Natural history and clinical implications of nondepressed skull fracture in young children.

BACKGROUND: Head injury is the most common cause of neurologic disability and mortality in children. Previous studies have demonstrated that depressed skull fractures (SFs) represent approximately one quarter of all SFs in children and approximately 10% percent of hospital admissions after head injury. We hypothesized that nondepressed SFs (NDSFs) in children are not associated with adverse neurologic outcomes. METHODS: Medical records were reviewed for all children 5 years or younger with SFs who presented to our Level I trauma center during a 4-year period. Data collected included patient demographics, Glasgow Coma Scale (GCS) score at admission, level of consciousness at the time of injury, type of SF (depressed SF vs. NDSF), magnitude of the SF depression, evidence of neurologic deficit, and the requirement for neurosurgical intervention. RESULTS: We evaluated 1,546 injured young children during the study period. From this cohort, 563 had isolated head injury, and 223 of them had SF. Of the SF group, 163 (73%) had NDSFs, of whom 128 (78%) presented with a GCS score of 15. None of the NDSF patients with a GCS score of 15 required neurosurgical intervention or developed any neurologic deficit. Of the remaining 35 patients with NDSF and GCS score less than 15, 7 (20%) had a temporary neurologic deficit that resolved before discharge, 4 (11%) developed a persistent neurologic deficit, and 2 died (6%). CONCLUSION: Children 5 years or younger with NDSFs and a normal neurologic examination result at admission do not develop neurologic deterioration. LEVEL OF EVIDENCE: Epidemiological study, level III.

Spatial analysis of injury-related deaths in Dallas County using a geographic information system.

This study applied a geographic information system (GIS) to identify clusters of injury-related deaths (IRDs) within a large urban county (26 cities; population, 2.4 million). All deaths due to injuries in Dallas County (Texas) in 2005 (N = 670) were studied, including the geographic location of the injury event. Out of 26 cities in Dallas County, IRDs were reported in 19 cities. Geospatial data were obtained from the local governments and entered into the GIS. Standardized mortality ratios (SMR, with 95% CI) were calculated for each city and the county using national age-adjusted rates. Dallas County had significantly more deaths due to homicides (SMR, 1.76; 95% CI, 1.54-1.98) and IRDs as a result of gunshots (SMR, 1.23; 95% CI, 1.09-1.37) than the US national rate. However, this increase was restricted to a single city (the city of Dallas) within the county, while the rest of the 25 cities in the county experienced IRD rates that were either similar to or better than the national rate, or experienced no IRDs. GIS mapping was able to depict high-risk geographic "hot spots" for IRDs. In conclusion, GIS spatial analysis identified geographic clusters of IRDs, which were restricted to only one of 26 cities in the county.

Focused bedside echocardiography in the surgical intensive care unit: comparison of 3 methods to estimate cardiac index.

We sought to determine which of 3 methods used to evaluate cardiac index (CI) is the most accurate using focused bedside echocardiography (ECHO). We hypothesized that the fractional shortening (FS) method would provide a more accurate estimate of CI than the left ventricular outflow tract/velocity-time integral (LVOT/VTI) or Simpson's methods. This was a prospective observational cohort study conducted in the surgical ICU of an urban level 1 trauma center utilizing all patients with a pulmonary artery catheter (PAC) in place. Three surgical intensive care unit (SICU) faculty and 3 fellows underwent focused cardiac ultrasound training. Focused ECHO exams-bedside echocardiographic assessment in trauma/critical care (BEAT)- were performed using the Sonosite portable ultrasound device (Bothall, Washington). Stroke volume (SV) measurements were prospectively obtained on all trauma/SICU patients, with a PAC in place, using FS, LVOT/VTI, and Simpson's methods. The investigators were blinded to the PAC data. From each measurement, CI was calculated and categorized as low, normal, or high, based on a normal range of 2.4 to 4.0 L/min per m(2). Each CI obtained from the PAC was similarly categorized. The association between the BEAT and PAC estimates of CI was evaluated for each method using chi-square goodness of fit. Eighty five BEAT exams were performed on consecutive SICU patients, 56% were on trauma and 44% on emergency general surgery patients. There was a statistically significant association between the CI estimate using the FS method (P = .012), but not the LVOT/VTI (P = .33) or Simpson's method (P = .74). Our data showed a significant association between the PAC estimate of CI and our estimate using the FS method. The other methods were difficult to obtain, subjective, and inaccurate. Fractional shortening was the method of choice to estimate CI for the BEAT exam performed by intensivists in SICU patients.

