2014 Oral Presentations
SCIENTIFIC SESSION VI: TRAUMA/CRITICAL CARE
TIME IS OF THE ESSENCE :EARLY EPIDURAL PLACEMENT SIGNIFICANTLY
REDUCES THE RISK OF RESPIRATORY FAILURE IN THE ELDERLY WITH RIB
FRACTURES
MH Ghneim MD , K Schnell , F Kang B.S , DC Jupiter PhD., ML Davis MD. JL Regner
MD, Scott and White Memorial Hospital
Background
Elderly persons constitute an increasing percentage of patients (pts) admitted to trauma
centers. The most frequent injury suffered by elderly is rib fractures (fx) with a resultant
high morbidity rate. Epidural analgesia (EA) is considered the optimal analgesic
modality for multiple rib fxs. However the beneficial effects on preventing complications
are not consistently supported in the literature. Our aim was to determine whether the
timing of EA placement influenced the rate of intubation in the elderly with rib fxs.
Secondary endpoints were to determine pt and trauma specific risk factors for
intubation.
Methods
Retrospective cohort study evaluated pts ≥55 with rib fxs admitted to Level I trauma
center (2007–2012). 57% of pts were >65. Exclusion criteria included GCS<13,
paralysis, abdominal trauma requiring surgery, or death from causes other than rib fxs.
Comorbidities evaluated were age, COPD, CAD, BMI, albumin, and pre-injury functional
status. Trauma data points were rib fxs, tube thoracostomy, and vertebral and lower
body fxs. Treatment modalities included pain medication, use of non-invasive positive
pressure ventilation and EA. Logistic regression analysis determined the contribution of
these factors and treatment modalities towards intubation.
Results
Patient specific risk factors that increase intubation include low albumin (OR 4,
p=0.0003), CAD (OR 3.7, p=0.001), lower extremity fxs (OR 2.5, p=0.05) and increasing
ISS (p=0.0001). Rib fxs’ main impact was to increase risk of intubation by multiplicative
factor of 1.16 per additional rib fx (p<0.03). Patients who received EA <6 hrs after
admission were 3.44 times less likely to require intubation than placement of EA >6hrs
(p=0.04).
Conclusion
Outcomes in the elderly with blunt chest trauma and rib fractures are influenced by the
pre-morbid conditions and the chest injury itself. Our study suggests that aggressive
early placement of epidural at < 6 hrs from time of admission decreases the risk of
intubation.
AUTOLOGOUS BONE MARROW MONONUCLEAR CELLS REDUCE
THERAPEUTIC INTENSITY FOR SEVERE TRAUAMTIC BRAIN INJURY IN
CHILDREN
Liao, GP, Hetz, RA, Walker, PA, Shah, SK, Jimenez, F, Kosmach, S, Day, MC, Lee,
DA, Worth, LL, Cox, CS, University of Texas Health Science Center at Houston
Background
The devastating effect of traumatic brain injury (TBI) is mediated by an acute secondary
neuroinflammatory response to the impact, and is clinically manifest as elevated
intracranial pressures (ICP) due to cerebral edema. The treatment effect of cell based
therapies in the acute post TBI period has not been clinically studied although
preclinical rodent data demonstrates the ability for autologous bone marrow derived
mononuclear cell (BMMNC) infusion to downregulate the acute inflammatory response.
We therefore sought to evaluate whether pediatric TBI patients receiving intravenous,
autologous BMMNCs within 48 hours of injury experienced a reduction in therapeutic
intensity relative to matched controls.
Methods
The primary outcome measure was the Pediatric Intensity Level of Therapy (PILOT)
scale, used to quantify treatment of cerebral edema. This scale was applied in a
retrospective cohort study comparing pediatric patients in a Phase I clinical trial treated
with intravenous autologous BMMNCs to a control group of age and severity matched
children at the same institution. Secondary outcome measures included the Pediatric
Logistic Organ Dysfunction (PELOD) score to look for differences in organ failure and
days of ICP monitoring as a surrogate for length of neurosurgical intensive care.
Results
A repeated measure mixed model with marginal linear predictions identified a significant
reduction in the PILOT score beginning at 24 hours post treatment through week one
(F<0.001). This divergence, also reflected in the PELOD score, was sustained through
two weeks. The mean duration of ICP monitoring was 8 days in the treated group, 5
days less than controls (p<0.04).
