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ABSTRACT: BACKGROUND: Recently, there has been a 58% increase in the number of observed cyclists in San Francisco. In 2009, 3.2% of commuters were traveling by bicycle in this city, which is well above the national average of less than 1%. Police reports are the industry standard for assessing transportation-related collisions and informing policies and interventions that address the issue. Previous studies have suggested that police reports miss a substantial portion of bicycle crashes not involving motor vehicles. No study to date has explored the health and economic impact of cyclist-only (CO) injuries for adults in the United States. Our objective was to use trauma registry data to investigate possible underrepresentation of certain cyclist injuries and characterize cost. METHODS: We reviewed hospital and police records for 2,504 patients treated for bicycle-related injuries at San Francisco General Hospital (SFGH). We compared incidence, injury severity, admission rate, and cost of injury for CO and auto-versus-bicycle (AVB) injuries treated at SFGH. We then calculated the cost of injury. RESULTS: Of all bicycle-related injuries at SFGH, 41.5% were CO injuries and 58.5% were AVB injuries. Those with CO injuries were more than four times as likely to be required of hospital admission compared with those with AVB injuries (odds ratio, 4.76; 95% confidence interval, 3.93-5.76; p < 0.0001). From 2000 to 2009, 54.5% of bicycle injuries treated at SFGH were not associated with a police report, revealing that bicycle crashes and injuries are underrecognized in San Francisco. Costs for care were significantly higher for AVB injuries and increased dramatically over time; total cost for CO and AVB injuries were $12.6 and $17.8 million. CONCLUSION: Based on this study, we conclude that trauma centers can play a key role in future collaborations to define issues and develop prevention strategies for CO crashes. LEVEL OF EVIDENCE: Epidemiologic/economic analysis, level III.
The journal of trauma and acute care surgery. 10/2012;
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Rochelle A Dicker,
Jennifer Mah,
Dahianna Lopez,
Catherine Tran,
Rosemary Reidy,
Megan Moore,
Phil Kreniske,
Ian Crane,
M Margaret Knudson,
Moon Li,
Rebecca Menza,
Martha Shuway,
Jennifer Alvidrez
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ABSTRACT: Injury prevention and screening efforts have long targeted risk factors for injury recurrence. In a retrospective study, our group found that mental illness is an independent risk factor for unintentional injury and reinjury. The purpose of this study was to administer a standard validated screening instrument and psychosocial needs assessment to admitted patients who suffer unintentional injury. We aimed to prospectively measure the prevalence of mental illness. We hypothesize that systematic screening for psychiatric disorders in trauma patients is feasible and identifies people with preexisting mental illness as a high-risk group for unintentional injury.
In this prospective study, we recruited patients admitted to our Level I trauma center for unintentional injury for a period of 18 months. A bedside structured interview, including the Mini International Neuropsychiatric Interview, and a needs assessment were performed by lay research personnel trained by faculty from the Department of Psychiatry. The validated needs assessment questions were from the Camberwell Assessment of Need Short Appraisal Schedule instrument. Psychiatric screening and needs assessment results, as well as demographic characteristics are reported as descriptive statistics.
A total of 1,829 people were screened during the study period. Of the 854 eligible people, 348 were able to be approached by researchers before discharge with a positive response rate of 63% (N = 219 enrolled). Interviews took 35 minutes ± 12 minutes. Chi-squared analysis revealed no difference in mechanism in those with mental illness versus no mental illness. Men were significantly more likely to be found to have a mental health disorder but when substance abuse was excluded, no difference was found. Four-way diagnostic grouping revealed the prevalence of mental illness detected.
This inpatient pilot screening program prospectively identified preexisting mental illness as a risk factor for unintentional injury. Implementation of validated psychosocial and mental health screening instruments is feasible and efficient in the acute trauma setting. Administration of a validated mental health screening instrument can be achieved by training college-level research assistants. This system of screening can lead to identification and treatment of mental illness as a strategy for unintentional injury prevention.
