Barriers to Breastfeeding During Surgery Residency

OBJECTIVE

Breastfeeding is a highly demanding experience, especially for surgical residents who pump after returning to work. We believe that there are obstacles to pumping and opportunities exist to improve support for this group. The objective of this study was to understand the experience of breastfeeding surgery residents and find opportunities for increased support.

DESIGN

Surveys were sent out through the Association of Program Directors in Surgery for distribution among current residents. A survey was also conducted in a private group of surgeon mothers to identify those who had previously been breastfeeding during residency.

SETTING

All surveys were performed online with results collected in a REDCap web-based application.

PARTICIPANTS

Participants were those who gave birth during their surgical residency.

RESULTS

67% of the 246 survey respondents stated that they did not have adequate time for pumping and 56% rarely had access to a lactation room. 69% of mothers reported a reduction in milk supply and 64% stated that the time constraints of residency shortened the total duration they breastfed. 59% of women did not feel comfortable asking to pump.

CONCLUSIONS

Surgical residents reported a lack of space, resources, and dedicated time for pumping. These deficiencies contribute to shorter breastfeeding duration. It is crucial to provide lactation rooms and to foster a supportive culture.

Trends in prehospital cervical collar utilization in trauma patients: Closer, but not there yet

OBJECTIVE

This study aims to assess the change in cervical spine (C-spine) immobilization frequency in trauma patients over time. We hypothesize that the frequency of unnecessary C-spine immobilization has decreased.

METHODS

A retrospective chart review of adult trauma patients transported to our American College of Surgeons-verified Level I trauma center from January 1, 2014, to December 31, 2021, was performed. Emergency medical services documentation was manually reviewed to record prehospital physiology and the application of a prehospital cervical collar (c-collar). C-spine injuries were defined as cervical vertebral fractures and/or spinal cord injuries. Univariate and year-by-year trend analyses were used to assess changes in C-spine injury and immobilization frequency.

RESULTS

Among 2906 patients meeting inclusion criteria, 12% sustained C-spine injuries, while 88% did not. Patients with C-spine injuries were more likely to experience blunt trauma (95% vs. 68%, p < 0.001), were older (46 years vs. 41 years, p < 0.001), and had higher Injury Severity Scores (31 vs. 18, p < 0.001). They also exhibited lower initial systolic blood pressures (108 mm Hg vs. 119 mm Hg, p < 0.001), lower heart rates (92 beats/min vs. 97 beats/min, p < 0.05), and lower Glasgow Coma Scale scores (9 vs. 11, p < 0.001). In blunt trauma, c-collars were applied to 83% of patients with C-spine injuries and 75% without; for penetrating trauma, c-collars were applied to 50% of patients with C-spine injuries and only 8% without. Among penetrating trauma patients with C-spine injury, all patients either arrived quadriplegic or did not require emergent neurosurgical intervention. The proportion of patients receiving a c-collar decreased in both blunt and penetrating traumas from 2014 to 2021 (blunt-82% in 2014 to 68% in 2021; penetrating-24% in 2014 to 6% in 2021).

CONCLUSIONS

Unnecessary C-spine stabilization has decreased from 2014 to 2021. However, c-collars are still being applied to patients who do not need them, both in blunt and in penetrating trauma cases, while not being applied to patients who would benefit from them.

Sigh Ventilation in Patients With Trauma: The SiVent Randomized Clinical Trial

Importance

Among patients receiving mechanical ventilation, tidal volumes with each breath are often constant or similar. This may lead to ventilator-induced lung injury by altering or depleting surfactant. The role of sigh breaths in reducing ventilator-induced lung injury among trauma patients at risk of poor outcomes is unknown.

Objective

To determine whether adding sigh breaths improves clinical outcomes.

Design, Setting, and Participants

A pragmatic, randomized trial of sigh breaths plus usual care conducted from 2016 to 2022 with 28-day follow-up in 15 academic trauma centers in the US. Inclusion criteria were age older than 18 years, mechanical ventilation because of trauma for less than 24 hours, 1 or more of 5 risk factors for developing acute respiratory distress syndrome, expected duration of ventilation longer than 24 hours, and predicted survival longer than 48 hours.

