Clay Cothren Burlew

Mental Health Center of Denver, Denver, Colorado, United States

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Publications (82)137.4 Total impact

  • Article: RibScore
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    ABSTRACT: BACKGROUND: There is currently no scoring system for rib fractures that relates detailed anatomic variables to patient outcomes. Our objective was to develop and validate a radiographic rib fracture scoring system based on computed tomographic chest findings. METHODS: We reviewed our trauma registry from September 2012 to April 2014 for all blunt trauma patients with one or more rib fractures visualized on chest computed tomography. We identified the following six candidate radiographic variables and tested their individual associations with pneumonia, respiratory failure, and tracheostomy: (1) six or more rib fractures, (2) bilateral fractures, (3) flail chest, (4) three or more severely (bicortical) displaced fractures, (5) first rib fracture, and (6) at least one fracture in all three anatomic areas (anterior, lateral, and posterior). We developed the “RibScore” by assigning 1 point for each variable, which was validated among the sample using univariate analyses, test performance characteristics, and the receiver operating characteristic area under the curve c statistic. RESULTS: A total of 385 patients with one or more rib fractures were identified; 274 (71.2%) were males, median age was 48 years, and median Injury Severity Score (ISS) was 17. Of these patients, 156 had six or more rib fractures, 120 had bilateral fractures, 46 had flail chest, 32 had three or more severely displaced fractures, 91 had a first rib fracture, and 58 had fractures in all three anatomic areas. Each RibScore component variable was associated with the three pulmonary outcomes by univariate analysis (p < 0.05). The median RibScore was 1 (range, 0–6). The distribution of the RibScore was as follows: score of 0, 41.9%); score of 1, 23.9%; score of 2, 15.4%; score of 3, 9.9%; score of 4, 7.6%; and score of five, 1.3%. RibScore was linearly associated with pneumonia (p < 0.01), acute respiratory failure (p < 0.01), and tracheostomy (p < 0.01). The receiver operating characteristic areas under the curve for the outcomes were 0.71, 0.71, and 0.75, respectively. CONCLUSION: The RibScore predicts adverse pulmonary outcomes and represents a standardized assessment of fracture severity that may be used for communication and prognostication of the severely injured trauma patient. LEVEL OF EVIDENCE: Prognostic study, level III.
    No preview · Article · Jan 2016 · Journal of Trauma and Acute Care Surgery
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    ABSTRACT: Background: Choice of empiric antibiotic(s) for early ventilator associated pneumonia (VAP) involves weighing the risks of potential infection with multi-drug resistant (MDR) pathogens against those of over-exposure to broad-spectrum agents. Although early VAP is believed to be rarely caused by MDR pathogens, the overall incidence of all methicillin resistant Staphylococcus aureus (MRSA) infections is increasing. We questioned if MRSA VAP is becoming more common and if these infections were occurring earlier in the patient's hospital course. We hypothesized that 1) early (2-4 d from intubation) VAP caused by MRSA is relatively uncommon and 2) those patients with early VAP because of MRSA had risk factors associated with a MDR organism infection. Methods: Bronchoscopies with lavage (BALs) from patients admitted to our SICU from 2010-2013 were reviewed. MRSA VAP was defined as growth of ≥10(5) cfu/mL from BAL. Multi-drug resistant risk factors included a previous MRSA infection or positive nasal swab, antibiotic use within 90 d, hospitalization for >5 d, hemodialysis, homelessness, intravenous drug use, and men having sex with men. Results: In the 3-y period, there were 438 cases of VAP. Forty-seven specimens from 43 patients had quantitative microbiologic confirmation of MRSA VAP for an overall prevalence of 10.7%. Of patients with early VAP, three of 106 (2.8%) were MRSA positive. Culture results were graphed according to ventilator days ( Fig. 1 ). The median days ventilated at the time of MRSA VAP were 8 d (range 2-81). All of the early MRSA VAP patients had identifiable risk factors for MRSA infection. The negative predictive value for patients not having a risk factor was one. Conclusions: These data suggest that the incidence of MRSA VAP is stable. Those patients with early MRSA VAP demonstrated traditional MDR risk factors. Patients without risk factors in the early time period could effectively be ruled out from having MRSA VAP and likely do not require empiric MRSA coverage.
