The Frequency of Reexpansion Pulmonary Edema after Trocar and Hemostat Assisted Thoracostomy in Patients with Spontaneous Pneumothorax

PURPOSE: Several risk factors for development of reexpansion pulmonary edema (REPE) after drainage of pneumothoraces have been reported, but the association between the method of thoracostomy and the development of REPE is unknown. The aim of this study was to compare the frequency of REPE after treatment of spontaneous pneumothorax with trocar or hemostat assisted closed thoracostomy. MATERIALS AND METHODS: We performed a prospective, observational study including 173 patients with spontaneous pneumothorax who visited the emergency department from January 2007 to December 2008. In 2007, patients were treated with hemostat-assisted drainage, whereas patients in 2008 were treated with trocar-assisted drainage. The main outcome was the development of REPE, determined by computed tomography of the chest 8 hours after closed thoracostomy. Outcomes in both groups were compared using univariate and multivariate analyses. RESULTS: Ninety-two patients were included, 48 (42 males) of which underwent hemostat-assisted drainage and 44 (41 males) underwent trocar-assisted drainage. The groups were similar in mean age (24+/-10 vs. 26+/-14 respectively). The frequencies of REPE after hemostat- and trocar-assisted drainage were 63% (30 patients) and 86% (38 patients) respectively (p=0.009). In multivariate analysis, trocar-assisted drainage was the major contributing factor for developing REPE (odds ratio=5.7, 95% confidence interval, 1.5-21). Age, gender, size of pneumothorax, symptom duration and laboratory results were similar between the groups. CONCLUSION: Closed thoracostomy using a trocar is associated with an increased risk of REPE compared with hemostat-assisted drainage in patients with spontaneous pneumothorax.

Changes in Preventable Death Rates and Traumatic Care Systems in Korea

PURPOSE: This study was performed in order to determine the changes over time in preventable and potentially preventable traumatic death rates, and to assess the factors that affected the deaths of trauma patients which occurred in Korean pre-hospital and hospital settings. METHODS: All trauma deaths occurring either in the emergency department (ED) or after admission at twenty Korean hospitals between August 2009 and July 2010 were retrospectively analyzed. The deaths were initially reviewed by a team of multidisciplinary specialists and classified into non-preventable, potentially preventable, and preventable deaths. Only preventable and potentially preventable deaths were the subject of our analysis. Structured data extraction included patient demographics, vital signs, injury severity, probability of survival, preventability of mortality, reported errors in the evaluation and management of the patient, and classification of error types (system, judgment, knowledge). RESULTS: During the study period, 446 trauma victims died in the ED or within 7 days after admission. The mean age was 52 years, 74.1% were men and the mean time from injury to death was 35.6 hours. The most common cause of death was head injury (44.7%) followed by hemorrhage (30.8%) and multi-organ failure (8.0%). The rates of preventable/potentially preventable deaths were 35.2% overall and 29.8% when limited to patients surviving to admission. Of all death classifications, 31.2% were potentially preventable and 4.0% were preventable. Errors leading to preventable death occurred in the emergency department (51.2%), pre-hospital setting (30.3%) and during inter-hospital transfer (60.8%). Most errors were related to clinical management (48.4%) and structural problems in the emergency medical system (36.5%). CONCLUSION: The preventable death rates for Korean trauma victims were higher than those found in other developed countries, possibly due to poorly established emergency medical systems for trauma victims in pre-hospital and hospital settings. A system wide approach based on the emergency medical system and well-developed in-hospital trauma teams should be adopted in order to improve the quality of care of trauma victims in Korea.

Characteristics of a Focused Assessment with Sonography for Trauma (FAST) in Hollow Viscus Injury

