Abstract: The goals of this study were to determine the incidence and duration of hypotension and hypoxia in the prehospital setting in patients with potentially survivable brain injuries, and to prospectively examine the association of these secondary insults with mortality and disability at hospital discharge.
Abstract: Police reports of severely injured pedestrians help identify hazardous traffic areas in San Francisco, but they under-report non-fatal collisions. We set out to: identify injured pedestrians who were missing from police collision reports, see what biases exist in injury reporting and assess the utility of broad categories of police severe injury (including fatal) for mapping and analysis.
Abstract: Trauma is a major public health problem and organized systems of trauma care have been shown to substantially reduce trauma-related mortality. Currently California and many other states have incompletely developed systems of trauma care delivery. This study was undertaken to determine how frequently patients incurring serious trauma in California receive treatment at a trauma center.
Abstract: The most effective treatment for traumatic injuries is to prevent them from occurring. Currently, few surgeons receive any formal training in injury' control and prevention. This study was designed to test the knowledge of injury prevention principles among practicing surgeons, in order to identify areas in need of intensified educational efforts.
Abstract: To conduct a multicenter study to validate the accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE) II system, APACHE III system, Trauma and Injury Severity Score (TRISS) methodology, and a 24-hour intensive care unit (ICU) point system for prediction of mortality in ICU trauma patient admissions.
Abstract: To assess the accuracy of emergency department (ED) provisional diagnosis (ProDx) as compared with the hospital discharge diagnosis (HDDx) and the impact on hospital morbidity and mortality among nonelderly and elderly persons presenting with acute nontraumatic abdominal complaints, a retrospective review was conducted of 1,863 nonelderly (younger than 65 years) and 428 elderly (65 years or older) adults admitted to a university hospital from its ED. The sensitivity/ specificity of the ProDx was 82%/86% for patients younger than 65 versus 68%/76% for those 65 or older. When the ProDx and HDDx did not agree, the overall disease-related morbidity was 16% for patients younger than 65 versus 45% for those 65 or older (P < .02). There were no differences in mortality based on agreement of the ProDx and HDDx. Prospective studies to determine the factors that are most useful in the ED diagnosis of acute nontraumatic abdominal disorders in the elderly are needed to improve the accuracy of diagnosis and reduce the incidence of morbidity in this high-risk group.
Abstract: To determine the incidence, nature, demographics, severity, and hospital charges associated with inpatient treatment of firearm-related injuries.
Abstract: The use of outcome indices as a means of evaluating institutional performance for delivery of medical care is at the forefront of federal health policy reforms. Because an enormous number of clinical and financial data are generated by ICU patients, it is inevitable that integrated bedside computers will be necessary to supply the type of information that is being sought by governmental and private insurance agencies involved in assessment of hospital performance. The Health Care Financing Administration already has adopted the APACHE data collection protocols and predictive models for the severity of illness adjustments that were used in assessing the 1986 hospital-specific death rate for acute myocardial infarction, congestive heart failure, stroke, and pneumonia. In our opinion, however, it is unlikely that any single system will be developed that can accurately estimate more than 50% of ICU deaths. The intention of the APACHE III system to include 78 diagnostic categories seems unrealistic. Furthermore, the number of data needed to document outcomes for both low- and high-risk admissions is impractical. We are evaluating APACHE III to determine whether the revisions to the definition for head trauma will represent a significant improvement in predicting outcomes for trauma patients. In the interim, the financial investment in the APACHE III automated bedside data collection system cannot be justified for trauma patients. Neither should it be used in ICUs that admit a large number of trauma patients as a tool for monitoring unit efficiency, guiding triage decisions, allocating staff and ICU beds, identifying risks of iatrogenic or other potential complications, or assessing quality of life, in spite of marketing efforts by the APACHE Corporation. We believe that using any of the APACHE systems for these purposes, at best, is premature, and potentially misrepresents the trauma patient population. Standards for patient classification already are in place for use in making determinations for institutional reimbursement from governmental and insurance agencies. The inequities for certain subgroups of patients, including trauma patients, could create situations in which care is rationed rather than allocated according to a plan that distributes resources efficiently. The APACHE system has several shortcomings and adds little, if anything, to the potential solutions for trauma quality assurance and resource allocation. Nor has the APACHE system established procedures for documenting institutional review of unexpected trauma deaths that would be equivalent, for example, to the type of audit filters applied by the American College of Surgeons in conjunction with the TRISS methodology.(ABSTRACT TRUNCATED AT 400 WORDS)
Abstract: To evaluate the use of 250 mL of a 7.5% sodium chloride solution, both with and without added dextran 70, for the prehospital resuscitation of hypotensive trauma patients.