    No preview · Article · Dec 2015 · Surgical Infections
  • Scott M Moore · Clay Cothren Burlew
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    ABSTRACT: Early provision of enteral nutrition (EN) in critically ill and injured patients has become standard practice in surgical intensive care units (ICUs) due to its proven role in reducing septic complications. Increasingly, intensivists are confronted with patients with an open abdomen due to the use of damage control surgery and the recognition of the abdominal compartment syndrome; the role and timing of EN in these challenging patients continue to be debated. Patients with an open abdomen are often among the sickest in the ICU and hence could benefit from early nutrition support. However, the exposed abdominal viscera can understandably create anxiety regarding the initiation of EN; there is theoretic concern over exacerbation of bowel distention with resultant inability to close the abdomen and an increased aspiration risk due to paralytic ileus. Recent studies have investigated the utility of EN in the patient with an open abdomen, addressing these clinical concerns. The goal of this clinical review is to provide guidance to physicians caring for these complex patients.
    No preview · Article · Dec 2015 · Nutrition in Clinical Practice
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    ABSTRACT: Background: Unconscious patients who present after being "found down" represent a unique triage challenge. These patients are selected for either trauma or medical evaluation based on limited information and have been shown in a single-center study to have significant occult injuries and/or missed medical diagnoses. We sought to further characterize this population in a multicenter study and to identify predictors of mistriage. Methods: The Western Trauma Association Multicenter Trials Committee conducted a retrospective study of patients categorized as found down by emergency department triage diagnosis at seven major trauma centers. Demographic, clinical, and outcome data were collected. Mistriage was defined as patients being admitted to a non-triage-activated service. Logistic regression was used to assess predictors of specified outcomes. Results: Of 661 patients, 33% were triaged to trauma evaluations, and 67% were triaged to medical evaluations; 56% of all patients had traumatic injuries. Trauma-triaged patients had significantly higher rates of combined injury and a medical diagnosis and underwent more computed tomographic imaging; they had lower rates of intoxication and homelessness. Among the 432 admitted patients, 17% of them were initially mistriaged. Even among properly triaged patients, 23% required cross-consultation from the non-triage-activated service after admission. Age was an independent predictor of mistriage, with a doubling of the rate for groups older than 70 years. Combined medical diagnosis and injury was also predictive of mistriage. Mistriaged patients had a trend toward increased late-identified injuries, but mistriage was not associated with increased length of stay or mortality. Conclusion: Patients who are found down experience significant rates of mistriage and triage discordance requiring cross-consultation. Although the majority of found down patients are triaged to nontrauma evaluation, more than half have traumatic injuries. Characteristics associated with increased rates of mistriage, including advanced age, may be used to improve resource use and minimize missed injury in this vulnerable patient population. Level of evidence: Epidemiologic study, level III.
    No preview · Article · Oct 2015

