The "Airmedical F.A.S.T." for trauma patients--the initial report of a novel application for sonography.

BACKGROUND: While established as an initial screening tool for the evaluation of injured patients at the trauma center, sonographic evaluation of the patient in the prehospital setting remains untested. The purpose of this study was to determine the feasibility of this procedure during prehospital helicopter transport. METHODS: Two qualified flight surgeons performed all imaging studies. Confirmatory endpoints were documented for all images obtained in flight. RESULTS: For this preliminary study, 100 patients are presented; 84 studies were analyzed; 16 were excluded due to patient weight (8), hemodynamic instability (6), or problems with machine calibration (2). Sensitivity was 81.3%; specificity was 100%. The positive predictive value was 100%; the negative predictive value was 95.7%. The accuracy was 96.4%. CONCLUSION: Sonographic studies obtained during air-medical transport are of similar quality and consistency as those obtained in the emergency department. The ability to detect hemoperitoneum in the field may challenge traditional algorithms for prehospital care as a result.

Blunt thoraco-abdominal injury.

Recent advances in blunt thoraco-abdominal trauma management include improvements in imaging, particularly in trauma bay ultrasound. Indications for non-operative management have expanded for solid organ and aortic injury. The physiology of abdominal compartment syndrome continues to be defined, with resulting improvements in care.

Sevoflurane mask anesthesia for urgent tracheostomy in an uncooperative trauma patient with a difficult airway.

PURPOSE: Proper care of the trauma patient often includes tracheal intubation to insure adequate ventilation and oxygenation, protect the airway from aspiration, and facilitate surgery. Airway management can be particularly complex when there are facial bone fractures, head injury and cervical spine instability. CLINICAL FEATURES: A 29-yr-old intoxicated woman suffered a motor vehicle accident. Injuries consisted of multiple abrasions to her head, forehead, and face, right temporal lobe hemorrhage, and complex mandibular fractures with displacement. Mouth opening was <10 mm. Blood pressure was 106/71 mm Hg, pulse 109, respirations 18, temperature 37.3 degrees C, SpO2 100%. Chest and pelvic radiographs were normal and the there was increased anterior angulation of C4-C5 on the cervical spine film. Drug screen was positive for cocaine and alcohol. The initial plan was to perform awake tracheostomy with local anesthesia. However, the patient was uncooperative despite sedation and infiltration of local anesthesia. Sevoflurane, 1%, inspired in oxygen 100%, was administered via face mask. The concentration of sevoflurane was gradually increased to 4%, and loss of consciousness occurred within one minute. The patient breathed spontaneously and required gentle chin lift and jaw thrust. A cuffed tracheostomy tube was surgically inserted without complication. Blood gas showed pH 7.40, PCO2 35 mm Hg, PO2 396 mm Hg, hematocrit 33.6%. Diagnostic peritoneal lavage was negative. Pulmonary aspiration did not occur. Oxygenation and ventilation were maintained throughout the procedure. CONCLUSION: Continuous mask ventilation with sevoflurane is an appropriate technique when confronted with an uncooperative trauma patient with a difficult airway.

Optimizing the management of blunt splenic injury in adults and children.

