Robert F. Lavery

Bio: Robert F. Lavery is an academic researcher from Rutgers University. The author has contributed to research in topics: Trauma center & Poison control. The author has an hindex of 30, co-authored 58 publications receiving 3595 citations. Previous affiliations of Robert F. Lavery include University of Medicine and Dentistry of New Jersey & University Hospital, Newark.

Prospective Validation of Computed Tomographic Screening of the Thoracolumbar Spine in Trauma

Abstract: Objective: Concern for thoracolumbar spine (TLS) injuries after major trauma mandates immobilization pending radiographic evaluation. Current protocols use standard posteroanterior and lateral radiographs of the thoracolumbar spine (XR/TLS), but many patients also undergo abdominal or thoracic computed tomographic (CT) scanning. We sought to evaluate whether helical truncal CT scanning performed to evaluate visceral trauma images the spine as well as dedicated XR/TLS. Methods: We prospectively studied 222 consecutive patients sustaining high-risk trauma requiring TLS screening because of clinical findings or altered mentation. The chest, abdomen, and pelvis were imaged with one intravenous contrast infusion. All patients had CT scan of the chest, abdomen, and pelvis (CT/CAP) and XR/TLS. Initial radiologic diagnoses were compared with the discharge diagnosis of acute fractures confirmed by thin-cut CT scan and/or clinical examination of the patient when alert. Results: Of 222 patients studied, 215 were fully evaluated. Thirty-six (17%) had acute TLS fractures. The accuracy of CT/CAP for TLS fractures was 99% (95% confidence interval [CI], 96-100%). The accuracy of XR/TLS was 87% (95% CI, 82-92%). Sensitivity, specificity, and positive and negative predictive values were better for CT/CAP than for XR/ TLS. CT/CAP found acute fractures XR/ TLS missed, and correctly classified old fractures XR/TLS read as "possibly" acute. The total XR/TLS misclassification rate was 12.6% (95% Cl, 8.4-19%); for CT/CAP it was 1.4% (95% CI, 0.3-3.3%). No fractures were missed by CT/CAP. No unstable fracture was missed by either technique. Conclusion: CT/CAP diagnoses TLS fractures more accurately than XR/TLS. Neither misses unstable fractures, but CT scanning finds small fractures that benefit by treatment and identifies chronic disease better. CT screening is far faster and shortens time to removal of spine precautions. CT scan-based diagnosis does not result in greater radiation exposure and improves resource use. Screening the TLS on truncal helical CT scanning performed for the evaluation of visceral injuries is more accurate than TLS imaging by standard radiography. CT/CAP should replace plain radiographs in high-risk trauma patients who require screening.

The utility of venous lactate to triage injured patients in the trauma center.

Abstract: Background: Field triage criteria for trauma patients results in over-triage rates of 30% to 50% to achieve under-triage rates of 10%. This large number of patients may stress trauma center resources. Elevated arterial lactate (ALAC) levels have been shown to be a marker of serious injury but the need for arterial sampling limits the utility of the determination. The goal of this study was: 1) to determine the correlation between venous lactate (VLAC) and ALAC; 2) to determine whether VLAC could identify those patients with serious injuries; and 3) to compare an elevated VLAC level against standard triage criteria (STC) in their ability to identify major injury. Study Design: Arterial and venous samples for blood gas and lactate analyses were obtained in 375 patients within 10 minutes of patient arrival to the trauma center. Arterial and venous samples were drawn within 2 minutes of each other, placed on ice, and analyzed within 10 minutes of sampling. The location of sampling was left to physician discretion. Data collected included injury mechanism, demographics, admission vital signs, emergency department disposition, length of stay, and injury severity scores (ISS). Admission to the ICU, need for emergency operation, length of stay, and death were noted. Emergency medical service staff were queried to determine which standard triage criteria (STC) were fulfilled. Results: The mean ALAC was 3.11 mmol/L (SD 3.45, 95% confidence interval [CI] 2.67 to 3.55) and mean VLAC was 3.43 mmol/L (SD 3.41, 95% CI 2.96 to 3.90). There was no significant difference between ALAC and VLAC. The correlation between ALAC and VLAC was 0.94 (95% CI 0.94 to 0.96, p=0.0001). An elevated VLAC predicted moderate to severe injury and there was a significant association between an increased lactate and maximum Abbreviated Injury Score (AIS) of 4 and 5 (ANOVA, F=8.26, p 2 days. In comparison with STC, a VLAC ≥ 2 mmol/L decreased under-triage in patients with ISS ≥ 13 by one half (11% versus 24%) for patients with ISS ≥ 13 and decreased over-triage by 28% (46% versus 64%). These data were most pronounced for patients injured in motor vehicle collisions. Conclusions: VLAC is an excellent approximation for ALAC. A VLAC ≥ 2 mmol/L appears to predict an ISS ≥ 13, the need for ICU resources, and prolonged hospital stays. VLAC was significantly better than STC in all patients and was most useful in victims of blunt trauma, especially motor vehicle collisions.

