Clinical Medicine Insights: Trauma and Intensive Medicine

Currently, most vital signs in the intensive care unit (ICU) are electronically monitored. However, clinical practice for urine output (UO) measurement, an important vital sign, usually requires manual recording of data that is subject to human errors. In this study, we assessed the ability of a novel electronic UO monitoring device to measure real-time hourly UO versus current clinical practice.

Patients were connected to the RenalSense Clarity RMS Sensor Kit with a sensor integrated within a standard sterile urinary catheter drainage tube to monitor urine flow in real time. The Clarity RMS Sensor Kit was modified to incorporate a standard urinometer (Unomedical) for the nursing staff to record UO as per their standard practice. The drainage bag was placed in a container on a scientific scale (Precisa BJ) to be used as the gold standard.

Nursing records for hourly UO were collected and compared with the electronically recorded UO. Sensor measurements and nursing staff manual records of UO were compared with the scale data.

The study setting was the ICU of Hadassah Hospital, Jerusalem.

Data from 23 patients with a urinary catheter were observed in this study.

A total of 1046 hours of UO were recorded from 23 subjects. Compared with the scale data, the measurements of hourly urine flow measured with the RenalSense system were closer, had a better correlation, and narrower limits of agreement to gravimetrically determined values than the measurements obtained by the nurses. In addition, continuous monitoring of UO provided graphical display of response to repeated diuretic administration.

An electronic device for recording UO has been shown to provide more reliable information of UO records and patient fluid status than current practice. Future applications of this device will provide valuable information to help set protocol goals such as decisions for timely fluid and diuretic administration and response.

Cervical spinal cord injury (CSCI) is a significant medical and socioeconomic problem. In Victoria, Australia, there has been limited research into the incidence of CSCI. The Austin Hospital's Victorian Spinal Cord Injury Service (VSCIS) is a tertiary referral hospital that accepts referrals for surgical management and ongoing neurological rehabilitation for south eastern Australia. The aim of this study was to characterise the epidemiology of CSCI managed operatively at the VSCIS over the last decade, in order to help fashion public health campaigns.

This was a retrospective review of medical records from January 2000 to December 2009 of all patients who underwent surgical management of acute CSCI in the VSCIS catchment region. Patients treated non-operatively were excluded. Outcome measures included: demographics, mechanism of injury and associated factors (like alcohol) and patient neurological status.

Men were much more likely to have CSCI than women, with a 4:1 ratio, and the highest incidence of CSCI for men was in their 20s (39%). The most common cause of CSCI was transport related (52%), followed by falls (23%) and water-related incidents (16%). Falls were more prevalent among those >50 years. Alcohol was associated in 22% of all CSCIs, including 42% of water-related injuries.

Our retrospective epidemiological study identified at-risk groups presenting to our spinal injury service. Young males in their 20s were associated with an increased risk of transport-related accidents, water-related incidents in the summer months and accidents associated with alcohol. Another high risk group were men >50 years who suffer falls, both from standing and from greater heights. Public awareness campaigns should target these groups to lower incidence of CSCI.

In neutropenic patients with acute leukemia, acute abdomen which is usually attributed to typhlitis may be encountered. However, the diagnosis of acute appendicitis is rarely described or confirmed.

A retrospective study of acute appendicitis in adult patients with acute leukemia was conducted at the Riyadh Armed Forces Hospital between January 1991 and December 2002 and then the study was continued at King Faisal Specialist Hospital and Research Centre in Riyadh between January 2004 and December 2006.

Acute appendicitis developed in three out of 408 patients with acute leukemia treated at both institutions. The incidence of acute appendicitis in adult patients with acute leukemia was 0.74%. Acute appendicitis was encountered during the neutropenic periods following the courses of cytotoxic chemotherapy given to control the leukemia. The three study patients were males and they presented with the classical clinical manifestations of acute appendicitis and they underwent successful appendicectomies. The radiological investigations were helpful in confirming the clinical diagnoses. Compared to the control group of patients, the study patients developed acute leukemia at a younger age and they also had higher rates of: infectious complications, relapse and mortality but lower rate of cytogenetic abnormalities and extramedullary disease.

The development of acute appendicitis in neutropenic patients with acute leukemia is an extremely rare event. The combination of the classical clinical manifestations as well as the compatible radiological features is essential diagnostically. Taking a decision to operate on these immunocompromised patients during the periods of severe pancytopenia is a real challenge to surgeons and hematologists. However, surgical intervention may be associated with long term complications such as relapse of the leukemia, infectious complications and decreased survival.

The purpose of this study was to investigate current management of anticoagulation in patients with suspected HIT while on CRRT and identify complications associated with anticoagulation in this setting.

This is a retrospective study of patients on CRRT with suspicion for HIT. Prevalence of HIT and anticoagulant use were collected for all patients. Outcomes included thromboembolic and bleeding events, final therapeutic doses of each anticoagulant, and time to reach therapeutic range. Thromboembolic and bleeding outcomes were compared between anticoagulants.

