Carrie Sims | University of Pennsylvania (original) (raw)

Papers by Carrie Sims

Research paper thumbnail of Mineralocorticoid deficiency in hemorrhagic shock

Journal of Surgical Research, 2013

In the critically ill, mineralocorticoid deficiency (MD) is associated with greater disease sever... more In the critically ill, mineralocorticoid deficiency (MD) is associated with greater disease severity, the development of acute renal insufficiency, and increased mortality. We hypothesized that severely injured trauma patients presenting with hemorrhagic shock would demonstrate a high degree of MD. We also hypothesized that MD in these patients would be associated with increased length of stay, hypotension, fluid requirements, and acute kidney injury (AKI). Thirty-two trauma patients in hemorrhagic shock on admission to the trauma bay (SBP <90 mm Hg × 2) were enrolled. Blood samples were obtained on ICU admission and 8, 16, 24, and 48 hours later. Plasma aldosterone (PA) and renin (PR) were assayed by radioimmunoassay. MD was defined as a ratio of PA/PR ≤2. Demographic data, injury severity score, ICU and hospital length of stay, fluid requirements, mean arterial pressure, serum sodium, hypotension, and risk for AKI were compared for patients with and without MD. At ICU admission, 48% of patients met criteria for MD. Patients with MD were significantly more likely to experience hypotension (MAP ≤60 mm Hg) during the study period. MD patients required significantly more units of blood in 48 h than non-MD patients (13 [7-22] versus 5 [2-7], P = 0.015) and had increased crystalloid requirements (18L [14-23] versus 9L [6-10], P < 0.001). MD patients were at higher risk for AKI according to RIFLE and AKIN criteria. MD is a common entity in trauma patients presenting in hemorrhagic shock. Patients with MD required a more aggressive resuscitative effort, were more likely to experience hypotension, and had a higher risk of AKI than non-MD patients. Future studies are needed to fully understand the impact of MD following trauma and the potential role for hormonal replacement therapy.

Research paper thumbnail of Tolstoy et al

Research paper thumbnail of nihms516984

Research paper thumbnail of Alpha Glutathione S‐Transferase (ΑGST): A Novel End Point Serum Marker In Traumatic Shock?

OBJECTIVES: GST belongs to a family of cytosolic proteins involved in cell protection. Having pre... more OBJECTIVES: GST belongs to a family of cytosolic proteins involved in cell protection. Having previously described the potential use of αGST as an endpoint in the management of decompensated shock and resuscitation in an animal model, we tested its utility in a clinical setting of trauma. METHODS: longitudinal identification of patients in the trauma bay (TB) and followed over 48hrs and data collected prospectively including other endpoints of resuscitation (BP, pulse, shock index (SI), lactate, base excess (BE), pH and Hb), blood and fluid requirements, ISS scores as well as clinical outcomes (mortality, length of stay, days ventilated, morbidities). Serum αGST was measured using a commercially available enzyme immunoassay (ELISA) kit at specific time points (TB, ICU, 8, 16 and 24 and 48 hours). Data was analyzed using Mann‐Whitney and Kruskal‐Wallis tests for non‐parametric data and Pearson correlation with a significance set at 5% throughout. RESULTS: 33 (88% male) patients were ...

Research paper thumbnail of Mineralocorticoid deficiency in hemorrhagic shock

Journal of Surgical Research, 2013

Background-In the critically ill, mineralocorticoid deficiency (MD) is associated with greater di... more Background-In the critically ill, mineralocorticoid deficiency (MD) is associated with greater disease severity, the development of acute renal insufficiency, and increased mortality. We hypothesized that severely injured trauma patients presenting with hemorrhagic shock would demonstrate a high degree of MD. We also hypothesized that MD in these patients would be associated with increased length of stay, hypotension, fluid requirements, and acute kidney injury (AKI).

Research paper thumbnail of Goal-Directed Ultrasound in the Detection of Long-Bone Fractures

Journal of Trauma-injury Infection and Critical Care, 2004

Background: New portable ultrasound (US) systems are capable of detecting fractures in the remote... more Background: New portable ultrasound (US) systems are capable of detecting fractures in the remote setting. However, the accuracy of ultrasound by physicians with minimal ultrasound training is unknown.

Research paper thumbnail of Epiploic appendagitis: adding to the differential of acute abdominal pain 1 1 Clinical Communications (Adults) is coordinated by Ron M. Walls, MD, of Brigham and Women’s Hospital and Harvard University Medical School, Boston, Massachusetts

Journal of Emergency Medicine, 1999

e Abstract-We report a patient with epiploic appendagitis who presented with acute abdominal pain... more e Abstract-We report a patient with epiploic appendagitis who presented with acute abdominal pain. Emergency Department and discharge courses are described. The pathophysiology, presentation, diagnosis, and treatment of this disorder are discussed. Knowledge of this uncommonly diagnosed entity and its usual benign course may allow the Emergency Physician to order the appropriate studies to help avoid unnecessary surgical treatment. © 1999 Elsevier Science Inc. e Keywords-epiploic; appendagitis; abdominal; torsion; acute Clinical Communications (Adults) is coordinated by Ron M. Walls,

Research paper thumbnail of Skeletal Muscle Acidosis Correlates with the Severity of Blood Volume Loss during Shock and Resuscitation

Journal of Trauma-injury Infection and Critical Care, 2001

Continuous assessment of tissue perfusion and oxygen utilization may allow for early recognition ... more Continuous assessment of tissue perfusion and oxygen utilization may allow for early recognition and correction of hemorrhagic shock. We hypothesized that continuously monitoring skeletal muscle (SM) PO2, PCO2, and pH during shock would provide an easily accessible method for assessing the severity of blood loss and the efficacy of resuscitation. Thirteen anesthetized pigs (25-35 kg) underwent laparotomy and femoral vessel cannulation. Multiparameter fiberoptic sensors were placed in the deltoid (SM) and femoral artery. Ventilation was maintained at a PaCO2 of 40-45 mm Hg. Total blood volume (TBV) was measured using an Evans blue dye technique. Animals were bled for 15 minutes, maintained at a mean arterial pressure (MAP) of 40 mm Hg for 1 hour, resuscitated (shed blood + 2 times shed volume in normal saline) and observed for 1 hour. Four animals served as controls (sham hemorrhage). Blood and tissue samples were taken at each time point. Blood loss ranged from 28.5-56% of TBV. SM pH and SM PO2 levels fell rapidly with shock. SM PO2 returned to normal with resuscitation; however, SM pH did not return to baseline. SM PCO2 significantly rose with shock, but returned to baseline promptly with resuscitation. There was a significant correlation between SM pH and blood volume loss at end shock (r2 = 0.73, p < 0.001) and recovery (r2 = 0.84, p < 0.001). Animals (n = 2) whose SM pH did not recover to 7.2 were found to have ongoing blood loss from biopsy sites and persistent tissue hypercarbia despite normal MAP. Continuous multiparameter monitoring of SM provides a minimally invasive method for assessing severity of shock and efficacy of resuscitation. Both PCO2 and PO2 levels change rapidly with shock and resuscitation. SM pH is directly proportional to lost blood volume. Persistent SM acidosis (pH < 7.2) and elevated PCO2 levels suggest incomplete resuscitation despite normalized hemodynamics.