Abstract: Small volume infusions of hypertonic saline combined with dextran are very effective in resuscitating animals that have been subjected to hemorrhagic shock, and seem to be effective in resuscitating trauma patients with severe injuries. In this study, the contribution of the dextran component was investigated in a prospective, three-armed, double-blind, randomized trial. Trauma patients transported by ambulance to the hospital with a systolic blood pressure of 90 mm Hg or less were given 250 mL of (1) normal saline (NS); (2) 7.5% NaCl (HS, for hypertonic saline); or (3) 7.5% NaCl in 6% dextran 70 (HSD). Infusion of the study solution was followed by administration of conventional isotonic fluids as the patients' conditions indicated. By predetermined hypothesis, the observed survival rates in the three treatment groups were compared with the predicted survival rates from the TRISS methodology. The 7.5% NaCl solution significantly improved upon the predicted survival for the entire cohort and for high-risk patients when compared with the survival estimates from the TRISS methodology. The addition of a colloid, in the form of 6% dextran 70, did not offer any additional benefit, at least in this setting of rapid urban transport.
Abstract: The APACHE II system for predicting outcomes in critically ill patients is now being used to evaluate quality of care for patients in surgical intensive care units, including trauma patients. The trauma data, however, on which the APACHE outcomes are based, were derived from only 364 ICU trauma patients. We compared the outcome predictions by APACHE II, TRISS, and a proposed 24-hour ICU point system in 1,000 ICU patients. [table: see text] p less than 0.025 by unpaired t test for predictive power of ICU point system versus APACHE II. Values of more than 15.5 represent poor agreement between the outcomes estimated from the model and the observed outcomes; a low value represents good agreement. The APACHE system significantly overestimated the risk of death in the lower ranges of predicted risk and underestimated the deaths in the higher ranges. Although TRISS was not developed for ICU trauma patients, it tended to perform better than APACHE II in our sample. The 24-hour ICU point system performed well, with accurate agreement between the outcomes estimated from the model and the observed outcomes.
Abstract: A group of 48 critically injured patients were entered into a prospective, double-blind, placebo-controlled trial to evaluate the efficacy of early infusion of PGE1 for reducing the incidence of severe respiratory failure and mortality. Secondary assessments examined the effects of the PGE1 infusion on plasma mediated suppression of PMN superoxide production and loss of PMN granule enzyme content. The incidence of severe respiratory failure was lower in the PGE1 group--13% versus 32%, but this did not reach significance. The overall morality was equivalent between the two groups--26% (PGE1) versus 28% (placebo). The suppressive activity of the patient plasma was assayed by measurement of normal PMN superoxide production relative to normal control plasma (ratio P:C). The baseline ratio P:C was 62 +/- 5% in the PGE1 group versus 60 +/- 5% in the placebo group. The day 1 plasma samples showed significant reversal of plasma suppressive activity in the PGE1 group--ratio P:C 88 +/- 5% versus 67 +/- 5% in the placebo group (P less than 0.02). In patients who received the full 7 days of infusion, the plasma suppressive activity remained significantly diminished in the PGE1 group--ratio P:C 77 +/- 4% versus 61 +/- 5% (P less than 0.04). The baseline lysozyme content of patient PMN's relative to that of normal control PMNs (ratio P:C) was 119 +/- 14% in the PGE1 group. A significant loss of lysozyme content was observed in the PGE1 group on day 1 of the infusion--ratio P:C 79 +/- 8% (P less than 0.03), and was associated with a reduction in the plasma suppressive activity.