The cuff leak test is not predictive of successful extubation.

In intubated patients the presence of a cuff leak (CL) is used as a predictor of successful extubation. CL is proposed to indicate laryngeal edema and predict which patients may develop complications such as postextubation stridor and eventual reintubation. Our objective was to evaluate the reliability of CL in our population of critically ill trauma patients. A retrospective chart review was performed of patients admitted to the trauma service who required mechanical ventilation. All patients undergo the CL test by a single respiratory therapist team before attempted extubation. Data collected included body mass index (BMI), endotracheal tube (ETT) size, length of time of mechanical ventilation, tidal volumes (Vt), and the size of the patient's trachea based on CT scan. The test is performed by the respiratory therapists and involves measuring expired Vt before and after the ETT cuff has been deflated and listening for an audible leak. A positive test result is defined as a CL greater than 10 per cent of Vt or, when volumes are not available, as audible air expired. From October 2005 to May 2006, 150 mechanically ventilated patients were identified and 49 charts were available for review. Forty-one patients had a cuff leak (+CL), whereas eight did not (-CL). The two cohorts were similar in age (+CL = 36.5 years, -CL = 38.1 years, P = 0.82), male gender (+CL = 70%, -CL = 50%, P = 0.25) ETT size (+CL = 7.4, -CL = 7.4, P = 0.57), and BMI (+CL = 28 kg/m2, -CL = 27 kg/m2, P = 0.71). The average tracheal diameter (+CL = 17.4 mm, -CL = 17.5 mm, P = 0.90) as well as the ratio of ETT and tracheal diameter was similar for the two cohorts (+CL = 0.65, -CL = 0.64, P = 0.73). Four patients (10%) in the +CL cohort failed extubation, whereas none of the -CL cohort failed (0%) (P = 0.40). The CL test does not reliably identify those patients who will require reintubation in our trauma population. In addition, the ratio of ETT and tracheal diameter is not predictive of successful extubation.

Adrenal insufficiency in hemorrhagic shock.

Adrenal insufficiency during sepsis is well documented. The association between hemorrhagic shock and adrenal insufficiency is unclear and may be related to ischemia, necrosis, or resuscitation. This study was designed to determine the incidence of relative adrenal insufficiency in hemorrhagic shock. A retrospective review of a prospectively gathered database for patients admitted to the trauma intensive care unit with hemorrhagic shock was undertaken. A random serum cortisol of <25 mcg/dL defined relative adrenal insufficiency. All of the cortisol levels were drawn within the first 24 hours of admission. Data analyzed included demographics, length of stay, injury mechanism, infections, and mortality. Fifteen patients presented with hemorrhagic shock, with 14 of 15 meeting the criteria for relative adrenal insufficiency. The average serum cortisol level was 15.8 (9-26.8). The average APACHE II score was 18.3 (4-33), and the average Injury Severity Score was 22.5 (8-41). The mechanism was blunt trauma in 10 patients and penetrating trauma in 5. The average intensive care unit and hospital length of stay were 13.2 and 27.4 days, respectively. There were five urinary tract infections, four blood stream infections, and two wound infections. Two of the 15 patients died. Relative adrenal insufficiency appears to be common in hemorrhagic shock. Future research is warranted to elucidate the pathophysiology, as well as to prospectively determine which patients may benefit from steroid replacement.

Adrenal insufficiency in the critically III trauma population.

Acute adrenal insufficiency has been demonstrated in a number of patients with shock. This study was designed to evaluate the rate of occult adrenal insufficiency in the critically ill trauma population and to determine the impact of hypoproteinemia on the use of random cortisol levels as a marker for adrenal insufficiency. Forty-four patients were prospectively enrolled on admission to the trauma intensive care unit, with three excluded, for a total n of 41. Random total serum cortisol and albumin levels were drawn on hospital Days 1, 4, 8, and 14. Occult adrenal insufficiency was defined as a cortisol less than 25 mcg/dL in the setting of an albumin greater than 2.5 g/dL. The prevalence of cortisol less than 25 mcg/dL ranged from 51 to 81 per cent during the study period, and peaked on Days 4 and 8. Albumin 2.5 g/dL or less ranged from 37 to 60 per cent, and this prevalence also peaked on Days 4 and 8. The patients with a low albumin had a high prevalence of low cortisol, ranging from 67 to 100 per cent. The prevalence of adrenal insufficiency, with low cortisol and normal albumin, ranged from 41 to 82 per cent during the study period. None of our patients with occult adrenal insufficiency were treated with steroids, which was a decision made by the treating physicians. Among the patients with occult adrenal insufficiency, survival was 100 per cent. Occult adrenal insufficiency is common in critically ill trauma patients, and is a dynamic entity that can be acquired and even resolved during critical illness. Random cortisol of 25 mcg/dL may actually not be an adequate marker of occult adrenal insufficiency. Low albumin predicts a low cortisol. Hemodynamically stable occult adrenal insufficiency should not be treated with steroid replacement in the critically ill trauma patient, as survival in our series was 100 per cent without replacement.

