A feasibility study of methodological issues and short-term outcomes in seriously injured older adults.

BACKGROUND: For any given traumatic injury, older adults experience a longer hospitalization, more complications, and higher mortality than do younger patients. OBJECTIVES: To prospectively identify problems in designing follow-up studies in seriously injured older adults without head injury and to examine outcomes after serious trauma in older adults who were sent to a level I trauma center. METHODS: A short-term descriptive follow-up design was used in which each patient served as his or her baseline. Eligible patients had injuries that required admission to an intensive care unit, a hospital length of stay longer than 72 hours, or surgery. Patients with isolated hip fractures, central nervous system injuries, and burn injuries were excluded. Data were collected by using standardized instruments during the acute hospital stay and 3 months after discharge from the hospital. RESULTS: During a representative 2-month period, 21% of a potential 77 subjects died in the hospital, 44% had cognitive impairment that precluded participation, and 17% declined to participate. Twenty older adults (mean age 73.5 years) who were injured in motor vehicle crashes (45%), falls (35%), or pedestrian accidents (15%) or who had gunshot wounds (5%) were enrolled. Ten percent died after discharge. Levels of physical disability at 3 months after discharge were higher than those before the injury (score on Sickness Impact Profile physical subscale 24.5 vs 10.9, P = .02), and psychological distress (Impact of Event Scale score 20.9) remained elevated. CONCLUSION: Mortality, disability, and posttraumatic psychological distress after discharge are problems in seriously injured older adults.

The invisible trauma patient: emergency department discharges.

BACKGROUND: As the malpractice and financial environment has changed, injured patients evaluated by the trauma team and discharged from the emergency department (ED) are now commonplace. The evaluation, care, and disposition of this population has become a significant workload component but is not reported to accrediting organizations and is relatively invisible to hospital administrators. Our objective was to quantify and begin to qualify the evolving picture of the trauma ED discharge population as a work component of trauma service function in an urban, Level I trauma center with an aeromedical program. METHODS: Trauma registry (contacts, mechanism, transport, injuries, and disposition) and hospital databases (ED closure, occupancy rates) were queried for a 5-year period (1999-2003). Trend analysis provided statistical comparisons for questions of interest. RESULTS: During the 5-year study period, the total number of trauma contacts rose by 18.1% (2,220 in 1999 vs. 2,622 in 2003; trend p < 0.05). This increase in total contacts was not a manifestation of an increase in admissions (1,672 in 1999 vs. 1,544 in 2003) but rather a reflection of a marked increase in patients seen primarily by the trauma team and discharged from the ED (473 in 1999 vs. 1,000 in 2003; trend p < 0.05). These ED discharge patients were increasingly transported by helicopter (12.3% in 1999 vs. 29.2% in 2003; trend p < 0.05) and less frequently from urban areas (57.1% in 1999 vs. 48.1% in 2003; trend p < 0.05) over the course of the study period. Average injury severity of this group increased over the study period (Injury Severity Score of 2.7 +/- 0.1 in 1999 vs. 3.3 +/- 0.1 in 2003; trend p < 0.05). ED length of stay for this group increased 19.8% over the study period (trend p < 0.05), averaging nearly 5 hours in 2003. CONCLUSION: The total number, relative percentage, and injury severity of patients evaluated by the trauma team and discharged from the ED has significantly increased over the last 5 years, representing nearly 5,000 patient care hours in 2003. Systems to care for these patients in a cost- and resource-efficient fashion should be put in place. The impact of this growing population of patients on the workload of the trauma center should be recognized by accrediting agencies, hospital administration, and Emergency Medical Services.

Integrating emergency general surgery with a trauma service: impact on the care of injured patients.

BACKGROUND: There has been considerable discussion on the national level on the future of trauma surgery as a specialty. One of the leading directions for the field is the integration of emergency general surgery as a wider and more attractive scope of practice. However, there is currently no information on how the addition of an emergency general surgery practice will affect the care of injured patients. We hypothesized that the care of trauma patients would be negatively affected by adding emergency general surgery responsibilities to a trauma service. METHODS: Our institution underwent a system change in August 2001, where an emergency general surgery (ES) practice was added to an established trauma service. The ES practice included emergency department and in-house consultations for all urgent surgical problems except thoracic and vascular diseases. There were no trauma staff changes during the study period. Trauma registry data (demographics, injuries, injury severity, and procedures) and performance improvement data (peer-review judgments for all identified errors, denied days, audit filters, and deaths) were abstracted for two 15-month periods surrounding this system change. Chi-square, Fisher's exact, and t tests provided between-group comparisons. RESULTS: The trauma staff evaluated a total of 5,874 patients during the 30-month study. There were 1,400 (51%) trauma admissions in the pre-ES group and 1,504 (48%) in the post-ES group, of which 1,278 and 1,434, respectively, met severity criteria for report to our statewide database (Pennsylvania Trauma Outcome Study [PTOS]). There were 163 (12.7% of PTOS) deaths in the pre-ES group compared with 171 (11.9% PTOS) deaths in the post-ES group (p = not significant [NS]). There was one death determined to be preventable by the peer review process for the pre-ES group, and none in the post-ES group. Both groups had 10 potentially preventable deaths, with the remaining mortalities being categorized as nonpreventable (p = NS). Unexpected deaths by TRISS methodology were 36 (2.8%) and 41 (2.9%) for the two groups, respectively (p = NS). There was no difference in the number of provider-specific complications between the groups (23, [1.8%] vs. 19 [1.3%], p = NS). The addition of emergency surgery has resulted in an additional average daily workload of 1.3 cases and 1.2 admissions. CONCLUSION: Despite an increase in trauma volume over the study period, the addition of emergency surgery to a trauma service did not affect the care of injured patients. The concept of adding emergency surgery responsibilities to trauma surgeons appears to be a valid way to increase operative experience without compromising care of the injured patient.

Fluid resuscitation and blood replacement in patients with polytrauma.

Hemorrhage is the most common cause of shock in patients with polytrauma, leading to cellular hypoxia and death. A large body of experimental and clinical research has greatly expanded our knowledge of cellular mechanisms and clinical outcomes in resuscitation of patients with hypovolemic shock. However, the fundamental principles of fluid resuscitation have not changed during the past few decades. Aggressive resuscitation to correct tissue hypoperfusion within 24 hours of injury is associated with improved clinical outcomes. Initial volume expanders of choice are crystalloid solutions, with blood and blood products used for patients who are hemodynamically unstable, patients with Class III and Class IV hemorrhage, and patients with ongoing uncontrolled sources of bleeding. The incidence of immunologic and infectious complications associated with blood transfusions in resuscitation of patients with polytrauma has not been shown to be any higher than in other clinical settings. Massive resuscitations, however, are associated with specific complications such as hypothermia, coagulopathy, and abdominal compartment syndrome. Novel blood substitutes, hypertonic saline, and minimally invasive hemodynamic monitoring techniques have the potential of optimizing fluid resuscitation in patients with polytrauma. Additional research using standardized animal models and randomized clinical trials is needed.

Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service.

BACKGROUND: Dwindling operative opportunities in trauma care may have a detrimental impact on career satisfaction among trauma surgeons and on career attractiveness to surgical trainees. Addition of emergency general surgery may alleviate some of these concerns. STUDY DESIGN: The trauma service at our institution incorporated nontrauma emergency general surgery over a 3-year period. The institution's trauma registry and hospital perioperative database were queried. The changes in operative caseload are described. Current trauma faculty anonymously completed a Web-based questionnaire about the addition of emergency general surgery to the trauma service. RESULTS: Operations for trauma decreased in 2002 compared with 1999, despite a higher number of penetrating injuries and total trauma contacts. Nontrauma general surgery operations performed by trauma faculty increased in proportion to coverage provided by the trauma service. In 2002, 57% of all cases performed by trauma surgeons were emergency general surgery, which accounted for 32% to 74% of an individual surgeon's caseload. In anonymously completed Web-based questionnaires, current trauma faculty expressed satisfaction with the combined trauma and emergency general surgery model. CONCLUSIONS: The combined trauma and nontrauma surgery service increased operative caseloads and improved satisfaction of trauma surgeons. A comprehensive trauma and emergency general surgery service may be an attractive model for the future of trauma surgery and provide logistical and medical advantages to the emergency general surgery patient population.

Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship.