Research paper thumbnail of Ringer???s ethyl pyruvate solution ameliorates ischemia/reperfusion-induced intestinal mucosal injury in rats

Critical Care Medicine, 2001

Pyruvate has been shown to be protective in numerous in vitro and in vivo models of oxidant-media... more Pyruvate has been shown to be protective in numerous in vitro and in vivo models of oxidant-mediated cellular or organ system injury. Unfortunately, the usefulness of pyruvate as a therapeutic agent is abrogated by its very poor stability in solution. In an effort to take advantage of the ability of pyruvate to scavenge reactive oxygen species while avoiding the problems associated with the instability of pyruvate in solution, we sought to determine whether a simple derivative, ethyl pyruvate, would be protective in an animal model of reactive oxygen species-mediated tissue injury, namely mesenteric ischemia and reperfusion in rats. Prospective, randomized trial. Animal research center. Male Sprague-Dawley rats. Under general anesthesia, rats were subjected to 60 mins of mesenteric ischemia followed by 60 mins of reperfusion. Controls (n = 6) received intravenous lactated Ringer's solution according this dosing schedule: 1.5 mL/kg bolus before ischemia, 3.0 mL/kg bolus before resuscitation, and 1.5 mL.kg-1.hr-1 by continuous infusion. Two experimental groups received similar volumes of either pyruvate (n = 6 each) or ethyl pyruvate (n = 9) solution made up exactly like lactated Ringer's solution except for the substitution of either pyruvate or ethyl pyruvate for lactate, respectively. To obtain tissues for assessing mucosal permeability and histology, five 10-cm long segments of small intestine were obtained at the following time points: baseline, after 30 and 60 mins of ischemia, and after 30 and 60 mins of reperfusion. Mucosal permeability to fluorescein isothiocyanate dextran (molecular weight 4000 Da) was assessed ex vivo by using an everted gut sac method. Compared with controls, treatment of rats with either pyruvate solution or ethyl pyruvate solution significantly ameliorated the development of intestinal mucosal hyperpermeability during the reperfusion. Treatment with ethyl pyruvate solution also significantly decreased the extent of histologic mucosal damage after mesenteric reperfusion. Treatment with Ringer's ethyl pyruvate solution ameliorated structural and functional damage to the intestinal mucosa in a rat model of mesenteric ischemia/reperfusion. Ethyl pyruvate solution warrants further evaluation as a novel therapeutic agent for preventing oxidant-mediated injury in various disease states.

Research paper thumbnail of MONITORING SKELETAL MUSCLE AND SUBCUTANEOUS TISSUE ACIDBASE STATUS AND OXYGENATION DURING HEMORRHAGIC SHOCK AND RESUSCITATION

Shock, 2005

Gastric tonometry correlates with the severity of blood loss during shock. However, tonometry is ... more Gastric tonometry correlates with the severity of blood loss during shock. However, tonometry is cumbersome, has a slow response time, and is not practical to apply in the acute resuscitation setting. We hypothesized that subcutaneous tissue (SC) and skeletal muscle (SM) pH, pCO2, and pO2 changes are comparable with changes seen in bowel tonometry during shock and resuscitation. Thirteen male mini-swine (25-35 kg; n = 4 control, n = 9 shock) underwent laparotomy and jejunal tonometry. A multisensor probe (Diametrics Medical, Roseville, MN) was placed in the carotid artery, the chest SC, and the adductor muscle of the leg (SM). PaCO2 was maintained between 40 and 45 mmHg. Shocked animals were hemorrhaged and kept at mean arterial pressure of 40 mmHg. Animals were bled until a reinfusion of >10% of the total shed blood was needed to maintain the mean arterial pressure at 40 mmHg. Animals were resuscitated with shed blood plus 2x shed volume in lactated Ringer's solution (20 min) and were observed for 3 h. The average blood loss was 47.2% +/- 8.7% of calculated blood volume. During the hemorrhagic phase, SM and SC displayed tissue acidosis (r2 = 0.951), tissue hypercapnea (r2 = 0.931), and tissue hypoxia (r2 = 0.748). Overall, pH displayed the best correlation between SM and SC during shock and resuscitation. PCO2 in the jejunum (tonometry), SM, and SC increased during decompensation. However, during resuscitation as tonometric pCO2 normalized, only SC pCO2 decreased to its baseline value, whereas the SM pCO2 decrease tended to lag behind. Bland-Altman analyses demonstrated that the variability of the tissue pH changes in SM and SC are predictable according to the phases of hemorrhage and resuscitation. Changes in tissue pH correlated during bleeding and during resuscitation among SC and SM, and these changes followed the trends in gut tonometry as well. Continuous pCO2 and pO2 monitoring in the SM and SC tissues had significant correlations during the induction of shock only. SM and SC continuous pH and pCO2 monitoring reflect bowel pCO2 values during hemorrhagic shock. The response of these indicators as potential surrogates of impaired tissue metabolism varies among tissues and according to the phases of hemorrhage or resuscitation.

Research paper thumbnail of Bladder Mucosa pH and Pco2 as a Minimally Invasive Monitor of Hemorrhagic Shock and Resuscitation

Journal of Trauma-injury Infection and Critical Care, 2004

Continuous monitoring of pH, Pco2, and Po2 using fiberoptic sensor technology has been proposed r... more Continuous monitoring of pH, Pco2, and Po2 using fiberoptic sensor technology has been proposed recently as a clinical monitor of the severity of shock and impaired tissue perfusion. Surrogates of gut tissue perfusion such as gastric tonometry, although cumbersome, have been used to indirectly quantify the degree of gut ischemia. The purpose of this study was to demonstrate the feasibility of monitoring bladder mucosa (BM) and to compare urinary bladder mucosa and proximal jejunum mucosa interstitial pH and Pco2 during hemorrhagic shock and resuscitation. Eleven male miniature swine (25-35 kg) (control, n = 4; shock, n = 7) underwent jejunal tonometry and cystostomy. A multisensor probe was placed adjacent to the BM. Urine was diverted. Normocarbia was maintained. Animals were hemorrhaged and kept at a mean arterial pressure of 40 mm Hg. When a constant infusion was required to maintain the mean arterial pressure at 40 mm Hg (decompensation), animals were resuscitated with shed blood plus two times the shed volume in lactated Ringer's solution (20 minutes) and observed for 2 hours. During decompensation, BM pH values decreased significantly from 7.33 +/- 0.08 to 7.01 +/- 0.2 (p < 0.01) and recovered to 7.11 +/- 0.19 at 120 minutes after completion of resuscitation. During decompensation, BM Pco2 values increased significantly compared with baseline (from 49 +/- 6 mm Hg to 71 +/- 19 mm Hg, p < 0.05) and returned to baseline with resuscitation. Jejunum mucosa and BM interstitial Pco2 correlated throughout shock and resuscitation (r = 0.49). Bland-Altman analysis demonstrated significant differences between jejunum mucosa (intramucosal pH) and BM interstitial pH. Shock-induced changes in the Pco2 of the BM are comparable to tonometric changes in the gut. These data suggest that continuous fiberoptic multisensor probe monitoring of the BM could potentially provide a minimally invasive method for the assessment of impaired tissue perfusion of the splanchnic circulation during shock and resuscitation.

