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Biomedical subjects

Patrick M Reilly

Publications and source records attributed to Patrick M Reilly.

At least 19 recordsLinked to original sources
PubMed2006

The impact of trauma activations on the care of emergency department patients with potential acute coronary syndromes.

STUDY OBJECTIVE: Trauma systems improve the care of trauma patients; however, it is possible that prioritizing the emergency care of trauma patients might adversely affect other potentially ill patients requiring the same resources. We seek to determine whether the presence of a concurrent trauma activation negatively affects processes of care and outcomes for patients with potential acute coronary syndromes. METHODS: Patients who presented to the emergency department (ED) with a potential acute coronary syndrome from July 2003 to June 2004 were stratified according to whether they presented concurrently with a trauma activation. Structured data collection included demographics, medical history, and daily tracking of inhospital course. Thirty-day follow-up was performed. The main outcome was a composite of inhospital cardiovascular complications and 30-day death and myocardial infarction. Secondary outcomes were time from triage to ECG acquisition, transfer to an evaluation room, return of laboratory results, disposition decision, and actual disposition. RESULTS: Patients who presented concurrently with (n=357) or not concurrently with (n=1,235) a trauma activation were similar with respect to demographic characteristics, cardiac risk factors, and TIMI risk score. The unadjusted incidence of 30-day adverse cardiovascular events between potential acute coronary syndrome patients who presented with and without a concurrent trauma activation was 6.2% versus 3.6% (unadjusted odds ratio 1.74 [95% confidence interval (CI) 1.03 to 2.93]). After adjustment for measures of patient acuity (triage classification, TIMI risk score) and ED volume (total patient care hours and ED activity), concurrent trauma activation was independently associated with increased rate of 30-day cardiovascular complications (odds ratio 1.72; 95% CI 1.01 to 2.92). CONCLUSION: The presence of a concurrent trauma activation at the time of presentation of a patient with potential acute coronary syndrome was associated with an increased incidence of 30-day adverse cardiovascular events. Although trauma activations improve the care of trauma patients, they may be associated with a negative impact on the care of other patients requiring contemporaneous resources.

Acute Disease↗
PubMed2006

The impact of a concurrent trauma alert evaluation on time to head computed tomography in patients with suspected stroke.

BACKGROUND: Emergency department (ED) overcrowding threatens quality of care by delaying the time to diagnosis and treatment of patients with time-sensitive diseases, such as acute stroke. OBJECTIVE: The authors hypothesized that the presence of a trauma alert evaluation would impede the time to head computed tomography (hCT) in patients with stroke-like symptoms. METHODS: This was a secondary analysis of prospectively collected data on patients with potential stroke who received an hCT in an urban trauma center ED from January 1, 2004, to November 30, 2004. Structured data collection included historical and examination items, National Institutes of Health (NIH) stroke scale score, laboratory and radiographic results, and final diagnosis. Admitted patients were followed in hospital. Patients who presented within one hour following a trauma evaluation were compared with patients who presented without concurrent trauma for triage time until completion of hCT. Chi-square, t-tests, and 95% confidence intervals (95% CIs) were used for comparisons. RESULTS: The 171 patients enrolled had a mean (+/- standard deviation) age of 60.7 (+/- 7) years; 60% were female; and 58% were African American. Of these, 72 patients had a significant cerebrovascular event (38 [22%] ischemic stroke, 25 [15%] transient ischemic attack, seven [4%] intracranial hemorrhage, one [0.6%] subarachnoid hemorrhage, and one [0.6%] subdural hematoma). The remaining diagnoses included 4.6% migraine, 2.3% seizure, 2.9% syncope, 2.3% Bell's palsy, and 2.9% vertigo. There was no significant difference in time to hCT in patients who presented during a trauma activation and those who did not (99 minutes [interquartile range (IQR) = 24-156] vs. 101 minutes [IQR = 43-151.5]; p = 0.537). In subgroup analysis of patients with a significant cerebrovascular event, times to hCT were also similar (24 minutes [IQR = 12-99] vs. 61 minutes [IQR = 15-126]; p = 0.26). CONCLUSIONS: In the authors' institution, the presence of concurrent trauma evaluation does not delay CT imaging of patients with potential stroke.

