Development and use of a prehospital-oriented EMS computer bulletin board service.

OBJECTIVE: To describe a Level 1 trauma center's response to the need for centralized information for EMS providers by implementing a computer bulletin board service (BBS). This service permits rapid retrieval of continuing education and reference information as well as an electronic forum for EMS-related issues. METHODS: A desktop computer with a modem supporting 14.4 kbps running Remote Access v2.01 is accessed by both local and toll-free telephone numbers. Users may connect using any personal computer or terminal equipped with a modem as no proprietary formats are used. The service is available 24 hours a day, free of charge, and requires users to register online. RESULTS: The first 41 months of experience has seen 9,592 calls answered by the BBS. 1,372 users, who may be individuals or groups, have registered on the service. Usage occurs in every county in the sponsor's state. In one sample period, 49% of the activity was educationally related, followed by discussion forums (26%). The BBS is used most heavily in the afternoon and evening hours. CONCLUSIONS: A prehospital-oriented EMS BBS has seen increasing utilization in its first 41 months of existence. It has rapidly established itself as a statewide mainstay of EMS information while being inexpensive to develop and maintain. It provides focused service to a target audience and is easily accessible. The development of similar local resources elsewhere is encouraged.

Cognitive trauma care is undervalued: adult splenic injury as a paradigm.

Nonoperative management (NOM) of adult splenic injury is evolving. Economic aspects of NOM have not been examined. We hypothesize that NOM reduces hospital and professional charges. Surgeon, radiologist, and hospital charges and reimbursements, and clinical outcome were obtained for 77 consecutive adult splenic injury patients (> or = 15 years old) over a 3-year period. NOM succeeded in 30 of 31 patients. NOM was associated with lower surgeon fee ($1,148 vs $4,452; P < 0.0001), surgeon reimbursement ($587 vs $2,773; P = 0.0001), and hospital charge ($18,982 vs $48,790; P = 0.001) relative to operative management. Radiologist fee ($1,776 vs $2,285) and reimbursement ($1,069 vs $1,537) were not significantly affected. No significant difference existed between surgeon (primary care provider) and radiologist reimbursement for NOM. ISS poorly correlated with economic variables. We conclude that cost reductions are another potential advantage of NOM. Surgeon reimbursement for the cognitive skills involved in NOM is minimal. Future health finance policy should recognize the cognitive aspects of trauma care.

Sternal fractures in blunt chest trauma: a practical algorithm for management.

A retrospective review of the medical records of blunt trauma patients with sternal fracture admitted to a level 1 trauma center from June 1990 to June 1993 was undertaken to determine the relationship between sternal fractures and clinically significant myocardial injury, and to assess the usefulness of cardiac evaluation and monitoring in these patients. Of 33 patients with sternal fracture, 31 were in motor vehicle crashes and 2 were pedestrians struck. All had Glasgow Coma Scale score = 15. No patient had a severe, life-threatening, associated injury (Abbreviated Injury Score of >3). No electrocardiogram or echocardiogram showed evidence of acute injury or ischemia. No arrhythmias requiring treatment were noted. No CPK-MB fraction was >5%. These results show that sternal fracture is not a marker for clinically significant myocardial injury. The management of sternal fracture patients should be directed toward the treatment of associated injuries.

Peritoneoscintigraphy in the diagnosis of traumatic diaphragmatic rupture.

Current diagnostic modalities for traumatic diaphragmatic hernia (TDH) have limitations. Prior models differ from human injury. This study evaluates peritoneoscintigraphy in a rabbit model of TDH simulating human blunt injury. Ten adult New Zealand rabbits (two control, eight experimental) underwent tracheostomy and left thoracotomy under anesthesia. Experimental animals received a radial phrenotomy (1.0 to 3.5 cm). Incisions were closed over thoracostomy tubes, and ventilation was discontinued. Catheters were inserted intraperitoneally, and radiotracer in saline was injected. A gamma counter was used to take sequential images. Transdiaphraghmatic isotope was seen in only two animals. Both had large injuries; in one, the catheter was directed toward the diaphragmatic defect. We conclude that peritoneoscintigraphy is insensitive in the detection of TDH. It is unlikely to be an effective technique coupled with diagnostic peritoneal lavage. Further efforts to refine diagnostic capability for TDH should be directed elsewhere, such as laparoscopy.

Antibiotic patterns associated with fungal colonization in critically ill surgical patients.

