantes de plasma, de culots globulaires et de plaquettes selon un rapport (1:1:1; 2007-2009) a des patients ayant subi leur traumatisme avant la mise en oeuvre d'un PTM par l'etablissement (2005-2007). Resultas: Sur 50 patients ayant subi des lesions hepatiques majeures, 35 (58 %) ont recu des traitements de reanimation apres la mise en place du PTM. Les caracteristiques propres aux patients et a leurs blessures etaient similaires entre les cohortes. L'application du PTM a significativement ameliore les rapports plasma:culots globulaires:plaquettes et reduit l'administration de cristalloides a des fins de reanimation liquidienne (p = 0,026). L'amelioration rapide de l'acidose naissante et de la coagulopathie a ete meilleure avec le PTM (p = 0,009). Plus de patients du groupe soumis au PTM ont aussi subi une fermeture aponevrotique abdominale primaire durant leur sejour hospitalier (p = 0,021). Cela s'est surtout observe avec les lesions de grade 4 (89 % c. 14 %). Le delai moyen avant la fermeture aponevrotique a ete de 4,2 jours. L'application du PTM n'a pas modifie le taux de survie global pour l'ensemble des traumatismes hepatiques majeurs (p = 0,61). Conclusion: La mise en place d'un PTM officiel reposant sur des rapports plasma et plaquettes eleves a donne lieu a une augmentation substantielle des fermetures de la paroi abdominale. Cela s'est produit en parallele avec une diminution du volume de cristalloides administres pour la reanimation liquidienne., Recent excitement surrounding the use of massive transfusion protocols (MTPs) with high plasma and platelet concentrations for injured patients in physiologic extremis is substantial. (1-20) While the effect on overall [...]

Background: Early transfusion of blood products for severely injured patients can improve volume depletion, acidosis, dilution and coagulopathy. There is concern that some patients are unnecessarily exposed to the risks of emergent transfusion with uncrossmatched red blood cell products (URBC) in the emergency department (ED). The goal of this study was to evaluate the transfusion practices in our ED among all patients who received URBC. Methods: We analyzed all injured patients transfused at least 1 URBC in the ED at a level-1 trauma centre between Jan. 15, 2007, and Jan. 14, 2008. Demographics, injuries and outcomes were reported. We used standard statistical methodology. Results: At least 1 URBC product was transfused into 153 patients (5% of all patients, mean 2.6 products) in the ED (median Injury Severity Score [ISS] 28; hemodynamic instability 94%). Sixty-four percent of patients proceeded to an emergent operation and 17% required massive transfusion. The overall mortality rate was 45%, which increased to 52% and 100% in patients who received 4 and 5 or more URBC products, respectively. Nonsurvivors had a higher median ISS (p = 0.017), received more URBC in the ED (p = 0.006) and possessed more major vascular injuries (p < 0.001). Among nonsurvivors, 67% died of uncontrollable hemorrhage. Unnecessary URBC transfusions in the ED occurred in 7% of patients. Conclusion: Overtransfusion was minimal based on clinical acumen triggers. Early transfer of patients receiving URBC products in the ED to the operating room, intensive care unit or angiography suite for ongoing resuscitation and definitive hemorrhage control must be strongly considered. Contexte : La transfusion rapide de produits du sang a des patients gravement traumatisms peut contrer la depletion volumique, l'acidose, la dilution et la coagulopathie. On craint que certains patients ne soient inutilement exposes aux risques que presente une transfusion d'extreme urgence d'hematies non soumises a une epreuve de compatibilite croisee en service d'urgence. L'etude visait a evaluer les habitudes transfusionnelles a notre service d'urgence et les patients qui ont recti des hematies non soumises a une epreuve de compatibilite croisee (HNSECC). Methodes : Nous avons analyse le dossier de tous les patients traumatises qui ont recu au moins 1 transfusion d'HNSECC a l'urgence dans un centre de traumatologie de niveau 1 entre le 15 janvier 2007 et le 14 janvier 2008. Les caracteristiques demographiques, les traumatismes et les resultats ont ete signales. Nous avons utilise une methodologie statistique normale. Resultats : Au moins 1 produit d'HNSECC a ete transfuse a 153 patients (5 % du total des patients, moyenne de 2,6 produits) a l'urgence (indice median de gravite de la blessure [IGB] 28; instabilite hemodynamique, 94 %). Soixante-quatre pour cent des patients ont subi une intervention d'extreme urgence et 17 % ont eu besoin d'une transfusion massive. Le taux de mortalite total a atteint 45 %, pour passer a 52 % et 100 % chez les patients qui ont recu 4 et 5 produits d'HNSECC respectivement. Les nonsurvivants presentaient un IGB median plus eleve (p = 0,017), ont recu plus d'HNSECC a l'urgence (p = 0.006) et avaient subi des traumatismes vasculaires plus importants (p < 0,001). Chez les non-survivants, 67 % sont morts d'une hemorragie incontrolable. Il y a eu transfusion inutile d'HNSECC a l'urgence chez 7 % des patients. Conclusion : La transfusion excessive etait minime compte tenu des facteurs declencheurs de l'acuite clinique. Il faut envisager serieusement de transferer rapidement les patients qui recoivent des HNSECC a la salle d'operation, aux soins intensifs ou au service d'angiographie pour les soumettre a une reanimation continue et controler definitivement l'hemorragie., The utility of early blood product transfusion in the treatment of severely injured patients is well understood. (1,2) It not only assists in addressing volume requirements and tissue oxygenation, but [...]

