[Show abstract][Hide abstract] ABSTRACT: Objective. To assess the impact of high-fidelity patient simulation on pharmacy resident knowledge, confidence, and competency with advanced resuscitation algorithms and interventions. Design. An overview of the institutional cardiopulmonary arrest algorithm and a review of pertinent medications and calculations were presented to postgraduate year 1 (PGY1) pharmacy residents, followed by participation in 3 simulated clinical scenarios using a high-fidelity mannequin. Assessment. An improvement of pharmacy resident knowledge, confidence, and competency with advanced resuscitation skills was observed. In addition, pharmacy residents demonstrated high performance levels with skills requiring advanced competency and proactive interactions with the cardiac arrest team. Conclusion. Incorporating high-fidelity patient simulation into an advanced resuscitation training program can help pharmacy residents achieve competency through the active learning of practical skills.
American journal of pharmaceutical education 04/2014; 78(3):59. · 1.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Unlike anterior stab wounds (SW), in which local exploration may direct management, posterior SW can be challenging to evaluate. Traditional triple contrast computed tomography (CT) imaging is cumbersome and technician-dependent. The present study examines the role of CT tractography as a strategy to manage select patients with back and flank SW. Hemodynamically stable patients with back and flank SW were studied. After resuscitation, Betadine- or Visipaque®-soaked sterile sponges were inserted into each SW for the estimated depth of the wound. Patients underwent abdominal helical CT scanning, including intravenous contrast, as the sole abdominal imaging study. Images were reviewed by an attending radiologist and trauma surgeon. The tractogram was evaluated to determine SW trajectory and injury to intra- or retroperitoneal organs, vascular structures, the diaphragm, and the urinary tract. Complete patient demographics including operative management and injuries were collected. Forty-one patients underwent CT tractography. In 11 patients, tractography detected violation of the intra- or retroperitoneal cavity leading to operative exploration. Injuries detected included: the spleen (two), colon (one), colonic mesentery (one), kidney (kidney), diaphragm (kidney), pneumothorax (seven), hemothorax (two), iliac artery (one), and traumatic abdominal wall hernia (two). In all patients, none had negative CT findings that failed observation. In this series, CT tractography is a safe and effective imaging strategy to evaluate posterior torso SW. It is unknown whether CT tractography is superior to traditional imaging modalities. Other uses for CT tractography may include determining trajectory from missile wounds and tangential penetrating injuries.
The American surgeon 04/2014; 80(4):403-407. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We conducted a prospective observational multi-institutional study to examine the natural history of the open abdomen (OA) after trauma and identify risk factors for failure to achieve definitive primary fascial closure (DPC) after OA use in trauma.
Adults requiring OA for trauma were enrolled during a 2-year period. Demographics, presentation, and management variables were used to compare primary fascial closure and non-primary fascial closure patients, with logistic regression used to identify independent risk factors for failure to achieve primary fascial closure.
A total of 572 patients from 14 American College of Surgeons-verified Level I trauma centers were enrolled. The majority were male (79%), mean (SD) age 39 (17) years. Injury Severity Score (ISS) was 15 or greater in 85% of patients and 84% had an abdominal Abbreviated Injury Scale (AIS) score of 3 or greater. Overall mortality was 23%. Initial primary fascial closure with unaltered native fascia was achieved in 379 patients (66%). Patients surviving at least 48 hours were grouped into those achieving DPC and those who did not achieve DPC after OA use. After logistic regression, independent risk factors for failure to achieve DPC included the number of reexplorations required (adjusted odds ratio [AOR], 1.3; 95% confidence interval (CI), 1.2-1.6; p < 0.001) the development of intra-abdominal abscess/sepsis (AOR, 2.4; 95% CI, 1.2-4.8; p = 0.011) bloodstream infection (AOR, 2.6; 95% CI, 1.2-5.7; p = 0.017), acute renal failure (AOR, 2.3; 95% CI, 1.2-5.7; p = 0.007), enteric fistula (AOR, 6.4; 95% CI, 1.2-32.8; p = 0.010) and ISS of greater than 15 (AOR, 2.5; 95% CI, 1.1-5.9; p = 0.037).