Secondary abdominal compartment syndrome: risk factors and outcomes.

Secondary abdominal compartment syndrome (ACS), defined as intra-abdominal hypertension with associated pulmonary, renal, or hemodynamic compromise in the absence of preceding abdominal operation or injury, can markedly increase surgical morbidity and mortality. We performed a retrospective chart review of the physiologic parameters and outcomes of 10 patients with secondary ACS. Ten patients developed secondary ACS after aggressive resuscitation, at an average of 20.2 hours. Four of the patients sustained burns greater than 40 per cent, three of the patients had penetrating extremity trauma, one patient had blunt abdominal trauma, one patient was struck by lightning, and one patient developed a retroperitoneal bleed while on heparin. The average bladder pressure was 40.6. The average volume given in the first 24 hours was 33,001 cc (range, 12,400 to 69,000). The average base deficit at admission was -12 (range, +1 to -25). Seven of the 10 patients had decreased urine output. Nine of the 10 patients had decreased tidal volumes on pressure control ventilation. All 10 patients were hypotensive, with 7 of the 10 requiring vasopressors. Overall mortality was 60 per cent, with 43 per cent mortality for those decompressed. Prompt recognition and treatment are mandatory for survival of ACS. We recommend routine bladder pressure monitoring for patients with ongoing resuscitation greater than 500 cc/hr.

Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma.

BACKGROUND: The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults. METHODS: Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively. RESULTS: Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05). CONCLUSION: Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.

The usefulness of serum troponin levels in evaluating cardiac injury.

The diagnosis and clinical significance of blunt cardiac injury remains controversial. Cardiac troponin I is not found in skeletal muscle and has a high sensitivity for myocardial ischemia or injury. We hypothesized that normal troponin levels 4 to 6 hours postinjury would effectively exclude the diagnosis of cardiac contusion. A prospective evaluation of all blunt trauma patients older than 16 and admitted with the possible diagnosis of blunt cardiac injury was undertaken. Patients in whom this diagnosis was considered had an electrocardiogram (EKG) on admission, serum troponin, CPK and isoenzymes 4 to 6 hours postinjury, and admission with overnight telemetry. Other laboratory data and radiographic imaging was obtained as indicated. Seventy-two patients met criteria for entry into the study. Data was incomplete or inaccurately obtained on six patients, and they were excluded. Forty patients had normal troponins and normal EKG's on admission and were discharged the following day without any untoward effect. Sixteen patients were admitted with abnormal EKGs. All of these 16 patients had normal troponins 4 to 6 hours after their injury. They all did well and were discharged the following day. Ten patients had elevated troponins 4 to 6 hours after injury. One died two days later from refractory cardiogenic shock. Another was noted to have severely depressed left ventricular function by echocardiography. The other eight patients sustained no cardiac sequelae and were discharged once recovered from injuries. In the hemodynamically stable patient a normal troponin 4 to 6 hours after injury excludes clinically significant blunt cardiac injury. This holds true whether the admission EKG is normal or not. An elevated troponin does not definitively diagnose a clinically significant contusion. However, these patients should be monitored at least for 24 hours. Patients suspicious for cardiac contusions who have normal troponins and no other serious injuries may be safely discharged to go home from the emergency department.

Blunt trauma and the role of routine pelvic radiographs.

We evaluated clinical factors that are predictive of pelvic X-ray findings. We sought to identify whether routine pelvic films are necessary in blunt trauma and addressed whether removal of these films would minimize cost. We performed a retrospective chart review of 111 patients without pelvic fractures and 108 with pelvic fractures seen at our Level 1 trauma center between August 1998 and September 1999. We evaluated initial hemodynamics, physical examination findings, laboratory data, and hospital charges. Patients with fractures had higher Injury Severity Scores (P < 0.001), a higher number of associated injuries (P < 0.001), and lower blood pressures (P < 0.001). The back and pelvic examinations were significantly associated with X-ray results (P < 0.001), and the potential savings with selective radiography was $168,300.00 per year. We believe that clinical factors identified in our study predict the need for pelvic X-ray. Because removal of these films would minimize cost we recommend the elimination of routine pelvic films for the awake and alert blunt trauma patient.

Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma.

OBJECTIVE: The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay. METHODS: This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fisher's exact test, Student's T test, and logistic regression analysis. RESULTS: The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47). CONCLUSION: Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

Newer diagnostic modalities for vascular injuries: the way we were, the way we are.

The article discusses the role of modalities in diagnosing vascular injuries starting with angiography and tracing the evolution of the use of color flow Doppler, CT, and CT angiography. It also addresses the controversy of minimal vascular injury and outlines vascular injuries that may be safely observed and followed-up. Finally, the evolution from angiography to the use of helical CT for the diagnosis of thoracic aortic injuries is reviewed in detail.

Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma.

BACKGROUND: Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The purpose of this multi-institutional study was to determine which factors predict successful observation of blunt splenic injury in adults. METHODS: A total of 1,488 adults (>15 years of age) with blunt splenic injury from 27 trauma centers in 1997 were studied through the Multi-institutional Trials Committee of the Eastern Association for the Surgery of Trauma. Statistical analysis was performed with analysis of variance and extended chi2 test. Data are expressed as mean +/- SD; a value of p < 0.05 was considered significant. RESULTS: A total of 38.5 % of patients went directly to the operating room (group I); 61.5% of patients were admitted with planned nonoperative management. Of the patients admitted with planned observation, 10.8% failed and required laparotomy; 82.1% of patients with an Injury Severity Score (ISS) < 15 and 46.6% of patients with ISS > 15 were successfully observed. Frequency of immediate operation correlated with American Association for the Surgery of Trauma (AAST) grades of splenic injury: I (23.9%), II (22.4%), III (38.1%), IV (73.7%), and V (94.9%) (p < 0.05). Of patients initially managed nonoperatively, the failure rate increased significantly by AAST grade of splenic injury: I (4.8%), II (9.5%), III (19.6%), IV (33.3%), and V (75.0%) (p < 0.05). A total of 60.9% of the patients failed nonoperative management within 24 hours of admission; 8% failed 9 days or later after injury. Laparotomy was ultimately performed in 19.9% of patients with small hemoperitoneum, 49.4% of patients with moderate hemoperitoneum, and 72.6% of patients with large hemoperitoneum. CONCLUSION: In this multicenter study, 38.5% of adults with blunt splenic injury went directly to laparotomy. Ultimately, 54.8% of patients were successfully managed nonoperatively; the failure rate of planned observation was 10.8%, with 60.9% of failures occurring in the first 24 hours. Successful nonoperative management was associated with higher blood pressure and hematocrit, and less severe injury based on ISS, Glasgow Coma Scale, grade of splenic injury, and quantity of hemoperitoneum.

Duplex directed caval filter insertion in multi-trauma and critically ill patients.

This study was undertaken to determine the safety and feasibility of inferior vena cava (IVC) filter insertion at the bedside using duplex imaging in multi-trauma and/or critically ill patients. From February 1996 to August 1997, 53 multi-trauma and/or critically ill patients, who were in the intensive care unit and referred for an IVC filter, were prospectively evaluated for possible duplex directed caval filter (DDCF) insertion. Screening IVC duplex scans were performed in all patients. Satisfactory ultrasound visualization in 46 patients (87%) allowed attempted DDCF insertion. All procedures were percutaneously performed at the bedside using Vena Tech IVC filters. The results from this series showed that DDCF insertion can be safely and rapidly performed at the bedside in multi-trauma or critically ill patients. The procedure is dependent on satisfactory visualization of the IVC by duplex ultrasonography, which was possible in 45 out of 53 (85%) patients. Insertion at the bedside substantially reduces the procedural cost and avoids the need for transport, radiation exposure, and intravenous contrast.

Blunt injury of the abdominal aorta: a review.

Injury to the abdominal aorta after blunt trauma occurs much less frequently than injury to the thoracic aorta. Although presentations vary, common themes continue to emerge with each patient. Within a 6-month period, our trauma unit diagnosed and treated two cases of blunt abdominal aortic trauma. Both patients were restrained passengers in motor vehicle crashes with resultant abdominal aortic injuries and demonstrated some of the most common associated injuries. Our two cases bring the number found in the literature to 62 and demonstrate the need for rapid recognition and treatment of this potentially lethal injury. This article is a comprehensive review of the management of abdominal aortic injury from blunt trauma.

Priorities in the management of profound shock.

This article discusses many of the aspects of profound shock, including historical perspectives on the concept of shock, the meaning of profound shock, and pathophysiology in shock. Organ systems in shock and methods of shock management also are presented.

