Reversal of pre-injury factor-Xa inhibitors with prothrombin complex concentrates in patients following traumatic brain injury.

INTRODUCTION: There is substantial debate on the best method to reverse factor Xa-inhibitors in patients following traumatic brain injury (TBI). Prothrombin complex concentrates (PCC) have been used for this indication but their role has been questioned. This study reported failure rates with PCC in patients following TBI and as a secondary objective, compared 4-factor (4 F-PCC) and activated PCC (APCC). MATERIAL AND METHODS: Consecutive patients with TBI on factor Xa-inhibitors admitted to one of two trauma centers were retrospectively identified. Patients with penetrating TBI, delays in PCC administration (>6 h), receipt of tranexamic acid, factor VIIa or no follow up CT-scan were excluded. The primary outcome was treatment failure defined as hematoma expansion > 20% from baseline for SDH, EDH or IPH, a new hematoma not present on the initial CT scan or any expansion of a SAH or IVH. Hematoma expansion was further categorized as symptomatic or asymptomatic, designated by a change in the motor GCS score, neurologic exam or change ≥ 3 in NIH Stroke Scale. Multi-variate analysis was performed. RESULTS: There were 43 patients with a mean age of 77 ± 13 years with primarily mild TBI (95%) after a ground level fall (79%). The mean dose was 41 ± 12 units/kg. Sixty percent received 4 F-PCC and 40% APCC. The incidence of treatment failure was 28% (12/43). Of the 12 patients with hematoma expansion, only 3 were symptomatic (9.3%). Hematoma expansion with 4 F-PCC and APCC were similar (27% vs. 29%,p = .859). Only sex was associated with hematoma expansion on multivariate analysis [OR (95% CI) = 6.7 (1.1 - 40.9)]. CONCLUSION: PCC was an effective option for factor Xa inhibitor reversal following TBI. The relationship between radiographic expansion and clinical expansion was poor.

The safety of continuous fascia iliaca block in patients with hip fracture taking pre-injury anticoagulant and/or antiplatelet medications.

BACKGROUND: Fascia iliaca compartment block (FICB) is an effective method to treat pain in adult trauma patients with hip fracture. Of importance is the high prevalence of preinjury anticoagulants and antiplatelet medications in this population. To date, we have not identified any literature that has specifically evaluated the safety of FICB with continuous catheter infusion in patients on antiplatelet and/or anticoagulant therapy. The purpose of this study is to quantify the complication rate associated with FICB in patients who are actively taking prescribed anticoagulant and/or antiplatelet medications prior to injury and identify factors that may predispose patients to an adverse event. METHODS: This retrospective study included consecutive adult trauma patients (age ≥18) with hip fracture who underwent placement of FICB within 24 h of admission and had been taking anticoagulant and/or antiplatelet medications pre-injury. Patients were excluded if their catheter was placed more than 24 h post-hospital admission. Patients were evaluated for demographics, injury severity, laboratory values, medication history, receipt of coagulation-related reversal medications, and complications related to FICB placement. Complications included bleeding at the insertion site requiring catheter removal and 30-day catheter site infection. The incidence of complications was reported and risk factors for complications were identified using univariate and multivariate statistics. RESULTS: There were 124 patients included. The mean age was 81 ± 10 years, and the most common mechanism was ground level fall (94%). Most patients were taking single antiplatelet therapy (65%), followed by anticoagulant alone (21%), combined antiplatelet and anticoagulant therapy (7.3%) and dual antiplatelet therapy (7.3%). The most common antiplatelet was aspirin (88%) and the most common anticoagulant was warfarin (60%). Of the patients taking warfarin, the average INR on admission was 2.3 ± 0.8. Only 1 bleeding complication (0.8%) was noted in a patient prescribed clopidogrel pre-injury which occurred 5 days post-catheter placement. This same patient was noted to have superficial surgical site bleeding most likely secondary to the use of enoxaparin for post-operative deep venous thrombosis prophylaxis. There were 4 orthopedic superficial surgical site infections (3.2%), all remote from the catheter site. The pre-injury medication prescribed in these patients was aspirin 81 mg, aspirin 325 mg, rivaroxaban and dabigatran, respectively. No factors were associated with a complication thus multivariate analysis was not performed. CONCLUSION: The incidence of complications associated with fascia iliaca compartment block (FICB) in adult trauma patients prescribed pre-injury anticoagulants or antiplatelet medications is low. In this retrospective review, we did not identify any complications that were directly associated with the FICB procedure. Fascia iliaca block with continuous infusion catheter placement can be safely performed on patients who are on therapeutic anticoagulant and/or antiplatelet agents.

N -acetylcysteine is associated with reduction of postconcussive symptoms in elderly patients: A pilot study.

INTRODUCTION: N -acetylcysteine (NAC) may be neuroprotective by minimizing postconcussion symptoms after mild traumatic brain injury (TBI), but limited data exist. This study evaluated the effects of NAC on postconcussion symptoms in elderly patients diagnosed with mild TBI. METHODS: This prospective, quasirandomized, controlled trial enrolled patients 60 years or older who suffered mild TBI. Patients were excluded if cognitive function could not be assessed within 3-hours postinjury. Patients were allocated to receive NAC plus standard care, or standard care alone, based on the trauma center where they presented. The primary study outcome was the severity of concussive symptoms measured using the Rivermeade Postconcussion Symptoms Questionnaire (RPQ). Symptoms were evaluated on days 0, 7, and 30. The RPQ scores were compared both within and between treatment groups. RESULTS: There were 65 patients analyzed (NAC, n = 34; control, n = 31) with an average age of 76 ± 10 years. Baseline demographics and clinical variables were similar. No group differences in head Abbreviated Injury Scale score or Glasgow Coma Scale score were observed. Baseline RPQ scores (6 [0-20] vs. 11 [4-20], p = 0.300) were indistinguishable. The RPQ scores on day 7 (2 [0-8] vs. 10 [3-18], p = 0.004) and 30 (0 [0-4] vs. 4 [0-13], p = 0.021) were significantly lower in the NAC group. Within-group differences were significantly lower in the NAC ( p < 0.001) but not control group ( p = 0.319). CONCLUSION: N -acetylcysteine was associated with significant improvements in concussion symptoms in elderly patients with mild TBI. These results justify further research into using NAC to treat TBI. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Identification of Risk Factors for Acute Kidney Injury from Intravenous Ketorolac in Geriatric Trauma Patients.

BACKGROUND: Ketorolac is an effective analgesic but the potential for acute kidney injury (AKI) is concerning, particularly in geriatric "G-60 trauma" patients. The objectives of this study are to report the incidence of AKI in patients who receive ketorolac, identify risk factors for AKI, and develop a risk factor-guided algorithm for safe utilization. METHODS: This retrospective cohort study included trauma patients age 60 years and older who received intravenous ketorolac. The primary endpoint was the incidence of AKI. RESULTS: Among 316 patients evaluated, the incidence of AKI was 2.5%. Patients with AKI received more nephrotoxins, had more comorbidities, and higher use of loop diuretics or vasopressors. Loop diuretic therapy and number of comorbidities were independent predictors of AKI. CONCLUSIONS: Risk for AKI with ketorolac was low, being more prevalent with comorbidities or receipt of loop diuretics.

72nd Southwestern Surgical Congress Claude H. Organ, Jr. memorial lecture: Rise ofacutecareroboticsurgery forcommonemergencygeneralsurgeryconditions.

Dr. Claude Organ rose above poverty, racism, and untold insurmountable odds to become a masterful surgeon and revered leader in numerous academic and professional circles. But it's his impact on surgical education and his philosophy to "teach, give back, and keep advancing" that inspired this lecture. Acute care robotic surgery (ACRS) utilizes the strengths of robotic assisted laparoscopic surgery (RALS) for a high-volume population of emergency general surgery (EGS) patients. The future benefits of ACRS may include improvements in resident training, patient safety, and outcomes. General surgery residencies that have a robust ACRS program are likely to be more competitive than those without.

The Role of Desmopressin on Hematoma Expansion in Patients with Mild Traumatic Brain Injury Prescribed Pre-injury Antiplatelet Medications.

