Oregon Health & Science University
Level 1 Trauma Center

Current Studies in The Trauma Program

Richard J. Mullins

RURAL TRAUMA SYSTEM STUDY GROUP

BACKGROUND
Acute care of a seriously injured patient is most effective if care is immediate and surgeons deliver treatments in an optimal sequence. Trauma systems are public health care policies intended to assure that patients receive effective acute care. Trauma system administrators promulgate guidelines, which are hypothesized to assure timely and efficient patient care. While trauma systems in urban communities have consistently improved outcome, clear evidence is lacking that statewide trauma systems have improved survival of injured patients in rural communities. Over the past ten years research published by our study group, the Rural Trauma Study Group, has indicated that Oregon’s trauma system has improved the outcome of seriously injured patients, particularly those with brain injury treated in the level 1 trauma centers. Our research has indicated that inter-hospital transfer decisions regarding brain injured patients treated in rural hospitals are a key area for further improvements in the effectiveness of Oregon’s statewide trauma system.

METHODS AND RESOURCES
Our outcomes research studies have been principally observational studies. The methods we use are similar to those reported in epidemiology texts. Plausible outcomes research depends upon accurate and comprehensive data on the population of interest. We have electronic copies of analyzable databases. These databases are extensive archives of information on hospitalized injured patients in Oregon and Washington State. Outcomes research is dependent upon appropriate use of robust statistical analyses. We perform our statistical analyses principally using SPSS. To evaluate the influence of trauma systems we have relied upon risk adjusted models, which predict patient’s survival. We have carefully developed methodology, which enables us to achieve a consistent insight into the quality of medical care. With our recent publications we have extended beyond outcomes studies, and have also examined the utility of evaluating processes of care and injury prevention. When students or residents participate in the outcomes studies performed by the Rural Trauma System Study Group, we encourage them to focus on testing a hypothesis using data and methods, which are already available. Our preference is for the new investigators to develop skill at manuscript preparation and publication.

PLANNED RESEARCH PROJECTS FOR THE FUTURE
Our current research plan for the next three years has three components. First we will obtain long-term follow-up on geriatric patients following injury-using SF-36, a questionnaire that provides a measure of quality of life. Second we will expand our brain injury database for the purpose of comparing the processes of care delivered to brain injured patients directly transported to level 1 or 2 trauma centers to processes of care delivered to similar patient who first present to rural hospitals. A third goal will be to complete an analyses of recently acquired data to determine if a decision rule can be developed which can accurately classify patients in rural hospitals who would benefit from transfer to a higher level trauma center. Funded by the Centers for Disease Control and Prevention R49/CCR 006283-07 and the Trauma Education and Research Fund.

Ladder Fall Study

Falls from ladders have been recognized as a common cause of significant morbidity and even mortality among patients admitted to the OHSU trauma service. The majority of patients fell from ladders while working at home. Many were over the age of 60. The current ladder fall study has two goals. First a detailed questionnaire has been developed to determine the exact mechanism of injury, which is the cause of the patient falling from the ladder. Second the characteristics of the patients preexisting health status, which might contribute to the ladder fall, are determined. The purpose of the questionnaire is to better define area where prevention training might be effective.

Hyponatremia Protocol Study

In this study we are investigating what causes hyponatremia in the trauma patient, and how it is best treated. Patients with brain injury are at increased risk for the development of cerebral edema if they have hyponatremia. The lower the serum sodium, the lower the osmolality and the greater the cell swelling, which may cause increases in intercranial pressure. The specific causes of hyponatremia can be divided into two physiologic mechanisms, excessive retention of water and excessive loss of sodium in urine. The first is commonly attributed to the syndrome of inappropriate antidiuretic hormone. The second may relate to the influence of naturetic peptide released from the injured brain. Therapeutic implications of these two diagnoses are clear: SIADH patients are treated with water restriction, while salt loss required transfusion with hypertonic sodium. Further study is being conducted to determine the utility of urine sodium concentrations in evaluating these patients.