Research paper thumbnail of Methylene Blue and Vasoplegia: Who, When, and How

Mini-reviews in Medicinal Chemistry, 2008

Systemic inflammatory response can be associated with clinically significant and, at times, refra... more Systemic inflammatory response can be associated with clinically significant and, at times, refractory hypotension. Despite the lack of uniform definitions, this condition is frequently called vasoplegia or vasoplegic syndrome (VS), and is thought to be due to dysregulation of endothelial homeostasis and subsequent endothelial dysfunction secondary to direct and indirect effects of multiple inflammatory mediators. Vasoplegia has been observed in all age groups and in various clinical settings, such as anaphylaxis (including protamine reaction), sepsis, hemorrhagic shock, hemodialysis, and cardiac surgery. Among mechanisms thought to be contributory to VS, the nitric oxide (NO)/cyclic guanosine monophosphate (cGMP) pathway appears to play a prominent role. In search of effective treatment for vasoplegia, methylene blue (MB), an inhibitor of nitric oxide synthase (NOS) and guanylate cyclase (GC), has been found to improve the refractory hypotension associated with endothelial dysfunction of VS. There is evidence that MB may indeed be effective in improving systemic hemodynamics in the setting of vasoplegia, with reportedly few side effects. This review describes the current state of clinical and experimental knowledge relating to MB use in the setting of VS, highlighting the potential risks and benefits of therapeutic MB administration in refractory hypotensive states.

Research paper thumbnail of Trauma Leadership: Does Perception Drive Reality

Journal of Surgical Research, 2011

Research paper thumbnail of Trauma Leadership: Does Perception Drive Reality

Journal of Surgical Education

Leadership plays a key role in trauma team management and might affect the efficiency of patient ... more Leadership plays a key role in trauma team management and might affect the efficiency of patient care. Our hypothesis was that a positive relationship exists between the trauma team members' perception of leadership and the efficiency of the injured patient's initial evaluation.We conducted a prospective observational study evaluating trauma attending leadership (TAL) over 5 months at a level 1 trauma center. After the completion of patient care, trauma team members evaluated the TAL's ability using a modified Campbell Leadership Descriptor Survey tool. Scores ranged from 18 (ineffective leader) to 72 (perfect score). Clinical efficiency was measured prospectively by recording the time needed to complete an advanced trauma life support (ATLS)-directed resuscitation. Assessment times across Leadership score groups were compared using Kruskal-Wallis and Mann-Whitney tests (p < 0.05, statistically significant).Seven attending physicians were included with a postfellowship experience ranging from ≤1 to 11 years. The average leadership score was 59.8 (range, 27–72). Leadership scores were divided into 3 groups post facto: low (18–45), medium (46–67), and high (68–72). The teams directed by surgeons with low scores took significantly longer than teams directed by surgeons with high scores to complete the secondary survey (14 ± 4 minutes in contrast to 11 ± 2 minutes, p < 0.009) and to transport the patient for CT evaluation (19 ± 5 minutes in contrast to 14 ± 4 minutes; p < 0.001). Attending surgeon experience also affected clinical efficiency with teams directed by less experienced surgeons taking significantly longer to complete the primary survey (p < 0.05).The trauma team's perception of leadership is associated positively with clinical efficiency. As such, more formal leadership training could potentially improve patient care and should be included in surgical education.

Research paper thumbnail of Complications of vena cava filters: A comprehensive clinical review

Despite the success of aggressive prophylaxis and screening, the occurrence of DVT and/or PE is n... more Despite the success of aggressive prophylaxis and screening, the occurrence of DVT and/or PE is not likely to be further reduced. The traditional treatment algorithm of anticoagulation therapy has been very effective. Heparin therapy has been shown to decrease the risk of fatal PE by 75% and to reduce the risk of recurrent PE from 25% to 2%. Long-term therapy with warfarin reduces the incidence of documented DVT from 47% to 2%. However, some patients have contraindication(s) to anticoagulation or prove intolerant of therapy. For this group of patients, a vena cava filter (VCF) may be of benefit. While VCF and the techniques of VCF deployment have evolved significantly over the last four decades, significant complications related to VCF are occasionally seen. This review provides a comprehensive overview of reported VCF-related complications.

Research paper thumbnail of Complications following thoracic trauma managed with tube thoracostomy

Injury-international Journal of The Care of The Injured

Tube thoracostomy is a common procedure used to treat traumatic chest injuries. Although the mech... more Tube thoracostomy is a common procedure used to treat traumatic chest injuries. Although the mechanism of injury traditionally does not alter chest tube management, complication rates may vary depending on the severity of injury. The purpose of this study was to investigate the incidence of and risk factors associated with chest tube complications (CTCs) following thoracic trauma.A retrospective chart review of all trauma patients (≥16 years old) admitted to an urban level 1 trauma centre (1/2007–12/2007) was conducted. Patients who required chest tube (CT) therapy for thoracic injuries within 24 h of admission and survived until CT removal were included. CTCs were defined as a recurrent pneumothorax or residual haemothorax requiring CT reinsertion within 24 h after initial tube removal or addition of new CT >24 h after initial placement. Variables including demographic data, mechanism, associated injuries, initial vital signs, chest abbreviated injury score (AIS), injury severity score (ISS), Glasgow coma score (GCS) and length of stay (LOS) and CT-specific variables (e.g. indication, timing of insertion, and duration of therapy) were compared using the chi square test, Mann–Whitney test, and multivariate analysis.154 patients were included with 22.1% (n = 34) developing a CTC. On univariate analysis, CTCs were associated with longer ICU and hospital LOS (p = 0.02 and p < 0.001), increased chest AIS (p = 0.01), and the presence of an extrathoracic injury (p = 0.047). Results of the multivariate analysis indicated that only increased chest AIS (OR 2.49; p = 0.03) was a significantly independent predictor of CTCs.CTCs following chest trauma are common and are associated with increased morbidity. The severity of the thoracic injury, as measured by chest AIS, should be incorporated into the development of CT management guidelines in order to decrease the incidence of CTCs.

