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Background: Limited data exist regarding the impact of advanced care planning for injured geriatric patients. We hypothesized that patients with advance directives limiting care (ADLC) compared with those without ADLC are more likely to undergo withdrawal of life-sustaining support (WLSS)., Methods: This is a propensity-matched analysis utilizing American College of Surgeons Trauma Quality Improvement Program patients 65 years or older who presented between 2017 and 2018. Patients with and without ADLC on admission were compared. The primary outcome was WLSS and days prior to WLSS. Additional factors examined included hospital length of stay (LOS), unplanned operations, unplanned intensive care unit admissions, and in-hospital cardiac arrests. Prior to matching, logistic regression model assessed factors associated with WLSS. Patients with and without ADLC were matched 1:1 via a propensity score using patient and injury factors as covariates, and matched pair analysis compared differences in WLSS between patients with and without ADLC., Results: There were 597,840 patients included: 44,001 patients with an ADLC (7.36%) compared with 553,839 with no ADLC (92.64%). Patients with an ADLC underwent WLSS more often than those with no ADLC (7.68% vs. 2.48%, p < 0.001). In a 1:1 propensity-matched analysis, patients with ADLC were more likely to undergo WLSS (odds ratio [OR], 2.38' 95% confidence interval [CI], 2.22-2.55), although stronger predictors of WLSS included severity of injury (Injury Severity Score, 25+; OR, 23.84; 95% CI, 21.55-26.36), unplanned intensive care unit admissions (OR, 3.30; 95% CI, 2.89-3.75), and in-hospital cardiac arrests (OR, 4.97; 95% CI, 4.02-6.15)., Conclusion: A small proportion of the geriatric trauma population had ADLC on admission. While ADLC was predictive of WLSS, adverse events were more strongly associated with WLSS. To ensure patient-centered care and reduce futile interventions, surgeons should delineate goals of care early regardless of ADLC., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2022 American Association for the Surgery of Trauma.)

Background: Decreasing the burden of mechanical ventilation for spinal cord injuries was never more relevant than during the COVID-19 pandemic. Data have shown diaphragm pacing can replace mechanical ventilation, decrease wean times, improve respiratory mechanics, and decrease hospital costs for patients with spinal cord injuries. This is the largest report of diaphragm pacing during the pandemic., Methods: This is a retrospective analysis of prospective Institutional Review Board approved databases of nonrandomized interventional experience at a single institution. Subgroup analysis limited to traumatic cervical spinal cord injuries that were implanted laparoscopically with diaphragm electrodes within 30 days of injury., Results: For the study group of early implanted traumatic cervical spinal cord injuries, 13 subjects were identified from a database of 197 diaphragm pacing implantations from January 1, 2020, to December 31, 2022, for all indications. All subjects were male with an average age of 49.3 years (range, 17-70). Injury mechanisms included falls (6), motor vehicle accident (4), gunshot wound (2), and diving (1). Time from injury to diaphragm pacing averaged 11 days (range, 3-22). Two patients are deceased and neither weaned from mechanical ventilation. Nine of the remaining 11 patients weaned from mechanical ventilation. Four patients never had a tracheostomy and 3 additional patients had tracheostomy decannulation. Three of these high-risk pulmonary compromised patients survived COVID-19 infections utilizing diaphragm pacing., Conclusion: Diaphragm pacing successfully weaned from mechanical ventilation 82% of patients surviving past 90 days. Forty-four percent of this group never underwent a tracheostomy. Only 22% of the weaned group required long term tracheostomies. Early diaphragm pacing for spinal cord injuries decreases mechanical ventilation usage and tracheostomy need which allows for earlier placement for rehabilitation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Handoffs are defined as the transfer of patient information, professional responsibility, and accountability between caregivers. This work aims to clarify the current state of transitions of care related to the management of trauma patients., Methods: A PubMed database and web search were performed for articles published between 2000 and 2020 related to handoffs and transitions of care. The key search terms used were: handoff(s), handoff(s) AND healthcare, and handoff(s) AND trauma. A total of 55 studies were included in qualitative synthesis., Results: This systematic review explores the current state of healthcare handoffs for trauma patients. Factors found to impact successful handoffs included process standardization, team member accountability, effective communication, and the incorporation of culture. This review was limited by the small number of prospective randomized studies available on the topic., Conclusion: Handoffs in trauma care have been studied and should be utilized in the context of published experience and practice. Standardization when applied with accountability has proven benefit to reduce communication errors during these transfers of care., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation. We sought to investigate factors associated with the development of VAP in critically ill trauma patients., Methods: We conducted a retrospective review of trauma patients admitted to our trauma intensive care unit between 2016 and 2018. Patients with ventilator-associated pneumonia were identified from the trauma database. Data collected from the trauma database included demographics (age, gender and race), mechanism of injury (blunt, penetrating), injury severity (injury severity score "ISS"), the presence of VAP, transfused blood products and presenting vital signs., Results: A total of 1403 patients were admitted to the trauma intensive care unit (TICU) during the study period; of these, 45 had ventilator-associated pneumonia. Patients with VAP were older (p = 0.030), and they had a higher incidence of massive transfusion (p = 0.015) and received more packed cells in the first 24 h of admission (p = 0.028). They had a higher incidence of face injury (p = 0.001), injury to sternum (p = 0.011) and injury to spine (p = 0.024). Patients with VAP also had a higher incidence of acute kidney injury (AKI) (p < 0.001) and had a longer ICU (p < 0.001) and hospital length of stay (p < 0.001). Multiple logistic regression models controlling for age and injury severity (ISS) showed massive transfusion (p = 0.017), AKI (p < 0.001), injury to face (p < 0.001), injury to sternum (p = 0.007), injury to spine (p = 0.047) and ICU length of stay (p < 0.001) to be independent predictors of VAP., Conclusions: Among critically ill trauma patients, acute kidney injury, injury to the spine, face or sternum, massive transfusion and intensive care unit length of stay were associated with VAP.

Background: Ventilator-associated pneumonia is associated with significant morbidity. Although the association of gender with outcomes in trauma patients has been debated for years, recently, certain authors have demonstrated a difference. We sought to compare the outcomes of younger men and women to older men and women, among critically ill trauma patients with ventilator-associated pneumonia (VAP)., Methods: We reviewed our trauma data base for trauma patients with ventilator-associated pneumonia admitted to our trauma intensive care unit between January 2016 and June 2018. Data collected included demographics, injury mechanism and severity (ISS), admission vital signs and laboratory data and outcome measures including hospital length of stay, ICU stay and survival. Patients were also divided into younger (<50) and older (≥50) to account for hormonal status. Linear regression and binary logistic regression models were performed to compare younger men to older men and younger women to older women, and to examine the association between gender and hospital length of stay (LOS), ICU stay (ICUS), and survival., Results: Forty-five trauma patients admitted to our trauma intensive care unit during the study period (January 2016 to August 2018) had ventilator-associated pneumonia. The average age was 58.9 ± 19.6 years with mean ISS of 18.2 ± 9.8. There were 32 (71.1%) men, 27 (60.0%) White, and 41 (91.1%) had blunt trauma. Mean ICU stay was 14.9 ± 11.4 days and mean total hospital length of stay (LOS) was 21.5 ± 14.6 days. Younger men with VAP had longer hospital LOS 28.6 ± 17.1 days compared to older men 16.7 ± 6.6 days, ( p < 0.001) and longer intensive care unit stay 21.6 ± 15.6 days compared to older men 11.9 ± 7.3 days ( p = 0.02), there was no significant difference in injury severity (ISS was 22.2 ± 8.4 vs. 17 ± 8, p = 0.09)., Conclusions: Among trauma patients with VAP, younger men had longer hospital length of stay and a trend towards longer ICU stay. Further research should focus on the mechanisms behind this difference in outcome using a larger database.

