Two cases of penetrating abdominal injury from needlefish impalement.

BACKGROUND: Needlefish injuries to humans are extremely rare. An extensive review of the medical literature reveals only 22 cases previously reported. Most injuries reported have occurred in the Indo-Pacific region, but there are scattered reports worldwide. OBJECTIVE: To report two cases of life-threatening penetrating abdominal injuries from needlefish impalement. CASE REPORT: A 19-year-old man and a 40-year-old woman were both struck in the abdomen by a needlefish and required emergent exploratory laparotomy for instability. Their injuries were a laceration of a branch of the left portal vein and a small bowel perforation, respectively. Both patients survived and recovered without incident. CONCLUSION: Although rare, penetrating injuries from needlefish can be life threatening. Treatment should be directed at the organ injured with appropriate antibiotic coverage.

Assessing teamwork in the trauma bay: introduction of a modified "NOTECHS" scale for trauma.

BACKGROUND: A modified nontechnical skills (NOTECHS) scale for trauma (T-NOTECHS) was developed to teach and assess teamwork skills of multidisciplinary trauma resuscitation teams. In this study, T-NOTECHS was evaluated for reliability and correlation with clinical performance. METHODS: Interrater reliability (intraclass correlation coefficient) and correlation with the speed and completeness of resuscitation tasks were assessed during simulation-based teamwork training and during actual trauma resuscitations. RESULTS: For T-NOTECHS ratings done in real time, intraclass correlation coefficients were .44 for simulated and .48 for actual resuscitations. Reliability was higher (intraclass correlation coefficient = .71) for video review of resuscitations. Better T-NOTECHS scores were correlated with better performance during simulations, evidenced by a greater number of completed resuscitation tasks (r = .50, P < .01) and faster time to completion (r = -.38, P < .05) In actual resuscitations, T-NOTECHS ratings improved after teamwork training (P < .001). Higher T-NOTECHS scores were correlated with better clinical performance, evidenced by faster resuscitation (r = -.13, P < .05) and fewer unreported resuscitation tasks (r = -.16, P < .05). CONCLUSIONS: Improvement in T-NOTECHS scores after teamwork training, and correlation with clinical parameters in simulated and actual trauma resuscitations, suggest its clinical relevance. Further evaluation, aiming to improve reliability, may be warranted.

In situ, multidisciplinary, simulation-based teamwork training improves early trauma care.

OBJECTIVE: Evaluate the impact of a team training curriculum for residents and multidisciplinary trauma team members on team communication, coordination and clinical efficacy of trauma resuscitation. DESIGN: Prospective, cohort intervention comparing pre- vs. post-training performance. The intervention was a human patient simulator (HPS)-based, in situ team training curriculum, comprising a one-hour web based didactic followed by HPS training in the emergency department (ED). Teams were trained in multidisciplinary groups of 5-8 persons. Each HPS session included three fifteen minute scenarios with immediate video-enabled debriefing. Structured debriefing and teamwork assessment was performed with a modified NOTECHS scale for trauma (T-NOTECHS). Teams were assessed for performance changes during HPS-based training, as well as in actual trauma resuscitations. SETTING: The Queen's Trauma Center (Level II); the primary teaching hospital for the University of Hawaii Surgical Residency. PARTICIPANTS: 137 multidisciplinary trauma team members, including residents (n = 24), ED and trauma attending physicians, nurses, respiratory therapists, and ED technicians. RESULTS: During HPS-based training sessions, significant improvements in teamwork ratings, and in clinical task speed and completion rates were noted between the first and the last scenario.244 real-life blunt trauma resuscitations were observed for six months before and after training. There was a significant improvement in mean teamwork scores from the pre-to post-training resuscitations. Moreover, there were significant improvements in the objective parameters of speed and completeness of resuscitation. This was manifest by a 76% increase in the frequency of near-perfect task completion (≤ 1 unreported task), and a reduction in the mean overall ED resuscitation time by 16%. CONCLUSIONS: A relatively brief (four-hour) HPS-based curriculum can improve the teamwork and clinical performance of multidisciplinary trauma teams that include surgical residents. This improvement was evidenced both in simulated and actual trauma settings, and across teams of varying composition. HPS-based trauma teamwork training appears to be an educational method that can impact patient care.

Visitor injuries in Hawai'i.

