Consecutive Trauma Admissions Research Articles

Venous thromboembolism in the high-risk trauma patient: do risks justify aggressive screening and prophylaxis?

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are considered to be a major source of morbidity and mortality among trauma patients. Several reports have identified high-risk patients with recommendations for management ranging from frequent duplex scanning to placement of prophylactic inferior vena cava (IVC) filters. We reviewed our experience with a large trauma population to determine whether such approaches are justified. We analyzed 2,868 consecutive trauma admissions over 22 months and identified 280 patients (10%) in high-risk groups who survived > or = 48 hours: (1) severe closed head injury with mechanical ventilation > or = 72 hours, (2) closed head injury with lower extremity fractures, (3) spinal column/cord injury, (4) combined pelvic and lower extremity fractures, and (5) major infrarenal venous injuries. The remaining nonthermal injury patients constituted the low-risk group. There were 280 high-risk patients, 213 of whom (76%) received prophylaxis with compression therapy. There were 12 cases of DVT (5%) with four nonfatal PE (1.4%). Six patients (2%) had therapeutic IVC filters inserted and only one patient had prophylactic placement. There were 38 deaths in this group, attributable primarily to severe closed head injury or spine injuries, and none were caused by PE. In the 2,249 low-risk patients, there were three cases of DVT (0.1%, p < 0.05 vs. high risk) and no PE (p < 0.05 vs. high risk). Although these patients were at increased risk for thromboembolic events, the overall incidence of DVT was still extremely low with no apparent PE deaths. In our patient population, aggressive screening and prophylactic IVC filters would not have benefited 95% of "high-risk" patients without DVT and would not have prevented any deaths. We could not identify any population, except perhaps venous injuries, where such expensive and potentially harmful maneuvers seemed justified. Our experience with DVT and PE does not support either aggressive screening or prophylactic IVC filters as the standards of care.

Infant survival after cesarean section for trauma.

Emergency cesarean sections in trauma patients are not justified and should be abandoned. A multi-institutional, retrospective cohort study was conducted of level 1 trauma centers. Trauma admissions from nine level 1 trauma centers from January 1986 through December 1994 were reviewed. Pregnant women who underwent emergency cesarean sections were identified. Demographic and clinical data were obtained on all patients undergoing a cesarean section. Fetal distress was defined by bradycardia, deceleration, or lack of fetal heart tones (FHTs). Maternal distress was defined by shock (systolic blood pressure < 90) or acute decompensation. Statistical analyses were performed. Of the 114,952 consecutive trauma admissions, more than 441 pregnant women required 32 emergency cesarean sections. All were performed for fetal distress, maternal distress, or both. Overall, 15 (45%) of the fetuses and 23 (72%) of the mothers survived. Of 33 fetuses delivered, 13 had no FHTs and none survived. Twenty infants (potential survivors) had FHTs and an estimated gestational age (EGA) of greater than or equal to 26 weeks, and 75% survived. Infant survival was independent of maternal distress or maternal Injury Severity Score. The five infant deaths in the group of potential survivors resulted from delayed recognition of fetal distress, and 60% of these deaths were in mothers with mild to moderate injuries (Injury Severity Score < 16). In pregnant trauma patients, infant viability is defined by the presence of FHTs, estimated gestational age greater than or equal to 26 weeks. In viable infants, survival after emergency cesarean section is acceptable (75%). Infant survival is independent of maternal distress or Injury Severity Score. Sixty percent of infant deaths resulted from delay in recognition of fetal distress and cesarean section. These were potentially preventable. Given the definition of fetal viability, our initial hypothesis is invalid.

The role of a substance abuse consultation team in a trauma center.

Trauma is a leading cause of morbidity and mortality in the U.S., and substance abuse makes an enormous contribution to this problem as well as to the increased cost of health care. A substance abuse consultation (SAC) team was developed to evaluate and intervene with trauma victims who are suspected of having problems with alcohol and/or other drugs. This study was undertaken to determine the effectiveness of this service. This study is a retrospective review of 100 consecutive trauma admissions who were felt to be at high risk for substance abuse and were referred to the SAC team for evaluation and intervention. This study was undertaken in a tertiary care teaching hospital in a cooperative effort between the trauma center and the addictions program. All 100 patients were diagnosed with psychoactive substance use disorders and 78 were referred for alcohol and other drug rehabilitation. Of these patients, 62% accepted a referral for drug and alcohol treatment. From these preliminary data, it appears that a SAC team may be effective in intervening with hospitalized trauma patients who have alcohol and other drug problems.

The white blood cell response to splenectomy and bacteraemia

The aim of this study was to determine the relationship of the white blood cell (WBC) count to bacteraemia, and the risk of bacteraemia after splenectomy. The case series study was carried out at the Vanderbilt University Level I Trauma Center, and included 11 870 consecutive trauma admissions: 258 required a splenectomy (191) or splenorrhaphy (67). Bacteraemia was defined as the presence of a positive blood culture. Statistical analysis included ANOVA, the non-parametric Kruskal-Wallis test and logistical regression. Forty-two (22 per cent) of the splenectomy patients had positive blood cultures, while only six (9 per cent) of the splenorrhaphy patients had positive cultures. For the group of patients requiring a splenectomy, the mean WBC count was higher and more persistent in patients with bacteraemia. Logistical regression demonstrated that the type of surgery does not significantly correlate with bacteraemia after accounting for severity of injury (TRISS). The study conclusions were as follows (1) for the group of patients with bacteraemia after splenectomy, the peak WBC count was higher and more persistent than that which occurred in the group of patients without bacteraemia after splenectomy; (2) the WBC count cannot be used to predict bacteraemia for an individual patient, but a WBC count greater than 20 000 after 10 days should initiate a vigorous search for infection; (3) the severity of injury (and not splenectomy/ splenorrhaphy) accounted for the increased risk of bacteraemia in population studied.

Safety of the blood supply. Surrogate testing and transmission of hepatitis C in patients after massive transfusion.

To define a risk profile for post-transfusion hepatitis C in patients receiving massive transfusion. Hepatitis C accounts for more than 90% of post-transfusion hepatitis. Two-hundred twenty-one of 8,765 consecutive trauma admissions to a Level I trauma center received more than 20 units of erythrocytes. Sixty-nine survivors had positive viral serologic tests at least 1 year after transfusion. Surrogate testing for hepatitis C using alanine aminotransferase (ALT) levels and antibodies to hepatitis B core antigen (Core) began in October 1986 and January 1987, respectively. Donor blood for group 1 (pre-ALT/Core) was transfused before surrogate screening was introduced. Donor blood for group 2 (post-ALT/Core) was transfused after surrogate screening. Sixty-nine patients received blood products from 4,987 donors (mean, 72.3 units of exposure). No patient tested positive for antibodies to hepatitis B surface antigen, human immunodeficiency virus, or human T-lymphotrophic virus type 1. However 23.2% tested positive for hepatitis C virus (HCV) as measured by a second-generation enzyme immunoassay (HCV 2.0) and a recombinant immunoblot assay (RIBA), and 21.7% tested positive by HCV 1.0. Antibodies to Core were found in 8.7% of patients. The risk for post-transfusion hepatitis C per unit of exposure is estimated to be 1.52% group 1 (pre-ALT/Core) and 0.239% for group 2 (post-ALT/Core). The introduction of ALT/Core donor screening by a blood bank reduced the incidence of post-transfusion hepatitis C by 84%. The risk for post-transfusion hepatitis C depends on units of exposure, screening techniques, and prevalence of hepatitis C in the donor population. In our community, the risk for post-transfusion hepatitis C is less than 0.2% per unit of exposure. The population of massively transfused patients may serve as our effective resource for monitoring the safety of the blood supply.

ANTITHROMBIN III AND TRAUMA PATIENTS

A prospective (cohort) study was conducted to determine the incidence of low antithrombin III (AT III) levels and the association with selected clinical variables in adult trauma patients. One hundred sixty AT III levels were obtained on 50 consecutive trauma admissions to a community-based level I trauma center. Antithrombin III levels were drawn as soon after admission as possible and every other day thereafter. Thirty-one patients (62%) had at least one low AT III level (< 80%), whereas 15 concurrently drawn control levels were all > or = 90%. Low AT III levels were more common in patients with one or more of the following: base deficit less than -4 (39% vs. 0, p = 0.002); Injury Severity Score > 15 (48% vs. 16%, p = 0.04); and blood transfusion (32% vs. 5%, p = 0.04). All other variables (shock, surgical intervention, subcutaneous heparin, and sequential compression devices) were not statistically significant, although all six patients with shock had low levels. In conclusion, over 60% of adult trauma patients had low AT III levels at some time during hospitalization and these patients were clearly more severely injured. Further studies are required to determine if these patients are more susceptible to thromboembolic phenomena.

Accuracy of the Prehospital Index in identifying major hemorrhage in trauma victims.

