Prediction of blunt traumatic injuries and hospital admission based on history and physical exam.

Background: We evaluated the ability of experienced trauma surgeons to accurately predict specific blunt injuries, as well as patient disposition from the emergency department (ED), based only on the initial clinical evaluation and prior to any imaging studies. It would be hypothesized that experienced trauma surgeons' initial clinical evaluation is accurate for excluding life-threatening blunt injuries and for appropriate admission triage decisions.

Methods: Using only their history and physical exam, and prior to any imaging studies, three (3) experienced trauma surgeons, with a combined Level 1 trauma experience of over 50 years, predicted injuries in patients with an initial GCS (Glasgow Coma Score) of 14-15.

Use of Gentamicin as Empiric Coverage for Ventilator-Associated Pneumonia: The "Con" Perspective.

Background: Gentamicin is used commonly as an empiric antibiotic prior to culture evidence in the treatment of ventilator-associated pneumonia (VAP) in surgical patients.

Methods: The published literature on the use of gentamicin for empiric therapy in VAP was reviewed and in combination with the author's personal experience, an evaluation has been made about the indications for the use of this antibiotic in VAP.

Results: Empiric gentamicin use appears to benefit less than 1% of patients in the treatment of presumptive VAP.

Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement.

This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation.

Computed tomography scans with intravenous contrast: low incidence of contrast-induced nephropathy in blunt trauma patients.

Background: Computed tomography (CT) with intravenous (IV) contrast is an important step in the evaluation of the blunt trauma patient; however, the risk for contrast-induced nephropathy (CIN) in these patients still remains unclear. The goal of this study was to describe the rate of CIN in blunt trauma patients at a Level 1 trauma center and identify the risk factors of developing CIN.

Methods: After internal review board approval, we reviewed our Level 1 trauma registry to identify blunt trauma patients admitted during a 1-year period.

A prospective study of the role of sleep related disordered breathing as a risk factor for motor vehicle crashes and the development of systemic complications in non-commercial drivers.

Introduction: Sleep related disordered breathing (SRDB), is an established risk factor for motor vehicle crashes (MVCs) involving commercial drivers. The role of SRDB in motor vehicle crashes involving non-commercial drivers is not well established.

Methods: Drivers involved in MVCs who were admitted to an American College of Surgeons accredited Level I trauma center for treatment of their injuries, and who could give informed consent and provide verbal responses to screening questionnaires were eligible for enrolment in this study.

Providing care for critically ill surgical patients: challenges and recommendations.

Providing optimal care for critically ill and injured surgical patients will become more challenging with staff shortages for surgeons and intensivists. This white paper addresses the historical issues behind the present situation, the need for all intensivists to engage in dedicated critical care per the intensivist model, and the recognition that intensivists from all specialties can provide optimal care for the critically ill surgical patient, particularly with continuing involvement by the surgeon of record. The new acute care surgery training paradigm (including trauma, surgical critical care, and emergency general surgery) has been developed to increase interest in trauma and surgical critical care, but the number of interested trainees remains too few.

Prospective, protocolized study evaluating effects of antibiotics on sputum culture results in injured patients.

Background: Appropriate utilization of antibiotics for critically ill patients involves tailoring the drug to culture results; however, the culture results must be reliable. We hypothesized that antimicrobial agents reduce significantly the reliability of cultures obtained between 1 and 24 h after antibiotic administration.

Methods: Patients were eligible for the study if they were ventilated mechanically and were suspected to have pneumonia.

Therapeutic anticoagulation can be safely accomplished in selected patients with traumatic intracranial hemorrhage.

Introduction: Therapeutic anticoagulation is an important treatment of thromboembolic complications, such as DVT, PE, and blunt cerebrovascular injury. Traumatic intracranial hemorrhage has traditionally been considered to be a contraindication to anticoagulation.

Hypothesis: Therapeutic anticoagulation can be safely accomplished in select patients with traumatic intracranial hemorrhage.

Motorcycle helmet use and legislation: a systematic review of the literature.

Although there has been a marked improvement in the safety profiles of cars and in car crash outcomes, there has been a marked worsening in outcomes of motorcycle collisions. Motorcycles account for only 2% of vehicle registrations in the United States, but motorcycle collisions account for 10% of traffic deaths. Further, motorcycle riders are 34 times more likely to die in a traffic collision than automobile drivers.

Repair of high-risk incisional hernias and traumatic abdominal wall defects with porcine mesh.

Complex ventral hernias represent a significant challenge to surgeons. We hypothesized that a wide underlay technique in combination with a novel biologic mesh would result in repair with a low recurrence rate. Medical records of patients undergoing ventral herniorrhaphy with XenMatrix biologic mesh were evaluated.

Reducing complications in trauma patients: use of a standardized quality improvement approach.

Injured patients are especially prone to developing complications. Using a multidisciplinary standardized approach to complication review is an effective method of evaluating quality improvement in patients on the trauma service. Collaboration between trauma surgeons and nurse clinicians is instrumental in improving the care of patients in each of the areas we identified.

Refeeding in the ICU: an adult and pediatric problem.

Purpose Of Review: To describe the etiology and complications of the refeeding syndrome.

Recent Findings: Complications of the refeeding syndrome can include electrolyte abnormalities, heart failure, respiratory failure, and death. This syndrome is of particular importance to critically ill patients, who can be moved from the starved state to the fed state rapidly via enteral or parenteral nutrition.

Nasal swabs collected routinely to screen for colonization by methicillin-resistant Staphylococcus aureus in intensive care units are a sensitive screening test for the organism in clinical cultures.

Background: Many hospitals screen patients for methicillin-resistant Staphylococcus aureus (MRSA) on admission to the intensive care unit (ICU). We hypothesized that this screening information could be used to assist with empiric antibiotic decisions.