BACKGROUND/OBJECTIVE: Desmopressin (DDAVP) has been suggested for antiplatelet medication reversal in patients with traumatic brain injury (TBI) but there are limited data describing its effect on clinical outcomes. The purpose of this study was to evaluate the effect of DDAVP on hematoma expansion and thrombosis in patients with TBI who were prescribed pre-injury antiplatelet medications. METHODS: Consecutive adult patients who were admitted to our level I trauma center and prescribed pre-injury antiplatelet medications between July, 2012, and May, 2018, were retrospectively identified. Patients were excluded if their hospital length of stay was < 24 h, if DDAVP was administered by any route other than intravenous, if they received a DDAVP dose < 0.3 mcg/kg or there was no evidence of brain hemorrhage on computed tomography (CT) scan. Patients were stratified based on the use of DDAVP, and the incidence of hematoma expansion was compared between groups. Thrombotic events were reviewed as a secondary outcome. Multivariate analysis was utilized to control for confounding variables. RESULTS: Of 202 patients included in analysis, 158 (78%) received DDAVP. The mean age was 76 ± 12 years; the most common injury mechanism was falls (76%); 69% had acute subdural hematoma, and 49% had multi-compartmental hemorrhage. Initial Glasgow coma score was between 13 and 15 for 91% of patients. Aspirin was the most common antiplatelet regimen prescribed (N = 151, 75%), followed by dual antiplatelet regimens (N = 26, 13%) and adenosine diphosphate (ADP)-receptor inhibitors (N = 25, 12%). The incidence of hematoma expansion was 14% and 30% for patients who did and did not receive DDAVP, respectively (p = 0.015). After controlling for age, injury severity score, multi-compartmental hemorrhage, and receipt of pre-injury high-dose aspirin (> 81 mg), ADP-receptor inhibitors, oral anticoagulants, prothrombin complex concentrates or platelets in a multivariate analysis, the association between DDAVP and hematoma expansion remained significant (adjusted OR 0.259 [95% CI 0.103-0.646], p = 0.004). Thrombotic events were similar between the two groups (DDAVP, 2.5%, no DDAVP, 4.5%; p = 0.613). CONCLUSIONS: DDAVP was associated with a lower incidence of hematoma expansion in patients with mild TBI who were prescribed pre-injury antiplatelet medications. These results justify a randomized controlled trial to further evaluate the role of DDAVP for this indication.

Utilization of Augmented Renal Clearance in Trauma Intensive Care Scoring System to Improve Vancomycin Dosing in Trauma Patients at Risk for Augmented Renal Clearance.

Background: The Augmented Renal Clearance in Trauma Intensive Care (ARCTIC) scoring system is a validated system to predict augmented renal clearance in trauma patients. This study examined the ability of the ARCTIC score to identify patients at risk for subtherapeutic vancomycin trough concentrations relative to estimated creatinine clearance (eCrCl) alone. Methods: Trauma patients admitted to the intensive care unit from September 2012 to December 2017 who received vancomycin and had a vancomycin trough concentration recorded were included. Patients were excluded if their serum creatinine concentration was >1.3 mg/dL, if they had received vancomycin doses <30 mg/kg per day, an improperly timed trough concentration measurement, or renal replacement therapy. The primary endpoint was an initial subtherapeutic vancomycin trough concentration (<10 mg/L). Classification and regression tree (CART) analysis was used to identify thresholds for the ARCTIC score and other continuous data where subtherapeutic troughs were more common. A step-wise logistic regression analysis was performed to control for confounders for subtherapeutic troughs whereby inclusion of ARCTIC was modeled sequentially after eCrCl. Results: A total of 119 patients with a mean age of 42 ± 17 years and eCrCl 142 ± 39 mL/min met the inclusion criteria. The mean daily vancomycin dose was 44 ± 9 mg/kg, and the incidence of subtherapeutic trough concentration was 46%. The CART analysis identified two variables creating three groups where subtherapeutic trough concentrations differed: eCrCl >105 mL/min and ARCTIC score ≥7, eCrCl >105 mL/min and ARCTIC score <7, and eCrCl ≤105 mL/min. The base logistic regression model identified eCrCl >105 mL/min and pelvic fracture as risk factors for subtherapeutic trough values. The final model included the addition of ARCTIC score ≥7, which improved the model significantly (p = 0.009). Predictors of subtherapeutic trough concentrations were (odds ratio [95% confidence interval]): eCrCl >105 mL/min (6.5 [1.66-25.07]), ARCTIC score ≥7 (3.26 [1.31-8.09]), and pelvic fracture (4.36 [1.27-14.93]). Conclusion: The ARCTIC score is useful when applied in conjunction with eCrCl. Patients with a eCrCl >105 mL/min and an ARCTIC score ≥7 may require a more aggressive dosing strategy.

