Comparison of the Effects of Hydralazine and Labetalol on Intracranial Pressure When Used for Blood Pressure Control in Patients With Intracranial Hemorrhage: A Retrospective Study.

Background Recommendations on optimal agents to manage blood pressure (BP) in patients with an intracranial hemorrhage (ICH) are lacking. A case series suggests that hydralazine can cause intracranial pressure (ICP) elevation in an ICH. The purpose of this study was to compare the effects of intravenous (IV) hydralazine to IV labetalol on ICP in patients with ICH. Materials and methods A retrospective chart review from September 2015 to September 2021 on adults admitted to a level I trauma center with ICH, requiring an external ventricular drain or ICP monitor, and pharmacologic intervention with IV hydralazine or IV labetalol. ICP measurements and clinical interventions 0-80 minutes prior to and after medication administration were compared. Data points were excluded if multiple antihypertensive agents were administered. Results A total of 27 patients were included (three received only hydralazine, 13 only labetalol, and 11 both). Twenty-seven doses of hydralazine and 115 doses of labetalol were compared. There was no significant difference in mean ICP 0-80 minutes following hydralazine and labetalol administration (p = 0.283). Of the hydralazine doses, 29.6% received intervention for elevated ICP, while 25.2% of labetalol doses received intervention (p = 0.633). Hydralazine patients received m = 0.56 interventions for ICP, and labetalol patients received m = 0.36 interventions (p = 0.223). Of the patients that required intervention for ICP management, hydralazine patients required m = 1.88 interventions, while labetalol patients required m = 1.41 interventions (p = 0.115).  Conclusion There was no significant difference in mean ICP at 0-80 minutes following administration of hydralazine or labetalol. There was also no significant difference in interventions required for elevated ICP management between groups. Larger studies are needed to confirm these findings.

Association of Cigarette Smoking History With Drug Abuse History and Arterial Carboxyhemoglobin in Trauma Activation Patients: A Retrospective Study.

Introduction The relationship between cigarette smoking and arterial carboxyhemoglobin (CoHb) in trauma activation patients has not been investigated. The aim was to determine if cigarette smoking is associated with drug abuse history and arterial CoHb levels. Methodology This is a retrospective review of level I trauma center activations aged 18-60 during 2018-2020. A medical record audit was performed to assess each patient's cigarette smoking and drug abuse history and admission arterial CoHb level. The CoHb levels and smoking history for each patient were used to construct a receiver operating characteristic curve. Results Of the 742 trauma activations aged 18-60, 737 (99.3%) had a documented cigarette smoking history. Smoking history was positive in 49.7% (366) and negative in 50.3% (371). The positive smoking proportion was greater in patients with a drug abuse history (63.9% (234/366)) than those with a negative history (31.0% (115/371); p<0.0001; odds ratio=4.0). In 717 patients with a CoHb value, the CoHb was higher in smokers (3.9±2.2%) than in non-smokers (0.5±0.4%; p<0.0001; Cohen d=2.2). A CoHb >1.5% was higher in smokers (93.3% (333/357)) than non-smokers (1.7% (6/360); p<0.0001; odds ratio=818.6). The receiver operating characteristic curve for the relationship between CoHb and cigarette smoking history showed an area under the curve of 0.980 (p<0.0001). Using an arterial CoHb level >1.5% to predict a positive smoking history and a CoHb level ≤1.5% to predict a non-smoking history, sensitivity was 93.3% (333/357), specificity was 98.3% (354/360), and accuracy was 95.8% (687/717). Conclusion Cigarette smoking in trauma activations aged 18-60 is associated with drug abuse history and increased arterial CoHb levels on trauma center arrival.

Trauma activation patient preinjury toxicology-positive proportions and associated risk conditions: A retrospective study.

