Post-mortem computed tomography assessment of medical support device position following fatal trauma: a single-center experience.

PURPOSE: To evaluate the percentage of misplaced medical support lines and tubes in deceased trauma patients using post-mortem computed tomography (PMCT). METHODS: Over a 9-year period, trauma patients who died at or soon after arrival in the emergency department were candidates for inclusion. Whole body CT was performed without contrast with support medical devices left in place. Injury severity score (ISS) was calculated by the trauma registrar based on the injuries identified on PMCT. The location of support medical devices was documented in the finalized radiology reports. RESULTS: A total of 87 decedents underwent PMCT, of which 69% (n = 60) were male. For ten decedents, the age was unknown. For the remaining 77 decedents, the average age was 48.4 years (range 18-96). The average ISS for the cohort was 43.4. Each decedent had an average of 3.3 support devices (2.9-3.6, 95% CI), of which an average of 1 (31.3%, 0.8-1.2, 95% CI) was malpositioned. A total of 60 (69.0%) had at least one malpositioned medical support device. The most commonly malpositioned devices were decompressive needle thoracostomies (n = 25/32, 78.1%). The least malpositioned devices were intraosseous catheters (n = 7/69, 10.1%). Nearly one quarter (n = 19/82, 23.2%) of mechanical airways were malpositioned, including 4.9% with esophageal intubation. CONCLUSION: Malpositioned supportive medical devices are commonly identified on post-mortem computed tomography trauma decedents, seen in 69.0% of the cohort, including nearly one quarter with malpositioned mechanical airways. Post-mortem CT can serve as a useful adjunct in the quality improvement process by providing data for education of trauma and emergency physicians and first responders.

Multimodal Analgesia and Decreased Opioid Use in Adult Trauma Patients.

BACKGROUND: There is an opioid epidemic in the United States. With the increased concern of over-prescribing opioids, physicians are seeking alternative pain management strategies. The purpose of this study is to review the impact of instituting a multimodal analgesia (MMA) guideline on decreasing opioid use in trauma patients at a Level 1 trauma center. METHODS: In 2017, an MMA guideline was developed and included anti-inflammatories, muscle relaxants, neuropathic agents, and local analgesics in addition to opioids. Staff were educated and the guideline was implemented. A retrospective review of medications prescribed to patients admitted from 2016 through 2018 was performed. Patients admitted in 2016 served as the control group (before MMA). In 2018, all patients received multimodal pain therapy as standard practice, and served as the comparison group. RESULTS: A total of 10 340 patients were admitted to the trauma service from 2016 through 2018. There were 3013 and 3249 patients for review in 2016 and 2018, respectively. Total morphine milligram equivalents were 2 402 329 and 1 975 935 in 2016 and 2018, respectively, a 17.7% decrease (P < .001). Concurrently, there was a statistically significant increase in the use of multimodal pain medications. A secondary endpoint was studied to evaluate for changes in acute kidney injury; there was not a statistically significant increase (0.56% versus 0.68%, P = .55). DISCUSSION: Implementation of an MMA guideline significantly reduced opioid use in trauma patients. The use of nonopioid MMA medications increased without an increased incidence of acute kidney injury.

The Impact of Hemodynamic Transesophageal Echocardiography on Acute Kidney Injury Management and Use of Continuous Renal Replacement Therapy in Trauma.

Resuscitation of critically ill trauma patients can be precarious, and errors can cause acute kidney injuries. If renal failure develops, continuous renal replacement therapy (CRRT) may be necessary, but adds expense. Hemodynamic transesophageal echocardiography (hTEE) provides objective data to guide resuscitation. We hypothesized that hTEE use improved acute kidney injury (AKI) management, reserved CRRT use for more severe AKIs, and decreased cost and resource utilization. We retrospectively reviewed 2413 trauma patients admitted to a Level I trauma center's ICU between 2009 and 2015. Twenty-three patients required CRRT before standard hTEE use and 11 required CRRT after; these are the "CRRT" and "CRRT/hTEE" groups, respectively. The hTEE group comprised 83 patients evaluated with hTEE, with AKI managed without CRRT. We compared the average creatinine, change in creatinine, and Acute Kidney Injury Network (AKIN) of "CRRT" with "CRRT/hTEE" and "hTEE." We also analyzed several quality measures including ICU length of stay and cost. "CRRT" had a lower AKIN score (1.6) than "CRRT/hTEE" (2.9) (P = 0.0003). "hTEE" had an AKIN score of 2.1 (P = 0.0387). "CRRT" also had increased ICU days (25.1) compared with "CRRT/hTEE" (20.2) (P = 0.014) and "hTEE" (16.8) (P = 0.003). "CRRT" accrued on average $198,695.81 per patient compared with "CRRT/hTEE" ($167,534.19) and "hTEE" ($53,929.01). hTEE provides valuable information to tailor resuscitation. At our institution, hTEE utilization reserved CRRT for worse AKIs and decreased hospital costs.

Geriatric chest wall injury: is it time for a new sense of urgency?

Geriatric trauma has become an increasingly recognized management concern for trauma centers, and hospitals alike, on a national scale. The population of the United States is aging, as life expectancy rates have demonstrated a steady climb to an average of 78.8 years of expected life. With pervasive efforts of medical screening, prevention and chronic medical condition management, more elderly people will lead more active lifestyles and will be more predisposed to injury. As best practice guidelines specific for the geriatric trauma population have yet to be developed, many researchers have identified management strategies that have offset complications and mortality rates inherent to this patient population after injury. The impact of rib fractures in the 65-year and older patient population has been well documented, as have the mortality and pneumonia rates yet, historically, little attention has been directed to curtailing these adverse outcomes with more advanced treatment options. With the advent of rib plating for rib fracture fixation and chest wall stabilization, the practice paradigm for rib fracture management is shifting, as a viable operative intervention now exists. In this review, we focus on the characteristics of the geriatric trauma patient, areas of management where improvement opportunities have been identified, chest wall injury in the elderly patient, rib plating as a treatment option and offer our data to facilitate a better understanding of rib plating's impact in the geriatric trauma patient.