Research paper thumbnail of Contemporary Comparison of Surgical and Interventional Arteriography Management of Blunt Renal Injury

Journal of Vascular and Interventional Radiology, 2011

High-grade renal injuries have traditionally been treated operatively. Alternatively, embolothera... more High-grade renal injuries have traditionally been treated operatively. Alternatively, embolotherapy is used to control hemorrhage, but there are few studies that validate this practice after renal injury. Embolotherapy may offer an effective and safe means to arrest hemorrhage after high-grade blunt renal injury.Retrospective analysis was performed of high-grade renal injury (grade III or higher). Patients who were initially treated with arteriography were compared with those who underwent surgery. Statistical analysis was performed with Wilcoxon rank-sum and χ2 tests.Sixty-nine patients were identified, 28 of whom had contrast agent extravasation on computed tomography (CT). Of these 69 patients, 17 underwent operation and 20 underwent arteriography. The surgical cohort had a higher injury severity score (39.6 vs 24.2; P < .01), but there was no difference in renal injury grade (P = .9). The arteriography cohort received significantly more contrast medium (P < .001). Contrast agent extravasation was confirmed angiographically in six of 12 patients who had this finding on CT, and embolotherapy controlled bleeding in all six. No significant difference was noted in transfusion need, recurrent hemorrhage, creatinine level at discharge, glomerular filtration rate, or length of stay (P > .4 for each endpoint). There was a trend toward a longer stay in the intensive care unit in the surgical cohort and a higher likelihood of discharge to home in the arteriography group (P = .08 for each endpoint).Embolotherapy offers a safe means to diagnose and arrest hemorrhage after renal injury. The additional contrast agent needed for imaging does not increase the incidence of nephropathy irrespective of renal injury grade.

Research paper thumbnail of The Surgical Revolving Door: Risk Factors for Hospital Readmission

Journal of Surgical Research, 2011

Unplanned hospital readmissions increase healthcare costs and patient morbidity. We sought to ide... more Unplanned hospital readmissions increase healthcare costs and patient morbidity. We sought to identify risk factors associated with early readmission in surgical patients.All admissions from a mixed surgical unit during 2009 were retrospectively reviewed and unplanned readmissions within 30 d of discharge were identified. Demographic data, length of stay, pre-existing diagnoses, and complications during the index admission were evaluated. T-tests and Fisher exact tests were used to examine the relationship of independent variables with readmission. Univariate and multivariate regression analysis were performed.A total of 1808 index admissions occurred during the study period. In all, 51 (3%) patients were readmitted within 30 d of discharge. The majority of readmissions (53%) were for infectious reasons. On univariate analyses, DVT (P = 0.004) and acute renal failure (P = 0.002) were associated with increased risk of readmission. Readmitted patients were also more likely to have public insurance (63% versus 37%, P = 0.03) and have a longer stay in the hospital (8 d, range 4–14 d versus 3 d, range 2–7 d, P = 0.001). Initial admission after trauma evaluation was associated with a decreased risk of readmission (OR 0.374, P = 0.004). Other demographic variables and pre-existing conditions were not associated with increased readmission. On multivariate logistic regression only DVT (P = 0.039) and LOS (P = 0.014) remained significant.Increased LOS and the development of a DVT are risk factors for early unplanned hospital readmission. Admission following trauma is associated with a decreased risk of readmission, possibly due to proactive multidisciplinary discharge planning and geographically-based nurse practitioner involvement.

Research paper thumbnail of Factors Associated With Mortality and Brain Injury After Falls From the Standing Position

Journal of Trauma-injury Infection and Critical Care, 2009

Trauma centers are increasingly tasked with evaluating patients who have sustained low-acuity mec... more Trauma centers are increasingly tasked with evaluating patients who have sustained low-acuity mechanisms of injury, such as fall from standing (FFS). Previous studies have shown that low-level falls are associated with a high incidence of injury in certain patient groups. The purpose of the current study was to assess risk factors associated with brain injury and death after fall from the standing position only. A retrospective analysis was performed on all patients who presented with FFS as the mechanism of injury from 2000 to 2005. Demographic variables, past medical history, use of warfarin, blood-alcohol level, initial vital signs, injuries, disposition, and mortality outcome were recorded. Data were analyzed to determine risk factors associated with brain injury, need for intensive care unit (ICU) admission, need for emergency operation, and mortality. A total of 808 patients were identified. Risk factors associated with brain injury, the need for ICU admission, and death included: Injury Severity Score, age &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or=60 years, blood-alcohol level greater than 80 mg/dL, warfarin use, systolic blood pressure &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;100 mm Hg, and Glasgow Coma Scale &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or=12. These risk factors had an additive effect for propensity for brain injury, ICU admission, and death. Increasing Injury Severity Score and use of warfarin had an independent association with mortality. FFS is a potentially morbid mechanism of injury in those who are using warfarin, those with Glasgow Coma Scale score &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or=12, and those who are not inebriated. Age more than 60 years is an additive, but not independent, risk factor for injury.

Research paper thumbnail of Clinical emergencies and outcomes in patients admitted to a surgical versus medical service

Resuscitation, 2011

The merit of rapid response systems (RRSs) remains controversial. A tailored approach to specific... more The merit of rapid response systems (RRSs) remains controversial. A tailored approach to specific groups may increase the efficacy of these teams. The purpose of this study was to compare differences in triggers for RRS activation, interventions, and outcomes in patients on medical and surgical services.A retrospective review RRS events was performed. The incidence of out of ICU cardiac arrests and hospital mortality were compared 2 years prior to and following RRS implementation. Call trigger, interventions, and disposition between medical and surgical patients were compared over a 15 month period.Out of ICU cardiac arrest was significantly more prevalent in the medical group both before and after implementation of RRS. The out of ICU cardiac arrest rate decreased 32% in the surgical group (p = 0.05) but hospital mortality did not change. Out of ICU cardiac arrest decreased 40% in the medical group (p < 0.001) and hospital mortality decreased 25% (p < 0.001) following RRS implementation. There were 1082 RRS activations, 286 surgical and 796 medical. Surgical patients were more likely to have received sedation within 24 h of evaluation (14% vs. 4%, p < 0.001). The majority of patients in both cohorts were discharged alive.Implementation of a RRS had greater impact on reduction of out of ICU cardiac arrest and mortality in medical inpatients. Triggers for activation and interventions were similar between groups; however, surgical patients demonstrated substantial risk for decompensation within the first 24 h following operation. More research is needed to evaluate the disproportionate benefit observed between cohorts.

