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Rib fractures are among the most common injuries identified in blunt trauma patients. Morbidity increases with increasing age and increasing number of rib fractures. The use of noninvasive ventilation has been shown to be helpful as a rescue technique avoiding intubation in patients who have become hypoxemic but little data with regard to its use to prophylactically prevent worsening respiratory status are available. We developed a chest trauma protocol for our “elderly” (>45 years) trauma patients and sought to determine whether this would improve pulmonary outcomes. We retrospectively reviewed our elderly chest trauma patients one year before (CTRL) and nine months after implementation (STU) of the chest trauma protocol. The protocol consisted of intravenous narcotics, oral nonsteroidal anti-inflammatory drugs, prophylactic noninvasive ventilation, and measurements of incentive spirometry. In the control year, there were 176 patients meeting study criteria, whereas 140 met the criteria in the STU group. The CTRL group had 11 unplanned ICU admissions (rate 0.063), six unplanned intubations (rate 0.034), and eight patients diagnosed with pneumonia (rate 0.045). These rates decreased in the STU group to two unplanned ICU admissions (0.014, P = 0.044), one unplanned intubation (rate 0.007, P = 0.138), and no patients with pneumonia (0.0, P = 0.010). Our chest trauma protocol has significantly decreased adverse pulmonary events in our older blunt chest trauma population with multiple rib fractures. This protocol has become our standard procedure for patients older than 45 years admitted with rib fractures.
Introduction In the older intensive care unit (ICU) trauma population, it is common to have to make decisions about end-of-life. We sought to demonstrate uncertainty of patients and providers in this area. Methods Our study is a prospective observational study of trauma patients 50 years and older admitted to the ICU. Patients or surrogates completed a survey including questions regarding end-of-life. Team members were surveyed with their expectation for patient outcome and appropriateness of palliative or comfort care. Patients were followed up for 6 months. Chi-square analysis and Fisher’s exact test were performed. Results 100 patients had data available for analysis. Surveys were completed by the patient for 39 while a surrogate completed the survey for 61 patients. There was a significant increase in uncertainty if a surrogate answered or if there had been no prior discussions about end-of-life. Nurse, resident, and attending predictions about hospital survival were similar with all groups predicting survival in 82%. 6-month survivors were only predicted to be alive 75% of the time. Ideas about comfort care were similar but there was more variation regarding a palliative care consult with nurses saying yes in 27% of surveys while physicians only said yes in 18%. Conclusions The significantly higher rates of uncertainty for both surrogates or in cases where no prior discussion had been had highlight the importance of having more conversations about end-of-life and documentation of advance directives prior to traumatic events. The difference in team member ideas about palliative care demonstrates a need for improved team communication.
Background The anticoagulation and coagulopathy associated with venovenous extracorporeal membrane oxygenation (VV-ECMO) lead to concern for increased risks of tracheostomy. The purpose of this study is to evaluate the safety of tracheostomy in patients on VV-ECMO. Methods Patients admitted between November 2015 and January 2019 to a dedicated intensive care unit for VV-ECMO were reviewed retrospectively. Results 96 patients underwent tracheostomy. Tracheostomy was performed percutaneously in 51 patients, open in 24, and hybrid in 21. 28 patients had postprocedure bleeding which was from the tracheostomy site in 13, the airway in 13, and both in 2. 6 patients had major tracheostomy site bleeding and 3 patients had major airway bleeding. 7 patients had minor tracheostomy site bleeding, 10 patients had minor airway bleeding, and 2 patients had minor bleeding at both. Bleeding complications were more common following percutaneous tracheostomy. Being on anticoagulation prior to tracheostomy was protective. Discussion Bleeding following tracheostomy in VV-ECMO is common with higher bleeding rates observed for those done percutaneously. Most complications were minor. Tracheostomy in patients on VV-ECMO appears safe
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