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: To evaluate the use of hypertonic saline/dextran solutions in the prehospital resuscitation of severely injured patients, we administered 250 mL of either 7.5% sodium chloride/dextran 70 (HSD) (n = 83) or lactated Ringer's solution (n = 83), followed by conventional isotonic fluids, to 166 trauma patients with systolic blood pressures less than or equal to 100 mm Hg, in a prospective, randomized, double-blinded clinical trial. Patients in the sodium chloride/dextran 70 group required less fluid before hospitalization and arrived in the emergency department with higher systolic blood pressures than patients in the lactated Ringer's solution group. The rate of survival to hospital discharge for the entire cohort was 64% for patients in the sodium chloride/dextran 70 group vs 59% for patients in the lactated Ringer's solution group. The rate of survival to hospital discharge for the patients with severe head injuries was 32% for the sodium chloride/dextran 70 group vs 16% for the lactated Ringer's solution group. Actuarial survival for patients with severe head injuries in the sodium chloride/dextran 70 group compared with patients with severe head injuries in the lactated Ringer's solution group did not quite reach statistical significance. There were no adverse side effects associated with sodium chloride/dextran 70 administration. Administration of small volumes of sodium chloride/dextran 70 before hospitalization increased the blood pressure of severely injured patients more effectively than did lactated Ringer's solution and showed tendencies toward improving survival in the patients with severe head injuries.
Abstract: We evaluated the potential side effects of rapidly infusing 250 mL of either 7.5% sodium chloride or 7.5% sodium chloride per 6% dextran 70, using lactated Ringer's as the control, to 106 critically injured patients in two prospective double-blinded emergency department trials. Eight patients had a significant hyperchloremic acidemia in association with infusion of the hypertonic solutions, but all eight were moribund before infusion and many factors other than hyperchloremia could have contributed to their acidemia. Other blood chemistry changes that might have been associated with the hypertonic solutions, such as hyperosmolality or hypernatremia, were made insignificant by other factors, such as high blood alcohol levels or concomitant administration of sodium bicarbonate. There were no cases of central pontine myelinolysis; bleeding was not potentiated. There was no difficulty with crossmatching of blood. No anaphylactoid reactions occurred. In a setting of limited volume resuscitation, the solutions are likely to have a favorable risk-to-benefit ratio.
Abstract: Animal studies and preliminary field patient trials suggest that hypertonic saline solutions can achieve resuscitation of hypovolemic shock with extremely small volumes. In the study reported here, we evaluated the effects of a hypertonic 7.5% NaCl/6% Dextran 70 (HSD) solution in the resuscitation of patients in the emergency room. Thirty-two patients were randomized into a prospective, randomized, placebo-controlled, double-blinded trial in which 250 ml of either HSD or, as a control, lactated Ringers (LR) was used as the initial fluid for resuscitation of patients with systolic blood pressures of 80 mmHg or less. The test solution was given intravenously, usually through a saphenous vein cut-down, over a period of 2-5 minutes. Conventional isotonic solutions were then given as necessary with an average of 2500 ml of fluid being given over the first 30 minutes of resuscitation. Survival was not improved, and the trial proved to be of most interest with regard to measurement of physiological quantities, which might have been expected to have been substantially abnormal because, in many cases, the measurements were made shortly after the infusion ran in. Very few abnormalities, however, were in fact detected. With the exception of one patient, the highest sodium concentration was 156 mEq/l, the highest chloride concentration was 126 mEq/1, and the highest osmolality was 401 mOsm/kg, and this value was obtained in a patient in the control LR group. Osmolality correlated far better with blood alcohol levels (Spearman's rank correlation coefficient = 0.81) than with any other variable, including sodium and chloride concentrations. The HSD solution was safe to use.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Animal studies with hypertonic solutions suggest that they can achieve resuscitation of hypovolemic shock with extremely small volumes. Such small volume resuscitation might be ideal in the field treatment of injured patients. Our studies to date, with 60 patients entered into a prospective, randomized, placebo-controlled, and double-blind clinical trial, suggest that the use of a 7.5% NaCl/Dextran 70 solution increases blood pressures during transport. The solutions have been safe, and we have encountered no adverse side effects from their use. Survival rates to date favor use of the solutions, but we do not have convincing statistical significance yet in that regard.