Methods: The medical records of patients admitted to a university-affiliated community hospital as well as a tertiary-care university hospital were reviewed.

A systematic method for follow-up improves removal rates for retrievable inferior vena cava filters in a trauma patient population.

Background: Retrievable inferior vena cava filters (rIVCF) reduce the short-term risk of pulmonary embolism without the filter and inferior vena cava (IVC) thrombosis that have been reported with the use of permanent filters. Studies have shown that most rIVCFs are not removed, leaving patients at risk for thrombotic complications of rIVCF retention. We hypothesize that the application of a systematic follow-up for rIVCF will improve filter removal rates, providing patients short-term prophylaxis from pulmonary embolism whereas avoiding complications of permanent filter retention.

A novel technique to skin graft abdominal wall wounds surrounding enterocutaneous fistulas.

Background: Enterocutaneous fistulas often are associated with large abdominal wall wounds. Successful skin grafting of these sites is difficult, as the bed is constantly bathed by enteric contents. A method to graft these sites successfully would provide an important advance in their treatment.

A trauma outreach program provided by a level I trauma center is an effective way to initiate peer review at referring hospitals and foster process improvements.

Background: The initial care of critically injured patients has profound effects on ultimate outcomes. The "golden hour" of trauma care is often provided by rural hospitals before definitive transfer. There are, however, no standardized methods for providing educational feedback to these hospitals for the purposes of performance improvement.

Early enteral nutrition can be successfully implemented in trauma patients with an "open abdomen".

Background: The presence of an "open abdomen" after a trauma laparotomy can complicate the nutritional management of injured patients.

Methods: The medical records of patients admitted to an American College of Surgeons-verified level 1 trauma center were evaluated. The timing of nutritional support was noted.

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.

Objective: To determine a) if a checklist covering a diverse group of intensive care unit protocols and objectives would improve clinician consideration of these domains and b) if improved consideration would change practice patterns.

Design: Pre- and post observational study.

Setting: A 24-bed surgical/burn/trauma intensive care unit in a teaching hospital.

Adjunctive measures for treating surgical infections and sepsis.

The history of adjunctive treatments for severe sepsis has been fraught with more failures than successes. To date, there have been few interventions that have been demonstrated to be efficacious by multiple large, well-designed, multicenter randomized clinical trials. However, recent research into treatment strategies using drotrecogin alfa (activated), effective blood glucose management, early goal-directed therapy, protocolization of care, and intensivist management has demonstrated positive results.

Antimicrobial therapy for acute colonic diverticulitis.

Background: Although guidelines and reviews have systematically evaluated diagnosis and surgical management of acute diverticulitis, they have focused only minimally on antibiotic selection for the treatment of this disease. We undertook a review of the literature to assess more clearly the use of specific antimicrobial agents in the treatment of patients with acute diverticulitis of the colon.

Methods: A MEDLINE search was conducted to identify original research, review papers, and guidelines on the use of antimicrobial agents for the treatment of acute diverticulitis.

Alkylpyrrolidiniumtrialkoxysilyl iodides as organic iodide sources for dye-sensitised solar cells.

Two new alkylpyrrolidiniumtriethoxysilyl iodides have been developed as iodide sources for DSSCs; the compound with an undecyl spacer between the siloxane and the pyrrolidinium moieties furnished higher open circuit voltages than the propyl analogue and higher efficiencies at low light intensity.

Prevention of catheter-related blood stream infection.

Purpose Of Review: Catheter-related blood stream infections are a morbid complication of central venous catheters. This review will highlight a comprehensive approach demonstrated to prevent catheter-related blood stream infections.

Recent Findings: Elements of prevention important to inserting a central venous catheter include proper hand hygiene, use of full barrier precautions, appropriate skin preparation with 2% chlorhexidine, and using the subclavian vein as the preferred anatomic site.

Bis(acetylacetonato)ruthenium(II) complexes containing alkynyldiphenylphosphines. Formation and redox behaviour of [Ru(acac)2(Ph2PC triple bond CR)2] (R=H, Me, Ph) complexes and the binuclear complex cis-[{Ru(acac)2}2(micro-Ph2PC triple bond CPPh2)}2].

Two equivalents of Ph(2)PC triple bond CR (R=H, Me, Ph) react with thf solutions of cis-[Ru(acac)(2)(eta(2)-alkene)(2)] (acac=acetylacetonato; alkene=C(2)H(4), 1; C(8)H(14), 2) at room temperature to yield the orange, air-stable compounds trans-[Ru(acac)(2)(Ph(2)PC triple bond CR)(2)] (R=H, trans-3; Me=trans-4; Ph, trans-5) in isolated yields of 60-98%. In refluxing chlorobenzene, trans-4 and trans-5 are converted into the yellow, air-stable compounds cis-[Ru(acac)(2)(Ph(2)PC triple bond CR)(2)] (R=Me, cis-4; Ph, cis-5), isolated in yields of ca. 65%.

Catalytic reduction of dinitrogen to ammonia at a single molybdenum center.

Since our discovery of the catalytic reduction of dinitrogen to ammonia at a single molybdenum center, we have embarked on a variety of studies designed to further understand this complex reaction cycle. These include studies of both individual reaction steps and of ligand variations. An important step in the reaction sequence is exchange of ammonia for dinitrogen in neutral molybdenum(III) compounds.

Impact of resident work-hour restrictions on trauma care.

Background: In July 2003, the American Council for Graduate Medical Education (ACGME) required residency programs to significantly restrict resident work hours. The effect of these regulations on trauma services has not yet been investigated. The purpose of this study was to evaluate the effect of the ACGME regulations on the care of injured patients and resident education.