Treatment Of Trauma Patients Research Articles

Posttraumatic Knee Stiffness

Commentary Complex periarticular knee trauma presents many challenges for both the patient and the physician. One of the most debilitating postoperative sequelae is knee stiffness. Although that complication is rare after elective knee surgery, Gaston et al.1 reported that 20% of the patients in their prospective study had stiffness (a residual knee flexion contracture of >5°) at twelve months after surgery for a tibial plateau fracture. Range of motion after both elective and emergency knee surgery has been shown in multiple studies to correlate with functional outcome. Although Miner et al.2 reported that knee flexion after total knee arthroplasty did not correlate directly with outcome, their findings did reveal a significant decrease in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores for patients with <95° of flexion. The WOMAC scores at twelve months postoperatively correlated with patient satisfaction and perceived improvement. In 2008, Ritter et al.3 studied the knee range of motion of patients after posterior cruciate-retaining arthroplasty and reported substantially worse outcomes in patients with <118° of total motion. Although multiple factors have been identified as increasing the risk of stiffness following total knee arthroplasty4 as well as after sports medicine reconstruction5, there have been no previous significant studies examining the predictors for knee stiffness after treatment of knee fracture. The authors of the current case-control study attempted to describe these factors by examining patients requiring knee manipulation after periarticular knee fracture. Although it is not an exact measure of postinjury stiffness, knee manipulation was chosen by the authors as the identifying marker of knee stiffness. This benchmark clearly does not capture all patients with potentially function-limiting knee stiffness; however, its use as the defining element of knee stiffness, as opposed to trying to define a specific critical range of motion, allows a relatively clear delineation between patient groups to allow for comparison. Despite a relatively small number of patients, the authors matched these patients with a control group with similar ages and fracture severity (as measured with the AO/OTA classification). The authors are to be commended for this effort and their success in carrying it out. Although patients treated with manipulation had a significant improvement in their range of motion compared with that before the manipulation, the final results revealed a significant difference between the final flexion of the case group compared with the control group (107° versus 124°). The factors associated with increased knee stiffness included extensor mechanism disruption, a need for fasciotomy, ongoing wound management, and three or more surgical procedures on the limb. Multiple factors found to have no impact on outcome included age, sex, side of injury, mechanism of injury, length of intensive care unit stay, head injury, use of continuous passive motion, and discharge to home versus to a rehabilitation facility. Finally the authors were able to conclude that late manipulation of a stiff knee after fracture is a worthwhile procedure, improving the range of motion by an average of 62°. As do all studies, this one had limitations whose impact must be recognized. The retrospective chart review limited the ability to verify the accuracy of documented knee motion measurements. The exact timing and nature of physical therapy compliance, which could have affected the results, could not be measured. Finally, there was some overlap between the category of open wound management and presence of fasciotomy that leads to difficulty in identifying whether each factor individually predicts knee stiffness (or both do together). Despite these limitations, this study definitely advances our knowledge in an area of orthopaedics in which there is a dearth of published knowledge. Simply put, this study will be very helpful to all orthopaedic surgeons who treat trauma patients. Clinically, this study has the potential to change how we view and treat periarticular knee injuries. Just as studies examining immediate intramedullary nailing of open tibial fractures ultimately led to a paradigm shift in orthopaedic trauma twenty years ago, this study may be the first step in changing how we manage these periarticular fractures in the future. A focus on closing wounds sooner, obtaining definitive fracture fixation sooner, and limiting the overall number of surgical interventions might improve patient outcomes after these very difficult injuries. Earlier identification of “at risk patients” could also lead to a decision to return to the operating room for manipulation and quadricepsplasty procedures earlier in the patient’s rehabilitation course. Furthermore, the study’s findings will enable orthopaedic surgeons to better counsel patients and their families with regard to expected outcomes. This additional knowledge should help most patients adjust more readily to their “new reality” as they proceed through the long and difficult rehabilitation process after major orthopaedic knee trauma.

Damage control surgery in the light of a new paradigm: damage control resuscitation.