Interventions

Sigh volumes producing plateau pressures of 35 cm H2O (or 40 cm H2O for inpatients with body mass indexes >35) delivered once every 6 minutes. Usual care was defined as the patient's physician(s) treating the patient as they wished.

Main Outcomes and Measures

The primary outcome was ventilator-free days. Prespecified secondary outcomes included all-cause 28-day mortality.

Results

Of 5753 patients screened, 524 were enrolled (mean [SD] age, 43.9 [19.2] years; 394 [75.2%] were male). The median ventilator-free days was 18.4 (IQR, 7.0-25.2) in patients randomized to sighs and 16.1 (IQR, 1.1-24.4) in those receiving usual care alone (P = .08). The unadjusted mean difference in ventilator-free days between groups was 1.9 days (95% CI, 0.1 to 3.6) and the prespecified adjusted mean difference was 1.4 days (95% CI, -0.2 to 3.0). For the prespecified secondary outcome, patients randomized to sighs had 28-day mortality of 11.6% (30/259) vs 17.6% (46/261) in those receiving usual care (P = .05). No differences were observed in nonfatal adverse events comparing patients with sighs (80/259 [30.9%]) vs those without (80/261 [30.7%]).

Conclusions and Relevance

In a pragmatic, randomized trial among trauma patients receiving mechanical ventilation with risk factors for developing acute respiratory distress syndrome, the addition of sigh breaths did not significantly increase ventilator-free days. Prespecified secondary outcome data suggest that sighs are well-tolerated and may improve clinical outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT02582957.

Rule of four: an anatomic and value-based approach to stent-graft inventory for blunt thoracic aortic injury

PURPOSE

As blunt thoracic aortic injury (BTAI) treatment has shifted from open to thoracic endovascular aortic repair (TEVAR), logistical challenges exist in creating and maintaining inventories of appropriately sized stent-grafts, including storage demands, shelf-life management and cost. We hypothesized that most injured aortas can be successfully repaired with a narrow range of stent-graft sizes and present a value-based anatomic approach to optimizing inventory.

METHODS

CT-scans of all patients with BTAI admitted to our Level I trauma center from Apr 2010-Dec 2018 were reviewed. Patients with anatomy incompatible with TEVAR were excluded. For each patient, after aortic sizing a set of two stent-grafts most likely to be utilized was selected from a list of twenty commercially available GORE conformable TAG endografts based on manufacturer instructions. Stent-graft sizes were then ranked based on the number of cases they would be suitable for. MATLAB was utilized to determine the combinations of stent-grafts which would cover the most patients.

RESULTS

Twenty-eight patients with BTAI were identified and three were excluded based on iliac diameter. Most patients were male (68%), mean age 42.3 ± 20.2 years, mean ISS 37.0 ± 9.8. Overall mortality was 25%. Of the 20 available stent-graft options, a combination of four stent-grafts would successfully treat 100% of the patients in this series.

CONCLUSIONS

Based on actual CT-scan aortic measurements, we demonstrated that an inventory of four sent-graft sizes was sufficient to treat 100% of patients with BTAI. These data can be utilized as a value-based anatomic approach to aortic stent-graft institutional inventory creation and maintenance.

Pediatric emergency resuscitative thoracotomy: A Western Trauma Association, Pediatric Trauma Society, and Eastern Association for the Surgery of Trauma collaborative critical decisions algorithm

LEVEL OF EVIDENCE

Literature synthesis and expert opinion, Level V.

Agitation in the Trauma Bay Is an Early Indicator of Hemorrhagic Shock

INTRODUCTION

Agitation on arrival in trauma patients is known as a sign of impending demise. The aim of this study is to determine outcomes for trauma patients who present in an agitated state. We hypothesized that agitation in the trauma bay is an early indicator for hemorrhage in trauma patients.

