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This review focuses on the application of geriatric expertise to care for traumatically injured patients through the use of geriatrician consultation versus a surgeon-led geriatric trauma service (GTS). We offer guidance on elements needed to establish an effective geriatric trauma service. Geriatrics expertise, through consultation, can have a positive effect on several important outcomes in the elderly injured. Several groups have published on recent successes with surgeon-led geriatric trauma services. Surgeon-led geriatric trauma services have shown improvements in discharge disposition and hospital length of stay and trends toward improved mortality. Regardless of approach, geriatrics experience and expertise as well as focused and intentional deployment of important resources appears to improve outcomes in geriatric trauma. Care for the elderly injured can be significantly improved by incorporating expertise in geriatrics. This can be accomplished by consultation of a geriatrician; however, consolidation of these patients onto a dedicated surgeon-led geriatric trauma service with dedicated hospital resources may be more effective.

INTRODUCTION While pediatric trauma centers (PTCs) and adult trauma centers (ATCs) exhibit equivalent trauma mortality, the optimal care environment for traumatically injured adolescents remains controversial. Race has been shown to effect triage within emergency departments (EDs) with people of color receiving lower acuity triage scores. We hypothesized that African-American adolescents were more likely triaged to an ATC than a PTC compared to their Caucasian peers. METHODS Institutional trauma databases from a neighboring, urban level one PTC and ATC were queried for gunshot wounds in adolescents (15-18 years old) presenting to the ED from 2015-2017. The PTC and ATC were compared in terms of demographics, services, and outcomes. Results were analyzed using univariate analysis and logistic regression. RESULTS Among 316 included adolescents, 184 were treated in an ATC versus 132 in a PTC. Patients at the PTC were significantly more likely to be younger (16.1 vs 17.5 years old, p < 0.001), Caucasian (16% vs 5%, p = 0.001) and privately insured (41% vs 30%, p = 0.002). At each age, the proportion of Caucasians treated at the PTC exceeded the proportion of African Americans (Figure 1). At the PTC, patients were more likely to receive inpatient and outpatient social work follow-up (89% vs 1%, p < 0.001). Adolescents treated at the PTC were less likely to receive opioids (75% vs 56%, p = 0.001) at discharge and to return to ED within six months (25% vs 11%, p = 0.005). On multivariate logistic regression, African American adolescents were less likely to be treated at a PTC (OR = 0.30, 95% CI 0.10, 0.85, p = 0.02) after controlling for age and injury severity score. CONCLUSION Disparities in triage of African-American and Caucasian adolescents after bullet injury leads to unequal care. African-Americans were more likely to be treated at the ATC, which was associated with increased opioid prescription, decreased social work support, and increased return to ED. LEVEL OF EVIDENCE Retrospective study, level IV.

Background The "Surgery for Abdomino-thoracic ViolencE (SAVE)" animate lab engages surgical residents in the management of penetrating injuries in a team setting. Senior residents, representing postgraduate year (PGY) 3-5, assume the role of team leader and facilitate the junior residents, PGY1-2, in operative management of simulated penetrating wounds. Residents completed five scenarios with increasing level of difficulty within set time limits. Senior residents were evaluated on their team's ability to "SAVE" their patient within the time allotted, as well as their communication and leadership skills. Methods General, vascular, urology, and plastic surgery residents (n = 79) were divided into 25 teams of three to four residents by "resident scores" (R scores, the sum of the team members' PGY) to create balanced teams with comparable years of clinical experience. Residents completed assessments of their senior resident's leadership ability and style. Results Evaluation of a resident's desired learning style changed across PGY with junior residents preferring more hands-on guidance compared with senior residents preferring only verbal correction. Resident leadership evaluations demonstrated that team leaders of varied resident years achieved the highest scores. Greater differences in the mismatch between autonomy provided to and desired by junior residents correlated to greater junior resident discomfort in expressing their opinion, confidence, and leadership ratings of senior residents. However, greater autonomy mismatch also correlated to more rapid time to task completion. Conclusion Different from our expectations, clinical experience alone did not define team leader success. Leadership is a powerful influence on the outcome of team performance and may be a skill, which can transcend overall clinical experience. A match between desired and provided resident autonomy and team cohesion may demonstrate a stronger effect on team success in stressful operative situations, such as trauma resuscitation. Enhancement of leadership skills early in residency training may represent an important focus for trauma surgery education.

