Effect of cocaine use on outcomes in traumatic brain injury.

CONTEXT: Animal and molecular studies have shown that cocaine exerts a neuroprotective effect against cerebral ischemia. AIMS: To determine if the presence of cocaine metabolites on admission following traumatic brain injury (TBI) is associated with better outcomes. SETTINGS AND DESIGN: Level-1 trauma center, retrospective cohort. MATERIALS AND METHODS: After obtaining Institutional Review Board (IRB) approval, the trauma registry was searched from 2006 to 2009 for all patients aged 15-55 years with blunt head trauma and non-head AIS <3. Exclusion criteria were pre-existing brain pathology and death within 30 min of admission. The primary outcome was in-hospital mortality; secondary outcomes were hospital length of stay (LOS), and Glasgow Outcome Score (GOS). STATISTICAL ANALYSIS: Logistic regression was used to determine the independent effect of cocaine on mortality. Hospital LOS was compared with multiple linear regression. RESULTS: A total of 741 patients met criteria and had drug screens. The screened versus unscreened groups were similar. Cocaine positive patients were predominantly African-American (46% vs. 21%, P < 0.0001), older (40 years vs. 30 years, P < 0.0001), and had ethanol present more often (50.7% vs. 37.8%, P = 0.01). There were no differences in mortality (cocaine-positive 1.4% vs. cocaine-negative 2.7%, P = 0.6) on both univariate and multivariate analysis. CONCLUSIONS: Positive cocaine screening was not associated with mortality in TBI. An effect may not have been detected because of the low mortality rate. LOS is affected by many factors unrelated to the injury and may not be a good surrogate for recovery. Similarly, GOS may be too coarse a measure to identify a benefit.

Midlevel practitioners can safely place intracranial pressure monitors.

BACKGROUND: Neurosurgical coverage is a challenge for many trauma centers. Midlevel practitioners (MLPs) can extend coverage by sharing the workload. Our objective was to determine whether the complication rates for intracranial pressure (ICP) monitor placement were similar between neurosurgeons and MLPs. METHODS: After obtaining institutional review board approval, the trauma registry at a Level I trauma center was searched for all ICP monitors placed between June 2005 and March 2010. Complications were classified as major or minor. The study was designed as a noninferiority trial with a 5% absolute difference in major complications defined as acceptable, a priori. Time to monitor placement was a secondary outcome and was analyzed by Wilcoxon rank sum and multiple linear regression. RESULTS: One hundred seven patients were identified. Fifteen patients were excluded (inserted by trauma surgeon or MLP under direct supervision, ventricular drain, or inserted at an outside facility). Of the remaining 92, 22 were inserted by neurosurgeons and 70 by MLPs. There was one major complication (cerebrospinal fluid leak) in a monitor placed by an MLP. The difference in complication rates was significantly less than 5% (1.4% vs. 0%, p = 0.0128). The minor complication rate was higher for MLPs (5.7% vs. 0%, p = 0.80). Craniotomy and placement on third shift were associated with shorter times to monitor placement. Nine monitors were inserted at the time of craniotomy, eight of them by the neurosurgeon. CONCLUSION: ICP monitors can be safely placed by midlevel practitioners with major complication rates not different from those of neurosurgeons.

Long-term functional and echocardiographic assessment after penetrating cardiac injury: 5-year follow-up results.