John C. Mayberry, MD

Rib Fracture Repair

Dr. Mayberry is leading the effort at OHSU to define the indications for rib fracture repair. He is the Principle Investigator on a Medical Research Foundation of Oregon supported study to enroll all patients with rib fractures at OHSU in a 6 month pain and disability follow up study.

He is also partnering with Dr. Tom Ellis of Orthopedics in developing a new rib fracture fixation plate that can be placed minimally-invasively. This new plating system has shown near biomechanical equivalence to standard meothods and may be available for human use in 2006.

Robert K. Goldman, MD

Basic Research

I am principally interested in translating knowledge gained from the lab into the clinical problem of shock. We are investigating the physiologic consequences of the intriguing biochemistry of nitric oxide. The physiology and biochemistry of nitrosothiols–long acting adducts of NO–are of special interest. Other investigations address organ dysfunction and organ protection during inflammatory stress.

Clinical Research

My main focus is evaluating outcomes concerning fundamental critical care issues germane to trauma patients. These problems, for example, have included liberation from mechanical ventilation, pulmonary embolism, and complications of liver injury. One of my hobbies is digital photography and applying computer technology toward conducting clinical research

Martin A. Schreiber, MD

The Relationship Between Hypercoagulability and Organ Failure

Despite major advances in critical care, the mortality in patients with Adult Respiratory Distress Syndrome and Multiple Organ Failure remains high. This study seeks to test the hypothesis that these deadly syndromes are associated with a hypercoagulable state. If this association can be established, newer therapies designed to combat the hypercoagulable state will be tested as prophylaxis for organ failure. This project is supported by the National Institutes of Health by a grant through the General Clinical Research Center at OHSU.

Coagulation Parameters after Splenectomy in Adult Trauma Patients

The prolonged risk of a hypercoagulable state following trauma splenectomy beyond acute thrombocytosis is not recognized by the trauma community or considered in the decision to preserve the spleen. An evaluation of a pure trauma patient population including the appropriate control group could significantly add to the trauma literature and potentially affect a change in the management of patients with splenic injuries. This study will also characterize the thrombophilia that follows trauma splenectomy. By doing this, it will clarify the optimal therapeutic prophylaxis. The proposed study will be unique in that it will be the first study in the literature to compare a trauma splenectomy population to the appropriate control group of trauma patients. The incidence of thromboembolic complications in untreated trauma patients is reported to be 58%. This is amongst the highest incidence for any population. The duration of time that this risk persists is unknown and has never been studied. Therefore, hypercoagulability following splenectomy in trauma patients cannot be distinguished from hypercoagulability from trauma without an equivalent control group. This study will control for trauma by selecting a concurrent and well-matched group of injured patients with splenic injuries who underwent splenic salvage. This project is supported by the National Institutes of Health by a grant through the General Clinical Research Center at OHSU.

Can TEG be used in place of anti-Factor Xa to assess enoxaparin levels in patients with comorbiditites?

The Effect of Fluid Resuscitation on Outcome After Trauma

In addition to stopping hemorrhage, fluid resuscitation is a critical aspect of the management of bleeding trauma patients. The optimal endpoints of resuscitation and the best resuscitation fluid have not been determined. This study is designed to determine the effect of 4 commonly used resuscitation fluids and 3 different resuscitation endpoints on coagulation, bleeding, survival and inflammation in a massive liver injury. This project has been submitted to the Department of the Navy for funding.

Resource Utilization in Head Injured Patients on Blood Thinners

This study is to determine if in fact there are statistically significant differences between patients receiving anti-coagulation therapy and those not receiving anti-coagulation therapy in regards to etiology, pathophysiology, management and outcome. This data will be further utilized to determine measures that may be taken to improve outcomes in this high-risk population. This study is currently not funded.

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