BACKGROUND There is a resurgence in the use of low-titer group O whole blood (LTOWB) for hemorrhagic shock. We hypothesized the use of LTOWB compared to component therapy (CT) would be independently associated with improved 24-hour mortality. STUDY DESIGN AND METHODS In this prospective observational study, trauma patients 18 years of age or older with massive transfusion protocol activations were included from August 17, 2018, to May 14, 2019. The primary outcome was 24-hour mortality. Secondary outcomes included 72-hour blood product totals, multiple organ dysfunction scores (MODS), and 28-day mortality. Multivariable logistic regression (MVLR) and Cox regression were performed to determine independent associations. RESULTS There were no clinically meaningful differences in measures of injury severity between study groups (CT, n = 42; LTOWB, n = 44). There was no difference in MODS between study groups. The unadjusted mortality was not statistically different between the study groups (9/42 [21%] for CT vs. 7/44 [16%] for LTOWB; p = 0.518). In the MVLR model, LTOWB increased the odds of 24-hour survival by 23% (odds ratio 0.81, 95% confidence interval 0.69-0.96; p = 0.017). Adjusted survival curve analysis indicated improved survival at both 24 hours and 28 days for LTOWB patients (p < 0.001). Further stratification showed an association between LTOWB use and survival when maximum clot firmness (MCF) was 60 mm or less (p = 0.009). CONCLUSIONS The use of LTOWB is independently associated with improved 24-hour and 28-day survival, and does not increase organ dysfunction at 72 hours. Use of LTOWB most impacted survival of patients with reduced clot firmness (MCF ≤60 mm). Collectively, these data support the clinical use and continued study of LTOWB for hemostatic resuscitation.

In the United States, there is a perceived divide regarding the benefits and risks of firearm ownership. The American College of Surgeons Committee on Trauma Injury Prevention and Control Committee designed a survey to evaluate Committee on Trauma (COT) member attitudes about firearm ownership, freedom, responsibility, physician-patient freedom and policy, with the objective of using survey results to inform firearm injury prevention policy development.A 32-question survey was sent to 254 current U.S. COT members by email using Qualtrics. SPSS was used for χ exact tests and nonparametric tests, with statistical significance being less than 0.05.Our response rate was 93%, 43% of COT members have firearm(s) in their home, 88% believe that the American College of Surgeons should give the highest or a high priority to reducing firearm-related injuries, 86% believe health care professionals should be allowed to counsel patients on firearms safety, 94% support federal funding for firearms injury prevention research. The COT participants were asked to provide their opinion on the American College of Surgeons initiating advocacy efforts and there was 90% or greater agreement on 7 of 15 and 80% or greater on 10 of 15 initiatives.The COT surgeons agree on: (1) the importance of formally addressing firearm injury prevention, (2) allowing federal funds to support research on firearms injury prevention, (3) retaining the ability of health care professionals to counsel patients on firearms-related injury prevention, and (4) the majority of policy initiatives targeted to reduce interpersonal violence and firearm injury. It is incumbent on trauma and injury prevention organizations to leverage these consensus-based results to initiate prevention, advocacy, and other efforts to decrease firearms injury and death.Prognostic/epidemiologic study, level I; therapeutic care, level II.

Many centers advocate use of triple-contrast (IV, oral, and rectal) CT for assessing hemodynamically stable patients with penetrating abdominopelvic trauma. Enteric contrast material has several disadvantages, leading our practice to pursue use of single-contrast (IV) CT. We conducted a retrospective review of electronic medical records at our institution to assess the accuracy of single-contrast CT for diagnosing bowel injuries in cases of penetrating abdominopelvic trauma.We retrospectively reviewed patients who presented to our emergency department between January 1, 2004, and March 1, 2014, with penetrating abdominopelvic trauma, underwent an abdominopelvic CT, and had surgery performed thereafter. We reviewed pertinent emergency department records for details regarding the site of injury, the number of injuries per patient, and the type of weapon used. We correlated CT reports with operative notes for presence and sites of bowel injury.A total of 274 patients (median age, 27 years old) met our inclusion criteria; 77% had sustained gunshot wounds (GSWs). CT showed bowel injury in 173 cases; surgery revealed bowel injury in 162 cases. CT had 142 true-positive, 31 false-positive, 81 true-negative, and 20 false-negative cases, resulting in sensitivity of 88%, specificity of 72%, positive predictive value of 82%, and negative predictive value of 80% for detecting bowel injuries. CT had the highest sensitivity and specificity in patients with multiple GSWs (94% and 79%, respectively) and those with injuries to the stomach and rectum.Single-contrast CT can show bowel injuries in patients with penetrating abdominopelvic trauma with accuracy comparable with that reported for triple-contrast CT.