Each year, 6 million people worldwide lose their lives due to serious injuries associated with major traumas. The most common cause of death among trauma patients is uncontrolled hemorrhage and associated coagulopahty. It is believed that 20 per cent of these individuals can be saved (1). Damage control surgery is a life-saving treatment modality that emerged by mid-20th century and undergone various changes so far (1–3). The damage control surgery consists of 5 steps. Initially, the patient triage must be performed properly. The second step takes place in the theatre. This first attempt must be completed within one hour at most. The temperature in the operation room must be at 26°C. All intravenous fluids should be warm. In this step, the aim would be to control hemorrhage, limit contamination and quickly re-close the surgical incision. During this instance, it is not recommended to execute definitive operation procedures for vessels, intestines or the liver. This means, it is not advisable to perform arterial grafting, vascular anastomosis or intestinal anastomosis. The abdomen must be cleaned, the vessels must be temporarily stitched, tied or pressured using balloon or tamp or shunting should be employed. Intestinal injuries should be temporarily bound and liver should be packed using pads. The abdomen must be closed as quickly and simply as possible. The third phase takes place in intensive care unit. Hypovolemia, acid-base equilibrium issues and coagulation should be tacked to stabilize the patient. The fourth phase entails definitive surgery. The fifth phase is the final step where the reconstruction and rehabilitation is conducted for all issues emerging during other phases (2). From past to present, the treatment approach for trauma patient includes protocolized resuscitation, followed by application of damage control surgery and finalized by taking patient into intensive care unit. Stabilizing patients in the intensive care unit, the treatment continues with gradual operations. In fact, it is now recommended to implement damage control resuscitation and damage control surgery in conjunction with each other. According to this recent paradigm, the physician should act in consideration of the patient’s physiological state, instead of managing the treatment by following pre-defined protocols. The patient’s physiological state must be closely observed through real-time monitoring and the treatment plan must be designed in accordance. In short, damage control surgery and damage control resuscitation must be construed as a single concept (2). The principle aim of this approach is to return the patient’s body heat to optimal levels, to remedy circulatory issues and to prevent coagulopahty. In this way, patient’s life will be saved from the vicious cycle or lethal triad (hypothermia, acidosis and coagulopathy). It is reported that majority of patients that receive this manner of treatment do not require further operation. In this way, even if the problems persist despite all treatment approaches, the surgical treatment applied to the patient will be more effective (1–3). In this issue of our journal, we are introducing one of the recently published, significant books on wartime surgery, War Surgery: Field Manual. This book review that you can find in the following pages of our journal presents philosophical changes in the approach to trauma patients, as we expressed above. It is apparent that we are going through a period of fundamental changes in the surgical mentality, similar to the periods following the first and second world wars. Furthermore, some authors even go far as to believe that we are at the beginning of the end for damage control surgery that came under intense discussions during 70s and became popular during 80s (3). Now, it is obvious that damage control resuscitation, integrated into damage control surgery, will be subject to further discussion. Hemostatic resuscitation is strongly highlighted both in civilian and military manuscripts and books. It should not be ignored the issues associated with coagulopahty becomes prominent in the treatment of traumatic patients and, unusual results may end up using artificial blood and blood products.

Prehospital dynamic tissue oxygen saturation response predicts in-hospital lifesaving interventions in trauma patients

Tissue oximetry (StO2) plus a vascular occlusion test is a noninvasive technology that targets indices of oxygen uptake and delivery. We hypothesize that prehospital tissue oximetric values and vascular occlusion test response can predict the need for in-hospital lifesaving interventions (LSI). We conducted a prospective, blinded observational study to evaluate StO2 slopes to predict the need for LSI. We calculated the DeO2 slope using Pearson's coefficients of regression (r2) for the first 25% of descent and the ReO2 slope using the entire recovery interval. The primary outcome was LSI defined as the need for emergent operation or transfusion in the first 24 hours of hospitalization. We created multivariable logistic regression models using covariates of age, sex, vital signs, lactate, and mental status. We assessed StO2 in a convenience sample of 150 trauma patients from April to November of 2009. In-hospital mortality was 3% (95% confidence interval [CI], 1.1-7.6); 31% (95% CI, 24-39) were admitted to the intensive care unit, 6% (95% CI, 2.8-11.1) had an emergent operation, and 10% (95% CI, 5.7-15.9) required transfusion. Decreasing DeO2 was associated with a higher proportion of patients requiring LSI. In the multivariate model, the association between the need for LSI and DeO2, Glasgow Coma Scale, and age persists. Prehospital DeO2 is associated with need for LSI in our trauma population. Further study of DeO2 is warranted to determine whether it can be used as an adjunct triage criterion or an endpoint for resuscitation.