BACKGROUND: Unlike prior guidelines for a positive toxicology screen, the 2022 national trauma data bank dictionary requires the exclusion of postinjury drugs. We aimed to (1) investigate the proportion of drugs in the toxicology screen that were given postinjury; (2) determine preinjury toxicology-positive associations with smoking, psychiatric, and drug abuse histories in an activation patient (ACT-Pt) cohort; and (3) explore whether ACT-Pt varied toxicology testing rates would produce similar preinjury toxicology-positive results. METHODS: In this retrospective study, the historic parent database included consecutive trauma center admissions where toxicology testing was discretionary. A supplementary electronic medical record audit of ACT-Pts age 18-60 years assessed smoking, psychiatric, and drug abuse histories. Subsequently, ACT-Pt age 18-100 years testing was encouraged by attending surgeons and, later routine testing was implemented. RESULTS: Of 2,076 patients in the historic parent database, discretionary toxicology testing occurred in 23.9% (n = 496) and the positive proportion was 58.9% (n = 292). However, 23.6% (n = 69) of the positive screens had the drug given postinjury. The preinjury positive-toxicology proportion was 45.0% (223/496). Preinjury toxicology positivity was greater in ACT-Pts age 18-60 years (52.3%) than in other patients (activations >60 years of age or consultations) (33.7%; p < 0.0001; odds ratio [OR] = 2.2). Smoking, psychiatric, and drug abuse histories were more common in ACT-Pts age 18-60 years preinjury toxicology-positive patients (74.4%, 51.3%, and 98.7%) than in negative patients (36.6%, 25.2%, and 25.2%; p < 0.0001). In ACT-Pts age 18-100 years, when compared to historic discretionary testing (32.7%), testing was increased with encouraged testing (62.1%; p < 0.0001; OR = 3.4) and routine testing (73.1%; p < 0.0001; OR = 5.6). ACT-Pt preinjury toxicology positivity was similar for historic discretionary (47.9%), encouraged (57.6%), and routine (51.3%) (p = 0.3670) testing. The meta-analytic toxicology-positive proportion for the three testing strategies was 49.8%. CONCLUSIONS: Substantial toxicology-positive findings are due to postinjury drug administration. Toxicology positivity is associated with ACT-Pts age 18-60 years and smoking, psychiatric, and drug abuse histories. ACT-Pt age 18-100 years preinjury toxicology positivity is 50% and does not vary with different testing proportions and strategies.

Trauma center admission risk conditions and the probability for developing alcohol withdrawal syndrome: A retrospective study.

BACKGROUND: Because the proportion of trauma patients developing alcohol withdrawal syndrome (AWS) is low, AWS risk conditions have not been precisely delineated. We aimed to create multifactor screening strategies to assess probabilities for the likelihood of developing AWS. METHODS: We performed a retrospective chart review of 1,011 trauma patients admitted to a Level I trauma center to investigate the associations between AWS and probable AWS risk conditions. Included patients were adults who met trauma registry inclusion criteria and had blood alcohol concentration (BAC) testing performed. Patients were excluded if they had a traumatic brain injury with a Glasgow Coma Score (GCS) ≤ 8, or no BAC testing performed. We defined heavy drinking as daily drinking or >7 per week. RESULTS: AWS had univariate associations with heavy drinking history, Injury Severity Score (ISS) ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, Intensive Care Unit (ICU) admission, serum aspartate aminotransferase (AST) ≥40 U/L, and cognitive preservation (GCS ≥13 with BAC ≥100 mg/dL) (all, p < 0.05). ICU admission, AST ≥40 U/L, cognitive preservation, male sex, and age ≥45 had associations with ISS ≥15 or alcohol misuse (all, p < 0.0001). For patients with age ≥45 and heavy drinking history or age <45 and heavy drinking history with ISS ≥15 and ICU admission, the AWS proportion (15.3%) was greater in comparison to other patients (0.3%). The AWS risk score was the sum of the following nine conditions, assigned a zero when the condition was absent and one when present (range 0-9): ISS ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, AST ≥40 U/L, and cognitive preservation. The AWS proportion was greater with a risk score of 5-9 (16.8%) than of 0-4 (1.2%; p < 0.0001). CONCLUSIONS: AWS in the setting of traumatic injury is associated with multiple risk conditions. The presence of multiple risk conditions might have additive effects that could contribute toward a clinical manifestation of AWS. The identified risk conditions may be associated with a hyperadrenergic state.

Trauma center risk conditions for blood alcohol-positive and alcohol misuse patients: a retrospective study.

Because few studies have assessed blood alcohol concentration (BAC)-positive risk conditions in trauma activation patients, this retrospective investigation pursued such an analysis. The parent database included consecutive trauma center admissions from January 21 to July 21 for 2018-2020. The supplementary electronic medical record audit of trauma activation patients aged 18-60 years (TA18-60) assessed alcohol misuse, smoking history, and serum bicarbonate levels. An alcohol misuse risk score was created by assigning a value of 0 (no) or 1 (yes) for each risk condition: 1) smoking history, 2) BAC-positive status, 3) BAC ≥ 100 mg/dL with Glasgow Coma Scale score (GCS) ≥ 13, 4) age ≥ 40 years, and 5) bicarbonate level ≥ 20 mmol/L in BAC-positive patients and summing the total score (range, 0-5). Of 2,076 patients, BAC testing occurred in 60.9% (n = 1,265). BAC positivity was greater in TA18-60 (36.9%) than in other patients (20.8%; P < 0.0001; odds ratio [OR] = 2.2). In the TA18-60 audit (n = 742), categorizations were available for BAC status, 98.5%; smoking history, 99.3%; alcohol misuse history, 99.5%; and bicarbonate level, 99.5%. BAC positivity was greater in smokers (41.3%) than in non-smokers (31.5%; P = 0.0061; OR = 1.5). BAC positivity was greater with alcohol misuse (87.0%) than without (17.7%; P < 0.0001; OR = 31.2). BAC-positive was associated with a greater proportion of bicarbonate levels < 20 mmol/L (52.0%) than BAC-negative (31.8%; P < 0.0001; OR = 2.3). The alcohol misuse proportion was greater with an alcohol misuse risk score of 3-5 (74.4% [142/191]) than with a risk score of 0-2 (10.4% [57/546]; P < 0.0001; OR = 24.9; area under the receiver operating characteristic curve = 0.89). This retrospective study demonstrates that BAC positivity is associated with TA18-60, smoking and alcohol misuse histories, and metabolic acidosis. An alcohol misuse history is associated with multiple risk conditions. Trauma center leadership should provide procedures to identify patients who are BAC-positive or have a positive smoking or alcohol misuse history. Then, such patients should be referred to care providers who can offer assistance and guidance for enhancing overall patient wellbeing.