METHODS

We performed a single-institution prospective observational study from September 2018 to December 2020 that included any trauma patient who arrived agitated, defined as a Richmond Agitation-Sedation Scale of +1 to +4. Variables collected included demographics, mechanism of injury, admission physiology, blood alcohol level, toxicity screen, and injury severity. The primary outcomes were need for massive transfusion (≥ 10 units) and need for emergent therapeutic intervention for hemorrhage control (laparotomy, preperitoneal pelvic packing, sternotomy, thoracotomy, or angioembolization).

RESULTS

Of 4657 trauma admissions, 77 (2%) patients arrived agitated. Agitated patients were younger (40 versus 46, P = 0.03), predominantly male (94% versus 66%, P < 0.0001) sustained more penetrating trauma (31% versus 12%, P < 0.0001), had a lower systolic blood pressure (127 versus 137, P < 0.0001), and a higher Injury Severity Score (17 versus 9, P < 0.0001). On multivariable logistic regression, agitation was independently associated with massive transfusion (odds ratio: 2.63 [1.20-5.77], P = 0.02) and emergent therapeutic intervention for hemorrhage control (odds ratio: 2.60 [1.35-5.03], P = 0.005).

CONCLUSIONS

Agitation in trauma patients may serve as an early indicator of hemorrhagic shock, as agitation is independently associated with a two-fold increase in the need for massive transfusion and emergent therapeutic intervention for hemorrhage control.

Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm

ABSTRACT

This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians.

LEVEL OF EVIDENCE

Consensus algorithm from the Western Trauma Association, Level V.

A national trauma data bank analysis of large animal-related injuries

INTRODUCTION

Large animal-related injuries (LARI) are relatively uncommon, but, nevertheless, a public hazard. The objective of this study was to better understand LARI injury patterns and outcomes.

MATERIALS AND METHODS

We performed a retrospective review of the 2016 National Trauma Data Bank and used ICD-10 codes to identify patients injured by a large animal. The primary outcome was severe injury pattern, while secondary outcomes included mortality, hospital length of stay, ICU admission, and mechanical ventilation usage.

RESULTS

There were 6,662 LARI included in our analysis. Most LARI (66%) occurred while riding the animal, and the most common type of LARI was fall from horse (63%). The median ISS was 9 and the most severe injuries (AIS ≥ 3) were to the chest (19%), head (10%), and lower extremities (10%). The overall mortality was low at 0.8%. Compared to non-riders, riders sustained more severe injuries to the chest (21% vs. 16%, p<0.001) and spine (4% vs. 2%, p<0.001). Compared to motor vehicle collisions (MVC), riders sustained fewer severe injuries to the head (10% vs. 12%, p<0.001) and lower extremity (10% vs. 12%, p=0.01). Compared to auto-pedestrian accidents, non-riders sustained fewer severe injuries to the head (11% vs. 19%, p<0.001) and lower extremity (10% vs. 20%, p<0.001).

CONCLUSION

Patients involved in a LARI are moderately injured with more complex injuries occurring in the chest, head, and lower extremities. Fall from horse was the most common LARI mechanism. Overall mortality was low. Compared to non-riders, riders were more likely to sustain severe injuries to the chest and spine. Severe injury patterns were similar when comparing riders to MVC and, given that most LARI are riding injuries, we recommend trauma teams approach LARI as they would an MVC.

A multicenter investigation of the hemodynamic effects of induction agents for trauma rapid sequence intubation

BACKGROUND

Several options exist for induction agents during rapid sequence intubation (RSI) in trauma patients, including etomidate, ketamine, and propofol. These drugs have reported variable hemodynamic effects (hypotension with propofol and sympathomimetic effects with ketamine) that could affect trauma resuscitations. The purpose of this study was to compare the hemodynamic effects of these three induction agents during emergency department RSI in adult trauma. We hypothesized that these drugs would display a differing hemodynamic profile during RSI.

METHODS

We performed a retrospective (2014-2019), multicenter trial of adult (≥18 years) trauma patients admitted to eight ACS-verified Level I trauma centers who underwent emergency department RSI. Variables collected included systolic blood pressure (SBP) and pulse before and after RSI. The primary outcomes were change in heart rate and SBP before and after RSI.