Peripherally inserted central catheters may lower the incidence of catheter-related blood stream infections in patients in surgical intensive care units.

BACKGROUND: Long-term central venous catheterization is associated with a higher rate of catheter-related blood stream infections (CR-BSI). It is unclear whether there is a difference in the CR-BSI rate associated with central venous catheters (CVCs) and peripherally inserted central catheters (PICCs) in long-stay patients in surgical intensive care units (SICUs). We hypothesized that PICC use reduces the rate of CR-BSI compared with use of antiseptic CVCs in these patients. METHODS: All 121 patients admitted to our SICU for ≥14 days between July 2005 and July 2006 were included. Central venous access was maintained with an antiseptic CVC (Arrow Guard silver/chlorhexidine; n = 263) or replacement with a PICC (n = 37). Experienced residents, using maximum barrier precautions and chlorhexidine skin preparation, placed central lines; a credentialed registered nurse placed PICCs similarly. A CR-BSI was defined by semi-quantitative catheter tip cultures with ≥15 colony-forming units and at least one positive blood culture with the same organism. Multivariable regression was performed to identify predictors of CR-BSI. RESULTS: There were 13 CVC infections and one PICC infection, resulting in an infection rate of 6.0/1,000 catheter-days for CVCs and 2.2/1,000 for PICCs. Infected and non-infected CVCs were in place a mean of 25 ± 11 and 16 ± 9 days, respectively. The infected PICC was in place for 19 days, whereas the remainder of the PICCs were in place a mean of 14 ± 17 days. Logistic regression demonstrated that line days (duration of catheterization) was the only independent predictor of CVC infection (p = 0.015). CONCLUSION: In this non-randomized study, PICC was associated with fewer CR-BSIs in long-stay SICU patients, although CVCs were in place longer than PICC lines. The only predictor of CVC infection was the duration the line was in place. These results suggest that minimizing the duration of central venous access and substituting PICC for CVC may reduce the incidence of CR-BSI in long-stay SICU patients.

Changing epidemiology of trauma deaths leads to a bimodal distribution.

Injury mortality was classically described with a trimodal distribution, with immediate deaths at the scene, early deaths due to hemorrhage, and late deaths from organ failure. We hypothesized that the development of trauma systems has improved prehospital care, early resuscitation, and critical care and altered this pattern. This population-based study of all trauma deaths in an urban county with a mature trauma system reviewed data for 678 patients (median age, 33 years; 81% male; 43% gunshot, 20% motor vehicle crashes). Deaths were classified as immediate (scene), early (in hospital, ≤4 hours from injury), or late (>4 hours after injury). Multinomial regression was used to identify independent predictors of immediate and early versus late deaths, adjusted for age, gender, race, intention, mechanism, toxicology, and cause of death. Results showed 416 (61%) immediate, 199 (29%) early, and 63 (10%) late deaths. Compared with the classical description, the percentage of immediate deaths remained unchanged, and early deaths occurred much earlier (median 52 vs 120 minutes). However, unlike the classic trimodal distribution, the late peak was greatly diminished. Intentional injuries, alcohol intoxication, asphyxia, and injuries to the head and chest were independent predictors of immediate death. Alcohol intoxication and injuries to the chest were predictors of early death, while pelvic fractures and blunt assaults were associated with late deaths. In conclusion, trauma deaths now have a predominantly bimodal distribution. Near elimination of the late peak likely represents advancements in resuscitation and critical care that have reduced organ failure. Further reductions in mortality will likely come from prevention of intentional injuries and injuries associated with alcohol intoxication.

