Delayed Intracranial Hemorrhage After Blunt Head Injury With Direct Oral Anticoagulants.

INTRODUCTION: Patients presenting to the Emergency Department (ED) following head injury are frequently evaluated with an initial computed tomography scan (CT) of the brain. Imaging is particularly important in patients who are receiving medications that alter normal blood hemostasis. As an imaging modality, CT has a high negative predictive value when used to rule out clinically significant acute intracranial hemorrhage. Patients receiving anticoagulant or antiplatelet therapy have both an increased risk of initial hemorrhage, as well as an increased risk of mortality above nonanticoagulated patients, should they suffer hemorrhage. Multiple studies of delayed intracranial hemorrhage have placed the risk among the patients taking warfarin at the time of head injury in the range of 0.6-6.0%. However, data regarding the risk of delayed intracranial hemorrhage in patients taking the class of agents referred to as Direct-Acting Oral Anticoagulants (DOACs) remains limited. This study aims to estimate this risk. METHODS: A retrospective chart review was performed to identify patients on DOACs who presented to our Level I trauma center following blunt head injury between January 2017 and August 2018. Patients with a negative initial head CT were selected. From this subset, data regarding demographics, injury characteristics, anticoagulant use, and antiplatelet use were collected. RESULTS: Overall, 314 patients were included; 129 patients taking rivaroxaban, 182 patients taking apixaban, and four patients taking dabigatran. In approximately 29% of the patients, the sole indication for admission was close monitoring following head injury while taking an anticoagulant agent. The mechanism of injury for the majority of the patients was fall. Of the 314 patients, three were found to have delayed intracranial hemorrhage on the repeated head CT (0.95%). Two of these three patients were on concomitant antiplatelet medication. None of the three individuals required neurosurgical intervention. CONCLUSIONS: at the time of submission, this is the largest study estimating the risk of delayed intracranial hemorrhage among patients on DOACs. Based on the results of this study, patients who sustain a blunt head injury while taking only DOACs; that is, without concurrent antiplatelet medication, admission, and repeat head CT may not be necessary after confirming a negative initial CT scan.

Use of a Dog Visitation Program to Improve Patient Satisfaction in Trauma Patients.

Clinical staff members all recognize the importance of attaining high patient satisfaction scores. Although there are many variables that contribute to patient satisfaction, implementation of a dog visitation program has been shown to have positive effects on patient satisfaction in total joint replacement patients. This innovative practice had not previously been studied in trauma patients. The purpose of this quasi-experimental study was to determine whether dog visitation to trauma inpatients increased patient satisfaction scores with the trauma physicians. A team consisting of a dog and handler visited 150 inpatients on the trauma service. Patient satisfaction was measured using a preexisting internal tool for patients who had received dog visitation and compared with other trauma patients who had not received a visit. This study demonstrated that patient satisfaction on four of the five measured scores was more positive for the patients who had received a dog visit.

Results of a clinical practice algorithm for the management of thoracostomy tubes placed for traumatic mechanism.

INTRODUCTION: The management and removal of thoracostomy tubes for trauma-related hemothorax and pneumothorax is controversial. General recommendations exist; however, institutional data related to an algorithmic approach has not been well described. The difficulty in establishing an algorithm centers about individualized patients' needs for subsequent management after thoracostomy tube placement. In our institution, we use the same protocol for all trauma patients who receive a thoracostomy tube with minimal complications. PURPOSE: To present the clinical outcomes of patients who required a tube thoracostomy for traumatic injury and were managed by an institutional protocol. METHODS: A retrospective chart review of 313 trauma patients at a single level I trauma institution from January 2008 through June 2012 was conducted. Inclusion criteria were patient age ≥ 18 years, involvement in a trauma, and requirement of a thoracostomy tube. The patients' charts were reviewed for demographic data, injury severity score (ISS), length of stay (LOS), and chest-tube specific data. Thoracostomy tube complications were defined as persistent air leak, persistent pneumothorax, recurrent pneumothorax, and clotting of thoracostomy tube. The patients were managed per our institutional algorithm. Descriptive statistics were performed. RESULTS: Most of the patients who required a thoracostomy tube had blunt-related traumas (271/313; 86.6%), while 42 patients (13.4%) sustained penetrating injuries. There were 215 (68.7%) male patients. The average age at time of injury was 45.7 ± 21.1 years and the mean ISS was 24.9 ± 15.9 (mean ± SD). Elevated alcohol levels were found in 65 of the 247 patients who were tested upon admission (26.3%). Overall, 15 patients (4.8%) developed a thoracostomy tube related complication: persistent air leak in six patients, persistent pneumothorax in six patients, recurrent pneumothorax in two patients, and clotted thoracostomy tube in one patient. The average LOS was 10.4 ± 8.4 days, and the mean length of thoracostomy tube placement was 5.9 ± 4.3 days. CONCLUSIONS: Our algorithmic thoracostomy tube management protocol resulted in a complication rate of 4.8%. By managing thoracostomy tubes in a systematic manner, our patients have improved outcomes following placement and removal compared to other studies.