Utilization of Geriatric Consultation and Team-Based Care.

Geriatric surgical patients experience higher mortality and morbidity rates than their younger counterparts. Three models of geriatric surgical care are described, with a focus on people, plans, and evaluation. These models include geriatric consultation services, geriatric wards, and geriatric multidisciplinary teams. The optimal care plan should be definitive, aggressive, sustainable, safe, and effective, with consideration for patient treatment preferences and wishes.

Lacosamide versus phenytoin for the prevention of early post traumatic seizures.

PURPOSE: To compare the efficacy and safety of lacosamide versus phenytoin for seizure prophylaxis following TBI. MATERIALS AND METHODS: All TBI patients who received prophylaxis with either phenytoin or lacosamide were retrospectively identified. The incidence of seizures within the first 7 days of injury were compared along with adverse effects requiring drug discontinuation. A planned sub-group analysis was performed for patients with severe TBI (GCS < 9). RESULTS: There were 481 patients (phenytoin, n = 116; lacosamide, n = 365). Demographics were similar but age (50 ±â€¯21 vs 58 ±â€¯22 years, P < .001) and initial GCS (11.3 ±â€¯4.3 vs 12.5 ±â€¯3.8, P = .010) were lower in the phenytoin group. The need for mechanical ventilation was higher (53% vs 38%, P = .004). Seizures occurred in 0.9% of the phenytoin group and 1.4% of the lacosamide group (P = 1.00). ADEs were significantly higher with phenytoin (5.2% vs 0.5%, P = .003). This difference remained significant upon multivariate analysis [OR(95% CI) = 9.4(1.8-48.9)]. Subgroup analysis for patients with severe TBI revealed no difference in seizures (phenytoin, 0% vs lacosamide, 1.5%; P = 1.00) but more ADEs with phenytoin (12.5% vs 0%, P = .010). CONCLUSION: There was no difference between lacosamide and phenytoin in the prevention of early post traumatic seizures in patients following TBI. Lacosamide may have a more tolerable side effect profile.

Stress Ulcer Prophylaxis in Neurocritical Care.

Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.

Identifying augmented renal clearance in trauma patients: Validation of the Augmented Renal Clearance in Trauma Intensive Care scoring system.

BACKGROUND: Augmented renal clearance (ARC) is common in trauma patients and associated with subtherapeutic antimicrobial concentrations. This study reported the incidence of ARC, identified ARC risk factors, and described a model to predict ARC (i.e., ARCTIC) that is specific to trauma patients. METHODS: Consecutive trauma patients who were admitted to the intensive care unit between March 2015 and January 2016 and had a measured creatinine clearance (CrCl) were considered for inclusion. Patients were excluded if their serum creatinine (SCr) was greater than 1.3 mg/dL. ARC was defined as a measured CrCl of 130 mL/min or greater. Demographic and trauma-specific variables were then compared, and multivariate analysis was performed. Using these results, a weighted scoring system was constructed and evaluated using receiver operating characteristic curve analysis. ARCTIC score cutoffs were chosen based on sensitivity, specificity, positive predictive value, and negative predictive value. The derived scoring system was then compared to a previously published scoring system for accuracy. RESULTS: There were 133 patients with a mean age of 48 ± 19 years and SCr of 0.8 ± 0.2 mg/dL. The mean measured CrCl was 168 ± 65 mL/min, and the incidence of ARC was 67%. Multivariate analysis revealed the following risk factors for ARC (age, <56: odds ratios [OR], 58.3; 95% confidence interval [CI], 5.2-658.9; age, 56 to 75: OR, 13.5; 95% CI, 1.2-151.7), SCr less than 0.7 mg/dL (OR, 12.5; 95% CI, 3-52.6), and male sex (OR, 6.9; 95% CI, 1.9-24.9). Using these results, the ARCTIC scoring system was: 4 points if younger than 56 years, 3 points if aged 56 years to 75 years, 3 points if SCr less than 0.7 mg/dL, and 2 points if male sex. Receiver operating characteristic curve analysis revealed an area (95% CI) of 0.813 (0.735-0.892) (p < 0.001). An ARCTIC score of 6 or higher had a sensitivity, specificity, positive predictive value, and negative predictive value of 0.843, 0.682, 0.843, and 0.682, respectively. CONCLUSION: The incidence of ARC in trauma patients is high. The ARCTIC score represents a practical, pragmatic system that can be easily applied at the bedside. An ARCTIC score of 6 or higher represents an appropriate cutoff to screen for ARC where antimicrobial adjustments should be considered. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

