Manuel Lorenzo

Methodist Dallas Medical Center, Dallas, Texas, United States

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Publications (8)12.03 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Trauma centers nationwide have been experiencing an increase in their elderly trauma patients because of an ever growing elderly population within the United States. Many studies have demonstrated the physiologic differences between an older trauma patient versus a younger trauma patient. Coupling these differences with their coexisting medical comorbidities, makes caring for this population extremely challenging. To meet these challenges, we organized a geriatric trauma unit specifically designed with a multidisciplinary approach to take a more aggressive stance to the care of the geriatric trauma patient. We created a geriatric trauma unit at our Level II trauma facility, called the G-60 unit. This unit opened for admission in August 2009. Inclusion criteria included all trauma patients older than 60 years. Data were abstracted from our G-60 unit from the period of August 2009 to July 2010. We compared these data to a similar patient population (control group) from January 2008 to December 2008. Our Trauma Data Bank yielded 673 patients for the above queried time period. The G-60 group contained 393 patients, while the control group had 280 patients. A decrease was seen among the G-60 group in all categories: average emergency department length of stay (LOS), average emergency department to operating room time, average surgical intensive care unit LOS, and average hospital LOS. A 3.8% mortality rate was found in the G-60 group compared with a 5.7% mortality rate in the control group. Our analysis also showed rate of 0% pneumonia, 1.3% respiratory failure, and 1.5% urinary tract infection in the G-6O group, while the control group had a rate of 1.8% pneumonia, 6.8% respiratory failure, and 3.9% urinary tract infection. Our data from the 1-year experience of our G-60 unit show that addressing the specific needs of elderly trauma patients will lead to better outcomes.
    The journal of trauma and acute care surgery. 01/2012; 72(1):119-22.
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    ABSTRACT: Providing analgesia for patients with rib fractures continues to be a management challenge. The objective of this study was to examine our experience with the use of a continuous intercostal nerve block (CINB). Although this technique is being used, little data have been published documenting its use and efficacy. We hypothesized that a CINB would provide excellent analgesia, improve pulmonary function, and decrease length of stay (LOS). Consecutive adult blunt trauma patients with three or more unilateral rib fractures were prospectively studied over 24 months. The catheters were placed at the bedside in the extrathoracic, paravertebral location, and 0.2% ropivacaine was infused. Respiratory rate, preplacement (PRE) numeric pain scale (NPS) scores, and sustained maximal inspiration (SMI) lung volumes were determined at rest and after coughing. Parameters were repeated 60 minutes after catheter placement (POST). Hospital LOS comparison was made with historical controls using epidural analgesia. Over the study period, 102 patients met inclusion criteria. Mean age was 69 (21-96) years, mean injury severity score was 14 (9-16), and the mean number of rib fractures was 5.8 (3-10). Mean NPS improved significantly (PRE NPS at rest = 7.5 vs. POST NPS at rest = 2.6, p < 0.05, PRE NPS after cough = 9.4, POST after cough = 3.6, p < 0.05) which was associated with an increase in the SMI (PRE SMI = 0.4 L and POST SMI = 1.3 L, p < 0.05). Respiratory rate decreased significantly (p < 0.05) and only 2 of 102 required mechanical ventilation. Average LOS for the study population was 2.9 days compared with 5.9 days in the historical control. No procedural or drug-related complications occurred. Utilization of CINB significantly improved pulmonary function, pain control, and shortens LOS in patients with rib fractures.
    The Journal of trauma 12/2011; 71(6):1548-52; discussion 1552. · 2.35 Impact Factor