Bispectral Index Alterations and Associations With Autonomic Changes During Hypnosis in Trauma Center Researchers: Formative Evaluation Study.

BACKGROUND: Previous work performed by our group demonstrated that intermittent reductions in bispectral index (BIS) values were found during neurofeedback following mindfulness instructions. Hypnosis was induced to enhance reductions in BIS values. OBJECTIVE: This study aims to assess physiologic relaxation and explore its associations with BIS values using autonomic monitoring. METHODS: Each session consisted of reading a 4-minute baseline neutral script and playing an 18-minute hypnosis tape to 3 researchers involved in the BIS neurofeedback study. In addition to BIS monitoring, autonomic monitoring was performed, and this included measures of electromyography (EMG), skin temperature, skin conductance, respiratory rate, expired carbon dioxide, and heart rate variability. The resulting data were analyzed using two-tailed t tests, correlation analyses, and multivariate linear regression analyses. RESULTS: We found that hypnosis was associated with reductions in BIS (P<.001), EMG (P<.001), respiratory rate (P<.001), skin conductance (P=.006), and very low frequency power (P=.04); it was also associated with increases in expired carbon dioxide (P<.001), skin temperature (P=.04), high frequency power (P<.001), and successive heart interbeat interval difference (P=.04) values. Decreased BIS values were associated with reduced EMG measures (R=0.76; P<.001), respiratory rate (R=0.35; P=.004), skin conductance (R=0.57; P<.001), and low frequency power (R=0.32; P=.01) and with increased high frequency power (R=-0.53; P<.001), successive heart interbeat interval difference (R=-0.32; P=.009), and heart interbeat interval SD (R=-0.26; P=.04) values. CONCLUSIONS: Hypnosis appeared to induce mental and physical relaxation, enhance parasympathetic neural activation, and attenuate sympathetic nervous system activity, changes that were associated with BIS values. Findings from this preliminary formative evaluation suggest that the current hypnosis model may be useful for assessing autonomic physiological associations with changes in BIS values, thus motivating us to proceed with a larger investigation in trauma center nurses and physicians.

Effect of contemplating patient care spiritual flow principles and mindfulness on trauma center nurses' wellbeing: a pilot trial.

Trauma nurses commonly encounter stress and burnout and have increased negative affect states and decreased positive affect traits. This study investigated whether trauma center nurses would have improvements in wellbeing scores after reading and contemplating Spiritual Flow: Pathways to Proficient Patient Care and Nurse & Physician Wellbeing (Spiritual Flow). Trauma center surgical intensive care unit nurses completed a baseline and follow-up survey before and after reading and contemplating Spiritual Flow, which provides insights into spirituality and mindfulness. The survey contained four positive affect (PA) items, each rated 1-very little to 5-extremely, that were summed to create a PA score (PAS). The seven negative affect (NA) survey items were similarly rated and reverse coded, 1-extremely to 5-very little, to create a nonstress score (NSS). The PAS (4-20) and NSS (7-35) were summed to create a wellbeing score (WS). Nurses rated the degree to which they felt more peaceful or inspired after contemplating the book. Thirty-seven of 39 (95%) routine nursing staff members completed both surveys. Follow-up values increased for WS (P = 0.0001) and NSS (P = 0.0001) after reading and contemplating Spiritual Flow compared to baseline values. No changes occurred for PAS (P = 0.1606). Because 16% of nurses had a high PAS on the baseline survey, further analyses were performed on the other 84%. Significantly increased values were noted on follow-up for PAS (P = 0.0171), NSS (P = 0.0015), and WS (P = 0.0003) compared to baseline scores. Of 37 nurses, 24 (64.9%) rated feeling more peaceful and/or inspired as moderately or quite a bit. This pilot study suggests that contemplating Spiritual Flow was associated with improvements in surgical intensive care trauma center nurse wellbeing. These preliminary findings need to be confirmed in an investigation that includes a control group and randomization.

