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    Samir Fakhry

    The low occurrence, nonspecific signs and symptoms, and high rate of associated morbidity and mortality of pulmonary embolus (PE) create major problems in the prevention, diagnosis, and treatment of PE. The purpose of this study was to... more
    The low occurrence, nonspecific signs and symptoms, and high rate of associated morbidity and mortality of pulmonary embolus (PE) create major problems in the prevention, diagnosis, and treatment of PE. The purpose of this study was to analyze the frequency and outcome of PE in an entire state's trauma population using a large, population-based, hospital discharge data base. With the inclusion of an entire population, the reported incidence, high risk groups of patients, and specific risk factors regarding PE were assessed. A multivariate, logistic regression model was created from the data to determine predictive power of selected risk factors in patients at risk. The data source was a statewide, hospital discharge data base that includes data on all hospitalized patients for all of the hospitals in North Carolina. Data were available from 1988 to 1993. Using primary discharge diagnosis and nine additional ICD-9 coded diagnoses from the discharge abstract, patients were selecte...
    The Glasgow Coma Scale (GCS), which is the foundation of the Trauma Score, Trauma and Injury Severity Score, and the Acute Physiology and Chronic Health Evaluation scoring systems, requires a verbal response. In some series, up to 50% of... more
    The Glasgow Coma Scale (GCS), which is the foundation of the Trauma Score, Trauma and Injury Severity Score, and the Acute Physiology and Chronic Health Evaluation scoring systems, requires a verbal response. In some series, up to 50% of injured patients must be excluded from analysis because of lack of a verbal component for the GCS. The present study extends previous work evaluating derivation of the verbal score from the eye and motor components of the GCS. Data were obtained from a state trauma registry for 24,565 unintubated patients. The eye and motor scores were used in a previously published regression model to predict the verbal score: Derived Verbal Score = -0.3756 + Motor Score * (0.5713) + Eye Score * (0.4233). The correlation of the actual and derived verbal and GCS scales were assessed. In addition the ability of the actual and derived GCS to predict patient survival in a logistic regression model were analyzed using the PC SAS system for statistical analysis. The predictive power of the actual and the predicted GCS were compared using the area under the receiver operator characteristic curve and Hosmer-Lemeshow goodness-of-fit testing. A total of 24,085 patients were available for analysis. The mean actual verbal score was 4.4 +/- 1.3 versus a predicted verbal score of 4.3 +/- 1.2 (r = 0.90, p = 0.0001). The actual GCS was 13.6 + 3.5 versus a predicted GCS of 13.7 +/- 3.4 (r = 0.97, p = 0.0001). The results of the comparison of the prediction of survival in patients based on the actual GCS and the derived GCS show that the mean actual GCS was 13.5 + 3.5 versus 13.7 + 3.4 in the regression predicted model. The area under the receiver operator characteristic curve for predicting survival of the two values was similar at 0.868 for the actual GCS compared with 0.850 for the predicted GCS. The previously derived method of calculating the verbal score from the eye and motor scores is an excellent predictor of the actual verbal score. Furthermore, the derived GCS performed better than the actual GCS by several measures. The present study confirms previous work that a very accurate GCS can be derived in the absence of the verbal component.
    Professional compensation is an important consideration for all physicians. Few objective data specific to trauma surgery are available to those seeking employment or contract renegotiation in the United States. National benchmark salary... more
    Professional compensation is an important consideration for all physicians. Few objective data specific to trauma surgery are available to those seeking employment or contract renegotiation in the United States. National benchmark salary data should assist trauma surgeons in securing fair and equitable compensation. The purpose of this study was to survey trauma surgeons who are members of the Eastern Association for the Surgery of Trauma regarding current salary levels, benefits, contract arrangements, practice descriptors, and opinions on professional reimbursement. Anonymous self-report questionnaires were mailed to active members of the Eastern Association for the Surgery of Trauma. Only general surgeons practicing in the United States were included. Data were maintained in a confidential database. Of 385 surveys mailed, 207 (53.7%) were returned. There were 172 usable questionnaires, for an overall response rate of 44.6%. Nearly 93% of respondents worked in states east of the Mississippi River. Mean age was 42.4 years (range, 33-50 years) and 94.7% were male. Over 66% of the surgeons were fellowship trained in trauma, and 44% were chiefs of trauma services. The mean years of experience was 8.8 years (range, 1-17 years). Most respondents worked at teaching institutions (88%) and Level I centers (66%). The mean annual compensation was $229,142+/-$78,045 (range, $90,000-$528,000). These salaries were comparable to ranges from academic surveys of general surgeons. Few surgeons had professional guidance negotiating their compensation. Survey respondents were aware of few objective data specific to trauma surgery. This preliminary survey provides a unique benchmark for trauma surgeon salaries. Trauma surgeons should benefit from a more informed and structured approach to salary negotiations. Detailed trauma surgeon-specific data obtained periodically are essential to ensuring fair and equitable compensation in this specialty.
    Trauma Score (TS), APACHE II score, and Injury Severity Score (ISS) have been utilized to quantitate severity of illness in various groups of patients. The purpose of this study was to compare the relationship of the APACHE II score, TS,... more
    Trauma Score (TS), APACHE II score, and Injury Severity Score (ISS) have been utilized to quantitate severity of illness in various groups of patients. The purpose of this study was to compare the relationship of the APACHE II score, TS, and "computer-derived" ISS with outcome in critically injured trauma patients. Data were recorded prospectively in a computer database for 428 consecutive trauma admissions. Stepwise discriminate analysis was utilized to determine the best predictor of both intensive care unit (ICU) and hospital outcome. Forty-two patients died in the ICU (10%), and another 18 patients died after leaving the ICU (4%), for a total mortality rate of 14%. The mean p value and partial R2 value obtained from stepwise discriminant analysis of the relationships between APACHE II score, TS, and ISS to ICU and hospital survival are shown. APACHE II score was the best predictor of both ICU and hospital outcome in these critically ill trauma patients. However, when combining all three measures (APACHE II score, TS, and ISS), only a portion of the variance in outcome is explained by the scores (R2 < 0.05). We conclude that scoring systems for outcome prediction should be utilized only as an adjunct to clinical assessment in the evaluation of the severity of illness and mortality risk in critically ill trauma patients.