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    ABSTRACT: Many elderly trauma patients have isolated orthopedic injuries compounded by chronic medical conditions. We organized a trauma unit, led by trauma surgeons, that is designed to expedite the care of geriatric patients through a multidisciplinary approach. The development of G-60, our Geriatric Trauma Unit, began with discussion between trauma surgeons and hospital administration. Dialogue between trauma surgeons and emergency department physicians yielded triaging, disposition, and admission criteria. Orthopedic surgeons helped implement a goal of operative management in 48 hours. Internal medicine assisted in optimizing chronic disease and providing preoperative clearance with involvement of cardiology and anesthesiology. Meetings were held among surgeons, physical therapists, occupational therapists, respiratory therapists, nutritionists, pharmacists, social workers, case managers, internists, a geriatrician, and physical medicine and rehabilitation. A unit in the hospital was chosen, and a paging system was implemented. Six months lapsed from inception to fulfillment. The multidisciplinary team has achieved several improvements in this population. Through a multidisciplinary approach, a geriatric trauma unit was created that expedites triage, optimizes chronic illness to facilitate definitive management, and provides safe discharge.
    The American surgeon 09/2011; 77(9):1144-6. · 0.92 Impact Factor
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    ABSTRACT: The management of trauma patients continues to be a major focus of resident training. The purpose of this review is to compare the mechanism and distribution of injuries in civilian and military trauma and to ascertain whether we are optimally preparing surgeons for the injuries seen on the battlefield. We performed a retrospective 5-year review of all trauma admissions to our urban trauma center (TC). We then compared this data with that recently acquired from Operation Iraqi Freedom (OIF). There were 7732 trauma patients seen during that time at our TC with 9.8 per cent sustaining gunshot wounds. Of those, 26 per cent sustained a gunshot wound to the thorax, and injuries to the abdomen and pelvis were sustained in 28.5 per cent. In total, truncal trauma accounted for 55 per cent of the injuries. Extremity injuries occurred in just 31 per cent. Data from OIF show the mechanism and distribution of injuries to be quite different. Improvised explosive devices accounted for greater than 50 per cent of the injuries in OIF. Truncal injuries accounted for just 14 per cent of the injuries seen and extremity injuries accounted for, a significant, 56 per cent of all the injuries observed. The civilian experience with gunshot wounds often focuses on truncal trauma, yet the military data show a need for knowledge of devastating injuries to the extremity. This divergent experience may be even more salient in the future as the battlefield is brought closer to home through domestic terrorism and the line is blurred between military and civilian trauma.
    The American surgeon 01/2011; 77(1):19-21. · 0.92 Impact Factor
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    ABSTRACT: Rib fractures continue to be a challenging problem from both a pulmonary and analgesia standpoint. As a result, numerous modalities have been used to treat this condition, but none has proven universally available and efficacious. The objective of this pilot study was to assess the efficacy of a novel technique for placing an elastomeric infusion pump (EIP) catheter (On-Q; Lake Forest, CA, USA) in the extrathoracic paraspinous space to create a continuous intercostal nerve block. This was a prospective, nonrandomized study conducted in the surgical intensive care unit (SICU) of an urban level II trauma center. We developed a novel technique for placing EIP catheters in the extrathoracic paraspinous space to provide continuous intercostal nerve blockade. We subsequently evaluated 30 consecutive blunt trauma patients with three or more unilateral rib fractures. The catheters were infused with local anesthetic, and the dose was titrated to achieve adequate analgesia. For each patient, preplacement numeric pain scale scores (NPSs) and sustained maximum inspiration (SMI) lung volumes were determined. Sixty minutes following placement of the catheters, the NPS and SMI were repeated. The patients were monitored for any procedural or drug-related complications. The mean age of the patients was 65 years (22-92 years); the mean ISS was 14 (9-16); and the mean number of rib fractures was 4.4 (3-8). Overall, the mean NPS significantly improved (preplacement NPS 9.03, postplacement NPS 3.06; p < 0.05) and was associated with a significant increase in the SMI (preplacement SMI 0.40 L, postplacement SMI 1.1 L; p < 0.05). The catheters remained in place for an average of 98 h (72-146 h), and there were no procedural- or drug-related complications. These pilot data indicate that the placement of EIP catheters in the extrathoracic paraspinous space may be a safe, viable, and efficacious procedure for ameliorating pain secondary to rib fractures.
    World Journal of Surgery 10/2010; 34(10):2359-62. · 2.23 Impact Factor
