Association of Patient Reported Global Health Measures with Frailty Scores in Acutely Injured Older Adults.

PURPOSE: The older population is particularly vulnerable to traumatic injury. Frailty scores, used to estimate the physiologic status of an individual, are key to identifying those most at risk for injury. Global health measures such as the Veterans RAND 12 Item Health Survey (VR-12) are quality of life measures that assess older adults' overall perception of their health and may serve as a useful adjunct when predicting frailty. Herein, we evaluated whether components of the VR-12 correlated with worse frailty scores over time. METHODS: Older adults (≥65) admitted to burn, trauma, or emergency general surgery services were prospectively enrolled. Demographics, frailty determined using the Trauma Specific Frailty Index (TSFI), and VR-12 surveys were collected at enrollment and 3, 6, 9, and 12-month follow-ups. A physical component score (PCS) and mental component score (MCS) was produced by VR-12 surveys for comparison purposes. RESULTS: Fifty-eight patients were enrolled, of which 8 died. No significant changes in PCS (p = 0.25) and MCS (p = 0.56) were observed over time. PCS (p = 0.97) and MCS (p = 0.78) at enrollment did not predict mortality. PCS (OR = 0.894 [0.84-0.95], p = 0.0004) and age (OR = 1.113 [1.012-1.223], p = 0.03) independently predicted enrollment frailty. CONCLUSION: These global measures of health could be utilized in lieu or in addition to frailty scores when assessing patients in the setting of acute injury. Studies are warranted to confirm this association.

Migrating motility complexes persist after severe traumatic shock in patients who tolerate enteral nutrition.

BACKGROUND: Postinjury small bowel ileus is poorly characterized and may be an important factor in intolerance to enteral nutrition (EN). We, therefore, placed jejunal manometry catheters in high-risk trauma patients. Our hypothesis was that the presence of "fasting migrating motility complex (MMC)" activity and conversion to a "fed pattern" at goal rate of EN would be present in those patients who tolerate jejunal feeding. METHODS: After obtaining baseline fasting manometry pressure tracings, jejunal feeding was advanced stepwise to a set goal while tolerance was monitored and intolerance was treated by a standard approach. RESULTS: Of the 10 study patients, 7 were able to be maintained on EN. Five (50%) had "fasting MMCs" and had good tolerance to early advancement of EN. The remaining five patients did not exhibit "fasting MMCs" and four had poor tolerance to early advancement of EN. Overall, nine patients reached goal rate of EN of which four converted to a "fed pattern." This, however, was not associated with later tolerance to EN. CONCLUSION: EN is feasible following severe traumatic shock. Surprisingly, half of the patients had fasting MMCs. This requires intact neural and motor function and was associated with good tolerance of early EN.

Computerized decision support for mechanical ventilation of trauma induced ARDS: results of a randomized clinical trial.

BACKGROUND: Variability and logistic complexity of mechanical ventilatory support of acute respiratory distress syndrome, and need to standardize care among all clinicians and patients, led University of Utah/LDS Hospital physicians, nurses, and engineers to develop a comprehensive computerized protocol. This bedside decision support system was the basis of a multicenter clinical trial (1993-1998) that showed ability to export a computerized protocol to other sites and improved efficacy with computer- versus physician-directed ventilatory support. The Memorial Hermann Hospital Shock Trauma intensive care unit (ICU) (Houston, TX; a Level I trauma center and teaching affiliate of The University of Texas Houston Medical School) served as one of the 10 trial sites and recruited two thirds of the trauma patients. Results from the trauma patient subgroup at this site are reported to answer three questions: Can a computerized protocol be successfully exported to a trauma ICU? Was ventilator management different between study groups? Was patient outcome affected? METHODS: Sixty-seven trauma patients were randomized at the Memorial Hermann Shock Trauma ICU site. "Protocol" assigned patients had ventilatory support directed by the bedside respiratory therapist using the computerized protocol. "Nonprotocol" patients were managed by physician orders. RESULTS: Of the 67 trauma patients randomized, 33 were protocol (age 40 +/- 3; Injury Severity Score [ISS] 26 +/- 3; 73% blunt) and 34 were nonprotocol (age 38 +/- 2; ISS 25 +/- 2; 76% blunt). For the protocol group, the computerized protocol was used 96% of the time of ventilatory support and 95% of computer-generated instructions were followed by the bedside respiratory therapist. Outcome measures (i.e., survival, ICU length of stay, morbidity, and barotrauma) were not significantly different between groups. Fio2 > or = 0.6 and Pplateau > or = 35 cm H2O exposures were less for the protocol group. CONCLUSION: A computerized protocol for bedside decision support was successfully exported to a trauma center, and effectively standardized mechanical ventilatory support of trauma-induced acute respiratory distress syndrome without adverse effect on patient outcome.

