Antibiotics and chest tubes (michael parra)

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EAST Practice Management Guideline 
Parameters for Prophylactic Antibiotics in Tube Thoracostomy for Traumatic Hemopneumothorax
Chairman: Fred A. Luchette, MD
Members: Phil Barie, MD, Michael Oswanski, MD, David A. Spain, MD
I. Recommendations (For isolated chest trauma)
A. Level 1
There are insufficient data to support a level I recommendation as a standard of care. 
B. Level 2
There are sufficient Class I & II data to recommend prophylactic antibiotic usage in patients receiving tube thoracostomy following chest trauma. A first generation cephalosporin should be used for no longer than 24 hours.
C. Level 3
Available data support a reduction in the incidence of pneumonia in trauma patients receiving prophylactic antibiotics when a tube thoracostomy is placed. There is insufficient data to suggest prophylactic antibiotics reduce the incidence of empyema.
 
Michael Parra, MD 
Trauma Research Director
Broward General Medical Center
Fort Lauderdale, Fl

--- On Sun, 11/2/08, trauma-list-request at trauma.org <trauma-list-request at trauma.org> wrote:

From: trauma-list-request at trauma.org <trauma-list-request at trauma.org>
Subject: trauma-list Digest, Vol 65, Issue 2
To: trauma-list at trauma.org
Date: Sunday, November 2, 2008, 5:40 AM

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Today's Topics:

   1. Vacation reply (hossamortho60 at hotmail.com)
   2. RE: Presumptive Antibiotic Administration And Chest Tube
      Insertion. (Robert F Smith)
   3. Re: (no subject) (Andrew J Bowman)
   4. Re: (no subject) (ALS79 at aol.com)
   5. Re: pelvic fractures (michael parra) (KMATTOX at aol.com)
   6. More BS Denials and Toeing the Party Line in Maryland about
      the	Trooper 2 Crash (Stephen Richey)
   7. Re: Presumptive Antibiotic Administration And Chest Tube
      Insertion. (Dr Timothy Hardcastle)
   8. NTSB Wants Safer Medical Flights (John Annen)
   9. RE: (no subject) (Bryan Bledsoe, DO)

 
BTW, what is the empyema rate for chest tubes placed in a resuscitative
setting? Or rate of pneumonia vs. pneumonia for similar ICU patients without
chest tubes? (Since you already did the work, so I won't have to, lol)

Rob Smith

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Jeffrey Hammond
Sent: Saturday, November 01, 2008 1:19 AM
To: Trauma &amp; Critical Care mailing list
Cc: trauma-list at trauma.org
Subject: Re: Presumptive Antibiotic Administration And Chest Tube Insertion.

Agree with Dr Mattox...but...the problem is most of the papers have chosen
the wrong end-point to study. Empyema is such an uncommon event that, as Ken
points out, it would take a huge study to show a significant reduction.
However, we looked at this 5 or so years ago in an effort to develop an
internal consensus and there was literature that  suggested that antibiotic
administration with a 1st generation cepha-drug was associated with a lower
pneumonia rate. That has been our practice.
 
Jeffrey Hammond MD, MPH
New Brunswick, NJ

----- Original Message -----
From: KMATTOX at aol.com
Date: Friday, October 31, 2008 6:47 pm
Subject: Re: Presumptive Antibiotic Administration And Chest Tube Insertion.
To: trauma-list at trauma.org

> There is NO good data on EITHER side of this  
> question.     It would take 20 
> years and somewhere close to  500,000 cases to reach some sort of even 
> crude statistical power, because  empyema from an uncomplicated tube 
> thoracostomy is
> so incrediably  low.     
> So.........over time there has been an agreement that if one is to use 
> any antibiotic at all, it should be one that has minimal
> complications.    My own recommendation is the 
> CHEAPEST oral  FIRST GENERATION
> cephalosomething in your city's or hospital's  
> pharmacy.    NO, NO, NO, do not 
> sneak in a second generation  cephalosporin, or anything 
> any stronger.    It 
> simply in not  necessary.    
>  
> k
>  
>  
>  
>  
> In a message dated 10/31/2008 2:06:30 P.M. Central Daylight Time, 
> Richard.Ferraro at chw.edu writes:
>  
> Rick  Ferraro Trauma Program Manager Mercy San Juan Medical  Center
> 
> 
> 
> Question: I want to get feed back on your practice as it  
> pertains to one
> time antibiotic administration before chest tube insertion  
> for blunt or
> penetrating trauma. 
> 
> 
> 
> I hope this finds all  well!
> 
> 
> 
> 
> 
> --
> trauma-list : TRAUMA.ORG
> To change your  settings or unsubscribe  visit:
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> 
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Doesa nyone have access to this article? I am not able to find it, even at
their website.