    To determine if an elevated score on the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system is associated with mortality of acutely ill gynecologic oncology patients. Gynecologic oncology patients admitted to the... more
    To determine if an elevated score on the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system is associated with mortality of acutely ill gynecologic oncology patients. Gynecologic oncology patients admitted to the surgical intensive care unit (ICU) were identified from the ICU data base. Their admission APACHE II score and type of gynecologic cancer were also extracted from the data base. Charts were reviewed to determine the disease status and reason for admission to the surgical ICU. Patient mortality was correlated with APACHE II scores. Forty-five gynecologic oncology patients were admitted to the surgical ICU from June 1988 to January 1992. They had a mean age of 62 years and various cancers: ovarian (24), cervical (16), and endometrial (five). The mean APACHE II score was 12 (range 2-26). Eight of 45 (18%) patients died. There was a significant correlation between APACHE II scores and mortality; patients with an APACHE II score of 20 or greater had a 78% risk of death compared to a 3% risk if the score was less than 20 (P < .001, chi 2 test). Elevated APACHE II scores are associated with mortality in acutely ill gynecologic oncology patients.
    Blunt small bowel injury (SBI) is uncommon, and its timely diagnosis may be difficult. The impact of operative delays on morbidity and mortality has been unclear. The purpose of this study was to determine the relationship of diagnostic... more
    Blunt small bowel injury (SBI) is uncommon, and its timely diagnosis may be difficult. The impact of operative delays on morbidity and mortality has been unclear. The purpose of this study was to determine the relationship of diagnostic delays to morbidity and mortality in blunt SBI. Patients with blunt SBI with perforation were identified from the registries of eight trauma centers (1989-1997). Patients with duodenal injuries were excluded. Data were extracted by individual chart review. Patients were classified as multi-trauma (group 1) or near-isolated SBI (group 2 with Abbreviated Injury Scale score < 2 for other body areas). Time to operation and its impact on mortality and morbidity was determined for each patient. A total of 198 patients met inclusion criteria: 66.2% were male, mean age was 35.2 years (range, 1-90 years) and mean Injury Severity Score was 16.7 (range, 9-47). 100 patients had multiple injuries (group 1). There were 21 deaths (10.6%) with 9 (4.5%) attributable to delay in operation for SBI. In patients with near-isolated SBI, the incidence of mortality increased with time to operative intervention (within 8 hours: 2%; 8-16 hours: 9.1%; 16-24 hours: 16.7%; greater than 24 hours: 30.8%, p = 0.009) as did the incidence of complications. Delays as short as 8 hours 5 minutes and 11 hours 15 minutes were associated with mortality attributable to SBI. The rates of delay in diagnosis were not significantly associated with age, gender, intoxication, transfer status, or presence of associated injuries. Delays in the diagnosis of SBI are directly responsible for almost half the deaths in this series. Even relatively brief delays (as little as 8 hours) result in morbidity and mortality directly attributable to "missed" SBI. Further investigation into the prompt diagnosis of this injury is needed.
    The purpose of this study was to determine whether gastric feeding tubes placed by the percutaneous endoscopic route resulted in fewer and less severe complications than open surgical gastrostomy (SG). Charts for all trauma patients... more
    The purpose of this study was to determine whether gastric feeding tubes placed by the percutaneous endoscopic route resulted in fewer and less severe complications than open surgical gastrostomy (SG). Charts for all trauma patients admitted 1/94 to 12/98, which had an electively placed feeding tube, were individually reviewed. All tube-related complications were recorded. Of 8119 patients screened, 158 (1.9%) met inclusion criteria. Percutaneous endoscopic gastrostomies (PEGs) were placed in 95 (60.1%) and surgical gastrostomies in 63 (39.9%). Most patients (79.1%) had AIS 3 or greater head or spinal cord injury as the primary diagnosis leading to tube placement. Overall, SG patients were 5.4 times more likely than PEG patients to have a complication from their gastrostomy tube (95% CI, 2.1-13.8). They were 2.6 times more likely to have a major complication (internal leakage, dehiscence, peritonitis, and fistula), and 5.5 times more likely to have a minor complication (unplanned removal, dislodgment, external leak, skin infection, and nonfunction). The groups did not differ on ISS, ICU LOS, total LOS, or mortality (p > 0.05). Overall, a total of 39 individual complications related to tube placement were noted in 26 separate patients (PEG, 7; SG, 19). All four of the major complications requiring operative intervention were in the SG group. There were 31 minor complications, 8 in the PEG group and 27 in the SG group. Mean total charges for placement were also significantly lower in the PEG group than the SG group ($1271 vs. $2761, p < 0.001) Gastrostomy tubes placed via the percutaneous endoscopic route had a significantly lower complication rate than surgically placed tubes. In addition, the charges incurred for their placement were also significantly less. Based on the findings of this study, PEG should be considered as the method of choice for gastric feeding tube placement for trauma patients who do not have specific contraindications to the procedure.
    ABSTRACT
    Recent reports have questioned the safety and efficacy of prehospital rapid sequence intubation (RSI) for patients with head trauma. The purpose of this study is to determine the rate of successful prehospital RSI, associated... more
    Recent reports have questioned the safety and efficacy of prehospital rapid sequence intubation (RSI) for patients with head trauma. The purpose of this study is to determine the rate of successful prehospital RSI, associated complications, and delays in transport of critically injured trauma patients treated by a select, well-trained group of paramedics with frequent exposure to this procedure and a rigorous quality control system. A helicopter paramedic group's database of patient flight records (1999 to 2003) was merged with registry data of a suburban Level I trauma center. Both databases included comprehensive performance improvement data. After Institutional Review Board approval, data were analyzed to determine RSI success rate, impact on oxygenation, delays in transport and complications associated with attempted RSI. Attempted RSI was defined as any insertion of the laryngoscope into the oropharynx. In all, 1,117 trauma patients were transported. One hundred and seventy-five had attempted RSI (74% male, mean age 31.1 +/- 19.2 years, 91% blunt trauma, 88% with Head/Neck AIS >or=2, mean Injury Severity Score 25.6, mean scene Glasgow Coma Scale score 4.8 +/- 2.4). One hundred and sixty-nine patients (96.6%) had successful scene RSI. Seventy percent were intubated on the first attempt, 89% by the second attempt, and 96% by the third attempt. Of the six patients (3.4% overall) who failed RSI, (2.3% overall) had scene cricothyroidotomy and two (1.1% overall) were managed by bag-valve mask. Complications included five (2.9%) right mainstem intubations and 2 (1.2%) endotracheal tube dislodgments en route. There were no esophageal intubations. Four patients in extremis (2.3%) had arterial desaturations associated with RSI. Arterial blood gas analyzed upon arrival revealed (mean pCO2 36.6 +/- 8, median 37). Attempted RSI was associated with a mean of 6 minutes of added scene time. Prehospital RSI for trauma patients can be safely and effectively performed with low rates of complication and without significant delay in transport. This study suggests that resources for prehospital airway management should be focused on training, regular experience, and close monitoring of a limited group of providers, thereby maximizing their exposure and experience with this procedure. This is particularly important given the high rates of traumatic brain injury encountered.