The Journal of trauma 06/2011; 70(6):1337-44. · 2.48 Impact Factor
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ABSTRACT: Pedestrian injury costs >$20 billion annually. Countermeasures such as blinking crosswalks can be expensive but expectedly vital to injury prevention efforts. We aimed to create a new framework of cost-driven surveillance. The purpose of our study was to carry out a detailed analysis of the hospital cost and its relationship to location of pedestrian injury. Targeting identified "high cost areas" with effective countermeasures could save lives and be most cost-effective. Our hypothesis is that pedestrian injury creates a tremendous public funding burden and that hotspot sites can be mapped based on corresponding hospital costs.
We conducted a retrospective analysis of billing records of 694 auto versus pedestrian victims treated at Level I trauma center in our city in the sample year 2004. Total cost was computed using cost to charge ratios for hospital and ambulance fees and actual cost of professional fees. City district "price tags" were assigned per detailed patient cost data to corresponding spatial analysis of intersections. χ(2) analyses were conducted on demographic variables. Multiple regression analysis determined predictors of total cost.
The total cost of injury was $9.8 million, whereas the total charge was $20.8 million. Ninety percent of victims resided in our City. Thirty-one percent were admitted and cost of their care accounted for 76% of the total. Admitted patients were older than nonadmitted patients (47 years vs. 38 years; t = 5.45; p = 0.00). Spatial analysis determined that of 11 city districts, three districts accounted for almost 50% of the total cost. Seventy-six percent of the total cost was publicly funded. The strongest predictors of cost were length of stay (â = 0.77; t(220) = 30.42; p = 0.000) and ventilator days (â = 0.51; t(220) = 6.69; p = 0.000).
These findings provide a roadmap to target costly hot spots for city planning of preventive countermeasures. In a climate of limited resources, this kind of roadmap outlines the three regions that could most benefit from countermeasures from both an injury prevention and cost-containment standpoint. Cost-driven surveillance is useful in city strategic planning for cost-effective and life-saving pedestrian injury prevention.
The Journal of trauma 04/2011; 70(4):985-90. · 2.48 Impact Factor
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ABSTRACT: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are sequelae of severe trauma. It is unknown if certain races are at greater risk of developing ALI/ARDS, and once established, if there are racial differences in the severity of lung injury or mortality.
Retrospective cohort study of 4,397 trauma patients (1,831 Caucasians, 871 African-Americans, 886 Hispanics, and 809 Asian/Pacific Islanders) requiring intensive care unit (ICU) admission between 1996 and 2007 at an urban Level I trauma center.
African-American patients were most likely to present in shock with penetrating trauma and receive a massive transfusion. The incidence of ALI/ARDS was similar by race (P = .99). Among patients who developed ALI/ARDS, there was no evidence to support a difference in partial pressure of oxygen in arterial blood to fraction of inspired oxygen (Pao(2)/Fio(2)) (P = .33), lung injury score (P = .67), or mortality (P = .78) by race.
Despite differences in baseline characteristics, the incidence of ALI/ARDS, severity of lung injury, and mortality were similar by race.
American journal of surgery 04/2011; 201(4):486-91. · 2.36 Impact Factor
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Ernest E Moore,
M Margaret Knudson,
Clay C Burlew,
Kenji Inaba, Rochelle A Dicker,
Walter L Biffl,
Ajai K Malhotra,
Martin A Schreiber,
Timothy D Browder,
Raul Coimbra,
Ernest A Gonzalez,
J Wayne Meredith,
David H Livingston,
Krista L Kaups
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ABSTRACT: Since the promulgation of emergency department (ED) thoracotomy>40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival.
Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively.
During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15-64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was >25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge.
Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.
The Journal of trauma 02/2011; 70(2):334-9. · 2.48 Impact Factor
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ABSTRACT: The severity and disparity of interpersonal violent injury is staggering. Fifty-three per 100,000 African Americans (AA) die of homicide yearly, 20 per 100,000 in Latinos, whereas the rate is 3 per 100,000 in Caucasians. With the ultimate goal of reducing injury recidivism, which now stands at 35% to 50%, we have designed and implemented a hospital-based, case-managed violence prevention program uniquely applicable to trauma centers. The Wraparound Project (WP) seizes the "teachable moment" after injury to implement culturally competent case management (CM) and shepherd clients through risk reduction resources with city and community partners. The purpose of this study was to perform a detailed intermediate evaluation of this multi-modal violence prevention program. We hypothesized that this evaluation would demonstrate feasibility and early programmatic efficacy. We looked to identify areas of programmatic weakness that, if corrected, could strengthen the project and enhance its effectiveness.
