AFTER PENETRATING ABDOMINAL TRAUMA WITH PERITONITIS
Despite stable vital signs, intraabdominal blood can be present.
The standard of care in patients with peritonitis resulting from a penetrating abdominal trauma, specifically that caused by a gunshot wound or a stab wound, is immediate laparotomy. Such patients may or may not present with cardiovascular compromise, and in a recently published prospective study, researchers observed that in some who were apparently hemodynamically stable, a great amount of "free" blood was discovered during laparotomy, necessitating intra-operative resuscitation, blood transfusion, and other lifesaving interventions.
During the two-year study period, 139 consecutive patients were enrolled; all had penetrating abdominal trauma and associated peritonitis with a systolic blood pressure of at least 90 mmHg prior to arrival at the ED and while there. Ninety-four percent of the study population was male, 72% had abdominal trauma resulting from a gunshot wound, and 28% had trauma resulting from a stab wound.
The researchers assessed the quantity of free blood found at the time of laparotomy by grading it according to four classes: class I, less than 750 mL3; class II, 750-1500 mL3; and classes III and IV, more than 1500 mL3.
Class I levels of blood were found in 82% of the patients, and while that represents the great majority of them, at least 750 mL3 of free blood was found intraoperatively in the other 18%, and 7% of those had more than 1500 mL3 despite normal blood pressure on presentation.
A quarter of the patients in the total sample were hypotensive while in the operating room, and 39% needed transfusions. Patients with classes III or IV blood loss had the greatest degree of intraoperative hypotension and needed the greatest number of blood transfusions and the most use of fluid resuscitation and vasopressor therapy. Forty percent of all patients were sent to the ICU after surgery; 78% of those required mechanical ventilation. Complications occurred in 25% of the total sample, most often intraabdominal abscess (12%), followed by wound infection (7%) and enterocutaneous fistula (4%).
The results of the study emphasize the need for acute operative management in apparently hemodynamically stable patients with peritonitis consequent to penetrating abdominal trauma, in whom there can be intraabdominal bleeding warranting immediate surgical intervention. The appearance of hemodynamic stability upon presentation to the ED should not cause nurses and other health care practitioners to underestimate the possible severity of such abdominal injury.
Brown CV, et al. Arch Surg 2005;140 (8):767-72.
'CLEARING' THE SPINE AFTER BLUNT TRAUMA
CT scanning and neurologic examination may suffice.
According to a new study, health care practitioners can confidently rely on computed tomographic (CT) scan results to accurately detect cervical spine injury after blunt trauma, possibly obviating the need for magnetic resonance imaging (MRI) in most cases.
Since 1998 the study researchers followed their institution's protocol for ruling out cervical spine injury consequent to blunt trauma through the use of helical CT scanning with sagittal reconstructions when clinical examination alone could not. However, they wondered whether MRI is necessary to detect possible cervical spine injury in two types of patients-those with normal neurologic examination and CT scan results but with continuing neck pain and those who are comatose but with movement in all four limbs.
Over a five-year period, data on 2,854 trauma patients admitted to a level II trauma center were prospectively collected. Ninety-one percent of the patients presented with blunt trauma, 56% of them with closed head injury. Approximately 58% of the patients received spine clearance based on clinical examination and, of the remainder, 40% underwent helical CT scanning to establish clearance (2% died prior to scanning). One hundred patients were found to have cervical spine injury, spinal cord injury, or both; 85% were diagnosed by helical CT scan and the rest by the abnormal findings on neurologic examination despite normal CT scan results.
Among patients who were conscious, 93 who were found to be neurologically intact and have normal CT scan results continued to have acute neck pain and therefore underwent MRI, in accordance with institutional protocol. Only 25% of them had abnormal MRI results, although, surprisingly, not as the result of injury-18.3% of such results were attributable to degenerative disc disease and 6.5% to spinal canal stenosis. The great majority of patients (75%) had normal MRI results. In the remaining group, 12 patients were comatose but had limb movement upon arrival at the ED; they had Glasgow Coma Scores of less than 9 and normal CT scan results, but none of the MRI showed cervical injury.
The CT scan proved to be an accurate clinical tool in the detection of cervical spine injury in a large percentage of patients, and the researchers concluded that, in the two groups of patients under consideration, MRI is not necessary to rule out cervical spine injury once normal CT scan results are confirmed; they also noted the disadvantages, in terms of cost and patient comfort, of routine MRI testing.
Schuster R, et al. Arch Surg 2005;140(8): 762-6.
STANDARDIZED ORDERS AFTER STROKE
Crucial interventions are performed more regularly.