From January 2013 through December 2015, 74 patients were identified with suspicion of HIT while on CRRT. During the period of HIT suspicion, 20 patients received argatroban, 18 received bivalirudin, 1 received fondaparinux, 4 received UFH infusions, 10 received prophylactic dosing subcutaneous UFH, and 21 received no anticoagulation. The median final therapeutic doses of argatroban and bivalirudin were 1.00 μg/kg/min and 0.075 mg/kg/h, respectively, with no difference in time to therapeutic range (17.6 h vs 18.2 h, P = .485). Compared with bivalirudin, patients treated with argatroban had significantly more therapeutic activated partial thromboplastin time (aPTT) values (54.5% vs 42.8%, P = .008). Four patients (20.0%) treated with argatroban and 5 patients (27.8%) treated with bivalirudin experienced major bleeding (P = .709). Three patients (15.0%) treated with argatroban and 4 patients (22.2%) treated with bivalirudin experienced thromboembolic events (P = .687).

Argatroban and bivalirudin were associated with similar rates of bleeding and thromboembolic events during the period of concurrent CRRT and thrombocytopenia, although patients treated with argatroban had more therapeutic aPTT values.

There is controversy about the appropriate treatment for severely displaced and unstable comminuted fracture of distal radius (type C of AO or OTA classification). Recently, there has been an increase in the number of predilection for surgical management of this fracture.

To determine the radiographic outcome in type C fractures of the distal radius treated with closed reduction and pin in plaster.

Eighty consecutive patients 60 male and 20 female, average age 40 years (22–60 years), with type C fractures of the distal radius seen between February 2001 and July 2003 in Shahid Kamiab Hospital of Mashad University, were treated by closed reduction and pin in plaster, followed up by anteroposterior and lateral radiographs to evaluate radial height, inclination and volar tilt.

There was significant improvement in the measurements of radial height, inclination and volar tilt after closed reduction and pin in plaster, and at the time the pins and plaster were removed. (P = 0.00).

Closed reduction and pin in plaster is an effective, simple and low cost method in type C fractures of distal radius with satisfactory outcome.

Magnetic resonance imaging (MRI) is often employed as the diagnostic modality of choice in occult and suspected pathological femoral neck fractures. We evaluated the clinical utility of MRI scan in this patient population.

Retrospective observational analysis of cases with a radiologically occult or suspected metastatic pathological neck of femur fracture.

From a total of 894 femoral neck fractures treated in our institution, 100 patients had and MRI scan pre-operatively for either occult fracture or suspected fracture secondary metastatic disease. Magnetic resonance imaging confirmed the presence of 13 simple fractures. A total of 14 patients had pathological features suggestive of metastasis, of which 12 were clearly visible on plain radiographs. Surgical plan did not change after MRI for any of these pathological fractures.

Results of this study demonstrate that an MRI scan had an impact on treatment selection only when a simple but radiographically occult fracture is suspected and but not in the context of suspected metastatic pathological fractures.

Trauma patients in rural areas are frequently transferred to regional trauma centers for expeditious evaluation and management of potentially life-threatening injuries. We sought to characterize how long the process takes, once it has begun, for acutely injured patients to be transferred from emergency departments (EDs) of referring hospitals to trauma centers and how the time is spent.

We conducted a retrospective multi-institutional case series study. We reviewed records of acutely injured trauma patients transferred from the EDs of 114 outlying hospitals to the EDs of three Level I or II regional trauma centers over a 12–24 month period. We calculated the duration of the transfer process and its component time intervals (reported as the mean ± standard deviation).

Among 1099 patients transferred from 114 referring hospitals, the mean Injury Severity Score was 11.6. Mortality was 5.9%. Half of all transfers were by ground ambulance, 36% by helicopter, and 13% by airplane. The mean time from patient presentation at the ED of the referring hospital until transfer request was 126 ± 94 min, and the mean time from transfer acceptance until arrival at the trauma center was an additional 119 ± 60 min. The mean time from transfer acceptance to departure of the patient from the ED of the referring hospital was 68 ± 48 min. Transportation time accounted for 48 ± 29 min, or 40% of the total time between transfer acceptance and arrival at the accepting hospital.

Interhospital transfer of acutely injured trauma patients takes a substantial amount of time even after acceptance of the patient, and actual time spent in transportation accounts for only 40% of the time from transfer acceptance to arrival of the patient at the receiving hospital, on average. Efforts to speed transfers should focus on shortening the time from transfer acceptance to departure from the referring hospital.

Agreement and correlation of arterial blood gases (ABGs) and venous blood gases (VBGs) at near normal values are well described but have not been well validated at extremes of values. We evaluated the agreement and correlation of ABG and VBG at extremes of values and assessed the utility of VBG as a screening tool.