We performed intermediate evaluation on the 18-month-old program. We selected the Centers for Disease Control and Prevention-recommended instrument used for unintentional injury prevention programs and applied it to the WP. The four sequential stages in this methodology are formative, process, impact, and outcome. To test feasibility of WP, we used process evaluation. To evaluate intermediate goals of risk reduction and early efficacy, we used impact evaluation.
Four hundred thirty-five people met screening criteria. The two case managers were able to make contact and screen 73% of gun shot victims, and 57% of stab wound victims. Of those not seen, 48% were in the hospital for <or=2 days. Fifty-four percent of those screened had identified needs and received CM services. Thirteen percent refused services. Of the high-risk clients receiving full services (N = 45), 60% were AA and 30% were Latino. Sixty percent of the AA had no contact with their fathers. CM "dose": In the first 3 weeks of enrollment, 40% of the time, case managers spent >6 h/wk with the client. Forty-one percent of the time, they spent 3 hours to 6 hours. Seventeen of 18 people who required >6 hours had two to three needs. Attrition rate is only 4%. The table demonstrates percent success thus far in providing risk reduction resources.
WP case managers served high-risk clients by developing trust, credibility, and a risk reduction plan. Cultural competency has been vital. Six of seven major needs were successfully addressed at least 50% of the time. The value of reporting these results has led WP to gain credibility with municipal stakeholders, who have now agreed to fund a third CM position. Intermediate evaluation provided a framework in our effort to achieve the ultimate goal of reducing recidivism through culturally competent CM and risk factor modification.
The Journal of trauma 12/2009; 67(6):1169-75. · 2.48 Impact Factor
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Walter L Biffl,
Krista L Kaups,
C Clay Cothren,
Karen J Brasel, Rochelle A Dicker,
M Kelley Bullard,
James M Haan,
Gregory J Jurkovich,
Paul Harrison,
Forrest O Moore,
Martin Schreiber,
M Margaret Knudson,
Ernest E Moore
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ABSTRACT: The optimal management of hemodynamically stable, asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe, cost-effective manner. Common evaluation strategies include local wound exploration (LWE)/diagnostic peritoneal lavage (DPL), serial clinical assessments (SCAs), and computed tomography (CT) imaging. The purpose of this multicenter study was to evaluate the clinical course of patients managed by the various strategies, to determine whether there are differences in associated nontherapeutic laparotomy (NONTHER LAP), emergency department (ED) discharge, or complication rates.
A multicenter, Institutional Review Board-approved study enrolled patients with AASWs. Management was individualized according to surgeon/institutional protocols. Data on the presentation, evaluation, and clinical course were recorded prospectively.
Three hundred fifty-nine patients were studied. Eighty-one had indications for immediate LAP, of which 84% were therapeutic. ED D/C was facilitated by LWE, CT, and DPL in 23%, 21%, and 16% of patients, respectively. On the other hand, LAP based on abnormalities on LWE, CT, and DPL were NONTHER in 57%, 24%, and 31% of patients, respectively. Twelve percent of patients selected for SCA ultimately had LAP (33% were NONTHER); there was no apparent morbidity due to delay in intervention.
Shock, evisceration, and peritonitis warrant immediate LAP after AASW. Patients without these findings can be safely observed for signs or symptoms of bleeding or hollow viscus injury. To limit the number of hospital admissions, we propose a uniform strategy using LWE to ascertain the depth of penetration; the patient may be safely discharged in the absence of peritoneal violation. Peritoneal penetration, absent evidence of ongoing hemorrhage or hollow viscus injury, should not be considered an indication for LAP, but rather an indication for admission for SCAs. We suggest that a prospective multicenter trial be performed to document the safety and cost-effectiveness of such an approach.
The Journal of trauma 06/2009; 66(5):1294-301. · 2.48 Impact Factor
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Current problems in surgery 01/2008; 44(12):772-6. · 1.42 Impact Factor
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Current problems in surgery 01/2008; 44(12):778-833. · 1.42 Impact Factor
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ABSTRACT: The spontaneous breathing pattern and its relationship to compliance, resistance, and work of breathing (WOB) has not been examined in patients with acute respiratory distress syndrome (ARDS) or acute lung injury (ALI). Clinically, the ratio of respiratory frequency to tidal volume (f/VT) during spontaneous breathing may reflect adaptation to altered compliance, resistance, and increased WOB. We examined the relationship between f/VT, WOB, and respiratory system mechanics in patients with ARDS/ALI.