The importance of empiric antibiotic dosing in critically ill trauma patients: Are we under-dosing based on augmented renal clearance and inaccurate renal clearance estimates?

BACKGROUND: An accurate assessment of creatinine clearance (CrCl) is essential when dosing medications in critically ill trauma patients. Trauma patients are known to experience augmented renal clearance (i.e., CrCl ≥130 mL/min), and the use of CrCl estimations may be inaccurate leading to under-/over-dosing of medications. As such, our Level I trauma center began using measured CrCl from timed urine collections to better assess CrCl. This study sought to determine the prevalence of augmented renal clearance and the accuracy of calculated CrCl in critically ill trauma patients. METHODS: This observational study evaluated consecutive ICU trauma patients with a timed 12-hour urine collection for CrCl. Data abstracted were patient demographics, trauma-related factors, and CrCl. Augmented renal clearance was defined as measured CrCl ≥130 mL/min. Bias and accuracy were determined by comparing measured and estimated CrCl using the Cockcroft-Gault and other formulas. Bias was defined as measured minus calculated CrCl, and accuracy was calculated CrCl that was within 30% of measured. RESULTS: There were 65 patients with a mean age of 48 years, serum creatinine (SCr) of 0.8 ± 0.3 mg/dL, and injury severity score of 22 ± 14. The incidence of augmented renal clearance was 69% and was more common when age was <67 years and SCr <0.8 mg/dL. Calculated CrCl was significantly lower than measured (131 ± 45 mL/min vs. 169 ± 70 mL/min, p < 0.001) and only moderately correlated (r = 0.610, p < 0.001). Bias was 38 ± 56 mL/min, which was independent of age quartile (p = 0.731). Calculated CrCl was inaccurate in 33% of patients and trauma-related factors were not predictive. CONCLUSION: The prevalence of augmented renal clearance in critically ill trauma patients is high. Formulas used to estimate CrCl in this population are inaccurate and could lead to under-dosing of medications. Measured CrCl should be used in this setting to identify augmented renal clearance and allow for more accurate estimates of renal function. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Geriatric trauma G-60 falls with hip fractures: A pilot study of acute pain management using femoral nerve fascia iliac blocks.

BACKGROUND: Hip fractures due to falls cause significant morbidity and mortality among geriatric patients. A significant unmet need is an optimal pain management strategy. Consequently, patients are treated with standard analgesic care (SAC) regimens, which deliver high narcotic doses. However, narcotics are associated with delirium as well as gastrointestinal and respiratory failure risks. The purpose of this pilot study was to determine the safety and effectiveness of ultrasound-guided continuous compartmental fascia iliaca block (CFIB) in patients 60 years or older with hip fractures in comparison with SAC alone. METHODS: We performed a retrospective study of 108 patients 60 years or older, with acute pain secondary to hip fracture (2012-2013). Patient variables were age, sex, comorbidities, and Injury Severity Score (ISS). Primary outcome was pain scores; secondary outcomes included hospital length of stay, discharge disposition, morbidity, and mortality. Statistical analysis was performed using (IBM SPSS version 22). For group comparison (SAC vs. SAC + CFIB) median test, repeated-measures analysis and Student's t test of transformed pain scores were used. RESULTS: Sixty-four patients received SAC only, and 44 patients received SAC + CFIB. Each CFIB placement was successful on first attempt without complications. Median time from emergency department arrival to block placement was 12.5 hours (interquartile range, 4-22 hours). Patients who received SAC + CFIB had significantly lower pain score ratings than patients treated with SAC alone. There were no differences in inpatient morbidity and mortality rates. Patients treated with SAC + CFIB were discharged home more often (p < 0.05). CONCLUSION: Ultrasound-guided CFIB is safe, practical, and readily integrated into the G-60 service for improved pain management of hip fractures. We are now conducting a prospective randomized control trial to confirm our observations. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Trauma-associated pneumonia: time to redefine ventilator-associated pneumonia in trauma patients.

