Prediction of blunt traumatic injuries and hospital admission based on history and physical exam.

BACKGROUND: We evaluated the ability of experienced trauma surgeons to accurately predict specific blunt injuries, as well as patient disposition from the emergency department (ED), based only on the initial clinical evaluation and prior to any imaging studies. It would be hypothesized that experienced trauma surgeons' initial clinical evaluation is accurate for excluding life-threatening blunt injuries and for appropriate admission triage decisions. METHODS: Using only their history and physical exam, and prior to any imaging studies, three (3) experienced trauma surgeons, with a combined Level 1 trauma experience of over 50 years, predicted injuries in patients with an initial GCS (Glasgow Coma Score) of 14-15. Additionally, ED disposition (ICU, floor, discharge to home) was also predicted. These predictions were compared to actual patient dispositions and to blunt injuries documented at discharge. RESULTS: A total of 101 patients with 92 blunt injuries were studied. 43/92 (46.7 %) injuries would have been missed by only performing an initial history and physical exam ("Missed injury"). A change in treatment, though often minor, was required in 19/43 (44.2 %) of the missed injuries. Only 1/43 (2.3 %) of these "missed injuries" (blunt aortic injury) required surgery. Sensitivity, specificity, and accuracy for injury prediction were 53.2, 95.9, and 92.3 % respectively. Positive and negative predictive values were 53.8 and 95.8 % respectively. Prediction of disposition from the ED was 77.8 % accurate. In 7/34 (20.6 %) patients, missed injuries led to changes in disposition. "Undertriage" occurred in 9/99 (9.1 %) patients (Predicted for floor but admitted to ICU). Additionally, 8/84 (9.5 %) patients predicted for floor admission were sent home from the ED; and 5/13 (38.5 %) patients predicted for ICU admission were actually sent to the floor after complete evaluations, giving an "overtriage" rate of 13/99 (13.1 %) patients. CONCLUSIONS: In a neurologically-intact group of trauma patients, experienced trauma surgeons would have missed 46.7 % of the actual injuries, based only on their history and physical exam. Once accurate diagnoses of injuries were completed, usually with the help of CT scans, admission dispositions changed in 20.6 % of patients. Treatment changes occurred in 44.2 % of the missed injuries, though usually minimal. Broad elimination of early imaging studies in alert, blunt trauma patients cannot be advocated.

Universal Pressure Ulcer Prevention Bundle With WOC Nurse Support.

PURPOSE: This study examined the effectiveness of a universal pressure ulcer prevention bundle (UPUPB) applied to intensive care unit (ICU) patients combined with proactive, semiweekly WOC nurse rounds. The UPUBP was compared to a standard guideline with referral-based WOC nurse involvement measuring adherence to 5 evidence-based prevention interventions and incidence of pressure ulcers. DESIGN: The study used a quasi-experimental, pre-, and postintervention design in which each phase included different subjects. Descriptive methods assisted in exploring the content of WOC nurse rounds. SUBJECT AND SETTING: One hundred eighty-one pre- and 146 postintervention subjects who met inclusion criteria and were admitted to ICU for more than 24 hours participated in the study. The research setting was 3 ICUs located at North Memorial Medical Center in Minneapolis, Minnesota. METHODS: Data collection included admission/discharge skin assessments, chart reviews for 5 evidence-based interventions and patient characteristics, and WOC nurse rounding logs. Study subjects with intact skin on admission identified with an initial skin assessment were enrolled in which prephase subjects received standard care and postphase subjects received the UPUPB. Skin assessments on ICU discharge and chart reviews throughout the stay determined the presence of unit-acquired pressure ulcers and skin care received. Analysis included description of WOC nurse rounds, t-tests for guideline adherence, and multivariate analysis for intervention effect on pressure ulcer incidence. Unit assignment, Braden Scale score, and ICU length of stay were covariates for a multivariate model based on bivariate logistic regression screening. RESULTS: The incidence of unit-acquired pressure ulcers decreased from 15.5% to 2.1%. WOC nurses logged 204 rounds over 6 months, focusing primarily on early detection of pressure sources. Data analysis revealed significantly increased adherence to heel elevation (t = -3.905, df = 325, P < .001) and repositioning (t = -2.441, df = 325, P < .015). Multivariate logistic regression modeling showed a significant reduction in unit-acquired pressure ulcers (P < .001). The intervention increased the Nagelkerke R-Square value by 0.099 (P < .001) more than 0.297 (P < .001) when including only covariates, for a final model value of 0.396 (P < .001). CONCLUSION: The UPUPB with WOC nurse rounds resulted in a statistically significant and clinically relevant reduction in the incidence of pressure ulcers.

