J Trauma
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This report describes a project funded by the Agency for Healthcare Research and Quality to evaluate the impact of providing hospitals with nonpublic report cards on trauma outcomes. The Survival Measurement and Reporting Trial for Trauma explores the feasibility of using the National Trauma Data Bank as a platform for measuring and improving trauma outcomes. ⋯ The initial findings of this trial suggest that there is significant variability in trauma mortality across centers caring for injured patients after adjusting for differences in patient casemix. This variation in risk-adjusted mortality presents an opportunity for improvement. The Survival Measurement and Reporting Trial for Trauma study is designed to test the hypothesis that nonpublic report cards can lead to improved population mortality for injured patients. The results of this study may have substantial implications in the future design and implementation of a national effort to report and improve trauma outcomes in the United States.
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Comparative Study
Trauma intensive care unit survival: how good is an educated guess?
Resource utilization in medicine is becoming a more and more urgent issue with ongoing national discussions on healthcare coverage. In the management of a trauma system, large amounts of resources and money are expended on individual patients in hope of a "great save." In addition, those of us caring for these patients are required to estimate outcomes daily to the family in an effort to choose the best course of care for an individual patient. Hence, we undertook a study to analyze the accuracy of outcomes predictions of various members of the healthcare team. ⋯ Although significantly better than chance prediction, the ability of members of the ICU team to predict survival of trauma patients remains poor, particularly on initial evaluation. A period of clinical observation improves the accuracy. Unfortunately, experience of the observer does not seem to improve accuracy of survival prediction. This data indicate that care must be taken when describing likely outcomes to patient family members.
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The majority of trauma patients (>90%) do not require any blood product transfusion and their mortality is <1%. However, 3% to 5% of civilian trauma patients will receive a massive transfusion (MT), defined as >10 units of packed red blood cells (PRBC) in 24 hours. In addition, more than 25% of these patients will arrive to emergency departments with evidence of trauma-associated coagulopathy. ⋯ Input and representation from departments of Trauma, Critical Care, Anesthesiology, Transfusion Medicine, and Emergency Medicine are necessary to successfully formulate (and implement) such a protocol. Once a protocol has been agreed upon, education of the entire nursing and physician staff is equally essential to the success of this effort. Once implemented, this process may lead to improved clinical outcomes and decreased overall blood utilization with extremely small wastage of vital blood products.
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Erythropoietin (EPO) can exert acute hemodynamic and anti-inflammatory effects in addition to erythropoiesis. We tested the hypothesis that EPO given at resuscitation with saline will improve capillary perfusion and tissue oxygenation in the gut using a hemorrhagic shock model. ⋯ Our results suggest that the addition of rHuEPO at the time of saline resuscitation may have beneficial effects in hemorrhagic shock by improving tissue perfusion and decreasing dysoxia in the gut.
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Supporting its therapeutic application in sepsis, p38 mitogen-activated protein kinase (MAPK) inhibition decreases cardiopulmonary injury and lethality with lipopolysaccharide challenge. However, only one preclinical study has reported the survival effects of a p38 inhibitor (SB203580, 100 mg/kg) during infection. We therefore tested SB203580 in mice (n = 763) challenged with intratracheal Escherichia coli and treated with antibiotics and fluids. ⋯ Thus, SB203580 had divergent effects on cardiac and lung function in E. coli challenged mice. Furthermore, high dose worsened survival and low dose did not improve it. Altogether, these findings suggest that clearly defining the risks and benefits of p38 MAPK inhibition is important before such treatment is applied in patients with or at risk of serious infection.