Chemical venous thromboembolic prophylaxis is safe and effective for patients with traumatic brain injury when started 24 hours after the absence of hemorrhage progression on head CT.

BACKGROUND: Venous thromboembolism (VTE) continues to be an important complication for patients with trauma, including patients with intracranial hemorrhage. We implemented a protocol starting chemical prophylaxis 24 hours after the absence of progression of hemorrhage on computed tomography (CT) to increase consistency with the use of chemical venous thromboembolic prophylaxis in this population. The objective of this study was to review the protocol of VTE prophylaxis for patients with traumatic brain injury at our institution to determine whether it has been effective and safe in preventing VTE without increasing intracranial hemorrhage. METHODS: A retrospective case series was conducted to study 205 patients with intracranial hemorrhage admitted to a Level I trauma center during a 24-month period. These patients were reviewed with respect to type of intracranial injury, need for surgery, injury severity, time to initiation of chemical prophylaxis, and progression of injury on brain CT. Patients with a hospital length of stay less than 3 days or nonstable CT were excluded in the analysis of administration of chemical prophylaxis. Time to chemical prophylaxis in relation to absence of progression on brain CT was examined as well as the subsequent risk of progression of hemorrhage and risk of VTE events. The overall rate of venous thromboembolism was compared with that of matched historical controls. RESULTS: All patients received mechanical prophylaxis in the form of sequential compression devices. One hundred sixty-two intracranial hemorrhages were identified in 122 patients who met the study's inclusion criteria. Of this group of patients who did not have progression of hemorrhage on follow-up CT, 76.2% received chemical prophylaxis during their hospitalization.No patients had progression of intracranial hemorrhage after initiation of chemical VTE prophylaxis, and no patients developed VTE. This represents a decrease of VTE from previous years. No other complications related to chemical VTE prophylaxis were identified. CONCLUSION: A protocol based on an early use of chemical venous thromboembolic prophylaxis after the absence of progression of tramatic intracranial hemorrhage does not result in increased progression of intracranial hemorrhage and reduced the rate of venous thromboembolic events at our institution.

Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality.

INTRODUCTION: Performance improvement driven by the review of surgical morbidity and mortality is often limited to critiques of individual cases with a focus on individual errors. Little attention has been given to an analysis of why a decision seemed right at the time or to lower-level root causes. The application of scientific performance improvement has the potential to bring to light deeper levels of understanding of surgical decision-making, care processes, and physician psychology. METHODS: A comprehensive retrospective chart review of previously discussed morbidity and mortality cases was performed with an attempt to identify areas where we could better understand or influence behavior or systems. We avoided focusing on traditional sources of human error such as lapses of vigilance or memory. An iterative process was used to refine the practical areas for possible intervention. Definitions were then created for the major categories and subcategories. RESULTS: Of a sample of 152 presented cases, the root cause for 96 (63%) patient-related events was identified as uni-factorial in origin, with 51 (34%) cases strictly related to patient disease with no other contributing causes. Fifty-six cases (37%) had multiple causes. The remaining 101 cases (66%) were categorized into two areas where the ability to influence outcomes appeared possible. Technical issues were found in 27 (18%) of these cases and 74 (74%) were related to disorganized care problems. Of the 74 cases identified with disorganized care, 42 (42%) were related to failures in critical thinking, 18 (18%) to undisciplined treatment strategies, 8 (8%) to structural failures, and 6 (6%) were related to failures in situational awareness. CONCLUSIONS: On a comprehensive review of cases presented at the morbidity and mortality conference, disorganized care played a large role in the cases presented and may have implications for future curriculum changes. The failure to think critically, to deliver disciplined treatment strategies, to recognize structural failures, and to achieve situational awareness contributed to the morbidities and mortalities. Future research may determine if focused training in these areas improves patient outcomes.

Aspiration pneumonia after stroke: intervention and prevention.

Fifteen million strokes occur worldwide each year with 5 million associated deaths and an additional 5 million people left permanently disabled. In the United States, about 780 000 people suffer a new or recurrent stroke each year. There were an estimated total 5.8 million stroke survivors as of 2008. Mortality from stroke is the third leading cause of death in America following heart disease and cancer. Chest infection may affect up to as many as one-third of stroke patients. This increases the morbidity and mortality of this patient population. Pneumonia causes the highest attributable mortality of all medical complications following stroke. A comprehensive multidisciplinary team approach is required at the hospital level. This requires active administrative commitment and participation. Implementation of evidence-based management strategies can improve outcomes and reduce costs. We sought to review the problem of post-stroke pneumonia and discuss strategies for prevention and intervention.

Reduction of radiation dose in pediatric brain CT is not associated with missed injuries or delayed diagnosis.