Universal consent practice in academic intensive care units (ICUs).

UNLABELLED: The purpose of this study was to determine national practice for obtaining consent in academic adult intensive care units (ICUs) for routine bedside procedures and to define universal consent rates by patient demographics within our own institution's ICUs. METHODS: A 10-question survey was sent to the program directors for all U.S. surgical and pulmonary critical care directors regarding consent practices. Further, the adoption of a universal consent protocol in an academic county hospital was studied. RESULTS: Cross-sectional study: Thirty-seven percent of program directors completed the survey. Consent rates varied from 35% to 97% by procedure, with only 14% using a universal consent document. Providers in Medical ICUs obtained consent more often than in Surgical ICUs for both central line and pulmonary artery catheter placement (82.8% and 93.1% vs. 52.6% and 52.6%, respectively). Prospective cohort study: At our institution, 90% of 363 patients or their proxies signed universal consent for procedures, 4.4% consent with exemptions, while 5.2% refused. Insured patients were 2.7 times more likely to sign full universal consent for bedside ICU procedures than uninsured patients. CONCLUSION: There was a national variation in ICU consent practices with an interest in a wider usage of universal consent protocols. The latter was adopted differentially based on patient demographics. Universal consent was widely accepted at our institution.

Trauma operative skills in the era of nonoperative management: the trauma exposure course (TEC).

BACKGROUND: Declining trauma operative experience adversely impacts learning and retention of operative skills. Current solutions, such as acute care surgery, may not provide relevant operative experience. We hypothesized that a structured skills curriculum using fresh cadavers would improve participants' self-confidence in surgical exposure of human anatomic structures for trauma. METHODS: The trauma exposure course, a single-day, 8-hour course with two trainees and one instructor per fresh cadaver, was designed by the faculty of a high-volume, urban, level I trauma center. Trainees included all trauma fellows (n = 6) and surgical chief residents (n = 12) in academic year 2007 to 2008. Using a structured, pretested curriculum, participants were trained by trauma faculty in operative exposure of 48 structures in the neck, chest, abdomen, pelvis, and extremities. For each exposure, participants' self-reported levels of operative confidence were measured using the operating score (OR score, 1 = not confident and 5 = highly confident) before the course (pre), immediately afterward (post), and at long-term follow-up (median, 6 months). RESULTS: Participation in the trauma exposure course resulted in a significant increase in OR scores for 44 of the 48 exposures (median scores, pre 3 vs. post 5, p < 0.0001), with no decline at long-term follow-up. Participants with less previous operative experience were most likely to benefit from the course. CONCLUSION: A structured skills curriculum using fresh cadavers improved participants' self-confidence in operative skills required for surgical exposure of human anatomic structures for trauma. This model of training may be beneficial for surgical residents and fellows, as well as practicing trauma surgeons.

Accuracy of cardiac function and volume status estimates using the bedside echocardiographic assessment in trauma/critical care.

BACKGROUND: Critically ill patients often require invasive monitoring to evaluate and optimize cardiac function and preload. With questionable outcomes associated with pulmonary artery catheters (PACs), some have evaluated the role of less invasive monitors. We hypothesized that the Bedside Echocardiographic Assessment in Trauma (BEAT) examination would generate cardiac index (CI) and central venous pressure (CVP) estimates that correlate with that of a PAC. METHODS: BEAT was performed on all SICU patients with a PAC in place. Prospective data included stroke volume and the inferior vena cava (IVC) diameter. The CI was calculated and correlated with that from the PAC. Each CI was then categorized as low, normal, or high. The IVC diameter was used to estimate the CVP. The association between the BEAT and PAC estimates of CI and CVP was evaluated using chi. RESULTS: Eighty-five BEAT examinations were performed, 57% on trauma and 37% on general surgery patients. Fifty-nine percent of the CI examinations and 97% of the IVC examinations contained quality images. Of these, the overall correlation coefficient was 0.70 (p < 0.0001). When CI was categorized, there was a significant association between the BEAT and PAC (p = 0.021). There was a significant association between the CVP estimate from the BEAT examination and the PAC (p = 0.031). CONCLUSION: Our data show a significant correlation between the CI and CVP estimates obtained from the BEAT examination and that from a PAC. BEAT provides a noninvasive method of evaluating cardiac function and volume status. Bedside echocardiography is teachable and should become a part of future critical care curricula.

