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Adult↗
Biomedical subjects
David T Harrington
Publications and source records attributed to David T Harrington.
The evolution of trauma care at a level I trauma center.
BACKGROUND: My colleagues and I compared trauma patient demographics and outcomes between two time periods in the last 10 years in our Level I trauma center to evaluate the impact of the marked evolution in trauma care and determine additional opportunities for improvement. METHODS: Our trauma registry was queried for adult trauma patients admitted from 1991 to 1993 (EARLY) and 1999 to 2001 (LATE). The EARLY period predated creation and maturation of a dedicated trauma service and Level I trauma center verification. Continuous data were compared using Student's t-test, and categorical data using chi-square. RESULTS: Increased transfers of severely injured patients from regional hospitals, combined with fewer admissions for "observation," resulted in fewer, but sicker, patients admitted in the LATE period. Patients were considerably older in the LATE period and mortality was higher. Despite higher acuity of patients, hospital and ICU lengths of stay were shorter in the LATE period. Nonoperative management of solid organ injuries was more common in the LATE period, but the overall operative volume was similar. Nonsurvivors in the LATE period had higher Injury Severity Scores and were older compared with the EARLY period. Mortality attributable to blunt CNS injury was higher, and that attributed to late sepsis and multiple organ failure was lower in the LATE period. CONCLUSIONS: Over the past decade, more older, severely injured patients have been admitted to our Level I trauma center. Overall mortality among these higher acuity patients has increased, with a marked shift in attributable mortality to CNS injury and away from late sepsis and multiple organ failure. This highlights the need for continued efforts to identify optimal management strategies for severe brain injury. Additional areas for improvement include enhancement of our regional trauma network and injury prevention initiatives.
Adult↗
Transfer times to definitive care facilities are too long: a consequence of an immature trauma system.
OBJECTIVE: The purpose of this study was to review our experience with interfacility transfers to identify problems that could be addressed in the development of a statewide trauma system. BACKGROUND: The fundamental tenet of a trauma system is to get the right patient to the right hospital at the right time. This hinges on well-defined prehospital destination criteria, interfacility transfer protocols, and education of caregivers. Patients arriving at local community hospitals (LOCs) benefit from stabilization and transfer to trauma centers (TCs) for definitive care. However, in the absence of a formalized trauma system, patients may not reach the TC in a timely fashion and may not be appropriately treated or stabilized at LOCs prior to transfer. METHODS: Our facility is a level I TC and regional referral center for a compact geographic area without a formal trauma system. The Trauma Registry was queried for adult patients admitted to the trauma service between January 1, 2001 and March 30, 2003. Patients were divided into 2 groups: those received directly from the scene (DIR) and those transferred from another institution (TRAN). Medical records were reviewed to elucidate details of the early care. Data are presented as mean +/- SEM. Continuous data were compared using Student t test, and categorical data using chi2. Transfer times were analyzed by one-way ANOVA. RESULTS: A total of 3507 patients were analyzed. The TRAN group had a higher Injury Severity Score (ISS) (17.5 versus 11.0, P < 0.05), lower Glasgow Coma Score (GCS) (13.3 versus 14.1, P < 0.05), lower initial systolic blood pressure (SBP) (130 versus 140, P< 0.05), and higher mortality (10% versus 79%, P < 0.05) than the DIR group. The average time spent at the LOC was 162 +/- 8 minutes. The subgroup of patients with hypotension spent an average of 134 minutes at the LOC, often receiving numerous diagnostic tests despite unavailability of surgeons to provide definitive care. Severe head injury (GCS = 3) triggered more prompt transfer, but high ISS was underappreciated and did not result in a prompt transfer in all but the most severely injured group (ISS > 40). Some therapeutic interventions were initiated at the LOCs, but many were required at the TC. A total of 23 (8%) TRAN patients required critical interventions within 15 minutes of arrival; mortality in this group was 52%. Mortality among those requiring laparotomy after transfer was 33%. CONCLUSIONS: All but the most severely injured patients spend prolonged periods of time in LOCs, and many require critical interventions upon arrival at the TC. It is unreasonable to expect immediate availability of surgeons or operating rooms in LOCs. Thus, trauma system planning efforts should focus on 1) prehospital destination protocols that allow direct transport to the TC; and 2) education of caregivers in LOCs to enhance intervention skill sets and expedite transfer to definitive care.
Adult↗
Lessons learned from a nightclub fire: institutional disaster preparedness.
