Colon Injuries and Infectious Complications in Concurrent Gunshot-Related Fractures

INTRODUCTION

Concurrent colonic injury among patients with gunshot-related fractures presents a potential risk for infectious complications. We hypothesized that colon injuries are associated with more infectious orthopedic complications among gunshot victims with concurrent fractures.

MATERIALS AND METHODS

We reviewed trauma patients arriving at our level 1 trauma center from January 1, 2019 to May 31, 2022 who suffered any gunshot-related fracture and also underwent an exploratory laparotomy. Of these patients, those with colon injuries were compared to those without colon injuries. Baseline characteristics, including antibiotic regimens, were collected in addition to outcomes of length of stay, intensive care unit admission, ventilator requirement, and development of infectious orthopedic complications.

RESULTS

Overall, 56 of the 107 included patients had colon injuries. Age, sex, race/ethnicity, and Injury Severity Score were similar between groups. Of patients with colonic injuries, 16.1% received early, repeat dosing of broad-spectrum antibiotics, while only 3.9% of patients without colonic injuries received this antibiotic dosing (P = 0.04). Interestingly, only patients with colon injuries developed infectious orthopedic complications and none of the patients without colon injuries developed such complications (10.7% versus 0.0%, P = 0.03). All patients with orthopedic infections had infected pelvic fractures. Length of stay was 3 d longer in the colon injury group (P = 0.04). There was no difference in intensive care unit admission, ventilator requirement, or death.

CONCLUSIONS

Concurrent colon injuries among patients with gunshot-related fractures are associated with higher risk of infectious orthopedic complications, likely from direct spread of fecal contaminant. Early, broad-spectrum antibiotics may be associated with reduced infectious orthopedic complications.

Comparison of outcomes between observation and tube thoracostomy for small traumatic pneumothoraces

BACKGROUND

Traumatic pneumothorax management has evolved to include the use of smaller caliber tube thoracostomy and even observation alone. Data is limited comparing tube thoracostomy to observation for small traumatic pneumothoraces. We aimed to investigate whether observing patients with a small traumatic pneumothorax on initial chest radiograph (CXR) is associated with improved outcomes compared to tube thoracostomy.

METHODS

We retrospectively reviewed trauma patients at our level 1 trauma center from January 1, 2016 through December 31, 2020. We included those with a pneumothorax size <30 mm as measured from apex to cupola on initial CXR. We excluded patients with injury severity score ≥ 25, operative requirements, hemothorax, bilateral pneumothoraces, and intensive care unit admission. Patients were grouped by management strategy (observation vs tube thoracostomy). Our primary outcome was length of stay with secondary outcomes of pulmonary infection, failed trial of observation, readmission, and mortality. Results are listed as mean ± standard error of the mean.

RESULTS

Of patients who met criteria, 39 were in the observation group, and 34 were in the tube thoracostomy group. Baseline characteristics were similar between the groups. Average pneumothorax size on CXR was 18 ± 1.0 mm in the observation group and 18 ± 0.84 mm in the tube thoracostomy group (p > 0.99). Average pneumothorax sizes on computed tomography were 25 ± 2.1 and 37 ± 3.9 mm in the observation and tube thoracostomy groups, respectively (p = 0.01). Length of stay in the observation group was significantly shorter than the tube thoracostomy group (3.6 ± 0.33 vs 5.8 ± 0.81 days, p < 0.01). While pneumothorax size on computed tomography was associated with tube thoracostomy, only tube thoracostomy correlated with length of stay on multivariable analysis; pneumothorax size on CXR and computed tomography did not. There were no deaths or readmissions in either cohort. One patient in the observation group required tube thoracostomy after 18 h for worsening subcutaneous emphysema, and one patient in the tube thoracostomy group developed an empyema.

CONCLUSIONS

Select patients with small traumatic pneumothoraces on initial chest radiograph who were treated with observation experienced an average length of stay over two days shorter than those treated with tube thoracostomy. Outcomes were otherwise similar between the two groups suggesting that an observation-first strategy may be a superior treatment approach for these patients.