Effects of early use of external pelvic compression on transfusion requirements and mortality in pelvic fractures.

BACKGROUND: We hypothesized that early use of external mechanical compression (EMC) reduces hemorrhage and mortality associated with pelvic fractures. METHODS: Patients with pelvic fractures and one of the following risk factors for hemorrhage were studied retrospectively: (1) unstable fracture pattern, or (2) any fracture in patients older than 55 years of age, or (3) fracture with systemic hypotension. Starting in November of 2003, EMC was performed using circumferential pelvic binders on patient arrival and continued for 24 to 72 hours. Patients who underwent EMC (n = 118) were compared with historical controls in the preceding year (n = 119). RESULTS: Patients in the EMC and control groups had similar fracture patterns, age, and injury severity. EMC had no effect on mortality (23% vs 23%, P = .92), need for pelvic angioembolization (11% vs 15%, P = .35), or 24-hour transfusions (5.2 +/- 10 vs 4.6 +/- 9 U, P = .64). CONCLUSIONS: Early EMC with pelvic binders does not reduce hemorrhage or mortality associated with pelvic fractures.

Increased risk of death associated with hypotension is not altered by the presence of brain injury in pediatric trauma patients.

BACKGROUND: Hypotension is a well-known predictor of mortality in pediatric trauma patients. However, it is unknown whether the mortality rate is higher in patients with traumatic brain injury (TBI) than in those without TBI. We hypothesized that systemic hypotension increases mortality in pediatric patients with TBI more than it does in pediatric patients with extracranial injuries only. METHODS: Multivariate logistic regression was used to determine the relationship between hypotension and the risk of death. Patients were then divided into 2 groups: TBI and No-TBI and the model was applied separately to each group. RESULTS: Overall mortality was 2%. After adjusting for confounding variables, hypotension remained a strong independent predictor of mortality. However, the increased risk of death was similar in patients with and without TBI. CONCLUSION: Hypotension is an important predictor of death in pediatric trauma patients. The increased risk of death associated with hypotension is similar with or without traumatic brain injury.

Transfusion of blood products and nosocomial infection in surgical patients.

PURPOSE OF REVIEW: Liberal transfusion of blood products may be associated with a worse clinical outcome, including in-hospital mortality. This review focuses on the mechanisms by which transfusions may result in an increased risk of bacterial infection. RECENT FINDINGS: The association between blood transfusion and worse outcome has been attributed to suppression of the recipient's immune function, the so called transfusion-related immunomodulation effect, as well as changes that may occur as blood ages. Despite several attempts to identify the mechanism by which transfusion worsens outcomes, this mechanism, as well as the role of leukoreduction in the mitigation of transfusion-related immunomodulation, have yet to be demonstrated. Bacterial contamination of the blood supply has become a serious problem in the past 20 years, and is currently the second leading cause of transfusion-associated death. Since the implementation of specific platelet transfusion protocols, the incidence of morbidity and mortality caused by infected platelet units appears to be markedly reduced. SUMMARY: Transfusion of blood and blood products can be life-saving interventions. Consequences of transfusion may ultimately result in worse outcomes. More research will be required in order to identify indications and practices that optimize outcomes of surgical patients who require a blood transfusion.