Predictive Value of Point-of-care Lactate Measurement in Patients Meeting Level II and III Trauma Team Activation Criteria that Present to the Emergency Department: A Prospective Study.

BACKGROUND: The aim of this study was to investigate the utility of early point-of-care (POC) lactate levels to help predict injury severity and ultimate emergency department (ED) disposition for trauma patients meeting Level II and III activation criteria. METHODS: This was a blinded, prospective cohort study including a convenience sample of patients meeting our triage criteria for Level II or III team activation with stable vital signs. Bedside lactate samples were collected during the secondary survey. Clinical care/disposition was at the discretion of physicians who remained blinded to the bedside lactate result. An elevated lactate was defined as >2.0 mmol/L. RESULTS: Ninety-six patients were in the study group; mean age was 41 ± 17 years, 26% were female, 57% were Hispanic, and 60% admitted. We found no difference in initial mean POC lactate levels (mmol/L) for admitted versus discharged groups and Injury Severity Score (ISS) ≥9 versus ISS <9 groups (3.71 [95% confidence interval (CI): 3.1-4.4] vs. 3.85 [95% CI: 2.8-4.9]; P = 0.99 and 3.54 [95% CI: 2.7-4.4] vs. 3.89 [95% CI: 3.1-4.6]; P = 0.60, respectively). Performance characteristics of early elevated lactate levels were poor both to predict need for hospital admission (sensitivity = 77% [65%-87%]; specificity = 26% [13%-43%]; negative predictive value [NPV] = 43% [27%-61%]; and positive predictive value [PPV] = 62% [56%-67%]) and to identify patients with ISS scores ≥9 (sensitivity = 76% [59%-89%]; specificity = 24% [14%-37%]; NPV = 65% [47%-80%]; and PPV = 36% [30%-41%]). CONCLUSIONS: For Level II/III, we found that early bedside lactate levels were not predictive of ISS ≥9 or the need for admission. LEVEL OF EVIDENCE: III (diagnostic test).

Costs and Characteristics of Undocumented Immigrants Brought to a Trauma Center by Border Patrol Agents in Southern Texas.

BACKGROUND: The objective of this study was to evaluate the costs, characteristics, and outcomes of patients brought to a Texas trauma center emergenct department after apprehension by Border Patrol (BP)/Immigration and Customs Enforcement (BP/ICE). MATERIALS AND METHODS: This is a secondary analysis of a trauma registry/financial records (1/1/11-12/31/14). Data were extracted utilizing a structured form. A multivariate ordinary least square was estimated to identify variables associated with hospital charges. RESULTS: A total of 128 patients were enrolled as the study group; mean age was 28.6 ± 6 years, 20.3% were female, 100% were Hispanic, the most common mechanism of injury (MOI) was motor vehicle crash (75%), and mean charge was $162,152 ± $295,441. Mean length of stay (LOS) was 13.2 ± 29.8 days; 92.2% survived to discharge. Bivariate analysis revealed that MOI differed by gender (P = 0.021). In the multivariate analysis, the only variable that associated with increased charge was LOS. Total charges for the 128 patients were $20.6M, total costs were $4.5M, and total payments were $0.99M. CONCLUSIONS: Undocumented immigrants apprehended by BP/ICE and brought to our trauma center utilized significant health-care resources.

Prior CT imaging history for patients who undergo whole-body CT for acute traumatic injury and are discharged home from the emergency department.