Our study identifies independent risk factors associated with failure to achieve primary fascial closure during initial hospitalization after OA use for trauma. Additional study is required to validate appropriate algorithms that optimize the opportunity to achieve primary fascial closure and outcomes in this population.
Prognostic study, level III.
The journal of trauma and acute care surgery. 01/2013; 74(1):113-22.
[Show abstract][Hide abstract] ABSTRACT: Standard venous thromboembolism (VTE) prophylaxis with enoxaparin results in inadequate protection in certain patients, with subtherapeutic plasma anti-Xa levels associated with elevated VTE rates. We hypothesized that many trauma patients would be subtherapeutic on the standard prophylactic dose of enoxaparin. Our goal was to adjust the enoxaparin dose to achieve target anti-Xa levels to take advantage of the drug based on its pharmacologic properties.
Patients admitted to the trauma service were included if they received at least three doses of prophylactic enoxaparin and underwent at least two screening venous duplex. Peak plasma anti-Xa levels of 0.2 IU/mL or less were considered low, and the dose was increased by 10 mg twice daily until adequate anti-Xa levels were obtained. A strict screening venous duplex protocol was followed. Patients were excluded if they were diagnosed with a deep venous thrombosis before beginning enoxaparin or did not have correctly timed anti-Xa levels.
Sixty-one trauma patients met inclusion criteria. There were three patients diagnosed with VTE (4.9%). Patients had a mean age of 45.9 years and were predominantly male (70.5%). Of the 61 patients, 18 (29.5%) had therapeutic anti-Xa levels on standard enoxaparin 30 mg twice daily. Compared with patients who had therapeutic anti-Xa levels on enoxaparin 30 mg twice daily, the 43 patients (70.5%) who were subtherapeutic were more likely to be male, have greater body weight, and larger body surface area. There were no significant bleeding events in the group that received an enoxaparin dose adjustment.
Most patients had subtherapeutic anti-Xa levels while on enoxaparin 30 mg twice daily, suggesting inadequate VTE prophylaxis. The need for routine use of a higher dose of prophylactic enoxaparin in trauma patients and the effects of routinely dose adjusting enoxaparin on VTE rates should be the study of future prospective, randomized trials.
Therapeutic study, level IV.
The journal of trauma and acute care surgery. 01/2013; 74(1):128-35.
[Show abstract][Hide abstract] ABSTRACT: Despite improvements in the diagnosis and management of acute kidney injury (AKI), posttraumatic renal dysfunction continues to be associated with increased morbidity and mortality. Intravenous (IV) contrast is known to induce AKI in high-risk groups including the elderly and critically ill. We sought to determine whether IV contrast exposure among high-risk trauma patients resulted in renal dysfunction as defined by the Acute Kidney Injury Network criteria.
We performed a 3-year retrospective analysis of all patients admitted to our Level I trauma center surgical intensive care unit for >48 hours. Patients with preexisting chronic renal dysfunction were excluded. We performed univariate and bivariate analyses to identify risk factors for AKI. Multivariable logistic regression analysis identified independent predictors for AKI. Subgroup analysis was undertaken among high-risk groups to include elderly patients (aged ≥65 years) with admission hypotension (systolic blood pressure <90 mm Hg) and an Injury Severity Score (ISS) ≥25.
Of the 6,317 patients, 571 (9.0%) patients met the inclusion criteria; 170 (29.8%) patients developed AKI. Age ≥65 years (odds ratio [OR] 2.26, 95% confidence interval [CI] = 1.06-4.80, p <0.034) and ISS ≥25 (OR 1.86, 95% CI = 1.12-3.07, p <0.015) were determined to be independent predictors of AKI. IV contrast was not identified to be a predictor of AKI. Upon subgroup analysis, IV contrast exposure was not a predictor of AKI among the elderly, hypotensive, or severely injured patients (ISS ≥25).