Background: Cervical spinal cord injury can result in catastrophic respiratory failure requiring mechanical ventilation with high morbidity, mortality, and cost. Diaphragm pacing was developed to replace/decrease mechanical ventilation. We report the largest long-term results in traumatic cervical spinal cord injury., Methods: In this retrospective review of prospective institutional review board protocols, all patients underwent laparoscopic diaphragm mapping and implantation of electrodes for diaphragm strengthening and ventilator weaning., Results: From 2000 to 2017, 92 patients out of 486 diaphragm pacing implants met the criteria. The age at time of injury ranged from birth to 74 years (average: 27 years). Time on mechanical ventilation was an average of 47.5 months (range, 6 days to 25 years, median = 1.58 years). Eighty-eight percent of patients achieved the minimum of 4 hours of pacing. Fifty-six patients (60.8%) used diaphragm pacing 24 hours a day. Five patients had full recovery of breathing with subsequent diaphragm pacing removal. Median survival was 22.2 years (95% confidence interval: 14.0-not reached) with only 31 deaths. Subgroup analysis revealed that earlier diaphragm pacing implantation leads to greater 24-hour use of diaphragm pacing and no need for any mechanical ventilation., Conclusion: Diaphragm pacing can successfully decrease the need for mechanical ventilation in traumatic cervical spinal cord injury. Earlier implantation should be considered., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The effectiveness of trauma center-based injury prevention programs is constrained by a number of variables. These include the wide range of injury types, the variety of possible interventions, institutional support and funding, and the knowledge and experience of the persons responsible for these programs. As the field of injury prevention has increased in complexity, so must the role and professional development of these injury prevention professionals responsible for these programs. Trauma center-based injury prevention coordinators are a diverse group with variable education and professional background especially related to public health, advocacy, epidemiology, biostatistics, and research. Furthermore, inconsistencies exist with their job titles, responsibilities, accountability, and authority, as well as the associated professional resources available to them. The American Trauma Society, with facilitation by the member organizations of the Trauma Prevention Coalition, has addressed the need to standardize the educational foundation for injury prevention coordinators by providing the basis of core competencies that are necessary to successfully oversee an American College of Surgeon's Committee on Trauma-verified trauma center's injury prevention program. This inaugural Injury Prevention Coordinators Course was launched in conjunction with the Society of Trauma Nurses 2015 annual conference in Jacksonville, FL, with 7 additional courses having been held through March 2016, comprising 150 participants. The goal of this 2-day, formal trauma center-based, course is to address and standardize key educational segments, including impact of trauma, program development, program evaluation, public health models, injury and data analysis, epidemiology, advocacy, building partnerships and coalitions, and the use of media promotion to ensure consistency throughout the industry.

Despite the potentially devastating impact of missed cervical spine injuries (CI), there continues to be a large disparity in how institutions attempt to make the diagnosis. To better streamline the approach among institutions, understanding incidence and risk factors across the country is paramount. We evaluated the incidence and risk factors of CI using the National Trauma Databank for 2008 and 2009. We performed a retrospective review of the National Trauma Databank for 2008 and 2009 comparing patients with and without CI. We then performed subset analysis separating injury by patients with and without fracture and ligamentous injury. There were a total of 591,138 patients included with a 6.2 per cent incidence of CI. Regression found that age, Injury Severity Score, alcohol intoxication, and specific mechanisms of motor vehicle crash (MVC), motorcycle crash (MCC), fall, pedestrian stuck, and bicycle were independent risk factors for overall injury (P < 0.0001). Patients with CI had longer intensive care unit (8.5 12.5 vs 5.1 7.7) and hospital lengths of stay (days) (9.6 14.2 vs 5.3 8.1) and higher mortality (1.2 per cent vs 0.3%), compared with those without injury (P < 0.0001). There were 33,276 patient with only fractures for an incidence of 5.6 per cent and 1875 patients with ligamentous injury. Just over 6 per cent of patients suffer some form of CI after blunt trauma with the majority being fractures. Higher Injury Severity Score and MVC were consistent risk factors in both groups. This information will assist in devising an algorithm for clearance that can be used nationally allowing for more consistency among trauma providers.

Femoral venous catheterization is a common, invasive procedure, which may lead to serious complications. Validated checklists are central to teaching and assessing procedural skills and may result in improved health care quality. The results of the first step of the validation of a femoral venous catheterization checklist are described. A comprehensive literature review of articles published on femoral venous catheterization did not yield a checklist validated by the Delphi method. A modified Delphi technique, involving a panel of 8 interdisciplinary, interinstitutional experts, was used to develop a femoral venous catheterization checklist. The internal consistency coefficient using Cronbach α was .99. Developing a 29-item checklist for teaching and assessing femoral venous catheterization is the first step in the validation process. For this checklist to become further validated, it should be implemented and studied in the simulation and clinical environments., (© 2013 by the American College of Medical Quality.)