Background: Supine anteroposterior (AP) chest radiography is an insensitive test for detecting posttraumatic pneumothoraces (PTXs). Computed tomography (CT) often identifies occult pneumothoraces (OPTXs) not diagnosed by chest radiography. All previous literature describes the epidemiology of OPTX in patients with blunt polytrauma. Our goal was to identify the frequency of OPTXs in patients with penetrating trauma. Methods: All patients with penetrating trauma admitted over a 10-year period to Grady Memorial Hospital with a PTX were identified. We reviewed patients&apos; thoracoabdominal CT scans and corresponding chest radiographs. Results: Records for 1121 (20%) patients with a PTX (penetrating mechanism) were audited; CT imaging was available for 146 (13%) patients. Of these, 127 (87%) had undergone upright chest radiography. The remainder (19 patients) had a supine AP chest radiograph. Fifteen (79%) of the PTXs detected on supine AP chest radiographs were occult. Only 10 (8%) were occult when an upright chest radiograph was used (p < 0.001). Posttraumatic PTXs were occult on chest radiographs in 17% (25/146) of patients. Fourteen (56%) patients with OPTXs underwent tube thoracostomy, compared with 95% (115/121) of patients with overt PTXs (p < 0.001). Conclusion: Up to 17% of all PTXs in patients injured by penetrating mechanisms will be missed by standard trauma chest radiographs. This increases to nearly 80% with supine AP chest radiographs. Upright chest radiography detects 92% of all PTXs and is available to most patients without spinal trauma. The frequency of tube thoracostomy use in patients with overt PTXs is significantly higher than for OPTXs in blunt and penetrating trauma. Contexte: La radiographie pulmonaire anteroposterieure en position couchee constitue un moyen non sensible de detecter le pneumothorax (PTX) post-traumatique. La tomodensitometrie (TDM) detecte souvent un pneumothorax occulte (PTXO) non diagnostique par une radiographie pulmonaire. Toutes les publications anterieures decrivent l&apos;epidemiologie du PTXO chez les patients qui ont subi un polytraumatisme contondant. Nous voulions determiner la frequence du PTXO chez les patients victimes d&apos;un traumatisme perforant. Methodes: Tous les patients victimes d&apos;un traumatisme perforant admis au cours d&apos;une periode de 10 ans a l&apos;Hopital commemoratif Grady qui avaient un PTX ont ete identifies. Nous avons etudie les TDM thoracoabdominales des patients et les radiographies pulmonaires correspondantes. Resultats: Nous avons verifie les dossiers de 1121 (20 %) patients victimes d&apos;un PTX (mecanisme perforant). L&apos;imagerie par TDM etait disponible pour 146 (13 %) des patients. De ce total, 127 (87 %) avaient eu une radiographie pulmonaire en position debout. Les autres (19 patients) avaient eu une radiographie pulmonaire anteroposterieure en position couchee. Quinze (79 %) des PTX detectes par des radiographies pulmonaires anteroposterieure en position couchee etaient occultes. Seulement 10 (8 %) etaient occultes lorsqu&apos;on a utilise la radiographie pulmonaire en position debout (p < 0,001). Le PTX post-traumatique etait occulte dans les radiographies pulmonaires de 17 % (25/146) des patients. Quatorze (56 %) des patients qui avaient un PTXO ont subi une thoracostomie comparativement a 95 % (115/121) des patients qui avaient un PTX evident (p < 0,001). Conclusion: La radiographie pulmonaire habituelle des traumatises rate jusqu&apos;a 17 % du total des PTX chez les patients traumatises par un mecanisme perforant. Ce pourcentage atteint presque 80 % pour les radiographies pulmonaires anteroposterieures en position couchee. La radiographie pulmonaire en position debout detecte 92 % des PTX et est disponible pour la plupart des patients qui n&apos;ont pas de traumatisme rachidien. La frequence du recours a la thoracostomie chez les patients qui ont un PTX evident est beaucoup plus elevee que chez ceux qui ont un PTXO dans les cas de traumatisme contondant et perforant., Occult pneumothorax (OPTX) is a pneumothorax (PTX) diagnosed by computed tomography (CT) that had not been previously identified by a supine anteroposterior (AP) chest radiograph. (1-7) With the increasing use [...]

Background: Tension pneumothorax requires emergent decompression. Unfortunately, some needle thoracostomies (NTs) are unsuccessful because of insufficient catheter length. All previous studies have used thickness of the chest wall (based on cadaver studies, ultrasonography or computed tomography [CT]) to extrapolate probable catheter effectiveness. The objective of this clinical study was to identify the frequency of NT failure with various catheter lengths. Methods: We evaluated the records of all patients with severe blunt injury who had a prehospital NT before arrival at a level-1 trauma centre over a 48-month period. Patients were divided into 2 groups: helicopter (4.5-cm catheter sheath) and ground ambulance (3.2 cm) transport. Success of the NT was confirmed by the absence of a large pneumothorax on subsequent thoracic ultrasonography and CT. Results: Needle thoracostomy decompression was attempted in 1.5% (142/9689) of patients. Among patients with blunt injuries, the incidence was 1.4% (101/7073). Patients transported by helicopter (74%) received a 4.5-cm sheath. The remainder (26% ground transport) received a 3.2-cm catheter. A minority in each group (helicopter 15%, ground 28%) underwent immediate chest tube insertion (before thoracic ultrasound) because of ongoing hemodynamic instability. Failure to decompress the pleural space by NT was observed via ultrasound and/or CT in 65% (17/26) of attempts with a 3.2-cm catheter, compared with only 4% (3/75) of attempts with a 4.5-cm catheter (p < 0.001). Conclusion: Tension pneumothorax decompression using a 3.2-cm catheter was unsuccessful in up to 65% of cases. When a larger 4.5-cm catheter was used, fewer procedures (4%) failed. Thoracic ultrasonography can be used to confirm NT placement. Contexte : Le pneumothorax compressif requiert une decompression urgente. Malheureusement, certaines thoracotomies a l&apos;aiguille echouent parce que les catheters ne sont suffisamment longs. Toutes les etudes anterieures se sont basees sur l&apos;epaisseur de la paroi thoracique (obtenue par examen de cadavres, echographie ou tomographie assistee par ordinateur) pour extrapoler l&apos;efficacite probable des catheters. L&apos;objectif de la presente etude clinique etait de mesurer la frequence de l&apos;echec des thoracotomies a l&apos;aiguille selon la longueur des catheters utilises. Methodes : Nous avons examine les dossiers de tous les patients victimes d&apos;un grave traumatisme ferme et soumis a une thoracotomie a l&apos;aiguille avant leur arrivee dans un centre de traumatologie de premier niveau sur une periode de 48 mois. Les patients ont ete repartis en deux groupes selon que leur transport s&apos;etait fait par helicoptere (gaine du catheter 4,5 cm) ou par ambulance (3,2 cm). La reussite de la thoracotomie a ete confirmee par l&apos;absence de pneumothorax volumineux a l&apos;echographie ou a la tomographie thoracique effectuee par la suite. Resultats : La decompression par thoracotomie a l&apos;aiguille a ete tentee chez 1,5 % des patients (142/9689). Parmi les patients victimes d&apos;un traumatisme ferme, l&apos;incidence s&apos;elevait a 1,4 % (101/7073). Les patients transportes par helicoptere (74 %) ont recu un catheter de 4,5 cm. Les autres (26 % transportes par voie terrestre) ont recu un catheter de 3,2 cm. Chez une minorite dans chaque groupe (helicoptere 15 %, transport terrestre 28 %) on a installe immediatement un drain thoracique (avant l&apos;echographie thoracique) en raison de l&apos;instabilite hemodynamique. L&apos;echographie et(ou) la tomographie ont revele l&apos;echec de la decompression de l&apos;espace pleural par thoracotomie effectuee a l&apos;aiguille dans 65 % des tentatives (17/26) au moyen d&apos;un catheter de 3,2 cm, contre 4 % seulement (3/75) au moyen d&apos;un catheter de 4,5 cm (p < 0,001). Conclusion : La decompression d&apos;un pneumothorax compressif a l&apos;aide d&apos;un catheter de 3,2 cm a echoue dans une proportion allant jusqu&apos;a 65 %. Lors de l&apos;utilisation d&apos;un catheter plus long (4,5 cm), un moins grand nombre d&apos;interventions ont echoue (4 %). On peut utiliser l&apos;echographie thoracique pour confirmer le positionnement du catheter de thoracotomie a l&apos;aiguille., Tension pneumothorax (TPTX) is defined as a pneumothorax (PTX) that results in the lateral shift of a patient's mediastinum concurrent to respiratory distress (or difficulty ventilating) and/or hypotension. (1) It [...]

Traumatic injuries to the mesenteric vessels are rare and often lethal. Visceral vessels, such as the superior mesenteric artery (SMA) and vein (SMV), supply blood to the small and large bowel by a rich system of collaterals. Because fewer than 100 such injuries have been described in the literature, they pose challenges in both diagnosis and management and can unfortunately result in high mortality rates. Prompt diagnosis, surgical intervention, and resuscitation can lead to improved outcomes. Here, we review the literature surrounding traumatic injuries of the SMA/SMV and discuss management strategies. [ABSTRACT FROM AUTHOR]