Critical Care in Trauma

The goal of care in trauma patients is to reestablish homeostasis, treat morbidity, prevent complications and mortality, and functionally rehabilitate this subset of patients. To achieve this goal, the intensivist utilizes and coordinates a multidisciplinary, evidence-based approach to ensure that resources are effectively and efficiently allocated to the patients that need them. Airway management and breathing are the highest priority when evaluating a trauma patient. The goal is to protect the airway, improve gas exchange, and relieve respiratory distress. Sedation is a useful tool in the ICU setting and increases patient safety and comfort. Critical illness, anxiety, pain, and delirium can result in significant agitation, which may lead to an increased stress response. Trauma patients are at an increased risk of developing pneumonia because of the need for prolonged mechanical ventilation, increased risk of aspiration, lung injury, and/or pain. Positioning, oral hygiene, aiding the clearing of secretions, and pain control can drastically reduce the risk. In addition, for those patients requiring prolonged intubation and mechanical ventilation, the implementation of weaning trials is beneficial. Multiple factors increase the risk of developing a deep vein thrombosis (DVT), including hypoperfusion due to blood loss and inadequate resuscitation, tissue injury, immobilization, and inflammation. It is recommended that chemical DVT prophylaxis is started within 72 hours from the time of injury barring any contraindications

Outcomes of Acinetobacter baumannii infection in critically ill surgical patients

Multi-drug resistant (MDR) organisms in intensive care units (ICUs) are a growing concern. The emergence of several infections with MDR Acinetobacter baumannii prompted a review of cases and evaluation of the efficacy of intervention. To determine the rate of clinical cure, the incidence of drug resistance, and the mortality rate associated with A. baumannii infection. Retrospective review of A. baumannii infections in three surgical ICUs between January, 2004 and November, 2005. Infection was identified in 291 patients, 20 of whom were excluded because of incomplete documentation. Of the remaining 271 patients, 71% were male, and the mean age was 47 +/- 18 years (range 13-90 years). Patients had a mean length of stay in the ICU of 14 days (range 0-136 days) before infection. The initial positive cultures were from bronchoalveolar lavage fluid (BAL) in 72.3%, blood in 16.2%, a catheter tip in 6.3%, urine in 1.8%, wound in 2.2%, and abscess in 1.1%. In 46.9% of patients, the first culture was polymicrobial. The Acinetobacter isolates were resistant or intermediate-resistant to imipenem-cilastatin in 81.2% of cases; 19.9% were resistant to all drugs except colistin, and two were resistant to all tested drugs. Colistin was used in 75.6% of patients (intravenous 61.5%, nebulized 38.5%). The mean duration of treatment was 13 +/- 8.9 days (range 0-56 days), and clinical cure was achieved in 73.8% of patients. Recurrent infection after initial cure was found in 19.2% of patients. There was no significant difference in clinical cure rates between patients treated with colistin and those treated with other culture-directed drugs (75.1% vs. 69.7%), or between patients treated with intravenous vs. nebulized colistin (72.4% vs. 79.5%). The mortality rate was 26.2% for the entire group and was significantly higher in the subgroup of transplant patients (n = 31) (64.5% vs. 21.4%; p < 0.001). The majority of A. baumannii isolates were MDR, and a significant proportion were sensitive only to colistin. Treatment of A. baumannii infection with colistin is effective by both intravenous and nebulized routes of administration. However, infection with A. baumannii in critically ill surgical patients is associated with a high mortality rate, particularly in transplant patients

Appendectomy versus nonoperative management of simple appendicitis: A post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter study using a hierarchical ordinal scale

BACKGROUNDControversy exists about the preferred initial treatment of appendicitis. We sought to compare the two treatments for initial management of simple appendicitis. METHODSIn this post hoc analysis of the Multicenter Study for the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, subjects were divided into appendectomy or nonoperative management (NOM; antibiotics only or percutaneous drainage) cohorts. A novel topic-specific hierarchical ordinal scale was created with eight mutually exclusive categories: mortality, reoperation, other secondary interventions, readmission, emergency department visit, wound complication, surgical site infection, and no complication. Pairwise comparisons of American Association for the Surgery of Trauma Imaging Severity Grade 1 (simple appendicitis) patients were compared using win-lose-tie scoring and the sums of appendectomy/NOM groups were compared. RESULTSA total 3,591 subjects were included: 3,262 appendectomy and 329 NOM, with significant differences in baseline characteristics between groups. Across 28 sites, the rate of NOM ranged from 0% to 48%, and the loss to follow-up rate was significantly higher for NOM compared with appendectomy (16.5% vs. 8.7%, p = 0.024). In the simple appendicitis hierarchical ordinal scale analysis, 2,319 subjects resulted in 8,714,304 pairwise comparisons; 75% of comparisons resulted in ties. The median (interquartile range) sums for the two groups are as follows: surgical, 400 (400-400), and NOM, 400 (-2,427 to 400) (p < 0.001). A larger proportion of appendectomy subjects (88.1%) had an outcome that was equivalent (or better) than at least half of the subjects compared with NOM subjects (NOM, 70.5%; OR [95% confidence interval], 0.3 [0.2-0.4]). CONCLUSIONIn contemporary American practice, appendectomy (compared with NOM) for simple appendicitis is associated with lower odds of developing clinically important unfavorable outcomes in the first year after illness. LEVEL OF EVIDENCETherapeutic/Care Management; Level III