Data from spontaneous breathing trials were collected from 33 patients (20 with ARDS, 13 with ALI) at various points in their disease course. WOB and respiratory system mechanics were measured with a pulmonary mechanics monitor that incorporates Campbell diagram software. Differences between the patients with ARDS and ALI were assessed with 2-sided unpaired t tests. Multivariate linear regression models were constructed to assess the relationship between f/VT and other pulmonary-related variables.
Patients with ARDS had significantly lower compliance than those with ALI (24 +/- 6 mL/cm H2O vs 40 +/- 13 mL/cm H2O, respectively, p < 0.001), but this did not translate into significant differences in either WOB (1.70 +/- 0.59 J/L vs 1.43 +/- 0.90 J/L, respectively, p = 0.30) or f/VT (137 +/- 82 vs 107 +/- 49, respectively, p = 0.23). Multivariate linear regression modeling revealed that peak negative esophageal pressure, central respiratory drive, duration of ARDS/ALI, minute ventilation deficit between mechanical ventilation and spontaneous breathing, and female gender were the strongest predictors of f/VT.
The characteristic rapid shallow breathing pattern in patients with ARDS/ALI occurs in the context of markedly diminished compliance, elevated respiratory drive, and increased WOB. That f/VT had a strong, inverse relationship to peak negative esophageal pressure also may reflect the influence of muscle weakness.
Respiratory care 09/2007; 52(8):989-95. · 2.01 Impact Factor
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ABSTRACT: More than one third of adults over the age of 65 suffer a fall each year, facing morbidity and mortality. Modifiable risk factors for falls have been identified, but specific recruitment strategies for prevention programs have not been evaluated. The purpose of this observational study was to evaluate recruitment strategies for a fall prevention program.
Participants were recruited during an 11-month period at a Level I trauma center. Participants were eligible if >65 years old, living independently, and had a fall. Recruitment modalities included (1) emergency medical services, (2) emergency department (ED), (3) primary care providers, and (4) media exposure leading to self-referral. Data were collected on baseline rate of fall victims seen in the ED, demographics, medical history, and source of referral.
There were 91 individuals referred, with 61 (67%) enrolled. Enrollment rates were higher among patients referred by self or primary care providers than among those referred by emergency medical services or the ED. There were no significant differences in demographics or medical history among the eligible but not referred ED population, the referred population, and the enrolled population. Reasons for not enrolling included inappropriate referral (33%), no response (17%), other illness (13%), and patients thinking that they do not need the services (37%).
These recruitment strategies were successful in enrolling a representative population of patients at risk for recurrent falls, but could be improved to capture more potential participants. Source of referral has a significant effect on rate of enrollment. We outline challenges and solutions to recruitment.
The Journal of trauma 08/2007; 63(1):142-6. · 2.48 Impact Factor
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The Pharos of Alpha Omega Alpha-Honor Medical Society. Alpha Omega Alpha 02/2007; 70(1):28-33.
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ABSTRACT: Twelve percent of Americans are diagnosed and treated for mental illness annually. The relationship between mental illness and intentional injuries such as assault and suicide has previously been described. However, unintentional injury among mentally ill adults has not been characterized. The purpose of this study was to identify relationships between mental illness diagnosis and unintentional injury. We hypothesized that diagnosed mental illness is an independent risk factor for unintentional injury and it increases the risk of recidivism.
In this retrospective cohort study, trauma registry data, medical records, and outpatient mental health care data from the San Francisco Department of Public Health Billing Information System (BIS) were used to identify patients admitted with unintentional injury at a Level I urban trauma center in 2003 and 2004. Data collected included mechanism of injury, patient outcome and disposition, mental health diagnoses, substance abuse history, presence of homelessness, number of repeat injury events, and outpatient mental health treatment history. The incidence of unintentional injury requiring admission to a trauma center and the risk of intentional injury recidivism in subjects with a mental illness diagnosis were compared with those in subjects without a mental illness diagnosis. The risk of recidivism in those who had received publicly funded outpatient treatment before their injury was also evaluated.
