Changes in serial laboratory test results in snakebite patients: when can we safely exclude envenoming?

Objectives: To determine which laboratory tests are first associated with severe envenoming after a snakebite, when (ie, how long after the bite) the test results become abnormal, and whether this can determine a safe observation period after suspected snakebite.

Design, Patients And Setting: Prospective cohort study of 478 patients with suspected or confirmed snakebite recruited to the Australian Snakebite Project from January 2002 to April 2009, who had at least three sets of laboratory test results and at least 12 hours of observation in hospital after the bite. Severe envenoming was defined as venom-induced consumption coagulopathy (VICC), myotoxicity, neurotoxicity or thrombotic microangiopathy.

Training and certification in surgical critical care: a position paper by the Surgical Critical Care Program Directors Society.

Delivery of Surgical Critical Care in the United States is facing multiple challenges including increasing complexity of care, escalating costs, shortage of well-trained physicians, and controversies about appropriate training and credentialing methods. In this position paper, the Surgical Critical Care Program Directors Society discusses some of these important issues and suggests a number of possible solutions.

Early outcomes of deliberate nonoperative management for blunt thoracic aortic injury in trauma.

Objective: Traumatic blunt aortic injury has traditionally been viewed as a surgical emergency, whereas nonoperative therapy has been reserved for nonsurgical candidates. This study reviews our experience with deliberate, nonoperative management for blunt thoracic aortic injury.

Methods: A retrospective chart review with selective longitudinal follow-up was conducted for patients with blunt aortic injury.

Parks promoting physical activity: synthesis of findings from interventions in seven national parks.

Background: We synthesized the results of 7 National Park Service pilot interventions designed to increase awareness of the health benefits from participation in recreation at national parks and to increase physical activity by park visitors.

Methods: A content analysis was conducted of the final evaluation reports of the 7 participating parks. Pooled data were also analyzed from a standardized trail-intercept survey administered in 3 parks.

Emergency innovation: implications for the trauma surgeon.

Background: Experimentation involving human subjects requires careful attention to the protection of their rights. Beginning with the Belmont Report in 1979, the United States has developed various sets of rules and regulations that identify the requirements for performing human subject research. In addition, these standards attempt to define the fundamental difference between what constitutes research versus clinical treatment versus innovation.

Envenoming by the rough-scaled snake (Tropidechis carinatus): a series of confirmed cases.

Objective: To describe demographic, geographical and clinical features of envenoming by the rough-scaled snake (RSS) (Tropidechis carinatus).

Design, Setting And Participants: Prospective cohort study of RSS snakebite victims, recruited between January 2004 and December 2008, as part of the Australian Snakebite Project. RSS envenoming cases were confirmed by snake identification and/or venom-specific enzyme immunoassay.

Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortality reduction.

Background: Exsanguinating hemorrhage necessitating massive blood product transfusion is associated with high mortality rates. Recent data suggest that altering the fresh frozen plasma to packed red blood cell ratio (FFP:PRBC) results in significant mortality reductions. Our purpose was to evaluate mortality and blood product use in the context of a newly initiated massive transfusion protocol (MTP).

Demographic and Financial Analysis of EMTALA Hand Patient Transfers.

In the United States, the Emergency Medical Treatment and Active Labor Act (EMTALA) effectively requires Level I trauma centers to accept hand trauma transfers for higher level of care if capacity exists. However, patient transfer for non-medical reasons, such as ability to pay, is still perceived as a common practice. We hypothesized that EMTALA would cause selective transfer of hand patients who were underinsured or uninsured, thus, effectively burdening a Level I trauma center.

Shear induced structure additives and nonlinear pressure drop effects in permeable flow.

In classical flow through permeable rock, the pressure drop is linearly distributed through the medium. Shear induced structure materials, surfactant/co-solute pairs, were added to retard flow in higher permeability rock samples. A novel core holder allows the axial pressure distribution along the flow direction to be measured.

Commitment to COT verification improves patient outcomes and financial performance.