PURPOSE: The usefulness of focused abdominal sonography for trauma (FAST) is now included in the frame work of the advanced trauma life support for examination of thoraco- abdominal trauma. Ultrasonographic screening is controversial in patients with hollow viscus injury. The purpose of this study is to determine the characteristics of emergency trauma sonographic findings in patients with hollow viscus injury. METHODS: All patients with isolated viscus injury after blunt abdominal trauma were retrospectively enrolled in this study during the 5-year period from December 1997 to November 2002. The patients were screened by using ultrasonography and an underwent explolaparotomy. The patients were diagnosed with a hollow viscus injury based on the surgical findings. Patients with viscus injury combined with parenchymal organ injury after abdominal trauma were excluded. Ultrasonographic examinations were performed by the experienced emergency physicians during the trauma resuscitation. RESULTS: Sixty patients were included in this study. The most common injury site was jejunum (23.3%). The common findings of emergency trauma sonography were free fluid collection (56.7%), none of fluid collection (38.3%), free air and fluid collection (3.3%), and free air (1.7%). The presence of mesenteric injury was significantly associated with fluid collection (x2=0009). CONCLUSION: The most common sonographic findings in hollow viscus injury patients after blunt abdominal trauma are free intraperitoneal fluid (anechoic or mixed echo pattern), normal, and free air (reverberation) in that order. Massive intraperitoneal fluid is more often detected in patients who have a viscus injury combined with a ruptured mesenteric vessel.

Resuscitation Outcomes and Clinical Characteristics Based on the Initial ECG Rhythm in Prehospital Traumatic Cardiac Arrest Patients

PURPOSE: The purpose of this study was to investigate the outcome of resuscitation and the clinical characteristics of patients with prehospital traumatic cardiac arrest. METHODS: We conducted a 14-year retrospective study of all pulseless patients with trauma for whom cardiopulmonary resuscitation (CPR) was initiated in an in-hospital setting during the period of January 1991 through February 2004. RESULTS: Four hundred nine patients, 287 males and 122 females, were included in this study. The mean age was 42+/-18 years (range 1-93 years). Eighty patients had pulseless electrical activity (PEA) rhythm, and three hundred twenty-nine patients had asystole rhythm on the initial ECG upon arrival at our emergency room. There were no significant differences in the interval from collapse to start of ACLS (27.1+/-33.4 min. vs 36.9+/-70.1 min., p=0.220), the duration of cardiopulmonary resuscitation (25.0+/-13.7 min. vs 26.4+/-9.9 min., p=0.394), the survival rates for more than 24 hours (5.0% vs 2.4%, p=0.221), and the number of patients discharged alive (1.3% vs 0.6%, p=0.545) between the PEA group and the asystole group. However patients in PEA group had a much higher return of spontaneous circulation (ROSC) rate than those in the asystole rhythm (52.5% vs 31.0%, p.0.001). The survival rates of narrow QRS tend to be higher than ones of wide QRS in ECG rhythm after ROSC (13.5% vs 7.4%, p=0.057). However, there was no difference in the survival discharge rate (p=0.196). There was no difference in 24 hours survival rate between the group that received defibrillation and the group that did not (0.9% vs 3.7%, p=0.099). The most common cause of death was a hemorrhagic shock. CONCLUSION: There was no difference in survival rate between the PEA and the asystole at an initial ECG rhythm. The overall survival rate of patients with prehospital cardiac arrest after trauma is very poor.

Comparison of Two Titration Methods of Vasopressor Infusion to Correct Septic Shock

BACKGROUND: Administration of a vasopressor is frequently required in treating septic shock. The conventional method of vasopressor infusion, which includes incremental titration of a vasopressor to raise blood pressure, is sometimes a time-consuming process that might prolong the duration of the shock. PURPOSE: This study was to evaluate whether a method of vasopressor infusion that starts from an acceptable maximal dose has advantages over a method of vasopressor infusion that starts from a low dose in patients with septic shock. SUBJECTS AND METHODS: Twenty-five patients with septic shock, which was not corrected with fluid resuscitation of 20~30 ml/kg, were randomized into two groups. The patients in the low-to-high group (n=13) received a vasopressor in an incremental manner starting from a low dose. The patients in the high-to-low group (n=12) received a vasopressor in a decremental manner starting from an acceptable maximal dose. The shock durations (time from the beginning of vasopressor infusion to correction of the shock), and the hemodynamic and metabolic parameters, including blood pressure, pulse rate, arterial lactate concentration, anion gap, base excess, and central venous oxygen saturation, before vasopressor infusion, and 2, 4, 6, 12, and 24 hours after vasopressor infusion were compared for the two groups. The length of ICU stay, the length of total hospital stay, the type of discharge, and the survival rate were also compared. RESULTS: The shock duration was shorter in the high-to-low group than in the low-to-high group (14.7+/-21 min. vs 41.9 +/-41 min., p=0.01). There were no differences between the two groups as to hemodynamic and metabolic parameters. The ICU stay was shorter in the high-to-low group than in the low-to-high group (7+/-7 days vs 10+/-22 days); however, the difference did not reach statistical significance (p=0.934). CONCLUSION: The method of vasopressor infusion starting from acceptable maximal dose shortens the duration of shock compared to the conventional incremental titration method.

