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Thomas M Scalea

Publications and source records attributed to Thomas M Scalea.

71 records · Page 4Linked to original sources
PubMed2003

Blood transfusion, independent of shock severity, is associated with worse outcome in trauma.

BACKGROUND: We have previously shown that blood transfusion in the first 24 hours is an independent predictor of mortality, intensive care unit (ICU) admission, and increased ICU length of stay in the acute trauma setting when controlling for Injury Severity Score, Glasgow Coma Scale score, and age. Indices of shock such as base deficit, serum lactate level, and admission hemodynamic status (systolic blood pressure, heart rate) and admission hematocrit were considered potential confounding variables in that study. The objectives of this study were to evaluate admission anemia and blood transfusion within the first 24 hours as independent predictors of mortality, ICU admission, ICU length of stay (LOS), and hospital LOS, with serum lactate level, base deficit, and shock index (heart rate/systolic blood pressure) as covariates. METHODS: Prospective data were collected on 15,534 patients admitted to a Level I trauma center over a 3-year period (1998-2000) and stratified by age, gender, race, Glasgow Coma Scale score, and Injury Severity Score. Admission anemia and blood transfusion were assessed as independent predictors of mortality, ICU admission, ICU LOS, and hospital LOS by logistic regression analysis, with base deficit, serum lactate, and shock index as covariates. RESULTS: Blood transfusion was a strong independent predictor of mortality (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.82-4.40; p < 0.001), ICU admission (OR, 3.27; 95% CI, 2.69-3.99; p < 0.001), ICU LOS (p < 0.001), and hospital LOS (Coef, 4.37; 95% CI, 2.79-5.94; p < 0.001) when stratified by indices of shock (base deficit, serum lactate, shock index, and anemia). Patients who underwent blood transfusion were almost three times more likely to die and greater than three times more likely to be admitted to the ICU. Admission anemia (hematocrit < 36%) was an independent predictor of ICU admission (p = 0.008), ICU LOS (p = 0.012), and hospital LOS (p < 0.001). CONCLUSION: Blood transfusion is confirmed as an independent predictor of mortality, ICU admission, ICU LOS, and hospital LOS in trauma after controlling for severity of shock by admission base deficit, lactate, shock index, and anemia. The use of other hemoglobin-based oxygen-carrying resuscitation fluids (such as human or bovine hemoglobin substitutes) in the acute postinjury period warrants further investigation.

Adult↗
PubMed2003

Protocol-driven nonoperative management in patients with blunt splenic trauma and minimal associated injury decreases length of stay.

BACKGROUND: The purpose of this study was to analyze the impact of more selective use of admission angiography combined with protocolized nonoperative management for blunt splenic injury. METHODS: This was a retrospective chart review of all patients with splenic injuries and Injury Severity Score < 20 managed by protocol and comparison with a prior matched group managed with admission angiography. RESULTS: Forty-three patients were managed under the protocol, with 22 patients treated with admission angiography and the remainder undergoing observation only. Nonoperative salvage was 100% in this group, with a length of stay of 3.3 days. The matched, nonprotocol group had a nonoperative salvage rate of 95%, with a length of stay of 6.8 days. CONCLUSION: Protocol-driven management of splenic injury using admission angiography selectively for higher grade splenic injuries led to a decreased length of stay, higher therapeutic yield, and decreased use of hospital resources without any increase in the failure rate of nonoperative management in a selected group of patients with isolated splenic injuries.

Adult↗
PubMed2003

Daily multidisciplinary rounds shorten length of stay for trauma patients.