Background Use of chlorhexidine and silver sulfadiazine-impregnated (CSS) central venous catheters (CVCs) has not been shown to decrease the catheter-related bloodstream infection rate in an ICU. The purpose of this study was to determine if use of minocycline and rifampin-impregnated (MR) CVCs would decrease central line-associated bloodstream infection (CLABSI) rates compared with those observed with use of CSS-impregnated CVCs. Study Design A total of 7,181 patients were admitted to a 24-bed university hospital surgical ICU: 2,551 between March 2004 and August 2005 (period 1) and 4,630 between April 2006 and July 2008 (period 2). All patients requiring CVC placement in period 1 had a CSS catheter inserted, and in period 2 all patients had MR CVCs placed. Results Twenty-two CLABSIs occurred during 7,732 catheter days (2.7 per 1,000 catheter days) in the 18-month period when CSS lines were used. After the introduction of MR CVCs, 21 catheter-related bloodstream infections occurred during 15,722 catheter days (1.4 per 1,000 catheter days). This represents a significant (p Conclusions The CLABSI rate decreased more with the use of MR CVCs compared with CSS CVCs in an ICU where the CLABSI rate was already low. The types of organisms causing infection were similar. With continued use of MR-impregnated CVCs in our ICU in the subsequent 5 years, we have seen sustained low rates of CLABSIs.

Traumatic lumbar hernias are rare but important injuries to diagnose in blunt abdominal trauma, both because of delayed complications of the hernia itself and because of well-documented association with bowel and mesenteric injuries. No study to our knowledge has determined whether specific features of the hernia—size of the wall defect, inferior or superior location, or the side of the hernia—bear any predictive value on the presence of underlying bowel and mesenteric injury. A retrospective query of the radiology information system yielded 21 patients with lumbar hernias which were diagnosed on CT. These were reviewed by three radiologists to confirm the presence of an acute lumbar hernia and to determine the size and location of the hernia. The patients’ medical records were reviewed to determine the presence of operatively confirmed bowel and/or mesenteric injuries, which occurred in 52 % of patients. A significant (p

The older adult patient with trauma is becoming a growing part of the overall trauma population. With the world population increasing in age, the rate of the traumatically injured older adult will continue to increase. Recognizing this problem and the fact that the elderly are at higher risk for injury and its complications will be necessary if the increasing volume of patients is to be dealt with. This review discusses these issues, as well as appropriate triage and treatment of injuries and associated comorbidities. Early recognition of injury, even minor, and expedited care using specialized teams will help to improve outcomes for these patients.

CT plays a crucial role in the evaluation of stable patients with blunt and penetrating trauma in the emergency department. Among the more severe injuries that may occur in penetrating and blunt trauma are those to the inferior vena cava (IVC). The purpose of this study was to evaluate and differentiate the CT findings associated with penetrating versus blunt trauma to the IVC to aid the radiologist in diagnosing IVC injuries.Cases of blunt and penetrating IVC injury were retrospectively identified using search queries. Criteria for inclusion were preoperative contrast-enhanced CT and surgically confirmed caval injury or direct findings of caval injury on CT with patient death before surgical confirmation could be obtained.Twelve cases of traumatic IVC injury were identified over a 9-year period: six blunt and six penetrating. The most common finding was a retroperitoneal hematoma, seen in 75% of cases. Eighty-three percent of blunt injuries were associated with hepatic lacerations and contrast material extravasation. Thirty-three percent of penetrating IVC injuries were associated with extravasation. Contour abnormalities were seen in 50% of blunt and 17% of penetrating injuries to the IVC. All three cases of IVC injury resulting in mortality occurred in the retrohepatic segment.Injury to the IVC is frequently fatal in patients with penetrating or blunt trauma. The CT appearance of IVC injury is dichotomous between the two causes, with blunt IVC injury more likely to show extravasation, contour abnormality, and associated hepatic laceration. Injury of the retrohepatic IVC portends a poor outcome. With the continued use of CT for evaluation of trauma patients, the radiologist should be familiar with IVC injury and its different CT appearances.

Introduction Near-continuous glucose monitoring is expected to increase time in range (TIR) of 80–120 mg/dL and to avoid hypoglycemia without increasing workload. We investigated a near-continuous glucose monitor in surgical critically ill and trauma patients. Methods Patients were enrolled at a surgical intensive care unit associated with a level 1 trauma center. Glucose measurements were compared to the gold standard Yellow Springs Instrument (YSI). The technology withdraws 0.13 mL of blood every 15 min from a central venous line, centrifuges the sample, and uses mid-infrared spectroscopy to measure glucose. We plotted a Clarke Error Grid, calculated Mean Absolute Relative Deviation (MARD) to analyze trend accuracy, and we present a Bland Altman plot of device versus standard glucose measurements. Results 24 patients were enrolled. One patient was withdrawn due to poor blood return from central venous line. A total of 347 glucose measurements from 23 patients were compared to the gold standard. 94.8% of the data points were in zone A of the Clarke Error Grid and 5.2% in zone B. The MARD was 8.02%. The majority of data points achieved the benchmark for accuracy. The remaining 5.2% are clinically benign. The MARD was below 10%. The Bland Altman plot shows good agreement between the device and reference glucose measurements. There were no device related adverse events. Conclusion Our data suggests that near continuous monitoring via infrared spectroscopy is safe and accurate for use in critically ill surgical and trauma patients. A large scale multi-center study is underway to confirm these findings.