Background: After an unsuccessful American College of Surgery Committee on Trauma visit, our level I trauma center initiated an improvement program that included (1) hiring new personnel (trauma director and surgeons, nurse coordinator, orthopedic trauma surgeon, and registry staff), (2) correcting deficiencies in trauma quality assurance and process improvement programs, and (3) development of an outreach program. Subsequently, our trauma center had two successful verifications. We examined the longitudinal effects of these efforts on volume, patient outcomes and finances.

The impact of hypopituitarism on function and performance in subjects with recent history of traumatic brain injury and aneurysmal subarachnoid haemorrhage.

Primary Objective: To correlate deficient pituitary function with life satisfaction and functional performance in subjects with a recent history of traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH).

Research Design: Cross-sectional study.

Methods And Procedures: Eighteen subjects with TBI and 16 subjects with SAH underwent pituitary hormonal and functional assessments 5-12 months following the event.

An evaluation of multidetector computed tomography in detecting pancreatic injury: results of a multicenter AAST study.

Background: Efforts to determine the suitability of low-grade pancreatic injuries for nonoperative management have been hindered by the inaccuracy of older computed tomography (CT) technology for detecting pancreatic injury (PI). This retrospective, multicenter American Association for the Surgery of Trauma-sponsored trial examined the sensitivity of newer 16- and 64-multidetector CT (MDCT) for detecting PI, and sensitivity/specificity for the identification of pancreatic ductal injury (PDI).

Methods: Patients who received a preoperative 16- or 64-MDCT followed by laparotomy with a documented PI were enrolled.

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.

Insulin increases the release of proinflammatory mediators.

Background: Strict glucose control with insulin is associated with decreased mortality in a mixed patient population in the intensive care unit. Controversy exists regarding the relative benefits of glucose control versus a direct advantageous effect of exogenous insulin. As a combined medical/surgical population differs significantly from the critically injured patient primed for secondary insult, our purpose was to determine the influence of insulin on activated macrophages.

Safety and effectiveness of high-dose midazolam for severe behavioural disturbance in an emergency department with suspected psychostimulant-affected patients.

Objectives: To trial high-dose midazolam sedation protocol for uncooperative patients with suspected psychostimulant-induced behavioural disorders. End-points were effectiveness and safety.

Methods: A prospective pilot study was undertaken with a convenience sample of adult, uncooperative patients with suspected psychostimulant-induced severe behavioural disorders.

Evaluation of group cognitive behavioral therapy for adults with ADHD.

Objective: A brief cognitive behavioral therapy (CBT) group intervention was designed to treat comorbid anxiety, depression, and low self-esteem and self-efficacy in adults with ADHD. It was hypothesised that participants would gain knowledge about ADHD, experience a reduction in comorbid symptoms, and benefit from the supportive aspect of group treatment.

Method: Participants in the study formed a CBT treatment group that attended six workshops and a waiting list control group.

CT angiography effectively evaluates extremity vascular trauma.

Traditionally, conventional arteriography is the diagnostic modality of choice to evaluate for arterial injury. Recent technological advances have resulted in multidetector, fine resolution computed tomographic angiography (CTA). This study examines CTA for evaluation of extremity vascular trauma compared with conventional arteriography.

Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental.

Background: During the past 40 years, management of solid organ injury in pediatric trauma patients has shifted to highly successful nonoperative management. Our purpose was to characterize children requiring operative intervention. We hypothesized that older children would be more likely to require operative intervention.

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.

Recruitment strategies for a fall prevention program: if we build it, will they really come?

Background: More than one third of adults over the age of 65 suffer a fall each year, facing morbidity and mortality. Modifiable risk factors for falls have been identified, but specific recruitment strategies for prevention programs have not been evaluated. The purpose of this observational study was to evaluate recruitment strategies for a fall prevention program.

Requests for 692 transfers to an academic level I trauma center: implications of the emergency medical treatment and active labor act.

Background: The Emergency Medical Treatment and Active Labor Act (EMTALA) effectively requires Level I trauma centers (TC) to accept all transfers for a higher level of care if capacity exists. We hypothesized that EMTALA would burden a Level I TC by a selective referral of a poor payer mix of primarily nonoperative patients.

Methods: All transfer calls (December 2003 and September 2005) to our Level I TC are handled by a dedicated transfer center.