PURPOSE: Efficient patient care depends on close communication between the trauma team, other surgical providers, nursing, physical therapy, and discharge planners. Communication is hampered by the number of services involved, the workload of each service, and the institution's training mission. We hypothesized that daily multidisciplinary "discharge rounds" would improve patient flow and increase readiness. METHODS: A senior trauma center physician leads discharge rounds, focusing on each patient's plan of care, including surgeries, diagnostic tests, and anticipated date of discharge or transfer. Present at rounds are the fellows leading each trauma team; an orthopedic surgeon; the hospital bed manager; the unit's discharge planner; the unit nursing staff; and physical, occupational, and speech therapists. RESULTS: Discharge rounds cover 90 inpatient trauma service beds in approximately 60 minutes each day. Discharge rounds have had a dramatic effect on patient flow. While maintaining the daily census, we have seen a 36% increase in patient volume and a 15% decrease in length of stay. "Bypass" status-inability to accept admissions-has been virtually eliminated. This effect has been sustained. CONCLUSION: By providing a forum for clear communications among all providers, discharge rounds have streamlined the care of complex trauma patients. As health care resources become ever more constrained, this sort of multidisciplinary effort is a viable option for senior physicians to directly impact hospital performance.

Humans↗
PubMed2003

A novel approach to the treatment of gunshot injuries to the sacrum.

Two patients (a 17-year-old male and a 19-year-old female) sustained single gunshot wounds to the abdomen. Given the nature of their wounds and presumed peritoneal penetration they were taken urgently to the operating room for exploratory laparotomy. Both patients sustained multiple intra-abdominal injuries including gastric and small and large bowel perforations. Given the extensive nature of these injuries both patients required bowel resections. Upon further exploration they were both noted to have significant bleeding from the bony aspect of their sacrum. A surgical hemostat (CoStasis; Cohesion Technologies, Inc., Palo Alto, CA) (4.5-9.0 cm3) was directly applied to the injured area of the sacrum in both cases after standard surgical hemostatic techniques were unsuccessful. After application no further attempts of hemostatic control by standard methods were attempted. In both cases the sacral bleeding ceased without any further surgical intervention. Postoperatively neither patient rebled from the sacral injuries. Penetrating injuries to the sacrum can be life threatening and difficult to control with standard surgical hemostatic techniques. CoStasis, a new surgical hemostat, was effective in obtaining immediate and definitive hemostatic control. Future prospective trials on the use of CoStasis in trauma patients are warranted.

Adolescent↗
PubMed2003

Nontherapeutic laparotomies revisited.

A wide variability exists in the reported incidents of complications following nontherapeutic laparotomy for trauma. We undertook this study to examine the decision-making leading to and complication rates related to the use of nontherapeutic laparotomy in an era of nonoperative management. We conducted a retrospective chart review of all nontherapeutic laparotomies as defined by the operating surgeon performed between May 1998 and May 2001. A total of 50 patients (6%) underwent nontherapeutic laparotomies predominantly for penetrating injury. The most frequent preoperative reason for nontherapeutic laparotomy was the question of hollow viscous or diaphragmatic injury on preoperative studies. Peritoneal signs on examination and peritoneal penetration on wound exploration were also frequent indications for surgery. Significant complication rates were low at approximately 12 per cent. Total length of stay was 7.3 days and 5 days if patients with significant other associative injuries were excluded. Overall morality was 4 per cent and unrelated to the nontherapeutic laparotomy in all cases. Overall incidence of nontherapeutic laparotomy has decreased with the use of abdominal helical CT and triple-contrast CT to evaluate penetrating injuries. Despite these advances diaphragmatic and hollow viscous injuries remain a concern. Although overall serious complication rates were low the use of nontherapeutic laparotomy adds significantly to length of stay and complications.

Abdominal Injuries↗
PubMed2002

Surgeon-performed focused assessment with sonography for trauma as an early screening tool for pregnancy after trauma.

BACKGROUND: Incidental pregnancy in trauma patients is associated with a high fetal mortality. Because of quality assurance reasons, many trauma centers have eliminated the rapid urine pregnancy screen. We sought to determine the utility and impact of the initial ultrasound examination in the diagnosis of pregnancy in female trauma patients. METHODS: Data were analyzed for all female trauma patients in whom pregnancy was diagnosed during a 5-year period. RESULTS: One hundred one (70%) of 144 pregnant women had an initial ultrasound examination. Eighteen patents had newly diagnosed pregnancies, of whom 8 of 9 patients (89%) at > or = 8 weeks' gestation were diagnosed by the initial ultrasound. This directly contributed to a significant decrease in the amount of radiation exposure (p < 0.001) compared with patients diagnosed by serum beta-human chorionic gonadotropin. CONCLUSION: An initial ultrasound examination should be considered in all female trauma patients of reproductive age. This may help to promote a reduction in fetal radiation exposure.