The Association of Time to Palliative Medicine Consultation on Geriatric Trauma Outcomes.

The integration of specialized geriatric providers with trauma services has received increased attention with promising results. Palliative medicine consultation (PMC) has been shown to reduce length of stay, improve symptom management, and clarify advance directives in the geriatric trauma population. The aim of this study was to evaluate whether PMC reduced tracheostomies and percutaneous endoscopic gastrostomies (trach/PEG) and readmission rates in the geriatric trauma population. Retrospective cohort analysis of patients 65 years of age and older, admitted to a Level I trauma center surgical intensive care unit from 2013 to 2014. Patients who died within 1 day were excluded. Statistical analyses included descriptive statistics, independent-samples t test for continuous variables, χ test for categorical variables, and logistic regression analysis. A total of 202 patients were included. Palliative medicine consultation occurred in 48%. Average time from admission to PMC was 2.91 days. Thirty-day readmission rate was 19.3%. Patients with a PMC (69.1%) were less likely to undergo trach/PEG (30.9%; p < .001) but more likely if the consult was late (>72 hr posttrauma; 22.0% vs. 40.4%; p = .05). Patients without a trach/PEG were more likely to survive 1 year posttrauma (85.7% vs. 14.3%; p = .003). Thirty-day readmission rates were similar between groups. In a logistic regression analysis, PMC, age, and injury severity score demonstrated an independent association with trach/PEG (all p < .05). Early palliative consults (<72 hr posttrauma) for geriatric trauma patients may reduce tracheostomy and percutaneous endoscopic gastrostomy procedures and hospital stays.

Body mass index interaction effects with hyperglycemia and hypocholesterolemia modify blunt traumatic brain injury outcomes: a retrospective study.

INTRODUCTION: There is controversy regarding obesity or body mass index (BMI) effects on postinjury mortality and mechanical ventilation. The aim was to assess outcome associations with BMI and postinjury blood glucose and cholesterol. METHOD: Adult blunt traumatic brain injury patients admitted to a level I trauma center and requiring ≥ 3 days of intensive care were investigated. Admission blood glucose and day-4 total cholesterol were captured from the medical records. Cholesterol ratio was calculated by dividing day-4 values by published national normative levels according to sex, age, and injury date. RESULTS: The parent cohort included 588 patients. The ventilator days ≥ 10 or died group, when compared to the ventilator days < 10 and lived group, had higher Injury Severity Score (ISS) (29.2±9.9 versus [vs.] 23.7±9.7, P < 0.0001), BMI (27.9±6.8 vs. 26.0±5.5, P = 0.0002), and admission glucose (182.6±79 vs. 155.4±59 mg/dl, P < 0.0001, n = 476) and lower emergency department Glasgow Coma Scale score (ED GCS) (6.9±4.7 vs. 10.3±5.0, P < 0.0001) and cholesterol ratio (0.64±0.2 vs. 0.70±0.2, P = 0.0018, n = 364). The ventilator days ≥ 10 or died group had independent associations with increased ISS (P = 0.0709), decreased ED GCS (P = 0.0078), and increased BMI÷cholesterol ratio (P = 0.0003). The ventilator days ≥ 10 or died group had independent associations with increased ISS (P = 0.0013), decreased ED GCS (P < 0.0001), and increased BMI × glucose (P < 0.0001). Ventilator days were increased with higher ISS (P < 0.0001), BMI (P = 0.0014) and glucose (P = 0.0031) and with lower ED GCS (P < 0.0001) and cholesterol ratio (P = 0.0004). Ventilator days had independent associations with increased ISS (P < 0.0001), decreased ED GCS (P = 0.0041), and increased BMI÷cholesterol ratio (P = 0.0010). Ventilator days had independent associations with increased ISS (P < 0.0001), decreased ED GCS (P < 0.0001), and increased BMI × glucose (P = 0.0041). CONCLUSION: For TBI patients, valid risk assessment measurements include ISS (anatomic injury burden), ED GCS (brain function), BMI (preinjury weight status), admission glucose (postinjury metabolism), and day-4 cholesterol ratio (postinjury inflammation).

Detecting delayed intracranial hemorrhage with repeat head imaging in trauma patients on antithrombotics with no hemorrhage on the initial image: A retrospective chart review and meta-analysis.

BACKGROUND: There is debate regarding routine repeat head computed tomography (CT) in blunt trauma patients on a pre-injury antithrombotic when the initial CT is negative for intracranial hemorrhage (ICH). DATA SOURCES: Retrospective chart review and systematic literature review with meta-analysis. CONCLUSIONS: In the chart review, 32.1% did not have a repeat head CT and 67.9% did. The delayed ICH incidence between those with and without a repeat head CT was similar (1.7% vs 0, p = .3101). The current study was combined with the identified 24 studies. Delayed ICH with or without routine repeat CT was similar between antiplatelet and anticoagulant categories (1.4% vs. 1.3%, p = .5322). Delayed ICH was lower for patients without routine repeat CT compared to those with routine repeat CT (0.8% vs 1.7%, p = .0008). For this patient population, repeat scans should be discretionary. Routine repeat CT may identify a larger proportion of minor delayed ICH.