Vacuum-assisted wound closure provides early fascial reapproximation in trauma patients with open abdomens.

BACKGROUND: Damage control and decompressive laparotomies salvage severely injured patients who would have previously died. Unfortunately, many of these patients develop open abdomens. A variety of management strategies exist. The end result in many cases, however, is a large ventral hernia that requires a complex repair 6 to 12 months after discharge. We instituted vacuum-assisted wound closure (VAWC) to achieve early fascial closure and eliminate the need for delayed procedures. METHODS: For 12 months ending June 2000, 14 of 698 trauma intensive care unit admissions developed open abdomens and were managed with VAWC dressing. This was changed every 48 hours in the operating room with serial fascial approximation until complete closure. RESULTS: Fascial closure was achieved in 13 patients (92%) in 9.9 +/- 1.9 days, and 2.8 +/- 0.6 VAWC dressing changes were performed. There were 2 wound infections, no eviscerations, and no enteric fistulas. CONCLUSIONS: Use of VAWC can safely achieve early fascial closure in more than 90% of trauma patients with open abdomens.

Nitroprusside in resuscitation of major torso trauma.

OBJECTIVE: Patients with thoracic aortic injury (TAI) usually have sustained other major trauma, and may require aggressive shock resuscitation. In the 24 hours after aortic repair and during resuscitation, our cardiothoracic surgeons request intravenous nitroprusside to maintain mean arterial pressure (MAP) less than 90 mm Hg to minimize bleeding at the repair. We compared the resuscitation response of patients who sustained major torso trauma (MTT) and TAI with that of patients who had MTT with no TAI to determine whether nitroprusside can effectively control MAP during resuscitation and whether use of nitroprusside, because of its peripheral vasodilatory effects, is associated with a favorable resuscitation response. METHODS: During the 9-month study period, 11 patients who sustained TAI and 38 patients who sustained MTT with no TAI met multiple organ failure risk/shock criteria and were resuscitated by a standardized protocol emphasizing volume loading and hemoglobin replacement to maintain systemic oxygen delivery index (DO2I) > or = 600 mL O2/min-m2 for the first 24 intensive care unit hours. For TAI patients, postoperative management included intravenous nitroprusside infusion titrated by the bedside nurse to maintain mean arterial pressure (MAP) less than 90 mm Hg during the same 24 hours. Data were obtained prospectively during resuscitation. Retrospectively, the resuscitation response of TAI and non-TAI patients was compared. RESULTS: For the TAI group, nitroprusside effectively controlled MAP (range, 77-87 mm Hg); for the non-TAI group, mean MAP exceeded 95 mm Hg within 5 hours. During the first 8 hours, MAP, pulmonary capillary wedge pressure, and systemic vascular resistance index were less, and DO2I was greater for the TAI than for the non-TAI group. The resuscitation goal of DO2I > or = 600 mL O2/ min-m2 was attained at 4 hours for the TAI group, and was attained at 12 hours for the non-TAI group. No revisions of aortic repairs were required during or as a result of resuscitation. CONCLUSION: During aggressive shock resuscitation, control of MAP using nitroprusside is feasible and is associated with a favorable resuscitation response. Nitroprusside may be a useful adjunct during shock resuscitation of MTT as a vasoactive agent that promotes peripheral tissue perfusion.

Blunt trauma resuscitation: the old can respond.