To determine a) if a checklist covering a diverse group of intensive care unit protocols and objectives would improve clinician consideration of these domains and b) if improved consideration would change practice patterns.Pre- and post observational study.A 24-bed surgical/burn/trauma intensive care unit in a teaching hospital.A total of 1399 patients admitted between June 2006 and May 2007.The first component of the study evaluated whether mandating verbal review of a checklist covering 14 intensive care unit best practices altered verbal consideration of these domains. Evaluation was performed using real-time bedside audits on morning rounds. The second component evaluated whether the checklist altered implementation of these domains by changing practice patterns. Evaluation was performed by analyzing data from the Project IMPACT database after patients left the intensive care unit.Verbal consideration of evaluable domains improved from 90.9% (530/583) to 99.7% (669/671, p.0001) after verbal review of the checklist was mandated. Bedside consideration improved on the use of deep venous thrombosis prophylaxis (p.05), stress ulcer prophylaxis (p.01), oral care for ventilated patients (p0.01), electrolyte repletion (p.01), initiation of physical therapy (p.05), and documentation of restraint orders (p.0001). Mandatory verbal review of the checklist resulted in a greater than two-fold increase in transferring patients out of the intensive care unit on telemetry (16% vs. 35%, p.0001) and initiation of physical therapy (28% vs. 42%, p.0001) compared with baseline practice.A mandatory verbal review of a checklist covering a wide range of objectives and goals at each patient's bedside is an effective method to improve both consideration and implementation of intensive care unit best practices. A bedside checklist is a simple, cost-effective method to prevent errors of omission in basic domains of intensive care unit management that might otherwise be forgotten in the setting of more urgent care requirements.

Objective: The purpose of this study was to determine the effects of a simple low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. Design: Preintervention and postintervention observational study. Setting: Twenty-four bed surgical/trauma/burn intensive care units in an urban university hospital. Patients: All mechanically ventilated patients that were admitted to the intensive care unit between June 1, 2004 and May 31, 2005. Interventions: An oral care protocol to assist in prevention of bacterial growth of plaque by cleaning the patients' teeth with sodium monoflurophosphate 0.7% paste and brush, rinsing with tap water, and subsequent application of a 0.12% chlorhexidine gluconate chemical solution done twice daily at 12-hour intervals. Measurements and main results: During the preintervention period from June 1, 2003 to May 31, 2004, there were 24 infections in 4606 ventilator days (rate = 5.2 infections per 1000 ventilator days). After the institution of the oral care protocol, there were 10 infections in 4158 ventilator days, resulting in a lower rate of 2.4 infections per 1000 ventilator days. This 46% reduction in ventilator-associated pneumonia was statistically significant (P = .04). Staff compliance with the oral care protocol during the 12-month period was also monitored biweekly and averaged 81%. The total cost of the oral care protocol was US$2187.49. There were 14 fewer cases of ventilator-associated pneumonia, which led to a decrease in cost of US$140 000 to US$560 000 based on the estimated cost per ventilator-associated pneumonia infection of US$10 000 to US$40 000. There was an overall reduction in ventilator-associated pneumonia without a change to the gram-negative or gram-positive microorganism profile. Conclusions: The implementation of a simple, low-cost oral care protocol in the surgical intensive care unit led to a significantly decreased risk of acquiring ventilator-associated pneumonia.

Extracorporeal membrane oxygenation (ECMO) is a technique for providing life support for patients experiencing both pulmonary and cardiac failure by maintaining oxygenation and perfusion until native organ function is restored. ECMO is used routinely at many specialized hospitals for infants and less commonly for children with respiratory or cardiac failure from a variety of causes. Its usage is more controversial in adults, but select medical centers have reported favorable findings in patients with ARDS and other causes of severe pulmonary failure. ECMO is also rarely used as a rescue therapy in a small subset of adult patients with cardiac failure. This article will review the current uses and techniques of ECMO in the critical care setting as well as the evidence supporting its usage. In addition, current practice management related to coding and reimbursement for this intensive therapy will be discussed.

To examine the feasibility and potential utility of a tracheostomy protocol based on a standardized approach to ventilator weaning.Prospective, observational data collection.Academic medical center.Surgical intensive care unit patients requiring mechanical ventilatory support.None.Tracheostomy practice in 200 patients was analyzed in relation to spontaneous breathing trial (SBT) weaning. Decision for, and performance of, tracheostomy occurred (median [interquartile range]) 5.0 (3.75-8.0) and 7.0 (5.0-10.0) days following initiation of mechanical ventilation, respectively. Duration of mechanical ventilation was greater in tracheostomy compared with nontracheostomy patients (15.0 [11.0-19.0] vs. 6.0 [4.0-8.0], p.001). For patients requiring ventilatory support foror = 20 days, 100% of patients were maintained via tracheostomy. A protocol based on weaning performance, which included technical considerations, was developed. Individuals who failed preliminary weaning assessment or SBT for 3 successive days following 5 days (nonreintubated patients) or 3 days (reintubated patients) of ventilatory support met tracheostomy criteria. The protocol was implemented on a pilot basis in 125 individuals. Of the 55 (44.0%) patients undergoing tracheostomy, 25 (45.5%) did so consistent with criteria. Eighteen patients (32.7%) underwent tracheostomy before the time interval of data collection targeting weaning protocol performance, and 12 patients (21.8%) passed SBT on one or more occasions, were not extubated, and proceeded to tracheostomy.A standardized approach in which the decision for tracheostomy is based on objective measures of weaning performance may be a means of using this procedure more consistently and effectively.