BACKGROUND: The treatment for splenic injury is evolving to an increased use of nonoperative management. We studied patients with blunt injury to the spleen to determine the overall success with splenic salvage and the reason that adults and children have different outcomes. METHODS: Patient records were reviewed retrospectively for information and parameters that may influence outcome. Patients were categorized by age and type of management. RESULTS: Two hundred sixty-seven patients (222 adults; 45 children < 16 years old) with blunt splenic trauma were treated over a 7.5-year period. Adults had a significantly higher injury severity score (ISS; 27.2 +/- 0.9 vs 19.9 +/- 2.0; P < .05), splenic injury score (SIS; 2.8 +/- 0.1 vs 2.3 +/- 0.1; P < .01), and mortality rate (11.7% vs 2.2%; P < .05) compared with children. Eighty-six adults and 3 children had emergent operation; 23 patients had splenorrhaphy. Nonoperative management was selected initially in 178 patients; 83% (105 adults and 42 children) were treated successfully. The ISS and SIS of patients in whom nonoperative management failed were different from those patients in whom treatment was successful (ISS, 27.5 +/- 2.1 vs 20.6 +/- 1.0; SIS, 3.6 +/- 0.2 vs 2.1 +/- 0.1; P < .05) but were similar to those patients who needed initial emergent operation. Adults and children who had successful nonoperative management had similar ISSs (21.4 +/- 1.1 vs 18.4 +/- 2.0) and SISs (2.0 +/- 0.1 vs 2.3 +/- 0.1). Overall splenic salvage was achieved in 64% of patients (57% of adults and 96 % of children). Salvage increased from 50% to 85% during the study period. CONCLUSIONS: Splenic preservation is possible in most adults and children with blunt injury with the appropriate use of both operative salvage and nonoperative treatment. The higher salvage rate and decreased need for operation in children is due to their lower severity of overall injury and splenic injury. Operative salvage has become less common in adults because more patients are selected for nonoperative management.

Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference.

OBJECTIVE: To assemble an international panel of experts to develop consensus recommendations on selected important issues on the use of ultrasonography (US) in trauma care. SETTING: R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md. The conference was held on December 4, 1997. PARTICIPANTS: A committee of two co-directors and eight faculty members, in the disciplines of surgery and emergency medicine, representing four nations. Each faculty member had made significant contributions to the current understanding of US in trauma. RESULTS: Six broad topics felt to be controversial or to have wide variation in practice were discussed using the ad hoc process: (1) US nomenclature and technique; (2) US for organ-specific injury; (3) US scoring systems; (4) the meaning of positive and negative US studies; (5) US credentialing issues; and (6) future applications of US. Consensus recommendations were made when unanimous agreement was reached. Majority viewpoints and minority opinions are presented for unresolved issues. CONCLUSION: The consensus conference process fostered an international sharing of ideas. Continued communication is needed to advance the science and technology of US in trauma care.

Effectiveness of a 2-specialty, 2-tiered triage and trauma team activation protocol.

STUDY OBJECTIVE: To determine the effectiveness, safety, and resource allocation of a 2-specialty, 2-tiered triage and trauma team activation protocol. METHODS: We conducted a 6-month retrospective analysis of a 2-specialty, 2-tiered trauma team activation system at an urban Level I trauma center. Based on prehospital data, patients with a high likelihood of serious injury were assigned to triage category 1 and patients with a low likelihood of serious injury were assigned to category 2. Category 1 patients were immediately evaluated by both emergency medicine and trauma services. Category 2 patients were evaluated initially by emergency medicine staff with a mandatory trauma service consultation. Main outcomes measured included mortality, need for emergency procedures, need for emergency surgery, complications, and discharge disposition. Potential physician-hours saved were calculated for category 2 cases. RESULTS: Five hundred sixty-one patients were assigned a triage classification (272 to category 1 and 289 to category 2). Category 1 patients had a higher mortality rate (95% confidence interval [CI] for difference of 15.9%, 11.1% to 20.7%, P < .0001), need for emergency surgery (10.7% versus 1.4%, 95% CI for difference of 9.3%, 5.2% to 13.4%; P < .0001), need for emergency procedures (89% of total procedures, 95% CI 83% to 95%; P < .0001), and discharges to rehabilitation facilities (95% CI for difference of 15.1%, 9.3% to 21.0%; P < .0001). The 2-tiered response system saved an estimated 578 physician-hours of time for the trauma service over the study period. CONCLUSION: This evaluation tool effectively predicts likelihood of serious injury, mortality, need for emergency surgery, and need for rehabilitation. Patients with a low likelihood of serious injury may be initially evaluated by the emergency medicine service effectively and safely, thus allowing more efficient use of surgical personnel.

Trauma triage: do AAMS transport guidelines do it effectively?