  • No preview · Article · Jun 2015 · Surgery

  • No preview · Article · Jan 2015 · Journal of Trauma and Acute Care Surgery

  • No preview · Article · Jan 2015 · Journal of Trauma and Acute Care Surgery
  • Clay Cothren Burlew
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    ABSTRACT: The optimal nutrition therapy for a critically injured patient is enteral nutrition.Despite initial hesitancy, recent literature supports the initiation ofenteral nutrition in the open abdomen.Enteral nutrition in this complex, post-injury patient population has been shown to decrease septic complications, increase fascial closure rates, and reduce mortality. Following post-trauma resuscitation and stabilization, all patients should be considered for enteral nutrition therapy to improve outcomes.
    No preview · Article · Jan 2015
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    ABSTRACT: Background Need for mechanical ventilation (MV) after spinal cord injury (SCI) is a risk factor for prolonged critical care. The purpose of this study was to identify the level of cervical SCI that requires MV, thereby defining candidates for tracheostomy. Methods Patients with cervical SCI over a 15-year period were reviewed. Results 163 patients sustained cervical SCI. Of 76 complete injuries, 91% required MV for >48°. By injury level, MV incidence was 100% for C2-4, 91% for C5, 79% for C6, and 80% for C7. Only one-quarter of patients with incomplete SCI required MV > 48°; GCS and ISS were significantly worse compared to patients not requiring MV. Conclusions Factors influencing the decision for tracheostomy in the cervical SCI patient include presence of a complete SCI, anatomic level of injury, GCS, ISS, and associated thoracic injury. Patients with complete cervical SCI often require prolonged MV. Conversely, the minority of incomplete SCI required MV; need for tracheostomy was likely performed for associated injuries. Utilizing identified factors permits a thoughtful approach to tracheostomy in this patient population.
    Full-text · Article · Oct 2014 · The American Journal of Surgery
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    ABSTRACT: The current management for blunt cerebrovascular injuries (BCVIs) includes repeat imaging 7 days to 10 days after initial diagnosis. This recommendation, however, has not been systematically evaluated. The purpose of this study was to evaluate the impact of early repeat imaging on treatment course. We hypothesized that a minority of patients with high-grade injuries (Grades III and IV) have complete resolution of their injuries early in their treatment course and hence repeat imaging does not alter their therapy.
    No preview · Article · Oct 2014 · Journal of Trauma and Acute Care Surgery
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    ABSTRACT: A dramatic rise in nonoperative management of many blunt and some penetrating traumatic injuries has occurred during the past four decades. This trend has lead some to suggest that trauma is no longer a surgical disease. We questioned what role the trauma surgeon plays in the care of the injured patient. We hypothesized that surgical intervention and judgment are still often required in both injured children and adults.
    Full-text · Article · Aug 2014 · Journal of Trauma and Acute Care Surgery
  • Clay Cothren Burlew

    No preview · Article · Aug 2014 · Journal of Trauma and Acute Care Surgery
  • Harry J. Henteleff · Neil G. Parry · Clay Cothren Burlew

    No preview · Article · Jun 2014 · Journal of the American College of Surgeons
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    ABSTRACT: To evaluate the efficacy of IV iron supplementation of anemic, critically ill trauma patients. Multicenter, randomized, single-blind, placebo-controlled trial. Four trauma ICUs. Anemic (hemoglobin < 12 g/dL) trauma patients enrolled within 72 hours of ICU admission and with an expected ICU length of stay of more than or equal to 5 days. Randomization to iron sucrose 100 mg IV or placebo thrice weekly for up to 2 weeks. A total of 150 patients were enrolled. Baseline iron markers were consistent with functional iron deficiency: 134 patients (89.3%) were hypoferremic, 51 (34.0%) were hyperferritinemic, and 64 (42.7%) demonstrated iron-deficient erythropoiesis as evidenced by an elevated erythrocyte zinc protoporphyrin concentration. The median baseline transferrin saturation was 8% (range, 2-58%). In the subgroup of patients who received all six doses of study drug (n = 57), the serum ferritin concentration increased significantly for the iron as compared with placebo group on both day 7 (808.0 ng/mL vs 457.0 ng/mL, respectively, p < 0.01) and day 14 (1,046.0 ng/mL vs 551.5 ng/mL, respectively, p < 0.01). There was no significant difference between groups in transferrin saturation, erythrocyte zinc protoporphyrin concentration, hemoglobin concentration, or packed RBC transfusion requirement. There was no significant difference between groups in the risk of infection, length of stay, or mortality. Iron supplementation increased the serum ferritin concentration significantly, but it had no discernible effect on transferrin saturation, iron-deficient erythropoiesis, hemoglobin concentration, or packed RBC transfusion requirement. Based on these data, routine IV iron supplementation of anemic, critically ill trauma patients cannot be recommended (NCT 01180894).
    No preview · Article · May 2014 · Critical care medicine
  • Janeen R Jordan · Ernest E Moore · James Haenel · Clay Cothren Burlew

