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Biomedical subjects

R C Mackersie

Publications and source records attributed to R C Mackersie.

At least 37 records · Page 2Linked to original sources
PubMed1992

An evaluation of provider-related and disease-related morbidity in a level I university trauma service: directions for quality improvement.

As the number of preventable trauma-related deaths plateaus as a result of trauma system development, new directions for quality improvement in trauma care must come from analyzing morbidity with standardized methods to establish thresholds for provider-related and disease-specific complications. To establish such thresholds and determine priorities for improvements in quality all trauma patients who died, who were admitted to the ICU or OR, who were hospitalized for more than 3 days, or who were interfacility transfers to an academic trauma service, were concurrently evaluated for 1 year. All complication events were defined, reviewed, tabulated, and classified using 135 categories of complications. These categories were subdivided into provider-specific and disease-specific complications. Provider-related complications were classified as justified or unjustified to allow identification of events with a potential for improvement. A total of 1108 patients were admitted (mean ISS, 17); there were 97 deaths. Three potentially preventable deaths were identified, 857 complication events were identified, and 285 provider-related complications were responsible for errors with potential for improvement in 59 events (21%). Disease-specific morbidity was primarily related to infection; pneumonia accounted for 36% of all infectious complications and systemic infection for only 8.6% of infectious complications. Organ failure and other major systemic complications occurred in 2%-8% of patients. This type of analysis forms the basis on which to determine thresholds of provider-specific and disease-specific morbidity in a trauma hospital and serves as a guide to direct efforts toward continuous quality improvement.

Adult↗
PubMed1991

Base deficit as an indicator of significant abdominal injury.

OBJECTIVE: To determine the relative predictive value of the arterial base deficit (BD) as an indicator of intra-abdominal injury (AI) and to compare BD with other indicators (chest injuries, pelvic fractures) of AI. DESIGN: Retrospective case-control analysis. SETTING: University of California San Diego Medical Center. MEASUREMENTS AND MAIN RESULTS: Between January 1985 and July 1988, 3,223 blunt trauma patients were admitted, with complete records available on 3,011. Using a "best fit" multiple logistic regression, BD less than or equal to -6 was the single most important indicator of AI (P less than or equal to .0001), and the odds ratio for AI increased with each category of increasing severity of BD. Admission hypotension, major chest injury, pelvic fracture, and field hypotension (in odds ratio order) also were significantly associated with AI. CONCLUSION: BD is a powerful indicator of AI. A normal BD does not exclude AI, but the presence of a BD less than or equal to -6 in a blunt trauma patient should be considered a strong indication for objective evaluation of the abdomen (ie, diagnostic peritoneal lavage).

Abdominal Injuries↗
PubMed1991

Organ procurement in patients with fatal head injuries. The fate of the potential donor.

A 46-month, retrospective review of all victims of fatal head injury at a level 1 trauma center was undertaken to estimate donor organ availability, determine causes of procurement failure, and analyze the functional results of organs transplanted from this group of donors. Causes of procurement failure in 126 patients who died principally from their head injuries included failure of initial resuscitation (14%), ineligibility (28%), failure of physiologic support (14%), and denial of consent (20%). Of 73 eligible donors, 29 (41%) were able to donate one or more vascular organs (heart, liver, kidney). In only one instance was an eligible donor not appropriately identified as such. Failure of physiologic support to prevent early death (25%), and denial of consent (34%) were found to be the two major, potentially remediable causes of procurement failure in this series. Based on this data, an estimated 29 patients/million population/year will survive initially and meet all eligibility requirements for organ donation. Data on 47 kidneys transplanted from the donor group demonstrated a 77% overall graft survival rate at a follow-up period averaging 23 months. Prolonged donor hypotension, but not the use of high-dose vasopressors, adversely affected allograft survival. The current limitations of organ procurement in victims of fatal head injury stem from a limited ability to maintain cardiopulmonary function long enough for the procurement process to be completed and a high overall rate (46%) of denial of consent for organ harvest by next of kin.

Brain Death↗
PubMed1991

The significance of critical care errors in causing preventable death in trauma patients in a trauma system.

