Trauma Surgery & Acute Care Open最新文献

Abstract:

Objectives: The American Association for the Surgery of Trauma (AAST) Critical Care Committee chose handoffs and transitions of care in the intensive care unit (ICU) as a clinically relevant topic for review. This clinical consensus document aims to provide practical guidance to the surgical intensivist on the best practices for patient handoffs and transitions of care.

Methods: A working group was formed from the committee-at-large to complete this work. The members of the working group were each assigned a subtopic to review using research to date. The research on which the recommendations are based was compiled at the discretion of the working group. Any topic with discrepant or minimal supporting literature was reviewed by the AAST Critical Care Committee through an anonymous survey.

Results: Recommendations for healthcare handovers include formally recognized handoffs at dedicated times, an interactive verbal exchange including all patients with a focus on what to anticipate or what is needs to be completed, tools to record and maintain information, and training to new providers on the handoff process and technology.

Conclusion: As clinicians, we strive to provide the best evidence-based care to our patients. It is essential to study these high states, ICU handoffs to enhance the safety, efficiency, and effectiveness of patient care transitions, ultimately leading to better patient outcomes and provider satisfaction.

Level of evidence: V.

Background: Many older adults with trauma have pre-existing serious illness like dementia, frailty, and organ insufficiency and are candidates for palliative care to improve outcomes and reduce downstream healthcare utilization. We hypothesize that baseline pain, depressive symptoms, and unpaid caregiving needs are associated with increased healthcare utilization in the year after trauma admission in seriously ill older adults.

Methods: Using the Health and Retirement Study (2008-2018) linked to Medicare claims, we identified adults aged ≥66 years admitted for trauma. We assessed pre-admission pain (none/mild vs moderate/severe), depressive symptoms (no-Center for Epidemiologic Studies Depression Scale (CES-D) <3 vs yes-CES-D ≥3) and unpaid caregiving needs (none vs any); and hospital characteristics: trauma center designation and palliative care service. The χ² tests were used for categorical variables, and t-tests were used for continuous variables. Associations of pain, depressive symptoms, unpaid caregiving needs with healthcare utilization were tested with negative binomial and Poisson regression models.

Results: Among 1693 older adults with serious illness, a third (35.7%) were older than 85 years, two-thirds were female (67.5%), and almost all were White (88.7%). Before trauma, 36.4% reported moderate/severe pain, 40.2% reported depressive symptoms (CES-D >3), and 34.9% reported any amount of hours/week of unpaid caregiving needs. Adjusted analyses demonstrated that compared with those without depressive symptoms, seriously ill older adults with depressive symptoms were less likely to be alive (incidence rate ratio (IRR) 0.61, 95% CI 0.41 to 0.91), had more emergency room visits (IRR 1.62, 95% CI 1.15 to 2.27), and more hospital visits (IRR 1.48, 95% CI 1.08 to 2.03) in the year after admission. Adjusted analyses of association of pain and caregiving with healthcare utilization were not significant.

Conclusions: Seriously ill older trauma patients with depressive symptoms have increased healthcare utilization in the year after discharge. Palliative care interventions may improve patient outcomes and reduce postdischarge healthcare utilization.

Level of evidence: III.

Background: Trauma is a major cause of mortality in the elderly population. Hyponatremia is the most common electrolyte imbalance in geriatric patients and has been demonstrated to be a risk factor for altered cognition, low bone density, falls, and death. We systematically and critically reviewed the literature to ascertain the association between hyponatremia and geriatric trauma outcomes.

Methods: We searched seven databases for articles published from inception to October 2023. Studies included reported on geriatric trauma, hyponatremia, and clinical outcomes. Two investigators independently reviewed 6535 abstracts, 235 full-text articles, and critically appraised each study. Study details, patient characteristics, and outcomes were independently extracted by two reviewers. Data quality assessment was performed using the Grading of Recommendations Assessment, Development, and Evaluation approach. Publication bias was assessed using funnel plot-based methods. A meta-analysis of risk ratios (RR) was performed using the random effects method.

Results: Four retrospective cohort studies involving 11 894 geriatric patients were included. Among these, 492 (21.4%) were classified as trauma patients due to a fall and 1806 (78.6%) were classified as a trauma patient due to the presence of a fracture. In total, 2298 (19.3%) patients were classified as hyponatremic (125-135 mmol/L) while 9596 (80.7%) were classified as normonatremic. The pooled RR for in-hospital mortality for hyponatremic patients was 2.23 (95% CI 1.51 to 3.74) with high heterogeneity across the studies (I²=82.17%).

Conclusions: Geriatric trauma patients presenting with hyponatremia appear to have an increased risk of in-hospital mortality. Given this association, national trauma registries should consider collecting serum sodium values for geriatric patients and providers should work to address hyponatremia as a possible contribution to falls. Given the paucity of published literature on this topic, there is a need for prospective studies evaluating the association between hyponatremia and geriatric trauma outcomes.

Level of evidence: Level III, systematic review with meta-analysis.