BACKGROUND: Over seven million tourists visit the Hawaiian Islands each year. Popular visitor activities such as surfing, scuba diving, ocean kayaking, parasailing, bicycle tours and hiking each have risks of serious injury. This study reviews visitors' activities that led to serious injuries requiring treatment at the state's only trauma center while vacationing in Hawai'i. METHODS: A retrospective electronic medical record review was conducted of all visitor and resident trauma patients admitted to The Queen's Medical Center (QMC) from January 2002-December 2006. Patient demographics, injury type and severity, mechanism of injury, and discharge status were collected and analyzed. RESULTS: A total of 8244 patients were admitted to QMC for major traumatic injuries over the five year study period. Of these, 466 (5.7%) were visitors. The most common mechanisms of visitor injuries were falls (23.6%), water-related injuries (22.8%), motor vehicle crashes (18.7%), motorcycle, moped, and recreational vehicle crashes (12.2%), assaults (7.3%), and bicycle crashes (4.0%). A disproportionate number of visitors sustained serious injuries while engaging in water-related activities: Visitors account for only 12.6% of the population on any given day, yet comprise 44.2% of the total admissions for Hawai'i's water-related injuries. Head and spine injuries make up over two-thirds (68.2%) of these water-related visitor injuries. CONCLUSIONS: As a general category, falls were responsible for the highest number of visitor trauma admissions. Of the recreational activities leading to high numbers of trauma admissions, water-related activities are the leading causes of serious injuries among visitors to Hawai'i. Water-related injury rates are significantly higher for Hawai'i's visitors than residents. Water safety education for visitors should be developed in multiple languages to educate and protect Hawai'i's visitors and visitor industry.

Using transcutaneous oxygen pressure measurements as selection criteria for activated protein C use.

BACKGROUND: Limited resources and the expense of Activated Protein C (APC) (drotrecogin alfa) may contribute to the reluctance to utilize this drug in sepsis. Employing the PROWESS criteria resulted in absolute reduction in 28-day mortality of 6.1%, representing a relative risk reduction of 19.4%. Additional patient categorization and selection may lead to less frequent drug use with the same survival advantage. We used transcutaneous partial pressure of oxygen (PtcO2) as an indicator of microcirculatory perfusion to identify which septic patients may benefit from APC. METHODS: Nineteen patients consecutively admitted with severe sepsis or septic shock that fulfilled the PROWESS criteria for APC treatment. APC was administered to patients with the PROWESS selection criteria, only if the PtcO2 information demonstrated tissue ischemia. RESULTS: Nineteen patients met the PROWESS criteria. Ten patients demonstrated poor tissue perfusion using PtcO2 monitors and received APC. Nine patients had adequate tissue perfusion and did not receive APC. There were no differences in age, gender, APACHE II scores, lactate levels, or organ failure between the two groups. The 10 patients who received APC had a mortality of 3 of 10 (30%). The survivors of this group uniformly converted to PtcO2 values consistent with survival within 12 hours to 24 hours of drug administration. The nine patients who did not receive APC had a mortality of 2 of 9 (22%), not statistically significant from those who received the drug (p = 0.89). CONCLUSION: Withholding APC did not result in an increase in mortality from severe sepsis in those patients who demonstrated adequate PtcO2 values. The transcutaneous oxygen measurement may be a useful adjuvant in addition to the other selection criteria for better identification of patients who may benefit from APC.

Peripheral blood hematocrit in critically ill surgical patients: an imprecise surrogate of true red blood cell volume.

BACKGROUND: Peripheral blood hematocrit (red blood cell volume/total blood volume) is conventionally used to determine the need for blood transfusions. In critically ill surgical patients, this variable may not accurately approximate true red blood cell volume. We compared peripheral blood hematocrit to (1) plasma volume, (2) estimated circulating blood volume, and (3) a normalized hematocrit to clarify their relationships. METHODS: Consecutive patients admitted to the surgical intensive care unit were evaluated using the BVA-100 Blood Volume Analyzer (Daxor Corporation, New York City, NY). Plasma volume was directly measured by serial tagged albumin concentration. Red blood cell volume was calculated using plasma volume and the peripheral blood hematocrit result. All volumes were presented as percentage deviation from ideal volumes. These ideal volumes were obtained using a patented formula incorporating ideal body weight as determined by Metropolitan Life tables. The peripheral blood hematocrit was compared with a "normalized" hematocrit, defined as the hematocrit value if plasma volume was adjusted to a normal whole blood volume. RESULTS: Eighty-six data points were recorded for 40 patients with average age 61 +/- 20 yr, APACHE II score 20 +/- 6, and a 13% mortality rate. The primary reasons for admission were severe sepsis/septic shock (n = 11), hemorrhagic shock (n = 7), respiratory failure (n = 20), and cardiac failure (n = 2). Bland-Altman analysis showed a mean difference of 3.4 +/- 7.8 hematocrit percentage points between normalized and peripheral blood hematocrit methods, with a 95% confidence interval of 1.7-5.1 and limits of agreement of +/-15.2 hematocrit percentage points. Peripheral blood hematocrit was lower than the normalized hematocrit in 48% of measurements, higher in 17%, and equivalent in 35%. CONCLUSIONS: Peripheral blood hematocrit may not accurately estimate red blood cell volume in a cohort of critically ill surgical patients. This remains to be validated in a larger group of patients, comparing these results with the double isotope technique.