PURPOSE: Appropriateness of helicopter transport for trauma patient transfer is under closer scrutiny with the development of regionalized trauma systems and managed care. This study was conducted to determine the effectiveness of the 14 Association of Air Medical Services (AAMS) guidelines in triaging trauma patients. METHODS: The application of the trauma transport guidelines for 511 patients flown to our trauma center with hospital stays of fewer than 3 days were analyzed to ensure high sensitivity to overtriage. Injury severity score (ISS), revised trauma score (RTS), Glasgow coma scale (GCS), and mortality rates associated with each of the guidelines were analyzed. RESULTS: Each guideline was associated with mortality greater than or equal to 20%, except motor vehicle, falls, amputation, and degloving. All guidelines had significant ISS (> 14), RTS (< 10), and GCS (< 12), except falls (ISS-6.7, RTS-11, GCS-13.3) and amputations (ISS-6.3, RTS-11, GCS-13.5). Degloving, motor vehicle, spinal cord, airway, and extrication also had a significantly higher RTS (> 12). CONCLUSION: The AAMS transport guidelines for trauma patients accurately predict the potential for serious or life-threatening injury, with the exception of falls and amputations. The rapid access to highly skilled reimplantation teams required by patients with amputations justifies helicopter transport. However, falls greater than 20 feet do not appear to identify potential for life-threatening injury.

Pancreatic trauma: a ten-year multi-institutional experience.

Our objective was to determine the incidence, management, and outcome of traumatic pancreatic injury. A retrospective review was performed of all patients with pancreatic injury admitted to two Level I trauma hospitals over a 10-year period. Comparisons were made with Chi square or Fisher's exact tests. Of 16,188 trauma admissions, 72 patients (0.4%) had pancreatic injury. The mean age was 30 years, and 30 patients (69%) were male. Mechanism of injury was gunshot in 32 (45%), blunt in 27 (37%), and stab wound in 13 (18%). The pancreas was involved in 1.1 per cent of patients with penetrating injuries compared to 0.2 per cent with blunt injuries (P < 0.01). There were 18 grade I (25%), 32 grade II (45%), 16 grade III (22%), and 5 grade IV (7%) injuries. Initial diagnosis was made intraoperatively in 63 patients and by computed tomography in 8. The mean injury grade was significantly lower on computed tomography compared to surgical exploration (0.4 vs 2.0; P < 0.05). Operative procedures included distal pancreatectomy in 23 (32%), exploration only in 22 (31%), external drainage in 13 (18%), pancreatorrhaphy in 4, internal drainage in 2, and proximal resection in 2. Mortality was 16.6 per cent and was not related to the mechanism or grade of injury. Mean Injury Severity Score and transfusion requirements were significantly greater in patients who died (P < 0.05). Morbidity occurred in 30 patients (42%), including pancreatic fistula (11%), pancreatitis (7%), and pancreatic pseudocyst (3%). Six patients (8%) developed intra-abdominal abscesses, and all had associated liver or intestinal injuries. In patients with grade I and II injuries, morbidity was higher with external drainage compared to exploration without drainage. Pancreatic injury is infrequent and is more often associated with penetrating trauma. Diagnosis is most commonly made by exploration and cannot be excluded by computed tomography. Drainage of low-grade injuries may not be necessary. Morbidity and mortality in patients with pancreatic trauma is significant and is primarily due to associated injuries.

Benchmarking the quality-monitoring process: a comparison of outcomes analysis by trauma and injury severity score (TRISS) methodology with the peer-review process.