Brainwave Self-Regulation During Bispectral IndexTM Neurofeedback in Trauma Center Nurses and Physicians After Receiving Mindfulness Instructions.

Fifty-seven level I trauma center nurses/physicians participated in a 4-day intervention to learn relaxed alertness using mindfulness-based instructions and EEG neurofeedback. Neurofeedback was provided by a Bispectral IndexTM (BIS) system that continuously displays a BIS value (0-100) on the monitor screen. Reductions in the BIS value indicate that power in a high-frequency band (30-47 Hz) is decreased and power in an intermediate band (11-20 Hz) is increased. A wellbeing tool with four positive affect and seven negative affect items based on a 5-category Likert scale was used. The wellbeing score is the sum of the positive affect items (positive affect score) and the reverse-scored negative affect items (non-stress score). Of functional concern were four negative affect items rated as moderately, quite a bit, or extremely in a large percent. Of greater concern were all four positive affect items rated as very slightly or none at all, a little, or moderately in over half of the participants. Mean and nadir BIS values were markedly decreased during neurofeedback when compared to baseline values. Post-session relaxation scores were higher than pre-session relaxation scores. Post-session relaxation scores had an inverse relationship with mean and nadir BIS values. Mean and nadir BIS values were inversely associated with NFB cognitive states (i.e., widening the visual field, decreasing effort, attention to space, and relaxed alertness). For all participants, the wellbeing score was higher on day 4 than on day 1. Participants had a higher wellbeing score on day 4 than a larger group of nurses/physicians who did not participate in the BIS neurofeedback trial. Eighty percent of participants demonstrated an improvement in the positive affect or non-stress score on day 4, when compared to day 1; the wellbeing, non-stress, and positive affect scores were substantially higher on day 4 than on day 1. Additionally, for that 80% of participants, the improvements in wellbeing and non-stress were associated with reductions in day 3 BIS values. These findings indicate that trauma center nurses/physicians participating in an EEG neurofeedback trial with mindfulness instructions had improvements in wellbeing. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03152331. Registered May 15, 2017.

Psychometric properties of the St. Elizabeth Youngstown hospital wellbeing inventory and non-burnout inventory for physicians and nurses.

BACKGROUND: Physicians and nurses have substantial problems with wellbeing and burnout. We examined the reliability and construct validity of a wellbeing inventory (WBI) administered to some physicians and nurses working in St. Elizabeth Youngstown Hospital (SEYH). METHODS: The SEYH-WBI, consisting of 4 positive affect (PA) items and 7 negative affect (NA) items developed from 5 validated surveys, was administered (n = 419). A non-burnout inventory (SEYH-NBI) consisting of 2 PA items and 3 NA items was derived from the SEYH-WBI. The Positive and Negative Affect Schedule (PANAS), a validated survey consisting of 10 PA items and 10 NA items, was conducted (n = 191). The Maslach Burnout Inventory (MBI), a validated survey consisting of 3 domains (3 items each), was completed (n = 150). RESULTS: For the SEYH-WBI, Cronbach coefficients were 0.76 for PA items and 0.83 for NA items. The NA item loading on factor 1 was 0.55-0.84 and the PA item loading on factor 2 was 0.47-0.89. Confirmatory indices were as follows: root mean square residual, 0.07 and Bentler Comparative Fit Index, 0.92. For the SEYH-NBI, Cronbach coefficients were 0.76 for PA items and 0.79 for NA items. The NA item loading on factor 1 was 0.80-0.87 and the PA item loading on factor 2 was 0.89-0.90. Confirmatory indices were as follows: root mean square residual, 0.02; and Bentler Comparative Fit Index, 0.99. PANAS correlations were as follows: SEYH-WBI PA and PANAS PA scores, r = 0.9; p <  0.0001; SEYH-WBI NA and PANAS NA scores, r = 0.9; p <  0.0001; SEYH-NBI PA and PANAS PA scores, r = 0.8; p <  0.0001; and SEYH-NBI NA and PANAS NA scores, r = 0.7; p <  0.0001. Correlations for SEYH-NBI and MBI were as follows: total NBI and total MBI, r = - 0.6, p <  0.0001; NA and emotional exhaustion, r = 0.6, p <  0.0001; PA and personal accomplishment, r = 0.3, p = 0.0003; and NA and depersonalization, r = 0.3, p = 0.0008. CONCLUSIONS: Validation assessments indicate that the SEYH-WBI and SEYH-NBI have acceptable psychometric performance. Similar findings in a larger cohort would be more compelling.