Abstract: Systemic arterial and mixed venous plasma concentrations of 6-keto-PGF1 alpha and TxB2 were measured by radioimmunoassay in 63 critically ill patients with major trauma (n = 20) or sepsis (n = 43). Patients undergoing elective catheterization procedures served as controls (n = 10). Arterial and mixed venous 6-keto-PGF1 alpha and TxB2 levels were significantly elevated in patients with recent major trauma or active sepsis. The 6-keto-PGF1 alpha levels were found to be significantly elevated in the non-survivors and in patients with hepatic failure. The presence of severe pulmonary failure was not associated with increased levels of either 6-keto-PGF1 alpha or TxB2. Comparison of arterial and mixed plasma samples did not demonstrate increased pulmonary release of either compound. Increased eicosanoid production may account, in part, for the local vascular and humoral responses to tissue injury or infection.
Abstract: The fluid required for initial resuscitation of trauma patients should reflect, at least in part, the severity of the original injuries and shock. We examined the hypothesis that the initial fluid requirements might also predict development of subsequent pulmonary failure and death. Fluid balances were calculated for the first 24 hours in the intensive care unit for 100 high-risk trauma patients. The mean (+/- 1 SD) fluid balance for 63 patients who developed pulmonary failure was 4.6 +/- 5.5 L; the mean balances for the 37 patients who did not develop pulmonary failure were 1.0 +/- 3.1 L. The balances in 23 patients who died and in 77 who survived were 6.8 +/- 5.4 and 2.2 +/- 4.5 L, respectively. A cutoff value of 3 L determined prospectively before beginning the study predicted pulmonary failure with a sensitivity of 52% and a specificity of 89%. For mortality, the 3-L cutoff point gave a sensitivity of 74% and a specificity of 74%. The predictive value of the fluid balance was independent of other prognostic indicators, such as revised trauma scores, injury Severity Scores, and modified APACHE II scores. This simple measurement should help in allocating intensive care unit resources, as patients in positive fluid balance are likely to require Swan-Ganz catheterization and are likely to require long-term mechanical ventilation. The fluid balance should also be useful in stratifying patients for entry into clinical trials.
Abstract: Neutrophils (PMNs) from patients with adult respiratory distress syndrome (ARDS) were assessed for light scattering, membrane potential, and phagocytic responses using fluorescent probes and flow cytometry to evaluate individual cells. Qualitative and quantitative oxidant responses were measured by nitroblue tetrazolium (NBT) and cytochrome c reduction assays, respectively. The results were correlated with the proportion of cells binding the PMN subset-specific monoclonal antibody 31D8. Despite an increased forward scatter signal (4.3 +/- 1.6 vs. 1.3 +/- 1.1 ARDS vs. control, P = 0.041) and spontaneous NBT test (12.6 +/- 4.7% vs. 2.5 +/- 0.8% positive, ARDS vs. control, P = 0.033) indicating in vivo priming of ARDS PMNs, there were no significant differences between ARDS and control PMNs in assays of stimulated membrane potential, NBT, and O.2- production or phagocytosis. However, positive correlations between the degree of prestimulus forward light scatter and subsequent O.2- production to FMLP (r = 0.673, P = 0.006) and between the percentage of bands and the O.2- response to PMA (r = 0.660, P = 0.003), suggest that the great variability of the ARDS PMN functional responses may relate to varying degrees of in vivo cell priming and/or deactivation. ARDS PMNs demonstrated a significantly lower percentage of 31D8 positive cells (73.4 +/- 7.5% vs. 94.5 +/- 1.6%, P = 0.012) and a lower level of 31D8 staining when compared to normals (60.1 +/- 10.4% of control level, P = 0.001). The lower 31D8 expression did not directly correlate with any functional parameter tested or with the proportion of immature cells. However, patients receiving an intravenous PGE1 infusion demonstrated a significant increase in 31D8 staining relative to controls and inhibition of PMA-stimulated O.2- production. The data suggest that the function of PMNs from ARDS patients varies widely and reflects great in vivo variation in cell priming. While the mechanism responsible for the lowered expression of the 31D8 antigen and its apparent modulation by PGE1 is unknown, 31D8 may be an indirect marker for in vivo stress factors that regulate the preferential release of a structurally distinct PMN subset from the bone marrow.