HYPOTHESIS: Old and young trauma patients are capable of hyperdynamic response during standardized shock resuscitation. DESIGN: The responses of old and young trauma patients resuscitated using a standardized protocol are compared in an inception cohort study. A standardized resuscitation protocol was used to attain and maintain an oxygen delivery index of 600 mL/min x m2 or greater (DO2I > or = 600) for the first 24 hours in the intensive care unit. Interventions, responses, and outcomes for old (> or = 65 years) and young (<65 years) patients are described. Data were analyzed using analysis of variance, the chi2 test, and the t test; P<.05 was considered significant. SETTING: A 20-bed shock trauma intensive care unit in a regional level I trauma center. PATIENTS: Patients at high risk of postinjury multiple organ failure, ie, major organ or vascular injury and/or skeletal fractures, initial base deficit of 6 mEq/L or greater, need for 6 units or more of packed red blood cells in the first 12 hours, or age of 65 years or older with any 2 previous criteria. INTERVENTIONS: Pulmonary artery catheter, crystalloid fluid infusion, packed red blood cell transfusion, and moderate inotrope support, as needed in that sequence, to attain DO2I > or = 600. MAIN OUTCOME MEASURES: Intensive care unit length of stay and survival. RESULTS: During 19 months ending June 1999, 12 old patients (58% male; age, 76 +/- 2 years [mean +/- SEM] [P<.0011; Injury Severity Score, 20 +/- 2 [P=.02]) and 54 young patients (61% male; age, 37 +/- 2 years; Injury Severity Score, 32 +/- 2) were resuscitated. Initially, for old patients (cardiac index, 2.0 +/- 0.2 L/min x m2) and for young patients (cardiac index, 3.0 +/- 0.2 L/min x m2; P=.01), 24-hour volumes were as follows: 16 +/- 3 L of crystalloid and 12 +/- 3 units of packed red blood cells for the old patients and 21 +/- 2 L of crystalloid and 19 +/- 2 units of packed red blood cells for the young patients. For old patients, 9 (75%) attained DO2I > or = 600, and 11 (92%) survived 7 or more days and 5 (42%) 30 or more days. For young patients, 45 (83%) attained the DO2I goal, and 48 (89%) survived 30 or more days. Intensive care unit length of stay was 25 +/- 9 days for the old patients and 23 +/- 2 days for the young patients. CONCLUSIONS: Elderly patients have initially depressed cardiac index but generate hyperdynamic response. Although ultimate outcome is poorer than in the younger cohort, resuscitation is not futile.

Age should not be a consideration for nonoperative management of blunt splenic injury.

BACKGROUND: Operative management of blunt splenic injury is recommended for adults > or = 55 years. Because this is not our practice, we did a retrospective review to compare outcomes of patients > or = 55 years old versus patients < 55 years old. METHODS: During a 5-year period ending in July of 1998, 461 patients (3%) admitted to our Level I trauma center had a blunt splenic injury. Eighty-six patients (19%) died within 24 hours of massive injuries, leaving 375 patients for evaluation. Data were obtained from our trauma registry and medical records. RESULTS: A total of 29 patients (8%) were > or = 55 years old (mean age, 67 +/- 2 years; mean injury severity score [ISS] 25 +/- 2). Of these, 18 patients (62%) underwent nonoperative management (NOM). A total of 346 patients (92%) were < 55 years old (mean age, 28 +/- 0.6; mean ISS, 20 +/- 1). Of these, 198 patients (57%) underwent NOM. The failure rate was not different between the two age groups (17% vs. 14%). However, the ISS and mortality rate were significantly higher in the older age group that failed (ISS, 29.3 +/- 2.6 vs. 19.5 +/- 2.1; mortality: 67% vs. 4%). None of the deaths could be attributed to splenic injury. CONCLUSION: Adults > or = 55 years old with blunt splenic injury are successfully treated by NOM. Although older adults had significantly greater injuries, they had similar failure rates of NOM when compared with younger adults. Older adults had significantly higher mortality, but this was not a result of their splenic injury. Therefore, age should not be a criteria for NOM of blunt splenic injury.