    Early surgical management of femoral shaft fracture (FSF) is considered the standard but patients are still treated nonsurgically. The purpose of this study was to analyze the results of management of FSF in a large population based data... more
    Early surgical management of femoral shaft fracture (FSF) is considered the standard but patients are still treated nonsurgically. The purpose of this study was to analyze the results of management of FSF in a large population based data base. Data were obtained from a statewide hospital discharge data base for 1989-1992. Adults having a FSF were stratified by ISS (ISS < 15 vs. ISS > or = 15) and management (nonsurgical, surgery within 1 day, surgery at 2-4 days, or surgery at > 4 days). Mortality rates and mean length of hospital stay were compared among groups. 2805 patients had FSFs: 69% were managed surgically and 31% nonsurgically. Mortality was higher for nonsurgical therapy in both ISS groups. In the surgically treated groups, length of hospitalization increased as delay to surgery increased. In patients with an ISS > or = 15, repair at 2-4 days was associated with the lowest mortality and shortest hospitalization, while a trend to higher mortality and longer hospitalization was noted with repair within 1 day. 31% of patients were treated nonsurgically with higher associated mortality. These results support "early" surgical fixation, which can shorten hospital stay without increasing mortality regardless of overall injury severity. The trend toward higher mortality in severely injured patients operated on within 1 day of admission suggests that this group warrants further study and individualized management.
    Blunt hollow viscus injury (HVI) is uncommon. No sufficiently large series has studied the prevalence of these injuries in blunt trauma patients. This study defines the prevalence of blunt HVI, in addition to the associated morbidity and... more
    Blunt hollow viscus injury (HVI) is uncommon. No sufficiently large series has studied the prevalence of these injuries in blunt trauma patients. This study defines the prevalence of blunt HVI, in addition to the associated morbidity and mortality rates for this diagnosis on the basis of a series of over 275,000 trauma admissions. Patients with blunt small bowel injury (SBI) were identified from the registries of 95 trauma centers for a 2-year period (1998-1999). Each HVI patient (case) was matched by age and Injury Severity Score with a blunt trauma patient receiving an abdominal workup who did not have HVI (control). Patient level data were abstracted by individual chart review. Institution level data were collected on total numbers for trauma admission demographics and on total diagnostic examinations performed. From 275,557 trauma admissions, 227,972 blunt injury patients were identified. HVI was rare, with 2,632 patients identified from this group. Perforating small bowel injury accounted for less than 0.3% of blunt admissions. Mortality and morbidity were high for HVI. Controlling for injury severity, patients with HVI were usually at higher risk of death than non-HVI patients. HVI is a rare but deadly phenomenon. The high mortality rates reflect the severity of the HVI and associated injuries. HVI patients should be carefully monitored for related injuries and complications.
    Trauma complicates 6% to 7% of all pregnancies. Adverse outcomes are rare when monitoring is normal and early warning signs absent. Trauma systems often use pregnancy as the sole criterion (PSC) for partial trauma team activation. This... more
    Trauma complicates 6% to 7% of all pregnancies. Adverse outcomes are rare when monitoring is normal and early warning signs absent. Trauma systems often use pregnancy as the sole criterion (PSC) for partial trauma team activation. This study compares outcomes of pregnant patients presenting with PSC versus other physiologic, mechanistic, or anatomic (OPMA) activation criteria. Three hundred fifty-two consecutive obstetric partial trauma team activation patients (2000-2005) were grouped by length of gestation and evaluated for activation criteria and early maternal and fetal outcomes. Data were analyzed using descriptive statistics and analysis of variance. Patients ranged in age from 16 to 44 (mean age, 28 +/- 6.4) and in weeks gestation between 1 and 40 weeks (mean, 25 +/- 8 weeks). Eighty-two percent had been in vehicle crashes. One hundred eighty-eight (58%) were activated based on PSC and 137 on OPMA. No PSC patient had injuries sufficient to warrant trauma service admission. Ninety-four percent of all PSCs of <20 weeks were discharged home from the emergency department. There were no maternal mortalities. There were four fetal mortalities; two pregnancies were terminally compromised before the trauma event. No patient in the PSC group required admission to the trauma service. There were seven cases of abruption (2%) and 18 cases of vaginal bleeding or discharge (6%). No case of vaginal bleeding or abruption in the first 20 weeks was hypotensive at the scene or on arrival. In this study, pregnancy was not an independent predictor of the need for trauma team activation. Standard OPMA trauma activation criteria apply equally to pregnant and nonpregnant patients. These data provide support for more judicious allocation of scarce trauma systems resources.
    Blunt small bowel injury (SBI) may be difficult to diagnose accurately. Diagnostic delays are associated with increased morbidity and mortality. A cross-sectional survey of members of the American Association for the Surgery of Trauma was... more
    Blunt small bowel injury (SBI) may be difficult to diagnose accurately. Diagnostic delays are associated with increased morbidity and mortality. A cross-sectional survey of members of the American Association for the Surgery of Trauma was conducted. A Likert-type multiple-choice scale was used to evaluate use and usefulness of diagnostic and laboratory tests. Data were analyzed by using univariate and multivariate techniques. A total of 461 of the 702 members (68%) surveyed responded, of which 133 members (29%) were excluded because they did not currently manage adult SBI. Of the remaining 328 respondents, 244 members (74%) reported prior experience as the most important influence on their current practice of diagnosing blunt SBI. None of the standard laboratory tests were reported as useful. Seventy-seven percent of respondents use computed tomographic (CT) scan most or all of the time for diagnosis (p < 0.05 compared with other modalities). Most respondents estimated their annual incidence of SBI at 5% with a >15% frequency of delay in diagnosis. Forty-four percent of the respondents estimated the mortality associated with a delay in diagnosis at < or =5%. Respondents varied significantly in their management of the patient with an unreliable abdominal exam and a CT scan finding of isolated free fluid. In patients with head injuries, 28% observe, 12% repeat the CT scan, 42% perform diagnostic peritoneal lavage, and 16% operate. For intoxicated patients, 51% observe, 11% repeat the CT scan, 26% perform diagnostic peritoneal lavage, and 10% operate. A more aggressive approach with diagnostic and operative intervention was significantly (p < 0.05) advocated by respondents practicing without residents, more than 15 years out from residency, or by those with a perception of higher morbidity and mortality from delays in diagnosis. There is significant variation in the diagnostic approach to the patient with suspected SBI. The perceived mortality of delayed diagnosis is much less than reported. Those surgeons with more experience or perception of greater morbidity and mortality from a delayed diagnosis are more aggressive. Further investigation into the diagnosis and treatment of this injury is needed.
