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Thomas Scalea

Publications and source records attributed to Thomas Scalea.

12 recordsLinked to original sources
PubMed2006

Pilot study of a web-based antibiotic decision management guide.

BACKGROUND: Use of electronic medical information resources by health-care professionals is increasing. Portable handheld computers have facilitated access to medical knowledge at the point of patient care. Little is known about the impact of mobile medical information tools on physician learning or improvement in decision-making. STUDY DESIGN: A 6-month prospective, randomized pilot study of 12 first-year trauma and critical care Fellows at the R Adams Cowley Shock Trauma Center was conducted from November 1, 2001 to May 31, 2002 at the University of Maryland. Six Fellows were randomized to use the Johns Hopkins Antibiotic Guide (JHABX) on the RIM Blackberry personal digital assistant (PDA) for 6 months of their clinical rotation. Six Fellows were randomized to the non-PDA-use arm. Three-month and 6-month examination raw scores on knowledge of infectious diseases management among Blackberry PDA users versus non-PDA users were obtained. Measurement of antibiotic decision accuracy by diagnosis at 3 and 6 months among Fellows randomized to use the JHABX on the RIM Blackberry PDA was also evaluated. RESULTS: PDA group demonstrated a considerable improvement in test scores over the 3-month time interval, compared with their baseline score (40.8 +/- 2.3 versus 34.3 +/- 4.6, p < 0.05) and compared with the non-PDA group (40.8 +/- 2.3 versus 36.8 +/- 3.3, p < 0.01). Improvement became even more notable at the 6-month interval again, compared with themselves (43.8 +/- 4.5 versus 34.3, p < 0.001) and the non-PDA group (43.8 +/- 4.5 versus 38.1 +/- 5.1, p < 0.001). There was no notable improvement in test scores at 3 months or 6 months in the control group. Overall antibiotic decision accuracy substantially improved from 66% during the initial 3-month period to 86.6% during the second 3-month period (p = 0.005) among users of the JHABX. This was most evident in respiratory, blood, and skin and soft tissue infections. CONCLUSIONS: Web-based handheld technology is highly effective for supplying information to support infectious disease clinical practice. In a hospital intensive care setting, results of this study demonstrate that resident physician knowledge and antibiotic decision selection accuracy improved among Fellows using the JHABX. Reasons for this difference can be multifold and not thoroughly evaluated from this small pilot study. Future studies on the impact of point-of-care technology on patient outcomes are warranted.

Anti-Bacterial Agents↗
PubMed2006

Mentors decrease compliance with best sterile practices during central venous catheter placement in the trauma resuscitation unit.

BACKGROUND: In the academic trauma unit during initial evaluation and resuscitation of trauma victims, central venous catheters are often placed by multiple operators. There are few data on compliance with accepted, standard sterile practices during such procedures. METHODS: Prospective data were tabulated from video capture of 144 consecutive central venous catheterizations in a trauma resuscitation unit, during peak hours, by a team of trained video technicians. The physicians were surgical and emergency medicine residents. The number of primary operators (trainees) and secondary operators (mentors) for each line was recorded from the video analysis, as well as physician adherence to the use of maximum barrier precautions (MBP; sterile gown, gloves, full operative drape, cap, and mask). Procedures were stratified by level of urgency: Emergent (n = 7), semi-emergent (n = 20), and elective (n = 113). RESULTS: The subclavian vein was used for 73% of the elective catheter placements. For elective central venous catheters, 99 of 113 primary operators (88%) observed MBP, whereas only 31 of 45 secondary operators (69%) did so (p < or = 0.01). Among the 45 elective central venous catheters placed with a secondary operator, there were four instances of frank contamination (9%). CONCLUSIONS: Secondary operators, typically trauma surgery attendings, trauma/critical care fellows, or senior surgical residents, function as mentors in academic institutions and act as role models. Secondary operators participated in many of the studied cases, yet failed to demonstrate consistent use of MBP. In elective central venous catheter placement, those where there was the greatest opportunity to follow MBP, we observed a statistically significant difference in compliance rate between the primary and secondary operators. The study suggests the need to address the performance of the secondary operators and to educate them, as although they may be technically experienced in placing central venous catheters, they may comply less consistently with MBP.