Tissue hemoglobin O2 saturation during resuscitation of traumatic shock monitored using near infrared spectrometry.

BACKGROUND: Near infrared (NIR) spectrometry offers a noninvasive monitor of tissue hemoglobin O2 saturation and has been developed to report a quantitative clinical variable, StO2 [= HbO2/(HbO2 + Hb)]. In this study, a prototype NIR oximeter was used to investigate the hypothesis that changes in systemic O2 delivery index (D(O2)I) would be reflected by changes in StO2 in skeletal muscle, subcutaneous tissue, or both, as reperfusion occurs during shock resuscitation. StO2 was also compared with other indices of severity of shock or adequacy of resuscitation, including arterial base deficit, lactate, gastric mucosal P(CO2) (PgCO2), and mixed venous hemoglobin O2 saturation (S(VO2)). METHODS: Skeletal muscle and subcutaneous tissue StO2 were monitored simultaneously in eight severely injured trauma patients (88% blunt mechanism; age, 42 +/- 6 years; Injury Severity Score, 27 +/- 3) during standardized shock resuscitation in the intensive care unit with the primary goal of D(O2)I > or = 600 mL O2/min/m2 for 24 hours, and for an additional 12 hours during transition from resuscitation to standard intensive care unit care. RESULTS: Skeletal muscle StO2 increased significantly from 15 +/- 2% (mean +/- SEM) at the start of resuscitation to 49 +/- 14% at 24 hours, and to approximately 55% from 25 to 36 hours. Subcutaneous tissue StO2 approximately 82% and was significantly greater than skeletal muscle StO2 throughout. D(O2)I increased significantly from 372 +/- 54 to 718 +/- 47 mL O2/min/m2 during resuscitation. Over 36 hours, mean D(O2)I and skeletal muscle StO2 were highly correlated (r = 0.95). Neither D(O2)I-PgCO2 nor D(O2)I-S(VO2) were significantly correlated; neither S(VO2) nor subcutaneous tissue StO2 changed significantly. CONCLUSION: Hemoglobin O2 saturation was monitored noninvasively and simultaneously in skeletal muscle and subcutaneous tissues as StO2 (%) by using a prototype NIR oximeter. Skeletal muscle StO2 tracked systemic O2 delivery during and after resuscitation. As a rapidly deployable, noninvasive monitor of peripheral tissue oxygenation and O2 delivery, skeletal muscle StO2 obtained using NIR spectrometry would be useful to guide resuscitation in the intensive care unit, to monitor resuscitation status in the operating room, and, potentially, in combination with indicators such as base deficit and lactate, to detect shock during initial assessment of the severe trauma patient in the emergency department.

Nonocclusive bowel necrosis occurring in critically ill trauma patients receiving enteral nutrition manifests no reliable clinical signs for early detection.

BACKGROUND: Nonocclusive bowel necrosis (NOBN) has been associated with early enteral nutrition (EN). The purpose of this study was to determine the incidence of this complication in our trauma intensive care unit population and to define a typical patient profile vulnerable to NOBN. METHODS: Thirteen cases of NOBN were identified among 4,311 patients (0.3%) over a 64-month period ending October 1998. Their charts were analyzed for a variety of clinical data, including prospective EN tolerance data in 4. RESULTS: Twelve (92%) patients were enterally fed prior to diagnosis for 10 +/- 8 days (range 3 to 21). Tachycardia (n = 12, 92%); fever/hypothermia, (n = 12, 92%), and an abnormal white blood cell count (n = 11, 85%) were consistently present. Abdominal distention was common but tended to be a late sign (n = 12). Seven (56%) survived. In 4 patients with tolerance data, 3 reached the goal rate of feeds prior to diagnosis. Two became distended at >12 hours from diagnosis. Gastric tonometry demonstrated a decreased NgpHi (<7.30) after starting EN in all 3 in whom it was monitored. CONCLUSIONS: NOBN developed in 0.3% of our trauma patients. Onset occurs in the second week in high-acuity patients who have had a period of EN tolerance. Clinical findings resemble bacterial sepsis with tachycardia, fever, and leukocytosis. Gastrointestinal specific signs are not consistent or occur late. Thus, we could not identify an early, useful clinical indicator. Gastric carbon dioxide tonometry may detect a vulnerable subgroup of patients.