Shift in Pre-Hospital Mode of Transportation for Trauma Patients during the COVID-19 Pandemic

Background

Since the start of the COVID-19 pandemic, we experienced alterations to modes of transportation amongst trauma patients suffering penetrating injuries. Historically, a small percentage of our penetrating trauma patients use private means of pre-hospital transportation. Our hypothesis was that the use of private transportation among trauma patients increased during the COVID-19 pandemic and was associated with better outcomes.

Methods

We retrospectively reviewed all adult trauma patients (Jan. 1, 2017 to Mar. 19, 2021), using the date of the shelter-in-place ordinance (Mar. 19, 2020) to separate trauma patients into pre-pandemic and pandemic patient groups. Patient demographics, mechanism of injury, mode of pre-hospital transportation, and variables such as initial ISS, Intensive Care Unit (ICU) admission, ICU length of stay (LOS), mechanical ventilator days, and mortality were recorded.

Results

We identified 11,919 adult trauma patients, 9,017 (75.7%) in the pre-pandemic group and 2,902 (24.3%) in the pandemic group. The number of patients using private pre-hospital transportation also increased (from 2.4% to 6.7%, p<0.001). Between the pre-pandemic and pandemic private transportation cohorts, there were reductions in mean ISS (from 8.1 ±10.4 to 5.3 ±6.6: p=0.02), ICU admission rates (from 15% to 2.4%: p<0.001) and hospital LOS (from 4.0 ±5.3 to 2.3 ±1.9: p=0.02). However, there was no difference in mortality (4.1% and 2.0%, p=0.221).

Conclusion

We found that there was a significant shift in pre-hospital transportation among trauma patients toward private transportation after the shelter-in-place order. However, this did not coincide with a change in mortality despite a downward trend. This phenomenon could help direct future policy and protocols in trauma systems when battling major public health emergencies.

Racial Disparities Among Trauma Patients During the COVID-19 Pandemic

INTRODUCTION

Given the disparate effects of the COVID-19 pandemic on people of color, we hypothesized that patients of color experienced a disproportionate increase in trauma during the COVID-19 pandemic.

MATERIALS AND METHODS

We compared trauma patients arriving in the 3 y before our statewide stay-at-home mandate on March 20, 2020 (PRE) to those arriving in the year afterward (POST). In addition to race/ethnicity, we assessed patient demographics and other clinical variables. Chi-squared, Fisher's exact, and Mann-Whitney U tests were used for univariate analyses. A multivariable logistic regression was performed to assess for associations with mortality.

RESULTS

During the study period, 8583 patients were included in the PRE group and 2883 were included in the POST group. There were increases in penetrating trauma (PRE 14.7%, POST 23.1%; P < 0.001) and mortality rates (PRE 3.20%, POST 4.60%; P < 0.001). From PRE to POST, the percentage of Black patients increased from 35.0% to 38.3% (P = 0.01) and the percentage of Hispanic patients increased from 19.2% to 23.0% (P < 0.001). After a multivariable analysis, Asian patients experienced an independent increase in mortality from PRE to POST (odds ratio 2.00, 95% confidence interval 1.13-3.54, P = 0.02).

CONCLUSIONS

Penetrating trauma and mortality rates increased during the pandemic. There was a simultaneous increase in the percentage of Black and Hispanic trauma patients. Asian patient mortality increased significantly after the start of the pandemic independent of other variables. Identifying racial/ethnic disparities is the first step in finding ways to improve dissimilar outcomes.

LAPRA-TY for laparoscopic repair of traumatic diaphragmatic hernia without intracorporeal knot tying

Case Presentation

A 38-year-old man was brought in by ambulance as a trauma activation after sustaining a self-inflicted stab wound in the left upper quadrant with a kitchen knife. His primary survey was unremarkable and his vital signs were normal. Secondary survey revealed a 2 cm transverse stab wound inferior and medial to the left nipple. Extended focused assessment with sonography for trauma (FAST) did not show intra-abdominal or pericardial fluid and chest X-ray did not show a definite pneumothorax or hemothorax.

What would you do?