Research paper thumbnail of Mineralocorticoid deficiency in hemorrhagic shock

Journal of Surgical Research, 2013

In the critically ill, mineralocorticoid deficiency (MD) is associated with greater disease sever... more In the critically ill, mineralocorticoid deficiency (MD) is associated with greater disease severity, the development of acute renal insufficiency, and increased mortality. We hypothesized that severely injured trauma patients presenting with hemorrhagic shock would demonstrate a high degree of MD. We also hypothesized that MD in these patients would be associated with increased length of stay, hypotension, fluid requirements, and acute kidney injury (AKI). Thirty-two trauma patients in hemorrhagic shock on admission to the trauma bay (SBP &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;90 mm Hg × 2) were enrolled. Blood samples were obtained on ICU admission and 8, 16, 24, and 48 hours later. Plasma aldosterone (PA) and renin (PR) were assayed by radioimmunoassay. MD was defined as a ratio of PA/PR ≤2. Demographic data, injury severity score, ICU and hospital length of stay, fluid requirements, mean arterial pressure, serum sodium, hypotension, and risk for AKI were compared for patients with and without MD. At ICU admission, 48% of patients met criteria for MD. Patients with MD were significantly more likely to experience hypotension (MAP ≤60 mm Hg) during the study period. MD patients required significantly more units of blood in 48 h than non-MD patients (13 [7-22] versus 5 [2-7], P = 0.015) and had increased crystalloid requirements (18L [14-23] versus 9L [6-10], P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). MD patients were at higher risk for AKI according to RIFLE and AKIN criteria. MD is a common entity in trauma patients presenting in hemorrhagic shock. Patients with MD required a more aggressive resuscitative effort, were more likely to experience hypotension, and had a higher risk of AKI than non-MD patients. Future studies are needed to fully understand the impact of MD following trauma and the potential role for hormonal replacement therapy.

Research paper thumbnail of Tolstoy et al

Research paper thumbnail of nihms516984

Research paper thumbnail of Alpha Glutathione S‐Transferase (ΑGST): A Novel End Point Serum Marker In Traumatic Shock?

OBJECTIVES: GST belongs to a family of cytosolic proteins involved in cell protection. Having pre... more OBJECTIVES: GST belongs to a family of cytosolic proteins involved in cell protection. Having previously described the potential use of αGST as an endpoint in the management of decompensated shock and resuscitation in an animal model, we tested its utility in a clinical setting of trauma. METHODS: longitudinal identification of patients in the trauma bay (TB) and followed over 48hrs and data collected prospectively including other endpoints of resuscitation (BP, pulse, shock index (SI), lactate, base excess (BE), pH and Hb), blood and fluid requirements, ISS scores as well as clinical outcomes (mortality, length of stay, days ventilated, morbidities). Serum αGST was measured using a commercially available enzyme immunoassay (ELISA) kit at specific time points (TB, ICU, 8, 16 and 24 and 48 hours). Data was analyzed using Mann‐Whitney and Kruskal‐Wallis tests for non‐parametric data and Pearson correlation with a significance set at 5% throughout. RESULTS: 33 (88% male) patients were ...

Research paper thumbnail of Mineralocorticoid deficiency in hemorrhagic shock

Journal of Surgical Research, 2013

Background-In the critically ill, mineralocorticoid deficiency (MD) is associated with greater di... more Background-In the critically ill, mineralocorticoid deficiency (MD) is associated with greater disease severity, the development of acute renal insufficiency, and increased mortality. We hypothesized that severely injured trauma patients presenting with hemorrhagic shock would demonstrate a high degree of MD. We also hypothesized that MD in these patients would be associated with increased length of stay, hypotension, fluid requirements, and acute kidney injury (AKI).

Research paper thumbnail of Goal-Directed Ultrasound in the Detection of Long-Bone Fractures

Journal of Trauma-injury Infection and Critical Care, 2004

Background: New portable ultrasound (US) systems are capable of detecting fractures in the remote... more Background: New portable ultrasound (US) systems are capable of detecting fractures in the remote setting. However, the accuracy of ultrasound by physicians with minimal ultrasound training is unknown.

Research paper thumbnail of Epiploic appendagitis: adding to the differential of acute abdominal pain 1 1 Clinical Communications (Adults) is coordinated by Ron M. Walls, MD, of Brigham and Women’s Hospital and Harvard University Medical School, Boston, Massachusetts

Journal of Emergency Medicine, 1999

e Abstract-We report a patient with epiploic appendagitis who presented with acute abdominal pain... more e Abstract-We report a patient with epiploic appendagitis who presented with acute abdominal pain. Emergency Department and discharge courses are described. The pathophysiology, presentation, diagnosis, and treatment of this disorder are discussed. Knowledge of this uncommonly diagnosed entity and its usual benign course may allow the Emergency Physician to order the appropriate studies to help avoid unnecessary surgical treatment. © 1999 Elsevier Science Inc. e Keywords-epiploic; appendagitis; abdominal; torsion; acute Clinical Communications (Adults) is coordinated by Ron M. Walls,

Research paper thumbnail of Skeletal Muscle Acidosis Correlates with the Severity of Blood Volume Loss during Shock and Resuscitation

Journal of Trauma-injury Infection and Critical Care, 2001

Continuous assessment of tissue perfusion and oxygen utilization may allow for early recognition ... more Continuous assessment of tissue perfusion and oxygen utilization may allow for early recognition and correction of hemorrhagic shock. We hypothesized that continuously monitoring skeletal muscle (SM) PO2, PCO2, and pH during shock would provide an easily accessible method for assessing the severity of blood loss and the efficacy of resuscitation. Thirteen anesthetized pigs (25-35 kg) underwent laparotomy and femoral vessel cannulation. Multiparameter fiberoptic sensors were placed in the deltoid (SM) and femoral artery. Ventilation was maintained at a PaCO2 of 40-45 mm Hg. Total blood volume (TBV) was measured using an Evans blue dye technique. Animals were bled for 15 minutes, maintained at a mean arterial pressure (MAP) of 40 mm Hg for 1 hour, resuscitated (shed blood + 2 times shed volume in normal saline) and observed for 1 hour. Four animals served as controls (sham hemorrhage). Blood and tissue samples were taken at each time point. Blood loss ranged from 28.5-56% of TBV. SM pH and SM PO2 levels fell rapidly with shock. SM PO2 returned to normal with resuscitation; however, SM pH did not return to baseline. SM PCO2 significantly rose with shock, but returned to baseline promptly with resuscitation. There was a significant correlation between SM pH and blood volume loss at end shock (r2 = 0.73, p &lt; 0.001) and recovery (r2 = 0.84, p &lt; 0.001). Animals (n = 2) whose SM pH did not recover to 7.2 were found to have ongoing blood loss from biopsy sites and persistent tissue hypercarbia despite normal MAP. Continuous multiparameter monitoring of SM provides a minimally invasive method for assessing severity of shock and efficacy of resuscitation. Both PCO2 and PO2 levels change rapidly with shock and resuscitation. SM pH is directly proportional to lost blood volume. Persistent SM acidosis (pH &lt; 7.2) and elevated PCO2 levels suggest incomplete resuscitation despite normalized hemodynamics.