The regionalization of trauma care has led to a decrease in preventable death after injury. This decrease has been attributed to earlier resuscitation and surgical intervention. Little emphasis, however, has focused on the critical care phase of trauma patient management. This study was undertaken to determine the significance of critical care errors (CCEs) on preventable mortality and morbidity in a regionalized system of trauma care. The records of 12,910 trauma patients admitted to six trauma centers over a three-year period were reviewed. The cause and preventability of death was determined by a panel of trauma experts. Critical care errors occurred in 151 (23%) of all patients with errors occurring during any phase of care. The CCEs were identified in 38 of 125 (30%) deaths of patients with errors in some phase of care. The CCEs were implicated as the cause of death in 30 (48%) of the 62 preventable deaths. The proportion of preventable deaths attributable to CCEs was higher than the proportion of preventable death attributable to errors in the resuscitative and operative phases of care (p less than 0.001, chi-square). These data indicate that CCEs significantly contribute to preventable mortality and morbidity in trauma patients. It is imperative that physicians caring for trauma patients possess expertise in the critical care management of injured patients.

Cause of Death↗
PubMed1991

Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures.

To evaluate the efficacy of opiate administration regimens, 32 patients with multiple rib fractures were prospectively randomized to receive either continuous epidural (ED) or continuous intravenous (IV) infusions of fentanyl. Dosage was titrated to individual subjective pain relief. Ventilatory function tests (VFTs), arterial blood gases (ABGs), and visual analog scores were obtained before and after the institution of analgesia. Post-analgesia values were compared with pre-analgesia values using a two-tailed paired t-test looking for significant changes produced by the analgesic method. Both methods significantly improved analog pain scores. The ED method produced improvement in both maximum inspiratory pressure (MIP) and vital capacity (VC), whereas IV analgesia only produced improvement in VC. Intravenous fentanyl produced increases in PaCO2 and decreases in PaO2, whereas no significant changes in ABGs were observed with ED fentanyl administration. Side effects were similar between the groups, with pruritus being more pronounced with ED fentanyl administration. The data demonstrate that the continuous ED fentanyl method offers excellent relief of pain and improvement in ventilatory function and has distinct advantages over IV fentanyl administration with respect to changes in ABGs and MIP. The continuous infusion of epidural opiates should be the preferred analgesic method for patients at high risk of developing pulmonary complications following multiple rib fractures.

Adult↗
PubMed1990

The asymptomatic patient with suspected myocardial contusion.

Diagnostic criteria and guidelines for hospital admission for suspected myocardial contusion (MCC) remain unclear. This study defines and examines the clinical sequelae of patients admitted with a suspicion of MCC. Criteria for observation following isolated, minor blunt chest trauma are suggested. Hospital and trauma registry records of patients admitted over a 33-month period with suspected MCC were reviewed. Conventional evaluation criteria, cardiac-related complications, and associated injuries were analyzed for 524 patients. Twenty-eight cardiac-related complications occurred in 27 of 524 patients (5%). These complications included 23 dysrhythmias, 3 infarctions, and 2 pericardial effusions. There were 23 patients with abnormal admission electrocardiograms and 4 with normal ones. Of the latter, one patient developed dysrhythmia 4 hours after admission, and three had other major multi-system injuries requiring admission to the intensive care unit. The overall incidence of cardiac-related complications in minimally injured patients was 0.1%. There were no complications in patients with isolated chest wall contusions, a normal admission electrocardiogram, and a normal rhythm at 4 hours. There was no significant association between creatine phosphokinase isoenzymes or echocardiogram and cardiac-related complications. The complete absence of significant cardiac sequelae in patients with isolated chest wall contusion, normal admission and 4-hour electrocardiograms, and no other associated major injuries suggests that these patients need not be admitted.

Adult↗
PubMed1990

Venous thromboembolism in patients with major trauma.