Andrew

On Sun, Sep 28, 2008 at 5:22 PM, <ALS79 at aol.com> wrote:

> For those interested in the origins of modern hospital-based medical
> helicopters, I offer the following - and forget about the Viet Nam
military
> experience, which is often cited by today's historical revisionists or
> deconstructionists. Hospital managers of the early 1980's couldn't
have
> cared less.
>
> The epicenter of modern hospital-based air medical services lies in an
> article published in the Harvard Business Review in 1980 entitled,
"The
> Health Care
> Market: Can Hospitals Survive?" The article was written by Jeff C.
> Goldsmith,
> who at the time was the Director of Health Planning at the University of
> Chicago Medical Center. The piece addresses the economic survival of
> American
> hospitals, vis-a-vis impending regulatory and health policy changes.
>
> It was the first to coin the term "captive systems of
distribution," which
> describes various methods that hospitals could use to escape their
markets'
> geographical constraints, and pluck patients from other markets including
> their
> competitors'. Among many, Goldsmith named freestanding clinics, taxi
cabs,
> ambulance services, outlying hospitals and aircraft to accomplish this
> patient
> feeder mission.
>
> Thereafter, hospital managers embraced this article as the
"bible" for the
> future. That is where the whole medical helicopter issue really took off
> (so to
> speak), not because of Viet Nam successes, but rather as a vehicle for
> economic survival going forward. Seemingly, everyone was getting into the
> helicopter
> business. And, in the early '80's, the American Society for
Hospital-Based
> Emergency Air Medical Services (ASHBEAMS) was founded in order to promote
> standardization and address safety concerns. It all metastasized from
there
> - not out
> of some selfless or noble generosity on the part of hospital managers to
> better serve the public, but rather as a strategy to optimize in-house
> census and
> net revenues. Follow the money.
>
> The Health Care Market: Can Hospitals Survive?
> Jeff C, Goldsmith, Harvard Business Review
> (Sept-Oct); (p..100-112), 1980
>
> Bob Kellow
>
>
>
>
>
>
> **************
> Looking for simple solutions to your real-life financial
> challenges?  Check out WalletPop for the latest news and information, tips
> and
> calculators.
>      (http://www.walletpop.com/?NCID=emlcntuswall00000001)
> --
> trauma-list : TRAUMA.ORG <http://trauma.org/>
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>

I'll send it to you in PDF.

Bob Kellow


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00001)

I am familiar with the statement below.   It is not a consensus  of the way 
to treat pelvic fractures in unstable patients in the  USA.   It is my view 
that the aggressive treatment actually  contributes to the mortality -  
IATROGENIA.      I  have NEVER been convienced that the MAST, the pelvic wrap
devices, 
or the  external fixators did anything but made the patient's access more  
difficult.    I also have not been convienced that the  embolization of
arterial 
vessels did anything to venous bleeding except got the  patient away from the 
aggressive fluid resuscitators for a few  hours.    We need a better way.    I 
am watching  the pelvic packing data and it looks interesting, but too few 
cases so  far.     The issue is selection of the few unstable patients  that 
need it.   For the majority of patients with pelvic fracture,  they need for
the 
emergency ohysicians, trauma surgeons and orthopedic surgeons  to keep their 
hands off for a while.  
 
k
 
 
 
 
 
In a message dated 10/31/2008 1:16:59 P.M. Central Daylight Time,  
michaelwparra at yahoo.com writes:

The
current management of pelvic fracture patients who  are
hemodynamically unstable in the United States consists of  aggressive
resuscitation, mechanical stabilization, and angioembolization.  Despite
this multidisciplinary approach, recent analysis confirms  an
alarming 40% mortality in these high-risk patients(7). The statement  by
Duchesne "we can not control for patient pelvic volume and degree  of
exsanguination in the presence of a closed or open  retro-peritoneum..."
is not an absolute.The implemetation of Pre-Peritoneal  Pelvic Packing
(PPP) is a rapid method for controlling pelvic  fracture-related
hemorrhage that can supplant the need for emergent  angiography. There
is a significant reduction in blood product transfusion  after PPP, and
this approach appears to reduce mortality in this select  high-risk
group of patients(7). We have used this technique with great  success
and low morbidity at our institution.  



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Decision to Airlift Patients Still Debated Officials Focus on Initial Injury
Assessment of Teens in Waldorf Auto Accident
     » *Top 35 Metro
Articles*<http://www.washingtonpost.com/wp-srv/metro/metro-mv.html?nav=tmv>
» *Most Popular on
washingtonpost.com*<http://www.washingtonpost.com/wp-srv/most-popular.html?nav=tmv>

By Aaron C.
Davis<http://projects.washingtonpost.com/staff/email/aaron+c.+davis/>
Washington Post Staff Writer

The emergency workers first on the scene of a Waldorf car accident in
September that preceded a fatal medical helicopter crash classified the
patients' injuries as not immediately life-threatening and in a category
that rarely meets the criteria for an airlift, state officials said
yesterday.