A complete trauma workup including studies requiring IV contrast exposure should be considered safe even among high-risk trauma patients.
The journal of trauma and acute care surgery. 01/2012; 72(1):61-6; discussion 66-7.
[Show abstract][Hide abstract] ABSTRACT: This study compares open tibia fractures in US Navy and US Marine Corps casualties from the current conflicts with those from a civilian Level I trauma center to analyze the effect of blast mechanism on limb-salvage rates.
Data from the 28,646 records in the University of California San Diego Trauma Registry from 1985 to 2006 was compared with 2,282 records from the US Navy and US Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database for the period of March 2004 to August 2007. Injuries were categorized by Gustilo-Anderson (G-A) open fracture classification. Independent variables included age, gender, mechanism of injury including blast mechanisms, shock, blood loss, prehospital time, procedures, Injury Severity Score, length of stay, and Mangled Extremity Severity Score (MESS). Dependent variables included early or late amputation and mortality.
The civilian group had 850 open tibia fractures with 45 amputations; the military group had 21 amputation patients (3 bilateral) in 115 open tibia fractures. Military group patients were more severely injured, more likely have hypotension, and had a higher amputation rate for G-A IIIB and IIIC fractures then civilian group patients. Blast mechanism was seen in the majority of military group patients and was rare in the civilian group. MESS scores had poor sensitivity (0.46, 95% confidence interval: 0.29-0.64) in predicting the need for amputation in the civilian group; in the military group sensitivity was better (0.67, 95% confidence interval: 0.43-0.85), but successful limb salvage was still possible in most cases with an MESS score of ≥7 when attempted.
Despite current therapy, limb salvage for G-A IIIB and IIIC grades are significantly worse for open tibia fractures as a result of blast injury when compared with typical civilian mechanisms. MESS scores do not adequately predict likelihood of limb salvage in combat or civilian open tibia fractures.
The Journal of trauma 05/2011; 70(5):1241-7. · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pedicabs are a new and controversial transportation innovation for tourists in congested areas in several U.S. cities. Scant literature on this trauma mechanism exists. The purpose of this study is to identify the incidence, demographics, morbidity, mortality, and potential for injury prevention of pedicab incidents amongst major trauma admissions at an urban, academic Level I Trauma Center.
Researchers conducted a retrospective review of the Trauma Registry from 2000 to 2009. All patients identified as being injured in a pedicab incident were reviewed. Demographics, diagnoses, toxicology, treatments, and injury severity scale (ISS) were collected. Outcomes included mortality, ICU, and hospital length of stay (LOS), discharge disposition, and hospital charges. A photographic survey of 50 local pedicabs was examined for the presence and use of safety equipment.
During the period of January 2000 to July 2009 there were 15 major trauma victims from identified pedicab incidents. Falling from the pedicab was the mechanism of injury in 14 of 15 cases. There were two fatalities in victims following severe traumatic brain injury. Traumatic brain injury, skull fracture, or loss of consciousness was seen in 11/15 victims. Ethanol ingestion was detected in blood tests of 10 of the 14 adult victims. Median charges of hospitalization due to a pedicab related injury was US$29,956 ± 77,482. A photographic survey of 50 local pedicabs reveals very limited use of safety belts by passengers despite existing city ordinances.
Major trauma victims of pedicab incidents in the United States suffer significant injuries and death. Most cases occurred in passengers falling from the pedicab at night after alcohol ingestion. There is an opportunity for implementation of strategies toward improved injury prevention with this new form of transport.
Journal of safety research 04/2011; 42(2):131-5. · 1.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report the unusual case of a 45-year-old woman who presented with multiple episodes of small bowel obstruction. Initial exploratory lap-roscopy did not reveal an etiology of the obstruction. Subsequent upper endoscopy identified a non-obstructing gastric trichobezoar which could not be removed endoscopically but was not thought to be responsible for the small bowel obstruction given its location. One week postoperatively, the patient experienced recurrence of small bowel obstruction. Repeat endoscopy disclosed that the trichobezoar was no longer located in the stomach and upon repeat laparotomy was extracted from the mid-jejunum. In the following 8 months, the patient had no further episodes of small bowel obstruction. Consequently, gastric bezoars should be included in the differential diagnosis of recurrent small bowel obstruction.