Adult↗
PubMed2006

Improved nurse job satisfaction and job retention with the transition from a "mandatory consultation" model to a "semiclosed" surgical intensive care unit: a 1-year prospective evaluation.

OBJECTIVE: The change from a "mandatory consultation" to a "semiclosed" surgical intensive care unit (SICU) model will impact nurses considerably. We hypothesize that nurse job satisfaction, job turnover rates, and hospital costs for temporary agency nurses will improve and these improvements will be more dramatic in SICU sections with greater involvement of a dedicated surgical critical care service (SCCS). DESIGN: Prospective longitudinal survey. SETTING: Tertiary-care university hospital. SUBJECTS: SICU staff nurses. INTERVENTIONS: Change from mandatory consultation to semiclosed SICU. MEASUREMENTS AND MAIN RESULTS: We surveyed SICU nurses during the year-long transition to a semiclosed SICU service (five time points, 3-month intervals). The first four surveys included ten questions on nurse job satisfaction. The final survey included two additional questions. All questions were on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Nurse job turnover rates and money spent on agency nurses were compared over time; 503 of a possible 914 surveys were completed (55% overall return rate). Nurse job satisfaction scores significantly improved over time for all questions (p < .05). Hospital spending on agency nurses decreased significantly (p = .0098). The yearly nurse job turnover rate dropped from 25% to 16% (p = .15). The scores for both year-end statements ("I am more satisfied with my job now than 1 year ago" and "The SCCS management of all orders has improved my job satisfaction") were significantly higher in sections with greater SCCS involvement (p = .0070 and p < .0001). CONCLUSIONS: Nurse job satisfaction improved significantly with the transition to a semiclosed SICU. This higher satisfaction was associated with a significant decrease in spending on temporary agency nurses and a trend toward increased staff nurse job retention. SICU sections with greater SCCS involvement had more dramatic improvements. This semiclosed SICU model may help retain SICU nurses in a competitive job market in which experienced nurses are in short supply.

Attitude of Health Personnel↗
PubMed2006

An acute care surgery model improves outcomes in patients with appendicitis.

OBJECTIVE: To compare outcomes of appendectomy in an Acute Care Surgery (ACS) model to that of a traditional home-call attending surgeon model. SUMMARY BACKGROUND DATA: Acute care surgery (ACS, a combination of trauma surgery, emergency surgery, and surgical critical care) has been proposed as a practice model for the future of general surgery. To date, there are few data regarding outcomes of surgical emergencies in the ACS model. METHODS: Between September 1999 and August 2002, surgical emergencies were staffed at the faculty level by either an in-house trauma/emergency surgeon (ACS model) or a non-trauma general surgeon taking home call (traditional [TRAD] model). Coverage alternated monthly. Other aspects of hospital care, including resident complement, remained unchanged. We retrospectively reviewed key time intervals (emergency department [ED] presentation to surgical consultation; surgical consultation to operation [OR]; and ED presentation to OR) and outcomes (rupture rate, negative appendectomy rate, complication rate, and hospital length of stay [LOS]) for patients treated in the ACS and TRAD models. Questions of interest were examined using chi tests for discrete variables and independent sample t test for comparison of means. RESULTS: During the study period, 294 appendectomies were performed. In-house ACS surgeons performed 167 procedures, and the home-call TRAD surgeons performed 127 procedures. No difference was found in the time from ED presentation to surgical consultation; however, the time interval from consultation to OR was significantly decreased in the ACS model (TRAD 7.6 hours vs. ACS 3.5 hours, P < 0.05). As a result, the total time from ED presentation to OR was significantly shorter in the ACS model (TRAD 14.0 hours vs. ACS 10.1 hour, P < 0.05). Rupture rates were decreased in the ACS model (TRAD 23.3% vs. ACS 12.3%, P < 0.05); negative appendectomy rates were similar. The complication rate in the ACS model was decreased (TRAD 17.4% vs. ACS 7.7%, P < 0.05), as was the hospital LOS (TRAD 3.5 days vs. ACS 2.3 days, P < 0.001). CONCLUSIONS: In patients with acute appendicitis, the presence of an in-house acute care surgeon significantly decreased the time to operation, rupture rate, complication rate, and hospital length of stay. The ACS model appears to improve outcomes of acute appendicitis compared with a TRAD home-call model. This study supports the efficacy and efficiency of the ACS model in the management of surgical emergencies.