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    ABSTRACT: Elderly trauma patients have a higher incidence of medical comorbidities when compared with their younger cohorts. Currently, the minimally accepted criteria established by the Committee on Trauma for the highest level of trauma activation (Level I) does not include age as a factor. Should patients older than 60 years with multiple injuries and/or a significant mechanism of injury be considered as part of the criteria for Level I activation? Would these patients benefit from a higher level of activation? The National Trauma Data Bank was queried for the period of January 1, 1999, to December 31, 2008, for all trauma patients and associated injury severity score (ISS). The data abstracted were based on age and ISS. The National Trauma Data Bank contained 802,211 trauma patients. Seventy-nine percent were younger than 60 years, and 21% were older than 60 years. Our analysis shows that in all levels of injury, patients older than 60 years have an increased risk for morbidity and mortality. We found a threefold increase in morbidity and a fivefold increase in mortality among the older (age >60 years) population with a minor ISS. Elderly patients with a major ISS demonstrated a twofold increase in morbidity and a fourfold increase in mortality. Patients with an ISS between 0 and 15 are often triaged to Level II activation. Our data would suggest that patients older than 60 years should be a criterion for the highest level of trauma activation.
    The Journal of trauma 07/2010; 69(1):88-92. · 2.35 Impact Factor
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    ABSTRACT: As early as 1979, suggestions were made to establish amputation teams and protocols in major metropolitan areas. It was recognized that preplanning on such calls would be valuable to carrying out rescues of that nature. Since then, questionnaires and collegial conversations reveal the existence of such teams remains the exception in our nation's cities. Our team was formed in 1984 after an emergency medical service request for a surgeon to perform an amputation on a person who had become entrapped with both arms in an industrial candy press was made. In its current form, the team consists of an attending trauma surgeon, a resident surgeon, a registered nurse, and a pilot, all hospital based. Equipment is limited to medications for sedation and pain control, two units of uncross-matched blood, and a prebundled duffle bag of bandages, a scalpel, various saws, and hemostats. Transportation to the scene is provided by the helicopter based at our level II trauma center. Since its inception, the team has been activated three to four times per year, resulting in nine amputation rescues. Three of these cases, presented here, are from an unusually busy 5 weeks during the spring of 2008. The first case involves a tree shredding device, the second, an industrial auger, and the third, a forklift and a steel toed boot. In these cases, the utilization of the amputation team resulted in successful patient rescues and outcomes. A field amputation team can be an integral part of any emergency medical service system, filling an infrequently used but helpful adjunct to emergency care.
    The Journal of trauma 12/2009; 67(6):1158-61. · 2.35 Impact Factor
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    ABSTRACT: Multidisciplinary rounds (MDRs) have been instituted for patient care since June 2005. Before June 2005, all care was provided by individual practitioners. MDRs include the surgical intensivist, surgical resident, patient's nurse, case manager, pharmacist, chaplain, nutritionist, and respiratory therapist. Our study examined the effect of MDRs on ventilator-associated pneumonia in trauma patients in open intensive care units (ICUs). Group 1 included patients from June 2003 to May 2005 before the implementation of MDRs, and Group 2 included patients after the institution of MDRs from June 2005 to May 2007. In Group 1, there were 83 ventilator-associated pneumonias (VAPs) during 2414 ventilator days. In Group 2, there were 49 VAPs during 2094 ventilator days. The ratio of VAPs per thousand ventilator days decreased from 34.4 to 23.4 between the two groups (P = 0.04). When comparing trauma patients in our open ICU with similar mean Injury Severity Score and mean Abbreviated Injury Score for chest and for head and neck, implementing MDRs significantly decreased our incidence of VAP.
    The American surgeon 12/2009; 75(12):1171-4. · 0.92 Impact Factor

Publication Stats

37 Citations
12.03 Total Impact Points

Institutions

  • 2009–2012
    • Methodist Dallas Medical Center
      Dallas, Texas, United States
  • 2011
    • Methodist Health System
      Dallas, Texas, United States