OBJECTIVE: To describe outcomes from a clinical trauma surgical education program that places the board-eligible/board-certified fellow in the role of the attending surgeon (fellow-in-exception [FIE]) during the latter half of a 2-year trauma/surgical critical care fellowship. SUMMARY BACKGROUND DATA: National discussions have begun to explore the question of optimal methods for postresidency training in surgery. Few objective studies are available to evaluate current training models. METHODS: We analyzed provider-specific data from both our trauma registry and performance improvement (PI) databases. In addition, we performed TRISS analysis when all data were available. Registry and PI data were analyzed as 2 groups (faculty trauma surgeons and FIEs) to determine experience, safety, and trends in errors. We also surveyed graduate fellows using a questionnaire that evaluated perceptions of training and experience on a 6-point Likert scale. RESULTS: During a 4-year period 7,769 trauma patients were evaluated, of which 46.3% met criteria to be submitted to the PA Trauma Outcome Study (PTOS, ie, more severe injury). The faculty group saw 5,885 patients (2,720 PTOS); the FIE group saw 1,884 patients (879 PTOS). The groups were similar in respect to mechanism of injury (74% blunt; 26% penetrating both groups) and injury severity (mean ISS faculty 10.0; FIEs 9.5). When indexed to patient contacts, FIEs did more operations than the faculty group (28.4% versus 25.6%; P < 0.05). Death rates were similar between groups (faculty 10.5%; FIEs 10.0%). Analysis of deaths using PI and TRISS data failed to demonstrate differences between the groups. Analysis of provider-specific errors demonstrated a slightly higher rate for FIEs when compared with faculty when indexed to PTOS cases (4.1% versus 2.1%; P < 0.01). For both groups, errors in management were more common than errors in technique. Twenty-one (91%) of twenty-three surveys were returned. Fellows' feelings of preparedness to manage complex trauma patients improved during the fellowship (mean 3.2 prior to fellowship versus 4.5 after first year versus 5.8 after FIE year; P < 0.05 by ANOVA). Eighty percent rated the FIE educational experience "great -5" or "exceptional- 6." Eighty-five percent consider the current structure of the fellowship (with FIE year) as ideal. Ninety percent would repeat the fellowship. CONCLUSION: The educational experience and training improvement offered by the inclusion of a FIE period during a trauma fellowship is exceptional. Patient outcomes are unchanged. The potential for an increased error rate is present during this period of clinical autonomy and must be addressed when designing the methods of supervision of care to assure concurrent senior staff review.

Early predictors of long-term disability after injury.

BACKGROUND: Improving outcomes after serious injury is important to patients, patients' families, and healthcare providers. Identifying early risk factors for long-term disability after injury will help critical care providers recognize patients at risk. OBJECTIVES: To identify early predictors of long-term disability after injury and to ascertain if age, level of disability before injury, posttraumatic psychological distress, and social network factors during hospitalization and recovery significantly contribute to long-term disability after injury. METHODS: A prospective, correlational design was used. Injury-specific information on 63 patients with serious, non-central nervous system injury was obtained from medical records; all other data were obtained from interviews (3 per patient) during a 2 1/2-year period. A model was developed to test the theoretical propositions of the disabling process. Predictors of long-term disability were evaluated using path analysis in the context of structural equation modeling. RESULTS: Injuries were predominately due to motor vehicle crashes (37%) or violent assaults (21%). Mean Injury Severity Score was 13.46, and mean length of stay was 12 days. With structural equation modeling, 36% of the variance in long-term disability was explained by predictors present at the time of injury (age, disability before injury), during hospitalization (psychological distress), or soon after discharge (psychological distress, short-term disability after injury). CONCLUSIONS: Disability after injury is due partly to an interplay between physical and psychological factors that can be identified soon after injury. By identifying these early predictors, patients at risk for suboptimal outcomes can be detected.

Evaluation of the lower spine after blunt trauma using abdominal computed tomographic scanning supplemented with lateral scanograms.

BACKGROUND: Patients at risk for thoracolumbar junction (TLJ) and lumbar spine (LS) injury after blunt trauma are classically evaluated using conventional radiographs. Frequently, these patients also undergo abdominal and pelvic computed tomographic (CT) scanning to exclude the presence of associated intra-abdominal injuries. Standard abdominal and pelvic CT scan usually includes an anteroposterior (AP) scout film (scanogram) obtained before the cross-sectional imaging. The objective of this study was to determine whether a lateral CT scanogram and axial CT views would provide adequate imaging to allow for evaluation of the TLJ and LS and therefore eliminate the need for conventional screening computed lumbar spine radiographs (CLSRs). METHODS: Patients who sustained blunt injury and required both CLSRs as well as abdominal and pelvic CT scans were prospectively identified. The study protocol (CT + S) added lateral CT scanograms to all helical abdominal and pelvic CT scan studies. The AP and lateral CT scanograms were included with the axial images, and these views were reviewed together during final radiographic interpretation and diagnosis. The results of CT + S were compared with readings of the CLSRs (AP and lateral) in a blinded fashion by a trauma radiologist. RESULTS: Lateral scanograms were generated for 71 patients. All scanograms were technically adequate, with image quality equal or superior to computed plain radiographs. Ten patients were found to have 20 fractures, 19 acute and 1 chronic. All abnormalities identified by plain radiographs were seen using CT + S (sensitivity, 100%; specificity, 100%). Eight transverse process and two spinous process fractures not seen on CLSRs were identified using CT + S. CONCLUSION: Our CT + S protocol (axial CT images plus AP and lateral scanograms) outperformed screening CLSRs in the detection of fractures of the lower spine (TLJ + LS) after blunt trauma. In addition, scanogram imaging is less dependent on body habitus and adds no additional cost or time to abdominal and pelvic CT scanning. Further study is required to determine whether CT + S can routinely replace conventional radiographs of the lower spine after blunt trauma.