Background Blunt cardiac injury (BCI) may manifest as cardiac contusion or, more rarely, as pericardial or myocardial rupture. Computed tomography (CT) is performed in the vast majority of blunt trauma patients, but the imaging features of cardiac contusion are not well described. Purpose To evaluate CT findings and associated injuries in patients with clinically diagnosed BCI. Materials and methods We identified 42 patients with blunt cardiac injury from our institution's electronic medical record. Clinical parameters, echocardiography results, and laboratory tests were recorded. Two blinded reviewers analyzed chest CTs performed in these patients for myocardial hypoenhancement and associated injuries. Results CT findings of severe thoracic trauma are commonly present in patients with severe BCI; 82% of patients with ECG, cardiac enzyme, and echocardiographic evidence of BCI had abnormalities of the heart or pericardium on CT; 73% had anterior rib fractures, and 64% had pulmonary contusions. Sternal fractures were only seen in 36% of such patients. However, myocardial hypoenhancement on CT is poorly sensitive for those patients with cardiac contusion: 0% of right ventricular contusions and 22% of left ventricular contusions seen on echocardiography were identified on CT. Conclusion CT signs of severe thoracic trauma are frequently present in patients with severe BCI and should be regarded as indirect evidence of potential BCI. Direct CT findings of myocardial contusion, i.e. myocardial hypoenhancement, are poorly sensitive and should not be used as a screening tool. However, some left ventricular contusions can be seen on CT, and these patients could undergo echocardiography or cardiac MRI to evaluate for wall motion abnormalities.

(CHSS)-coated catheters to minocycline-rifampin (MR)coated catheters led to a significant reduction in central line-associated bloodstream infections (CLABSI) in a busy surgical ICU, with relatively low baseline CLABSI rates. This is not surprising based on a meta-analysis regarding these catheters. The authors found that there was no reduction in CLABSI with CHSS catheter use; however, a change from uncoated catheters to CHSS catheters led to reduction in the incidence of CLABSI in the trauma ICU/burn unit at my institution. I have some issues with the study of Bonne and colleagues. First, the authors did not delineate any other infection control interventions implemented during the study period that could also have reduced CLABSI. Second, the authors supplied no data to support their statement that the MR catheters did not increase the incidence of antibiotic-resistant organisms (eg, minimum inhibitory concentration [MIC] creep among skin organisms at the catheter insertion site). Third, the authors used CLABSI as their outcomes measure, and this surveillance definition can be met if catheter-drawn blood cultures are positive when percutaneous blood cultures are negative. As such, drawing blood cultures through contaminated catheter hubs falsely elevates the incidence of CLABSI, but drawing blood through intraluminally coated catheters could lead to elution of antibiotics into blood culture media, which, at least hypothetically, could lead to falsenegative results, and this was an uncontrolled variable in the study. Last, catheter duration was 21⁄2 days shorter during MR catheter use, which was an important uncontrolled variable that favors MR catheters.

Background Medical errors are common, and physicians have notably been poor medical error reporters. In the SICU, reporting was generally poor and reporting by physicians was virtually nonexistent. This study was designed to observe changes in error reporting in an SICU when a new card-based system (SAFE) was introduced. Study design Before implementation of the SAFE reporting system, education was given to all SICU healthcare providers. The SAFE system was introduced into the SICU for a 9-month period from March 2003 through November 2003, to replace an underused online system. Data were collected from the SAFE card reports and the online reporting systems during introduction, removal, and reimplementation of these cards. Reporting rates were calculated as number of reported events per 1,000 patient days. Results Reporting rates increased from 19 to 51 reports per 1,000 patient days after the SAFE cards were introduced into the ICU (p≤ 0.001). Physician reporting increased most, rising from 0.3 to 5.8 reports per 1,000 patient days; nursing reporting also increased from 18 to 39 reports per 1,000 patient days (both p≤0.001). When the SAFE cards were removed, physician reporting declined to 0 reports per 1,000 patient days (p=0.01) and rose to 8.1 (p=0.001) when the cards were returned, similar to nursing results. A higher proportion of physician reports were events that caused harm compared with no effect (p Conclusions A card reporting system, combined with appropriate education, improved overall reporting in the SICU, especially among physician providers. Nurses were more likely to use reporting systems than were physicians. Physician reports were more likely to be of events that caused harm.