    a) To examine the accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Glasgow Coma Scores as predictors of the outcome of patients following resuscitation from cardiac arrest; b) to study the impact of the... more
    a) To examine the accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Glasgow Coma Scores as predictors of the outcome of patients following resuscitation from cardiac arrest; b) to study the impact of the components of APACHE II on the prediction. A nationwide study in Finland with prospectively collected data on all patients admitted to intensive care after cardiac arrest during a 14-month period. Two thirds of the cardiac arrest patients included in the study were randomly selected to derive predictive models, and the remaining one third constituted the validation sample. A total of 25 medical and surgical ICUs in Finland (13 in tertiary referral centers). Six-hundred nineteen consecutive cardiac arrest patients. Fifteen patients less than 16 yrs were excluded. Variables included in the APACHE II or Glasgow Coma Scores were collected at the time of ICU admission and then three times after admission, at 24-hr intervals. ICU- and hospital-mortality rates and a 6-month mortality rate after ICU admission were studied. Of 604 study patients, 370 (61.3%) patients died in the hospital. The most accurate prediction of hospital outcome was based on data collected after the first day of ICU care, not on the admission values. Twenty-one (21.9%) of 96 patients with a low APACHE II score (less than or equal to 9) died compared with 66 (84.6%) of 78 patients with a high APACHE II score (greater than or equal to 25) (p less than .001). Of 160 patients with a normal Glasgow Coma Score (14 to 15), 45 (28.1%) died, whereas there were 114 (81.4%) nonsurvivors among 140 patients with a low Glasgow Coma Score of 3 (p less than .001). The performance of predictive models, including age, the Chronic Health Evaluation, and either the Acute Physiology Score (Acute Physiology Score model) or the Glasgow Coma Score (Glasgow Coma Score model) were compared with the prediction according to the APACHE II in the validation sample. When using 80% probability of death as a decision rule, the Acute Physiology Score model determined 35 of 153 patients to have high risk of death, 29 of whom died (the positive predictive value being 82.9%). The Glasgow Coma Score model predicted 34 patients to die, 26 of whom died (positive predictive value 76.5%), and the APACHE II score predicted seven deaths, five of whom actually died (positive predictive value 71.4%). The APACHE II scoring system cannot be recommended as a prognostic tool to support clinical judgement in cardiac arrest patients, but by modifying it, a more accurate prediction of poor outcome could be achieved. The Glasgow Coma Score explained to a great extent the predictive power of the APACHE II.
    To determine the association between measures of medical manpower available to treat trauma patients and county trauma death rates in the United States. The primary hypothesis was that greater availability of medical manpower to treat... more
    To determine the association between measures of medical manpower available to treat trauma patients and county trauma death rates in the United States. The primary hypothesis was that greater availability of medical manpower to treat trauma injury would be associated with lower trauma death rates. When viewed from the standpoint of the number of productive years of life lost, trauma has a greater effect on health care and lost productivity in the United States than any disease. Allocation of health care manpower to treat injuries seems logical, but studies have not been done to determine its efficacy. The effect of medical manpower and hospital resource allocation on the outcome of injury in the United States has not been fully explored or adequately evaluated. Data on trauma deaths in the United States were obtained from the National Center for Health Statistics. Data on the number of surgeons and emergency medicine physicians were obtained from the American Hospital Association and the American Medical Association. Data on physicians who have participated in the American College of Surgeons (ACS) Advanced Trauma Life Support Course (ATLS) were obtained from the ACS. Membership information for the American Association for Surgery of Trauma (AAST) was obtained from that organization. Demographic data were obtained from the United States Census Bureau. Multivariate stepwise linear regression and cluster analysis were used to model the county trauma death rates in the United States. The Statistical Analysis System (Cary, NC) for statistical analysis was used. Bivariate and multivariate analyses showed that a variety of medical manpower measures and demographic factors were associated with county trauma death rates in the United States. As in other studies, measures of low population density and high levels of poverty were found to be strongly associated with increased trauma death rates. After accounting for these variables, using multivariate analysis and cluster analysis, an increase in the following medical manpower measures were associated with decreased county trauma death rates: number of board-certified general surgeons, number of board-certified emergency medicine physicians, number of AAST members, and number of ATLS-trained physicians. This study confirms previous work that showed a strong relation among measures of poverty, rural setting, and increased county trauma death rates. It also found that counties with more board-certified surgeons per capita and with more surgeons with an increased interest (AAST membership) or increased training (ATLS) in trauma care have lower per-capita trauma death rates.(ABSTRACT TRUNCATED AT 400 WORDS)
    This study used population-based data bases to assess the association of trauma centers with per capita county hospitalization and trauma death rates in the State of North Carolina. The current study extended previous work using two North... more
    This study used population-based data bases to assess the association of trauma centers with per capita county hospitalization and trauma death rates in the State of North Carolina. The current study extended previous work using two North Carolina data bases to assess the association of the presence of a trauma center with per capita county trauma death rates. Data on per capita county trauma hospitalizations and deaths were obtained from the state hospital discharge data base and the North Carolina Medical Examiner's data base. Bivariate and multivariate analysis techniques were used. The dependent variables of interest were prehospital, hospital, and total trauma death rates and hospitalization rates for injury. Bivariate analysis identified a number of factors associated with per capita county hospitalizations and trauma death rates. These included the per cent unemployment, racial distribution, county alcohol tax receipts, and advanced life support certified emergency medical services providers. The per capita trauma death rates were significantly lower in counties with trauma centers compared with those without trauma centers (4.0 +/- 0.5 and 5.0 +/- 1.1 deaths per 10,000 population, p = 0.0001, respectively). The per capita hospitalizations for trauma were also lower in counties with trauma centers. Multivariate modeling showed that the presence of a trauma center and advanced life support providers were the best predictors of decreased per capita county trauma death rates. The study showed that the presence of a trauma center and advanced life support training were the two medical system factors that were the best predictors of the per capita county prehospital and total trauma death rates. These findings are consistent with the hypothesis that trauma centers are associated with a decrease in trauma death rates.