Radial arterial line placement is an invasive procedure that may result in complications. Validated checklists are central to teaching and assessing procedural skills and may result in improved health care quality. The results of the first step of the validation of a radial arterial line placement checklist are described. A comprehensive literature review of articles published on radial arterial line placement did not yield a checklist validated by the Delphi method. A modified Delphi technique, involving a panel of 9 interdisciplinary, interinstitutional experts, was used to develop a radial arterial line placement checklist. The internal consistency coefficient using Cronbach α was .99. Developing a 22-item checklist for teaching and assessing radial arterial line placement is the first step in the validation process. For this checklist to become further validated, it should be implemented and studied in the simulation and clinical environments.

Background: Injury is the leading cause of death for all Americans aged 1 to 35 years, and injury-related costs exceed $100 billion per year in the United States. Trauma centers can be important resources for risk identification and prevention strategies. The authors review 3 important resources for injury prevention education and research: the National Trauma Data Bank, geographic information systems, and an overview of injury prevention education., Data Sources: The National Trauma Data Bank and the Trauma Quality Improvement Program are available through the Web site of the American College of Surgeons. Links to research examples using geographic information systems software and the National Trauma Data Bank are provided in the text. Finally, resources for surgical educators in the area of injury prevention are summarized and examples provided., Conclusions: Database research, geographic information systems, and injury prevention education are important tools in the field of injury prevention. This article provides an overview of current research and education strategies and resources., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Foley catheterization (FC) is known to result in complications. Validated checklists are central to teaching/assessing procedural skills and may result in improved health care quality. The results of the first step of the validation of male and female FC checklists are described. A comprehensive literature review of articles published on FC did not yield a checklist validated by the Delphi method. A modified Delphi technique involving a panel of 7 experts was used to develop FC checklists. The internal consistency coefficients using Cronbach's α were .91 and .88, respectively, for males and females. Developing a 24-item male FC checklist and a 23-item female FC checklist for teaching/assessing FC is the first step in the validation process. For these checklists to become further validated, they should be implemented and studied in the simulation and the clinical environments.

Nasogastric (NG) tube insertion is known to result in complications. Validated checklists are central to teaching and assessing procedural skills and may result in improved health care quality. The results of the first step of the validation of an NG tube insertion checklist are described. A comprehensive literature review of articles published on NG tube insertion did not yield a checklist validated by the Delphi method. A modified Delphi technique, involving a panel of 9 interdisciplinary, interinstitutional experts, was used to develop an NG tube insertion checklist. The internal consistency coefficient using Cronbach's α was .80. Developing a 19-item checklist for teaching and assessing NG tube insertion is the first step in the validation process. For this checklist to become further validated, it should be implemented and studied in the simulation and clinical environments.

Lumbar puncture (LP) is known to result in complications. Procedure skills should be taught and evaluated more effectively to improve health care quality. Validated checklists are central to teaching and assessing procedural skills. The results of the first step of the validation of an adult LP checklist are described. A comprehensive literature review of articles published on LP did not yield a checklist validated by the Delphi method. A modified Delphi technique, involving a panel of 9 experts, was used to develop a 20-item LP checklist for teaching and assessing LP, the first step in the validation process. The internal consistency coefficient using Cronbach's α was 0.79. The authors used a modified Delphi method to develop a checklist for teaching and assessing LP. For this checklist to become further validated, it should be implemented and studied in the simulation and clinical environments.

Thoracentesis is an invasive procedure known to result in complications. Procedure skills should be taught and evaluated more effectively to improve health care quality. Validated checklists are central to teaching and assessing procedural skills. The results of the first step of the validation of a thoracentesis checklist are described. A comprehensive literature review of articles published on thoracentesis did not yield a validated checklist. A modified Delphi technique, involving a panel of 8 interdisciplinary, interinstitutional experts, was used to develop a thoracentesis checklist. The internal consistency coefficient using Cronbach's α was .94. Developing the 23-item thoracentesis checklist for teaching and assessing thoracentesis is the first step in the validation process. For this checklist to become further validated, it should be implemented and studied in the simulation and clinical environments.