Blunt versus penetrating subclavian artery injury: presentation, injury pattern, and outcome.

BACKGROUND: Subclavian artery (SCA) injuries are rare vascular injuries and may be difficult to manage. The majority of SCA injuries are secondary to penetrating trauma. The purpose of this report is to examine the injury patterns, diagnostic and therapeutic approaches, and outcome of patients with blunt and penetrating SCA injuries. METHODS: Retrospective review RESULTS: Fifty-six patients sustained SCA injuries (25 blunt, 31 penetrating). SCA injury location was evenly distributed between the proximal, middle, and distal SCA after penetrating trauma; proximal injuries were rare (2 of 25) with blunt mechanisms. A radial arterial pulse deficit was present in only 3 of 25 blunt injuries and 9 of 31 penetrating injuries. Complications occurred more commonly in both groups of patients with initial systolic blood pressures less than 90 mm Hg. Survival was 76% in blunt and 81% in penetrating groups; limb salvage was similar (92% in blunt and 97% in penetrating groups). Complete brachial plexus injuries were more common with blunt injuries. CONCLUSION: SCA injuries are rare vascular injuries with an associated high morbidity and mortality, regardless of mechanism. Blunt mechanisms result in more middle and distal injuries and more frequent complete brachial plexus injuries. Complications are related to the hemodynamic status of the patient upon presentation, and not to mechanism of injury.

Delayed complications of nonoperative management of blunt adult splenic trauma.

OBJECTIVE: To determine the incidence and type of delayed complications from nonoperative management of adult splenic injury. DESIGN: Retrospective medical record review. SETTING: University teaching hospital, level I trauma center. PATIENTS: Two hundred eighty patients were admitted to the adult trauma service with blunt splenic injury during a 4-year period. Men constituted 66% of the population. The mean (+/-SEM) age was 32.2+/-1.0 years and the mean (+/-SEM) Injury Severity Score was 22.8+/-0.9. Fifty-nine patients (21%) died of multiple injuries within 48 hours and were eliminated from the study. One hundred thirty-four patients (48%) were treated operatively within the first 48 hours after injury and 87 patients (31%) were managed nonoperatively. MAIN OUTCOME MEASURES: We reviewed the number of units of blood transfused, intensive care unit length of stay, overall length of stay, outcome, and complications occurring more than 48 hours after injury directly attributable to the splenic injury. RESULTS: Patients managed nonoperatively had a significantly lower Injury Severity Score (P<.05) than patients treated operatively. Length of stay was significantly decreased in both the number of intensive care unit days as well as total length of stay (P<.05). The number of units of blood transfused was also significantly decreased in patients managed nonoperatively (P<.05). Seven patients (8%) managed nonoperatively developed delayed complications requiring intervention. Five patients had overt bleeding that occurred at 4 days (3 patients), 6 days (1 patient), and 8 days (1 patient) after injury. Three patients underwent splenectomy, 1 had a splenic artery pseudoaneurysm embolization, and 1 had 2 areas of bleeding embolization. Two patients developed splenic abscesses at approximately 1 month after injury; both were treated by splenectomy. CONCLUSION: Significant numbers of delayed splenic complications do occur with nonoperative management of splenic injuries and are potentially life-threatening.

Operative treatment of truncal vascular injuries in children and adolescents.