BACKGROUND: The high prevalence of ventilator-associated pneumonia (VAP) in trauma patients has been reported in the literature, but the reasons for this observation remain unclear. We hypothesize that trauma factors play critical roles in VAP etiology. METHODS: In this retrospective study, 1,044 ventilated trauma patients were identified from December 2010 to December 2013. Patient-level trauma factors were used to predict pneumonia as study endpoint. RESULTS: Ninety-five of the 1,044 ventilated trauma patients developed pneumonia. Rib fractures, pulmonary contusion, and failed prehospital intubation were significant predictors of pneumonia in a multivariate model. CONCLUSIONS: It is time to redefine VAP in trauma patients based on the effect of rib fractures, pulmonary contusions, and failed prehospital intubations. The Centers for Disease Control and Prevention definition of VAP needs to be modified to reflect the effect of trauma factors in the etiology of trauma-associated pneumonia.

Who will cover the cost of undocumented immigrant trauma care?

BACKGROUND: Health care reform under the "Patient Protection and Affordable Care Act" (PPACA) will lead to changes in reimbursement. Although this legislation provides a mechanism for uninsured Americans to obtain coverage, it excludes undocumented immigrants (UDI). Reimbursement for UDIs comes from the disproportionate share hospital (DSH) program and was previously supported by Section-1011 of the 2003 Medicare Modernization Act (S1011). The PPACA details a cut of DSH funds starting in 2014. This could impose a significant financial burden on trauma centers. METHODS: From May 2005 to May 2008, we retrospectively reviewed all trauma-related emergency room visits by UDIs. We quantified charges for three entities: emergency department physicians, trauma surgeons, and the hospital. We applied our average institutional collection rate to these charges and compared these projected collections with the actual collections. RESULTS: Over a three-year period, we identified 1,325 trauma UDIs. The financial records revealed a projected emergency department physicians collection of $452,686, a projected trauma surgeons collection of $1.2 million, and a projected hospital collection of $6.9 million (total $8.6 million). Actual funding from S1011 provided $1.7 million and DSH provided $1.9 million (total $3.6 million). Texas State Funding and UDI self-payment contributed $611,082. Overall, our institution had a reimbursement discrepancy of $4.3 million with DSH/S1011 assistance. This increased to $6.0 million after the termination of S1011 and may increase to $7.9 million under PPACA. CONCLUSION: These figures underestimate the total cost of UDI trauma care as it only includes three entities. Our data represent a fraction of national figures. Failure to address these issues could result in ongoing financial problems for trauma centers. LEVEL OF EVIDENCE: II, economic and decision analysis.

Geriatric trauma service: a one-year experience.

BACKGROUND: Trauma centers nationwide have been experiencing an increase in their elderly trauma patients because of an ever growing elderly population within the United States. Many studies have demonstrated the physiologic differences between an older trauma patient versus a younger trauma patient. Coupling these differences with their coexisting medical comorbidities, makes caring for this population extremely challenging. To meet these challenges, we organized a geriatric trauma unit specifically designed with a multidisciplinary approach to take a more aggressive stance to the care of the geriatric trauma patient. METHODS: We created a geriatric trauma unit at our Level II trauma facility, called the G-60 unit. This unit opened for admission in August 2009. Inclusion criteria included all trauma patients older than 60 years. Data were abstracted from our G-60 unit from the period of August 2009 to July 2010. We compared these data to a similar patient population (control group) from January 2008 to December 2008. RESULTS: Our Trauma Data Bank yielded 673 patients for the above queried time period. The G-60 group contained 393 patients, while the control group had 280 patients. A decrease was seen among the G-60 group in all categories: average emergency department length of stay (LOS), average emergency department to operating room time, average surgical intensive care unit LOS, and average hospital LOS. A 3.8% mortality rate was found in the G-60 group compared with a 5.7% mortality rate in the control group. Our analysis also showed rate of 0% pneumonia, 1.3% respiratory failure, and 1.5% urinary tract infection in the G-6O group, while the control group had a rate of 1.8% pneumonia, 6.8% respiratory failure, and 3.9% urinary tract infection. CONCLUSION: Our data from the 1-year experience of our G-60 unit show that addressing the specific needs of elderly trauma patients will lead to better outcomes.