Hyperglycemia is associated with complications in the surgical intensive care unit. The purpose of this study was to determine the efficacy and safety of nurse-driven insulin infusion protocols in lowering blood glucose (BG) in critical illness.All patients in a 24-bed surgical intensive care unit who required i.v. insulin infusions during 3 noncontiguous 6-month periods from 2002 to 2004 were evaluated. In the preintervention phase, 71 patients received a physician-initiated insulin infusion without a developed protocol. They were compared with 95 patients who received a nurse-driven insulin infusion protocol with a target BG of 120 to 150 mg/dL and to 119 patients who received a more stringent protocol with a target BG of 80 to 110 mg/dL.There was a stepwise decrease in average daily BG levels, from 190 to 163 to 132 mg/dL (p0.001). The less stringent protocol decreased the time to achieve a BG level150 mg/dL from 14.1 to 7.4 hours compared with physician-driven management (p0.05) resulting in similar time on an insulin infusion (53 versus 48 hours). The more intensive protocol brought BG levels150 mg/dL in 7.2 hours and111 mg/dL in 13.6 hours, but increased the length of time a patient was on an insulin infusion to 77 hours. The incidence of severe hypoglycemia (BG40 mg/dL) was statistically similar between the groups, ranging between 1.1% and 3.4%.Implementation of a nurse-driven protocol led to more rapid and more effective BG control in critically ill surgical patients compared with physician management. Tighter BG control can be obtained without a significant increase in hypoglycemia, although this is associated with increased time on an insulin infusion.

Traumatic pseudoaneurysms can cause compression of adjacent structures and hemorrhage. The mortality rate for bleeding visceral artery pseudoaneurysms is particularly high, and surgical repair is all but impossible in some cases. The authors describe two cases in which traumatic pseudoaneurysms of the internal iliac and superior mesenteric arteries were successfully treated with a low-profile stent-graft (Jostent) designed for coronary use. The technical and regulatory issues pertinent to this device are discussed.

The older adult patient with trauma is becoming a growing part of the overall trauma population. With the world population increasing in age, the rate of the traumatically injured older adult will continue to increase. Recognizing this problem and the fact that the elderly are at higher risk for injury and its complications will be necessary if the increasing volume of patients is to be dealt with. This review discusses these issues, as well as appropriate triage and treatment of injuries and associated comorbidities. Early recognition of injury, even minor, and expedited care using specialized teams will help to improve outcomes for these patients.

Thromboembolic events (TEs), including pulmonary embolisms (PEs), are life threatening. Older patients with trauma are at significantly higher risk for these complications. In March 2003, a deep vein thrombosis (DVT) prophylaxis protocol was implemented for use in all trauma patients admitted to our hospital. Here we report on the results of using this protocol for patients aged 65 years or older. A risk-stratified DVT/PE prophylaxis protocol was developed, incorporating specific injuries and history and physiologic parameters, which favored aggressive therapy and included patients at highest risk for dying from PEs. Between March 2003 and June 2005, these data were collected on all trauma patients admitted to our level I hospital. Comparisons were made with historical controls (patients admitted in 2002, before implementation of this protocol). TE rates for the study period trended lower for patients aged 65 or older (6.4% vs 2.2%, P.1). This protocol did not increase the incidence of bleeding events in this patient population. Protocol-based, risk-adjusted DVT/TE prophylaxis is safe and efficacious in elderly trauma patients who are at increased risk for TEs.

To determine whether there is a benefit to platelet transfusion in mild traumatic brain injury (MTBI) patients with intracranial hemorrhage (ICH), taking antiplatelet therapy before hospitalization.The study design retrospectively reviewed patients admitted to a Level I trauma center during a 2-year period with an isolated MTBI (Glasgow Coma Scale score ≥13, ICH seen on a head computed tomographic scan (head computed tomography [HCT]), and taking an antiplatelet agent before hospitalization. HCT's were categorized based on the Marshall Classification, Rotterdam Score, and ICH volume. Hospital records were reviewed noting neurologic, cardiac, respiratory events, and discharge Glasgow Outcome Scale.There were 1,101 patients with TBI hospitalized during the 2-year study period. Three hundred twenty-one of these patients had an MTBI with ICH at the time of admission, and from this group, 113 were taking an antiplatelet agent. Only 4 (1.2%) of the 321 patients suffered a neurologic decline. All were gradual in nature, and none required emergent intervention. An analysis of the 113 patients taking antiplatelet agents, comparing patients who were not given a platelet transfusion with those who received a platelet transfusion, found no significant difference in the rate of HCT progression, neurologic decline, or Glasgow Outcome Scale at hospital discharge between the two groups. There was a trend, which was not significant, toward more medical declines in patients who received a platelet transfusion. A further review, analyzing all 321 patients with ICH showed receiving a transfusion of any type (i.e., platelets, fresh frozen plasma, or blood) was a strong predictor of medical decline (p0.0001). The odds ratio of having a medical decline after transfusion was 5.8 (95% confidence interval, 1.2-28.2).Platelet transfusion did not improve short-term outcomes after MTBI. Further randomized controlled trials need to be done to truly assess if there is no benefit in platelet transfusion in patients taking antiplatelet agents suffering an MTBI. Because the overall outcome in MTBI patients is favorable, platelet transfusion in these patients may not be indicated.

