Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study.

BACKGROUND: The natural history and optimal management of retained hemothorax (RH) after chest tube placement is unknown. The intent of our study was to determine practice patterns used and identify independent predictors of the need for thoracotomy. METHODS: An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of chest tube within 24 hours of trauma admission and RH on subsequent computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors of successful intervention for each of the management choices chosen and complications. RESULTS: RH was identified in 328 patients from 20 centers. Video-assisted thoracoscopy (VATS) was the most commonly used initial procedure in 33.5%, but 26.5% required two and 5.4% required three procedures to clear RH or subsequent empyema. Thoracotomy was ultimately required in 20.4%. The strongest independent predictor of successful observation was estimated volume of RH ≤300 cc (odds ratio [OR], 3.7 [2.0-7.0]; p < 0.001). Independent predictors of successful VATS as definitive treatment were absence of an associated diaphragm injury (OR, 4.7 [1.6-13.7]; p = 0.005), use of periprocedural antibiotics for thoracostomy placement (OR, 3.3 [1.2-9.0]; p = 0.023), and volume of RH ≤900 cc (OR, 3.9 [1.4-13.2]; p = 0.03). No relationship between timing of VATS and success rate was identified. Independent predictors of the need for thoracotomy included diaphragm injury (OR, 4.9 [2.4-9.9]; p < 0.001), RH >900 cc (OR, 3.2 [1.4-7.5]; p = 0.007), and failure to give periprocedural antibiotics for initial chest tube placement (OR 2.3 [1.2-4.6]; p = 0.015). The overall empyema and pneumonia rates for RH patients were 26.8% and 19.5%, respectively. CONCLUSION: RH in trauma is associated with high rates of empyema and pneumonia. VATS can be performed with high success rates, although optimal timing is unknown. Approximately, 25% of patients require at least two procedures to effectively clear RH or subsequent pleural space infections and 20.4% require thoracotomy.

The relationship between post-traumatic ventilator-associated pneumonia outcomes and American College of Surgeons trauma centre designation.

INTRODUCTION: The relationship between outcomes following severe trauma and American College of Surgeons (ACS) trauma centre designation has been studied. Little is known, however, about the association between ACS level and outcomes associated with ventilator-associated pneumonia (VAP). METHODS: The National Trauma Databank (NTDB, Version 5.0) was queried to identify adult (age 18)trauma patients who (1) developed VAP and (2) were admitted to either an ACS level I or level II centre.Transfer and burn patients were excluded. Univariate analysis defined differences between patient cohorts. Logistic regression analysis was utilised to identify independent risk factors for mortality. RESULTS: A total of 3465 patients were identified where 65.6% were admitted to a level I facility and 34.4%to a level II centre. Patients admitted to a level I centre were more likely to have an age > 55 (71.5% vs.66.8%, p = 0.004) and to be hypotensive (SBP < 90) on admission (16.2% vs. 13.6%, p = 0.042). They were also more likely to have a longer duration of mechanical ventilation (18.5 days vs. 16.5 days, p = 0.001),longer hospital LOS (34.2 days vs. 29.6 days, p < 0.001) and a higher rate of early (±7 days) tracheostomy(33.1% vs. 29.1%, p = 0.017). Level I admission was, however, associated with lower mortality rates (10.8%vs. 14.7%, p = 0.001) and a higher likelihood of achieving discharge to home (20.2% vs. 16.1%, p < 0.001).Logistic regression analysis identified admission to a level II facility as an independent risk factor for mortality (OR 1.34, 95% CI 1.08­1.66; p = 0.008) in patients developing post-traumatic VAP. CONCLUSION: For adults who develop VAP after trauma, admission to a level I facility is associated with improved survival. Further prospective study is needed.

Outcomes of blunt assault at a level I trauma center.

BACKGROUND: Physical assault is common in trauma patients. Penetrating injuries resulting from interpersonal violence have been well described in literature, but there have been few studies examining the injury patterns due to assaults with hands and feet or blunt instruments. METHODS: The Trauma Registry of an American College of Surgeons Level I center was queried for all patients with an E-code diagnosis of assault by hands and feet or blunt instrument for the period of January 1, 1992 to September 30, 2005. Demographic and injury pattern data were analyzed. Univariate and multivariable analysis was performed to identify independent predictors of mortality. RESULTS: There were 3,286 patients identified (89.7% male) with a mean age of 36 years +/- 13 years and mean injury severity score of 8 +/- 7. Overall, 65 (2.0%) patients required laparotomy, 10 (0.3%) required craniectomy, and 1 (0.03%) patient required thoracotomy. Traumatic brain injury was present in 66.5% (2,184). Mortality was 2.4% (80). Patients older than 55 years were more likely to be severely injured (injury severity score > or = 16) (23.4% vs. 14.6%, p < 0.001) and were more likely to die of injuries (4.8% vs. 2.1%, p < 0.05). Nineteen (0.6%) patients had documented fractures of the cervical spine and cervical spinal cord injury was not observed in any patient. CONCLUSIONS: Injuries due to assault rarely require operative intervention and have a low risk of cervical spine or cord injuries. However, many result in traumatic brain injury. Patients older than 55 years tend to be more severely injured and at higher risk of mortality.

American College of Surgeons trauma centre designation and mechanical ventilation outcomes.