Wound exploration at bedside.Admit for observation and serial examinations.Exploratory laparotomy and open repair of traumatic diaphragmatic injury (TDI).Thoracotomy and open repair of TDI.Diagnostic laparoscopy and laparoscopic repair of TDI.

Trauma advanced practice provider programme development in an academic setting to optimize care coordination

Background

Benchmark data from the Trauma Quality Improvement Program (TQIP) identified an opportunity for improvement in our trauma programme. Our unexpected return to the intensive care unit (ICU) was found to be higher than the national averages and we also noticed that our readmission rate had increased. We chose to address these complications as continuous quality improvement projects. It was hypothesized that restructuring the workflow of the trauma advanced practice providers (APPs) to focus on the delivery of comprehensive clinical care would decrease return to ICU and readmission rates of trauma patients.

Methods

The development of the APP programme occurred from 2012 to 2014. First, APP daily shifts were extended to mirror the resident physicians’ coverage. Second, the APPs’ original job description was expanded from ‘task-oriented’ workflow to providing comprehensive clinical care. Third, the APPs were involved in the evaluation and decision-making process for transferring trauma patients from the ICU. Finally, the APPs implemented a new discharge process that included all information in a standardized format and a follow-up phone call 24–48 hours after discharge. The trauma registry at our verified, academic level I trauma center was use to assess our ICU and hospital readmission rates during the time we instituted the new APP workflow programme.

Results

In 2012, our ICU readmission rate was 5.7% (TQIP=1.9%) but then decreased to 4.4% in 2013 (TQIP=2.5%) and 2.1% in 2014 (TQIP=2.8%). Our hospital readmission rate was 2.0% in 2012 but then decreased to 1.38% and 0.96% over the next 2 years.

Conclusions

After extending the APP service coverage, implementing a comprehensive clinical care model and standardizing the discharge process, our unplanned return to ICU rates have decreased to below the TQIP national average and hospital readmission rates have also decreased by half.

Level of evidence

III.

Research: Testing of a Novel Portable Body Temperature Conditioner Using a Thermal Manikin

A battery-operated active cooling/heating device was developed to maintain thermoregulation of trauma victims in austere environments while awaiting evacuation to a hospital for further treatment. The use of a thermal manikin was adopted for this study in order to simulate load testing and evaluate the performance of this novel portable active cooling/heating device for both continuous (external power source) and battery power. The performance of the portable body temperature conditioner (PBTC) was evaluated through cooling/heating fraction tests to analyze the heat transfer between a thermal manikin and circulating water blanket to show consistent performance while operating under battery power. For the cooling/heating fraction tests, the ambient temperature was set to 15°C ± 1°C (heating) and 30°C ± 1°C (cooling). The PBTC water temperature was set to 37°C for the heating mode tests and 15°C for the cooling mode tests. The results showed consistent performance of the PBTC in terms of cooling/heating capacity while operating under both continuous and battery power. The PBTC functioned as intended and shows promise as a portable warming/cooling device for operation in the field.

The effect of shock resuscitation fluids on apoptosis

BACKGROUND

Recent data suggest that the type of resuscitation fluid used to treat hemorrhagic shock contributes to cellular dysfunction

METHODS

Rats were hemorrhaged, exposed to a hypovolemic shock period for 75 minutes, and then resuscitated for 1 hour. Treatment animals were assigned randomly to lactate Ringer's solution, normal saline solution, bicarbonate Ringer's solution, hypertonic saline solution, rat plasma solution, ketone Ringer's solution, or nonresuscitation. After resuscitation, lung and liver samples were collected and evaluated for apoptosis by using ligation-mediated polymerase chain reaction.

RESULTS

Nonresuscitated shock rats had significantly higher levels of apoptosis in lung and liver. Rats treated with normal saline solution, bicarbonate Ringer's solution, ketone Ringer's solution, and hypertonic saline solution had significantly lower levels of apoptosis in lung compared with nonresuscitated animals. Rats treated with bicarbonate Ringer's solution and ketone Ringer's solution had significantly lower levels of apoptosis in liver tissue when compared with nonresuscitated animals.

CONCLUSIONS

Cellular damage results from hemorrhagic shock. The use of resuscitation fluids decreases apoptosis during shock.