Circulating blood volume measurements correlate poorly with pulmonary artery catheter measurements.

BACKGROUND: Determination of the intravascular volume status of a critically ill surgical patient is paramount for appropriate fluid and cardiovascular management. Many clinical parameters have been utilized to estimate intravascular volume but none are precise indicators of circulating blood volume. The purpose of this observational pilot study was to compare measured blood volume with hemodynamic parameters obtained from the pulmonary artery catheter and to determine if incorporation of these measurements altered treatment decisions in critically ill surgical patients. METHODS: Blood volume measurements were prospectively obtained in twenty surgical intensive care unit patients with a pulmonary artery catheter when intravascular volume status was deemed uncertain by traditional clinical parameters. RESULTS: There was a statistically significant, but weak, correlation between blood volume results and pulmonary artery occlusion pressure, but no correlation with central venous pressure, cardiac index, and stroke volume index. Blood volume information altered treatment in 21% of instances, and 5 of these 6 patients demonstrated a favorable clinical response. CONCLUSIONS: Circulating blood volume measurements may be useful in critically ill surgical patients when clinical appraisal of intravascular volume is uncertain. This remains to be validated in a larger, prospective randomized trial.

A prospective randomized trial comparing oxygen delivery versus transcutaneous pressure of oxygen values as resuscitative goals.

Transcutaneous pressure of oxygen (PtcO2) correlates with arterial pressure of oxygen (PaO2) in nonshock states, but in shock states, PtcO2 approximates cardiac output with no response to increasing fraction of inspired oxygen (FiO2) and PaO2. An incremental change of more than 21 mmHg in PtcO2 in response to an FiO2 of 1.0 (identified as the oxygen challenge test [OCT]) implies adequate tissue perfusion, and lack of response has been associated with mortality. Patients with severe sepsis and septic shock requiring pulmonary artery catheters were randomized to two groups: the oxygen delivery (DO2) group was treated to a DO2 and mixed venous oxygen saturation goals, and the PtcO2 group was treated to achieve an OCT value of 40 mmHg or more. The DO2 (n = 30) and PtcO2 (n = 39) groups were similar in baseline characteristics. Mortality rate was 12 (40%) of 39 for the DO2 group and 5 (13%) of 39 for the PtcO2 group (P = 0.02). Logistic regression analysis of the statistically significant variables between survivors and nonsurvivors demonstrated that inability to reach the PtcO2 goal at 24 h after resuscitation (T24) and a positive cardiac history are associated with mortality (P < 0.001). The area under the receiver operating curve was 0.824 for the OCT at T24. The best OCT value was 25 mmHg at T24 with positive and negative predictive values of 87% and 90%, respectively. Treating patients with severe sepsis/septic shock to an OCT value of 25 mmHg or more may provide a specific end point of resuscitation that may be associated with better survival than resuscitating to the central hemodynamic parameters of DO2 and mixed venous oxygen saturation.

Hypothyroidism and adrenal insufficiency in sepsis and hemorrhagic shock.

HYPOTHESIS: We hypothesized that hypothyroidism and adrenal insufficiency frequently occur together in critically ill patients. DESIGN: A prospective observational study. SETTING: Surgical intensive care unit of a university-affiliated tertiary referral center. PATIENTS: Sixty-six consecutive patients with severe sepsis, septic shock, and hemorrhagic shock who required pulmonary artery catheterization for resuscitation were studied. INTERVENTIONS: Thyrotropin and baseline cortisol levels were obtained at 3 am followed by intravenous injection of 250 mug of cosyntropin, a synthetic adrenocorticotropic hormone derivative. A second measurement of the cortisol level was performed 1 hour later. MAIN OUTCOME MEASURES: Incidence of hypothyroidism and adrenal insufficiency and mortality. RESULTS: Mean (SD) age was 62 (19) years. The mean (SD) Acute Physiology and Chronic Health Evaluation II score was 21 (5). Twenty-seven patients (40.9%) had severe sepsis, 31 (46.9%) had septic shock, and 8 (12.1%) had hemorrhagic shock. Five patients (7.6%) had hypothyroidism alone and 35 (53.0%) had only adrenal insufficiency. Eight patients (12.1%) had both hypothyroidism and adrenal insufficiency. All patients with endocrine abnormalities were treated. Mortality for the total group was 15 (22.7%) of 66 patients. CONCLUSION: There is a 12% incidence of simultaneous hypothyroidism and adrenal insufficiency in our study and the routine testing for both may be indicated in this population of critically ill patients.