Paracentesis is an invasive procedure known to result in complications. Procedure skills should be taught and evaluated more effectively to improve health care quality. Validated checklists are central to teaching and assessing procedural skills. The results of the first step of the validation of a paracentesis checklist are described. A comprehensive literature review of articles published on paracentesis did not yield a validated checklist. A modified Delphi technique, involving a panel of 8 interdisciplinary, interinstitutional experts, was used to develop a paracentesis checklist. The internal consistency coefficient using Cronbach's α was .92. Developing the 24-item paracentesis checklist for teaching and assessing paracentesis is the first step in the validation process. For this checklist to become further validated, it should be implemented and studied in the simulation and clinical environments.

Although most thoracic trauma may be treated non-operatively, major thoracic trauma accounts for 25% of trauma deaths. Except for provision of a definitive airway and/or relief of a tension pneumothorax with a needle decompression, the vast majority of thoracic trauma is best served with "load and go," high-flow oxygen, placement of an IV line and administration of crystalloid solutions as the clinical scenario would indicate. Understanding the mechanism of injury is helpful in establishing both prehospital and in-hospital management priorities. Patients who sustain a single penetrating wound to the chest have the best survivability after a resuscitative thoracotomy. Practicing chest assessment skills is vital to being a good prehospital provider. Ultrasound, NIRS tissue oxygenation and telemedicine will likely become more commonly employed as prehospital monitoring options. PEEP, or "over bagging," may exacerbate a simple or open pneumothorax, converting it to a tension pneumothorax.

The American Association for the Surgery of Trauma challenged the trauma community to improve a 22 per cent average removal rate for retrievable inferior vena cava filters (r-IVCFs). Since 2006, we maintained a "filter registry" documenting all IVCFs placed in trauma patients. Our goal was to improve removal rates for r-IVCF. Patients receiving an IVCF before implementation of filter registry, 2003-2005, comprised the control group. Patients receiving an IVCF after implementation of filter registry, 2006-2009, comprised the study group. Data obtained included age, gender, Injury Severity Score (ISS), length of stay (LOS), mortality, filter inserted, placement indication, removal rates, and reasons why removal did not occur. Fisher exact test and chi square were used for nominal variables. Stepwise logistic regression analysis was used to define predictors of removing and not removing an IVCF. Three hundred seven patients received an IVCF, 142 preregistry and 165 postregistry. No significant difference existed between groups in age, gender, ISS, placement indication, or mortality. A significant difference existed between groups in LOS and presence of deep vein thrombosis (DVT) and pulmonary embolism. A total of 98.2 per cent of postregistry patients received a Günther Tulip filter and all retrievals were performed by Interventional Radiology. Retrieval rates improved, 15.5 to 31.5 per cent post registry (P < 0.001). No differences existed in lost to follow-up (LTF) between groups. Univariate analysis identified age, IVC clot, DVT, and LTF as predictors for not removing a filter. Stepwise logistic regression revealed the filter registry independently predicts the removal of an r-IVCF. A filter registry is effective in improving rates of removal for r-IVCFs.

Objective: Postpartum hemorrhage is a leading cause of maternal mortality. Massive transfusion in obstetric patients is rare. Recombinant Factor VIIa (rFVIIa) use in trauma patients with massive transfusion is efficacious. Our goal was to evaluate the safety and efficacy of rFVIIa use in obstetric patients with massive postpartum hemorrhage (MPH)., Methods: Patients records with MPH from 2003 to 2006 were reviewed. Data collected were demographics, APACHE II scores, International Normalized Ratio (INR), fibrinogen level, blood product administration, rates of pulmonary embolism (PE), deep vein thrombosis (DVT), myocardial infarction (MI), hysterectomy, and mortality. Continuous variables within groups were analyzed with paired t-test, and independent t-test between groups. Categorical variables were compared via chi2 or Fishers Exact test and significance was denoted by a p < or = 0.05., Results: Twenty-seven patients with MPH were investigated, eight received rFVIIa (study group) and 19 did not (control group). All patients received a massive transfusion, six units of packed red blood cells (pRBCs), via a massive transfusion protocol. The study group's mean APACHE II score 25.8 +/- 8.5, predicted mortality of 56.2 percent, was higher than control, p = 0.009. An increase in transfused units of cryoprecipitate, p < 0.001, pRBCs, p = 0.004, decrease in INR, p < 0.001, and length of stay in the high risk obstetrical unit, p = 0.019, existed in the study group. Hysterectomy was required in 85.7 percent of the study group. No patients developed a DVT, PE, or MI and all survived., Conclusions: Recombinant Factor VIIa use in MPH is safe, improves coagulopathy, was not effective in decreasing blood product transfusion requirements, and may contribute to an improved predicted mortality.