Conclusion
Intravenous autologous BMMNC therapy reduces the treatment intensity required to
manage ICP, severity of organ injury, and duration of neurosurgical intensive care after
severe TBI. This corroborates pre-clinical findings that autologous BMMNC attenuate
the secondary effects of inflammation on edema in the early post TBI period.
CONTRAST EXTRAVASATION ON ADMISSION CT SCAN FOR TRAUMA: WHICH
PATIENTS NEED AN INTERVENTION?
Sprunt JM, Ali S, Reifsnyder A, Brown C, University of Texas Southwestern - Austin
Background
There is controversy in the existing literature regarding the optimal management of
contrast extravasation (CE) seen on computed tomographic (CT) scanning during the
evaluation of trauma patients. Some authors recommend routine intervention for all CE
while others have advocated a selective approach to intervention.
Methods
Retrospective study of all trauma admissions to our level 1 trauma center over a sixyear period (2006-2011). Patients who were found to have CE on admission CT scan
were included. Patients who underwent an intervention (operative or angiographic) were
compared to those who had no intervention.
Results
237 trauma patients were found to have 240 CE’s on admission CT scan. The most
common location of CE was a solid organ (42%, n = 100), followed by soft
tissue/muscle (27%, n = 65), pelvis (18%, n = 43), and vascular (13%, n = 32). A total of
149 patients (63%) underwent surgical or angiographic intervention, while 88 patients
(37%) were managed without an intervention. Patients who underwent an intervention
were more often male (76% vs. 63%, p = 0.03), severely injured (ISS: 24 vs. 19, p =
0.006), hypotensive (18% vs. 6%, p = 0.007), and tachycardic (106 vs. 99, p = 0.03).
The intervention group more often had a CE of a solid organ (50% vs. 30%, p = 0.002)
or vascular structure (17% vs. 7%, p = 0.02). There was no difference in the rate of
pelvic CE (15% vs. 23%, p = 0.16). The intervention group more often had a large (>/=
1.5 cm) blush (69% vs. 50%, p = 0 .003).
Conclusion
Nearly 40% of trauma patients with CE on admission CT scan can be managed without
a surgical or angiographic intervention. Further studies are needed to determine which
trauma patients with CE on admission CT scan can be safely managed without
intervention.
A ROBUST PERFORMANCE IMPROVEMENT PROCESS TO REDUCE
PULMONARY EMBOLISM IN TRAUMA PATIENTS
Pommerening MJ, Siedel HH, Cotton BA, Wade CE, Holcomb JB, University of Texas
Medical School at Houston
Background
Pulmonary embolism (PE) is a well-known complication after trauma and can be
associated with significant morbidity and mortality. In 01/2009, we implemented a robust
performance improvement (PI) process aimed at improving our current prophylaxis
measures. This included several sequential interventions, such as auditing for missed
doses, adding a “PE Prophylaxis” section to daily progress notes, developing formal
prophylaxis guidelines, including thrombelastography-guided recommendations for
placing prophylactic IVC filters in high-risk patients.
Methods
We retrospectively reviewed adult trauma patients admitted to a Level-1 trauma center
over a six-year period. Patients admitted in 2006-2008 (Pre-PI) were compared to
those admitted in 2009-2011 (Post-PI) after implementation of the PI process.
Purposeful logistic regression was used to compare PE rates before and after PI
implementation.
Results
Of 23,863 trauma admissions during the study period, 11,292(47%) were Pre-PI and
12,571(53%) were Post-PI. Post-PI patients were older, more often transferred from
outside hospitals, and more often had traumatic brain injuries (all p<0.001). When
controlling for confounders, PI did not result in reduced odds of developing PE (OR
1.04; 95%CI 0.80-1.34). Among the 263(1.1%) patients who developed PE, PI was
associated with significantly fewer patients who were not given any prophylaxis prior to
PE (8% vs. 46%; p<0.001) as well as a significantly reduced time to initiating
prophylaxis (median time, 47 hours vs. 105 hours; p<0.001).
Conclusion
Implementation of a PI process was not associated with any measurable reduction in
PE however did demonstrate an association with improved delivery of PE prophylaxis.
Our results demonstrate that well-developed PI measures can effectively improve
delivery of patient care, however improved care may not translate to improved patient
outcomes. These findings suggest that current prophylactic strategies and therapies for
PE may be inadequate or, given the inherent hypercoagulable state following trauma,
that some PEs are simply not preventable with current therapies.