    No preview · Article · May 2014
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    ABSTRACT: Background The role of stenting for blunt cerebrovascular injuries (BCVI) continues to be debated, with a trend toward more endovascular stenting. With the recent intracranial stenting trial halted in favor of medical therapy, however, management of BCVI warrants reassessment. The study purpose was to determine if antithrombotic therapy, rather than stenting, was effective in post-injury patients with high-grade vascular dissections and pseudoaneurysms. Study Design In 1996 we began screening for BCVI. Following the 2005 report on the risks of carotid stenting for BCVI, a virtual moratorium was placed on stenting at our institution; our primary therapy for BCVI has been antithrombotics. Patients with grade II (luminal narrowing > 25%) and grade III (pseudoaneurysms) injuries were included in the analysis. Results Grade II or III BCVIs were diagnosed in 195 patients. Prior to 2005, 25% (21/86) of patients underwent stent placement with 2 patients suffering stroke. Of patients treated with antithrombotics, 1 had a stroke. After 2005, only 2% (2/109) of patients with high-grade injuries had stents placed. After 2005 no patient treated with antithrombotics suffered a stroke and there was no rupture of a pseudoaneurysm. Conclusions Antithrombotic treatment for BCVI is effective for stroke prevention. Routine stenting entails increased costs and potential risk for stroke, and does not appear to add further benefit. Intravascular stents should be reserved for the rare patient with symptomatology or a markedly enlarging pseudoaneurysm.
    No preview · Article · May 2014 · Journal of the American College of Surgeons
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    ABSTRACT: Early tracheostomy has been advocated for adult trauma patients to improve outcomes and resource utilization. We hypothesized that timing of tracheostomy for severely injured children would similarly impact outcomes. Injured children undergoing tracheostomy over a 10-year period (2002-2012) were reviewed. Early tracheostomy was defined as post-injury day ≤7. Data were compared using Student's t test, Pearson chi-squared test and Fisher exact test. Statistical significance was set at p<0.05 with 95% confidence intervals. During the 10-year study period, 91 patients underwent tracheostomy following injury. Twenty-nine (32%) patients were <12years old; of these, 38% received early tracheostomy. Sixty-two (68%) patients were age 13 to 18; of these, 52% underwent early tracheostomy. Patients undergoing early tracheostomy had fewer ventilator days (p=0.003), ICU days (p=0.003), hospital days (p=0.046), and tracheal complications (p=0.03) compared to late tracheostomy. There was no difference in pneumonia (p=0.48) between early and late tracheostomy. Children undergoing early tracheostomy had improved outcomes compared to those who underwent late tracheostomy. Early tracheostomy should be considered for the severely injured child. Early tracheostomy is advocated for adult trauma patients to improve patient comfort and resource utilization. In a review of 91 pediatric trauma patients undergoing tracheostomy, those undergoing tracheostomy on post-injury day ≤7 had fewer ventilator days, ICU days, hospital days, and tracheal complications compared to those undergoing tracheostomy after post-injury day 7.
    Full-text · Article · Apr 2014 · Journal of Pediatric Surgery
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    ABSTRACT: The diagnosis of blunt abdominal trauma can be challenging and resource intensive. Observation with serial clinical assessments plays a major role in the evaluation of these patients, but the time required for intra-abdominal injury to become clinically apparent is unknown. The purpose of this study was to determine the amount of time required for an intra-abdominal injury to become clinically apparent after blunt abdominal trauma via physical examination or commonly followed clinical values. A retrospective review of patients who sustained blunt trauma resulting in intra-abdominal injury between June 2010 and June 2012 at a Level 1 academic trauma center was performed. Patient demographics, injuries, and the amount of time from emergency department admission to sign or symptom development and subsequent diagnosis were recorded. All diagnoses were made by computed tomography or at the time of surgery. Patient transfers from other hospitals were excluded. Of 3,574 blunt trauma patients admitted to the hospital, 285 (8%) experienced intra-abdominal injuries. The mean (SD) age was 36 (17) years, the majority were male (194 patients, 68%) and the mean (SD) Injury Severity Score (ISS) was 21 (14). The mean (SD) time from admission to diagnosis via computed tomography or surgery was 74 (55) minutes. Eighty patients (28%) required either surgery (78 patients, 17%) or radiographic embolization (2 patients, 0.7%) for their injury. All patients who required intervention demonstrated a sign or symptom of their intra-abdominal injury within 60 minutes of arrival, although two patients were intervened upon in a delayed fashion. All patients with a blunt intra-abdominal injury manifested a clinical sign or symptom of their intra-abdominal injury, resulting in their diagnosis within 8 hours 25 minutes of arrival to the hospital. All diagnosed intra-abdominal injuries from blunt trauma manifested clinical signs or symptoms that could prompt imaging or intervention, leading to their diagnosis within 8 hours 25 minutes of arrival to the hospital. All patients who required an intervention for their injury manifested a sign or symptom of their injury within 60 minutes of arrival. Therapeutic study, level IV. Epidemiologic study, level III.
    Full-text · Article · Apr 2014
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    ABSTRACT: While the incidence of postinjury multiple-organ failure (MOF) has declined during the past decade, temporal trends of its morbidity, mortality, presentation patterns, and health care resources use have been inconsistent. The purpose of this study was to describe the evolving epidemiology of postinjury MOF from 2003 to 2010 in multiple trauma centers sharing standard treatment protocols. "Inflammation and Host Response to Injury Collaborative Program" institutions that enrolled more than 20 eligible patients per biennial during the 2003 to 2010 study period were included. The patients were aged 16 years to 90 years, sustained blunt torso trauma with hemorrhagic shock (systolic blood pressure < 90 mm Hg, base deficit ≥ 6 mEq/L, blood transfusion within the first 12 hours), but without severe head injury (motor Glasgow Coma Scale [GCS] score < 4). MOF temporal trends (Denver MOF score > 3) were adjusted for admission risk factors (age, sex, body max index, Injury Severity Score [ISS], systolic blood pressure, and base deficit) using survival analysis. A total of 1,643 patients from four institutions were evaluated. MOF incidence decreased over time (from 17% in 2003-2004 to 9.8% in 2009-2010). MOF-related death rate (33% in 2003-2004 to 36% in 2009-2010), intensive care unit stay, and mechanical ventilation duration did not change over the study period. Adjustment for admission risk factors confirmed the crude trends. MOF patients required much longer ventilation and intensive care unit stay, compared with non-MOF patients. Most of the MOF-related deaths occurred within 2 days of the MOF diagnosis. Lung and cardiac dysfunctions became less frequent (57.6% to 50.8%, 20.9% to 12.5%, respectively), but kidney and liver failure rates did not change (10.1% to 12.5%, 15.2% to 14.1%). Postinjury MOF remains a resource-intensive, morbid, and lethal condition. Lung injury is an enduring challenge and should be a research priority. The lack of outcome improvements suggests that reversing MOF is difficult and prevention is still the best strategy. Epidemiologic study, level III.
    No preview · Article · Mar 2014
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    Nina E. Glass · Clay Cothren Burlew
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    ABSTRACT: Pelvic fractures can lead to life-threatening hemorrhage, particularly as they tend to occur in the setting of polytrauma. Several approaches to hemorrhage control have been employed in pelvic fracture patients over the years. This review describes the indications, operative technique, and outcomes for preperitoneal pelvic packing (PPP). Pelvic packing should be considered for every hemodynamically unstable patient with a significant pelvic fracture. We describe how this can be accomplished in coordination with other resuscitative efforts and operative needs.
    Preview · Article · Mar 2014

Publication Stats

588 Citations
137.40 Total Impact Points

Institutions

  • 2011-2015
    • Mental Health Center of Denver
      Denver, Colorado, United States
    • University of Colorado Hospital
      • Department of Surgery
      Denver, Colorado, United States
  • 2009-2015
    • University of Colorado
      • Department of Surgery
      Denver, Colorado, United States
  • 2012
    • Denver Health and Hospital Authority
      Denver, Colorado, United States