This case study describes an abdominal aortic injury and lumbar vertebral body fracture after blunt trauma. Abdominal aortic pseudoaneurysm is a rare complication of blunt abdominal trauma. Recent data reveal seven other reports in the literature. We describe a case of an inframesocolic abdominal aortic injury and lumbar vertebral body fracture from blunt trauma in a 16-year-old male after a hyperextension injury while body board surfing.

Background: This study attempts to validate the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for spleen, liver, and kidney injuries using the National Trauma Data Bank (NTDB)., Study Design: All NTDB entries with Abbreviated Injury Scale codes for spleen, liver, and kidney were classified by OIS grade. Injuries were stratified either as an isolated intraabdominal organ injury or in combination with other abdominal injuries. Isolated abdominal solid organ injuries were additionally stratified by presence of severe head injury and survival past 24 hours. The patients in each grading category were analyzed for mortality, operative rate, hospital length of stay, ICU length of stay, and charges incurred., Results: There were 54,148 NTDB entries (2.7%) with Abbreviated Injury Scale-coded injuries to the spleen, liver, or kidney. In 35,897, this was an isolated abdominal solid organ injury. For patients in which the solid organ in question was not the sole abdominal injury, a statistically significant increase (p < or = 0.05) in mortality, organ-specific operative rate, and hospital charges was associated with increasing OIS grade; the exception was grade VI hepatic injuries. Hospital and ICU lengths of stay did not show substantial increase with increasing OIS grade. When isolated organ injuries were examined, there were statistically significant increases (p < or = 0.05) in all outcomes variables corresponding with increasing OIS grade. Severe head injury appears to influence mortality, but none of the other outcomes variables. Patients with other intraabdominal injuries had comparable quantitative outcomes results with the isolated abdominal organ injury groups for all OIS grades., Conclusions: This study validates and quantifies outcomes reflective of increasing injury severity associated with increasing OIS grades for specific solid organ injuries alone, and in combination with other abdominal injuries.

Trauma patients on prescribed warfarin therapy sustaining intracranial hemorrhage can be difficult to manage. Rapid normalization of coagulopathy is imperative to operative intervention and may affect outcomes. To identify and expedite warfarin reversal, we designed a protocol to administer a prothrombin complex concentrate. A Proplex T protocol was instituted in May 2004. It dictated that trauma patients with an International Normalized Ratio (INR) greater than 1.5, history of prescribed warfarin therapy, and intracranial hemorrhage on CT scan receive a prothrombin complex concentrate for reversal of their coagulopathy. Neither the protocol nor the factor concentrate was validated for use in this subset of trauma patients; therefore, adherence to the protocol and use of the factor concentrate was not mandatory. Patients not administered the prothrombin complex concentrate received vitamin K and fresh-frozen plasma. The protocol resulted in an increased number of patients receiving Proplex T (54.3% vs 35.4%, P = 0.047). Protocol patients had improved times to normalization of INR (331.3 vs 737.8 minutes, P = 0.048), number of patients with reversal of coagulopathy (73.2% vs 50.9%, P = 0.026), and time to operative intervention (222.6 vs 351.3 minutes, P = 0.045) compared with control subjects. There were no differences in intensive care unit (ICU) days, hospital days, or mortality. The Proplex T protocol increased the number of patients who received prothrombin complex concentrate, provided rapid normalization of INR, and improved time to operative intervention.