    Traumatic brain injury (TBI) is the leading cause of death from blunt trauma, with an estimated cost to society of over dollar 40 billion annually. Evidence-based guidelines for TBI care have been widely discussed, but in-hospital... more
    Traumatic brain injury (TBI) is the leading cause of death from blunt trauma, with an estimated cost to society of over dollar 40 billion annually. Evidence-based guidelines for TBI care have been widely discussed, but in-hospital treatment of these patients has been highly variable. The purpose of this study was to determine whether management of TBI patients according to a protocol based on the Brain Trauma Foundation (BTF) guidelines would reduce mortality, length of stay, charges, and disability. In 1995, a protocol following the BTF guidelines was developed by members of the Level I trauma center's interdisciplinary neurotrauma task force. Inclusion criteria for the protocol were blunt head injury, age > 14 years, and Glasgow Coma Scale score < or = 8. An extensive educational process was conducted to develop compliance among all disciplines for this new management strategy. A historical control group of patients eligible for the protocol was identified by retrospecti...
    The low occurrence, nonspecific signs and symptoms, and high rate of associated morbidity and mortality of pulmonary embolus (PE) create major problems in the prevention, diagnosis, and treatment of PE. The purpose of this study was to... more
    The low occurrence, nonspecific signs and symptoms, and high rate of associated morbidity and mortality of pulmonary embolus (PE) create major problems in the prevention, diagnosis, and treatment of PE. The purpose of this study was to analyze the frequency and outcome of PE in an entire state's trauma population using a large, population-based, hospital discharge data base. With the inclusion of an entire population, the reported incidence, high risk groups of patients, and specific risk factors regarding PE were assessed. A multivariate, logistic regression model was created from the data to determine predictive power of selected risk factors in patients at risk. The data source was a statewide, hospital discharge data base that includes data on all hospitalized patients for all of the hospitals in North Carolina. Data were available from 1988 to 1993. Using primary discharge diagnosis and nine additional ICD-9 coded diagnoses from the discharge abstract, patients were selecte...
    A working knowledge of documentation and coding for physician services (DCPS) is increasingly important for a successful practice. There is no standardized, widely available educational offering available to surgical residents in DCPS.... more
    A working knowledge of documentation and coding for physician services (DCPS) is increasingly important for a successful practice. There is no standardized, widely available educational offering available to surgical residents in DCPS. The purpose of this study was to survey surgical residents and attendings for their knowledge of documentation and coding and their opinions about its importance in their training and practice. A convenience sample of 60 surgical residents and 46 attendings from 5 surgical residency training programs were administered a written survey on DCPS. The majority of residents were male (60%), in university-based programs (82%), and planned to work in a surgical specialty (55%) A larger proportion of attendings were male (80%) and in general surgery practice (62%), and a smaller proportion was university based (61%). Similar proportions of residents and attendings, 82% and 89%, respectively, stated they had not received adequate training in DCPS. The vast majority of residents (85%) felt they were novices at coding and billing, whereas 61% of attendings stated that they were somewhat knowledgeable. As a group, residents answered 54% of 25 knowledge questions correctly, and attendings answered 77% correctly. Ninety-two percent of residents believed that expertise in DCPS would make a difference in their practice, whereas 80% of attendings stated that this knowledge was currently important to their practice. Similar proportions of residents and attendings, 85% and 87%, respectively, thought that it should be an important part of residency training. Residents in this survey are aware of the importance of DCPS but feel inadequately prepared for this area of practice. The residents' knowledge of basic concepts in DCPS is marginal. Attendings surveyed had similar opinions and somewhat better knowledge of the subject. A widely available, standardized educational offering on DCPS is needed and should be provided as part of the practice-based core competencies of surgical residency training.
    In a series of 565 morbidly obese patients having one of five gastric bariatric procedures done at North Carolina Memorial Hospital between May 1975 and December 1982, 55 patients had 58 complications requiring reoperation. These... more
    In a series of 565 morbidly obese patients having one of five gastric bariatric procedures done at North Carolina Memorial Hospital between May 1975 and December 1982, 55 patients had 58 complications requiring reoperation. These complications included a leak from the stomach or anastomosis, stomal obstruction, and subphrenic abscess. Weight loss after vertical banded gastroplasty appears to be comparable to that following gastric bypass with Roux-en-Y gastrojejunostomy. The complication rate of vertical banded gastroplasty is the lowest of the gastric obstructive operations we have done.
    Blunt injury to the colon is rare. Few studies of adequate size and design exist to allow clinically useful conclusions. The Eastern Association for the Surgery of Trauma Multi-institutional Hollow Viscus Injury (HVI) Study presents a... more
    Blunt injury to the colon is rare. Few studies of adequate size and design exist to allow clinically useful conclusions. The Eastern Association for the Surgery of Trauma Multi-institutional Hollow Viscus Injury (HVI) Study presents a unique opportunity to definitively study these injuries. Patients with blunt HVI were identified from the registries of 95 trauma centers over 2 years (1998-1999). Patients with colon injuries (cases) were compared with blunt trauma patient undergoing a negative laparotomy (controls). Data were abstracted by chart review. Of the 227,972 patients represented, 2,632 (1.0%) had an HVI and 798 had a colonic/rectal injury (0.3%). Of patients diagnosed with HVI, 30.2% had a colon injury. No physical findings or imaging modalities were able to discriminate colonic injury. Logistic regression modeling yielded no clinically useful combination of findings that would reliably predict colonic injury. In patients undergoing laparotomy, presence of colon injury was associated with a higher risk of some complications but not mortality. Colon injury was associated with increased hospital (17.4 vs. 13.1, p < 0.001) and intensive care unit (9.7 vs. 6.9, p = 0.003) length of stay. Almost all colon patients (92.0%) underwent laparotomy within 24 hours of injury. Colonic injury after blunt trauma is rare and difficult to diagnose. No diagnostic test or combination of findings reliably excluded blunt colonic injury. Despite the inadequacy of current diagnostic tests, almost all patients with colonic injury were taken to the operating room within 24 hours. Even with relatively prompt surgery, patients with colon injury were at significantly higher risk for serious complications and increased length of stay. In contrast to small bowel perforation, delay in operative intervention appears to be less common but is still associated with serious morbidity.