To determine the sensitivity of the Prehospital Index (PHI) in identifying patients with severe blood loss, a one-year review was conducted at a regional trauma facility. The study population consisted of 217 consecutive trauma admissions (ages 3 to 88 years). Patients were managed using standard resuscitation techniques; blood transfusions were ordered at the discretion of attending physicians and did not follow any preplanned protocol. Medical records were examined to determine total blood requirements for each patient during the first 12 hours of hospitalization, the emergency department (ED) disposition, and final outcome of treatment. The following clinical variables were analyzed (unpaired t-test) to determine their value as predictors of blood loss: age, gender, mechanism of injury, initial vital signs, revised trauma score, PHI, and injury severity score. Forty-two percent (92 patients) received transfusions during the first 12 hours of hospitalization. The best predictor of blood loss was the Prehospital Index. Of the total group, 45% had a PHI greater than 3; 77% (75/98) of these patients required transfusion and received an average of 7.1 units of packed cells. Fifty-five percent (119/217) had a PHI less than or equal to 3; 86% (102/119) of these patients did not require transfusion. The data suggest that patients with PHI scores greater than 3 require close hemodynamic monitoring to rule out significant blood loss and may warrant immediate cross-matching on arrival to the ED.

Comparison of APACHE II, trauma score, and injury severity score as predictors of outcome in critically injured trauma patients

Trauma Score (TS), APACHE II score, and Injury Severity Score (ISS) have been utilized to quantitate severity of illness in various groups of patients. The purpose of this study was to compare the relationship of the APACHE II score, TS, and "computer-derived" ISS with outcome in critically injured trauma patients. Data were recorded prospectively in a computer database for 428 consecutive trauma admissions. Stepwise discriminate analysis was utilized to determine the best predictor of both intensive care unit (ICU) and hospital outcome. Forty-two patients died in the ICU (10%), and another 18 patients died after leaving the ICU (4%), for a total mortality rate of 14%. The mean p value and partial R2 value obtained from stepwise discriminant analysis of the relationships between APACHE II score, TS, and ISS to ICU and hospital survival are shown. APACHE II score was the best predictor of both ICU and hospital outcome in these critically ill trauma patients. However, when combining all three measures (APACHE II score, TS, and ISS), only a portion of the variance in outcome is explained by the scores (R2 < 0.05). We conclude that scoring systems for outcome prediction should be utilized only as an adjunct to clinical assessment in the evaluation of the severity of illness and mortality risk in critically ill trauma patients.

The Staged Celiotomy for Trauma Issues in Unpacking and Reconstruction

This article describes the important clinical events and decisions surrounding the reconstruction/unpacking portion of the staged celiotomy for trauma. Of 13,817 consecutive trauma admissions, 1175 received trauma celiotomies. Of these, 107 patients (9.1%) underwent staged celiotomy with abdominal packing. The authors examined medical records to identify and characterize: (1) indications and timing of reconstruction, (2) criteria for emergency return to the operating room, (3) complications after reconstruction, and (4) abdominal compartment syndrome (ACS). Fifty-eight patients (54.2%) survived to reconstruction, 43 (74.1%) survived to discharge; 9 patients (15.5%) were returned to the operating room for bleeding; 13 patients required multiple packing procedures. There were 117 complications; 8 patients had positive blood cultures, abdominal abscesses developed in 6 patients, and ACS developed in 16 patients. 1. Reconstruction should occur after temperature, coagulopathy, and acidosis are corrected, usually within 36 hours after the damage control procedure. 2. Emergent reoperation should occur in any normothermic patient with unabated bleeding (greater than 2 U packed cells/hr). 3. ACS occurs in 15% of patients and is characterized by high peak inspiratory pressure, CO2 retention, and oliguria. Lethal reperfusion syndrome is common but preventable.

LONG-TERM FOLLOW-UP OF UNSUCCESSFUL VIOLENT SUICID ATTEMPTS

Of 9046 consecutive trauma admissions, all suicide attempts (n = 156) were identified: 38 patients (24%) died in hospital; 118 (76%) were discharged and received long-term follow-up (mean = 2.8 years). Factors assessed included suicidal ideation and planning, reason for attempt; number of attempts, methods, dates of prior and subsequent attempts; psychiatric diagnoses, substance abuse history, treatment and medication compliance, hospitalizations, incidence of family depression and suicide; education level, job history, and living conditions. 104 (88%) patients were interviewed and 14 (12%) were lost to follow-up. Seventy-seven of the patients (74%) used guns in their attempt; their mean ISS was 14.2. Seven (6.7%) made repeat suicide attempts (all unsuccessful). Late mortality was 7% (one related to index suicide, five to chronic illness, one to motor vehicle crash). Most patients (96%) had psychiatric diagnoses at discharge, 77 of 93 (83%) had diagnosed depression. Sixty-six percent (69 of 104) had histories of alcohol abuse, 42% (42 of 101) histories of drug abuse. Thirty-five percent (34 of 96) were noncompliant with psychiatric follow-up and 70% (16 of 23) were noncompliant with alcohol abuse treatment. (1) Repeat attempts were rare (7%) after failed suicide attempts. (2) No late deaths resulted from repeat suicide attempts. (3) Risk factors associated with repeat attempts were younger age (p = 0.002), prior attempts (p = 0.02), family history of suicide (p = 0.03), schizophrenia (p = 0.005), and not living at home (p = 0.04). (4) Identifying patients with these risk factors, ensuring that they receive inpatient alcohol abuse treatment, along with sustained psychiatric treatment and help in maintaining home environments, may prevent repeat suicide attempts.