BACKGROUND: On February 20, 2003, a nightclub fire caused a multiple casualty disaster, with 215 victims requiring treatment at area hospitals. In this report, we describe the events, the surgical response at our trauma center, and the lessons learned in institutional disaster preparedness. METHODS: Information regarding the fire was obtained from public access media and state governmental and hospital reports. Patient information was obtained through review of our trauma registry, patient records, and questionnaires sent to regional hospitals. RESULTS: Four hundred thirty-nine patrons were in the building at the time of the fire, of whom 96 died at the scene. One hundred people ultimately died. Two hundred fifteen patients were evaluated at area hospitals: 64 at our trauma center and 151 at 15 other area facilities. Seventy-nine patients were admitted: 47 to our center and 32 to other hospitals. Eight patients were transferred from Rhode Island Hospital (RIH) to other Level I trauma centers. Twenty-eight (60%) of the patients admitted to RIH were intubated for inhalation injury. For patients admitted to RIH, the extent of the total body surface burn was less than 20% in 33 patients (70%), 21% to 40% in 12 patients (26%), and greater than 40% in 2 patients (4%). The average age was 31 years (range, 18-43 years). Previous disaster planning drills facilitated a quick institutional response directed by a surgeon. The trauma floor of the hospital, which normally consists of a 10-bed trauma intensive care unit (ICU), an 11-bed step-down unit, and a 22-bed medical-surgical floor, was cleared of patients and converted into a 21-bed burn ICU and a 34-bed acute burn ward. Surgical residents were mobilized into teams assigned to the emergency department, ICUs, and surgical floors. In addition to the in-house trauma attending already present, four additional surgical staff members were called in to help man the emergency department and burn wards. Two operating rooms became dedicated burn rooms where 23 cases were performed the first week. In total, 43 operative procedures and 9 bedside tracheostomies were performed over 8 weeks. Over the first 4 weeks, 132 bronchoscopies were performed for diagnostic purposes and pulmonary toilet. There were no deaths. CONCLUSION: Disaster planning as well as personnel and institutional commitment resulted in an optimal response to a multiple casualty incident. Still, lessons were learned that will further improve readiness for future disasters.
Adolescent↗
Halo vest immobilization in the elderly: a death sentence?
BACKGROUND: Cervical spine fractures (CSFs) in elderly patients are increasingly common as the population ages. In many centers, halo vest immobilization (HVI) is the treatment of choice. Our anecdotal experience suggested that elderly patients treated with HVI have frequent bad outcomes. The purpose of this study was to compare the outcomes of elderly and younger CSF patients as related to treatment (HVI, surgery, or hard collar). METHODS: Registry data from our Level I trauma center were reviewed to identify patients admitted with CSFs during an 80-month period. We excluded those with Glasgow Coma Scale (GCS) score of 3 at admission or death within 24 hours of admission. Patients were grouped as OLD (aged > or = 66 years) or YNG (aged 18-65 years). Data were compared using chi and Student's t test, with p < 0.05 considered statistically significant. RESULTS: One hundred twenty-nine OLD (aged 79.7 +/- 0.7 years) and 289 YNG (aged 38.3 +/- 0.8 years) patients met study criteria. Injury Severity Score was higher in YNG (18.9 +/- 0.8 vs. 14.8 +/- 1.0, p < 0.05), and GCS score was the same (OLD, 13.7 +/- 0.2; YNG, 13.0 +/- 0.2; p = 0.06) in both, but mortality was higher in OLD patients (21% vs. 5%, p < 0.05). OLD HVI patients had higher mortality than YNG HVI (40% vs. 2%). Among OLD patients, age, Injury Severity Score, GCS, and number of comorbidities were the same for each treatment subgroup. Despite this, mortality for the HVI subgroup was higher than either the surgery or collar subgroup. Of the OLD HVI patients that died, 14 died with pneumonia and 10 had a cardiac or respiratory arrest that preceded death. CONCLUSION: OLD patients with CSFs have higher mortality than YNG. HVI in OLD patients is associated with the worst outcomes, irrespective of injury severity, and should be considered a last resort. Further study is warranted to determine the optimal treatment for CSF in OLD patients.
Adult↗
Selective clinical management of anterior abdominal stab wounds.
BACKGROUND: The optimal management of clinically stable patients with anterior abdominal stab wounds (AASWs) is debated. We implemented a protocol of serial clinical assessments to determine the need for laparotomy. The purpose of this study was to determine whether the approach is safe and effective. METHODS: Records of patients sustaining AASWs from 1999 to 2003 were reviewed. RESULTS: Seventy-seven patients sustained AASWs. Twenty-five were taken directly to the operating room because of hypotension (5), evisceration (7), or peritonitis (15). Seventeen patients had diagnostic peritoneal lavage (DPL) for associated thoracoabdominal wounds and 5 had local wound exploration (LWE) off protocol. The remaining 30 patients were managed with serial clinical assessments and were discharged uneventfully. CONCLUSION: Patients sustaining AASWs who present without hypotension, evisceration, or peritonitis may be managed safely under a protocol of serial clinical evaluations. This approach should be compared with LWE/DPL in a prospective, randomized multicenter trial.
