Class of 2012 Abstract / Specific Aims: During pre-hospital transport, trauma patients may be given a long-acting neuromuscular blocker (NMB) to facilitate endotracheal intubation or to prevent movement. The purpose of this study was to determine the rate of long-acting NMB use and evaluate the concurrent use of sedatives. Methods: This was a retrospective cohort study conducted in a tertiary care, academic emergency department of trauma patients aged 18-89 years who were intubated in the pre-hospital setting. The primary outcome was to determine the rate of long-acting NMB use. The use of post- intubation sedatives was compared between the groups using Wilcoxon rank-sum test or Fisher’s exact test, using an a priori alpha level of 0.05 for all analyses. Main Result: A total of 51 patients were included in final analyses. All patients received etomidate or midazolam for intubation. 86% (n=44) received succinylcholine, 10% (n=5) were given rocuronium and 4% (n=2) did not receive a NMB. After intubation, 75% (n=38) received an additional long-acting NMB to prevent movement (vecuronium (n=22) or rocuronium (n=16)) . Overall, 82% (n=42) of patients received a long- acting NMB during transport. There was no difference in the rate of post-intubation sedative use between groups (79% versus 67%, respectively, p=0.42). The long-acting NMB group received midazolam less promptly after intubation (16 versus 7 minutes, respectively, p=0.04). Conclusions: The use of long-acting NMB is common during the pre-hospital transport of trauma patients. Some of these patients may not be given sedatives or have delays in receiving sedatives following intubation and be at risk of being paralyzed without sedation.

Class of 2011 Abstract / OBJECTIVES: To compare fixed equianalgesic doses of morphine and fentanyl with regard to analgesic response for patients who presented to the ED with moderate to severe pain. METHODS: A retrospective cohort study of clinical data obtained through patient medical record review. Median pain reduction on the numeric pain scale was compared between the morphine and fentanyl groups. Independent variables of interest included: Age, sex, weight, initial pain score, injury severity, triage severity and injury type. RESULTS: : Pain scores were reported to be worse in the fentanyl group, p= 0.0002. However pain reduction was similar between the groups; median (IQR) of 2 (1-3) and 2 (1-4) in the morphine and fentanyl groups respectively, p= 0.6707. Injuries were more severe in the fentanyl group; injury severity score (ISS) median (IQR) of 5 (1-9) and 9 (3-12), p=0.0312 and more patients in the fentanyl group required additional opioids within 30 min of their first ED opioid dose, 15 (18%) and 31 (37%), p=0.006. CONCLUSION: Patients in both the morphine and fentanyl groups received similar analgesic response. Patients in the fentanyl group had a higher severity of injury, received higher doses of opioids from the EMS, and required the second dose of opioid sooner than patients in the morphine group.

Due to the increasing healthcare costs and reduced length of hospital stay it is becoming increasingly important to identify individuals who are ‘at risk’ of experiencing long-term health issues. The purpose of the study was to: (1) determine if resilience, self efficacy and depression changed from inpatient to 3-month follow up; (2) examine the relationship between resilience, self efficacy, depression, and quality of life (social roles/activity limitations) at inpatient and 3-month follow up; and (3) identify if resilience at inpatient is related to change scores in selfefficacy and depression at 3-month follow up. Results from the paired sample t-test indicated that participants did not experience a significant change from inpatient to 3-month follow up in resilience or self-efficacy, but a significant decrease in depression was observed. Findings also indicated significant correlations between resilience, self-efficacy, and depression during inpatient stay and resilience, self-efficacy, depression, and quality of life at 3-month follow up. However, there was no relationship found between resilience and change scores in self-efficacy and depression. Future resilience research should continue to identify the variables that are most strongly related to resilience so effective interventions can be developed that improve rehabilitation outcomes, decrease secondary and chronic conditions as well as aid in the successful reintegration of individuals into their lives after a traumatic injury.

Infection after trauma complicates the patients clinical course. Infection leads to longer critical care and hospital stays, has been associated with increased mortality rates and places considerable cost pressures on health economies. The predictors of infection after severe injury are not known, and the effects on outcomes other than mortality are under-reported. The overall objective of this research was to characterise factors predictive of infection in severely injured patients admitted to critical care. A prospective cohort study of 271 patients investigated admission factors predictive of the development of infection. A second study of 280 patients evaluated post-injury immune cell changes and the association with infection. Thirdly the relationship between early coagulopathy and infections was investigated in 158 patients. Finally a study of 385 patients examined the use of Tranexamic Acid (TXA) and its association with infection and other outcomes. Infection was a significant burden for severely injured patients. Admission hypoperfusion was the only early characteristic associated with the development of infection, and a dose dependent relationship was observed between severity of shock and increased percentage of infection (p<0.01). Lymphopenia prolonged to day four post injury was strongly predictive infection (OR 0.10, CI 0.02-0.48, p<0.01). At 24 hours, the anticoagulant Protein C was lower in those with infection (Infection: 70.2 iu/dL vs. No infection: 83.3 iu/dL p=0.02), and increased fibrinolysis was also associated with infectious complications (Infection: 6156 μg/L vs. No infection: 3324 μg/L p=0.03). There was a trend to a beneficial relationship between TXA and infection, and it was independently associated with reduced organ failure (OR 0.27, CI: 0.10 – 0.73, p=0.01) and mortality (OR 0.16 CI 0.03 - 0.86, p=0.03). In severely injured patients, admission shock, prolonged lymphopenia and early coagulation dysfunction post severe injury were independent predictors of infection. Timely modulation of these responses after trauma may help to reduce the burden of infection.