Correlation of the Serum Antithrombin III to Injury Severity in Patients with Severe Trauma

PURPOSE: Antithrombin III (AT-III) is a serum protease inhibitor that inhibits the blood coagulation protease thrombin and is seen to be present in low levels in cases of shock, sepsis, or major trauma. Coagulopathy and hemorrhage are known contributors to trauma prognosis but the actual relationships of AT-III to mortality and to injury severity are unknown. The purpose of this study was to determine the correlation between AT-III and injury severity. METHODS: This study was a retrospective analysis of data collection from January 1, 2003, to December 31, 2003. Sixty patients with multiple trauma were studied. The revised trauma score (RTS), the injury severity score (ISS), the systemic inflammatory response syndrome score (SIRS), the acute physiology and chronic health evaluation III (APACHE III), the length of ICU stay, the base-deficit value and the serum lactate were measured to evaluate injury severity. We estimated the relation between the severity of injury and the serum level of AT-III. RESULTS: In patients with multiple trauma, the serum AT-III level was lower in the non-survival group (12.6 mg/dL) than it was in the survival group (17.2 mg/dL) (p=0.004). Among the previous injury severity evaluation system, the unit of transfusion for 24 hours had the strongest correlation with AT-III (R=0.546, p=0.000). The base deficit (R=0.418, p=0.001), the length of ICU stay (R=0.415, p=0,030), the APACHE III (R=0.367, p=0.021), and the RTS (R=0.247, p=0.006) were also correlated with AT-III. A logistic regression showed a strong association between the AT-III level and the mortality rate (mortality rate = 1.067- 0.370 x AT -III, p= 0.004). CONCLUSION: In patients with severe trauma, The serum AT-III level was correlated with the RTS, the APACHE III, the number of transfusion units, the severity of shock, and the length of ICU stay. The serum AT-III level also showed a strong correlation with mortality.

Effect of Standard Cardiopulmonary Resuscitation on Cerebral Blood Flow and Coronary Perfusion Pressure in the Canine Model of Simulated Ventricular Tachycardia

PURPOSE: The purpose of this study was to evaluate the hemodynamic effects of external chest compression in state of the heart's beating. METHODS: Ten mongrel dogs were used in this study. Ventricular tachycardia was simulated by using a rapid ventricular pacing and ventricular rate was adjusted and maintained at the rate necessary to achieve a 50-mmHg fall in the baseline systolic aortic pressure. External chest compression was initiated after 4 minutes of simulated ventricular tachycardia and was continued for 4 minutes. Hemodynamic measurements, including the systolic and the diastolic aortic pressure, the right atrial pressure, the carotid blood flow, and the end tidal CO2 tension, were done at baseline, during the simulated ventricular tachycardia (VT), and during the simulated ventricular tachycardia with external chest compression (VT+ECC). RESULTS: The systolic aortic pressure, the diastolic aortic pressure, and the mean right atrial pressure were higher during VT+ECC than during VT (99+/-12 vs 92+/-8 mmHg, p=0.157, 59+/-8 vs 55+/-12 mmHg, p=0.140, and 23+/-8 vs 8+/-2 mmHg, p<0.001, respectively). The carotid blood flow was higher during VT+ECC than during VT (273+/-203 vs 136+/-76 mL/min., p=0.011). The calculated coronary perfusion pressure was lower during VT+ECC than during VT ( 26+/-8 vs 40+/-9 mmHg, p<0.001). The end tidal CO2 tension was not different between VT+ECC and VT. CONCLUSION: In the canine model of simulated ventricular tachycardia, external chest compression had a contradictory hemodynamic effect, including an increase in the cerebral blood flow and a decrease in the coronary perfusion pressure.