OBJECTIVE: The association between hospital volume and outcomes following mechanical ventilation has been previously examined in diverse patient populations. The American College of Surgeons (ACS) Committee on Trauma has outlined criteria for trauma centre level designations with specific requirements for both specialty capabilities and hospital volume. Our objective is to determine the relationship between ACS centre designation and outcomes for trauma patients undergoing mechanical ventilation. METHODS: We conducted a retrospective cohort study using the National Trauma Databank (NTDB), identifying 13,933 adult (age>or=18) trauma patients receiving mechanical ventilation for greater than 48 h from 2000 to 2004 who were admitted to either an ACS Level I or Level II trauma centre. The primary endpoints examined were mortality, pneumonia and Acute Respiratory Distress Syndrome (ARDS). Univariate analysis defined differences between those patients admitted to ACS Level I and Level II facilities. Logistic regression analysis was used to identify if ACS level designation was an independent risk factor for the goal outcomes. RESULTS: Patients admitted to a Level I facility and mechanically ventilated for greater than 48 h were more commonly greater than age 55 (71.3% vs. 67.9%, p<0.01), hypotensive (SBP<90) (16.1% vs. 12.8%, p<0.01), and likely to have sustained injury due to penetrating mechanism (11.1% vs. 5.1%, p<0.01). On univariate analysis, mortality and the incidence of pneumonia did not differ between the two groups. Level I admission was, however, less commonly associated with the development of ARDS (5.8% vs. 7.7%, p<0.01) and patients admitted to Level I facilities were significantly more likely to be discharged to home than Level II counterparts (29.7% vs. 22.9%, p<0.01). Logistic regression revealed that, while ACS Level designation was not a predictive factor for mortality or the development of pneumonia, admission to an ACS Level II facility was an independent predictor for the development of ARDS [p<0.01, odds ratio, 95% CI: 1.35 (1.18-1.59)]. CONCLUSION: For trauma patients requiring mechanical ventilation for >48 h, ACS trauma centre designation had no effect on overall mortality or the incidence of pneumonia. Compared to Level I counterparts, however, patients admitted to an ACS Level II facility were significantly more likely to develop ARDS following trauma. This finding needs further investigation in a large, prospective analysis.

Pyloric exclusion in the treatment of severe duodenal injuries: results from the National Trauma Data Bank.

Pyloric exclusion (PEX) has traditionally been used in the management of complicated duodenal injuries to temporarily protect the duodenal repair and prevent septic abdominal complications. We used the American College of Surgeons National Trauma Data Bank (v 5.0) to evaluate adult patients with severe duodenal injuries [American Association for the Surgery of Trauma (AAST) Grade > or = 3] undergoing primary repair only or repair with PEX within 24 hours of admission. Propensity scoring was used to adjust for relevant confounding factors during outcomes comparison. Among 147 patients with severe duodenal injuries, 28 (19.0%) underwent PEX [15.9% (11/69) Grade III vs 34.0% (17/50) Grade IV-V]. Despite similar demographics, PEX was associated with a longer mean hospital stay (32.2 vs 22.2 days, P = 0.003) and was not associated with a mortality benefit. There was a trend toward increased development of septic abdominal complications (intra-abdominal abscess, wound infection, or dehiscence) with PEX that was not statistically significant. After multivariable analysis using propensity score, no statistically significant differences in mortality or occurrence of septic abdominal complications was noted between those patients undergoing primary repair only or PEX. The use of PEX in patients with severe duodenal injuries may contribute to longer hospital stay and confers no survival or outcome benefit.

Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist.

OBJECTIVE: The use of "care bundles" in the prevention of ventilator-associated pneumonia (VAP) and other intensive care unit (ICU) complications have been increasingly used in critical care practice. However, the effective implementation of these strategies represents a challenge in a busy Level I trauma ICU. We devised a daily "Quality Rounds Checklist" (QRC) tool for use in the ICU to increase compliance with these prophylactic measures and identify areas for improvement in quality of care. METHODS: A prospective before-after design was used to examine the effectiveness of the QRC tool in promoting compliance with 16 prophylactic measures for VAP, deep venous thrombosis or pulmonary embolism, central line infection and other ICU complications. Compliance was assessed for 1 month before institution of the QRC. On daily analysis, the QRC was then applied by the ICU fellow to assess compliance. Any deficiencies were actively corrected in real time. Compliance was assessed by a multidisciplinary team for the next 3 months and compared with the pre-QRC compliance rates. RESULTS: Implementation of the QRC tool facilitated improvement of all measures not already at >95% compliance. Compliance with VAP prevention measures of head of bed elevation >30 degrees (35.2% vs. 84.5%), sedation holiday (78.0% vs. 86.0%), and prophylaxis for both peptic ulcer disease (76.2% vs. 92.3%) and deep venous thrombosis (91.4% vs. 92.8%) were all increased. A decrease in central line duration >72 hours (62.4% vs. 52.8%) and ventilator duration >72 hours (74.0% vs. 61.7%) was also noted. Additionally, a decrease in mean monthly rates per 1,000 device days of VAP (16.3 vs. 8.9), central line infection (11.3 vs. 5.8) and self-extubation (7.8 vs. 2.2) was demonstrated. CONCLUSION: Introducing a daily QRC tool facilitated improved compliance rates for 16 clinically significant prophylactic measures in a busy Level I trauma ICU. The daily use of this tool, requiring just a few minutes per patient to complete, results in a sustainable improvement in patient outcomes.