Adult↗
PubMed2006

Analgesic use in intubated patients during acute resuscitation.

BACKGROUND: Pain relief can often be overlooked during a busy trauma resuscitation, especially in patients who are intubated. We sought to investigate qualitative and quantitative aspects of analgesic use in intubated patients during the acute phase of resuscitation. METHODS: We evaluated a retrospective cohort of consecutive adult patients who were intubated during the acute trauma resuscitation (first 6 hours) from January 2001 to May 2002 at a Level I trauma center in the United States. Patient demographics, injuries, vital signs, medications, trauma bay procedures, and disposition status were analyzed. Analgesia was recorded as the type of analgesic, route of administration, elapsed time to receive the first analgesic, total dosage, and time intervals between two successive doses. Fisher's exact test, chi test, and ANOVA were used to analyze data. RESULTS: A total of 120 patients were included. Sixty-one (51%) patients received analgesia during their stay in the emergency department. Using logistic regression analysis, patients who more likely to receive analgesia were those who did not require immediate surgical operation and were transferred to the intensive care unit (odds ratio [OR]=3.91; 95% CI=1.75-8.76) and those who were admitted during the hours of 8 am to 6 pm (OR=3.17; CI=1.40-7.16). Among those patients receiving analgesia, 30 (25%) patients received analgesia within 30 minutes upon arrival. The mean time of receiving the first analgesia dose was 57 minutes. The average morphine equivalent dose given to the patients was 15.7 mg. The most frequently given single dose was 100 mug of intravenous fentanyl. Most of the analgesics (37%) were given between 30 to 60 minutes apart. CONCLUSION: Our findings suggest that patients who are intubated during the acute resuscitation probably receive inadequate analgesia. The inadequacy appears to be in the timing and repetition of administration, rather than the dose. Patients who were transferred early to the intensive care unit were more likely to receive analgesics.

Acute Disease↗
PubMed2006

Maintaining patient throughput on an evolving trauma/emergency surgery service.

BACKGROUND: The case-management team (CMT) has been an effective tool to decrease denied days and improve hospital throughput on a trauma service. With the addition of emergency general surgery (EGS) to our practice, we reviewed the ability of the case management team to absorb EGS patients on the inpatient trauma service while maintaining the improvements initially realized. METHODS: An interdisciplinary CMT was implemented in January 1999. CRNPs were added in August 2003 to address the Accreditation Council for Graduate Medical Education resident work-hour restrictions. "Key communications" for each CMT member are reported three times per week as defined by a hospital-approved policy. Beginning in August 2001, the trauma service was expanded to include EGS patients. Data from the trauma registry, hospital utilization review, and finance office were analyzed before (1998 and 1999) and after (2003 and 2004) the addition of EGS. Tests of proportion were used to evaluate questions of interest. RESULTS: The number of injured patients admitted to the trauma service remained relatively constant during the study periods, ranging from a high of 1,365 in 1999 to a low of 1,116 in 2003. Beginning in 2003, the influx of emergency surgery patients to the service was marked. By 2004, there were 561 emergency surgery admissions, representing more than 30% of the total service admissions. As a result, the total number of service admissions has dramatically increased, reaching 1,833 in CY 2004, a 56% increase from CY 1998 levels. Hospital length of stay data varied from a low of 5.5 days in CY 1999 to a high of 6.9 days in CY 2003. Length of stay appeared to be associated with injury severity (mean Injury Severity Score 11.8 in 1999 and 13.1 in 2003) and case mix, but not associated with denied days. The percent of denied days decreased over the study periods, from 4.6% in 1998 (before the implementation of the CMT) to 0.5% in 2004 (p<0.01). The percent of readmissions also fell significantly over the study periods (4.0% in 1998 to 1.8% in 2004; p<0.01). CONCLUSIONS: The initial improvements in patient throughput noted after the introduction of a CMT in January 1999 have been maintained in recent years despite the addition of an EGS component to the trauma service. Percent denied days and readmissions have continued to decrease. The length of stay for these patients remains, in part, dependent on other factors. The CMT plays an integral role in maintaining the efficiency of a trauma/emergency surgery service.