The risk of venous thromboembolism after trauma is thought to be high, but the specific risk factors and the incidence of venous thromboembolism in the trauma population are poorly defined. Between October 1, 1987, and March 1, 1988, 719 patients were evaluated; 542 had no risk factors and 177 had at least 1 risk factor. No venous thromboembolism occurred in any of the 542 patients without a risk factor, whereas 12 of 177 patients (7%) with at least 1 risk factor had a venous thromboembolism. Pneumatic compression hose was the most common form of prophylaxis used, but it could not be applied to 35% of limbs because of plaster immobilizers, external fixators, complex wounds, or traction. In the high-risk group, 25 patients (14%) received no prophylaxis because of a physical impediment to application of these hose and a contraindication to anticoagulation. Age greater than 45 years was the only risk factor predictive of venous thromboembolism by logistic regression analysis. Patients with more than one risk factor had a significantly higher incidence of venous thromboembolism than those with only one risk factor. We conclude that a selected subgroup of trauma patients appears to be at risk of venous thromboembolism and should receive prophylaxis. Approximately one in seven high-risk patients cannot receive anticoagulant or mechanical prophylaxis because of their injuries.

Adult↗
PubMed1990

Pain management following trauma and burns.

Effective pain management in trauma patients requires an understanding of both the physiologic responses to injury, and the potential modification of these responses produced by analgesic and anesthetic agents. Complex, multisystem injuries occur frequently and therapeutic intervention for the control of pain must be carefully incorporated within the overall management plan. Pain management strategies for specific injuries are discussed.

Analgesics↗
PubMed1990

Complications in evaluating abdominal trauma: diagnostic peritoneal lavage versus computerized axial tomography.

We reviewed our experience with 2,809 DPL's and 1,331 CT's obtained in the resuscitative phase over a 3-year period in our trauma system to determine the significant complications associated with each modality. There were 25 DPL complications: eight false negatives, three false positives, and 14 technical errors. There were 46 CT complications including 25 false negative scans, three false positive scans, and 18 delays to the operating room from obtaining abdominal CT evaluation, with two of these delays resulting in preventable deaths. Although both modalities had low complication rates (0.9% DPL vs. 3.4% CT), DPL was associated with less preventable mortality and morbidity than CT in the evaluation of abdominal trauma.

Abdominal Injuries↗
PubMed1990

Blunt carotid artery dissection: incidence, associated injuries, screening, and treatment.

Blunt carotid dissection (BCD) is a rare injury occurring in less than one in 1,000 victims of blunt injuries. Using a 4-year experience in a trauma system with 14 cases of BCD, we performed a matched blunt trauma patient case-control analysis to determine if there were patterns of injuries that were associated with increased risk of BCD. Patients with combinations of head, facial, and cervical spine injuries with or without extremity fractures proved to be at significantly increased risk for BCD. Duplex scanning appears to be a useful screening tool for these patients. Anticoagulation was the preferred treatment once neurologic deficits were present.

Adult↗
PubMed1989

Intra-abdominal injury following blunt trauma. Identifying the high-risk patient using objective risk factors.

The initial physical examination is frequently unreliable in identifying patients with blunt trauma at high risk for having serious intra-abdominal injury. Intra-abdominal injury may be associated with specific injuries or risk factors, but the usefulness of such objective clinical criteria in predicting intra-abdominal injury has not previously been determined. The presence or absence of each of 11 clinical indicators and their association with serious intra-abdominal injury were analyzed in 3223 patients with blunt trauma. Linear and logistic regressions were used to determine which factors were significant predictors of an increased probability of intra-abdominal injury. Arterial base deficit less than -3 mEq/L, major chest injury, hypotension, and pelvic fractures were found to significantly increase the chance of intra-abdominal injury. Early diagnostic evaluation of the abdomen using diagnostic peritoneal lavage or computed tomography should be strongly considered in patients with blunt trauma who present with these associated factors.

Abdominal Injuries↗
PubMed1989

Thoracotomy during trauma resuscitations--an appraisal by board-certified general surgeons.

As trauma systems have developed and board-certified in-house surgeons are now immediately available, enthusiasm has returned for thoracotomy as part of initial resuscitation. This study evaluated the impact of thoracotomy by board-certified surgeons during the resuscitative phase of treatment. Resuscitative thoracotomy, performed on patients in cardiac arrest within 20 minutes of arrival in the hospital, was undertaken in 113 of 4,752 patients over a 4 1/2-year period. Resuscitative thoracotomy added nothing to beneficial survival in patients with a blunt mechanism despite the addition of a board-certified surgeon. Survivors of penetrating injury had a probability of survival (Ps) of 0.48. Most patients suffering penetrating deaths had severe and advanced physiologic derangements at the time of admission despite similar anatomic injuries to survivors.