Catheterization, Central Venous↗
PubMed2005

Vacuum-assisted closure for the treatment of complex chest wounds.

BACKGROUND: Destruction of chest wall musculature from trauma, empyema, or local infection limits closure options, especially with muscle flaps. While the vacuum-assisted closure system (VAC; KCI International, San Antonio, TX) has been used for wounds in other anatomic locations, we have found no series for chest wounds. METHODS: This is a retrospective review of trauma registry data from the R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine from 2000 to 2003. RESULTS: Seventeen patients were identified and divided into two groups. Group I consisted of seven patients with primary chest wall processes: four necrotizing soft-tissue infections and three with thoracic trauma resulting in significant loss of chest wall musculature. Group II consisted of ten patients with empyema and varying levels of chest wall extension. Six were postpneumonic and four postoperative. Wound size averaged 16 x 7 cm (range, 7 x 3 cm to 21 x 11 cm). The VAC duration averaged nine days (range, 3 to 21 days) and changed every two to three days. Fourteen wounds were culture positive; nine staphylococcus aureus, two alpha hemolytic streptococcus, and one each with enterococcus, Citrobacter, and anaerobes. Eight were polymicrobial. There were no deaths. All wounds healed without rotational muscle flaps. Ten underwent delayed primary closure, four split-thickness skin graft, and three healed by secondary intention. There was one significant complication: a wound infection after delayed primary closure which required reoperation. CONCLUSIONS: Closure of complex chest wall wounds can present significant technical challenges. The VAC system is a simple, useful, and novel alternative to conventional wound care even with large, infected wounds.

Adult↗
PubMed2005

A Jehovah's Witness with complex abdominal trauma and coagulopathy: use of factor VII and a review of the literature.

Management of acute bleeding in patients who are Jehovah's Witnesses remains a challenge. Clearly, the most important concept is meticulous and early hemostasis to minimize ongoing blood loss. This is generally followed by supportive measures. Dilutional coagulopathy can present a real challenge, as therapeutic options are quite limited in this group of patients. We present a patient who arrived in hemorrhagic shock, and despite early surgical therapy, his significant blood loss caused dilutional coagulopathy that we treated with activated factor VIIa. While use of factor VIIa after injury is gaining popularity, data on its use in patients who are Jehovah's Witnesses is quite limited. In this case, we believe the product was life-saving. Most importantly, there were no religious objections to its use. In appropriate patients, when surgical bleeding is controlled and there is still evidence of dilutional coagulopathy, factor VIIa may have a real role in patients, particularly those who are Jehovah's Witnesses.

Abdominal Injuries↗
PubMed2004

The combination of platelet-enriched autologous plasma with bovine collagen and thrombin decreases the need for multiple blood transfusions in trauma patients with retroperitoneal bleeding.

OBJECTIVES: Bleeding from blunt and penetrating retroperitoneal injuries during operative exploration are often difficult to control surgically and can be associated with significant blood loss. Our goals were to evaluate and compare the efficacy of a topical autologous platelet-enriched plasma combined with bovine collagen and thrombin (PCT) to Gelfoam/thrombin (G/T) in relation to hemostatic control/blood transfusion (BTx) requirements and subsequent outcome. METHODS: Prospective data were collected on all patients who underwent operative exploration for retroperitoneal injuries in which either PCT or G/T was applied with or without packing over a 2.5-year period. Patients were stratified by age, gender, mechanism of injury, preoperative international normalized ratio, pH, hematocrit, intraoperative blood loss, and BTx requirements. Subsequent BTx requirements were calculated within 48 hours of the surgical procedure. Outcome was measured by intensive care unit and hospital length of stay and mortality. RESULTS: A total of 78 patients met study criteria. Patients who received G/T had a significantly greater number of early postoperative transfusions (p < 0.001) and a longer hospital (p < 0.001) and intensive care unit length of stay (p < 0.007). There was no difference in mortality. CONCLUSION: PCT is a rapidly available topical hemostat that is associated with a significant decrease in the need for postoperative blood transfusions and intensive care unit and hospital length of stay. A randomized prospective trial to confirm these results is warranted.

Adult↗
PubMed2003

Resuscitation from hemorrhagic shock: experimental model comparing normal saline, dextran, and hypertonic saline solutions.