BACKGROUND: One measure of optimal function within a trauma center is the ability to critically examine outcomes from the process of care within the institution, yet guidelines for evaluation of the peer-review process are lacking. This study was conducted to determine the correlation between mortality analysis performed by the peer-review process (PR) within a trauma division and outcome analysis as determined by Trauma and Injury Severity Score (TRISS) methodology. METHODS: The mortality peer-review data for an entire year at our level I trauma center served as the study population. Information was obtained on probability of survival, and a determination of preventability was made using standard, preexisting criteria. Peer review involves assigning each outcome to a specific category through the process of multidisciplinary assessment. Probability of survival data was not used for this purpose. Kappa analysis was performed to determine the degree of agreement in each category and then tested for significance. RESULTS: One hundred four deaths in 1,868 trauma patients (5.5%) were reviewed at our multidisciplinary conference. Outcomes were judged as preventable, potentially preventable, or nonpreventable. Death directly related to exsanguination was typically categorized as potentially preventable. Kappa analysis demonstrated the greatest agreement between PR and TRISS in the nonpreventable category (kappa = 0.213) and the least agreement in the potentially preventable category (kappa = -0.197). Overall, the kappa Z statistic was nonsignificant (Z = 1.24). CONCLUSIONS: Multidisciplinary peer-review outcomes analysis is at least as effective as the computer-generated TRISS probability of survival data for evaluating quality of care in a trauma center and may be more effective for analysis of potentially preventable outcomes.

Response after out-of-hospital cardiac arrest in the trauma patient should determine aeromedical transport to a trauma center.

OBJECTIVE: To evaluate whether aeromedical transport of trauma patients who sustain an out-of-hospital cardiac arrest (OHCA) is justified. DESIGN: Retrospective chart review. METHODS: We reviewed the outcome of 67 consecutive patients after OHCA with initial resuscitation who were transported to a Level I trauma center. Statistical analysis was used to develop a predictive model for survival. RESULTS: The overall survival was 19%. One of 28 patients with a second OHCA survived (p = 0.005). Logistic regression analysis demonstrated that the Revised Trauma Score at trauma center arrival (1.0 +/- 0.25, nonsurvivors vs. 5.15 +/- 0.86, survivors, p = 0.0001), Injury Severity Score (34.9 +/- 2.9, nonsurvivors vs. 21.3 +/- 4.1, p = 0.037) and a sinus-based cardiac rhythm at the time of aeromedical team arrival were predictive of survival (R2 = 0.57, p = 0.0001). Survivors were more likely to have been transported from an outside hospital (28% vs. 8% for scene runs), had a sinus rhythm on team arrival (42% vs. 3%), and maintained a sinus rhythm on arrival at the trauma center (41% vs. 0%); however, these parameters were not predictive of survival in the statistical model. The neurologic outcome of the 13 survivors was good (preinjury state) in three cases, moderate disability (independent living) in three, severe disability (needing assistance) in five, and persistent vegetative state in two. Regression analysis was unable to differentiate survivors with a good neurologic recovery from the rest of the patient population. CONCLUSIONS: These results suggest that: (1) trauma patients who are resuscitated to a sinus rhythm after OHCA should be transported to a trauma center; (2) Revised Trauma Score and Injury Severity Score are useful to predict survival; and (3) neurologic outcome is not accurately predicted by this model.

Analysis of deaths within 24 hours of injury: cost-benefit implications for organ and tissue donations.

OBJECTIVE: To determine useful predictors of successful organ donation in patients who die within 24 hours of injury (early deaths). DESIGN: Retrospective review of a 3-year experience at a Metropolitan Level I Trauma Center. MATERIALS AND METHODS: All 223 early deaths among 5,719 trauma patients in a 3-year period were reviewed. This group represented 62% of all trauma deaths. RESULTS: Forty-six patients (21%) donated 102 vascularized organs and made 66 donations of tissues. Patients with isolated severe head injuries had the highest rate of successful donation (33%). Those with severe head injury and another severe organ injury had a lower rate of donation (13%), and donation was rare (1%) among patients with severe organ injury in the absence of head injury (p < 0.001). There were no organ donors among victims >65 years old or in 64 of 65 patients with a Revised Trauma Score of <2.2. The Revised Trauma Score was significantly higher in organ donors (3.39 vs. 3.07, p < 0.05). The cost-benefit ratio for early deaths was $6,512 per organ/tissue recovered. CONCLUSIONS: Decisions regarding the resuscitation of trauma patients who have characteristics associated with a recognized low rate of organ donation should be made exclusive of the potential for organ recovery.

The surgical management of intra-abdominal inflammatory conditions during pregnancy.