Sustaining a Spinal Cord Injury at any point in time is life altering – physically, emotionally, and financially – for all persons affected by the injury, but it can place unique challenges on younger married couples. This study examines the transition to injury for 18 couples (ages 21-55). Data were collected using individual interviews with each partner at three time points following injury, as well as observation in the rehabilitation setting (Creekview). This resulted in 96 individual interviews and 300 hours of observation. Using a combination of the life course perspective and cognitive sociology as guiding theoretical frameworks and grounded theory analysis, I examined how the health care institution influenced the couples’ relationships during their rehabilitation stay and the subsequent transition home. Overall, this study found that Creekview shaped a thought community that emphasizes a return to walking and high levels of physical recovery. Patients who achieved these goals constructed positive narratives about the future while those with lower levels of recovery constructed negative narratives over time. Additionally, because of the dominant medical narrative of wait and see regarding physical recovery, many respondents constructed fuzzy narratives about the future that reflect ambiguity about what life would look like following injury. Additionally, Creekview staff and couples accepted and reinforced the dominant cultural narrative that women are natural caregivers, but larger social structures of class, gender, and the division of paid and unpaid labor work together to push some women into caregiving faster or prevent other women from engaging in caregiving. Expanding on Aneshensel et al.’s (1995) caregiving career, this study examines how younger couples move through the caregiving career when the expected outcome is not long-term care placement or death. This study identified three main types of caregivers, each with their own path of caregiving – Naturalized, Constrained, and Resistant caregivers. Overall, the transition to injury is complex for patients and partners and this study highlights some of the ways the marital relationship is affected by a non-normative, unexpected transition.

No description available.

Further understanding of the cellular and molecular mechanisms involved in traumatic injury, and how they are modulated during drug interaction, can facilitate novel treatment strategies for future trauma patients. We hypothesize that the pharmacological agent, Androstenetriol (AET), up regulates host immune response by modulating the continued expression of mediators, including cytokines. In a double-blinded experiment, rats were hemorrhaged, driven by volume or pressure conditions, then resuscitated with fluids and packed red blood cells following a subcutaneous injection of either vehicle or drug. Blood was collected at various time points and cytokine levels were determined by analyses with both multiplex and conventional ELISA assays. Both MCP-1 and GRO/KC increase in surviving animals; trauma increases IL-lα levels in rat plasma, whereas hemorrhage decreases IL-lα over time; IL-6 plasma levels measured 6 hours after hemorrhage may correlate with mortality; AET may act by mechanisms to modify specific TH1 cytokines (INF-y) to promote survival.

As part of an effort to understand psychological consequences among family members of patients sustaining a traumatic injury, medical research has turned to the role of resilience – or the ability to bounce back from and maintain psychological well-being in the wake of an adverse event— in mitigating the potential distress (i.e., depression and burden) of caregiving (Bonanno, 2004; Roberson et al., under review). This study sought to examine the ability for trait-resilience to predict trajectories of distress over the course of a year among 124 family members and loved ones of patients admitted to a Level I Trauma Center. A cross-lagged path model examining resilience, burden, and depression at baseline, 3, 6, and 12 months after injury showed that, while depression strongly predicted later burden, resilience was not a significant predictor of either outcome in the model. When depression and burden were subjected to a person-centered analysis (i.e., latent growth curve analysis), two major classes were identified: caregivers with high, chronic distress (33% of the sample) and low-moderate distress that declined over time. A three-class solution for caregiver burden further identified a moderate, increasing trajectory class. Predictive discriminant analyses revealed that trait-resilience was a major differentiating trait between class membership (rs = .23 for depression; rs = .32 for burden); further, presence of PTSD symptoms at baseline, gender, and history of depression were shown to be strong factors in distinguishing class membership across both outcomes. This study helps shed insight into the well-being of caregivers in the wake of a loved one's traumatic injury, in addition to possible identifying risk factors while patients are still admitted in the ICU. Lastly, the study provides alternatives for analyses that focus on longitudinal outcomes, particularly person- vs. variable-centered solutions.