No correlation between lower extremity deep vein thrombosis and pulmonary embolism proportions in trauma: a systematic literature review.

PURPOSE: To assess the effect of surveillance on deep vein thrombosis (DVT) and pulmonary embolism (PE) rates, the efficacy of chemoprophylaxis and mechanical prophylaxis, and the relationship between DVT and PE. METHODS: A 23 year, systematic literature review was performed in PubMed. Twenty publications with > 13,000 patients were reviewed. Analyzed traits included: DVT surveillance utilization, the total number of patients included in each study, the number of patients developing DVT and/or PE, chemoprophylaxis and mechanical prophylaxis utilization. When event proportions from individual studies were combined, a weighted mean proportion was computed based on the size of each individual cohort. Combined event proportions were compared with other combined event proportions, according to differences in intervention. Inter-group event proportions were compared using Chi-Square or Fisher's exact test, as appropriate. RESULTS: DVT rates increase with surveillance (10.7% vs. 2.5%, p < 0.001). PE rates were similar regardless of surveillance (p = 1.0). Chemoprophylaxis lowered both DVT rates (8.2% vs. 10.7%; p < 0.0001) and PE rates (1.2% vs. 1.9%; p = 0.0050). Mechanical prophylaxis did not decrease DVT rates (10.2% vs. 11.5%; p = 0.2980) or PE rates (1.7% vs. 1.6%; p = 1.0). In patients with neither chemoprophylaxis nor mechanical prophylaxis, DVT rate was 11.5%, PE was 1.6%. When chemoprophylaxis and/or mechanical prophylaxis were given, DVT rate was 8.6% (p < 0.0189) and PE was 1.3% (p = 0.4462). PE proportions were not decreased with mechanical prophylaxis or surveillance. DVT and PE rates were not associated (p = 0.7574). CONCLUSIONS: The results suggest that PE is not associated with lower extremity DVT in adult trauma patients.

Learning receptive awareness via neurofeedback in stressed healthcare providers: a prospective pilot investigation.

OBJECTIVE: Because physicians and nurses are commonly stressed, Bispectral Index™ (BIS) neurofeedback, following trainer instructions, was used to learn to lower the electroencephalography-derived BIS value, indicating that a state of receptive awareness (relaxed alertness) had been achieved. RESULTS: Ten physicians/nurses participated in 21 learning days with 9 undergoing ≤ 3 days. The BIS-nadir for the 21 days was decreased (88.7) compared to baseline (97.0; p < 0.01). From 21 wellbeing surveys, moderately-to-extremely rated stress responses were a feeling of irritation 38.1%; nervousness 14.3%; over-reacting 28.6%; tension 66.7%; being overwhelmed 38.1%; being drained 38.1%; and people being too demanding 52.4% (57.1% had ≥ 2 stress indicators). Quite a bit-to-extremely rated positive-affect responses were restful sleep 28.6%; energetic 0%; and alert 47.6% (90.5% had ≥ 2 positive-affect responses rated as slightly-to-moderately). For 1 subject who underwent 4 learning days, mean BIS was lower on day 4 (95.1) than on day 1 (96.8; p < 0.01). The wellbeing score increased 23.3% on day 4 (37) compared to day 1 (30). Changes in BIS values provide evidence that brainwave self-regulation can be learned and may manifest with wellbeing. These findings suggest that stress and impairments in positive-affect are common in physicians/nurses. Trial Registration ClinicalTrials.gov NCT03152331. Registered May 15, 2017.

Evaluation of operating room reverse Trendelenburg positioning and its effect on postoperative hypoxemia, aspiration, and length of stay: a retrospective study of consecutive patients.