Late fatal hemorrhage in pediatric liver trauma.

The cumulative evidence supports nonoperative management of hepatic trauma in children who are hemodynamically stable and who require less than 50% blood volume replacement to maintain a stable blood count. This management approach, based on the use of either serial computed tomography scans, liver/spleen scans, or ultrasonography to diagnose the injury and document resolution, achieves results that exceed those of operative management for all injuries. Late complications, which may be seen in nonoperated patients, include hemobilia, bile peritonitis, abscesses and bleeding, occur with less frequency than operated patients. We report the first case of late exsanguinating hemorrhage of a resolving hepatic injury.

Obesity and increased mortality in blunt trauma.

To determine the effect of admission body weight on blunt trauma victims, a chart review of all patients greater than 12 years of age admitted to Sentara Norfolk General Hospital between January 1 and July 31, 1987 was undertaken. The charts of 351 patients were reviewed; 184 records contained admission height and weight. These 184 patients made up the study group and age, gender, injuries, Injury Severity Score (ISS), ventilator days (VD), complications, length of stay (LOS), and outcome were noted. Body Mass Index (BMI) (weight (kg)/(height(m))2, was calculated for each patient. The average ISS was 21.87 (range, 1-66) and the average BMI was 25.15 kg/m2 (range, 16-46 kg/m2). The overall mortality for the population was 9%. The population was grouped according to BMI: average (less than 27 kg/m2), overweight (27-31 kg/m2), and severely overweight (greater than 31 kg/m2). The mortality of 5.0% and 8.0% in the average and overweight groups was not different. The severely overweight group had a higher mortality at 42.1% compared with the other two groups (p less than 0.0001). The groups did not differ in age, ISS, LOS, nor VD. Age, BMI, and ISS were subjected to regression analysis. By this method BMI and ISS were independent determinants of outcome (p less than 0.0001). There was an increase in complications, mainly pulmonary problems, in the SO group (p less than 0.05). The three groups were subdivided into survivors and nonsurvivors. The nonsurvivors had a longer average LOS at 26.6 days compared with nonsurvivors in the overweight (5.0 days) or severely overweight (8.62 days) groups (p less than 0.007). The severely group was characterized by a rapid deterioration and demise that was unresponsive to intervention. ISS did not differ among nonsuvivors. Among survivors the severely overweight group had a lower ISS, 9.73. This was different from the overweight group (21.57) and from the average group (20.21) (p less than 0.04).

Dynamic computed tomography as an ancillary screening test for traumatic thoracic aortic injuries: a critical review.

While the divergence of opinion on the matter of diagnostic modalities will probably continue, dynamic computed tomography scans should be considered as a necessary study in assessing a possible traumatic thoracic aortic injury. The use of this modality will decrease the need for thoracic angiograms and invariably increase the yield.

The rapid infusion system: a superior method for the resuscitation of hypovolemic trauma patients.

The rapid infusion system (RIS), which can deliver fluids/blood products rapidly at precise rates and normothermic conditions, was compared with conventional fluid administration (CFA) in a randomized study of 36 hypovolemic trauma patients. Admission stratification criteria of the groups were similar relative to age, Glasgow Coma Score (GCS), Injury Severity Score (ISS) and plasma lactate. Despite the lack of difference in blood loss between the 24-h survivors of the two groups, the CFA group required greater total fluids (23.6/20.21), red blood cells (5.5/4.61), fresh frozen plasma (FFP) (2.8/1.91), platelets (523/204 ml), and crystalloids (12.9/10.61). Lactate levels were lower in the RIS group at virtually all times from hours 1 to 24 (4.3/5.3 mM/l, t-value = 3.3, DF = 279, P = 0.001). Post-admission hypothermia was greater in the CFA group at all times during the first 24 h (35.2/36.4 degrees C, t-value = 5.6, DF = 250, P = 0.001). The mean partial thromboplastin time was significantly higher in the CFA group (47.3/35.1 s, t-value = 3.1, DF = 279, P = 0.002). The PTT and PT were related to the degree of lactic acidosis (P = 0.0001) and hypothermia (P = 0.001) but not to the amount of FFP given (P = 0.14). The hospital costs, days in the ICU, and days on the ventilator were greater for the CFA group, as was the incidence of pneumonia (0/11 vs. 6/17; P = 0.03). Hypovolemic trauma patients resuscitated with the RIS needed fewer fluid/blood products and had less coagulopathy; more rapid resolution of hypoperfusion acidosis; better temperature preservation; and fewer hospital complications than those resuscitated with conventional methods of fluid/blood product administration.