Adolescent↗
PubMed2002

Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality.

BACKGROUND: Traditional fluid resuscitation strategy in the actively hemorrhaging trauma patient emphasizes maintenance of a normal systolic blood pressure (SBP). One human trial has demonstrated improved survival when fluid resuscitation is restricted, whereas numerous laboratory studies have reported improved survival when resuscitation is directed to a lower than normal pressure. We hypothesized that fluid resuscitation titrated to a lower than normal SBP during the period of active hemorrhage would improve survival in trauma patients presenting to the hospital in hemorrhagic shock. METHODS: Patients presenting in hemorrhagic shock were randomized to one of two fluid resuscitation protocols: target SBP > 100 mm Hg (conventional) or target SBP of 70 mm Hg (low). Fluid therapy was titrated to this endpoint until definitive hemostasis was achieved. In-hospital mortality, injury severity, and probability of survival were determined for each patient. RESULTS: One hundred ten patients were enrolled over 20 months, 55 in each group. The study cohort had a mean age of 31 years, and consisted of 79% male patients and 51% penetrating trauma victims. There was a significant difference in SBP observed during the study period (114 mm Hg vs. 100 mm Hg, p < 0.001). Injury Severity Score (19.65 +/- 11.8 vs. 23.64 +/- 13.8, p = 0.11) and the duration of active hemorrhage (2.97 +/- 1.75 hours vs. 2.57 +/- 1.46 hours, p = 0.20) were not different between groups. Overall survival was 92.7%, with four deaths in each group. CONCLUSION: Titration of initial fluid therapy to a lower than normal SBP during active hemorrhage did not affect mortality in this study. Reasons for the decreased overall mortality and the lack of differentiation between groups likely include improvements in diagnostic and therapeutic technology, the heterogeneous nature of human traumatic injuries, and the imprecision of SBP as a marker for tissue oxygen delivery.

Adult↗
PubMed2002

Pelvic fracture in geriatric patients: a distinct clinical entity.

BACKGROUND: The purpose of this study was to describe differences in demographics, injury pattern, transfusion needs, and outcome of pelvic fractures in older versus younger patients. METHODS: This was a retrospective registry review of all patients with pelvic fractures admitted directly from the scene between January 1998 and December 1999. RESULTS: We cared for 234 patients with pelvic fractures during the study period. Mean age was 37.2 years, 51% were men, and mean Injury Severity Score (ISS) was 19. Overall mortality was 9%. Eighty-three percent were under the age of 55 years and 17% were older than 55 years. Severe pelvic fractures (AP3, LC3) were more common in young patients (p < 0.05). Admitting systolic blood pressure was lower and heart rate higher, although ISS was not different between the two age groups. Older patients were 2.8 times as likely to undergo transfusion (p < 0.005), and those undergoing transfusion required more blood (median, 7.5 units vs. 5 units). Older patients underwent angiography more frequently and were significantly more likely to die in the hospital even after adjusting for ISS (p < 0.005). This was most marked with ISS 15 to 25. Lateral compression (LC) fractures occurred 4.6 times more frequently in older patients than anteroposterior (AP) compression, and 8.2 times more frequently in those older patients undergoing transfusion as compared with AP compression. Ninety-eight percent of LC fractures in older patients were minor (LC1,2). However, older patients with LC fractures were nearly four times as likely to require blood compared with younger patients. CONCLUSION: In older patients, pelvic fractures are more likely to produce hemorrhage and require angiography. Fracture patterns differ in older patients, with LC fractures occurring more frequently, and commonly causing significant blood loss. The outcome of older patients with pelvic fractures is significantly worse than younger patients, particularly with higher injury severity. Recognition of these differences should help clinicians to identify patients at high risk for bleeding and death early, and to refine diagnostic and resuscitation strategies.