We performed a retrospective, observational study of ABG and VBG collected at the same time. Statistical analysis included Bland-Altman plot analysis, Pearson correlations, and sensitivity/specificity tests. For limits of agreement (LOA), we set a threshold of ±0.10 units for pH and ±2.4 mm Hg for partial pressure of carbon dioxide (pCO₂). A threshold of 80% sensitivity was considered appropriate for VBG to be used as a screening tool for abnormal ABG values.

There were 1684, 1744, and 1769 paired pH, pCO₂, and HCO_3¯ results, respectively. Mean difference (MD) for arterial and venous pH was 0.017 (95% confidence interval [CI]: 0.014-0.020; 95% LOA: −0.11 to 0.15), and Pearson correlation was 0.78 (P < .0001). At venous pH <7.35, MD was 0.025 (95% CI: 0.019-0.030; 95% LOA: −0.12 to 0.17). Sensitivity of venous pH <7.35 identifying arterial pH <7.35 was 85.0%. MD for arterial and venous pCO₂ was −2.5 (95% CI: −2.9 to −2.0; 95% LOA: −21.7 to 16.8), and Pearson correlation was 0.70 (P < .0001). At venous pCO₂ >45 mm Hg, MD was −4.1 (95% CI: −4.9 to −3.3; 95% LOA: −25.7 to 17.5). Sensitivity of venous pCO₂ >45 mm Hg identifying arterial pCO₂ >45 mm Hg was 67.6%. MD for arterial and venous HCO_3¯ was −0.3 (95% CI: −0.4 to −0.2; 95% LOA: −4.8 to 4.2), and Pearson correlation was 0.90 (P < .0001).

Venous blood gases cannot reliably replace ABGs due to poor agreement in acidemia and hypercarbia. Venous blood gases can be used as a screening tool for acidemia but are unsuitable for hypercarbia.

To identify significant risk factors associated with repeat emergency department (ED). Visits for violent injuries in youth firearm victims.

The study subjects of this retrospective cohort study were firearm victims aged 18 and younger presenting to a Pediatric Emergency Department/Trauma Center at Children's Hospital of Wisconsin between 1990 and 1995. The primary outcome was subsequent Emergency Department visits (REDV) at any emergency department in Milwaukee for a violent injury.

A total of 495 subjects were eligible for the present study in the pediatric firearm victim's ED visit database. Eighty-five percent (n = 420) were males and 82% were African-Americans. Mean age was 15 years old (s.d = ±3.6). A majority of them had a single-parent family. Eighty-eight subjects (17.8%) had a prior history of ED visit due to violence. During the study time, 201 subjects had at least one REDV. In the multivariable model, a subject without a social worker consulting at the hospital were more likely to have REDV compared to subjects with a social worker consulting (O.R = 1.749; p-value = 0.047), controlling for guardian and disposition. Subjects disposed to detention center or police custody were more likely to have REDV compared to subjects disposed to home or a hospital (O.R = 5.351; p-value = 0.003).

Our analysis indicates that individuals with guardians, those who did not receive social worker intervention on their initial visit, and those discharged in police custody were associated with increased repeat ED visits due to a violent injury.

Hip fractures are common, expensive and lead to considerable morbidity and mortality. An ageing population in the United Kingdom means that rates of this injury are increasing, making them a pressing public health issue. The National Institute of Health and Care Excellence (NICE) recommends that extramedullary implants are used over intramedullary nails to fix intertrochanteric fractures, which make up half of all hip fractures. However, there is currently no guidance on the preferred type of extramedullary device whether this be the commonly used dynamic hip screw (DHS) or another newer device. It has been suggested that a percutaneous compression plate (PCCP) can reduce complications and improve functional outcome compared with the traditional DHS.

In patients with intertrochanteric hip fractures, is the PCCP more effective than the DHS in terms of relevant intraoperative and postoperative outcomes such as blood loss, implant failure, and mortality?

We first searched for relevant information in the NICE Clinical Guideline on Hip Fracture Management (CG124), then National Health Service (NHS) evidence for Clinical Knowledge Summaries, then the Cochrane library for systematic reviews. Finally, we conducted an electronic search of the PubMed database.

We selected five systematic reviews and eight primary studies for review. The main findings were that the PCCP was associated with significantly less blood loss, fewer blood transfusions, and shorter operating times compared with the DHS. However, no significant differences were found in postoperative pain, orthopaedic performance, and mortality rates between the two methods. There was no comparison of cost-effectiveness between the two methods.

The PCCP is superior to the DHS in terms of intraoperative blood loss and, potentially, non-orthopaedic postoperative complications such as deep vein thrombosis and nosocomial infection. However, there was no significant difference in mortality rates between the two methods. Current studies on this topic have several methodological issues and some are of relatively poor quality. Further higher quality research and cost-effectiveness are necessary to further evaluate the efficacy of these methods.