Hepatic angiography in patients undergoing damage control laparotomy.

OBJECTIVE: Patients undergoing damage control (DC) laparotomy require intensive and aggressive resuscitation, and may require additional maneuvers to control parenchymal bleeding. Those patients suffering significant liver injury are at high risk for arterial bleeding deep within the liver, and many require hepatic angiography in addition to hepatic packing. We reviewed our experience with hepatic angiography, and sought to determine its safety in the DC population of penetrating and blunt trauma patients. METHODS: A 3-year (June 1997-May 2000) retrospective review generated 37 DC patients. Patients sustaining hepatic trauma constituted the study group. Patients undergoing angiography in addition to DC laparotomy were compared with the group of patients not undergoing angiography. Data regarding mechanism of injury, patient demographics, extent of hepatic injury, and presence of associated injuries were collected. Physiologic parameters including vital signs at admission, lowest pH and base excess in the operating room, and lactate levels in the intensive care unit, as well as volumes of fluid resuscitation throughout all phases of DC were examined. Complications including death, intra-abdominal processes, acute respiratory distress syndrome and/or multiple organ dysfunction syndrome, and acute renal failure were reviewed. RESULTS: Nineteen patients (51%) had hepatic trauma and underwent perihepatic packing as a part of DC laparotomy. Eleven had sustained penetrating injury and 8 had blunt injury. There was 1 American Association for the Surgery of Trauma grade I, 5 grade II, 3 grade III, and 10 grade IV injuries. Nine patients in the study population underwent angiography, and eight of these were hepatic artery angiograms. One hepatic angiogram was obtained before operation and seven were obtained in the immediate postoperative period. Six underwent embolization of bleeding hepatic vessels, for a therapeutic liver angiography rate of 75%. There was no statistical difference in physiologic parameters or fluid requirements between the patients who underwent angiography and those who did not. There were no mishaps or complications from angiography or while in the angiography suite. CONCLUSION: Hepatic angiography is a safe adjunct to the principles of damage control. It has a high therapeutic ratio, with no significant untoward effect in this small study population.

Characteristics and outcomes of serious traumatic injury in older adults.

OBJECTIVES: To describe the seriously injured older adult; characterize and compare the differences in injury characteristics and outcomes in three subgroups of seriously injured older adults: aged 65 to 74, 75 to 84, and 85 and older; and identify risk factors for death, complications, and discharge placement at hospital discharge. DESIGN: A retrospective secondary analysis of a statewide trauma data set from 1988 through 1997. SETTING: Data submitted from all designated trauma centers in Pennsylvania. PARTICIPANTS: The data set yielded 38,707 patients with a mean age of 77.5 years with serious injury (mean number of injuries=3.6, mean number of body systems involved=2). MEASUREMENTS: Key outcomes were mortality, complications, and discharge placement. Abbreviated Injury Score categorized injuries and Injury Severity Score (ISS) quantified anatomic severity of injury. RESULTS: Mortality was 10%. Mean length of stay was 11.5 days. Just over half (52.2%) of survivors were discharged home; 25.4% were discharged to a skilled nursing facility. Injury severity, total number of injuries, complications, and increasing age were predictors of mortality (P <.01). The presence of preexisting comorbid medical conditions increased the odds of experiencing a complication over threefold. Increasing age, total number of injuries, injury to extremities or abdominal contents, injuries due to falls, and lower functional level predicted discharge to a skilled nursing facility (P <.01). CONCLUSIONS: Traumatic injuries affect older adults of all ages and are typically multisystem and life threatening. The standard ISS does not fully capture the potential for mortality in older adults and does not predict discharge placement. The majority of older adults survive multisystem injury. Our findings indicate the need to examine outcomes beyond mortality and to make the identification and management of comorbid conditions a priority. A geriatric consultation service could be an important addition to the interdisciplinary trauma team.

Massive blood loss in trauma patients.

Preview An injured and bleeding patient who is pale, confused, hypotensive, and anuric is an obvious candidate for transfusion to counteract hemorrhagic shock. However, not all patients with shock have such classic signs, at least not until hemodynamic compromise becomes severe. The authors summarize the basic principles of patient evaluation and care in emergency situations. They also describe some adverse consequences of massive transfusions and present tips on how to avoid or minimize them.