Subsidence of collarless uncemented femoral stems in total hips replacements performed for trauma

IntroductionCollarless, uncemented, femoral stems give excellent results in elective hip replacements but few studies look at outcomes in trauma patients. The presence of osteoporosis and subsequent widened femoral canal may compromise the mechanical stability of uncemented femoral stems resulting in early subsidence. The aim of this study was to assess whether early subsidence occurred when collarless uncemented stems were used to treat trauma patients. Materials and methodsPost-operative radiographs of 46 patients, mean age 71, who underwent an uncemented, collarless, total hip replacement for trauma, were reviewed. The difference in distance from the calcar to the prosthesis tip between the immediate post operative radiograph and the subsequent follow-up radiograph was calculated and adjusted for magnification. The same procedure was performed on 36 age-matched patients, who underwent elective hip replacements for osteoarthritis. Hospital notes were reviewed to assess for complications and DEXA scans reviewed for trauma patients where available. ResultsThe mean femoral stem subsidence was significantly greater in the fracture cohort than in elective patients (p=0.001) with mean subsidence of 4.27mm (range 0.02–22.05mm) and 1.57mm (range 0–5.5mm), respectively. In the fracture cohort there were 4 revisions within 6 months of surgery, 1 for infection and 3 for femoral stem subsidence leading to dislocation. There were no revisions in the elective cohort. Discussion and conclusionsThis study showed that collarless uncemented stems subsided significantly more when performed for fractures and had a high early revision rate. We recommend that uncemented collarless should not be used in trauma patients requiring total hip replacement.

Isolated right diaphragmatic rupture following blunt trauma

Blunt diaphragmatic injuries are usually caused by blunt trauma or penetrating injuries. The diagnosis may be delayed or missed because of the confusing clinical and radiographic findings and the presence of multiple associated injuries. We report the case of an isolated right diaphragm rupture in a 56-year-old man who sustained blunt thoracic trauma after car accident 2 weeks before presentation. No other injuries were detected, and he was subjected to laparotomy. Diaphragmatic rupture is perceived as an emergency entity. The late appearance of such an injury, without other accompanying injuries, is rare and should be in mind by clinicians treating trauma patients who have a delayed presentation after the injury.

Clinical experience of smoking cessation advice in hospital trauma units

Cigarette smoking is increasingly well recognized as an inhibiting factor in fracture healing, and risk factor for non-union. We assessed whether adequate smoking cessation advice and support was given to cigarette smokers undergoing fracture management, based upon the United States Public Health Service ‘Five As’ Smoking Cessation Guidelines—evidence-based guidelines outlining effective strategy to promote smoking cessation, by taking a smoking history, advising the patient to stop smoking, assessing motivation to stop and facilitating cessation via support groups and pharmacological interventions (Ask, Advise, Assess, Assist, Arrange). Our study was conducted within three large orthopaedic units in the Mersey deanery, UK. A questionnaire was completed by 156 cigarette smokers—inpatients and outpatients—undergoing fracture management (87 M, 69 F, 18–89 years, mean age 48.2 years). All patients included within the study had been seen by an orthopaedic practitioner prior to completing the questionnaire. We assessed whether a member of the orthopaedic team had addressed each patient’s smoking habits based upon the ‘Five As’ approach. A smoking history had been taken from 66% of smokers, 54% of those patients (36% of smokers) were advised to stop smoking. Motivation to stop smoking was assessed in only 4% of patients, whilst assistance and support relating to smoking cessation was offered to only 2.5% of patients. The assessment of smoking prevalence, and subsequent promotion of smoking cessation amongst trauma patients, is clearly suboptimal. We suggest highlighting the significance of smoking as a risk factor for impaired fracture healing amongst all healthcare professionals treating trauma patients, and the incorporation of smoking cessation advice and support into the management of orthopaedic trauma in order to promote improved fracture healing.

Transthoracic Echo Helps Determine Fluid and Cardiac Status in Trauma Patients

The Focused Assessment with Sonography for Trauma (FAST) has become a valuable study for determining presence of intra-abdominal hemorrhage and need for surgical intervention in trauma patients. These authors evaluated the clinical value of transthoracic Focused Rapid Echocardiographic Examination (FREE) for assessing fluid volume and cardiac function in trauma patients. …

Fibrinogen concentrate for management of bleeding

Fibrinogen concentrate for management of bleeding

El acceso intraóseo para fluidoterapia en situación de combate. Experiencia de la sanidad militar española en Afganistán

ObjectivesTo describe the Spanish military medical staff’s experience with the use of intraosseous lines for fluid therapy in a combat zone. Patients and methodsDescriptive study of 25 patients (30 needles). The patients were injured by firearms or explosive devices, or had multiple injuries, and were attended by Spanish military physicians in western Afghanistan (Herat) between March 2007 and June 2008. ResultsThe bone puncture was performed on 19 patients in prehospital settings. The remaining 6 patients underwent the procedure in the Spanish military hospital. All patients were men; the mean (SD) age was 26 (2.3) years. Most belonged to the Afghan National Army (64%) and had injuries caused by explosive devices (68%). The largest percentage of injuries involved the lower limbs (56%). A line could be inserted in 76% of the cases (100% at the military hospital). The first-choice site of puncture was the anterior tibial tuberosity. Fluids and medications were successfully administered through the intraosseous lines. No complications occurred during needle insertion, but 5 patients reported pain. ConclusionOur experience suggests that intraosseous access can provide an alternative to venous access for treating trauma patients in combat zones.

Ectopy in Trauma Patients: Cautions for Use of Heart Period Variability in Medical Monitoring

Heart period variability measurements have been proposed for use in early prediction of mortality or the requirement for lifesaving interventions in trauma patients. However, the presence of even one ectopic beat (EB) and/or electromechanical noise compromises the accurate calculation of heart period variability. We tested the hypothesis that ECGs from trauma patients exhibit a greater frequency of EBs than healthy human research subjects. Continuous ECGs were recorded in 20 healthy human subjects at rest, 108 healthy human subjects undergoing experimentally induced progressive central hypovolemia (via lower body negative pressure, LBNP), and 245 trauma patients. The proportions of subjects/patients with at least one EB were identified in each group. ECG waveforms from 20% and 18% of healthy human subjects at rest or undergoing LBNP, respectively, contained at least one EB. ECG waveforms from 36% of the trauma patients were found to contain either EBs (35%) or electromechanical noise (1%). A significant number of EBs occur in healthy subjects both at rest and during progressive reduction in central blood volume, and trauma is associated with a near doubling of this incidence. As both EBs ' and noise result in invalid heart period variability calculations, these metrics as currently calculated could not be used in approximately 36% of trauma patients. The limited use in nearly two of every five trauma patients indicate that it is unlikely that continuous heart period variability measurements could substantially improve pre-hospital or emergency room decision-support in trauma.

Trauma Patients at Non-trauma Centers: Tips for Detection and Improved Outcomes

It's 3:02 am and you hear the telltale tire screeching at the ED doors. You go outside to find a 25-year-old man with multiple gunshot wounds to the chest, abdomen, and left leg. Unfortunately, this scene may be familiar for nurses working in both trauma centers and in non-trauma centers. Treating trauma patients at designated trauma centers, and treating the severely injured at a level I center, designated by the American College of Surgeons, is associated with improved survivial.1 However, some areas are still without organized trauma systems or field trauma triage criteria.

Evaluation of Prehospital and Emergency Department Systolic Blood Pressure as a Predictor of In-Hospital Mortality

Hypotension is a trauma activation criterion validated by multiple studies. However, field systolic blood pressures (SBP) are still met with skepticism. How significant is the role of prehospital (PH) and emergency department (ED) SBP in the patient's overall condition? A review of the trauma registry over a 5-year period was conducted. PH SBPs were stratified into four categories: severe (SBP 80 mmHg or less), moderate (81-100 mmHg), mild hypotension (101-120 mmHg), and normotension (greater than 120 mmHg). These four groups were further subcategorized into the patients who were hypotensive, SBP 90 mmHg or less in the ED, versus those that were not (SBP greater than 90 mmHg). Data for 6964 patients were analyzed. Patients with PH SBP of 80 mmHg or less compared with patients who had PH SBP of greater than 80 mmHg had higher mortality (OR, 9; 95% CI, 6.45-12.84). Patients with both PH SBP 80 mmHg or less and ED SBP 90 mmHg or less had the highest risk of mortality (50%) and highest need for emergent operative intervention (54%). PH and ED hypotension is a strong predictor of in-hospital mortality and need for emergent surgical intervention in trauma patients. Field or ED blood pressures should serve as a significant marker of the patient's condition.