[Show abstract][Hide abstract] ABSTRACT: An increasing proportion of trauma patients are on anticoagulation or antiplatelet therapy. Unlike warfarin, where measuring international normalized ratio can help direct management, measuring platelet inhibition from clopidogrel (Plavix) is not standardized. We report the use of a new P2Y12 point-of-care assay (VerifyNow; Accumetrics, San Diego, CA) to determine the magnitude of platelet inhibition in trauma patients using clopidogrel.
Trauma patients in 2009 were queried for clopidogrel use by prehospital personnel and the trauma team. Blood was obtained on admission for patients reportedly taking clopidogrel and was assayed for platelet inhibition using the VerfiyNow-P2Y12 device that measures P2Y12 reaction units and photometrically determines platelet inhibition percentage within 30 minutes. Patient demographics including age, Injury Severity Score, mechanism of injury, and complications from hemorrhage were also analyzed.
In the time studied, 46 patients taking clopidogrel were assayed for platelet inhibition. The mean age was 75.9 years±11.8 years, and the most common mechanism of injury was fall (86.9%). Platelet inhibition ranged from 0% to 89%. There were no deaths, and only two patients, from the 0% and>30% inhibition group, had hemorrhagic complications (increased intracranial hemorrhage).
The P2Y12 point-of-care assay determined that a large percentage of patients had undetectable or low platelet inhibition despite reportedly being on clopidogrel therapy. These patients may be clopidogrel nonresponders or noncompliant. It is unlikely that clopidogrel reversal therapies, such as platelet transfusions or Desmopressin, would be beneficial in this group. Further studies stratifying the percent platelet inhibition needed to increase bleeding complications is warranted to optimize management strategies.
The Journal of trauma 01/2011; 70(1):65-9; discussion 69-70. · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Acute renal failure (ARF) in trauma patients is associated with high mortality rates. There is currently no consensus definition for renal failure, however, the American College of Surgeons' Committee on Trauma (ACSCOT) defines ARF as a serum creatinine > or =3.5, blood urea nitrogen > 100, or renal replacement therapy. We hypothesize that by using the Acute Kidney Injury Network (AKIN) staging system we would identify smaller changes in renal function that may impact outcome, and may serve as a marker for mortality and other organ dysfunction.
We retrospectively identified all trauma patients admitted to the surgical intensive care unit (SICU) for >48 hours during a 3-year period ending December 2007. Hourly urine output, serum creatinine, demographic data, trauma scores, admission vital signs, ICU and hospital length of stay, need for renal replacement therapy, organ failure, and death were collected and were stratified according to AKIN and ACSCOT renal dysfunction criteria. Trauma patients admitted to the SICU who did not develop renal dysfunction were used as controls.
A total of 571 patients were studied. Of those, only 17 patients (3.0%) were classified as having ARF by the ACSCOT criteria, whereas 170 (29.8%) had kidney injury using the AKIN criteria (146, stage 1; 15, stage 2; 9, stage 3). Compared with patients admitted to the ICU for > or =48 hours with normal renal function, patients meeting AKIN criteria had longer hospital and ICU length of stay (p < 0.001). Patients meeting AKIN criteria also had an increased incidence of multiple organ failure and death (p < 0.03).
Stratification using the AKIN criteria for acute kidney injury identifies an increased number of patients with renal dysfunction compared with the current ACSCOT criteria. Importantly, these patients have an increased risk of multiple organ failure and death. Inclusion into the AKIN criteria may be a marker for later morbidity and mortality.
The Journal of trauma 09/2009; 67(2):283-7; discussion 287-8. · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The gut origin of the inflammatory response in trauma patients has been difficult to define. "In vivo" generation of neutrophil-activating factors by gut proteases may be a cause of multiorgan failure after hemorrhagic shock, and can be prevented with the serine protease inhibitor nafamostat mesilate (Futhan). The objective of this study was to determine the effect of nafamostat mesilate given by enteroclysis on enteric serine protease activity, neutrophil activation, and transfusion requirements during hemorrhagic shock.