Adolescent↗
PubMed2006

Timing of pulmonary emboli after trauma: implications for retrievable vena cava filters.

BACKGROUND: Four recent reports of the retrieval of optional vena cava filters (VCF) in trauma patients had average implant durations of 10, 19, and 19 days (one not specified). Two patients in these studies had pulmonary emboli after VCF removal. No evidence-based guidelines exist on the appropriate time to remove optional VCF. The purpose of this study was to examine the timing of pulmonary emboli (PE) and determine the optimal time to remove optional VCFs. METHODS: A multicenter retrospective chart review of trauma patients who had a postinjury PE between January 2001 and December 2004 was performed. We examined the demographics, prophylaxis at the time of PE (pharmacologic [unfractionated or low molecular weight heparin] or sequential compression devices [SCD]), diagnostic test used, timing of PE from the date of injury, and survival outcome. RESULTS: In all, 146 patients were identified, mean age 45.1 (+/- 21.1 SD); Injury Severity Score 18.0 (+/- 12.1 SD). Diagnosis was obtained by spiral computed tomography (N = 93), pulmonary arteriogram (N = 18), V/Q (N = 26), autopsy (N = 6), clinical (N = 6), and unknown (N = 3). Overall mortality was 17.8% (N = 26). Pulmonary embolism was felt to contribute to or was the cause of death in 85% (N = 22) of these patients. Two late PE deaths occurred (days 21 and 43). Sixty (37%) patients had pharmacologic prophylaxis at the time of PE and 83 (50.9%) had SCDs. Average time from injury to PE was 7.9 days (+/- 8.1 SD), the longest being 43 days postinjury. Eleven percent of PE occurred after 21 days, including fatal PE. CONCLUSIONS: Clinical criteria defining the time to remove optional VCFs without exposing patients to the risk of PE by removing a filter too soon should be determined.

Humans↗
PubMed2006

Anemia management program reduces transfusion volumes, incidence of ventilator-associated pneumonia, and cost in trauma patients.

BACKGROUND: Strategies to restrict transfusions are gaining acceptance in critical care. We implemented an anemia management program (AMP) for trauma patients in the Surgical Intensive Care Unit. AMP was based on a transfusion trigger of 7 g/dL hemoglobin once hemodynamic sufficiency was achieved. We hypothesized that AMP would decrease the transfusion of packed red blood cells (PRBCs) and cost without detriment in clinical outcomes. METHODS: Transfusion data were retrospectively collected for all trauma patients treated in our Surgical Intensive Care Unit between July 2002 and December 2003. AMP was implemented in a step-wise fashion during a 6-month period (January to June 2003). Data were compared for the 6-month period before (Group I, July to December 2002) and after (Group II, July to December 2003) complete AMP implementation. Blood transfusion volumes were compared using negative binomial regression. Clinical outcomes (length of stay [LOS], death, myocardial infarction [MI], and ventilator-associated pneumonia [VAP]) were compared using risk ratios. Age, sex, and injury severity score (ISS) were examined as potential confounders. RESULTS: In all, 514 trauma patients were treated during the study period (n = 270 in Group I and n = 244 in Group II). Group I and Group II were similar in age (mean: 43.6 versus 42.9) and ISS (mean: 18.3 versus 17.0). Mean PRBCs per patient transfused decreased from 23.1 units to 17.1 units (p = 0.057), reflecting a 22.5% reduction adjusted for confounders (p = 0.097). Outcome data revealed no differences in LOS (mean: 6.4 versus 5.9, p = 0.920), risk of death (4.1% versus 6.1%, p = 0.158), or MI (0.7% versus 0.8%, p = 0.974), but a significant reduction in the incidence of VAP (8.1% versus 0.8%, p = 0.002). Total PRBC cost decreased during the study period from 503,000 dollars to 397,000 dollars. CONCLUSIONS: An anemia management program appears to be safe when applied in the acute ICU phase of trauma care. Implementation of AMP in the ICU reduced the volume of PRBCs transfused with significant cost savings. No significant differences in length of stay, mortality rate, or MI rate were seen. The significant decrease in the rate of VAP requires further elucidation. Further long-term and larger studies are indicated.