Trauma Patients Return to Productivity

Economic issues threaten the development of a national trauma system. Much work has focused on the cost of trauma care; little has been done to define society's long-term economic return. We asked three questions about high cost trauma patients: (1) Do they survive?, (2) Do they continue to require expensive care?, and (3) Do they return to productivity? Of 6,129 consecutive trauma admissions, 114 had hospital charges over $100,000 (mean = $143,000), 102 (89.5%) were discharged alive, and 10 (8.8%) were lost to followup. Ninety-two patients or families were interviewed at least 1 year (mean = 2.6 year) after discharge. There were 88 survivors and 4 deaths (3.5%). Of the 88 survivors 73% had no limitation of ADLs, 67% received rehabilitation, 58% were still improving, and 37% were involved in litigation. Five survivors (5.7%) were confined to a nursing home, 48 (54.5%) had returned to productivity (RTP), 35 (39.8%) were unemployed, and five of these still require medical therapy. We conclude: (1) The majority of high cost patients survive (89.5%) and return to productivity (54.5%); (2) the severity of injury predicts survival but not return to productivity; and (3) the RTP rate may be increased by addressing nonmedical need.

Exclusion of Cervical Spine Injury

Trauma room lateral cervical spine radiographs (LCSR) may improve the safety of intubation and transportation of multiply injured patients by providing earlier recognition of spinal vertebral injuries. We prospectively evaluated 60 consecutive trauma admissions to determine the impact of clearance of cervical spine radiographs on patient care. Fifty-three patients had no cervical spine injury (CSI). Intubations, emergency head CT scan, aortography, or urgent operation (less than 6 hours after admission) were required in the majority of patients and preceded complete cervical spine clearance in all but one instance. The median time for radiologic clearance of the cervical spine was 15 hours (range, 1.5 to 181). LCSR failed to identify three of the seven acute CSI (all three had C7 fractures). The spine-injured were managed with cervical collars and no new neurologic injury developed. We conclude that: 1) LCSRs do not appear to alter urgent management of multiply injured patients during resuscitation and transportation; 2) chest radiographs and emergency investigations should not be delayed by repeated LCSR in the trauma room as it may be difficult to fully exclude CSI in many trauma patients; 3) we support the current ATLS guidelines, which suggest that all patients should be presumed to have an unstable CSI until the presence of cervical injury has been excluded.

Behavioral Correlates and Staff Recognition of Alcohol Use in a University Hospital Trauma Service

Hospital course and admission blood alcohol levels were compared in 242 consecutive adult trauma admissions. A 33% overall intoxication rate was found. Intoxicated patients were more likely to be young, male, and Hispanic or black and to be involved in fights, stabbings, and automobile accidents in which they were presumed to be at fault. These patients were also more likely to manifest disruptive behavior in the emergency room. Disruptive behavior on the ward was not correlated with alcohol intoxication at admission, but was correlated with the history of head injury. Staff recognition of intoxication was high, but only about 7% of the patients who were intoxicated at admission were referred to alcohol treatment programs. More frequent referrals for such treatment might decrease trauma center admissions and the high costs associated with them.

Review of multiple traumatic injuries in an urban pediatric population.

In an urban children's hospital setting, 95 consecutive multiple trauma admissions over a five-year period were classified by the Modified Injury Severity Scale (MISS) system. As previously designed, the MISS represents a numerical consolidation of the Abbreviated Injury Scale and Glasgow Coma Scale. Our data support the accuracy of the MISS scoring in predicting the outcome of the injured child. Detailed examination of our experience with hepatic (n = 33), splenic (n = 13), and renal (n = 38) injuries, in light of recent developments, reaffirms the efficacy of selective, conservative (nonoperative) management in the majority of abdominal solid organ injuries in children. A brief epidemiologic review of urban pediatric trauma follows.