CT Diagnosis of Rib Fractures and the Prediction of Acute Respiratory Failure

Abstract: Background:The number of rib fractures has been reported to correlate with mortality after blunt chest trauma. These reports, however, predate routine truncal helical computed tomographic (CT) scanning and their conclusions are based on data derived from plain chest radiographs (CXR). CT scan provid

Emergency Department Discharge of Patients With a Negative Cranial Computed Tomography Scan After Minimal Head Injury

Abstract: Head injury remains one of the most common reasons for seeking medical attention after injury: it is been estimated that more than 1.5 million people are treated for head injuries annually in the United States. 1 The vast majority of head injuries are minor, but the optimal evaluation and treatment protocol of this large group of patients remains controversial. 2–16 Recommendations on the use of cranial computed tomography (CT) scanning vary from mandatory scanning in all patients to more selective use based on a constellation of findings on the history and physical examination. Hospital admission or prolonged supervised observation remains a current standard of practice for patients who have sustained a loss of consciousness (LOC) even though diagnostic studies have excluded an intracranial injury. 3,7,12 The major reason for this practice is the perception that there is an important but undefined false-negative rate in these patients, despite the absence of abnormalities on physical examination, skull radiography, and cranial CT. Case reports on patients who “talked and then deteriorated” have also contributed to this practice. 2,17 It is also believed that even if no significant injury is discovered when a patient is first evaluated, inpatient observation is the best means to identify any missed injury and would allow rapid treatment to be instituted. Finally, medicolegal considerations may cause medical providers to err on the side of caution and admit such patients to the hospital, because there are no prospectively collected data defining the risk of subsequent injury when patients with minimal head injury (MHI) are sent home after a negative evaluation. The purpose of this study was to evaluate prospectively the incidence of intracranial injury in patients who sustained MHI and the practice of mandatory hospital admission or supervised observation of patients after MHI, particularly when a CT scan was interpreted as negative for intracranial injury.

A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit.

Abstract: Introduction: Trauma centers successfully save lives of severely injured patients who would have formerly died. However, survivors often have multiple complications and morbidities associated with prolonged intensive care unit (ICU) stays. Because the reintegration of patients into the society to lead an active and a productive life is the ultimate goal of trauma center care, we questioned whether our "success" may condemn these patients to a fate worse than death? Methods: Charts on all patients ≥18 years with ICU stay ≥ 10 days, discharged alive between June 1, 2002, and May 31, 2005, were reviewed. Patients with complete spinal cord injuries were excluded. Demographics, Injury Severity Score (ISS), presence of severe traumatic brain injury (TBI; Head Abbreviated Injury Scale [AIS] score = 4 or 5), presence of extremity fractures, need for operative procedures, ventilator days, complications, and discharge disposition were collected. Glasgow Outcome Scale score was calculated on discharge. Patients were contacted by phone to determine general health, work status, and using this data, Glasgow Outcome Scale score and a modified Functional Independence Measure (FIM) score were calculated. Results: Two hundred and forty-one patients met inclusion criteria. Thirty-three patients died postdischarge from the hospital and 39 were known to be alive from the electronic medical records but were unable to be contacted. Sixty-nine patients could not be tracked down and were ultimately considered as lost to follow-up. The remaining 100 patients who were successfully contacted participated in the study. Eighty-one percent were men with a mean age of 42 years, mean and median ISS of 28. Severe TBI was present in 50 (50%) patients. Mean and median follow-up was 3.3 years from discharge. At the time of follow-up, 92 (92%) patients were living at home, 5 in nursing homes, and 3 in assisted living, a shelter, or halfway house. FIM scores ranged from 6 to 12 with 55% reached a maximal FIM score of 12. One quarter of patients had FIM scores ≤ 10 and 10% had locomotion scores of ≤2 (very dependent). Seventy percent considered themselves to be less active. Seventy-six patients were either working or in full-time school before their trauma. Of the 24 patients not working preinjury, 12 were ≥55 years of age. At the time of follow―up, 37 patients (49%) were back to work or school. Severe TBI patients (57%, 21 of 37) were less likely to return to work when compared with 38% (12 of 38; p = 0.03) without severe TBI. There was no relationship with age, ISS, presence of any TBI, head AIS, presence of any extremity fracture, extremity AIS, or ventilator days in patients who did or did not return to work. Conclusions: These data demonstrate that ICU survivors >3 years after severe injury have significant impairments including inability to return to work or regain previous levels of activity and that the goal of reintegrating patients back into the society is not being met. Further studies better defining the limitations and barriers to improved quality of life are necessary. Survival, although important, is no longer a sufficient outcome to measure trauma center success.

Part 9: Post-Cardiac Arrest Care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Abstract: There is increasing recognition that systematic post–cardiac arrest care after return of spontaneous circulation (ROSC) can improve the likelihood of patient survival with good quality of life. This is based in part on the publication of results of randomized controlled clinical trials as well as a description of the post–cardiac arrest syndrome. 1–3 Post–cardiac arrest care has significant potential to reduce early mortality caused by hemodynamic instability and later morbidity and mortality from multiorgan failure and brain injury. 3,4 This section summarizes our evolving understanding of the hemodynamic, neurological, and metabolic abnormalities encountered in patients who are initially resuscitated from cardiac arrest. The initial objectives of post–cardiac arrest care are to ● Optimize cardiopulmonary function and vital organ perfusion. ● After out-of-hospital cardiac arrest, transport patient to an appropriate hospital with a comprehensive post–cardiac arrest treatment system of care that includes acute coronary interventions, neurological care, goal-directed critical care, and hypothermia. ● Transport the in-hospital post–cardiac arrest patient to an appropriate critical-care unit capable of providing comprehensive post–cardiac arrest care. ● Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest.

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

Abstract: It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.

Part 8: Adult Advanced Cardiovascular Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Abstract: The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

Part 14: Pediatric Advanced Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Abstract: In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1 Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below). Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9 It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …