Is state trauma funding associated with mortality among injured hospitalized patients?

Background: We sought to quantify the association between state trauma funding and (1) in-hospital mortality and (2) transfers of injured patients.

Methods: We conducted an observational cross-sectional study of states with publicly available trauma funding data. We analyzed in-hospital mortality using linked data from the Nationwide Inpatient Sample (NIS), American Hospital Association (AHA) Annual Survey, and these State Department of Public Health trauma funding data.

Characterizing re-triage guidelines: A scoping review of states' rules and regulations.

Background: State guidelines for re-triage, or emergency inter-facility transfer, have never been characterized across the United States.

Methods: All 50 states' Department of Health and/or Trauma System websites were reviewed for publicly available re-triage guidelines within their rules and regulations. Communication was made via phone or email to state agencies or trauma advisory committees to obtain or confirm the absence of guidelines where public data was unavailable.

Re-triage moderates association between state trauma funding and lower mortality of trauma patients.

Background: Severely injured patients who are re-triaged (emergently transferred from an emergency department to a high-level trauma center) experience lower in-hospital mortality. Patients in states with trauma funding also experience lower in-hospital mortality. This study examines the interaction of re-triage, state trauma funding, and in-hospital mortality.

The Association of Limited English Proficiency With Morbidity and Mortality After Trauma.

Introduction: Disparities following traumatic injury by race/ethnicity and insurance status are well-documented. However, the relationship between limited English proficiency (LEP) and outcomes after trauma is poorly understood. This study describes the association between LEP and morbidity and mortality after traumatic injury.

Pelvic fracture pattern predicts the need for hemorrhage control intervention-Results of an AAST multi-institutional study.

Background: Early identification of patients with pelvic fractures at risk of severe bleeding requiring intervention is critical. We performed a multi-institutional study to test our hypothesis that pelvic fracture patterns predict the need for a pelvic hemorrhage control intervention.

Methods: This prospective, observational, multicenter study enrolled patients with pelvic fracture due to blunt trauma.

The Triage of Injured Patients: Mechanism of Injury, Regardless of Injury Severity, Determines Hospital Destination.

The target rate for trauma undertriage is <5 per cent, but rates are as high as 30 to 40 per cent in many trauma systems. We hypothesized that high undertriage rates were due to the tendency to undertriage injured elderly patients and a growing elderly population. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database over a 5-year period.

Beyond emergency surgery: redefining acute care surgery.

Background: Considerable debate exists regarding the definition, skill set, and training requirements for the new specialty of acute care surgery (ACS). We hypothesized that a patient subset could be identified that requires a level of care beyond general surgical training and justifies creation of this new specialty.

Materials And Methods: Reviewed patient admissions over 1-y to the only general surgical service at a level I trauma center-staffed by trauma and/or critical care trained physicians.

Recent developments in the assessment of the multiply injured trauma patient.

Purpose Of Review: To provide an update on the recent developments and controversies in the assessment of the traumatically injured patient.

Recent Findings: Recent literature suggests that: whole-body computed tomography (CT) is an effective strategy in more severely injured blunt trauma patients; 64-slice CT scanning now provides an effective noninvasive screening method for blunt cerebrovascular injury; the need for MRI imaging, in addition to CT, for the diagnosis of occult ligamentous injury of the cervical spine remains an unresolved controversy; point-of-care testing has made significant improvements in our ability to predict which patients will need a massive transfusion; and thromboelastography has enhanced our ability to tailor a hemostatic resuscitation more accurately.

Summary: The recent advances in the assessment of the multiply injured patient allow clinicians to more efficiently diagnose a patient's injuries and implement treatment in a more timely manner.

Service: 2010 Western Trauma Association presidential address.

Service is central to the mission of a trauma surgeon and inextricably interwoven into our professional lives and activities. It is important to recognize the role that professional associations play in leveraging service as well as the need to continue to cultivate the ethic of service in medical education and in our training programs.

Prospective randomized trial of LC+LCBDE vs ERCP/S+LC for common bile duct stone disease.

Objective: To compare outcome parameters for good-risk patients with classic signs, symptoms, and laboratory and abdominal imaging features of cholecystolithiasis and choledocholithiasis randomized to either laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC+LCBDE) or endoscopic retrograde cholangiopancreatography sphincterotomy plus laparoscopic cholecystectomy (ERCP/S+LC).

Design: Our study was a prospective trial conducted following written informed consent, with randomization by the serially numbered, opaque envelope technique.

Setting: Our institution is an academic teaching hospital and the central receiving and trauma center for the City and County of San Francisco, California.

Where do we go from here? Interim analysis to forge ahead in violence prevention.

Background: The severity and disparity of interpersonal violent injury is staggering. Fifty-three per 100,000 African Americans (AA) die of homicide yearly, 20 per 100,000 in Latinos, whereas the rate is 3 per 100,000 in Caucasians. With the ultimate goal of reducing injury recidivism, which now stands at 35% to 50%, we have designed and implemented a hospital-based, case-managed violence prevention program uniquely applicable to trauma centers.