Purpose of review Appropriate measurements of success in trauma systems are evolving. We review the rationale behind prior trauma and rehabilitation outcomes measures, and how they have led to the current rehabilitation tools in use today. In addition, we review the difficulties with current methods and future improvements that need to occur. Recent findings As medicine marches toward improved used of clinical evidence, trauma practitioners have worked for improved outcomes research. A major part of this is that outcomes such as functional status and quality of life are as important as mortality statistics. Trauma rehabilitation outcomes are thus more important, yet in the past all such tools have had major impediments to implementation across a heterogeneous trauma population. Newly recognized major domains such as quality of life, preinjury status, patient perceptions, and actual function at work have not been adequately addressed with current rehabilitation measures. At this time, no clinically applicable trauma rehabilitation score exists. Summary Trauma rehabilitation outcomes are an important measurement of trauma system effectiveness. A more effective, easily applied rehabilitation score is needed to adequately assess all appropriate domains of clinical improvement in the injured patient.

Current guidelines recommend using antiseptic- or antibiotic-impregnated central venous catheters (CVCs) if, following a comprehensive strategy to prevent catheter-related blood stream infection (CR-BSI), infection rates remain above institutional goals based on benchmark values. The purpose of this study was to determine if chlorhexidine/silver sulfadiazine-impregnated CVCs could decrease the CR-BSI rate in an intensive care unit (ICU) with a low baseline infection rate.Pre-intervention and post-intervention observational study in a 24-bed surgical/trauma/burn ICU from October, 2002 to August, 2005. All patients requiring CVC placement after March, 2004 had a chlorhexidine/silver sulfadiazine-impregnated catheter inserted (post-intervention period).Twenty-three CR-BSIs occurred in 6,960 catheter days (3.3 per 1,000 catheter days)during the 17-month control period. After introduction of chlorhexidine/silver sulfadiazine-impregnated catheters, 16 CR-BSIs occurred in 7,732 catheter days (2.1 per 1,000 catheter days; p = 0.16). The average length of time required for an infection to become established after catheterization was similar in the two groups (8.4 vs. 8.6 days; p = 0.85). Chlorhexidine/silver sulfadiazine-impregnated catheters did not result in a statistically significant change in the microbiological profile of CR-BSIs, nor did they increase the incidence of resistant organisms.Although chlorhexidine/silver sulfadiazine-impregnated catheters are useful in specific patient populations, they did not result in a statistically significant decrease in the CR-BSI rate in this study, beyond what was achieved with education alone.

BACKGROUND: Daily spontaneous-breathing trials (SBTs) are promulgated as the best method for assessing readiness for discontinuation of mechanical ventilation. SBT protocols have also been shown to improve outcomes as opposed to wild-type implementation of daily SBT recommendations. Here we determine whether implementation of a mandatory, protocol-driven daily SBT on all ventilated patients in the ICU improves extubation rates and accelerates liberation from mechanical ventilation. STUDY DESIGN: A daily 30-minute SBT protocol was introduced into an academic surgical ICU in July 2005 and followed through September 2006. Decisions about next steps (continued mechanical support versus liberation) after each trial were recorded. Owing to the low liberation rate, physicians began (in January 2006) recording the reasons for continuing mechanical ventilation after a passing SBT. Differences in patient outcomes were compared for the first and last 8 weeks of the study period, corresponding to similar times in the academic and calendar years. RESULTS: Four hundred eighty-eight patients experienced 547 mechanical ventilation episodes from July 2005 to September 2006. A total of 2,835 safety evaluations for SBTs were completed. Rate of extubations of passing patients after the first 8 weeks of implementation (n = 73 patients) was 27% (35 extubations of 131 passed trials). This rate improved in the last 8 weeks to 42% (42 of 101) (p < 0.02) (n = 57 patients). Reintubation rate was similar at 6% for the first 8 weeks and 8% for the final 8 weeks (p = 0.65), including self-extubations. CONCLUSIONS: Implementation of a daily SBT protocol resulted in improvement of extubation rates during the year of implementation without a change in the reintubation rate. Requesting that physicians enumerate reasons for continuing mechanical ventilation in the face of a passing breathing trial was associated with a sustained improvement in extubation rate.