Of the 1,709 patients admitted for unintentional injury, 20% had a diagnosis of mental illness. Individuals with mental illness had twice the rate of unintentional injury requiring admission (2.2-2.4 people in 1,000 vs. 1.0-1.1 in 1,000) and 4.5 times the odds of injury recidivism (odds ratio [OR] = 4.5, 95% confidence interval [CI] 3.3-6.1) as those who did not have a mental illness diagnosis. Mental illness was a more robust predictor of injury recidivism than substance abuse (OR = 3.2, 95% CI 2.3-4.3) or homelessness (OR = 2.3, 95% CI 1.5-3.4). Compared with the nonmentally ill group, subjects with mental illness had a longer hospital stay and were less likely to be discharged home. Also, their injuries were more likely the result of falling or being hit by cars, and less likely the result of motor vehicle collisions than subjects without mental illness.
Mental illness is an independent risk factor for unintentional injury and injury recidivism. Individuals with mental illness also have a different pattern of injury and hospitalization. They tended to suffer from different mechanisms of injury, stayed in the hospital longer, and were more likely to be discharged to a skilled nursing facility. Recognition of mental illness as a risk factor for injury may prompt re-examination of resource allocation for mental health and injury prevention and highlights the mentally ill as a prime target population for unintentional injury prevention efforts.
The Journal of trauma 01/2007; 61(6):1299-304. · 2.48 Impact Factor
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ABSTRACT: Traumatic thoracic aortic injury (TAI) is traditionally treated with immediate surgery. Previously published studies have established the safety and efficacy of treating TAI with endovascular stents. Our hypothesis was that stents are supplanting operative repair as the primary therapy for TAI.
Retrospective cohort.
University level I trauma center.
Blunt trauma patients admitted to a level I trauma center diagnosed with TAI between September 1997 and November 2003 were identified from an institutional trauma registry (N = 25). Data were abstracted from medical records and analyzed. Three groups were defined: surgical repair (cardiopulmonary bypass or clamp and sew) (n = 10); medical management (n = 8); and endovascular stent (n = 7).
Prior to 2002, 9 (75%) of 12 patients were treated by surgical repair, 2 (17%) by medical management, and 1 (8%) by endovascular stent. Since 2002, 1 patient (8%) was treated by surgical repair, 6 (46%) by medical management, and 6 (46%) by endovascular stent. Injury Severity Scores were comparable between the surgical cohort (mean +/- SEM score, 34.9 +/- 3.4), stent placement (35.1 +/- 3.7), and medical management (29.9 +/- 2.8) (P = .48). Overall survival was 80% with no differences in morbidity or mortality. The stented group had shorter hospital lengths of stay compared with surgical management (28 vs 46 days) (P<.05). The 1 operative case since 2002 was a combined arch/innominate injury that anatomically precluded stent placement.
Initial reports suggested thoracic aortic stents as an alternative for injured patients with prohibitive operative risks. Our data suggest stent placement is quickly evolving into the primary therapy for TAI across all Injury Severity Score profiles.
Archives of Surgery 03/2006; 141(2):177-80. · 4.24 Impact Factor
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The Journal of trauma 02/2006; 60(1):204-8. · 2.48 Impact Factor
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ABSTRACT: To assess the effects of step-changes in tidal volume on work of breathing during lung-protective ventilation in patients with acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS).
Prospective, nonconsecutive patients with ALI/ARDS.
Adult surgical, trauma, and medical intensive care units at a major inner-city, university-affiliated hospital.
Ten patients with ALI/ARDS managed clinically with lung-protective ventilation.
Five patients were ventilated at a progressively smaller tidal volume in 1 mL/kg steps between 8 and 5 mL/kg; five other patients were ventilated at a progressively larger tidal volume from 5 to 8 mL/kg. The volume mode was used with a flow rate of 75 L/min. Minute ventilation was maintained constant at each tidal volume setting. Afterward, patients were placed on continuous positive airway pressure for 1-2 mins to measure their spontaneous tidal volume.