Attitude of Health Personnel↗
PubMed1989

Epidemiology and pathology of traumatic deaths occurring at a Level I Trauma Center in a regionalized system: the importance of secondary brain injury.

We reviewed the hospital records and autopsy data of all deaths occurring at a Level I Trauma Center during a 1-year interval to determine the epidemiology of traumatic death in a regionalized system of care: 1,581 patients were admitted and 106 died (6.6%). Nonsurvivors (NS) differed significantly from survivors (S) in age, Trauma Score, Injury Severity Score, and probability of survival, but there was no difference between NS and S in scene time or transport time. Of the NS 91.4% died within 7 days; only 8.6% died after 7 days. Central nervous system (CNS) injury was responsible for 48.1% of deaths, followed by hemorrhage (36.8%) and cardiovascular disease (5.7%). Sepsis was responsible for 5.5% of deaths. Secondary brain injury was found at autopsy in 66% of patients dying of CNS injury. The relatively small number of septic deaths may be due, in part, to improvements in treatment associated with regionalization of trauma care. The frequency of secondary brain injury, despite rapid transport and evacuation of mass lesions, suggests that it may play a major role in the pathophysiology of CNS death occurring in a trauma system.

Adult↗
PubMed1988

Video recording trauma resuscitations: an effective teaching technique.

Since the initial hour after injury is the most crucial time for trauma patients, resuscitation technique is of vital importance. Standardized courses for first-hour management (ATLAS) have been widely accepted. A teaching format based upon video recording of every resuscitation has been developed. Tapes are reviewed by the staff and by the individuals involved in a particular resuscitation. In a weekly resuscitation review conference, actual footage is presented to the trauma team members, specific aspects of a resuscitation are critiqued, and supplemental didactic information is presented. Legal problems have been avoided by making the review and conference a part of the quality assurance process. Patient anonymity is preserved by positioning the video camera at the foot of the resuscitation bed. Tapes are erased after each conference. Video recording allows analysis of: 1) priorities during the resuscitation; 2) cognitive integration of the workup by the team leader; 3) physical integration of the workup by the team leader; 4) team member adherence to assigned responsibilities, resuscitation time, errors or breaks in technique; and 5) behavior change over time. In 3 1/2 years, more than 2,500 resuscitations have been recorded. Over a 3-month period, average resuscitation time to definitive care decreased for age- and injury severity-matched patient groups cared for by one team. Resuscitations have become more efficient and adherence to assigned responsibilities better. Weekly review of resuscitation contributes to improved technique and trauma care.

Critical Care↗
PubMed1988

Major skeletal injuries in the obtunded blunt trauma patient: a case for routine radiologic survey.

Trauma patients obtunded as a result of head injury, hypotension, alcohol, or drugs have an unreliable physical examination which may lead to errors or delays in diagnosis. To define the extent of routine radiologic survey needed in patients with a depressed level of consciousness, the records of 789 adults with blunt injuries and a Glasgow Coma Score (GCS) of 10 or less on admission were reviewed. Major skeletal injury (MSI), was defined as one or more fractures or dislocations of the axial spine, pelvis, hip, or long bones of the lower extremity. The overall incidence of MSI was 31%. Injuries to the axial spine were present in 14% of patients, while 10% sustained pelvic fractures or hip dislocations and 15% sustained femur or tibia-fibula fractures. Patients who sustained MSI had lower admission CRAMS, Trauma Score, GCS, and admission blood pressure compared to non-MSI patients (p less than 0.002). An analysis of mechanisms of injury showed that pedestrians struck by a motor vehicle (57%), and victims of motorcycle accidents (40%) had increased incidences of MSI (p less than 0.05). Patients suffering falls (18%) and assaults (2%) had a decreased incidence of MSI (p less than 0.01). The high incidence of potentially occult MSI in obtunded patients after blunt trauma demonstrated by this data suggests the need for routine radiologic survey including the axial spine, pelvis and long bones of the lower extremity. Mechanism of injury, CRAMS, TS, and GCS may be useful in the early identification of a particularly high-risk group.

Adolescent↗