Ethics, equipoise, and evidence: when should investigators decide to not test their hypothesis.

In an excellent investigation of endotracheal tube cuff pressure assessment, "Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Transport," Chapman et al measured endotracheal tube cuff pressure in patients who arrive at their emergency department after being intubated in the field. This, the first published American study of this type, presents clear and convincing evidence that patients who undergo endotracheal intubation before transport have endotracheal tube cuff pressures that exceed safe limits. Although a study of this type has not been conducted on patients who are endotracheally intubated by emergency medicine physicians within the confines of an emergency department, we pose the question to the academic and clinical emergency medicine community, "Should such a study be conducted?" Instead, should the evidence offered by Chapman et al, in addition to that of other publications, be enough to prompt emergency physicians to abandon the practice of endotracheal intubation without measurement and/or control of endotracheal tube cuff pressure? To adequately understand the complexity of such an apparently simple question, it is necessary to consider 2 concepts: equipoise and evidence.

Longitudinal associations between depression and functioning in midlife women.

Associations between depression and impaired functioning are well known and have been documented in numerous clinical, primary care and epidemiological studies. Reviews of this research have focused on the elderly. Recent studies suggest that women become increasingly vulnerable during the menopausal transition to declines in physical and role function and increases in depressive symptoms.

Ultrasound-guided peripheral intravenous access in the intensive care unit.

Purpose: Central venous catheters continue to be a popular means of maintaining vascular access in surgical intensive care units despite well-described complications. With edema, obesity, and difficult to visualize veins potentially affecting the surgically ill, inability to obtain peripheral intravenous (PIV) access may hinder the clinician's ability to avoid the use of central lines. With ultrasound gaining increased popularity for obtaining vascular access, we evaluated its utility in ultrasonagraphically placing PIV catheters for the purposes of either avoiding central venous access or removing central venous catheters.

Pulmonary embolism after injury: more common than we think?

Background: We have previously demonstrated that pulmonary embolism (PE) can occur early and explain hypoxia immediately after injury. We hypothesized that an increased awareness of early PE would result in an increased incidence, an earlier diagnosis, and a decreased mortality of PE after injury.

Methods: The trauma registry identified patients diagnosed with a PE between time period (TP) 1 (June 1999 and December 2004) and TP 2 (January 2005 and December 2006).

Controversy in trauma resuscitation: do ratios of plasma to red blood cells matter?

Since a report in October 2007 of dramatic improvements in trauma mortality in a military population when massive transfusion of red blood cells (RBC) was accompanied by plasma replacement at 1:1 proportions, interest in the plasma-to-RBC ratio during resuscitation in both the trauma and transfusion communities has been intense. Over the 7-month period from August 2008 through February 2009, a further 9 major studies examining experience with plasma replacement in massively transfused civilian trauma patients have been published. This flood of observational studies is likely to continue.

Vascular injuries after blunt chest trauma: diagnosis and management.

Background: Although relatively rare, blunt injury to thoracic great vessels is the second most common cause of trauma related death after head injury. Over the last twenty years, the paradigm for management of these devastating injuries has changed drastically. The goal of this review is to update the reader on current concepts of diagnosis and management of blunt thoracic vascular trauma.

Trauma patients can be safely extubated in the emergency department.

Background: Many trauma patients are intubated for conditions that fully resolve during their emergency department (ED) stay. Often, these patients remain intubated until after they leave the ED.

Objective: The objective of this study was to examine the prognosis of patients extubated in the ED.

Endograft repair of traumatic aortic injury-a technique in evolution: a single institution's experience.

Objective: We evaluated a large single center experience of endograft repair of blunt traumatic injury of the thoracic aorta.

Summary Background Data: Traumatic aortic transection is a devastating injury with high morbidity and mortality. Endograft repair of these injuries has reduced the rates of death and paraplegia seen with open surgical treatment in the past.

Prehospital hypocapnia and poor outcome after severe traumatic brain injury.

Background: The Brain Trauma Foundation (BTF) Guidelines for prehospital management of traumatic brain injury (TBI) recommend a goal end-tidal carbon dioxide of 30 mm Hg to 35 mm Hg in patients without signs of herniation.

Methods: We examined prehospital concordance with BTF Guidelines, selected demographic and physiologic variables and outcomes for 100 consecutive admissions to a well-established Level I regional trauma center. All patients had blunt TBI with Glasgow Coma Score < or = 8 without signs of herniation.

Functional outcomes of posttraumatic lower limb salvage: a pilot study of anterolateral thigh perforator flaps versus muscle flaps.

Background: Functional outcomes of lower extremity reconstruction compared with amputation have been evaluated. However, there are little comparative data among the different reconstructive options. With the recent increase in perforator flaps, we compared the functional outcomes of muscle and perforator flaps.

Crash and occupant predictors of pulmonary contusion.

Objectives: Pulmonary contusions (PCs) are a common injury sustained in motor vehicle collisions. The crash and occupant characteristics of PC in motor vehicle collisions are currently unknown. Additionally, the clinical significance and the impact on mortality have not been determined.