    The relative impact of inhalation injury, burn size, and age on overall outcome following burn injury was examined in 1447 consecutive burn patients over a five and a half year period. The overall mortality for all patients was 9.5% (138... more
    The relative impact of inhalation injury, burn size, and age on overall outcome following burn injury was examined in 1447 consecutive burn patients over a five and a half year period. The overall mortality for all patients was 9.5% (138 of 1447). The presence of inhalation injury, increasing burn size, and advancing age were all associated with an increased mortality (p < 0.01). The incidence of inhalation injury was 19.6% (284 of 1447) and correlated with increasing percent total body surface area (%TBSA) burn (r = 0.41, p < 0.01) and advancing age (r = 0.15, p < 0.01). The overall mortality for patients with inhalation injury was 31% (88 of 284) compared with 4.3% (50 of 1163) for those without inhalation injury. Using multivariate analysis inhalation injury was found to be an important variable in determining outcome, but the most important factor in predicting mortality was %TBSA burn (accuracy = 92.8%) or a combination of %TBSA burn and patient age (accuracy = 93.0%). Adding inhalation injury only slightly improved the ability to predict mortality (accuracy = 93.3%). The presence of inhalation injury is significantly associated with mortality after thermal injury but adds little to the prediction of mortality using %TBSA and age alone.
    Prospective identification of patients who will not survive has been proposed as a means of limiting utilization of medical resources including critical care. This study prospectively compared prediction of outcome for surgical ICU... more
    Prospective identification of patients who will not survive has been proposed as a means of limiting utilization of medical resources including critical care. This study prospectively compared prediction of outcome for surgical ICU patients by clinical assessment and the APACHE II score. Five hundred seventy-eight patients were assessed within 24 hours of admission by the ICU attending physician and predicted to live or die. An APACHE II score was calculated in that same time period. All data were stored in a data base and compared with actual SICU outcome. There were 40 deaths in 578 patients (6.9%). The clinical assessment had an overall accuracy of 95.2% vs. 90.9% for APACHE II. The Pearson correlation coefficients for the two methods of prediction were 0.59 for clinical assessment and 0.44 for APACHE II. Predictive power was not greatly improved by combining both prediction methods. Over 40% of patients predicted to die by both methods actually survived. This study demonstrates that clinical assessment is superior to APACHE II in predicting outcome in this group of surgical patients, although the difference is small. In addition, this study suggests that neither clinical assessment nor the APACHE II score, when obtained within 24 hours of admission, is very reliable at predicting which surgical ICU patients will die.
    Side impact crashes, the most lethal type, account for 26% of all motor vehicle crashes in the United States. The purpose of this study is to delineate side impact airbag (SIAB) deployment rates, injury rates, and analyze crash factors... more
    Side impact crashes, the most lethal type, account for 26% of all motor vehicle crashes in the United States. The purpose of this study is to delineate side impact airbag (SIAB) deployment rates, injury rates, and analyze crash factors associated with SIAB deployment and occupant injury. All passenger vehicles equipped with SIABs that were involved in a side impact crash were identified from the National Automotive Sampling System database. Crashes with multiple impacts, ejections, unbelted drivers or rollovers were excluded from the study. The outcome variables of interest were SIAB deployment and driver injury. SIAB deployment was compared in similar crashes to analyze the impact on driver's injury severity score. Other crash factors were also examined to analyze what role they play in SIAB deployment rates and injury rates, such as plane of contact, striking object and Delta-V. The data set for this study contained 247 drivers in near and far side crashes in vehicles with installed SIABs. Overall SIAB deployment was 43% in side impact crashes. A significant factor associated with both the SIAB deployment rate and the driver's injury rate was increased Delta-V. SIABs do not deploy consistently in crashes with a high Delta-V or with a lateral primary direction of force and a front plane of contact. In these two scenarios, further research is warranted on SIAB deployments. With SIAB deployment, it appears drivers are able to sustain a higher Delta-V impact without serious injury.
    Pneumatoceles are cystic lesions of the lungs often seen in children with staphylococcal pneumonia and positive-pressure ventilation. Acinetobacter calcoaceticus is an aerobic, short immobile gram-negative rod, or coccobacillus, which is... more
    Pneumatoceles are cystic lesions of the lungs often seen in children with staphylococcal pneumonia and positive-pressure ventilation. Acinetobacter calcoaceticus is an aerobic, short immobile gram-negative rod, or coccobacillus, which is an omnipresent saprophyte. The variant anitratus is the most clinically significant pathogen in this family, usually presenting as a lower respiratory tract infection. Acinetobacter has been demonstrated to be one of the most common organisms found in the ICU. We present three critically ill surgery patients with Acinetobacter pneumonia, high inspiratory pressures, and the subsequent development of pneumatoceles. One of these patients died from a ruptured pneumatocele, resulting in tension pneumothorax. Treatment of pneumatoceles should center on appropriate intravenous antimicrobial therapy. This should be culture directed but is most often accomplished with Imipenem. Percutaneous, computed tomographic-guided catheter placement or direct tube thoracostomy decompression of the pneumatocele may prevent subsequent rupture and potentially lethal tension pneumothorax.
    Recent reports have questioned the safety and efficacy of prehospital rapid sequence intubation (RSI) for patients with head trauma. The purpose of this study is to determine the rate of successful prehospital RSI, associated... more
    Recent reports have questioned the safety and efficacy of prehospital rapid sequence intubation (RSI) for patients with head trauma. The purpose of this study is to determine the rate of successful prehospital RSI, associated complications, and delays in transport of critically injured trauma patients treated by a select, well-trained group of paramedics with frequent exposure to this procedure and a rigorous quality control system. A helicopter paramedic group's database of patient flight records (1999 to 2003) was merged with registry data of a suburban Level I trauma center. Both databases included comprehensive performance improvement data. After Institutional Review Board approval, data were analyzed to determine RSI success rate, impact on oxygenation, delays in transport and complications associated with attempted RSI. Attempted RSI was defined as any insertion of the laryngoscope into the oropharynx. In all, 1,117 trauma patients were transported. One hundred and seventy-five had attempted RSI (74% male, mean age 31.1 +/- 19.2 years, 91% blunt trauma, 88% with Head/Neck AIS >or=2, mean Injury Severity Score 25.6, mean scene Glasgow Coma Scale score 4.8 +/- 2.4). One hundred and sixty-nine patients (96.6%) had successful scene RSI. Seventy percent were intubated on the first attempt, 89% by the second attempt, and 96% by the third attempt. Of the six patients (3.4% overall) who failed RSI, (2.3% overall) had scene cricothyroidotomy and two (1.1% overall) were managed by bag-valve mask. Complications included five (2.9%) right mainstem intubations and 2 (1.2%) endotracheal tube dislodgments en route. There were no esophageal intubations. Four patients in extremis (2.3%) had arterial desaturations associated with RSI. Arterial blood gas analyzed upon arrival revealed (mean pCO2 36.6 +/- 8, median 37). Attempted RSI was associated with a mean of 6 minutes of added scene time. Prehospital RSI for trauma patients can be safely and effectively performed with low rates of complication and without significant delay in transport. This study suggests that resources for prehospital airway management should be focused on training, regular experience, and close monitoring of a limited group of providers, thereby maximizing their exposure and experience with this procedure. This is particularly important given the high rates of traumatic brain injury encountered.