Background: Mortality for patients with pelvic fracture with hemorrhagic shock ranges from 21% to 57%. ResQFoam administered intra-abdominally has previously been shown to provide a survival benefit in large-animal models of abdominal exsanguination. It also significantly decreased mortality in models of retroperitoneal hemorrhage with complex pelvic fracture when deployed in the preperitoneal space. We hypothesized that percutaneously administered ResQFoam into the abdominal cavity could decrease mortality in exsanguinating pelvic hemorrhage.

Methods: Using non-coagulopathic Yorkshire swine, the injury model consisted of a unilateral, closed-cavity retroperitoneal vascular hemorrhage (with intraperitoneal communication) combined with a complex pelvic fracture. After the injury, animals received fluid resuscitation alone (control, n=14), fluid resuscitation with ResQFoam deployed in the preperitoneal pelvic space (n=10), or fluid resuscitation with ResQFoam deployed intra-abdominally (n=10). Hemodynamic monitoring was continued for 3 hours or until death.

Results: Intra-abdominal and preperitoneal use of ResQFoam provided a similar significant survival benefit compared with controls. The median survival times for the intra-abdominal and preperitoneal ResQFoam groups were 87 and 124 min, respectively, compared with 17 min for the control group (p=0.008 and 0.002, respectively). The survival rate at 3 hours was 40% for both ResQFoam groups compared with 0% in controls (p=0.020). There was no significant difference in the median survival time or overall survival curves between the two ResQFoam groups (p=0.734 and p=0.975, respectively). Both ResQFoam groups stabilized mean arterial pressure and significantly reduced hemorrhage rate. The average hemorrhage rate in control animals was 4.9±4.6 g/kg/min compared with 0.6±0.6 g/kg/min and 0.5±0.5 g/kg/min in the intra-abdominal (p=0.008) and preperitoneal (p=0.002) ResQFoam groups, respectively.

Conclusions: Similar survival benefit and hemorrhage control were achieved with ResQFoam in the treatment of exsanguinating pelvic hemorrhage with complex pelvic fracture whether it was administered preperitoneally or intra-abdominally. Thus, ResQFoam can be administered intra-abdominally to treat either abdominal or pelvic hemorrhage.

Level of evidence: Not applicable (animal study).

Background: The use of standing electric motorized scooters (eScooters) has skyrocketed since its first release in 2016. This quickly popularized form of transportation has been associated with significant injury and even death. These eScooter-related traumatic injuries led to local advocacy efforts, resulting in safety restrictions including speed limit geofencing, sidewalk restrictions, and limiting the number of eScooter providers in high-density population areas. We hypothesized that these local safety restrictions decreased the number of eScooter-related injuries presenting to our trauma center. .

Methods: This is a retrospective cohort study of eScooter-crash patients presenting to our Level 1 trauma center from July 2018 to June 2023. Variables included patient demographics, injury severity score (ISS), and mortality. The primary outcome was the rate of eScooter patients presenting over time in relation to the implementation of local-regional safety regulations.

Results: A total of 381 patients presented after eScooter crashes. Males were 73.8% of patients. The average age was 38.6 years; 45+ years was the most common age group at 33%, followed by ages 25-34 (31%). The mean ISS was 9±6, with ISS 0-9 (65.1%), 10-15 (24.4%), 16-24 (8.4%), and >25 (20.1%). There were three (0.8%) deaths. The median number of eScooter patients per month with prespeed limits was nine and post five (p=0.005), showing a 44.4% decrease in injured patients. After February 2022 restrictions, the rate precipitously declined with a median of two (p=0.033), reflecting an additional 60% decrease in injured patients.

Conclusion: Local advocacy resulting in increased safety regulations was associated with a significant reduction in injured patients secondary to eScooter use. This demonstrates the importance of advocacy efforts in response to changes in injury patterns and mechanisms of injury. We believe that our work can serve as a model for other urban centers seeking to reduce eScooter-related injuries and implement effective safety measures.

Level of evidence: IV, prognostic/epidemiologic.

Background: Multiple rib fractures commonly result from blunt chest trauma. These fractures can lead to prolonged impairment in pulmonary function and often require long-term rehabilitation. This pilot study aimed to evaluate the feasibility of a remote spirometry device for continuous monitoring of lung function in patients with multiple rib fractures.

Methods: Between January 2021 and April 2021, we implemented a remote spirometry system for adult patients with multiple rib fractures and collected their clinical data. We used a Restart system to monitor the respiratory parameters of patients. This system included a wireless spirometer and a Healthy Lung mobile application. A portable spirometer was used to measure forced vital capacity (FVC), peak expiratory flow (PEF), and forced expiratory volume in 1 second.

Result: In total, 21 patients were included in this study. We categorized the participants into two age groups: those older and those younger than 65 years. No significant differences were observed between the two groups regarding demographic characteristics or device adoption rates. However, we observed that patients under 65 years demonstrated more remarkable improvement in pulmonary function than their older counterparts, with significant differences in FVC (110% vs 10%, p=0.032) and PEF (64.2% vs 11.9%, p=0.003).

Conclusion: The adoption of the remote spirometry device is similar between older and younger patients with rib fractures. However, the device improves pulmonary function more in patients in a younger age group. This tool may be effective as a real-time, continuous pulmonary function monitoring system for patients with multiple rib fractures.

Level of evidence: Level IV.