Objective: The purpose of this prospective study was to assess the impact of a two-tiered trauma response protocol on the expediency of identification, evaluation, and treatment of trauma patients in the Emergency Department., Materials and Methods: At a Level I Trauma Center serving a suburban/urban population of approximately one million people, Emergency Department length of stay was tabulated for all consecutive Trauma Service admissions 6 months before and 6 months after implementation of a two-tiered trauma response protocol. This protocol, which uses specific triage criteria, consisted of the standard Surgery-supervised trauma code response and an additional Emergency Medicine-supervised trauma alert response., Results: Trauma Service admissions numbered 532 in the pre-protocol period and 512 in the period after implementation of the protocol. In the first period, the Emergency Department length of stay was 289 minutes; in the second period, it was 241 minutes. Of the 512 patients in the post-protocol period, 183 were triaged to the new trauma alert group, reducing the number of Trauma Service consultations and decreasing Emergency Department length of stay by 139 minutes. The two levels of trauma response allowed accurate identification of the most seriously injured patients and improved the ability to predict those patients who would require direct disposition to the operating room or intensive care unit., Conclusions: Implementation of a two-tiered trauma response significantly decreased Emergency Department length of stay, allowed Emergency Medicine physicians to more rapidly identify, evaluate, and treat trauma patients requiring hospitalization, improved identification of patients requiring operating room or intensive care unit resources, and was time efficient and resource efficient.

A rare case of blunt chest trauma resulting in internal mammary artery hemorrhage and cardiac tamponade is presented. Thoracotomy revealed anterior mediastinal hemorrhage but no pericardial hematoma. The significance of chest wall vessel hemorrhage as a cause of widened mediastinum is reiterated. The importance of accurate angiographic assessment and vigilant care of victims of blunt chest trauma who present with a widened mediastinum is emphasized.

Although the majority of trauma patients are discharged home rather than to a rehabilitation facility, the timeliness of their return to function (RTF) has received little study. The present prospective study attempted to identify those factors that would predict delayed RTF. The study group consisted of patients admitted to a level I trauma center for at least 24 hours, who were of working age (18-64 years), who passed a cognitive screening examination, and who were discharged home. Demographic data and psychological profiles were collected on all participants. Patients were followed by telephone at approximately 1 1/2, 3, and 6 months after discharge. Five hundred seventy patients were entered into the study; complete follow-up data were available for 441. Statistical methods were modeled after survival analysis using a proportional hazards multiple regression to identify variables prognostic of RTF time. This type analysis is independent of time, providing a "risk" of RTF at any point in time after the injury. It also allowed the calculation a relative hazards ratio (RHR), which quantifies the impact of a prognostic variable on RTF time. Injury Severity Score (ISS) and age were found to be associated with RTF (p < 0.0001 for each). After correcting for ISS and age, five additional factors were found to be associated with RTF. Higher educational level and living in a non-family household were associated with faster RTF. Less than 100% income replacement by disability income, pre-injury hostility, and litigation related to the injury were associated with slower RTF. There were a number of other demographic, work-related, and psychosocial factors that were not related with RTF.(ABSTRACT TRUNCATED AT 250 WORDS)

Overtriage (i.e.; transport of patients with minimal injuries to a trauma center) has been accepted as necessary to avoid missing clinically significant injuries. We reviewed our experience with 344 patients (ISS less than or equal to 4) who were admitted to a level I trauma center during a 2-year period. The trauma team was activated for 209 patients (TA), and emergency department referrals accounted for 135 (ED). One hundred seventy-three patients (TA = 64%, ED = 36%) met American College of Surgeons' Committee on Trauma (ACSCOT) field triage criteria (FTC). Mechanism of injury, especially ejection from a motor vehicle, was the most frequently utilized FTC indicator. We found no differences between the TA and ED groups relative to Trauma Score, Glasgow Coma Scale score, Injury Severity Score, length of stay, or ICU days. Mean total costs were higher for the TA group than for the ED group. The TA group had a higher nursing acuity level than the ED group. Compliance with FTC yields an inherent overtriage of minimally injured patients; however, noncompliance with FTC compounds the overtriage rate. Failure to comply with FTC is costly, labor intensive, and may represent misuse of the trauma system. We propose continual re-education of prehospital personnel, increased responsibility of all hospitals in the trauma center catchment area, and protocols for "downstaging" trauma resuscitation in minimally injured patients.