Fungal infections (FI) in surgical patients are increasing; mortality approaches 50 per cent. Prior studies identified factors predicting fungal colonization (FC) including broad spectrum antibiotics (BSA). This study investigates antibiotic patterns predicting FC. Other risk factors and outcomes are analyzed. A total of 72 consecutive SICU patients receiving > or = 7 days BSA were followed. None received prophylactic antifungals. Input data: Age, APACHE II, surgical procedure, lines, ulcer prophylaxis, TPN duration, antibiotic/antifungal regimen. Outcome data: FC, FI, length of SICU and hospital stay, mortality. A total of 32 patients (44%) developed FC; five (16%) developed FI (P = 0.08). All infected patients died (P = 0.0002). FC of GU (25%), respiratory (19%), and GI (19%) tracts were common. Multiple site colonization occurred in 25 per cent of colonized patients. Metronidazole and duration of ventilation predicted FC. APACHE II and TPN duration predicted mortality. Mortality occurred exclusively among patients requiring systemic antifungals. Among BSA, only metronidazole independently predisposed to FC. Other predictors of colonization and mortality agree with prior studies. The high mortality among patients requiring systemic antifungals implies that a more aggressive approach to prophylaxis may be warranted.

"Adult" trauma surgeons with pediatric commitment: a logical solution to the pediatric trauma manpower problem.

Pediatric trauma care by "adult" surgeons is debated, despite the paucity of pediatric trauma surgeons; 424 patients < or = 17 admitted to a Level I Center run by "adult" surgeons were analyzed. Demographics mirrored NPTR (mean ISS 11.5; mean age 10). "Adult" critical care surgeons treated MTOS-comparable patients with outcomes comparable to MTOS. Among other specialists, only neurosurgeons saw a MTOS-comparable population. Nonoperative protocols for solid organ injury were used appropriately. Z for all patients was +0.17 with M 0.908. Ps was 0.951; acute survival was 0.958 with 18 deaths (mean Ps 0.158). There were two unexpected survivors and one unexpected death; 73% of survivors had age-appropriate locomotion. Pediatric trauma outcomes by "adult" surgeons compare favorably to national standards. The recommendation that pediatric trauma care be directed by pediatric surgeons should be qualified in view of such outcomes and the paucity of pediatric trauma surgeons.

Computed tomography is inaccurate in estimating the severity of adult splenic injury.

Computed tomography (CT) is increasingly utilized in evaluation of adult splenic injury (SI). CT correlation with operative findings, CT relationship to successful nonoperative (NO) management, and CT reading reproducibility were examined. Records of patients > or = 15 years old admitted over a 3-year period were reviewed. Computed tomography scans were graded by two radiologists blinded to clinical results. Computed tomography scans were performed on 49 of 77 patients with SI. Eighteen underwent initial operation (OR) and 31 initial NO. Operative patients had higher Injury Severity Scores and Abdominal Abbreviated Injury Scale scores (p < 0.0001). Grade II readings predominated in the NO group (55%). Nonoperative management was successful for 9 grade III and 3 grade IV readings. Computed tomography matched OR grade in 10 readings, underestimated it in 18, and overestimated it in 6. Computed tomography missed SI in five patients. Radiologists disagreed on 9 of 45 (20%) scans. Computed tomography poorly predicted operative findings. Interobserver variability was common. SI management should not be based solely on CT severity.

Tracheostomy and percutaneous endoscopic gastrostomy in the management of the head-injured trauma patient.

Forty-three trauma patients underwent tracheostomy (TRACH) and percutaneous endoscopic gastrostomy (PEG) over 21 months. Thirty-one patients had a head injury with Abbreviated Injury Scale > or = 3 associated with multi-trauma. This study was undertaken to analyze demographic and outcome variables with respect to timing of TRACH/PEG in this population. Patients were divided into EARLY (< or = 7 days) and LATE (> 7 days) groups and were analyzed for admission Glasgow Coma Scale, Apache II, Injury Severity Score, and [(A-a)DO2] at time of TRACH/PEG. Outcome variables were ICU length of stay (LOS), hospital LOS, days of mechanical ventilation (MV) post-TRACH/PEG, complications, and mortality. Esophagogastroduodenoscopy findings with PEG and days to full enteral nutrition were recorded. All demographic variables were statistically similar between the EARLY and LATE groups. The EARLY group had shorter hospital LOS (P < 0.05), total Intensive Care Unit LOS (P < 0.05), ICU LOS post-TRACH/PEG (P < 0.05), and fewer days of MV post-TRACH/PEG (P < 0.05). There were no procedure-related complications of TRACH/PEG in either group. Full Esophagogastroduodenoscopy performed at the time of PEG had a high diagnostic yield in both groups. We conclude that TRACH/PEG performed within the first 7 days of injury in the head trauma patient is the procedure of choice for long-term airway protection, mechanical ventilation, and enteral nutrition. Combined use of these procedures reduces ICU and hospital LOS and shortens the course of MV.

Pharmacologic and clinical considerations in selecting crystalloid, colloidal, and oxygen-carrying resuscitation fluids, Part 1.