BACKGROUND/PURPOSE: Pediatric truncal vascular injuries are rare, but the reported mortality rate is high (35% to 55%), and similar to that in adults (50% to 65%). This report examines the demographics, mechanisms of injury, associated trauma, and results of treatment of pediatric patients with noniatrogenic truncal vascular injuries. METHODS: A retrospective review (1986 to 1996) of a pediatric (< or = 17 years old) trauma registry database was undertaken. Truncal vascular injuries included thoracic, abdominal, and neck wounds. RESULTS: Fifty-four truncal vascular injuries (28 abdominal, 15 thoracic, and 11 neck injuries) occurred in 37 patients (mean age, 14+/-3 years; range, 5 to 17 years); injury mechanism was penetrating in 65%. Concomitant injuries occurred with 100% of abdominal vascular injuries and multiple vascular injuries occurred in 47%. Except for aortic and one SMA injury requiring interposition grafts, these wounds were repaired primarily or by lateral venorrhaphy. Nonvascular complications occurred more frequently in patients with abdominal injuries who were hemodynamically unstable (systolic blood pressure [BPS] <90) on presentation (19 major complications in 11 patients versus one major complication in five patients). Thoracic injuries were primarily blunt rupture or penetrating injury to the thoracic aorta (nine patients). Thoracic aortic injuries were treated without bypass, using interposition grafts. In patients with thoracic aortic injuries, there were no instances of paraplegia related to spinal ischemia (clamp times, 24+/-4 min); paraplegia occurred in two patients with direct cord and aortic injuries. Concomitant injuries occurred with 83% of thoracic injuries and multiple vascular injuries occurred in 25%. All patients with thoracic vascular injuries presenting with BPS of less than 90 died (four patients), and all with BPS 90 or over survived (eight patients). There were 11 neck wounds in 9 patients requiring intervention, and 8 were penetrating. Overall survival was 81%; survival from abdominal vascular injuries was 94%, thoracic injuries 66%, and neck injuries 78%. CONCLUSIONS: Survival and subsequent complications are related primarily to hemodynamic status at the time of presentation, and not to body cavity or vessel injured. Primary anastomosis or repair is applicable to most nonaortic wounds. The mortality rate in pediatric abdominal vascular injuries may be lower than previously reported.

Are scene flights for penetrating trauma justified?

OBJECTIVE: To evaluate the medical efficacy of helicopter scene flights for patients with noncranial penetrating injuries. DESIGN: A retrospective review of 122 consecutive victims of noncranial penetrating injuries evacuated by helicopter from the scene of injury to a level I trauma center. There were no medical criteria for accepting or rejecting a request for a scene flight by any public safety agency or emergency medical service (EMS). Flights were dispatched if the weather permitted and if a helicopter was available. RESULTS: The majority of patients were critically wounded. Their average Revised Trauma Score was 10.6, and 15.6% of the patients died (19 of 122), including all 11 patients who required prehospital cardiopulmonary resuscitation. Helicopter transport from the scene did not hasten trauma center arrival for any of the 122 patients. Ninety-two of the first-responder EMS units (75.4%) were advanced life support units (ALS) with crews of paramedics. The remaining 30 (24.6%) first-responder EMS units were basic life support units (BLS) with crews of emergency medical technicians (EMTs). Six of 122 patients (4.9%) required medical interventions by the medical flight crews beyond the capabilities of the ground EMS personnel. Only 3 of the 92 patients (3.3%) treated by first-responding paramedics received medical interventions by the medical flight crews beyond those authorized for paramedics (one cricothyroidotomy and two needle thoracenteses). Two of the 30 patients (6.7%) treated by first-responding EMTs received medical interventions by the medical flight crews not authorized for the EMTs. The on-scene paramedics performed endotracheal intubation on 10 patients. However, because of subsequent clinical deterioration, the medical flight crews performed endotracheal intubations on nine additional patients. In addition, two patients intubated by the first-responding paramedics required reintubation by the medical flight crews. CONCLUSIONS: Scene flights in this metropolitan area for patients who suffered noncranial penetrating injuries demonstrated that these flights were not medically efficacious. This conclusion rests on the findings that arrival at a trauma center was not hastened by scene flights and that only 4.9% of patients required prehospital care by the medical flight crew beyond the capabilities of the first-responding EMS personnel (2.5 and 6.7% for ALS and BLS responders, respectively). Based on this experience, we believe that in metropolitan areas, scene flights for victims of noncranial penetrating injuries should be restricted to critically injured patients likely to require prehospital care by the medical flight crew that is beyond the capabilities of the first responders or when the scene flight is likely to significantly hasten the arrival of the injured patient to an appropriate trauma center.