BACKGROUND: In 2014, this group published an investigation of surgical patients from 2012 who had substantial rates of postoperative hypoxemia (POH) and perioperative pulmonary aspiration (POPA). Therefore, we investigated whether intraoperative reverse Trendelenburg positioning (RTP) decreases POH and POPA rates. METHODS: Consecutive ASA I-IV surgical patients who had preoperative pulmonary stability requiring general anesthesia with endotracheal intubation were evaluated. Using pulse oximetry, hypoxemia was documented intraoperatively and during the 48 h following PACU discharge. POPA was the presence of a pulmonary infiltrate with hypoxemia. In early 2015, a multifaceted effort was undertaken to enhance anesthesiologist and operating nurse awareness of RTP to potentially decrease POH and POPA rates. Analyses included (1) combining 2012 and 2015 cohorts to assess risk conditions, (2) comparing post-campaign 2015 (increased RTP) and 2012 cohorts, and (3) comparing 2015 patients with audit-documented RTP during surgery to the other 2015 patients. RESULTS: Combining the 500 patients in 2012 with the 1000 in 2015 showed that POH had increased mortality (2.3%), compared to no POH (0.2%; p = 0.0004). POH had increased postoperative length of stay (LOS) (4.6 days), compared to no POH (2.0 days; p < 0.0001). POPA had increased mortality (7.7%) and LOS (8.8 days), compared to no POPA (0.4%; p = 0.0004; 2.3 days; p < 0.0001). Open aortic, cranial, laparotomy, and neck procedures had greater POH (41.3%) and LOS (4.0 days), compared to other procedures (16.3%; p < 0.0001; 2.2 days; p < 0.0001). Glycopyrrolate on induction had lower POH (17.4%) and LOS (1.9 days), compared to no glycopyrrolate (21.6%; p = 0.0849; 2.7 days; p < 0.0001). POH was lower (18.1%) in 2015, than in 2012 (25.6%; p = 0.0007). POPA was lower with RTP in 2015 (0.6%), than in 2012 (4.8%; p = 0.0088). For the 2015 patients, LOS was lower with audit-documented RTP (2.2 days), compared to other patients (2.7 days; p = 0.0246). CONCLUSIONS: These findings are only hypothesis-generating. A randomized clinical trial is needed to confirm whether RTP has an inverse association with POH and POPA, and if RTP and glycopyrrolate are associated with improved outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02984657.

Laparoscopic Splenectomy in Hemodynamically Stable Blunt Trauma.

BACKGROUND AND OBJECTIVES: No criteria define indications for laparoscopic splenectomy in trauma. This investigation compared characteristics of trauma patients and outcomes between laparoscopic and open splenectomies. METHODS: Patients were identified retrospectively by using ICD-9 codes. Included patients were 18 or older, with a blunt splenic injury from January 1, 2011, through December 31, 2014, and required splenectomy. Excluded patients had penetrating trauma, successful nonoperative management, or successful embolization. Variables included demographics, presenting characteristics, injury severity scores, abdominal abbreviated injury scores, splenic injury grade, surgical indication and approach (open or laparoscopic), surgery length, intra-operative blood loss, transfusions, length of stay, complications, mortality, and discharge disposition. RESULTS: Forty-one patients underwent open splenectomy, and 11 underwent laparoscopic splenectomy. The mean age was 48.7 years, and men comprised the sample majority (36/52). The groups were well matched for age, abdominal injury scores, and admission vital signs. The open group had a significantly lower level of consciousness and more acidosis compared with the laparoscopic group. Most laparoscopic splenectomies were performed after failed nonoperative management or embolization. The indications for open splenectomy were a positive focused assessment with sonography for trauma and computed tomography results. Laparoscopic patients had significantly longer times between presentation and surgery and longer operations, but had significantly less blood loss and fewer transfusions compared with the open group. There were no differences in mortality, length of stay, complications, or discharge dispositions. CONCLUSION: Laparoscopic splenectomy is useful in patients with blunt trauma in whom conservative management produced no improvement and who do not have other injuries to preclude laparoscopy.

Palliative Medicine Consultation Reduces Length of Stay, Improves Symptom Management, and Clarifies Advance Directives in the Geriatric Trauma Population.

The impact of Palliative Medicine Consultation (PMC) on geriatric trauma patients' outcomes was evaluated. It was hypothesized that patients with PMC would have a shorter length of stay. Patients aged 65 years or older and admitted to trauma services were analyzed. Patients with a PMC were more likely to have a documented advance directive discussion (P < .001) and a code status update (P < .001). Length of stay was reduced for patients with a PMC on or before trauma day 2 compared to those with a PMC after trauma day 2. Palliative Medicine should be consulted early into a geriatric patient's hospital stay.

The Lack of Common Goals and Communication Within a Level I Trauma System: Assessing the Silo Effect Among Trauma Center Employees.

We assessed our level I trauma center's employees' perception of inter- and intradepartmental relationships to determine whether employees who work less often with patients feel less involved-the silo effect. We prospectively evaluated employees who provide direct patient care using the Trauma System Survey tool. Of 1155 employees, 699 responded. Combined interdepartmental relationships showed that 93% believed their unit communicated well with other units, and 86% thought other units communicated well with their unit. However, 69% experienced miscommunication between units. To reduce silos, communication is key. Training and multiunit events may help reduce these silos further.

Trauma patient adverse outcomes are independently associated with rib cage fracture burden and severity of lung, head, and abdominal injuries.