Multidetector Row Computed Tomography in the Management of Penetrating Neck Injuries

Penetrating neck trauma may occur from gun shots, stabbings, and accidental injury. Approximately 50% of gunshot and 10%-20% of stab-wound patients are reported as having severe injuries and the mortality from severe vascular injuries is reported as high as 50%. Penetrating traumatic neck injury is no longer best managed with exploratory surgery or conventional angiography in the stable patient. Computed tomography angiography has proven to be a useful, safe, and reliable means of diagnosis. Experience with interpreting and reconstructing computed tomography images, understanding the clinically important findings, and avoiding pitfalls is critical for successful patient care. Therefore, radiologists and clinicians who treat trauma patients need to familiarize themselves with the computed tomography angiography technique and appearances of vascular injury and know when to recommend further evaluation, such as interventional angiography or open surgery.

Heart-Rate Complexity for Prediction of Prehospital Lifesaving Interventions in Trauma Patients

Traditional vital signs often fail to identify critically injured patients soon enough to permit timely intervention. To improve our ability to forecast the need for prehospital lifesaving interventions (LSIs), we applied heart-rate complexity (HRC) analysis to the electrocardiogram (ECG) of patients en route to trauma centers. Analysis of ECG and clinical data from 374 patients en route by helicopter to three urban Level I trauma centers was conducted. Waveforms from 182 patients were excluded (because of ectopy, noise, or inadequate length). Of the remaining 192 patients, 54 received 66 LSIs in the field (LSI group): intubation (n = 52), cardiopulmonary resuscitation (n = 5), cricothyroidotomy (n = 2), and pneumothorax decompression (n = 7); 138 patients did not (non-LSI group). In the field, heart rate, blood pressure, and the Glasgow Coma Scale score (GCS(TOTAL)) and its motor component (GCS(MOTOR)) were recorded. ECG was recorded during flight. Ectopy-free, 800-beat sections of ECG were identified off-line and analyzed by HRC methods including Sample Entropy (SampEn) and Detrended Fluctuations Analysis (DFA). There was no difference between LSI and non-LSI patients in heart rate or blood pressure. SampEn was lower in LSI than in non-LSI (0.88 +/- 0.03 vs. 1.11 +/- 0.03), as was DFA (1.09 +/- 0.05 vs. 1.33 +/- 0.03) and GCS(MOTOR) (3.4 +/- 0.4 vs. 5.7 +/- 0.1) (all p < 0.0001). By logistic regression, SampEn, DFA, and GCS(MOTOR) were independently associated with LSIs (area under the receiver operating characteristic curve, 0.897). Decreased HRC is associated with LSIs in prehospital trauma patients. HRC may be useful as a new vital sign for identification of the severely injured.

Should Echogenic Material in the Urinary Bladder Noticed on FAST Preclude Urinary Catheter Insertion in a Trauma Patient Until Further Evaluation?

Serious urethral and bladder injuries are most often associated with severe blunt trauma. The most common diagnostic tool used to assess lower urinary tract injuries is a retrograde urethrogram. However, the decision to place a Foley catheter is often made on clinical grounds during initial stabilization phase of a trauma victim. If there is a clinical suspicion of a urethral injury, a Foley catheter should not be introduced until further evaluation is made. Focused abdominal sonography for trauma (FAST) is a major tool for primary evaluation of trauma victims. Treating trauma patients, we encountered an unusual "pick up", namely, blood clots in the urinary bladder in two patients. We report on two cases of severely traumatized patients on which FAST examination detected an echogenic material in the bladder. This correlated with severe injuries to the urethra and urinary bladder. Moreover, ignorance of this finding in a patient without obvious clinical signs of urethral injury (Patient 1) led to a Foley catheter insertion, and as a consequence, a complex jatrogenic injury to the urethra. On the basis of this study, we hypothesize that the presence of an echogenic material on FAST examination should be considered blood until proven otherwise, and a urinary bladder catheter should not be passed, even in the absence of clinical signs of urethral injury. Since urogenital trauma is rare, this concept should be validated in the prospective study in a high-volume trauma center.