Several interventions have been identified by researchers as defining the best practice after a patient suffers a stroke; for instance, the administration of thrombolytic medication in the first few hours after the stroke is critical in minimizing damage to the brain. But studies have shown that many of the interventions recommended in consensus guidelines are not consistently prescribed or performed, despite the evidence of their benefits.
In a recently published study, researchers applied a principle that has proven successful in improving the quality of hospital care, generally, to the treatment of ischemic stroke: the use of a standardized medical order template. The practice was implemented in six hospitals in California, specifically at admission and discharge. Practitioners using the admission forms were required to check off the appropriate treatments as indicated in the guidelines; contraindications for each were also listed, serving to draw attention to possible drawbacks and to also provide an acceptable rationale for a practice recommendation not being followed. Nursing discharge orders were also standardized, ensuring that directions concerning all aspects of poststroke management, such as medication regimen and follow-up appointments, were explicitly reviewed with the patient.
Researchers at the hospitals analyzed data on patients with stroke during a three-month period in the year preceding the one in which the use of the new medical order sheets was initiated. The comparable data from the year after the initiation of the practice were then analyzed. Six interventions were selected as the measures of the quality of care: the administration of thrombolytic medication within three hours of the onset of symptoms, the use of an antithrombotic agent within 48 hours of arrival at the ED, the implementation of a regimen for the prevention of deep vein thrombosis by the second day, instruction in smoking cessation before discharge, and the prescription of lipid-lowering and antithrombotic medications at discharge.
The records of 413 patients were reviewed, 187 in the earlier group, and 226 in the later group. The results revealed that 63% of patients in the second group underwent all six interventions, compared with 44% in the first. Overall, four of the six interventions were more often performed after the use of the standardized medical order sheets was implemented, the exceptions being the administration of thrombolytic medication within three hours of the onset of symptoms, possibly consequent to the small eligibility sample size, and the discharge instructions concerning smoking cessation.
The researchers concluded that, although there may have been other, broader factors that contributed to the higher rates of the performance of the interventions, such as the intensified advertising of lipid-lowering medication, the results of the study support the practice of using standardized medical orders sheets based on the best care practices.
The California Acute Stroke Pilot Registry Investigators. Neurology 2005;65(3):360-5.
PATIENT SAFETY IN CRITICAL CARE
Serious errors and adverse events occur frequently.
The findings of a new study sponsored by the Agency for Healthcare Research and Quality reveal that there is still considerable progress to be made in the prevention and limitation of medical mistakes made in ICUs.
The researchers monitored 391 patients in intensive care settings, the medical ICU and the coronary care unit, over the course of a year, for a total of 189 days. Between both units, there were 1,490 patient-days observed for the purpose of investigating the incidence and types of medical mistakes. The researchers drew a distinction between serious medical errors, those that cause or could cause harm or injury, and adverse events, impairment of the patient's condition attributable to medical management rather than underlying disease. Predominantly, hospital interns collected the study data by observing routine ICU proceedings such as order entry, patient rounds, and bedside procedures, as well as reviewing incident reports and patient charts.
The study revealed 120 adverse events among 20% (79) of the ICU patients; 45% events were deemed preventable, such as the development of fatal septic shock from a contaminated central venous catheter. Such events most often affected the respiratory system (19%), and 15% of them resulted in complications of infection. Forty-seven percent of the events were attributable to medication error, an example of which is the continuation of a furosemide IV drip despite orders to discontinue it in the presence of dehydration; however, the majority of such medication errors resulted from the prescription or administration of incorrect dosages.
Two hundred and twenty-three serious medical errors also were observed, 24 (11%) of which were considered to be possibly life threatening, and 78% of which were medication errors.
Another significant finding concerned the point at which medical missteps were found to have occurred. Although a constantly emergent and chaotic atmosphere is, of course, characteristic of the ICU, 91% of the observed serious medical errors and adverse events occurred during the provision of routine patient care, not during risky or greatly technical procedures. Additionally, only 26% of the mistakes were attributable to deficits in knowledge in any health care provider; a majority (53%) were attributable to "skill-based slips and lapses" occurring, for example, in the carrying out of orders, such as the failure to take precautions or to follow protocol.
Noting that these findings may not be generalizable to all critical care settings, the researchers conclude that further study is necessary. Additionally, they suggest that improvements in that area may be effected through the promotion of a climate in which communication and forthrightness regarding safety issues among both nurses and physicians are heightened.
Rothschild JM, et al. Crit Care Med 2005; 33(8):1694-700.