The timely diagnosis and treatment of intra-abdominal conditions during pregnancy can challenge the surgical consultant. Familiarity with the anatomic and physiologic changes present in normal pregnancy is essential, as is the knowledge of relative risk by trimester. The general surgeon will be called upon to diagnose and treat appendicitis, biliary tract disease (including pancreatitis), and liver disease. Knowledge of how these conditions become manifest is essential. The surgical consultant should be aware that virtually all complications that occur in the management of these conditions are caused by delay in the detection of the disease process.

Resident supervision in the operating room: does this impact on outcome?

Resident supervision by faculty is a sine qua non of surgical education, yet objective standards for supervision are difficult to quantify. Over a 12-month period, using departmental data on morbidity, mortality outcome, and faculty status in the operating room, the association between complications, death, and attending physician presence were analyzed by Chi-square tests of association in 2 x 2 contingency tables, or by the Mantel-Haenszel Chi-square to control for a stratifying variable. A total of 4417 cases were reported. Attending physicians were either scrubbed or present in the OR 91.8% of the time, although there was considerable variation among services. The overall mortality rate was 6.2% and complications occurred in 7.0% overall. Greater attending physician presence was significantly associated with lower mortality and complication rates overall. When stratified by service, the association was less marked. However, presence of attending physicians varied significantly by service. To adjust for this variation, elective services were compared with all the "nonelective" services. When this categorization was used as the stratifying variable, the association between increased attending physician involvement and decreased complication and mortality rates was statistically significant (Mantel-Haenszel Chi-square, p < 0.0005 for both).

Efficacy of deep venous thrombosis prophylaxis in trauma patients and identification of high-risk groups.

The incidence of deep venous thrombosis (DVT) and the efficacy of prophylactic measures were prospectively evaluated in all patients admitted to a level I trauma center during 1991. Patients with Injury Severity Scores (ISS) > 9 who survived a minimum of 48 hours (n = 395) were monitored using venous Doppler and ultrasound studies during hospitalization (total, 1308 studies). Two hundred eighty-one patients (71%) were randomly assigned to low-dose heparin or sequential compression devices. There were 18 cases of lower extremity DVT (4.6%) and four cases (1.0%) of pulmonary emboli (PE), three of which were fatal. Eight patients (2.9%) on prophylaxis and 10 (8.8%) without prophylaxis developed DVT (p < 0.02 by Chi-square). There were two PEs in each group. Fourteen of these 18 patients sustained blunt trauma and included seven spinal fractures or subluxations (four paraplegic) and four severe head injuries. This represented 14.0% of 50 patients admitted with spinal injuries and 4.3% of 92 patients with severe head injuries. Compared with those with no neurologic injury (7 of 253 or 2.7%), the risk of DVT is significantly higher in the spinal injury patients (p < 0.001, Chi-square) and twice as high as in the head injury group, although not statistically significant (p = 0.4, Chi-square). Three of the four patients with penetrating trauma and DVT had venous injuries. We conclude that DVT prophylaxis can significantly reduce the incidence of DVT in trauma patients with ISS > 9. Patients with severe neurologic injuries (particularly spinal cord) are at high risk for DVT and PE and may be considered for a prophylactic Greenfield filter.

Trauma systems, shock, and resuscitation.

This review of early care covers issues pertaining to the analysis of system function, prehospital intravascular volume replacement, diagnosis of proximity vascular injury, the role of emergency thoracotomy, and the value of transesophageal echocardiography. The first six articles deal with various aspects of system function, from triage to analysis of outcome. The next series of articles reviews work in progress evaluating optimal fluid for resuscitation. Hypertonic saline and dextran combinations have been shown to restore vital signs better than isotonic solutions; they are safe, require smaller volumes, and may improve head injury outcome. Danger lies in the restoration of perfusion without hemorrhage control. Two articles on emergency thoracotomy review the indications and outcome in blunt and penetrating trauma. Survival in blunt trauma is virtually zero. An article and two editorials summarize state of the art for diagnosis and treatment of proximity vascular injury. Two articles describe the potential use of the new technique of transesophageal echocardiography. This new modality has not formed a solid indication at present and can be considered investigational in trauma care.