Trauma complicates 6 to 7 per cent of all pregnancies, but fetal demise secondary to maternal trauma occurs much less frequently. This study was done to analyze the incidence of fetal demise as a function of 21 maternal characteristics determined within the first 24 hours after trauma. Nine instances of fetal demise were identified from 73 pregnant patients with trauma admitted to four Level I trauma centers from a combined data base of 30,000 patients. Maternal factors examined by logistic regression were Injury Severity Score (ISS), Trauma Score (TS), Abbreviated Injury Scale (AIS), fluid requirements in the initial 24 hours, systolic blood pressure (SBP), heart rate (HR), hemoglobin, hematocrit and arterial blood gas analysis. Fetal demise was found to be associated with increasing ISS, increasing face and abdominal AIS, increasing fluid requirements, maternal acidosis and maternal hypoxia. Standard maternal laboratory and physiologic parameters, such as hemoglobin and hematocrit, oxygen and hemoglobin saturation, partial pressure of carbon dioxide, SBP and HR were not predictive. The TS was also found to be nonpredictive.

The impact of paralysis followed by intubation was studied in patients who had been traumatized and subsequently admitted to Lehigh Valley Hospital Center. Trauma admission records between January 1987 and June 1988 were reviewed. Fifty-seven patients, intubated for control of agitation and combativeness, were divided into high injury severity (HIS) and low injury severity (LIS) subgroups using admission trauma (TS) and injury severity scores (ISS). Thirty-eight (70%) were classified as HIS and 19 (30%) as LIS. All HIS patients had significant injuries diagnosed following paralysis with intubation (PWI). Mortality in the HIS group was 9%. The LIS subgroup was compared to a randomly selected group of similarly injured blunt trauma patients who did not require PWI. There were significant differences (P less than 0.05) in age, hospital cost, hours per day of nursing care, and percent of patients with an ETOH level greater than 100 mg%. Emergency paralysis with intubation is an effective method for controlling the uncooperative, combative, seriously injured patient. However, patients with low injury severity who require restraint have higher costs and require more care if they are paralyzed and intubated than if they are not.

Lack of case documentation has led to controversy over the existence of asymptomatic occult cervical spine injury. We report a case of an elderly patient involved in a motor vehicle accident who sustained an asymptomatic occult cervical spine injury, and review the literature with regard to this controversial injury.

To evaluate the impact cirrhosis has on survival the records of 40 cirrhotic trauma victims from the registries of two Level 1 trauma centers were reviewed and probability of survival calculated using the TRISS methodology. Mechanism of injury, anatomic location, involvement of single or multiple sites, presence of ascites, elevations in serum glutamic oxaloacetic transaminase (SGOT), alkaline phosphatase, serum bilirubin, prothrombin time (PT), and hypoalbuminemia were tabulated for each patient. Contingency tables were created for injury and hepatic parameters, as related to survival, and subjected to chi square analysis. Loglinear analysis was performed on all significant parameters to evaluate the independent effects of injury characteristics and hepatic insufficiency on survival. Predicted survival was 93%; observed survival was 70% (Z = -6.92; p less than 0.001). Cause of death was multiple-system organ failure (9) and closed head injury (3). Admission markers of poor outcome included one or more of the following: ascites, elevated PT or bilirubin, history of motor vehicle accident, multiple trauma, or blunt abdominal trauma requiring laparotomy. Loglinear analysis revealed that the presence of ascites, elevated PT, or bilirubin, further diminished the rate of survival for any individual injury characteristic. We concluded that survival among cirrhotic trauma victims was significantly lower than predicted. In addition the presence of hepatic insufficiency further diminishes survival, regardless of the injury sustained.

This work has been based on 15 years experience with more than 10,000 needle aspiration biopsies of the breast. Fine-needle aspiration biopsy was used in place of open breast biopsy for definitive operation in breast cancer. Our experience with 2,623 aspiration biopsies over a 3 year period has been reviewed. There was a total of 323 cancers, of which 257 (80 percent) were unequivocally diagnosed by fine-needle aspiration biopsy. Definitive operation was performed in 244 of these patients (95 percent) without open biopsy. Thirteen had an excisional biopsy before definitive operation at the request of the referring physician. The sensitivity was 80 percent and the specificity was 98 percent. There were no false-positive diagnoses. The positive predictive value was 100 percent. False-negative diagnoses were made in 9 percent of the patients, half of whom had nonpalpable carcinomas. Our experience shows that fine-needle aspiration biopsy is accurate in the diagnosis of breast cancer, and when the finding is positive, it can be used for definitive breast operation, eliminating the need for open biopsy. A management algorithm has also been presented herein.