Aged↗
PubMed2005

Experience with the recovery filter as a retrievable inferior vena cava filter.

PURPOSE: This study evaluates clinical experience with the Recovery filter as a retrievable inferior vena cava (IVC) filter. MATERIALS AND METHODS: One hundred seven Recovery filters were placed in 106 patients with an initial clinical indication for temporary caval filtration. Patients were followed up to assess filter efficacy, complications, eventual need for filter removal, time to retrieval, and ability to remove the filter. RESULTS: The patient cohort consisted of 62 men and 44 women with a mean age of 48 years (range, 18-90 y). Mean implantation time was 165 days. Indications for filter placement in patients with deep vein thrombosis (DVT) and/or pulmonary embolism (PE) included contraindication to anticoagulation (n = 33), complications of anticoagulation (n = 8), poor cardiopulmonary reserve (n = 6), large clot burden (n = 3), and PE while receiving anticoagulation (n = 1). Indications for filter placement in patients without proven PE or DVT included immobility after trauma (n = 35); recent intracranial hemorrhage, neurosurgery, or brain tumor (n = 18); and other surgical or invasive procedure (n = 3). Three patients (2.8%) had symptomatic PE after placement of the Recovery filter. No caval thromboses were detected. No symptomatic filter migrations occurred. Recovery filter removal was attempted in 15 of 106 patients (14%) at a mean of 150 days after placement. The Recovery filter was successfully retrieved in 14 of 15 patients (93%); one removal was unsuccessful at 210 days after placement. Ninety-two filters (87%) currently remain in place. CONCLUSIONS: Although all the filters were placed with the intention of being removed, a large percentage of filters were not retrieved. The Recovery filter was safe and effective in preventing PE when used as a retrievable IVC filter.

Adolescent↗
PubMed2005

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.

Abbreviated Injury Scale↗
PubMed2005

The evolving role of interventional radiology in trauma care.

BACKGROUND: Although the traditional role of radiology in trauma care has been diagnostic, therapeutic interventional radiology (IR) techniques have now become essential in the management of many injuries. We hypothesized that IR has evolved at our institution over the last decade from a largely diagnostic to a more therapeutic role in the care of the injured patient. METHODS: Demographic information, computed tomographic scans of the chest and abdomen, and angiographic procedures (APs) performed within 48 hours of admission were reviewed in all patients evaluated at a Level I trauma center for the periods 1993 to 1995 and 2000 to 2002. All APs performed with the intent to embolize, stent, or insert a device into a vessel were designated as therapeutic. Analysis by means of chi provided between-group comparisons for questions of interest and the Student's t test was used for comparison of means. RESULTS: A total of 4,750 patients were reviewed, 1,677 from the time period 1993 to 1995 and 3,073 from the period 2000 to 2002. Overall injury severity as measured by the Injury Severity Score (ISS) was similar in both groups (9.6 vs. 9.9, p = not significant). The number of angiograms obtained decreased significantly from 7.1% to 4.0% of all patients (p < 0.01). Concurrently, the fraction of all angiograms that were considered therapeutic rose from 10% to 22% (p < 0.05). The overall number of aortic arch angiograms decreased over time (from 3.6% to 0.9%, p < 0.01), and the percentage of positive examinations increased from 5.0% to 21.4%. In comparison, the number of computed tomographic scans of the chest increased from 1.6% of all patients to 10.8% (p < 0.01). CONCLUSION: Axial imaging studies are being used more frequently to screen trauma patients for injury. Concurrently, diagnostic APs are less frequently performed but are more frequently positive. In addition, IR studies are increasingly focused on therapeutic intervention. IR program development and support is an integral aspect of modern trauma care. These findings have prompted our institution to equip the IR suite to function as an active resuscitation area similar to the trauma bay and intensive care unit.