Acceptability of blood and blood substitutes

Alternatives to donor blood have been developed in part to meet increasing demand. However, new biotechnologies are often associated with increased perceptions of risk and low acceptance. This paper reviews developments of alternatives and presents data, from a field-based experiment in the UK and Holland, on the risks and acceptance of donor blood and alternatives (chemical, genetically modified and bovine). UK groups perceived all substitutes as riskier than the Dutch. There is a negative association between perceived risk and acceptability. Solutions to increasing acceptance are discussed in terms of implicit attitudes, product naming and emotional responses.

Trauma. Vol. 25, No. 1 of Anesthesia Clinics.

Trauma. Vol. 25, No. 1 of Anesthesia Clinics. Shamir MY, Weiss YG, eds. Philadelphia: Elsevier/Saunders, 2007. ISBN 1-4160-4278-4. 206 pages, $184.00 annual subscription for four issues, $84.00 for a single issue. Anesthesiologists not practicing at a Level I trauma center typically spend limited time considering or treating trauma patients. However, the events of September 11 and the current escalation in urban warfare that impacts many modern cities require all anesthesiologists to take heed of this typically under-appreciated area of study. A consistent theme throughout much of this text is the issue of preparedness. The authors draw from the experiences of September 11, the bombing of the U.S. Marine barracks in Beirut, Lebanon, sarin gas poisoning in Japan, and multiple other incidents that may be smaller in scope but nonetheless have devastating impact. The authors draw attention to the need for appropriate triage and the real possibility of a patient “surge” that can overrun even the best-prepared hospitals. Of particular concern is the treatment of patients who have been exposed to toxic substances, as these individuals can be both critically ill and pose a danger to health care workers. These patients require appropriate decontamination while their caregivers require proper protective equipment. This monograph features focused overviews of airway management and hemorrhagic shock, dealing with multiple areas such as the impact of laryngotracheal trauma, facial fractures, fluid resuscitation, and blood administration strategies. General consideration for the critically injured patient includes a good overview of the mechanisms associated with the development of acute lung injury and its management as well as the role of vasopressors for treatment of patients with hemodynamic instability. The book features a particularly interesting discussion of ‘Nonsurgical Treatment of Major Bleeding.” The use of the terms “nonsurgical treatment” and “major bleeding” in the same sentence initially appeared to be an oxymoron. The authors, however, addressed the utilization of angiography/embolization and various blood component factors, including a detailed discussion of the use of recombinant activated factor VIIa. Most anesthesiologists would probably still choose to allow our surgical colleagues to intervene. However, as innovative technologies advance and specialized blood component therapies become more ubiquitous, these refinements may become a more central part of clinical care. More focused areas of discussion include a review of trauma in the geriatric, obese, and pregnant patients. These chapters provided an excellent summary of the demographics of these patient populations as well as the specific types of injury patterns most likely to be seen in them. A summary of the importance of glucose control was also emphasized in an attempt to improve patient outcomes, particularly in the neurological trauma and critical care setting. The chapter on regional anesthesia acts as a reminder that these techniques can be employed in certain instances in well-chosen patients. The authors might have included more discussion about specific types of traumatic injuries such as head and blunt force trauma. However, they may have intentionally not provided such discussion, since these are commonly covered topics in textbooks on trauma management. Additionally, the arrangement of the chapters seems disjointed. One typically expects the topics that add most to the overall discussion to be placed in a more prominent position toward the beginning of the text. Even though human simulation plays an important role in preparedness, placement of the chapter on simulation in anesthesia within the middle of the text seems out of place, since little new information is provided within this discussion. The editors have successfully addressed a broad scope of topics within the area of anesthesia and trauma. Discussion ranges from innovations in trauma practice to disaster planning and implementation. Emphasis is appropriately centered on the importance that preparedness takes in the successful implementation of any trauma protocol, ranging from an individual motor vehicle accident to trauma due to battlefield engagements, to massive disasters secondary to acts of terrorism. This monograph does an overall good job of providing insight into the areas that were covered, but due to the limitations of scope, should not be considered to be a replacement for standard textbooks on trauma anesthesia and resuscitation. David A. Nakata, MD, MBA Associate Professor of Clinical Anesthesia [email protected] Indira Danturti, MD CA-3 resident [email protected] Department of Anesthesiology University of Indiana School of Medicine Indianapolis, IN