Work of breathing and other variables were measured with a pulmonary mechanics monitor (Bicore CP-100). Work of breathing progressively increased (0.86 +/- 0.32, 1.05 +/- 0.40, 1.22 +/- 0.36, and 1.57 +/- 0.43 J/L) at a tidal volume of 8, 7, 6, and 5 mL/kg, respectively. In nine of ten patients there was a strong negative correlation between work of breathing and the ventilator-to-patient tidal volume difference (R = -.75 to -.998).
: The ventilator-delivered tidal volume exerts an independent influence on work of breathing during lung-protective ventilation in patients with ALI/ARDS. Patient work of breathing is inversely related to the difference between the ventilator-delivered tidal volume and patient-generated tidal volume during a brief trial of unassisted breathing.
Critical Care Medicine 02/2006; 34(1):8-14. · 6.33 Impact Factor
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ABSTRACT: Pressure-control ventilation (PCV) and pressure-regulated volume-control (PRVC) ventilation are used during lung-protective ventilation because the high, variable, peak inspiratory flow rate (V (I)) may reduce patient work of breathing (WOB) more than the fixed V (I) of volume-control ventilation (VCV). Patient-triggered breaths during PCV and PRVC may result in excessive tidal volume (V(T)) delivery unless the inspiratory pressure is reduced, which in turn may decrease the peak V (I). We tested whether PCV and PRVC reduce WOB better than VCV with a high, fixed peak V (I) (75 L/min) while also maintaining a low V(T) target.
Fourteen nonconsecutive patients with acute lung injury or acute respiratory distress syndrome were studied prospectively, using a random presentation of ventilator modes in a crossover, repeated-measures design. A target V(T) of 6.4 + 0.5 mL/kg was set during VCV and PRVC. During PCV the inspiratory pressure was set to achieve the same V(T). WOB and other variables were measured with a pulmonary mechanics monitor (Bicore CP-100).
There was a nonsignificant trend toward higher WOB (in J/L) during PCV (1.27 + 0.58 J/L) and PRVC (1.35 + 0.60 J/L), compared to VCV (1.09 + 0.59 J/L). While mean V(T) was not statistically different between modes, in 40% of patients, V(T) markedly exceeded the lung-protective ventilation target during PRVC and PCV.
During lung-protective ventilation, PCV and PRVC offer no advantage in reducing WOB, compared to VCV with a high flow rate, and in some patients did not allow control of V(T) to be as precise.
Respiratory care 01/2006; 50(12):1623-31. · 2.01 Impact Factor
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The Journal of trauma 12/2005; 59(5):1228-30. · 2.48 Impact Factor
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ABSTRACT: The international consensus definitions for acute respiratory distress syndrome (ARDS) have formed the basis for recruitment into randomized, controlled trials and, more recently, standardized the protocols for ventilatory treatment of acute lung injury. Although possibly appropriate for sepsis-induced ARDS, these criteria may not be appropriate for posttraumatic ARDS if the disease patterns are widely divergent. This study tests the hypothesis that standard ARDS criteria applied to the trauma population will capture widely disparate forms of acute lung injury and are too nonspecific to identify a population at risk for prolonged respiratory failure and associated complications.
Patients with and Injury Severity Score > or = 16 ventilated for > 12 hours were prospectively enrolled. Clinical data, including elements of cardiovascular, renal, hepatic, hematologic, neurologic, and pulmonary function, were collected daily. Two hundred fifty-four patients were enrolled over a 36-month period, of whom 70 met the consensus definitions of ARDS. Patients from whom support was withdrawn within 48 hours were excluded. The remaining 61 patients were stratified into two groups on the basis of intubation (n = 12) days.
There was considerable disparity in severity and clinical course. A mild, limited form of ARDS was characterized by earlier onset (group 1, 2 days; group 2, 4 days; p = 0.002), fewer intubation days (7 days vs. 28 days; p < 0.001), and less severe derangements in lung mechanics. A significant difference between the two groups was also seen in systemic inflammatory response syndrome score, incidence of sepsis, and incidence of multiple organ failure.
The criteria for ARDS, when applied to the trauma population, capture a widely disparate group and has poor specificity for identifying patients at risk. Recruitment of trauma patients for ARDS studies or preemptive ventilatory management based solely on these criteria may be ill-advised.
The Journal of trauma 09/2004; 57(3):522-6; discussion 526-8. · 2.48 Impact Factor