Angiography↗
PubMed2005

The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma.

BACKGROUND: Controversy persists regarding the most efficient and effective method of cervical spine evaluation after blunt trauma. Historic guidelines for patients undergoing computed tomography (CT) of the head advocate imaging the occiput-C2 as part of that study. For the remaining cervical spine, plain cervical spine radiographs (CSR) with supplemental CT are recommended. Many patients who require head CT also undergo supplemental cervical spine CT after plain CSR, which leads to separate, discontinuous cervical spine CT scans. We sought to determine the incidence of this in our population. We hypothesized that plain CSR alone often proves inadequate to evaluate the cervical spine in patients who require head CT. METHODS: The Eastern Association for the Surgery of Trauma (EAST) guidelines for cervical spine evaluation after blunt trauma were previously adopted and followed during the study period from December 1, 2002 to July 1, 2003. Our protocol included cross-table lateral and anteroposterior CSR with the occiput-C2 imaged with the head CT. We used segmental cervical spine CT to supplement those regions inadequately visualized by plain films. The electronic charts of 848 consecutive blunt trauma victims were retrospectively reviewed. The data abstracted included demographics, injury severity score, and the use and results of head CT and radiographic evaluation of the cervical spine. RESULTS: Of 848 consecutive blunt trauma patients, 716 (84.4%) underwent head CT. Average age was 44 years old, and average Injury Severity Score was 9. Seventy-six patients (11.6%) had clinical cervical spine examination alone, whereas 640 (89.4%) underwent plain CSR. In 178 patients (27.8%), plain two-view CSR visualized the entire cervical spine. Plain CSR were inadequate to visualize the complete cervical spine in 462 patients (72.2%). Of these patients, segmental CT was performed in 400 (87.6%). The remaining 62 (13.4%) patients did not have radiologic completion of their cervical spine evaluation before clinical examination. Nineteen patients (3.0%) had cervical spine fractures diagnosed on CT, of which only 6 (31.6%) were seen on plain CSR. The sensitivity and specificity of CSR to detect fractures was 31.6 and 99.2%, respectively. CONCLUSION: Plain CSR are inadequate to fully evaluate the cervical spine after blunt trauma, and supplemental CT is commonly required. Complete cervical spine CT is available, efficient, and accurate. Our findings support a growing body of literature that suggests that this modality should be used for blunt trauma patients who require radiographic evaluation of the cervical spine. Plain cervical spine radiographs need not be obtained. The EAST guidelines for cervical spine evaluation after blunt trauma should be updated to reflect this evolving practice pattern.

Cervical Vertebrae↗
PubMed2005

Respiratory complications and mortality risk associated with thoracic spine injury.