OBJECTIVE: To compare the effectiveness of normal saline, dextran, hypertonic, and hypertonic-hyperoncotic solutions in hemorrhagic shock. DESIGN: Laboratory investigation. SETTING: University hospital, Emergency Surgery and Intensive Care staff. SUBJECTS: Thirty-two large white female pigs. INTERVENTIONS: Routine care included: anesthesia and sedation (ketamine 10 mg/kg, droperidol 0.25 mg/kg, diazepam 0.7 mg/kg, fentanyl 0.006 mg/kg, 2% enflurane, 20% nitrous oxide, pancuronium bromide 0.13 mg/kg); volume-controlled ventilation (Paco(2) 35-40 torr; 4.7-5.4 kPa); cannulation of right carotid artery and pulmonary artery. Three flow probes (subdiaphragmatic aorta, superior mesenteric artery, right renal artery) and regional venous catheters (superior mesenteric vein, right renal vein) were positioned. Animals were bled to 45 mm Hg for 1 hr and resuscitated with four different fluids and blood to normal aortic blood flow and hemoglobin. MEASUREMENTS AND MAIN RESULTS: Mean arterial pressure and blood flow through abdominal aorta ([OV0312](aor)), mesenteric artery ([OV0312](mes)), and renal artery ([OV0312](ren)) were continuously monitored. Cardiac output, systemic and regional oxygen delivery ([U1E0A]o(2), [U1E0A]o(2mes), [U1E0A]o(2ren)), and consumption ([OV0312]o(2), [OV0312]o(2mes), [OV0312]o(2ren)) were recorded every 30 mins. Baseline [OV0312](aor) was restored with different amounts of fluids in the four groups: normal saline (91.35 +/- 22.18 mL/kg); dextran (16.24 +/- 4.42 mL/kg); hypertonic (13.70 +/- 1.44 mL/kg); and hypertonic-hyperoncotic (9.11 +/- 1.20 mL/kg). The amount of sodium load was less using dextran and hypertonic-hyperoncotic and sodium levels were only transiently increased after hypertonic infusion. Mean arterial pressure and cardiac output were normalized in all groups. Animals resuscitated with normal saline and dextran showed increased pulmonary artery pressures. [U1E0A]o(2) was significantly higher after hypertonic-hyperoncotic infusion, because of reduced hemodilution. Hypertonic and hypertonic-hyperoncotic normalized [OV0312](mes), [U1E0A]o(2mes), [OV0312]o(2mes), [OV0312](ren), and [U1E0A]o(2ren), whereas normal saline and dextran did not achieve this result. At the end of the experiment, hypertonic-hyperoncotic maintained mean arterial pressure, cardiac output, and [U1E0A]o(2) until the end of observation in contrast to normal saline, dextran, and hypertonic. CONCLUSIONS: Resuscitation with a small volume of hypertonic-hyperoncotic solution allows systemic and splanchnic hemodynamic and oxygen transport recovery, without an increase in pulmonary artery pressure. It only transiently increased sodium concentration.

Animals↗
PubMed2003

Operative management and outcome of iliac vessel injury: a ten-year experience.

The purpose of this study is to review demographics and examine and stratify risk factors related to the outcome of operatively treated iliac vascular injuries. We conducted a retrospective review of 78 cases of iliac vessel injury. Patients with blunt and penetrating injury had statistically similar length of hospital stay and intensive care unit stay, incidence of shock, and mortality. Shock on admission and bleeding hematoma are linked, and shock increased mortality with an odds ratio of 5.2 (P = 0.002). A review of operative technique and outcome demonstrated a low mortality of 25 per cent in arterial bypass of an isolated arterial injury versus a mortality of 83 per cent in the combined injury group. Patients treated with primary repair of venous injuries had a lower incidence of shock and mortality compared with patients treated with venous ligation. We conclude that, if matched for severity of injury and physiologic instability, the mechanism of injury does not affect mortality. Shock is the most significant prognostic factor for mortality. Operative management must be based on presence of shock.

Adolescent↗
PubMed2003

Air following splenic embolization: infection or incidental finding?