Research paper thumbnail of Ringer???s ethyl pyruvate solution ameliorates ischemia/reperfusion-induced intestinal mucosal injury in rats

Critical Care Medicine, 2001

Pyruvate has been shown to be protective in numerous in vitro and in vivo models of oxidant-media... more Pyruvate has been shown to be protective in numerous in vitro and in vivo models of oxidant-mediated cellular or organ system injury. Unfortunately, the usefulness of pyruvate as a therapeutic agent is abrogated by its very poor stability in solution. In an effort to take advantage of the ability of pyruvate to scavenge reactive oxygen species while avoiding the problems associated with the instability of pyruvate in solution, we sought to determine whether a simple derivative, ethyl pyruvate, would be protective in an animal model of reactive oxygen species-mediated tissue injury, namely mesenteric ischemia and reperfusion in rats. Prospective, randomized trial. Animal research center. Male Sprague-Dawley rats. Under general anesthesia, rats were subjected to 60 mins of mesenteric ischemia followed by 60 mins of reperfusion. Controls (n = 6) received intravenous lactated Ringer&amp;amp;#39;s solution according this dosing schedule: 1.5 mL/kg bolus before ischemia, 3.0 mL/kg bolus before resuscitation, and 1.5 mL.kg-1.hr-1 by continuous infusion. Two experimental groups received similar volumes of either pyruvate (n = 6 each) or ethyl pyruvate (n = 9) solution made up exactly like lactated Ringer&amp;amp;#39;s solution except for the substitution of either pyruvate or ethyl pyruvate for lactate, respectively. To obtain tissues for assessing mucosal permeability and histology, five 10-cm long segments of small intestine were obtained at the following time points: baseline, after 30 and 60 mins of ischemia, and after 30 and 60 mins of reperfusion. Mucosal permeability to fluorescein isothiocyanate dextran (molecular weight 4000 Da) was assessed ex vivo by using an everted gut sac method. Compared with controls, treatment of rats with either pyruvate solution or ethyl pyruvate solution significantly ameliorated the development of intestinal mucosal hyperpermeability during the reperfusion. Treatment with ethyl pyruvate solution also significantly decreased the extent of histologic mucosal damage after mesenteric reperfusion. Treatment with Ringer&amp;amp;#39;s ethyl pyruvate solution ameliorated structural and functional damage to the intestinal mucosa in a rat model of mesenteric ischemia/reperfusion. Ethyl pyruvate solution warrants further evaluation as a novel therapeutic agent for preventing oxidant-mediated injury in various disease states.

Research paper thumbnail of MONITORING SKELETAL MUSCLE AND SUBCUTANEOUS TISSUE ACIDBASE STATUS AND OXYGENATION DURING HEMORRHAGIC SHOCK AND RESUSCITATION

Shock, 2005

Gastric tonometry correlates with the severity of blood loss during shock. However, tonometry is ... more Gastric tonometry correlates with the severity of blood loss during shock. However, tonometry is cumbersome, has a slow response time, and is not practical to apply in the acute resuscitation setting. We hypothesized that subcutaneous tissue (SC) and skeletal muscle (SM) pH, pCO2, and pO2 changes are comparable with changes seen in bowel tonometry during shock and resuscitation. Thirteen male mini-swine (25-35 kg; n = 4 control, n = 9 shock) underwent laparotomy and jejunal tonometry. A multisensor probe (Diametrics Medical, Roseville, MN) was placed in the carotid artery, the chest SC, and the adductor muscle of the leg (SM). PaCO2 was maintained between 40 and 45 mmHg. Shocked animals were hemorrhaged and kept at mean arterial pressure of 40 mmHg. Animals were bled until a reinfusion of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;10% of the total shed blood was needed to maintain the mean arterial pressure at 40 mmHg. Animals were resuscitated with shed blood plus 2x shed volume in lactated Ringer&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s solution (20 min) and were observed for 3 h. The average blood loss was 47.2% +/- 8.7% of calculated blood volume. During the hemorrhagic phase, SM and SC displayed tissue acidosis (r2 = 0.951), tissue hypercapnea (r2 = 0.931), and tissue hypoxia (r2 = 0.748). Overall, pH displayed the best correlation between SM and SC during shock and resuscitation. PCO2 in the jejunum (tonometry), SM, and SC increased during decompensation. However, during resuscitation as tonometric pCO2 normalized, only SC pCO2 decreased to its baseline value, whereas the SM pCO2 decrease tended to lag behind. Bland-Altman analyses demonstrated that the variability of the tissue pH changes in SM and SC are predictable according to the phases of hemorrhage and resuscitation. Changes in tissue pH correlated during bleeding and during resuscitation among SC and SM, and these changes followed the trends in gut tonometry as well. Continuous pCO2 and pO2 monitoring in the SM and SC tissues had significant correlations during the induction of shock only. SM and SC continuous pH and pCO2 monitoring reflect bowel pCO2 values during hemorrhagic shock. The response of these indicators as potential surrogates of impaired tissue metabolism varies among tissues and according to the phases of hemorrhage or resuscitation.

Research paper thumbnail of Bladder Mucosa pH and Pco2 as a Minimally Invasive Monitor of Hemorrhagic Shock and Resuscitation

Journal of Trauma-injury Infection and Critical Care, 2004

Continuous monitoring of pH, Pco2, and Po2 using fiberoptic sensor technology has been proposed r... more Continuous monitoring of pH, Pco2, and Po2 using fiberoptic sensor technology has been proposed recently as a clinical monitor of the severity of shock and impaired tissue perfusion. Surrogates of gut tissue perfusion such as gastric tonometry, although cumbersome, have been used to indirectly quantify the degree of gut ischemia. The purpose of this study was to demonstrate the feasibility of monitoring bladder mucosa (BM) and to compare urinary bladder mucosa and proximal jejunum mucosa interstitial pH and Pco2 during hemorrhagic shock and resuscitation. Eleven male miniature swine (25-35 kg) (control, n = 4; shock, n = 7) underwent jejunal tonometry and cystostomy. A multisensor probe was placed adjacent to the BM. Urine was diverted. Normocarbia was maintained. Animals were hemorrhaged and kept at a mean arterial pressure of 40 mm Hg. When a constant infusion was required to maintain the mean arterial pressure at 40 mm Hg (decompensation), animals were resuscitated with shed blood plus two times the shed volume in lactated Ringer&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s solution (20 minutes) and observed for 2 hours. During decompensation, BM pH values decreased significantly from 7.33 +/- 0.08 to 7.01 +/- 0.2 (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01) and recovered to 7.11 +/- 0.19 at 120 minutes after completion of resuscitation. During decompensation, BM Pco2 values increased significantly compared with baseline (from 49 +/- 6 mm Hg to 71 +/- 19 mm Hg, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05) and returned to baseline with resuscitation. Jejunum mucosa and BM interstitial Pco2 correlated throughout shock and resuscitation (r = 0.49). Bland-Altman analysis demonstrated significant differences between jejunum mucosa (intramucosal pH) and BM interstitial pH. Shock-induced changes in the Pco2 of the BM are comparable to tonometric changes in the gut. These data suggest that continuous fiberoptic multisensor probe monitoring of the BM could potentially provide a minimally invasive method for the assessment of impaired tissue perfusion of the splanchnic circulation during shock and resuscitation.