BACKGROUND: Cervical spinal cord injury (SCI) has a well-established association with a high risk of respiratory complications. We sought to determine whether high-thoracic (HT) SCI was associated with a similar increased risk of respiratory complications and death. METHODS: This was a retrospective cohort study of all adult patients with thoracolumbar injuries entered into the Pennsylvania Trauma System Foundation registry between January 1993 and December 2002. Records were reviewed for the documentation of respiratory complications (intubation, tracheostomy, bronchoscopy, pneumonia) and mortality. The data were then evaluated controlling for age, sex, Glasgow Coma Scale, and Injury Severity Score. RESULTS: In all, 11,080 patients met inclusion criteria: 4,258 patients had thoracic spine fractures and 6,226 patients had lumbar spine fractures, all without SCI; and 596 patients had thoracic SCI (T1 to T6, 231; T7 to T12, 365). Respiratory complications occurred in 51.1% of patients with T1 to T6 SCI (versus 34.5% in T7 to T12 SCI and 27.5% in thoracic fractures). The need for intubation, the risk of pneumonia, and risk of death were significantly greater for patients with T1- to T6-level spinal cord injuries. Among patients with an Injury Severity Score less than 17 (n = 6427), the relative mortality risk was 26.7 times higher among those who developed respiratory complications (9.9% versus 0.4%). CONCLUSION: Compared with patients with low thoracic SCI or thoracolumbar fractures, patients with HT-SCI have an increased risk of pneumonia and death. Respiratory complications significantly increase the mortality risk in less severely injured patients. The current findings suggest that HT-SCI patients warrant intensive monitoring and aggressive pulmonary care and attention, similar to that given for patients with cervical SCI.

Adolescent↗
PubMed2004

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.

Clinical Competence↗
PubMed2004

Alternating day emergency medicine and anesthesia resident responsibility for management of the trauma airway: a study of laryngoscopy performance and intubation success.

STUDY OBJECTIVE: We compare laryngoscopy performance and overall intubation success in trauma airways when primary airway management alternated between emergency medicine and anesthesia residents on an every-other-day basis. METHODS: Data on all trauma intubations during approximately 3 years were prospectively collected. Primary airway management was assigned to emergency department (ED) residents on even days and anesthesia residents on odd days. Emergency medicine residents intubated patients who arrived without notification or who needed immediate intubation before anesthesia arrived. The study was conducted in an inner-city, Level I trauma center with approximately 50,000 ED patients and 1,800 major trauma cases a year. Main outcomes were success or failure at laryngoscopy and the number of laryngoscopy attempts needed for intubation. RESULTS: Six hundred fifty-eight trauma patients were intubated during the study period. Laryngoscopy was successful in 654 of 656 cases. Two (0.3%) patients underwent cricothyrotomy after failed laryngoscopy, and 2 (0.3%) patients had awake nasal intubation without laryngoscopy. The specific number of laryngoscopy attempts was unknown in 6 cases (3 from each service), resulting in 650 cases for laryngoscopy performance analysis. Overall, 87% of patients were intubated on first attempt, and 3 or more attempts occurred in 2.9% of patients. Laryngoscopy performance by service (broken down by 1, 2, and >or=3 attempts) was as follows: emergency medicine 86.4%, 11%, and 2.6% versus anesthesia 89.7%, 6.7%, and 3.6%. Analysis by service was done by using Wilcoxon Mann-Whitney testing (P=.225). CONCLUSION: There were no differences in laryngoscopy performance and intubation success in trauma airways managed on an every-other-day basis by emergency medicine versus anesthesia residents.

Adult↗
PubMed2004

Nonoperative management of abdominal gunshot wounds.

Mandatory surgical exploration for gunshot wounds to the abdomen has been a surgical dictum for the greater part of this past century. Although nonoperative management of blunt solid organ injuries and low-energy penetrating injuries such as stab wounds is well established, the same is not true for gunshot wounds. The vast majority of patients who sustain a gunshot injury to the abdomen require immediate laparotomy to control bleeding and contain contamination. Nonoperative treatment of patients with a gunshot injury is gaining acceptance in only a highly selected subset of hemodynamically stable adult patients without peritonitis. Although the physical examination remains the cornerstone in the evaluation of patients with gunshot injury, other techniques such as computed tomography, diagnostic peritoneal lavage, and laparoscopy allow accurate determination of intra-abdominal injury. The ability to exclude internal organ injury nonoperatively avoids the potential complications of unnecessary laparotomy. Clinical data to support selective nonoperative management of certain gunshot injuries to the abdomen are accumulating, but the approach has risks and requires careful collaborative management by emergency physicians and surgeons experienced in the care of penetrating injury.

Abdominal Injuries↗