Adult↗
PubMed2002

Persistent systemic inflammatory response syndrome is predictive of nosocomial infection in trauma.

BACKGROUND: Admission systemic inflammatory response syndrome (SIRS) score has been previously reported to be an accurate predictor of infection and outcome in trauma. However, these data were limited to only one SIRS score at admission. A prior study in surgical intensive care unit (ICU) patients reported that the SIRS score on ICU day 2 declined after completion of resuscitation, and was a more accurate predictor of outcome. Our objective in this follow-up study was to prospectively evaluate the utility of daily SIRS scores in prediction of nosocomial infection and outcome in high-risk trauma patients. METHODS: Prospective data were collected on 702 consecutive trauma patients admitted over a 12-month period to the ICU. SIRS scores were calculated daily. Centers for Disease Control and Prevention guidelines were used for the diagnosis of infection. Multivariate linear regression was used for statistical analysis. RESULTS: Five hundred seventy-three (82%) patients sustained blunt injuries and 129 (18%) sustained penetrating injuries. The mean age was 43 +/- 21 years, with an overall mortality of 11.4%. Two hundred ninety (41.3%) of the study patients acquired a nosocomial infection (respiratory site most common), with an associated mortality rate of 12.4%. SIRS (defined as SIRS score >/= 2) on hospital days 3 through 7 was a significant predictor of nosocomial infection and hospital length of stay. Persistent SIRS to hospital day 7 was associated with a significant risk for increased mortality (relative risk, 4.7; 95% confidence interval, 1.41-12.87; p = 0.047). CONCLUSION: Persistent SIRS is predictive of nosocomial infection in trauma. Daily monitoring of SIRS scores is easily accomplished and should be considered in all high-risk trauma patients. Persistent SIRS in trauma should initiate early diagnostic interventions for determination of source of infection, and consideration of early empiric antimicrobial therapy.

Adult↗
PubMed2002

The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions.

BACKGROUND: Pelvic fractures may be associated with significant hemorrhage. Although this hemorrhage may emanate from the pelvic vasculature, it may also be secondary to abdominal visceral injury. The purpose of this study was to determine factors associated with pelvic and/or abdominal visceral bleeding in hypotensive patients with pelvic fractures to guide the appropriate therapeutic intervention sequence for these difficult-to-manage patients. METHODS: Medical records of all hypotensive (systolic blood pressure < or = 90 mm Hg) patients with pelvic fractures seen at a Level I trauma center from January 1995 to December 1999 were evaluated. Records were abstracted for age, base deficit, 24-hour blood requirement, hemoperitoneum (positive ultrasound, diagnostic peritoneal lavage, or computed tomographic scan), abdominal hemorrhage discovered at celiotomy, pelvic hemorrhage discovered at angiography, emergency department disposition, Injury Severity Score, and mortality. Pelvic fracture categories were derived by adapting the Young-Burgess pelvic fracture classification scheme. Lateral compression (LC) I and anteroposterior compression (APC) I fractures were characterized as stable fracture patterns (SFPs), and APC II, APC III, LC II, LC III, and vertical shear were characterized as unstable fracture patterns (UFPs). RESULTS: Of 231 hypotensive patients, 38 patients died in the emergency department, leaving 193 surviving initial resuscitation. One hundred seven patients stabilized (group I) and were transferred to the intensive care unit. Eighty-six patients (group II) required ongoing resuscitation and underwent celiotomy and/or angiography in an attempt to manage their hemorrhage. Within group II, in the SFP population, abdominal hemorrhage was responsible for hypotension in 34 of 40 (85%), and 10 patients died (25%). In patients with UFP injury, hemorrhage was predominantly from a pelvic source, as shown by 27 positive angiograms in the 46 patients (59%). Twenty-four of 46 (52%) UFP patients died. In patients with a UFP, 14 had both angiography and celiotomy. Four patients underwent angiography before celiotomy and one of four (mortality, 25%) died. In contrast, 10 patients underwent celiotomy before angiography and 6 of 10 died (mortality, 60%). CONCLUSION: Patients with signs of ongoing shock with SFP pelvic injury and hemoperitoneum require celiotomy as the initial intervention, as the hemorrhagic focus is predominantly intraperitoneal. In patients with UFP, even in the presence of hemoperitoneum, consideration should be given to angiography before celiotomy.