Research paper thumbnail of Methylene Blue and Vasoplegia: Who, When, and How

Mini-reviews in Medicinal Chemistry, 2008

Systemic inflammatory response can be associated with clinically significant and, at times, refra... more Systemic inflammatory response can be associated with clinically significant and, at times, refractory hypotension. Despite the lack of uniform definitions, this condition is frequently called vasoplegia or vasoplegic syndrome (VS), and is thought to be due to dysregulation of endothelial homeostasis and subsequent endothelial dysfunction secondary to direct and indirect effects of multiple inflammatory mediators. Vasoplegia has been observed in all age groups and in various clinical settings, such as anaphylaxis (including protamine reaction), sepsis, hemorrhagic shock, hemodialysis, and cardiac surgery. Among mechanisms thought to be contributory to VS, the nitric oxide (NO)/cyclic guanosine monophosphate (cGMP) pathway appears to play a prominent role. In search of effective treatment for vasoplegia, methylene blue (MB), an inhibitor of nitric oxide synthase (NOS) and guanylate cyclase (GC), has been found to improve the refractory hypotension associated with endothelial dysfunction of VS. There is evidence that MB may indeed be effective in improving systemic hemodynamics in the setting of vasoplegia, with reportedly few side effects. This review describes the current state of clinical and experimental knowledge relating to MB use in the setting of VS, highlighting the potential risks and benefits of therapeutic MB administration in refractory hypotensive states.

Research paper thumbnail of Trauma Leadership: Does Perception Drive Reality

Journal of Surgical Research, 2011

Research paper thumbnail of Trauma Leadership: Does Perception Drive Reality

Journal of Surgical Education

Leadership plays a key role in trauma team management and might affect the efficiency of patient ... more Leadership plays a key role in trauma team management and might affect the efficiency of patient care. Our hypothesis was that a positive relationship exists between the trauma team members' perception of leadership and the efficiency of the injured patient's initial evaluation.We conducted a prospective observational study evaluating trauma attending leadership (TAL) over 5 months at a level 1 trauma center. After the completion of patient care, trauma team members evaluated the TAL's ability using a modified Campbell Leadership Descriptor Survey tool. Scores ranged from 18 (ineffective leader) to 72 (perfect score). Clinical efficiency was measured prospectively by recording the time needed to complete an advanced trauma life support (ATLS)-directed resuscitation. Assessment times across Leadership score groups were compared using Kruskal-Wallis and Mann-Whitney tests (p < 0.05, statistically significant).Seven attending physicians were included with a postfellowship experience ranging from ≤1 to 11 years. The average leadership score was 59.8 (range, 27–72). Leadership scores were divided into 3 groups post facto: low (18–45), medium (46–67), and high (68–72). The teams directed by surgeons with low scores took significantly longer than teams directed by surgeons with high scores to complete the secondary survey (14 ± 4 minutes in contrast to 11 ± 2 minutes, p < 0.009) and to transport the patient for CT evaluation (19 ± 5 minutes in contrast to 14 ± 4 minutes; p < 0.001). Attending surgeon experience also affected clinical efficiency with teams directed by less experienced surgeons taking significantly longer to complete the primary survey (p < 0.05).The trauma team's perception of leadership is associated positively with clinical efficiency. As such, more formal leadership training could potentially improve patient care and should be included in surgical education.

Research paper thumbnail of Complications of vena cava filters: A comprehensive clinical review

Despite the success of aggressive prophylaxis and screening, the occurrence of DVT and/or PE is n... more Despite the success of aggressive prophylaxis and screening, the occurrence of DVT and/or PE is not likely to be further reduced. The traditional treatment algorithm of anticoagulation therapy has been very effective. Heparin therapy has been shown to decrease the risk of fatal PE by 75% and to reduce the risk of recurrent PE from 25% to 2%. Long-term therapy with warfarin reduces the incidence of documented DVT from 47% to 2%. However, some patients have contraindication(s) to anticoagulation or prove intolerant of therapy. For this group of patients, a vena cava filter (VCF) may be of benefit. While VCF and the techniques of VCF deployment have evolved significantly over the last four decades, significant complications related to VCF are occasionally seen. This review provides a comprehensive overview of reported VCF-related complications.

Research paper thumbnail of Complications following thoracic trauma managed with tube thoracostomy

Injury-international Journal of The Care of The Injured

Tube thoracostomy is a common procedure used to treat traumatic chest injuries. Although the mech... more Tube thoracostomy is a common procedure used to treat traumatic chest injuries. Although the mechanism of injury traditionally does not alter chest tube management, complication rates may vary depending on the severity of injury. The purpose of this study was to investigate the incidence of and risk factors associated with chest tube complications (CTCs) following thoracic trauma.A retrospective chart review of all trauma patients (≥16 years old) admitted to an urban level 1 trauma centre (1/2007–12/2007) was conducted. Patients who required chest tube (CT) therapy for thoracic injuries within 24 h of admission and survived until CT removal were included. CTCs were defined as a recurrent pneumothorax or residual haemothorax requiring CT reinsertion within 24 h after initial tube removal or addition of new CT >24 h after initial placement. Variables including demographic data, mechanism, associated injuries, initial vital signs, chest abbreviated injury score (AIS), injury severity score (ISS), Glasgow coma score (GCS) and length of stay (LOS) and CT-specific variables (e.g. indication, timing of insertion, and duration of therapy) were compared using the chi square test, Mann–Whitney test, and multivariate analysis.154 patients were included with 22.1% (n = 34) developing a CTC. On univariate analysis, CTCs were associated with longer ICU and hospital LOS (p = 0.02 and p < 0.001), increased chest AIS (p = 0.01), and the presence of an extrathoracic injury (p = 0.047). Results of the multivariate analysis indicated that only increased chest AIS (OR 2.49; p = 0.03) was a significantly independent predictor of CTCs.CTCs following chest trauma are common and are associated with increased morbidity. The severity of the thoracic injury, as measured by chest AIS, should be incorporated into the development of CT management guidelines in order to decrease the incidence of CTCs.