Increased accuracy of CTs in the identification of traumatic injuries compared with physical examination or conventional radiography is well documented. Our goal was to identify the most effective strategy for decreasing radiation exposure while retaining the benefits of computerized imaging. Based on a literature review and our trauma registry, the mortality risk of untreated injuries was compared with that of patients who received treatment of injuries diagnosed by CT. Because automated exposure control of tube current is not routinely used with brain CT, this region was identified as the initial focus for a dose-saving algorithm. CT settings were adjusted for children studies and the new settings were implemented into four protocols based on age. Images were compared and reviewed by radiologists for the ability to identify traumatic injuries. Effective dose (ED) was estimated using Monte Carlo simulations. The lifetime incidence and mortality for thyroid cancer and leukemia were assessed. In-hospital mortality of unidentified injury in trauma patients is 8.0%. Forty dose-saving CTs were performed and no injuries were missed. The ED decreased by 5.2-, 4.5-, 2.62-, and 2.5-fold in each group. Decreasing the ED is achievable, theoretically decreases the cancer risk and does not increase the missed injury rate.

A disciplined approach to implementation of evidence-based practices decreases ICU and hospital length of stay in traumatically injured patients.

BACKGROUND: Evidence-based medicine has gained wide acceptance in practice of medicine since the 1990s. The objective of our study was to demonstrate the effect of evidence-based critical care practices on ICU and hospital length of stay in mechanically ventilated trauma patients. MATERIALS AND METHODS: Retrospective cohort using historic controls. During 2004, several different evidence-based practices were implemented, including low tidal volume ventilation, protocol driven trauma resuscitation, and a sepsis bundle. Outcomes in critically ill, mechanically ventilated patients who were ≥ 18 y old were compared between a historic control group (2000-2003) and the study group after implementation (2005-2008). Patients were identified using the institutional trauma registry (NATIONAL TRACS). Gender, age, ISS, mechanism of injury, and mortality were also examined to identify trends in epidemiology. RESULTS: From 2000 to 2003. there were 6920 trauma admissions and during 2005-2008 there were 8911 (increase of 28.8%). These included 217 and 337 (increase of 55.3%) admissions to the ICU of mechanically ventilated patients, respectively. The mean age was 43.9 y versus 45.9 y (P = 0.258). Males were 66.4% versus 71.8% (P = 0.610). The mean ISS was 29 versus 27 (P = 0.25). Blunt mechanism was 87% versus 89% (P = 0.913). Mortality rate was 36.4% versus 36.5% (P = 0.944). The mean number of ICU days and hospital days decreased from 7.6 versus 5.5 (P = 0.02) and 13.2 versus 9.7 (P = 0.03), respectively. CONCLUSION: The application of evidence-based critical care practices decreases length of ICU and hospital stay, but not mortality, in critically ill, mechanically ventilated trauma patients. Our trauma volume, including critically ill patients, increased during the study periods.

A modern analysis of a historical pediatric disaster: the 1927 Bath school bombing.

BACKGROUND: Children have unique anatomy and physiology that may necessitate a unique approach to a pediatric surge. An analysis of the Bath school bombings of 1927, the largest pediatric terrorist disaster in U.S. history, provides an opportunity to gain perspective on pediatric patterns of injury and future disaster preparedness. MATERIALS AND METHODS: Eighty-nine contemporary newspaper accounts, the official coroner's inquest, interviews, online resources, and the Michigan state archives of the disaster were reviewed with respect to the demographics, pattern of injury, gender, age, duration of hospitalization, relative distance of each classroom from the blast, and severity of injuries sustained using the Injury Severity Scale (ISS). RESULTS: Eighty-seven children and three teachers were unable to safely evacuate the building; 36 children (41%) were dead on-site, 40 sustained mild injuries (76.9%), nine sustained moderate injuries (17.3%), and one sustained serious injuries (1.9%). Mean ISS scores decreased with increasing relative distance of each classroom from the primary blast, while the classrooms involved in structural collapse had the highest initial mortality and ISS score. Patterns of injury sustained imply a predominance of crush and penetrating trauma. CONCLUSIONS: Mean ISS scores and initial mortality by classroom were a function of proximity to the blast and structural collapse. The pattern of injury closely approximates those of other pediatric disasters such as Columbine, Oklahoma City, and 911. The absence of severe abdominal trauma and one reported hospital mortality may reflect an initial under-triage of patients, possibly due to the medical technology of the times.

Hematocrit, systolic blood pressure and heart rate are not accurate predictors for surgery to control hemorrhage in injured patients.

Hematocrit (Hct), systolic blood pressure (SBP), and heart rate (HR) are considered to closely correlate with hypovolemia in injured patients. The clinical importance of these parameters in the early recognition of occult but clinically significant hemorrhage remains to be demonstrated. We undertook this study to assess the clinical importance of these parameters in the early recognition of occult hemorrhage in injured patients. A retrospective study of 7880 patients admitted to a Level I trauma center was carried out. Patients who underwent surgery were divided into the hemorrhage (n = 160) and no-hemorrhage group (n = 228). Hematocrit, SBP, and HR were correlated and receiver operating characteristic (ROC) curves were plotted. The ROC curves for Hct, SBP, and HR showed suboptimal areas under the graph. Even for different Hct thresholds and for hypotension and tachycardia, low predictive values were found. Although Hct, SBP, and HR levels were significantly altered among patients who require surgery for hemorrhage, the low predictive values of each parameter renders them as clinically unreliable individual tools for recognition of hemorrhagic patients who need surgery. Although useful in aggregate, as a pattern, or as indications for further diagnostic studies, these common parameters have limited usefulness individually.