Les traumatismes spinaux (TS) touchent environ 17 810 personnes chaque année en Amérique du Nord. À la suite de ces lésions, la plupart des individus atteints vont perdre l’habilité à effectuer des mouvements simples et certains peuvent présenter des paralysies d’un ou plusieurs membres. Également, ces patients vont souffrir de troubles du sommeil, de détresse émotionnelle (anxiété et dépression) et de déficits cognitifs (mémoire). L’occurrence d’un traumatisme crânien (TC) concomitant est sous-estimée et sous-diagnostiquée dans 12.4 à 74% des patients TS, pouvant affecter considérablement la réhabilitation post-traumatisme. Bien que les soins prodigués actuellement permettent une certaine récupération après TS ou TC, il semble nécessaire de développer des thérapies adaptées dans le cadre des TS-TC concomitants. Afin de combler ce manque de connaissances après TS-TC concomitant, nous avons développé un nouveau modèle animal de TS-TC concomitant. En utilisant des approches comportementales et électrophysiologiques, nous avons examiné l’impact d’un TS-TC concomitant sur les fonctions motrices, le sommeil, l’état émotionnel et les capacités cognitives. Un groupe de rats recevant un TS-TC concomitant a été comparé avec un groupe ne recevant qu’un TS seul et un groupe contrôle (SHAM), recevant une laminectomie et une craniotomie sans TS et TC. La locomotion globale et le sommeil ont été évalués à chaque semaine pendant un mois par le test de session en arène ouverte et par électroencéphalographie pour évaluer l’architecture du sommeil, l’analyse spectrale des états de vigilance, incluant spécifiquement la dynamique de l’activité delta en sommeil sans mouvement rapide des yeux (sommeil NREM). L’état émotionnel et les capacités cognitives ont été testés 6 semaines post-traumatisme. L’anxiété et la dépression ont été testées en arène ouverte et par le test de préférence au sucrose respectivement. La mémoire de travail et la mémoire spatiale ont été testées par le test du labyrinthe en Y et par le test de reconnaissance spatiale d’objets respectivement. Le TS-TC et le TS seul ont induit des déficits moteurs en comparaison au groupe SHAM. La durée et la qualité de l’éveil et du sommeil n’ont pas été affectées par le TS seul ou le TS-TC concomitant, malgré une tendance à la hause de l’activité spectrale et de la dynamique de l’activité delta en sommeil NREM après TS-TC. Ni le TS-TC ou le TS seul n’a affecté l’état émotionnel. Seule la mémoire de travail a été affectée après TS-TC en comparaison aux groupes SHAM et TS seul. Les résultats obtenus suggèrent que la mémoire de travail pourrait être considérée comme un potentiel biomarqueur de lésion concomitante de la moelle épinière et du cerveau. De plus amples expériences seront nécessaires afin de décrire complétement ce nouveau modèle animal de TS-TC concomitant comme d’une part, la réalisation de mesures comportementales spécifiques dans les phases aigue et chronique post-traumatisme et d’autre part, une mesure de la neuro-inflammation et de la plasticité par immunohistochimie au niveau de l’hippocampe. Le développement de ce nouveau modèle animal va permettre la création et l’adaptation d’outils diagnostiques et thérapeutiques pour les patients présentant des TS-TC concomitants. / Spinal cord injuries (SCI) affect 17,810 people in North America every year. In this condition, most individuals will lose the ability to perform simple motor actions and will additionally suffer from sleep disturbances, emotional distress (anxiety and depression) and cognitive impairments (memory). The occurrence of traumatic brain injury (TBI) in SCI population is underestimated and missed-diagnosed in 12.4 to 74% of SCI patients, impeding the implementation of optimal rehabilitation strategies and drug therapies. Although specialized care is critically needed to improve rehabilitation outcomes in these patients, specialized dual diagnosis care and evidence-based approaches for treatment are currently lacking. To address this knowledge gap, we developed and characterized a novel rodent model of concomitant TBI and SCI. Using a combination of behavioral and electrophysiological techniques, we examined the impact of concomitant TBI and SCI on motor function, sleep, emotional state, and cognition. A group of rats receiving concomitant TBI and SCI were compared with control groups that received SCI only or surgical procedures without injuries (SHAM group). Global locomotion and sleep were evaluated each week for one month by using the open-field test and electroencephalography to evaluate sleep architecture, the spectral composition of vigilance states, including delta activity during non-rapid eye movement (NREM) sleep. Emotional states and cognition were assessed at 6 weeks after surgery. Anxiety and depression were tested using the open-filed and sucrose preference tests, respectively. Working memory and spatial memory were evaluated by Y Maze test and spatial object recognition test, respectively. We found that concomitant TBI-SCI and SCI alone both impacted locomotor abilities, by comparison to the intact state. The duration and quality of wakefulness and sleep were not significantly affected by SCI or TBI-SCI, despite spectral analysis showing a tendency for TBI-SCI to increase NREM sleep delta activity. Neither concomitant TBI SCI nor SCI significantly impacted anxiety and depressive-like behaviors in comparison to the SHAM group. By contrast, working memory was significantly impaired after TBI-SCI but was preserved in SHAM and SCI groups. This result suggests that working memory could potentially be used as a biomarker of these concomitant injuries. Further experiments are needed to fully characterize this novel animal model. This includes performing more specific behavioral tests in the acute and chronic stages after injury. Also, immunochemistry experiments directed on molecular markers of neuro-inflammation and plasticity are needed. This novel animal model will be useful to create and adapted diagnosis and therapeutic tools for TBI-SCI patients.