Research paper thumbnail of Contemporary Comparison of Surgical and Interventional Arteriography Management of Blunt Renal Injury

Journal of Vascular and Interventional Radiology, 2011

High-grade renal injuries have traditionally been treated operatively. Alternatively, embolothera... more High-grade renal injuries have traditionally been treated operatively. Alternatively, embolotherapy is used to control hemorrhage, but there are few studies that validate this practice after renal injury. Embolotherapy may offer an effective and safe means to arrest hemorrhage after high-grade blunt renal injury.Retrospective analysis was performed of high-grade renal injury (grade III or higher). Patients who were initially treated with arteriography were compared with those who underwent surgery. Statistical analysis was performed with Wilcoxon rank-sum and χ2 tests.Sixty-nine patients were identified, 28 of whom had contrast agent extravasation on computed tomography (CT). Of these 69 patients, 17 underwent operation and 20 underwent arteriography. The surgical cohort had a higher injury severity score (39.6 vs 24.2; P < .01), but there was no difference in renal injury grade (P = .9). The arteriography cohort received significantly more contrast medium (P < .001). Contrast agent extravasation was confirmed angiographically in six of 12 patients who had this finding on CT, and embolotherapy controlled bleeding in all six. No significant difference was noted in transfusion need, recurrent hemorrhage, creatinine level at discharge, glomerular filtration rate, or length of stay (P > .4 for each endpoint). There was a trend toward a longer stay in the intensive care unit in the surgical cohort and a higher likelihood of discharge to home in the arteriography group (P = .08 for each endpoint).Embolotherapy offers a safe means to diagnose and arrest hemorrhage after renal injury. The additional contrast agent needed for imaging does not increase the incidence of nephropathy irrespective of renal injury grade.

Research paper thumbnail of The Surgical Revolving Door: Risk Factors for Hospital Readmission

Journal of Surgical Research, 2011

Unplanned hospital readmissions increase healthcare costs and patient morbidity. We sought to ide... more Unplanned hospital readmissions increase healthcare costs and patient morbidity. We sought to identify risk factors associated with early readmission in surgical patients.All admissions from a mixed surgical unit during 2009 were retrospectively reviewed and unplanned readmissions within 30 d of discharge were identified. Demographic data, length of stay, pre-existing diagnoses, and complications during the index admission were evaluated. T-tests and Fisher exact tests were used to examine the relationship of independent variables with readmission. Univariate and multivariate regression analysis were performed.A total of 1808 index admissions occurred during the study period. In all, 51 (3%) patients were readmitted within 30 d of discharge. The majority of readmissions (53%) were for infectious reasons. On univariate analyses, DVT (P = 0.004) and acute renal failure (P = 0.002) were associated with increased risk of readmission. Readmitted patients were also more likely to have public insurance (63% versus 37%, P = 0.03) and have a longer stay in the hospital (8 d, range 4–14 d versus 3 d, range 2–7 d, P = 0.001). Initial admission after trauma evaluation was associated with a decreased risk of readmission (OR 0.374, P = 0.004). Other demographic variables and pre-existing conditions were not associated with increased readmission. On multivariate logistic regression only DVT (P = 0.039) and LOS (P = 0.014) remained significant.Increased LOS and the development of a DVT are risk factors for early unplanned hospital readmission. Admission following trauma is associated with a decreased risk of readmission, possibly due to proactive multidisciplinary discharge planning and geographically-based nurse practitioner involvement.

Research paper thumbnail of Factors Associated With Mortality and Brain Injury After Falls From the Standing Position

Journal of Trauma-injury Infection and Critical Care, 2009

Trauma centers are increasingly tasked with evaluating patients who have sustained low-acuity mec... more Trauma centers are increasingly tasked with evaluating patients who have sustained low-acuity mechanisms of injury, such as fall from standing (FFS). Previous studies have shown that low-level falls are associated with a high incidence of injury in certain patient groups. The purpose of the current study was to assess risk factors associated with brain injury and death after fall from the standing position only. A retrospective analysis was performed on all patients who presented with FFS as the mechanism of injury from 2000 to 2005. Demographic variables, past medical history, use of warfarin, blood-alcohol level, initial vital signs, injuries, disposition, and mortality outcome were recorded. Data were analyzed to determine risk factors associated with brain injury, need for intensive care unit (ICU) admission, need for emergency operation, and mortality. A total of 808 patients were identified. Risk factors associated with brain injury, the need for ICU admission, and death included: Injury Severity Score, age &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or=60 years, blood-alcohol level greater than 80 mg/dL, warfarin use, systolic blood pressure &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;100 mm Hg, and Glasgow Coma Scale &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or=12. These risk factors had an additive effect for propensity for brain injury, ICU admission, and death. Increasing Injury Severity Score and use of warfarin had an independent association with mortality. FFS is a potentially morbid mechanism of injury in those who are using warfarin, those with Glasgow Coma Scale score &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or=12, and those who are not inebriated. Age more than 60 years is an additive, but not independent, risk factor for injury.

Research paper thumbnail of Clinical emergencies and outcomes in patients admitted to a surgical versus medical service

Resuscitation, 2011

The merit of rapid response systems (RRSs) remains controversial. A tailored approach to specific... more The merit of rapid response systems (RRSs) remains controversial. A tailored approach to specific groups may increase the efficacy of these teams. The purpose of this study was to compare differences in triggers for RRS activation, interventions, and outcomes in patients on medical and surgical services.A retrospective review RRS events was performed. The incidence of out of ICU cardiac arrests and hospital mortality were compared 2 years prior to and following RRS implementation. Call trigger, interventions, and disposition between medical and surgical patients were compared over a 15 month period.Out of ICU cardiac arrest was significantly more prevalent in the medical group both before and after implementation of RRS. The out of ICU cardiac arrest rate decreased 32% in the surgical group (p = 0.05) but hospital mortality did not change. Out of ICU cardiac arrest decreased 40% in the medical group (p < 0.001) and hospital mortality decreased 25% (p < 0.001) following RRS implementation. There were 1082 RRS activations, 286 surgical and 796 medical. Surgical patients were more likely to have received sedation within 24 h of evaluation (14% vs. 4%, p < 0.001). The majority of patients in both cohorts were discharged alive.Implementation of a RRS had greater impact on reduction of out of ICU cardiac arrest and mortality in medical inpatients. Triggers for activation and interventions were similar between groups; however, surgical patients demonstrated substantial risk for decompensation within the first 24 h following operation. More research is needed to evaluate the disproportionate benefit observed between cohorts.