Resident fatigue in 2010: where is the beef?

BACKGROUND: The Accreditation Council for Graduate Medical Education Common Program Requirements for all residency programs (effective July 1, 2011) will limit postgraduate year-1 duty hour length to 16 hours of call. Previous studies have shown some decrement in post-call task performance. We designed a study to evaluate if these decrements still exist in 2010 and to determine specifically when they occur. METHODS: Fourteen residents were tested on 4 simulator tasks during 5 separate call periods. These tasks were completed serially at 4 different time (T) intervals (T0, T12, T18, and T24) over a 24-hour period. Task performance was measured at each of these intervals. The residents completed a post-call survey. RESULTS: Over the 24-hour call there was a trend toward decreased time for the completion of tasks with preservation of accuracy and efficiency. The performance of some residents actually improved and there was minimal correlation between perceived fatigue and performance. CONCLUSIONS: These data show no decrease in junior or senior resident task performance over a 24-hour call period, and do not support the 2011 Accreditation Council for Graduate Medical Education maximum duty hour length of 16 hours.

The creation of a geriatric trauma unit "G-60".

Many elderly trauma patients have isolated orthopedic injuries compounded by chronic medical conditions. We organized a trauma unit, led by trauma surgeons, that is designed to expedite the care of geriatric patients through a multidisciplinary approach. The development of G-60, our Geriatric Trauma Unit, began with discussion between trauma surgeons and hospital administration. Dialogue between trauma surgeons and emergency department physicians yielded triaging, disposition, and admission criteria. Orthopedic surgeons helped implement a goal of operative management in 48 hours. Internal medicine assisted in optimizing chronic disease and providing preoperative clearance with involvement of cardiology and anesthesiology. Meetings were held among surgeons, physical therapists, occupational therapists, respiratory therapists, nutritionists, pharmacists, social workers, case managers, internists, a geriatrician, and physical medicine and rehabilitation. A unit in the hospital was chosen, and a paging system was implemented. Six months lapsed from inception to fulfillment. The multidisciplinary team has achieved several improvements in this population. Through a multidisciplinary approach, a geriatric trauma unit was created that expedites triage, optimizes chronic illness to facilitate definitive management, and provides safe discharge.

Should age be a factor to change from a level II to a level I trauma activation?

BACKGROUND: Elderly trauma patients have a higher incidence of medical comorbidities when compared with their younger cohorts. Currently, the minimally accepted criteria established by the Committee on Trauma for the highest level of trauma activation (Level I) does not include age as a factor. Should patients older than 60 years with multiple injuries and/or a significant mechanism of injury be considered as part of the criteria for Level I activation? Would these patients benefit from a higher level of activation? METHODS: The National Trauma Data Bank was queried for the period of January 1, 1999, to December 31, 2008, for all trauma patients and associated injury severity score (ISS). The data abstracted were based on age and ISS. RESULTS: The National Trauma Data Bank contained 802,211 trauma patients. Seventy-nine percent were younger than 60 years, and 21% were older than 60 years. Our analysis shows that in all levels of injury, patients older than 60 years have an increased risk for morbidity and mortality. We found a threefold increase in morbidity and a fivefold increase in mortality among the older (age >60 years) population with a minor ISS. Elderly patients with a major ISS demonstrated a twofold increase in morbidity and a fourfold increase in mortality. CONCLUSION: Patients with an ISS between 0 and 15 are often triaged to Level II activation. Our data would suggest that patients older than 60 years should be a criterion for the highest level of trauma activation.