BACKGROUND: There is almost no data describing the long-term functional outcome of patients after penetrating cardiac injury. METHODS: A retrospective study at a Level I trauma center from 2000 to 2009. RESULTS: Sixty-three patients had penetrating cardiac injuries from 28 stabbings and 35 gunshots. Men comprised 89% (56) of the patients. Overall, there were 21 survivors (33%) and 42 died in the emergency room or perioperative period. The mean age did not significantly differ between survivors (36 years ± 12 years) compared with those who died (30 years ± 11 years; p=0.07). There was an increased chance of survival after being stabbed compared with being shot (17 patients vs. 4 patients; odds ratio=12; p=0.002). Thirteen (62%) had injuries to the right ventricle only. Three patients died during follow-up: one from lung cancer and two other patients died from myocardial infarctions, one 9 years later at the age of 45 years and the other 8 years later at the age of 55 years. The survivors had functional follow-up evaluations from 2 months to 114 months (median, 71; interquartile range, 34-92 months) and echocardiographic follow-up from 2 months to 107 months (median, 64; interquartile range, 31-84 months) after their injuries. Functionally, all patients were in NYHA class 1 status, except one patient in class II who was 54 years old and had a mild exertional limitation. The previously injured area could only be identified by echocardiogram in one patient who had a patch repair of a ventricular septal defect (VSD). The mean ejection fraction improved over time from a mean of 51% ± 8% in the immediate postoperative period to 60% ± 9% after a mean follow-up of 59 months (p=0.01). After surgery, 43% of patients had a mild to moderate pericardial effusion; however, the long-term follow-up studies showed that all these had resolved. Wall motion abnormalities occurred in 33% of patients in the immediate postoperative period and, again, all these resolved during long-term follow-up. CONCLUSIONS: Patients who survive penetrating cardiac injuries, without coronary arterial or valvular disruption, have an excellent long-term functional outcome with minimal subsequent cardiac morbidity related to the injury. Full physiologic recovery and normal cardiac function can be expected if the patient survives.

The utility of bronchoscopy after inhalation injury complicated by pneumonia in burn patients: results from the National Burn Repository.

There are no guidelines to determine when bronchoscopy is appropriate in patients with inhalation injury complicated by pneumonia. We reviewed the National Burn Repository from 1998 to 2007 to determine if there is any difference in outcome in burn patients with inhalation injury and pneumonia who did and did not undergo bronchoscopy. Three hundred fifty-five patients with pneumonia did not undergo bronchoscopy, 173 patients underwent one bronchoscopy, and 96 patients underwent more than one bronchoscopy. Patients with a 30 to 59% surface area burn and pneumonia who underwent bronchoscopy had a decreased duration of mechanical ventilation compared with those who did not (21 days, 95% CI: 19-23 days vs 28 days, 95% CI: 25-31 days, P=.0001). When compared with patients who did not undergo bronchoscopy, patients having a single bronchoscopy had a significantly shorter length of intensive care unit stay and hospital stay (35+/-3 vs 39+/-2, P=.04, and 45+/-3 vs 49+/-2, P=.009). The hospital charges were on average much higher in those patients who did not undergo bronchoscopy, compared with those who did ($473,654+/-44,944 vs $370,572+/-36,602, P=.12). When compared with patients who did not undergo bronchoscopy, patients who did have one or more bronchoscopies showed a reduced risk of death by 18% (OR=0.82, 95% CI: 0.53-1.27, P=.37). Patients with inhalation injury complicated by pneumonia seem to benefit from bronchoscopy. This benefit can be seen in a decreased duration of mechanical ventilation, decreased length of intensive care unit stay, and decreased overall hospital cost. In addition, there was a trend toward an improvement in mortality. The aggressive use of bronchoscopy after inhalation injury may be justified.

Efficacy of prophylactic inferior vena cava filter placement in bariatric surgery.

BACKGROUND: To determine whether prophylactic placement of an inferior vena cava (IVC) filter in bariatric patients deemed to be at high risk is effective in reducing their risk of pulmonary embolism. The study was performed at a bariatric center in a community hospital. METHODS: This was a retrospective study of all patients in the Hurley Bariatric Center database who had undergone surgery from April 2000 to June 2006. We compared the incidence of deep venous thrombosis (DVT), pulmonary embolism (PE), and all-cause perioperative mortality in patients who received prophylactic IVC filters and those who did not. Patients received prophylactic filters for risk factors identified in their preoperative evaluation. The charts and electronic medical records were reviewed retrospectively for any DVTs, PEs, and deaths within 30 days. RESULTS: A total of 1851 patients were identified as low risk and did not receive an IVC filter. Among these patients, 12 DVTs, 11 PEs, and 4 deaths occurred. Of the 248 high-risk patients who received IVC filters, 3 DVTs, 2 PEs, and 2 deaths occurred. The difference in the rates of PE was not significant (P = 0.69). CONCLUSION: The incidence of PE in the high-risk group was not significantly different from that of the low-risk group. Thus, the use of prophylactic IVC filters reduces the risk of PE in high-risk patients, a group known to have a much greater incidence of morbidity and mortality, to a rate comparable to the baseline risk of a low-risk group. Additional study is necessary to better define the risk groups.