Variations in pediatric trauma transfer patterns in Northern California pediatric trauma centers (2001-2009).

Background: Due to the scarcity of specialized resources for pediatric trauma, "regionalization," or a system designed to get "the right child, to the right place, at the right time," is vital to quality pediatric trauma care. In Northern California, four pediatric trauma centers serve 3.9 million children within a geographically diverse area of 113,630 square miles.

Trauma Center-Based Surveillance of Nontraffic Pedestrian Injury among California Children.

Introduction: Every year in the United States, thousands of young children are injured by passenger vehicles in driveways or parking areas. Little is known about risk factors, and incidence rates are difficult to estimate because ascertainment using police collision reports or media sources is incomplete. This study used surveillance at trauma centers to identify incidents and parent interviews to obtain detailed information on incidents, vehicles, and children.

Deciphering the use and predictive value of "emergency medical services provider judgment" in out-of-hospital trauma triage: a multisite, mixed methods assessment.

Background: "Emergency medical services (EMS) provider judgment" was recently added as a field triage criterion to the national guidelines, yet its predictive value and real world application remain unclear. We examine the use and independent predictive value of EMS provider judgment in identifying seriously injured persons.

Methods: We analyzed a population-based retrospective cohort, supplemented by qualitative analysis, of injured children and adults evaluated and transported by 47 EMS agencies to 94 hospitals in five regions across the Western United States from 2006 to 2008.

The forgotten trauma patient: outcomes for injured patients evaluated by emergency medical services but not transported to the hospital.

Background: Injured patients who are not transported by an ambulance to the hospital are often not included in trauma registries. The outcomes of these patients have until now been unknown. Understanding what happens to nontransports is necessary to better understand triage validity, patient outcomes, and costs associated with injury.

Management of pediatric occult pneumothorax in blunt trauma: a subgroup analysis of the American Association for the Surgery of Trauma multicenter prospective observational study.

Background: Occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Increased use of computed tomography has led to a rise in the detection of OPTX. Optimal management remains undefined.

Evidence-based practice strategy: increasing timely nutrition in mechanically ventilated trauma surgical patients.

Malnutrition is common in the intensive care unit (ICU) and is related to higher incidence of morbidity and mortality among seriously ill patients. Achieving a quality nutritional care plan is a challenge to critical care practitioners and dietitians worldwide. The multifaceted and advanced therapies in the ICU historically take priority over nutritional assessments and interventions and may cause delay in achieving quality nutritional care.

Blunt traumatic occult pneumothorax: is observation safe?--results of a prospective, AAST multicenter study.

Background: An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma patients. Indications for intervention remain controversial. We sought to determine which factors predicted failed observation in blunt trauma patients.

The efficacy of a two-tiered trauma activation system at a level I trauma center.

Background: By using current American College of Surgeons trauma center triage criteria, 52% of patients transported to our level I trauma center are discharged home from the emergency department (ED). Because the majority of our trauma transports were based solely on mechanism of injury, we instituted, in 1990, a two-tiered trauma team activation system. Patients are triaged into major and minor trauma alert categories based on prehospital provider information.

Validation of a prehospital trauma triage tool: a 10-year perspective.

Background: Triage of the trauma patient in the field is a complex and challenging issue, especially deciding when to use aeromedical transport. The American College of Surgeons Committee on Trauma recently defined an acceptable under-triage rate [seriously injured patient not taken to a trauma center (TC)] as 5%, whereas over-triage rates may be as high as 25% to 50%. Effective utilization of prehospital helicopter transport requires both accurate assessment of patients and effective communication.

A county hospital surgical practice: a model for acute care surgery.

Background: Trauma surgery has changed significantly over the past decade. Nonoperative evidence-based algorithms have become common and surgical trauma volume has become increasingly difficult to maintain. The acute care surgery (ACS) model, which integrates trauma, critical care, and emergency surgery, has been proposed as a future model of trauma practice.

Barriers to screening for domestic violence in the emergency department.

The identification of victims of domestic violence is important to prevent further abuse and injury. The purposes of this pilot project were to identify potential barriers emergency department registered nurses encounter in screening patients for domestic violence and to assess nurses' educational backgrounds for continuing education and training needs. The most significant potential barriers to screening identified were a lack of education and instruction on how to ask questions about abuse, language barriers between nurses and patients, a personal or family history of abuse, and time issues.