The pharmacologic properties of crystalloid, colloidal, and oxygen-carrying resuscitation fluids are described, and the findings of clinical trials of these solutions are discussed. Fluid administration is a fundamental part of resuscitation therapy. Crystalloid solutions supply water and sodium to maintain the osmotic gradient between the extravascular and intravascular compartments. Examples are lactated Ringer's injection and 0.9% sodium chloride injection. Colloidal solutions, such as those containing albumin, dextrans, or starches, increase the plasma oncotic pressure and effectively move fluid from the interstitial compartment to the plasma compartment. Oxygen-carrying resuscitation fluids, such as whole blood and artificial hemoglobin solutions, not only increase plasma volume but improve tissue oxygenation. Clinically, colloidal solutions are generally superior to crystalloids in their ability to expand plasma volume. However, colloids may impair coagulation, interfere with organ function, and cause anaphylactoid reactions. Crystalloid solutions represent the least expensive option and are less likely to promote bleeding, but they are more likely to cause edema because larger volumes are needed. Favorable experience with inexpensive hypertonic crystalloids with improved plasma volume expansion properties may favor a return to resuscitation with crystalloid solutions. Oxygen-carrying resuscitation fluids are indicated when the patient has lost more than 25% of the total blood volume. Tailoring therapy to the individual patient and close monitoring are essential to safe and effective fluid resuscitation.

Unexpected death on the non-ICU trauma ward.

To characterize trauma patients who die unexpectedly on the ward (unexpected ward deaths = UWDs), 1,011 trauma-related deaths occurring at a level I trauma center over a 10-year period were reviewed for location of death. Seventy-four deaths occurred on the non-ICU trauma ward (i.e., nonmonitored med-surg floor). Fifty patients were "do not resuscitate" (expected deaths). Twenty-four patients (mean age, 58.0 years) died unexpectedly (2.4% of trauma-related deaths). The majority had a central nervous system injury or a precipitating event that occurred at night. Twelve (50%) of the UWDs were determined by peer review to be potentially preventable and were the result of delayed diagnosis (n = 6), aspiration (n = 3), or cardiorespiratory arrest (n = 3). We conclude that unexpected trauma center deaths related to events occurring on the non-ICU trauma ward (2.4% of trauma deaths) occur mostly at night in older, neurologically impaired patients and that half of these deaths may be potentially preventable. Increased awareness of this issue and an environment for direct patient observation may reduce the number of these potentially preventable deaths.

Maternal predictors of fetal demise in trauma during pregnancy.

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.

Bilateral femoral nerve neuropathy following blunt trauma. Case report.

A unique case of bilateral compressive injury of the femoral nerves is reported in a 19-year-old man. Traumatic femoral nerve neuropathy following operative injury, penetrating injury, anticoagulant therapy with hemorrhage, and stretch injury has been described previously, and the literature concerning this unusual clinical problem is reviewed. Bilateral traumatic femoral nerve neuropathy resulting from compressive injury has not been previously reported.

A reassessment of the peritoneal lavage leukocyte count in blunt abdominal trauma.

Nine hundred and three patients undergoing diagnostic peritoneal lavage (DPL) over a 6-year period were retrospectively reviewed to evaluate the utility of the white blood cell (WBC) count in the lavage fluid. Eleven patients (1.2%) had dialysate WBC counts greater than 500/mm3, with erythrocyte counts less than 10(5)/mm3. Nine of these patients who were lavaged within 4 hours of injury had no intra-abdominal pathology. Two patients, lavaged after 4 hours, demonstrated intra-abdominal injury. Two hundred twenty-three patients (24.7%) had grossly clear dialysate which was not sent for laboratory analysis. None of these patients required laparotomy. We conclude that the WBC count in DPL fluid is of no diagnostic value in victims of blunt abdominal trauma who are lavaged within 4 hours of injury. In addition, laboratory analysis of clear dialysate is not required in these patients.

Plasma platelet products and exercise-induced myocardial ischemia.

Peripheral plasma concentrations of PF-4 and TxB2 were measured by RIA in 26 patients who underwent exercise stress testing. In group A (n = 15; age 50 +/- 16, mean +/- S.D.) in whom blood sampling was performed by venipuncture, seven patients had a positive stress test associated with an increase in PF-4 concentrations from 3.3 +/- 1.6 ng/ml to 6.9 +/- 3.6 (mean +/- S.D.); six of them demonstrated a greater than 50% increase in PF-4; and only one of eight with a negative stress test had such an increase. In group B (n = 11; 49 +/- 10 yr), patients also underwent postexercise thallium-201 scanning and blood samples were obtained through an intravenous catheter. These patients consistently demonstrated higher PF-4 values (before exercise 7.5 +/- 3.9 ng/ml; after exercise 11.9 +/- 7.1), regardless of the results of the exercise and thallium studies. TxB2 concentrations were unchanged in both groups. To further evaluate the effect of catheter-collected samples on PF-4, five healthy males had serial concurrent blood sampling in opposite arms via both venipuncture and catheter. Although PF-4 concentrations in venipuncture samples were constant, those collected through the catheter increased as a function of time. On the basis of the findings in group A, enhanced platelet activation appears to be associated with exercise-induced ischemia. The observations in group B and the healthy controls indicated that catheter-collection of samples artifactually increased PF-4 concentrations.