Adult↗
PubMed2002

Preliminary trial of a noninvasive brain acoustic monitor in trauma patients with severe closed head injury.

BACKGROUND: There is no simple way to assess the injured patient after a loss of consciousness. Computed tomographic scanning is required to rule out anatomic injuries, and invasive intracranial pressure monitoring is needed for the patient with severe traumatic brain injury (TBI). We hypothesized that a noninvasive acoustic monitoring system could provide useful clinical data on the severity and progression of TBI. METHODS: Twenty-eight consecutive patients with severe TBI and an indication for invasive intracranial pressure monitoring were studied using the Brain Acoustic Monitor (BAM). Monitoring occurred for 1- to 3-hour time periods on the day of enrollment and each day until the patient's condition stabilized. BAM signals were categorized on the basis of amplitude and positive-to-negative deflection ratio, and then compared with the patient's clinical outcome. RESULTS: BAM signal correlated very strongly with clinical outcome: in 27 of 29 sessions with a normal signal, patients were discharged at a Glasgow Coma Scale score > 13, whereas in 36 of 42 sessions with an abnormal signal, the patient either died or left the hospital with a Glasgow Coma Scale score < 9 (p < 0.00001). The correlation between clinical outcome and initial BAM reading was even stronger: 10 of 10 patients with a normal signal did well, as compared with 3 of 18 patients with an abnormal signal. CONCLUSION: Noninvasive monitoring of the injured brain can discriminate those patients who will have a poor clinical outcome from those who will do well. Further trials of the BAM are indicated.

Acoustics↗
PubMed2002

Detrimental effects of rapid fluid resuscitation on hepatocellular function and survival after hemorrhagic shock.

Because end-organ injury can occur with reperfusion following hemorrhage or ischemia, we hypothesized that aggressive intravenous fluid resuscitation would aggravate tissue injury in a fixed-volume model of hemorrhagic shock. Unanesthetized chronically prepared male rats were hemorrhaged 33-36 mL/kg for 2.5 h. Then Lactated Ringers Solution (3x hemorrhage volume) was infused over 5 min (FAST), 20 min (MEDIUM), 180 min (SLOW), or not at all (NO RESUS). Plasma ornithine carbamoyltransferase (OCT), lactate, and creatinine were measured as indices of hepatocellular injury, anaerobic metabolism, and renal function, respectively. At 1 h post-resuscitation (PR), MAP was greater after SLOW and MEDIUM treatment (tx) than after other txs (P < 0.05). OCT increased earliest after FAST tx to values greater than those after other txs from 30 min to 24 h PR (P < 0.01). Plasma lactate was elevated immediately before resuscitation in all groups (P < 0.01) and returned to baseline at 3 h PR after SLOW tx compared to 5 h PR after FAST tx (P < 0.05). Creatinine at 5 h PR was less in the groups treated with intravenous fluid compared to the NO RESUS group, P < 0.05. Survival at 72 h was reduced in the FAST (57%) and NO RESUS (58%) groups compared to the SLOW (87%) and MEDIUM (85%) groups (P < 0.05). Thus, overly aggressive fluid tx accelerates hepatocellular injury, is no better than lesser rates of resuscitation at correcting plasma lactate and preserving renal function, and provides no overall survival benefit.

Animals↗
PubMed2002

Efficacy of computed tomography in the diagnosis of pancreatic injury in adult blunt trauma patients: a single-institutional study.