    The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical... more
    The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.
    Trauma complicates 6% to 7% of all pregnancies. Adverse outcomes are rare when monitoring is normal and early warning signs absent. Trauma systems often use pregnancy as the sole criterion (PSC) for partial trauma team activation. This... more
    Trauma complicates 6% to 7% of all pregnancies. Adverse outcomes are rare when monitoring is normal and early warning signs absent. Trauma systems often use pregnancy as the sole criterion (PSC) for partial trauma team activation. This study compares outcomes of pregnant patients presenting with PSC versus other physiologic, mechanistic, or anatomic (OPMA) activation criteria. Three hundred fifty-two consecutive obstetric partial trauma team activation patients (2000-2005) were grouped by length of gestation and evaluated for activation criteria and early maternal and fetal outcomes. Data were analyzed using descriptive statistics and analysis of variance. Patients ranged in age from 16 to 44 (mean age, 28 +/- 6.4) and in weeks gestation between 1 and 40 weeks (mean, 25 +/- 8 weeks). Eighty-two percent had been in vehicle crashes. One hundred eighty-eight (58%) were activated based on PSC and 137 on OPMA. No PSC patient had injuries sufficient to warrant trauma service admission. Ninety-four percent of all PSCs of <20 weeks were discharged home from the emergency department. There were no maternal mortalities. There were four fetal mortalities; two pregnancies were terminally compromised before the trauma event. No patient in the PSC group required admission to the trauma service. There were seven cases of abruption (2%) and 18 cases of vaginal bleeding or discharge (6%). No case of vaginal bleeding or abruption in the first 20 weeks was hypotensive at the scene or on arrival. In this study, pregnancy was not an independent predictor of the need for trauma team activation. Standard OPMA trauma activation criteria apply equally to pregnant and nonpregnant patients. These data provide support for more judicious allocation of scarce trauma systems resources.
    The literature on blunt splenic trauma provides little evidence-based direction for nonsurgical management. The appropriate role of computed tomography (CT) after initial diagnosis, activity restriction and follow-up are continuing... more
    The literature on blunt splenic trauma provides little evidence-based direction for nonsurgical management. The appropriate role of computed tomography (CT) after initial diagnosis, activity restriction and follow-up are continuing controversies. Active EAST members were surveyed regarding in-hospital management and follow-up of patients with isolated and near-isolated blunt splenic injury. Analyses were performed using descriptive and correlational statistics. A 38.4% response rate was obtained. 82.6% of respondents practiced at a Level I trauma centers. 97% of respondents considered hemodynamic instability as the primary indication for immediate splenectomy. 71.6% of respondents preferred ultrasound for initial imaging in hemodynamically stable patients. One-third of respondents admitted stable Grade I patients to monitored settings. 85.5% would not routinely perform predischarge abdominal CT scan in the absence of clinical deterioration, extravasation on initial CT or high-grade injury. Activity restriction varied by grade (table). The majority of respondents (78.1%) relied on clinical judgment alone for activity recommendations in lower grades of injury while a higher reliance on CT was used for Grades IV and V (49.8%). Despite the lack of evidence-based guidelines, many in-hospital and follow-up practices were reasonably consistent. However, some important contradictions were noted (such as monitoring very low risk patients and not intervening in patients with contrast blush). Activity restrictions were usually based on clinical judgment supplemented by CT at the highest grades of injury. Lack of evidence-based guidelines and high reliance on clinical judgment underscore the need for a well-designed prospective study to define optimal management and follow-up.
    Critical care consumes a significant portion of health care costs. Although there are currently increasing pressures to limit expenditures, data are not always available to allow physicians and patients to make informed therapeutic or... more
    Critical care consumes a significant portion of health care costs. Although there are currently increasing pressures to limit expenditures, data are not always available to allow physicians and patients to make informed therapeutic or triage decisions regarding prolonged intensive care unit (ICU) stays. The purpose of this study was to evaluate long-term outcome, quality of life, and charges in surgical patients requiring prolonged ICU stays (> 14 days). Adults requiring over 14 days of surgical ICU care from January 1991 to September 1993 were selected from our ICU data base. Survivors to hospital discharge were evaluated for outcome and quality of life by mail survey and/or telephone interview in addition to chart review. Eighty-three patients spent over 14 days in the surgical ICU during the study period. Fifty-two patients (62.6%) survived to hospital discharge. Average age was 53 years, average ICU length of stay was 26 days, and average hospital length of stay was 50 days. Complete follow-up data were available for 39 patients (75%). Thirty of the 39 patients (77%) were alive at an average follow-up of 18 months. Long-term survival in patients over 65 years old was 67% compared with 83% for younger patients (p < 0.05). Seventy percent reported less than 50% functional recovery. Seventy percent wer living at home and 23% were on disability. Of 11 patients employed before discharge, five had returned to work. Eighty percent of respondents reported good to fair quality of life, and 81% stated that they would undergo critical care again. The average ICU charge was $51,512 per patient, and the average hospital charge was $164,019 per patient. The average charge to achieve one long-term survivor was $247,812. In this population, prolonged ICU stays resulted in acceptable quality of life and a relatively high survival rate despite significant economic investment. This study does not support withdrawal of therapy or triage decisions based solely or primarily on age or length of ICU stay.