Prothrombin complex concentrate versus standard therapies for INR reversal in trauma patients receiving warfarin.

BACKGROUND: Prothrombin complex concentrate (PCC) is recommended as a therapy to be considered for the reversal of warfarin's effects. Few published data are available on the use of PCC for this indication in traumatically injured patients. OBJECTIVE: To determine whether the addition of PCC to standard approaches to warfarin reversal more rapidly corrects the international normalized ratio (INR) in injured patients. METHODS: A retrospective analysis was performed in trauma patients who were on warfarin preinjury from January 2007 to September 2009 at North Memorial Medical Center. Data were collected from medical records and the trauma registry. Patients were separated based on whether or not they received PCC. The groups were compared on the basis of demographics, units of fresh frozen plasma (FFP), vitamin K use, units of PCC, number of patients achieving an INR of 1.5 or less, time to an INR of 1.5 or less, mortality, intensive care unit (ICU) and hospital length of stay, and the incidence of thromboembolic events during hospitalization. RESULTS: Thirty-one patients were included in the analysis; 13 patients who received a total mean (SD) dose of 2281 (1053) units (25.6 [12.2] units/kg) of PCC (Profilnine SD) were compared to 18 patients who did not receive PCC. There was no significant difference between groups in FFP units received or the number of patients who received vitamin K. Most patients in both groups achieved an INR of 1.5 or less (92% PCC vs 89% no PCC). However, the mean time to achieve an INR of 1.5 or less was 16:59 (20:53) hours in the PCC group versus 30:03 (23:10) hours in the no PCC group (p = 0.048). There were 3 deaths in the PCC group and no deaths in the no PCC group (p = 0.06). ICU and hospital length of stay and number of thromboembolic events did not differ significantly between the 2 groups. CONCLUSIONS: PCC, when added to FFP and vitamin K, resulted in a more rapid time to reversal of the INR.

A role for epinephrine in post-traumatic hypokalemia.

We have previously described a high incidence of admission hypokalemia in trauma patients at our institution. We subsequently performed a prospective study of 112 trauma patients to examine the possible etiologies of post-traumatic hypokalemia. Trauma patients >or=5 years old were evaluated within 6 h of injury with a variety of studies including catecholamines, cortisol, and insulin levels, with studies repeated 24 to 36 h after admission. No potassium replacement was given during this time. Demographic factors such as age, types of injury, and severity of injuries were collected. We found that the mean age of those with post-traumatic hypokalemia (

Hypokalemia following trauma.

Frequent hypokalemia was noted immediately after trauma, and it was hypothesized that hypokalemia occurred more frequently in the more severely injured. A retrospective trauma registry and chart review was done on 546 trauma patients looking at admission potassium, a variety of lab tests related to potassium, specific injuries, hospital/ICU lengths of stay, and general patient demographics. Admission hypokalemia (K < 3.6 meq/l) was more frequent in those with closed head injuries (41.1% vs. 27.5%, P < .001) and in those who suffered spinal cord injuries (54.5% vs. 33.6%, P < .05). Hyperglycemia was more frequent with admission hypokalemia (45.2% vs. 29.7%, P < .001). Hypokalemia occurred more frequently in younger patients (28.6 vs. 37.7 y, P < .001). Also, the pediatric group, ages 5-14, had admission hypokalemia more frequently than those ages 15-59, or those ages > 59 (54.9% vs. 34.5% vs. 16.7%, P < .001). Glasgow Coma Scores (GCS) were significantly lower (12.0 vs. 13.5, P < .001) and Injury Severity Scores (ISS) were higher (17.4 vs. 13.4, P < .001), with admission hypokalemia. Additionally, hypokalemia was a positive predictor of ISS (P = .05). Hypokalemic patients more likely needed a ventilator, (26.6% vs. 16.5%, P < .01) but did not have significantly more ventilator days (P > .05). Subsequently, hypokalemic patients had longer ICU lengths of stay (LOS) (2.6 vs. 1.5 days, P < .005) and longer hospital LOS (8.5 vs. 5.6 days, P < .001). When stratified into categories of "severe": (K < 3.1 meq/l), "moderate": (K = 3.1-3.3 meq/l), and "mild": (K = 3.4-3.5 meq/l) hypokalemia, those with severe hypokalemia had significantly lower GCS (10.0 vs. 13.1, p < .05), higher serum glucose levels (167 vs. 137 mg/dl, P < .05), lower creatinine levels (.77 vs. .95 mg/dl, P < .05), and longer hospital lengths of stay (13.1 days vs. 7.6 days, P < .05 results).