A Crisis in the Delivery of Care to Patients With Brain Injuries in South Texas

To determine the opinions of neurosurgeons regarding the care of the injured and to assess the impact of these attitudes on the care of the patients with brain injuries. A survey was sent to the 2,465 active members of the American Association of Neurologic Surgeons. A manpower assessment of neurosurgical coverage of South Texas was also performed. In total, 872 surveys were returned (35%). Seventy-one percent of the respondents were over the age of 44. Eighty-seven percent of neurosurgeons stated that they currently provide trauma care: 74% at Level I or II trauma centers. The majority of neurosurgeons treated <5 trauma patients per week, 80% placed 2 or fewer intracranial pressure (ICP) monitors per month. Fifty-nine percent of the respondents preferred not to treat trauma patients because of (1) perceived increased medicolegal risk (80%), (2) conflict with elective practice (75%), (3) time required (70%), and (4) inadequate compensation (65%). Fifty-six percent received no compensation for trauma call. The majority of neurosurgeons indicated that no personnel other than neurosurgeons should be allowed to perform trauma craniotomies (90%) or insert ICP monitors (76%). However, 61% thought that non-neurosurgeons should be able to perform neuro-critical care. A maldistribution of neurosurgeons was identified in South Texas, with much of the population uncovered for trauma care. Significant delays in definitive neurosurgical care were identified as a result of this maldistribution. One-half of neurosurgeons prefer not to care for trauma patients because of perceived added time commitment, conflicts with elective practice, lack of compensation, and perceived medicolegal risk. But, they thought that only neurosurgeons should provide emergency neurosurgical procedures. These attitudes appear to impinge on the care of the patients with brain injuries in South Texas.

Prehospital Hypotension is a Predictor of the Need for an Emergent, Therapeutic Operation in Trauma Patients With Normal Systolic Blood Pressure in the Emergency Department: Lipsky AM, Gausche-Hill M, Henneman PL, et al. J Trauma 2006;61:1228–33

The focus of the study was to ascertain the extent by which prehospital hypotension would indicate the need for emergent surgical intervention in trauma patients who had normal blood pressures in the emergency department (ED). This prospective, observational, cohort study, conducted at Harbor-UCLA Medical Center, evaluated 1028 trauma patients meeting Los Angeles County trauma criteria and who also were normotensive (systolic blood pressure > 90 mm Hg in adults, > 2 × [age in years] + 70 mm Hg in children < 10 years old, or who had palpable pulses) in the ED. Of the 1028 patients, 71 (7%) were hypotensive in the field and three times more likely to receive an emergent operation when compared to the normotensive prehospital group (odds ratio [OR] 4.5, 95% confidence interval [CI] 2.7–7.6). The prehospital hypotensive group also demonstrated an increased overall mortality (OR 2.3, 95% CI 0.8–6.9). Blunt and penetrating traumas with prehospital hypotension were both 2.5 times more likely to have an emergent surgery (OR 3.3, 95% CI 1.5–7.2 and OR 4.9, 95% CI 2.2–10.7, respectively). The ED disposition of trauma patients was statistically significant (p = 0.04) with a greater percentage of prehospital hypotensive patients being admitted to the hospital and in higher level of care. The authors concluded that prehospital hypotension is strongly predictive of therapeutic, emergent surgery in trauma patients with normal blood pressures in the ED.

ATLS in Europe

Different protocols and algorithms exist for the primary treatment of the polytraumatized patient mostly with some differences in priorities and sequence, depending on local but even national customs. ATLS provides the physician with essential tools for the primary assessment of the trauma patient, organized in a strict sequence of assessment and as much as possible evidence based. Based an the motto “treat first what kills first” and “do no further harm”, it allows even the less experienced physician involved in trauma care, to diagnose and treat the possibly lethal injuries of the trauma patient in the correct sequence and prevents him to overlook the less obvious lesions. In 1986 ATLS was introduced in the UK and has been spreading out to 13 more European countries. In 2006 the ACS assigned a chair in the Committee on Trauma to the European ATLS countries. From now on Europe, to a certain extent, can influence the further development of ATLS. It is a challenge to introduce this program further in Europe, making it possible to treat trauma patients across the different boarders in Europe, using a system that has proven itself and that allows physicians involved in trauma care, to speak one common language.