Abdominal Injuries↗
Legal prosecution of alcohol-impaired drivers admitted to a level I trauma center in Rhode Island.
BACKGROUND: Despite harsh legislation, driving under the influence of alcohol (DUI) is exceedingly common, and alcohol-related motor vehicle crashes (MVCs) account for significant morbidity, mortality, and economic loss. Legal sanctions can keep offenders off the road (protecting other drivers and pedestrians) and ensure compliance with treatment programs (reducing recidivism). However, even with clear evidence of a transgression, the law seems to be inconsistently enforced among trauma patients. The purpose of this study was to measure the rate of legal prosecution among impaired drivers admitted to a trauma center after MVCs, and to determine the recidivism rate among these individuals. METHODS: Our trauma registry was queried to identify intoxicated drivers admitted during an 18-month period. Court records identified patients who had been charged with traffic offenses, including prior (2 years) and subsequent (1 year) charges. RESULTS: Blood alcohol concentration (BAC) was measured in 387 (74%) of 525 drivers, of whom 137 (35%) had BAC > or =100 mg/dL. Of 113 state residents, 22 (19%) were charged with an offense related to the MVC. Of 12 charged with DUI, 10 were convicted, for an overall DUI conviction rate of just 9%. Seven (32%) of those who were charged had prior or subsequent charges. Of 91 patients not charged for the index event, 31 (34%) had prior or subsequent charges. CONCLUSION: Alcohol is involved in a large percentage of MVCs in our region. The infrequency of prosecution for DUI despite property damage and/or personal injury, and the high recidivism rate, are significant social concerns. These data suggest the need for processes to facilitate legal prosecution--possibly including revision of legislation involving reporting of BACs.
Accidents, Traffic↗
Implementation of a tertiary trauma survey decreases missed injuries.
BACKGROUND: Missed injuries (MIs) adversely affect patient outcome and damage physician/institutional credibility. The primary and secondary surveys are designed to identify all of a patient's injuries and prioritize their management; however, MIs are prevalent in severely injured and multisystem trauma patients, especially when the patient's condition precludes completion of the secondary survey. We hypothesized that implementation of a routine tertiary trauma survey (TS) would reduce the incidence of MIs in a Level I trauma center. METHODS: In mid 1999, a TS form was created and TS documentation was mandated on all trauma intensive care unit (TICU) patients within 24 hours of admission. Patient data, including TS documentation and injury patterns, were concurrently recorded in an institutional trauma registry. Data were compared for patients admitted in 1997 to 1998 (PRE period) and 2000 to 2001 (POST period) using chi or Student's test. RESULTS: MIs decreased from 2.4% to 1.5% overall, and from 5.7% to 3.4% in TICU patients, after TS implementation. Patients with MIs were slightly older (49 vs. 45 years; > 0.05) and had higher Injury Severity Scores (21 vs. 10; < 0.05) than patients without MIs. Sixty percent of MI patients had brain injuries, 56% were admitted to the TICU, and 26% went directly from the emergency department to the operating room. The large majority of MIs in the POST period were detected in patients not undergoing timely TS. CONCLUSION: ICU patients-particularly brain injury victims and those undergoing emergent surgical procedures-appear to be at highest risk for MI. Implementation of a standardized TS decreased MIs by 36% in our Level I trauma center, and more timely TS would likely have further reduced MIs. A TS should be routine in trauma centers.
Adult↗
Isolated brain injury as a cause of hypotension in the blunt trauma patient.
BACKGROUND: Emerging evidence suggests that, contrary to standard teaching, isolated brain injury may be associated with hypotension. This study sought to determine the frequency of isolated brain injury-induced hypotension in blunt trauma victims. METHODS: Hypotensive adult trauma patients were categorized according to the cause of hypotension: hemorrhagic (hemoglobin < 11.0), neurogenic, isolated brain, or other. Their clinical data and outcomes were compared. RESULTS: The cause of hypotension was hemorrhagic in 113 (49%), isolated brain injury in 30 (13%), neurogenic in 14 (6%), and other causes in 24 (10%). Fifty (22%) were indeterminate. Hemorrhagic, isolated brain, and neurogenic groups were similar in age, Injury Severity Score, and systolic blood pressure. The Glasgow Coma Scale score of the isolated brain group was lower than in the hemorrhagic group (4.4 vs. 8.4, p < 0.05). Mortality was higher in the isolated brain group compared with the hemorrhagic group (80% vs. 50%, p < 0.05) and in the subgroup of hemorrhagic patients with versus without associated brain injury (57% vs. 39%, p < 0.05). CONCLUSION: Isolated brain injuries account for 13% of hypotensive events after blunt trauma and are associated with an increased mortality compared with hemorrhage-induced hypotension. In hypotensive brain-injured patients, hemorrhagic sources should be excluded rapidly, and the focus should be on resuscitation.
Adult↗