Blunt traumatic thoracic aortic injuries: early or delayed repair--results of an American Association for the Surgery of Trauma prospective study.

Background: The traditional approach to stable blunt thoracic aortic injuries (TAI) is immediate repair, with delayed repair reserved for patients with major associated injuries. In recent years, there has been a trend toward delayed repair, even in low-risk patients. This study evaluates the current practices in the surgical community regarding the timing of aortic repair and its effects on outcomes.

Hemostatic efficacy of modified amylopectin powder in a lethal porcine model of extremity arterial injury.

Study Objective: Rapid hemostasis is crucial in controlling severe extremity hemorrhage. Our objective is to evaluate the hemostatic efficacy of a newly modified amylopectin powder in a model of severe extremity arterial hemorrhage.

Methods: Anesthetized pigs underwent severe, reproducible femoral artery injuries.

Comparative study of decompressive craniectomy after mass lesion evacuation in severe head injury.

Objective: This study was conducted to evaluate outcome after decompressive craniectomy (DC) in the setting of mass evacuation with or without intracranial pressure (ICP) monitoring.

Methods: Over a 48-month period (March 2000 to March 2004), 54 of 967 consecutive head injury patients underwent DC for evacuation of a mass lesion. DC was performed without ICP monitoring in 27 patients who required urgent decompression (group A) and in 27 patients who did not require urgent surgery and who had their ICP monitored for 1 to 14 days before surgery (group B).

Daily multidisciplinary discharge rounds in a trauma center: a little time, well spent.

Background: Patient flow in a trauma center can be improved by multidisciplinary discharge rounds (MDR), but the content and logistics of MDR discussions have not been well quantified for purposes of improvement and adoption. We characterized the discussion content and time spent during MDRs and measured success rates in implementing communicated plans.

Methods: Bedside MDRs in seven patient care units were observed during consecutive working days in a major academic trauma center.

Major hepatic necrosis: a common complication after angioembolization for treatment of high-grade liver injuries.

Background: The management of high-grade liver injuries often involves a combination of operative and nonoperative strategies. Angioembolization (AE) is frequently used in the management of these injuries. Morbidity in patients with high-grade hepatic injuries remains high despite improvements in mortality with a multimodality approach.

Use of recombinant factor VIIa to facilitate organ donation in trauma patients with devastating neurologic injury.

Background: Organ donation serves a public health function but is also an important part of end-of-life care. Nearly 40% of organ donors are the victims of traumatic brain injury (TBI). We report on a series of patients with nonsurvivable TBI and severe coagulopathy or active hemorrhage who went on to successful organ donation with the use of recombinant factor VIIa (rFVIIa).

Avoiding common technical errors in subclavian central venous catheter placement.

Background: Proficiency in placing infraclavicular subclavian venous catheters can be achieved through practice and repetition. But few data specifically document insertion technical errors, which mentors could teach novice operators to avoid.

Study Design: Surgical, medical, and anesthesia textbooks and procedural handbooks were reviewed.

Blunt splenic injuries in the adolescent trauma population: the role of angiography and embolization.

Background: Splenic artery embolization (SAE) improves non-operative splenic salvage rates in adults, but its utility and safety in the pediatric population is less well defined.

Objective: Because adolescent trauma patients are often triaged to adult trauma centers, we were interested in evaluating SAE in this particular population. We hypothesize that angiography and embolization is a safe and effective adjunct to non-operative management in the adolescent population.

Blunt cerebrovascular injuries: does treatment always matter?

Background: Blunt cerebrovascular injuries (BCVI) have become an increasingly recognized entity. Stroke as a result of these injuries can have devastating consequences. Optimal screening criteria, diagnostic imaging, and therapy for BCVIs have not been elucidated.

Reversal of coagulopathy in critically ill patients with traumatic brain injury: recombinant factor VIIa is more cost-effective than plasma.

Background: Traumatic brain injury (TBI) is the leading cause of death and disability after trauma. Coagulopathy is common in this patient population and requires rapid reversal to allow for safe neurosurgical intervention and prevent worsening of the primary injury. Typically reversal of coagulopathy is accomplished with the use of plasma.

Management of maxillofacial injuries with severe oronasal hemorrhage: a multicenter perspective.

Background: Airway establishment and hemorrhage control may be difficult to achieve in patients with massive oronasal bleeding from maxillofacial injuries. This study was formulated to develop effective algorithms for managing these challenging injuries.

Methods: Trauma registries from nine trauma centers were queried over a 7-year period for injuries with abbreviated injury scale face >/= 3 and transfusion of >/=3 units of blood within 24 hours.

Automatic pre-hospital vital signs waveform and trend data capture fills quality management, triage and outcome prediction gaps.

Trauma Triage errors are frequent and costly. What happens in pre-hospital care remains anecdotal because of the dual responsibility of treatment (resuscitation and stabilization) and documentation in a time-critical environment. Continuous pre-hospital vital signs waveforms and numerical trends were automatically collected in our study.