Sixteen pigs weighing 21 to 26 kg were divided into control and treatment groups. A laparotomy was performed under anesthesia, and catheters were placed in the duodenum, midjejunum, and terminal ileum. Pigs were bled 30 mL/kg over 30 minutes and maintained at a mean arterial pressure of 30 mm Hg for 60 minutes. Shed blood was then used to maintain a mean arterial pressure of 45 mm Hg for another 3 hours. Treated animals received 100 mL/kg of 0.37 mmol/L nafamostat mesilate in GoLYTELY through the duodenal catheter at 1 L/h. Control animals received GoLYTELY only. Samples of enteral content and blood were taken at baseline, after shock, and at 30-minute intervals during resuscitation. Animals were killed after 3 hours of resuscitation. Enteral trypsin-like activity at the three gut sites was measured by spectrophotometry. Activation of naive human neutrophils by pig plasma was measured by the percentage of cells having pseudopods larger than 1 microm on microscopy. Lung, liver, and small bowel were analyzed by histology and myeloperoxidase assay.
Both control and nafamostat mesilate-treated groups had significant reductions in protein and protease levels in the duodenum during enteroclysis; however, only nafamostat mesilate-treated animals had persistent suppression of protease activity throughout the experiment. Nafamostat mesilate-treated animals had a lower transfusion requirement of shed blood, 18.1 +/- 4.5 mL/kg versus 30 +/- 0.43 mL/kg (p = 0.002). Nafamostat mesilate-treated animals had significantly less neutrophil activation than controls at 150 minutes after resuscitation (33.7 +/- 6.48% vs. 42.4 +/- 4.57%,p = 0.01) and 180 minutes after resuscitation (31.1 +/- 3.31% vs. 46.9 +/- 4.53%, p = 0.0002). Lung myeloperoxidase activity was lower in nafamostat mesilate-treated animals (0.31 +/- 0.14) than in control animals (0.16 +/- 0.04, p = 0.04). Histology of liver and small intestine showed less injury in nafamostat mesilate-treated animals.
Nafamostat mesilate given by means of enteroclysis with GoLYTELY significantly reduces enteral protease levels, leukocyte activation, and transfusion requirements during resuscitation from hemorrhagic shock. This strategy may have clinical promise.
The Journal of trauma 04/2004; 56(3):501-10; discussion 510-1. · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The development of trauma systems reduces preventable mortality and the measurement of standardized complications creates further opportunity for improvement in morbidity. The annual incidence of complications in a trauma population has been previously reported but the frequency change over time in a single institution is not well studied.
All patients who were hospitalized for more than 24 hours, who died, were admitted to the Intensive Care Unit (ICU) or Intermediate Care Unit (IMU), or were inter-facility transfers prospectively evaluated for 12 consecutive years. A total of 13,382 patients were studied (range, 862-1234 patients per year). Complication events were collected using 135 standardized definitions including disease and provider outcomes.
The overall incidence of complications has remained stable over time. Provider events, disease events, and patients developing three or more complications have remained unchanged as well. Specific disease complications including pneumonia, deep vein thrombosis (DVT), and small bowel obstruction have fallen over time. Improvements in provider errors have also occurred.
This data suggests that most complications have a finite threshold despite the use of a stable trauma staff, implementation of standardized protocols, and emphasis on consistency of practice. Further reductions will require new research for disease-related treatment and new strategies for consistency and error reduction rather than our current models of continuous quality improvement.
The Journal of trauma 02/2003; 54(1):26-36; discussion 36-7. · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The genitourinary system lies in the retroperitoneal space and shares the perineum with the rectum and major neurovascular
structures. As a result, penetrating trauma to the genitourinary system usually is associated with injury to multiple organ
systems and requires a multidisciplinary effort with an organized and thorough evaluation of all injuries.