Professional responsibilities have been a concern of surgeons since antiquity; however, the last 25 years have displayed a dramatic growth of both professional and societal attention to moral and ethical issues involved in the delivery of health care. This increased interest in medical ethics has occurred because of such factors as the greater technological power of modern medicine, the assigning of social ills to the responsibility of medicine, the growing sophistication of patients and the information available to them, the efforts to protect the civil rights of the increasing disadvantaged groups in our society, and the continued rapidly escalating costs of health care, including medical malpractice costs. All of these factors contribute to the urgency of dealing with ethical and moral issues involved in the delivery of modern emergency surgical care.1

Background: Thromboembolic events (TE) such as deep venous thrombosis (DVT) and pulmonary embolism (PE) are common after trauma. Our Trauma Practice Management Committee developed an evidence-based DVT/PE prophylaxis guideline using a modified Delphi approach to standardize care and reduce TE rates. Our objective was to evaluate the applicability, efficacy, and safety of this guideline in the traumatized patient, especially those admitted first to the intensive care unit (ICU). Methods: We developed a risk-stratified DVT/PE prophylaxis guideline incorporating specific injuries, pertinent history, and physiologic parameters, favoring aggressive therapy in those at highest risk of dying from a PE. We prospectively collected data using this guideline in all patients admitted to the trauma or orthopedic-trauma services that were expected to stay for more than 48 hours (March-December 2003). Comparison was made with historical controls. Data collected included DVT, PE, prophylaxis level chosen, inferior vena cava filters, admission service and location, TRISS scores, length of stay, outcomes, adverse events, and specific risk factors. Results: TE rates after implementation of the guideline were lower than historical controls for all patients (1.9% vs. 1.0%, p = 0.059) and for patients admitted first to the ICU (6.3% vs. 2%, p = 0.018). Completed sheets were collected for 46% of the targeted population. No bleeding events caused by guideline anticoagulation were noted, and one death occurred after inferior vena cava filter placement. Nine of the 12 TEs in the treatment group were in patients with spine or closed-head injury, delaying chemical prophylaxis. Conclusion: Form-based, risk-adjusted prophylaxis against TE leads to lower TE rates in a general and orthopedic ICU trauma population. Protocol compliance should be enforced.

Severe acute respiratory distress syndrome (ARDS) is associated with a high level of mortality. Extracorporeal life support (ECLS) during severe ARDS maintains oxygen and carbon dioxide gas exchange while providing an optimal environment for recovery of pulmonary function. Since 1989, we have used a protocol-driven algorithm for treatment of severe ARDS, which includes the use of ECLS when standard therapy fails. The objective of this study was to evaluate our experience with ECLS in adult patients with severe ARDS with respect to mortality and morbidity.We reviewed our complete experience with ELCS in adults from January 1, 1989, through December 31, 2003. Severe ARDS was defined as acute onset pulmonary failure, with bilateral infiltrates on chest x-ray, and PaO2/fraction of inspired oxygen (FiO2) ratioor =100 or A-aDO2600 mm Hg despite maximal ventilator settings. The indication for ECLS was acute severe ARDS unresponsive to optimal conventional treatment. The technique of ECLS included veno-venous or veno-arterial vascular access, lung "rest" at low FiO2 and inspiratory pressure, minimal anticoagulation, and optimization of systemic oxygen delivery.During the study period, ECLS was used for 405 adult patients age 17 or older. Of these 405 patients, 255 were placed on ECLS for severe ARDS refractory to all other treatment. Sixty-seven percent were weaned off ECLS, and 52% survived to hospital discharge. Multivariate logistic regression analysis identified the following pre-ELCS variables as significant independent predictors of survival: (1) age (P = 0.01); (2) gender (P = 0.048); (3) pHor =7.10 (P = 0.01); (4) PaO2/FiO2 ratio (P = 0.03); and (5) days of mechanical ventilation (P0.001). None of the patients who survived required permanent mechanical ventilation or supplemental oxygen therapy.Extracorporeal life support for severe ARDS in adults is a successful therapeutic option in those patients who do not respond to conventional mechanical ventilator strategies.

Background: Carbamazepine intoxication is associated with seizures, coma, arrhythmias, and death. In acute intoxications, charcoal hemoperfusion enhances removal of the drug but is associated with thrombocytopenia, coagulopathy, hypothermia, and hypocalcemia. Alternatively, high-efficiency hemodialysis can be used without the side effects of charcoal hemoperfusion. Case Report: We report an 18-month-old comatose, convulsing child with plasma carbamazepine 27 μg/mL treated with high efficiency hemodialysis. Therapeutic carbamazepine levels were obtained after 4.5 hours of high-efficiency hemodialysis. The patient developed no untoward side effects, improved clinically, and was subsequently discharged home without sequelae. We conclude that high-efficiency hemodialysis is a safe, effective alternative to charcoal hemoperfusion in the pediatric population.