Emergency room thoracotomy for penetrating chest injury: effect of an institutional protocol.

BACKGROUND: Emergency room thoracotomy (ERT) can be life saving in patients with penetrating chest injury. A protocol was established at our institution stating that ERT be performed for cases of cardiac tamponade secondary to penetrating chest trauma on patients with vital signs/mentation in the field or on arrival to the emergency room. To validate our protocol, we reevaluated patients undergoing ERT at our institution. METHODS: In our retrospective review, there were 49 patients undergoing ERT over a 6-year period. RESULTS: Survival in patients with vital signs was approximately 50%. Survival in those without was 0%. Compared with the preprotocol data, the number of ERTs declined from 32.2 cases per year to 8.1 cases per year. Overall survival increased from 4% to 20%. Neurologic outcome remained unchanged. CONCLUSION: We believe that the data validate our protocol, and the establishment of a guideline has enabled us to maximize patient survival and minimize exposure risks to our staff.

Development and implementation of clinical pathways for the management of four trauma diagnoses.

Clinical pathways are similar to the production algorithms developed by industry. They are being adapted for use in healthcare to reduce resource utilization, decrease variability, and control expenditures. At Boston Medical Center we identified four trauma diagnoses that we believed to be amenable to the design and implementation of clinical pathways: closed head injury, penetrating wound to the abdomen, penetrating wound to the chest, and penetrating wound to an extremity. Upon implementation of these pathways, appropriate nonoperative, single-system, short-stay trauma patients were enrolled in them. This article details the process by which the four diagnoses were identified and the pathways designed, implemented, and evaluated. Preliminary data demonstrate a significant decrease in resource utilization following implementation of the pathways, without an adverse impact on readmission rates, length of stay, or mortality.

The origins of casualty evacuation and echelons of care: lessons learned from the American Civil War.

The American Civil War produced many victims of battle who challenged the medical community. Not long after the war started the medical community was forced to make rapid, significant changes in how soldiers were evacuated, how they were cared for both immediately and long-term, and how the spread of fatal infectious diseases was controlled. This was the era in which nurses proved their importance and became a permanent segment of trauma care.

Endotracheal reintubation: a closer look at a preventable condition.

We designed a prospective study of endotracheal intubations and reintubations in our inner city Level 1 Trauma Center, to determine the frequency and causes of reintubation and evaluate the impact of an educational intervention aimed at minimizing unplanned extubations (UEs). After an initial 3-month phase, efforts were instituted to educate healthcare providers to the causes of reintubation noted. An identical 3-month period was then studied to evaluate the efficacy of the interventions. There were 862 patients, all adults, in the initial phase of the study, with 40 reintubation events in 22 patients; of the 808 in the second phase, there were 16 reintubations in 13 patients. The reintubation rate decreased from 4.4% to 1.9% (p = 0.005). Reintubations after UEs decreased from 14% to 5.2% (rate ratio, 0.374; 95% confidence interval = 0.141, 0.990). Multiple reintubation events decreased from 45% to 18.8% (p = 0.07). Increased provider education and protocol changes were associated with lower reintubation rates.

Predictive accuracy of the TRISS survival statistic is improved by a modification that includes admission pH.

OBJECTIVE: To determine if pH measured at the time of hospital admission and corrected for PCO2 was an independent predictor of trauma survival. DESIGN: Phase 1 was a retrospective case-control analysis of 1708 patients, followed by multivariate multiple logistic regression analysis of a subset of 919 patients for whom the Revised Trauma Score (RTS), Injury Severity Score (ISS), and pH were available. Phase 2 was a prospective comparison of a mathematical model of survival derived in phase 1 (pH-TRISS) with the TRISS method in 508 of 1325 subsequently admitted trauma patients. SETTING: Urban level 1 trauma center. PATIENTS: All patients admitted with blunt or penetrating trauma during the study period. MAIN OUTCOME MEASURES: Survival vs mortality. RESULTS: In phase 1, factors significantly associated with mortality by t test and chi 2 analysis included the RTS, ISS< Glasgow Coma Scale, corrected pH (CpH), and sum of the head, chest, and abdominal components of the Abbreviated Injury Scale-85 (AIS85) (HCAISS) (for all, P < .0001). The TRISS statistic was also a significant predictor of survival (P < .004). Age, sex, and the extremity and soft tissue components of the AIS85 were not associated with mortality. In a multivariate analysis of the RTS, HCAISS, and CpH, all were significant predictors of mortality. Even when controlling for RTS and HCAISS, CpH remained a significant predictor of mortality (P < .008). In phase 2, when pH-TRISS was tested prospectively against TRISS in a new group of patients, the new statistic appeared to provide a more accurate prediction of survival. CONCLUSIONS: The arterial pH measurement obtained on hospital arrival and corrected for PCO2 is a significant independent predictor of survival and adds to the predictive accuracy of the TRISS survival statistic. Age, sex, and the extremity and soft tissue components of the AIS85 did not contribute to the accuracy of the TRISS statistic in this patient population.

Emergency autotransfusion in hypovolemia.

Autotransfusion as a technique in managing hypovolemia has been enjoying renewed popularity. Autotransfusion from hemothorax is the most common application of the procedure; this consists of collection, anticoagulation, and retransfusion. The advantages include compatibility, no time delay required in laboratory type and crossmatch, and no transmission of disease. The use of autologous blood in managing hypovolemia in chest trauma has proven to be a practical and beneficial adjunct to traditional fluid and homologous blood therapy and should be considered by every emergency department.