    Research suggests that weight influences patient care and outcomes. Health-care providers (HCPs) sometimes rely on patient self-reports or HCP estimates of height and weight. The purpose of this study was to determine the accuracy of... more
    Research suggests that weight influences patient care and outcomes. Health-care providers (HCPs) sometimes rely on patient self-reports or HCP estimates of height and weight. The purpose of this study was to determine the accuracy of self-reported height and weight and HCP estimations of height, weight, and body mass index (BMI) classification when compared with measured height, weight, and calculated BMI. Attending physicians, residents, and nurses provided height and weight estimates along with BMI categorizations for 110 trauma patients at a large, teaching hospital with a Level I trauma center. Patients provided reports of their heights and weights. Measured heights and weights were obtained with appropriate calibrated devices, and BMIs were calculated. Estimates and categorizations were then compared with measured and calculated values. HCPs were 41% and 53% accurate in estimating height and weight, respectively. Self-reports had higher accuracy (69% and 92%, respectively) but still resulted in a BMI misclassification of 32%. Twenty-two percent of patient self-reports were unobtainable. When HCPs attempted to categorize a patient into a BMI group, the accuracy was 56%. Functioning, calibrated instruments for measuring height and weight were frequently unavailable in relevant hospital locations. This study demonstrated that HCPs' estimates of height, weight, and BMI category are highly inaccurate. Patient self-reports are better, but are unavailable at times. Objective measurements with calibrated instruments are necessary for accuracy in research studies and for patient safety in clinical practice. Efforts to ensure the availability of calibrated instruments may be necessary in the hospital setting.
    In trauma practice, basilar skull fracture is an extremely common finding while transverse/sigmoid venous sinus thrombosis is generally considered quite a rare complication. During evaluation of cervical computed tomography (CT)... more
    In trauma practice, basilar skull fracture is an extremely common finding while transverse/sigmoid venous sinus thrombosis is generally considered quite a rare complication. During evaluation of cervical computed tomography (CT) angiography after trauma, we identified five patients in just three months with unexpected transverse/sigmoid venous sinus obstruction ipsilateral to a basilar skull fracture. This number represented a surprisingly high percentage of our neurosurgical trauma consults for the study period (31%). Three of the five patients were found to have sinus thrombosis: two with right transverse/sigmoid sinus thrombosis experienced significant neurological deficits and prolonged hospital courses even with anti-coagulation therapy; one patient with a left transverse/sigmoid sinus thrombosis had a good outcome with anti-coagulation therapy. The other two of the five patients had outflow obstruction, likely from focal epidural bleeding and extrinsic compression: one patient with partial obstruction in the right transverse-sigmoid junction, due to epidural bleeding, experienced a difficult recovery; one patient with a right sigmoid sinus obstruction presented and remained asymptomatic and experienced a benign hospital course. Two of the five patients had a posterior temporal hemorrhagic area ipsilateral to the affected sinus, suggesting that this finding may have represented hemorrhagic venous infarction rather than traumatic contusion. We propose that a basilar skull fracture in the region of temporal or occipital bone should be considered as a significant risk factor for the development of transverse/sigmoid venous sinus obstruction and may be an under-recognized and treatable cause of increased intracranial pressure. Failure to detect this complication may explain, in part, unexpected clinical outcomes.
    Emergency operative intervention has been one of the cornerstones of the care of the injured patient. Over the past several years, nonoperative management has increasing been recommended for the care of selected blunt abdominal solid... more
    Emergency operative intervention has been one of the cornerstones of the care of the injured patient. Over the past several years, nonoperative management has increasing been recommended for the care of selected blunt abdominal solid organ injuries. The purpose of this study was to utilize a large statewide, population-based data set to perform a time-series analysis of the practice of physicians caring for blunt solid organ injury of the abdomen. The study was designed to assess the changing frequency and the outcomes of operative and nonoperative treatments for blunt hepatic and splenic injuries. Data were obtained from the state hospital discharge data base, which tracks information on all hospitalized patients from each of the 157 hospitals in the state of North Carolina. All trauma patients who had sustained injury to a solid abdominal organ (kidney, liver, or spleen) were selected for initial analysis. During the 5 years of the study, 210,256 trauma patients were admitted to the state's hospitals (42,051 +/- 7802 per year). The frequency of nonoperative interventions for hepatic and splenic injuries increased over the period studied. The frequency of nonoperative management of hepatic injuries increased from 55% in 1988 to 79% in 1992 in patients with hepatic injuries and from 34% to 46% in patients with splenic injuries. The rate of nonoperative management of hepatic injuries increased from 54% to 64% in nontrauma centers compared with an increase from 56% to 74% in trauma centers (p = 0.01). In patients with splenic injuries, the rate of nonoperative management increased from 35% to 44% in nontrauma centers compared with an increase from 33% to 49% in trauma centers (p < 0.05). The rate of nonoperative management was associated with the organ injury severity, ranging from 90% for minor injuries to 19%-40% for severe injuries. Finally, in an attempt to compare blood use in operatively and nonoperatively treated patients, the total charges for blood were compared in the two groups. When compared, based on organ injury severity, the total blood used, as measured by charges, was lower for nonoperatively treated patients. This large, statewide, population-based time-series analysis shows that the management of blunt injury of solid abdominal organs has changed over time. The incidence of nonoperative management for both hepatic and splenic injuries has increased. The study indicates that the rates of nonoperative management vary in relation to the severity of the organ injury. The rates increase in nonoperative management were greater in trauma centers than in nontrauma centers. These findings are consistent with the hypothesis that this newer approach to the care of blunt injury of solid abdominal organs is being led by the state's trauma centers.
    In reviewing the literature on burn therapy and observing clinical burn care, we noted differences among institutions and individual experts in several areas. To study variation in burn care, we surveyed the 140 burn centers listed by the... more
    In reviewing the literature on burn therapy and observing clinical burn care, we noted differences among institutions and individual experts in several areas. To study variation in burn care, we surveyed the 140 burn centers listed by the American Burn Association to determine how burn care is currently administered in the United States and Canada. Responses were obtained from 83 hospitals (60%). The survey addressed resuscitation, operative and nonoperative wound care, medications, antimicrobial agents, and pain control. The major influence on care appeared to be the experience of the director (considered "very influential" in 85%) compared with the literature ("very influential" in 12%) and habit/what works for us ("very influential" in 48%). The Parkland formula was used "always" or "often" by 78%, and the Brooke formula "never" by 81% of respondents. Lactated Ringer's solution was the most popular initial fluid, and most (78%) respondents changed fluids after 24 hours. However, the fluids used in the second 24 hours varied equally among several choices. The use of colloids also varied without a set pattern. Furosemide (Lasix) and nonsteroidal antiinflammatory drugs were used "rarely" or "never" by 67% of centers in the acute stage. H2 blockers were used for gastritis prophylaxis "always" or "often" in 60% (vs 53% for antacids and 20% for sucralfate [Carafate]). Tube feedings were started on day 1 after burn injury "always" by less than 30% of centers. Total parenteral nutrition was not commonly used. Most centers use of silver sulfadiazine on the body and hands, but facial topical antimicrobial therapy varied.(ABSTRACT TRUNCATED AT 250 WORDS)
    The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults. Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of... more
    The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults. Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively. Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05). Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.