Blunt trauma patients with prehospital pulseless electrical activity (PEA): poor ending assured.

Background: The paucity of information on the outcome of patients experiencing prehospital pulseless electrical activity (PEA) after blunt injury led to the present study.

Methods: A retrospective review was performed of all blunt trauma victims with prehospital PEA from 1997 to 2001 in an urban county trauma system.

Results: One hundred ten patients, 78 men and 32 women, met study criteria.

The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system.

Background: Continuing controversy surrounding the value of scene helicopter evacuation of urban trauma victims led to the present study.

Methods: A retrospective review was performed of all patients brought to our trauma center from the injury scene by helicopter from 1990 to 2001.

Results: The study included 947 consecutive patients, 911 with blunt trauma and 36 with penetrating injuries.

A new operation with inadequate Brescia fistulae for preservation of more proximal veins.

Purpose: The purpose of this study was to test the hypothesis that venous outflow of a Brescia fistula that is patent but unusable for one of a variety of reasons can provide adequate drainage to sustain a prosthetic arteriovenous graft based on the brachial artery, thus sparing more proximal veins for future access procedures.

Methods: The operation consists of placement of a prosthetic graft between the brachial artery in the antecubital space and the cephalic vein at the wrist.

Results: Between December 1998 and November 1999, 14 patients (eight male and six female; age range, 34 to 73 years; mean age, 51 years) underwent the operation.

Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma.

Objective: The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay.

Methods: This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.

Covering the "open abdomen": a better technique.

"Damage control" in severe abdominal trauma, abdominal compartment syndrome, necrotizing fasciitis of the abdominal wall, and necrotizing pancreatitis often preclude closure of the fascia after laparotomy. Many techniques have been reported for temporary coverage of the exposed viscera, but most have had documented problems. We report the successful use, since 1989, of a temporary sutureless coverage.

Surgical salvage of failed radiocephalic arteriovenous fistulae: techniques and results in 29 patients.

From August 1987 through February 1995 we performed 42 surgical procedures in 29 patients with occluded or stenotic radiocephalic arteriovenous fistulae. Operations were designed to preserve native veins for cannulation (Group I) or to preserve access in the same forearm, bypassing the failed fistula (Group II). For 27 procedures in 22 Group I patients, cumulative primary patency was 70%, 57%, and 47% at 6, 12, and 18 months, respectively.

Repair of a post-traumatic common iliac arteriovenous fistula.

The management of a patient with a post-traumatic common iliac arteriovenous fistula which was repaired surgically is reported. The current use of less-invasive endoluminal techniques is reviewed.

ICU scoring systems do not allow prediction of patient outcomes or comparison of ICU performance.

Recent revisions of the major ICU scoring systems have broadened their database markedly and increased their statistical accuracy. For a specific patient, however, the systems cannot be accurate enough to direct management decisions. Significant questions remain about the reliability of these systems for comparing different ICUs and different patient populations, especially in surgical and trauma patients.

The accuracy of computed tomography in the diagnosis of blunt small-bowel perforation.

Background: Computed tomography (CT) is commonly used to evaluate patients with possible blunt intra-abdominal injury. One of its reported weaknesses is failure to demonstrate intestinal trauma. However, CT accuracy in identifying blunt small-bowel perforation has not been adequately assessed.

Benefits of early admission to a comprehensive trauma center for patients with spinal cord injury.

Patients with spinal cord injury may be admitted directly to a trauma center with a dedicated rehabilitation unit or transferred there days or weeks later. This study analyzed the relationship between time of transfer to a Level I Trauma Center with a spinal cord injury service and efficacy of subsequent rehabilitation. We examined the records of all patients admitted to the service between September 1981 and August 1983 and followed at least one year.

Intestinal injuries missed by computed tomography.

Isolated intestinal injuries are frequently difficult to diagnose using only physical examination and routine laboratory studies. Between 1980 and 1988, ten patients were identified who had intestinal injuries and had computed tomographic (CT) scans before operation. For none of these scans was the initial reading considered diagnostic of intestinal injury.