Abstract: Prostaglandin E1 (PGE1) is currently being evaluated in clinical trials to determine its usefulness in the treatment of adult respiratory distress syndrome (ARDS). The drug is administered to ARDS patients by continuous intravenous infusion at dosage rates of up to 30 ng/kg/min for 7 days. The present study was conducted to determine the pulmonary extraction efficiency and pharmacokinetics of PGE1 under these conditions. Plasma levels of PGE1 were determined by high performance liquid chromatography in 14 patients who either had ARDS or were considered to be at risk of developing ARDS following trauma or sepsis. Predose plasma levels of PGE1 were below the detection limit of the assay (50 pg/ml). At a dosage rate of 30 ng/kg/min, pulmonary arterial and systemic arterial plasma levels ranged from 265 to 1,009 pg/ml and 50 to 796 pg/ml, respectively. The pulmonary extraction ratio (Ep) of PGE1 varied from 0.11 to 0.90 and was independent of dose but dependent on cardiac output. The data were adequately described by first-order pharmacokinetic equations which assumed that the lung was the only site of PGE1 clearance. Nine of 10 patients with AaPO2/FlO2 below 510 mm Hg had Ep greater than 0.7 and high pulmonary intrinsic clearance for PGE1 (ca. 250 L/min), but all 4 patients with AaPO2/FlO2 above 510 mm Hg had Ep less than 0.6 and low intrinsic clearance (ca. 37 L/min or less). The intrinsic clearance of the lung for PGE1 in ARDS patients therefore appears to decrease abruptly once a threshold of severe respiratory failure is achieved.
Abstract: Cardiovascular resuscitation of the severely injured patient in the field remains unsatisfactory because large volumes of intravenous fluid are needed to keep up with ongoing blood losses and because only small volumes of fluid can be given. In the first study reported here, small volumes (less than or equal to 12 mL/kg) of 3% NaCl were given to patients who were having surgery for severe injuries. The 3% NaCl restored blood pressure, pH, and urine output with approximately one half of the cumulative fluid requirement of patients who received isotonic fluids (p less than 0.05). In a second study, 7.5% NaCl/dextran 70, 250 mL, was given in a prospective, randomized, and double-blinded trial to injured patients in the field. Blood pressure in the hypertonic/hyperoncotic group increased 49 mmHg during transport (p less than 0.005); blood pressure in patients given lactated Ringer's solution increased 19 mmHg (NS). Survival favored the hypertonic/hyperoncotic group. The 7.5% NaCl/dextran 70 solution appears particularly promising for treatment of injured patients in the field.
Abstract: Several mechanisms contributing to the development of post-traumatic alterations in organ function are reviewed. The importance of interactions between clotting and inflammatory mediators is detailed. A discussion of management strategies emphasizes the role of early recognition and aggressive treatment of organ dysfunction.
Abstract: A 7-day infusion of prostaglandin E1 (PGE1), an immunomodulator, was evaluated in a prospective, randomized, placebo-controlled, double-blinded trial in surgical patients with the adult respiratory distress syndrome (ARDS). The drug seemed to improve pulmonary function--only two PGE1 patients died with severe pulmonary failure compared with nine placebo patients (p = 0.01). Survival at 30 days after the end of the infusion--the predetermined end point of the study--was significantly better in the patients given PGE1 (p = 0.03), with 15 of 21 PGE1 patients (71%) alive at this time compared with seven of 20 placebo patients (35%). Improvement in overall survival in the PGE1 patients did not reach statistical significance (p = 0.08). Overall survival in patients initially free of severe organ failure, however, was significantly better in the PGE1 patients (p = 0.03). Of the six PGE1 patients free of severe organ failure at time of entry, all survived to leave the hospital; of the 10 placebo patients initially free of severe organ failure, four survived. The drug had no serious side effects and did not potentiate susceptibility to infection. PGE1 is a promising agent for the treatment of ARDS.