Pitfalls in the evaluation and resuscitation of the trauma patient.

The management of the trauma patient presents the practitioner with a host of challenges, and the pace, variety of venues, and multidisciplinary nature of the field combine to create a system complexity that is laden with potential pitfalls. This review summarizes some of the general principles of medical errors and examines some of the more common pitfalls encountered in the initial resuscitation and evaluation of the major trauma patient.

Acute coagulopathy of trauma: hypoperfusion induces systemic anticoagulation and hyperfibrinolysis.

Background: Coagulopathy is present at admission in 25% of trauma patients, is associated with shock and a 5-fold increase in mortality. The coagulopathy has recently been associated with systemic activation of the protein C pathway. This study was designed to characterize the thrombotic, coagulant and fibrinolytic derangements of trauma-induced shock.

Early coagulopathy after traumatic brain injury: the role of hypoperfusion and the protein C pathway.

Introduction: Early coagulopathy after traumatic brain injury (TBI) is thought to be the result of injury-mediated local release of tissue factor, although the precise mechanisms that cause hypoperfusion and early systemic coagulopathy in TBI patients are unknown. We have previously reported that early systemic coagulopathy after trauma is present only when tissue injury is associated with severe hypoperfusion leading to the activation of the protein C pathway. However, the role of hypoperfusion as an important mechanism for the development of coagulopathy early after TBI is unclear.

The spontaneous breathing pattern and work of breathing of patients with acute respiratory distress syndrome and acute lung injury.

Background: The spontaneous breathing pattern and its relationship to compliance, resistance, and work of breathing (WOB) has not been examined in patients with acute respiratory distress syndrome (ARDS) or acute lung injury (ALI). Clinically, the ratio of respiratory frequency to tidal volume (f/VT) during spontaneous breathing may reflect adaptation to altered compliance, resistance, and increased WOB. We examined the relationship between f/VT, WOB, and respiratory system mechanics in patients with ARDS/ALI.

Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway?

Objectives: Coagulopathy following major trauma is conventionally attributed to activation and consumption of coagulation factors. Recent studies have identified an acute coagulopathy present on admission that is independent of injury severity. We hypothesized that early coagulopathy is due to tissue hypoperfusion, and investigated derangements in coagulation associated with this.

Field triage, and the fragile supply of "optimal resources" for the care of the injured patient.

Conventional field triage schemes, including those discussed in this series of reports, assume a high degree of consistency in the availability of resources at designated receiving hospitals. In an organized trauma system, designated trauma receiving facilities of all levels are typically required to maintain a high level of consistency in terms of available facility and human resources for the care of the injured patient. These resources, both facility and provider, are becoming increasingly vulnerable to gaps in availability, however, for a variety of reasons.

History of trauma field triage development and the American College of Surgeons criteria.

The use of trauma field triage criteria is designed to match a patient's injury type and severity to prioritized transport and an institution with the resources to provide timely, definitive care. Triage schemes used in austere environments created by war or mass casualty events are less applicable to day-to-day civilian trauma. Civilian triage criteria, developed and refined over the past 25 years, rely on physiologic, anatomic, and mechanistic indicators of severe injury in an attempt to optimize overtriage and undertriage.

Effects of tidal volume on work of breathing during lung-protective ventilation in patients with acute lung injury and acute respiratory distress syndrome.

Objective: To assess the effects of step-changes in tidal volume on work of breathing during lung-protective ventilation in patients with acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS).

Design: Prospective, nonconsecutive patients with ALI/ARDS.

Setting: Adult surgical, trauma, and medical intensive care units at a major inner-city, university-affiliated hospital.

Work of breathing during lung-protective ventilation in patients with acute lung injury and acute respiratory distress syndrome: a comparison between volume and pressure-regulated breathing modes.

Background: Pressure-control ventilation (PCV) and pressure-regulated volume-control (PRVC) ventilation are used during lung-protective ventilation because the high, variable, peak inspiratory flow rate (V (I)) may reduce patient work of breathing (WOB) more than the fixed V (I) of volume-control ventilation (VCV). Patient-triggered breaths during PCV and PRVC may result in excessive tidal volume (V(T)) delivery unless the inspiratory pressure is reduced, which in turn may decrease the peak V (I). We tested whether PCV and PRVC reduce WOB better than VCV with a high, fixed peak V (I) (75 L/min) while also maintaining a low V(T) target.

Serum levels of Hsp60 correlate with the development of acute lung injury after trauma.

Background: Previous studies have shown that heat shock protein 60 (Hsp60) is a danger signal for the immune system and appears to be a key endogenous inflammatory mediator that activates the toll-like receptors and causes the release of proinflammatory cytokines and nitric oxide by immune competent cells, but no data are available for trauma patients. The purpose of this study was to determine whether Hsp60 could be detected in the serum of patients early after severe trauma and whether its serum level might correlate with the development of acute lung injury (ALI) in trauma patients.

Methods: Clinical data were collected prospectively during a 12-month period for trauma patients who were ventilated mechanically for more than 24 h and who met the following inclusion criteria: Injury Severity Score > or =16, age >18 years.