OBJECTIVE: We hypothesized that lung injury and rib cage fracture quantification would be associated with adverse outcomes. SUBJECTS AND METHODS: Consecutive admissions to a trauma center with Injury Severity Score ≥ 9, age 18-75, and blunt trauma. CT scans were reviewed to score rib and sternal fractures and lung infiltrates. Sternum and each anterior, lateral, and posterior rib fracture was scored 1 = non-displaced and 2 = displaced. Rib cage fracture score (RCFS) = total rib fracture score + sternal fracture score + thoracic spine Abbreviated Injury Score (AIS). Four lung regions (right upper/middle, right lower, left upper, and left lower lobes) were each scored for % of infiltrate: 0% = 0; ≤ 20% = 1, ≤ 50% = 2, > 50% = 3; total of 4 scores = lung infiltrate score (LIS). RESULTS: Of 599 patients, 193 (32%) had 854 rib fractures. Rib fracture patients had more abdominal injuries (p < 0.001), hemo/pneumothorax (p < 0.001), lung infiltrates (p < 0.001), thoracic spine injuries (p = 0.001), sternal fractures (p = 0.0028) and death or need for mechanical ventilation ≥ 3 days (Death/Vdays ≥ 3) (p < 0.001). Death/Vdays ≥ 3 was independently associated with RCFS (p < 0.001), LIS (p < 0.001), head AIS (p < 0.001) and abdominal AIS (p < 0.001). Of the 193 rib fracture patients, Glasgow Coma Score 3-12 or head AIS ≥ 2 occurred in 43%. A lung infiltrate or hemo/pneumothorax occurred in 55%. Thoracic spine injury occurred in 23%. RCFS was 6.3 ± 4.4 and Death/Vdays ≥ 3 occurred in 31%. Death/Vdays ≥ 3 rates correlated with RCFS values: 19% for 1-3; 24% for 4-6; 42% for 7-12 and 65% for ≥ 13 (p < 0.001). Death/Vdays ≥ 3 was independently associated with RCFS (p = 0.02), LIS (p = 0.001), head AIS (p < 0.001) and abdominal AIS (p < 0.001). Death/Vdays ≥ 3 association was better for RCFS (p = 0.005) than rib fracture score (p = 0.08) or number of fractured ribs (p = 0.80). CONCLUSION: Rib fracture patients have increased risk for truncal injuries and adverse outcomes. Adverse outcomes are independently associated with rib cage fracture burden. Severity of head, abdominal, and lung injuries also influence rib fracture outcomes.

Timing for deep vein thrombosis chemoprophylaxis in traumatic brain injury: an evidence-based review.

Multiple studies have addressed deep vein thrombosis chemoprophylaxis timing in traumatic brain injuries. However, a precise time for safe and effective chemoprophylaxis is uncertain according to experts. A comprehensive literature review on brain injuries was performed to delineate temporal proportions for 1) spontaneous intracranial hemorrhage (ICH) progression, 2) post-chemoprophylaxis ICH expansion, and 3) post-chemoprophylaxis deep vein thrombosis. Twenty-three publications were found including more than 5,000 patients. Spontaneous ICH expansion at 24 hours was 14.8% in 1,437 patients from chemoprophylaxis studies and 29.9% in 1,257 patients not in chemoprophylaxis studies (P < 0.0001). With low-risk ICH (n = 136), 99% of spontaneous ICH expansion occurred within 48 hours. In moderate or high-risk ICH (n = 109), 18% of spontaneous ICH expansion occurred after day 3. If patients with pre-chemoprophylaxis ICH expansion are included, the post-chemoprophylaxis ICH expansion proportion was 5.6% in 1,258 patients with chemoprophylaxis on days 1 to 3 and was 1.5% in 401 with chemoprophylaxis after day 3 (P = 0.0116). If patients with pre-chemoprophylaxis ICH expansion were excluded, the post-chemoprophylaxis ICH expansion proportion was 3.1% in 1,570 patients with chemoprophylaxis on days 1 to 3 and was 2.8% in 582 with chemoprophylaxis after day 3 (P = 0.7769). In diffuse axonal injury (n = 188), the post-chemoprophylaxis ICH expansion proportion was 1.6% with chemoprophylaxis after day 3. The deep vein thrombosis proportions were as follows: chemoprophylaxis on days 1 to 3, 2.6% in 2,384 patients; chemoprophylaxis on days 4 or 5, 2.2% in 831; and chemoprophylaxis on day 8, 14.1% in 99 (P < 0.0001). Spontaneous ICH expansion proportions at 24 hours substantially vary between chemoprophylaxis and non-chemoprophylaxis studies. Chemoprophylaxis should not be given within 3 days of injury for moderate-risk or high-risk ICH. Chemoprophylaxis is reasonable when low-risk patients have not developed ICH expansion within 48 hours post-injury. Chemoprophylaxis is also acceptable after day 3, when low-risk patients develop ICH expansion within 48 hours post-injury. In diffuse axonal injury patients who have not developed ICH within 72 hours, chemoprophylaxis is reasonable. Deep vein thrombosis proportions significantly increase when chemoprophylaxis is withheld for greater than 7 days.