Paramedics who arrived later considered the teens' injuries potentially
more
serious because their car was crushed. The process of ordering the rescue
flight, however, had begun without that assessment and with a less serious
triage rating than officials had previously said.

Four people died in the helicopter crash that occurred in Walker Mill
Regional Park as the teens were being flown from Waldorf to Prince George's
Hospital on Sept. 27.

Robert R. Bass, executive director of the Maryland Institute for Emergency
Medical Services, said he thought the triage discrepancy could be
"explained
fairly easily." The initial rating -- Category D, the lowest for trauma
victims under Maryland's triage guidelines -- was assigned by members of
Waldorf's fire department, Bass said. The patients were later listed as
Category C on paperwork filed by Charles
County<http://www.washingtonpost.com/ac2/related/topic/Charles+County?tid=informline>paramedics,
Bass said.

He said the flight was justified because the vehicle damage paramedics
observed could have indicated patients with internal injuries. The most
serious trauma classifications are categories A and B.

The mother of Ashley Younger, the 17-year-old patient who was killed in the
helicopter crash, has questioned whether the airlift was necessary.
Stephanie Younger said her daughter had been able to call her on a cellphone
after the auto accident.

Some state lawmakers also have been critical of the program, saying the way
Maryland's emergency workers are taught to evaluate potential internal
injuries results in "overtriage" and many unnecessary airlifts.

The triage discrepancy came to light late last week in about 16 minutes of
taped communications between responders and dispatchers released by Bass's
agency. The initial Category D assessment was first reported by the Baltimore
Sun<http://www.washingtonpost.com/ac2/related/topic/The+Baltimore+Sun+Company?tid=informline>.


The tapes also revealed an exchange between a state police helicopter
dispatcher and pilot Stephen J. Bunker that suggested at least a perception
among Maryland State
Police<http://www.washingtonpost.com/ac2/related/topic/Maryland+State+Police?tid=informline>that
they are often called to transport accident victims from the Waldorf
area. In the tape, Bunker asked where he was being deployed and the
dispatcher responded, "Waldorf, where else?" Bass said. Bunker died
in the
crash.

"The comment was that they would not frequently drive," Bass said.
"We heard
that, went back and looked at it, and found nothing to substantiate the
comment." He said an analysis of requested rescue flights by county and
population showed that Eastern Shore counties request airlifts more often.

Also killed in the helicopter crash were Trooper Mickey C. Lippy, an onboard
paramedic, and Tonya
Mallard<http://www.washingtonpost.com/ac2/related/topic/Tonya+Mallard?tid=informline>,
a volunteer emergency worker. Jordan
Wells<http://www.washingtonpost.com/ac2/related/topic/Jordan+Wells?tid=informline>,
18, the second patient, survived.
=============
Once again, Dr. Bass manages to demonstrate his blatant disregard for (or
ignorance of) the evidence against both mechanism of injury and the use of
helicopters.  Why is he still in charge out there?  Why has no one tried to
remove him from office?  Surely, if there are as many problems with Maryland
EMS as have come to light in recent months, then perhaps the man who runs it
like his own personal fiefdom and treats his EMS providers like his serfs
should be held to account for the fraud, waste, abuse and deaths that
result.

Also, I would like to point out the fact he more or less brushed off the
possible propensity for a county to abuse helicopters, even in a state that
has the worst record of such offenses in the US.   Yeah, the Eastern Shore
does likely fly more people but this is explainable since they are farther
from Baltimore and Valhal....oops, Shock/Trauma.   How about giving us a
county-by-county breakdown of the rate of flights rather than sidestepping
the issue?  It's cheaper to simply ignore the possibility of a problem than
to fix it and we all know MIEMSS needs to keep expenses low so the state can
focus on delivering state of the art prehospital care such as mechanism of
injury based triage, "mother, may I?" protocols and aeromedical
transport.