BACKGROUND: Recurrent CT imaging is believed to significantly increase lifetime malignancy risk. We previously reported that high acuity, admitted trauma patients who received a whole-body CT in the emergency department (ED) had a history of prior CT imaging in 14% of cases. The primary objective of this study was to determine the CT imaging history for trauma patients who received a whole-body CT but were ultimately deemed safe for discharge directly home from the ED. METHODS: This was a retrospective cohort study conducted at an academic ED. All trauma patients who were discharged directly home from the ED after whole-body CT were analyzed. The decision to utilize whole-body CT was at the discretion of the caring physician during the study period. Clinical data for the most recent trauma visit was recorded in a structured fashion on a standardized data collection instrument utilizing the hospital system electronic medical record (EMR). Subsequently, study investigators reviewed a shared, electronic radiological archive for the 6-hospital system to evaluate prior CT exposure for each patient. RESULTS: 165 patients were in the study group. The mean age of the study group was 39+/- 16 years old, 40% were female and 64% were Hispanic. The most common mechanism of injury in our study group was motor vehicle crash (MVC) (66%). In our study group, 25% had at least one prior CT. The most common prior studies performed were: CT abdomen/pelvis (13%), CT head (9.1%), CT face (6.7%), and CT chest (1.8%). Within a multivariate logistic regression model we found that the large majority of patient characteristics and mechanisms of injury were not associated with a positive prior CT imaging history. CONCLUSION: We found a positive history for prior CT for 25% of trauma patients who received whole-body CT scan but were discharged from the ED to home.

Impact of Starting an Emergency Medicine Residency Program on Overall Mortality Rate in a Regional Trauma Center.

BACKGROUND: CHRISTUS Spohn Hospital Corpus Christi - Memorial began an Emergency Medicine Residency Program in March 2007. During each of the three years of their residency, residents are required to complete a trauma surgery rotation. These emergency medicine residents are the only residents participating on this rotation as there is no surgical residency. The Department of Acute Care Surgery, Trauma and Surgical Critical Care analyzed the impact of the residents on trauma patient care outcomes with the hypothesis that there were no differences. METHODS: Data including length of stay in the hospital, length of stay in the intensive care unit, time spent in the emergency department (ED), morbidities and mortalities were compiled from the trauma registry for patients from the year before the residents began (March 1, 2006 to February 28, 2007) and compared with patients from the first year the residents began their trauma rotations (March 1, 2007 to February 29, 2008). T-tests and Mann-Whitney U tests were used to compare continuous variables and a Chi-square test was used to analyze the categorical variable (mortality). Linear and logistic regression analyses were also performed in order to adjust for potential confounding factors. RESULTS: Trauma patient admission rates were 1,316 before and 1,391 after the residents began. No statistically significant differences were found among all of the outcome variables during the two time periods except for time spent in the ED (P = 0.00), which increased during the year the residents began (236.83 ± 4.53 minutes in 2006 compared to 297.40 ± 5.55 minutes in 2007). Linear and logistic regression analyses confirmed these results with the exception of a statistically significant decrease in mortality with the residents on the trauma service (2.8% in 2006 and 2.1% in 2007, P = 0.00) after adjustment for multiple confounding factors. CONCLUSION: The addition of emergency medicine residents to the trauma care service did increase ED length of stay, but did not increase overall hospital or intensive care unit length of stay. There was a statistically significant decrease in adjusted morbidity and mortality, thus supporting our hypothesis that the residency program did not negatively impact the trauma service and its goals of high quality patient care.

Prior CT imaging history for patients who undergo PAN CT for acute traumatic injury.

Objective. A single PAN scan may provide more radiation to a patient than is felt to be safe within a one-year period. Our objective was to determine how many patients admitted to the trauma service following a PAN scan had prior CT imaging within our six-hospital system. Methods. We performed a secondary analysis of a prospectively collected trauma registry. The study was based at a level-two trauma center and five affiliated hospitals, which comprise 70.6% of all Emergency Department visits within a twelve county region of southern Texas. Electronic medical records were reviewed dating from the point of trauma evaluation back to December 5, 2005 to determine evidence of prior CT imaging. Results. There were 867 patients were admitted to the trauma service between January 1, 2012 and December 31, 2012. 460 (53%) received a PAN scan and were included in the study group. The mean age of the study group was 37.7 ± 1.54 years old, 24.8% were female, and the mean ISS score was 13.4 ± 1.07. The most common mechanism of injury was motor vehicle collision (47%). 65 (14%; 95% CI [11-18]%) of the patients had at least one prior CT. The most common prior studies performed were: CT head (29%; 19-42%), CT Face (29%; 19-42%) and CT Abdomen and Pelvis (18%; 11-30%). Conclusion. Within our trauma registry, 14% of patients had prior CT imaging within our hospital system before their traumatic event and PAN scan.