The use of splenic embolization for nonoperative management has increased. With increased use of this adjunct, a new and frequent finding has been air within the areas of infarction in patients with or without clinical signs of infection. The purpose of this study was to determine if air within areas of splenic infarction is pathologic of infection or rather an incidental finding. A retrospective review over the past 3 years of inpatients undergoing splenic embolization and having pre- and postembolization abdominal computed tomography scans were reviewed for the findings of free air as well as any clinical signs of infection. A total of 96 consecutive patients were included. Of these, 12 had evidence of infarction with air. Six of these patients had undergone distal embolization with intraparenchymal air, but no symptoms. These were successfully observed. Two patients demonstrated subcapsular air/fluid levels, which underwent drainage with splenic preservation. Cultures were negative for infection. The remaining 4 underwent splenectomy. Of these, all had large collections of air. Two of these 4 spleens were infected: 1 with alpha-hemolytic Streptococcus and one with Clostridia perfringens. The remainder was sterile. This gave an overall infection rate of 17 per cent of patients with evidence of air. This yield increased to 33 per cent if the patient had symptoms and 50 per cent in those with large amounts of air and symptoms. Overall, we feel that air following embolization is a concern, but does not constitute infection. Patients with large amounts of air and signs and symptoms of infection will have a far higher infectious rate, 50 per cent in this limited series. In these patients, evaluation for infection is indicated; that being percutaneous sampling versus splenectomy.

Embolization, Therapeutic↗
PubMed2002

Trauma deaths in an Italian urban area: an audit of pre-hospital and in-hospital trauma care.

In Italy, a comprehensive regional study of trauma deaths has never been performed. We examined the organization and delivery of trauma care in the city area of Milan, using panel review of trauma deaths. Two panels evaluated the appropriateness of care of all trauma victims occurred during 1 year, applying predefined criteria and judging deaths as not preventable (NP), possible preventable (PP), and definitely preventable (DP). Two hundred and fifty-five deaths were reviewed. Blunt trauma were 78.04% and motor vehicle crashes accounted for over 50%. Most victims (73.72%) died during pre-hospital settings and 91.1% died within the first 6h, principally because of central nervous system injuries in blunt and hemorrhage in penetrating trauma. Panels judged 57% of deaths NP, 32% PP, 11% DP (inter-panel K-test 0.88). Preventable deaths were higher after in-hospital admission. Main failures of treatment were lack in airway control or intravenous infusions in pre-hospital and mismanagement with missed injuries in emergency department. The high rate of avoidable deaths in Milan supports the need of trained pre-hospital personnel and of well equipped referring hospitals for trauma.

Accidents↗
PubMed2002

Impact of community-acquired infection on acquisition of nosocomial infection, length of stay, and mortality in adult blunt trauma patients.

The incidence of community-acquired infections (CA) and how it relates to the incidence of nosocomial infections (NI) in the adult blunt trauma population is unknown. We evaluated this incidence and assessed the impact of age on morbidity and mortality. Prospective data were collected on blunt trauma patients admitted >48 h over a 2-year period. Each patient was screened for infection by an infectious disease specialist. The Centers for Disease Control and Prevention (CDC) guidelines were used to diagnose infection. Of the 2,645 patients admitted, 86% were <65 years of age and 14% were > or =65 years of age. There was not a significant difference in Injury Severity Score (ISS) between the two groups. A total of 201 (8.8%) of the younger patients were diagnosed with CA; of these, 52.2% acquired a NI. Additionally, 65 (17.4%) of the older patients were diagnosed with a CA; of these, 57% acquired a NI. The combination of CA and NI led to the most significant increases in intensive care (ILOS), hospital (HLOS) length of stay, and mortality. Patients with the CA had a significantly greater risk of obtaining an NI in both age groups. The relative risk (RR) of an older patient presenting with a CA was two times greater than in patients <65 years old. The greatest relative risk of mortality (RRM) was demonstrated with the combination of CA and NI, and age. However, once infected with both CA and NI, younger patients had a greater RRM (5.0 vs. 3.9) in the group-specific comparison. CA significantly increases the risk of blunt trauma patients acquiring an NI. The combination of CA and NI led to the most significant increases in HLOS, ILOS, and mortality. Increased age is associated with a significantly higher incidence of CA, ILOS, HLOS, and mortality. Once infected with both CA and NI, younger patients have a greater risk of mortality.

Adult↗