Does the potential for organ donation justify scene flights for gunshot wounds to the head?

OBJECTIVE: The goal of this study was to evaluate helicopter transport to an urban level I trauma center from the scene of injury for patients with self-inflicted gunshot wounds to the head. DESIGN: This study is a retrospective review of the prehospital, hospital, and billing records. MEASUREMENTS AND MAIN RESULTS: Despite the fact that 10 of 28 patients (36%) had an airway established by the medical flight crews, scene flights did not enhance survival. Twenty-seven of 28 patients (96%) died. The remaining patient's survival could not be attributed to the scene flight. We estimated that 27 of 28 patients would have arrived at the trauma center sooner if they had been transported by the first-responder emergency medical services ground unit. Flight service charges were approximately one-third of the hospital charges. As a group, patients with a self-inflicted gunshot wound to the head had the highest rate of organ donation in this trauma center (26%). Twenty-nine organs were harvested from the seven donors. CONCLUSIONS: The use of helicopter scene flights from the scene of injury for patients with a self-inflicted gunshot wound to the head provides no medical advantage to the victims, but provides a high-yield source of desperately needed organs. The prompt establishment of an airway in the field may prolong patient survival long enough to allow evaluation for organ donation. Helicopter transport of these patients is justified only as a means of rapidly delivering the personnel capable of providing advanced airway skills to the scene. Patients requiring CPR in the field after isolated gunshot wounds to the head will not live long enough to become organ donor candidates; therefore, there is no benefit to helicopter transport for these patients.

Reevaluation of the linkage between acute hemorrhagic shock and bacterial translocation in the rat.

The present study was undertaken to determine the conditions under which acute periods of hemorrhagic shock induce bacterial translocation. Rats (at least six per group) were anesthetized intraperitoneally with the barbiturate, pentobarbital (50 or 65 mg/kg), or the inhalation anesthetic methoxyflurane. Following anesthesia, the femoral artery was catheterized, from which blood was withdrawn to maintain a mean arterial blood pressure of 30 mmHg for 30, 60, or 90 min, followed by reinfusion of shed blood. Instrumented, but nonshocked animals served as controls. Rats were sacrificed at 0, 2, or 24 hr postshock, and quantitative bacterial cultures of the mesenteric lymph node complex (MLN), liver, and spleen were made. Within groups, the effects of heparinization were also determined. In pentobarbital-treated animals, regardless of the extent of heparinization, consistent translocation to both MLN and distant organs occurred when shock was prolonged for 90 min, and assessment of translocation was made 24 hr after reinfusion of shed blood. Furthermore, a mortality rate of approximately 30% was found in rats subjected to this protocol. The magnitude of translocation was less consistent, and did not differ from that in sham shock controls, under other conditions of shock and evaluation. In rats anesthetized with methoxyflurane, no mortality occurred, and no statistical significance between the incidence or degree of translocation in shocked animals vs. sham shock controls could be demonstrated, regardless of the shock protocol. In additional studies, effects of these anesthetics on intestinal morphology and superior mesenteric arterial (SMA) flow in the context of hemorrhagic shock were assessed.(ABSTRACT TRUNCATED AT 250 WORDS)

Mucormycosis in trauma patients.

Cutaneous mucormycosis is a rare but often fatal infection in trauma patients. We retrospectively reviewed a 9-year experience with mucormycosis among injured patients. Eleven patients had biopsy- or culture-proven mucormycosis. Nine patients were victims of blunt trauma, two patients had burns measuring greater than 50% TBSA. No patient was at increased risk because of underlying disease or immunosuppression prior to injury. All 11 patients had open wounds on admission. Four patients died of mucormycosis. All nonsurvivors had phycomycotic gangrenous cellulitis of the head, the trunk, or both. In contrast, survivors had involvement of only the extremities. Because of underlying disease, contaminating wounds, antibiotic use, or immunocompromise secondary to shock and sepsis, trauma patients are at risk of developing mucormycosis. To successfully treat mucormycosis, diagnosis must be prompt and accompanied by aggressive debridement and parenteral administration of amphotericin B.