-- 
Stephen L. Richey, CRT
Aviation Injury Research Project Leader
Saginaw Valley State University
Work E-mail: slrichey at svsu.edu
Home Office Phone: 248-366-4452

"Hier stehe ich. Ich kann nicht anders. Gott helfe mir. Amen."-
Martin
Luther, before the Diet of Worms, 16. April 1521

> Rick Ferraro Trauma Program Manager Mercy San Juan Medical Center
>
>
>
> Question: I want to get feed back on your practice as it pertains to one
> time antibiotic administration before chest tube insertion for blunt or
> penetrating trauma.
>
>
>
> I hope this finds all well!
>
>
>
>
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
Single dose 1g Kefazolin prevents pneumonia and wound site sepsis, not
empyema. Used it at my previous institution and they don't here in Durban

Dr T C Hardcastle
M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
Principal Specialist Trauma Surgeon /
Honorary Lecturer UKZN Dept Surgery
Deputy Director - IALCH Trauma Service


It often takes the FAA quite some time to enact rules to address issues on the
NTSB's list. Jujst as one example, the fuel/air mixture issue addressed in
the second paragraph of the bulletin stems from the crash of TWA flight 800,
which occurred on 17 July 1996, with the NTSB probable cause report released on
23 August 2000. At least the NTSB is now paying more attention to the issue, and
having it on their list will certainly bring more attention to medical flight
safety.
>From AVwebFlash, Volume 14, Number 44b,
http://www.avweb.com/eletter/archives/avflash/1241-full.html#199085

NTSB Wants Safer Medical Flights 
  The NTSB this week issued its annual list of "Most Wanted Safety
Improvements,"
and topping the list for aviation: Emergency Medical Services (EMS)
Flights, making the list for the first time. "Although the Board has
issued recommendations to improve EMS safety, the FAA has not
implemented the changes," the NTSB said.
"In the last 11 months, there have been nine EMS accidents, resulting
in 35 fatalities." The board also wants to improve runway safety by
implementing better information and alerts, and requiring pilots to
calculate landing distances based on current information. Other items
on the list were better practices for flying in icing conditions, crew
resource management training, and crew member fatigue. The board would
also like to see widespread use of image recorders in cockpits, even in
smaller aircraft that are not now required to have recording devices,
to help in post-accident analyses.
One item that was on last year's list has been resolved --
"Eliminate Flammable Fuel/Air Vapors in Fuel Tanks on Transport
Category Aircraft." The FAA enacted a rule in July that requires
fuel/air mixtures in all fuel tanks to be below a prescribed
flammability level for all newly manufactured aircraft that have more
than 30 seats. "All of these safety-related issues highlighted in the
Most Wanted List should be addressed promptly," said board chairman
Mark Rosenker. "Though we are encouraged by progress being made,
resulting in some items being removed from the list, several of these
safety concerns have been on this list since its inception."


      
See attached

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Andrew J Bowman
Sent: Saturday, November 01, 2008 2:57 PM
To: Trauma &amp, Critical Care mailing list
Subject: Re: (no subject)

Doesa nyone have access to this article? I am not able to find it, even at
their website.

Andrew

On Sun, Sep 28, 2008 at 5:22 PM, <ALS79 at aol.com> wrote:

> For those interested in the origins of modern hospital-based medical
> helicopters, I offer the following - and forget about the Viet Nam
military
> experience, which is often cited by today's historical revisionists or
> deconstructionists. Hospital managers of the early 1980's couldn't
have
> cared less.
>
> The epicenter of modern hospital-based air medical services lies in an
> article published in the Harvard Business Review in 1980 entitled,
"The
> Health Care
> Market: Can Hospitals Survive?" The article was written by Jeff C.
> Goldsmith,
> who at the time was the Director of Health Planning at the University of
> Chicago Medical Center. The piece addresses the economic survival of
> American
> hospitals, vis-a-vis impending regulatory and health policy changes.
>
> It was the first to coin the term "captive systems of
distribution," which
> describes various methods that hospitals could use to escape their
markets'
> geographical constraints, and pluck patients from other markets including
> their
> competitors'. Among many, Goldsmith named freestanding clinics, taxi
cabs,
> ambulance services, outlying hospitals and aircraft to accomplish this
> patient
> feeder mission.
>
> Thereafter, hospital managers embraced this article as the
"bible" for the
> future. That is where the whole medical helicopter issue really took off
> (so to
> speak), not because of Viet Nam successes, but rather as a vehicle for
> economic survival going forward. Seemingly, everyone was getting into the
> helicopter
> business. And, in the early '80's, the American Society for
Hospital-Based
> Emergency Air Medical Services (ASHBEAMS) was founded in order to promote
> standardization and address safety concerns. It all metastasized from
there
> - not out
> of some selfless or noble generosity on the part of hospital managers to
> better serve the public, but rather as a strategy to optimize in-house
> census and
> net revenues. Follow the money.
>
> The Health Care Market: Can Hospitals Survive?
> Jeff C, Goldsmith, Harvard Business Review
> (Sept-Oct); (p..100-112), 1980
>
> Bob Kellow
>
>
>
>
>
>
> **************
> Looking for simple solutions to your real-life financial
> challenges?  Check out WalletPop for the latest news and information, tips
> and
> calculators.
>      (http://www.walletpop.com/?NCID=emlcntuswall00000001)
> --
> trauma-list : TRAUMA.ORG <http://trauma.org/>
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
--
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