Seven hundred fifty-three consecutive deaths in a level I trauma center: the argument for injury prevention.

BACKGROUND: The past century has seen improvement in trauma care, with a resulting decrease in therapeutically preventable deaths. We hypothesize that further major reduction in injury mortality will be obtained through injury prevention, rather than improvements in therapy. METHODS: Seven hundred fifty-three deaths in an American College of Surgeons-verified, Level I trauma center were reviewed as they occurred. Deaths were classified as therapeutically not preventable, possibly preventable, or preventable. These charts were also reviewed for factors that might have prevented or lessened the severity of the injury. RESULTS: Mean age was 43, mean Glasgow Coma Scale score was 5, mean Revised Trauma Score was 4, mean Injury Severity Score was 41, and mean probability of survival was 0.25 (according to TRISS). Forty-six percent underwent cardiopulmonary resuscitation in the field, 52% died within 12 hours, 74% died within 48 hours, and 86% died within 7 days. Primary causes of death included central nervous system injury in 51%, irreversible shock in 21%, multiple injuries (shock plus central nervous system injury) in 9%, multiple organ failure/sepsis and other causes in 3%, and pulmonary embolus in 0.1%. Seven hundred one (93%) were classified as not preventable with a change in therapy, 32 (4.2%) were classified as potentially preventable with a change in therapy, and 20 were classified as preventable with a change in therapy (2.6%). Forty-six percent had cardiopulmonary resuscitation performed before or immediately on arrival to the hospital. Another 23% had vital signs present on arrival, but had a Glasgow Coma Scale score of

Is there an upper limit of intracranial pressure in patients with severe head injury if cerebral perfusion pressure is maintained?

Authors of recent studies have championed the importance of maintaining cerebral perfusion pressure (CPP) to prevent secondary brain injury following traumatic head injury. Data from these studies have provided little information regarding outcome following severe head injury in patients with an intracranial pressure (ICP) greater than 40 mm Hg, however, in July 1997 the authors instituted a protocol for the management of severe head injury in patients with a Glasgow Coma Scale score lower than 9. The protocol was focused on resuscitation from acidosis, maintenance of a CPP greater than 60 mm Hg through whatever means necessary as well as elevation of the head of the bed, mannitol infusion, and ventriculostomy with cerebrospinal fluid drainage for control of ICP. Since the institution of this protocol, nine patients had a sustained ICP greater than 40 mm Hg for 2 or more hours, and five of these had an ICP greater than 75 mm Hg on insertion of the ICP monitor and later experienced herniation and expired within 24 hours. Because of the severe nature of the injuries demonstrated on computerized tomography scans and their physical examinations, these patients were not aggressively treated under this protocol. The authors vigorously attempted to maintain a CPP greater than 60 mm Hg with intensive fluid resuscitation and the administration of pressor agents in the four remaining patients who had developed an ICP higher than 40 mm Hg after placement of the ICP monitor. Two patients had an episodic ICP greater than 40 mm Hg for more than 36 hours, the third patient had an episodic ICP greater than of 50 mm Hg for more than 36 hours, and the fourth patient had an episodic ICP greater than 50 mm Hg for more than 48 hours. On discharge, all four patients were able to perform normal activities of daily living with minimal assistance and experience ongoing improvement. Data from this preliminary study indicate that intense, aggressive management of CPP can lead to good neurological outcomes despite extremely high ICP. Aggressive CPP therapy should be performed and maintained even though apparently lethal ICP levels may be present. Further study is needed to support these encouraging results.