Blunt trauma to the pancreas is an uncommon injury, which can be difficult to diagnose. Most studies are multi-institutional, include both helical and axial CT, and report sensitivities of 40 to 67 per cent. We evaluated the efficacy of spiral CT for the diagnosis of blunt pancreatic injury in a single large-volume institution. We retrospectively reviewed 22,000 blunt trauma patients seen between 1996 and 2000. Pancreatic injury was identified in 40 patients (0.2%). All patients evaluated with spiral CT were given both oral and intravenous contrast. A total of 40 blunt pancreatic injuries were identified. The mean age was 35 years. Seventy-five per cent were male. Mean Injury Severity Scale score was 29 and overall mortality 12.5 per cent. Thirty-one patients (78%) underwent laparotomy. Twelve patients went directly to the operating room for urgent exploration and 19 had a preoperative CT. CT was positive for pancreatic injury in 13 patients (sensitivity 68%). All 13 patients had confirmed pancreatic injury at the time of surgery (positive predictive value = 100%). Using the American Association for the Surgery of Trauma grading system operative findings and CT correlated in 68 per cent of those patients who had both CT and laparotomy. CT underestimated pancreatic injury in the remaining 31 per cent. Nine patients were managed nonoperatively without complication, and six had pancreatic injury on CT. The other three had a negative CT but had clinical and laboratory evidence of pancreatic injury. Overall CT scan was 68 per cent (19 of 28) accurate in diagnosing pancreatic injury. We conclude that CT scan is only moderately sensitive and can underestimate or miss pancreatic injury. Although CT moderately correlated with injury grade it was highly predictive for presence of injury. The new multidetector helical scanner may improve our diagnostic ability.

Adult↗
PubMedDate not supplied

Tolerance and efficacy of enteral nutrition in traumatic brain-injured patients induced into barbiturate coma.

BACKGROUND: There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain-injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enteral nutrition in a select group of trauma patients. METHODS: Prospective data were collected on severe traumatic brain-injured patients over a 4-year period. Patients were stratified by whether or not they were induced into a barbiturate coma. Barbiturate coma was defined as per American Association of Neurological Surgeons (AANS) guidelines. All patients were initially fed via the enteral route via a nasogastric feeding tube. Patients who did not tolerate feedings within 48 hours started receiving prokinetic agents. Feeding tolerance was defined as ability to tolerate enteral feedings with <150 mL of gastric residuals every 6 hours for >72 hours. RESULTS: Fifty-seven patients were induced into a barbiturate coma. All were victims of blunt-force trauma. Forty-two of 57 (74%) patients were men, with a mean age of 37+/-12 years and a mean injury severity score of 24+/-10. Thirty-eight of the 57 (67%) patients had an isolated traumatic brain injury. All 57 patients failed enteral nutrition via the nasogastric route after the first 48 hours of nutrition initiation after barbiturate coma was fully achieved by protocol criteria. Prokinetic agents demonstrated no improvement in feeding tolerance after the subsequent 48-72 hours. Of the 12 patients who had a postpyloric feeding tube placed, only 25% tolerated enteral nutrition for >48 hours. CONCLUSIONS: Patients with traumatic brain injury induced into barbiturate coma develop a significant ileus that is refractory to prokinetic agents. Only a marginal improvement is seen when the postpyloric route is obtained. Early parenteral nutrition should be considered in this patient population.

Adult↗
PubMedDate not supplied

Nonoperative management of spleen and liver injuries.

The spleen and liver are the 2 most commonly injured abdominal organs following trauma. Trends in management have changed over the years, and the majority of these injuries are now managed nonoperatively. Splenic injuries can be managed via simple observation or with angiography and embolization. Recent data suggest that there are few true contraindications in the setting of hemodynamic stability. Success rate of nonoperative management may be as high as 95%. Liver injuries can be approached similarly. In the setting of a hemodynamically stable patient, observation with or without angiography and embolization may similarly be used. As many as 80% of patients with liver injury can be successfully managed without laparotomy. This review will discuss current concepts in nonoperative management of liver and spleen, including diagnosis, patient selection, nonoperative management strategies, benefits, risks, and complications.

Angiography↗