RESULTS

There were 2,092 patients who met criteria, 85% received etomidate (E), 8% ketamine (K), and 7% propofol (P). Before RSI, the ketamine group had a lower SBP (E, 135 vs. K, 125 vs. P, 135 mm Hg, p = 0.04) but there was no difference in pulse (E, 104 vs. K, 107 vs. P, 105 bpm, p = 0.45). After RSI, there were no differences in SBP (E, 135 vs. K, 130 vs. P, 133 mm Hg, p = 0.34) or pulse (E, 106 vs. K, 110 vs. P, 104 bpm, p = 0.08). There was no difference in the average change of SBP (E, 0.2 vs. K, 5.2 vs. P, -1.8 mm Hg, p = 0.4) or pulse (E, 1.7 vs. K, 3.5 bpm vs. P, -0.96, p = 0.24) during RSI.

CONCLUSION

Contrary to our hypothesis, there was no difference in the hemodynamic effect for etomidate versus ketamine versus propofol during RSI in trauma patients.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Cerebrospinal Fluid Cultures in Traumatic Brain Injury: Is It Worth It? A Two-Center Study

Background: Patients with traumatic brain injury (TBI) frequently develop leukocytosis, fever, and tachycardia that may lead to extensive medical investigations to rule out an infectious process. Cerebrospinal fluid (CSF) is often acquired during this workup, however, the utility of this practice has not been studied previously. We hypothesized that CSF cultures would unlikely yield positive results in patients with TBI. Patients and Methods: A retrospective review was conducted of all patients with TBI admitted to two level 1 trauma centers at urban, academic institutions from January 2009 to December 2016. Data collected included patient demographics, presenting Glasgow Coma Score (GCS), injury profile, injury severity scores (ISS), regional abbreviated injury scale (AIS), hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, and culture results. For purposes of the analysis, CSF cultures with Staphylococcus epidermidis, Staphylococcus aureus, or Candida underwent a chart review and were considered contaminates if indicated. Results: There were 145 patients who had CSF cultures obtained with a median age of 39 years; 77.2% were male. The majority of patients presented after blunt trauma with median GCS of 6, head AIS of 4, and ISS of 25. These patients had prolonged median ICU and hospital stays at 13 and 22 days, respectively. Six (4.1%) CSF cultures demonstrated growth. Four (2.8%) were deemed contaminants, with two growing Staphylococcus epidermidis only, one with both Staphylococcus epidermidis and Staphylococcus aureus, and one with Candida. Two cultures (1.4%) were positive and grew Enterobacter cloacae. Of note, both patients had prior instrumentation with an external ventricular drain. Conclusion: Obtaining CSF cultures in patients with TBI is of low yield, especially in patients without prior external ventricular drain. Other sources of infectious etiologies should be considered in this patient population.

Chest and Pelvis X-Rays as a Screening Tool for Abdominal Injury in Geriatric Blunt Trauma Patients

BACKGROUND

This study evaluates the utility of chest (CXR) and pelvis (PXR) X-ray, as adjuncts to the primary survey, in screening geriatric blunt trauma (GBT) patients for abdominal injury or need for laparotomy.

METHODS

We performed a retrospective analysis of patients 65-89 years in the 2014 National Trauma Data Bank. X-ray injuries were identified by ICD9 codes and defined as any injury felt to be readily detectable by a non-radiologist. X-ray findings were dichotomized as "both negative" (no injury presumptively apparent on CXR or PXR) or "either positive" (any injury presumptively apparent on CXR or PXR). Rates of abdominal injuries and laparotomy were compared and used to calculate sensitivity and specificity. The primary outcomes were abdominal injury and laparotomy. The secondary outcomes included mortality, ventilator days, and hospital days.

RESULTS

A total of 202 553 patients met criteria. Overall, 9% of patients with either positive X-rays had abdominal injury and 2% laparotomy vs. 1.1% and .3% with both negative (P < .001). The specificity for any positive X-ray was 79% for abdominal injury and 78% for laparotomy. The sensitivity was 69% for abdominal injury and laparotomy. The either positive group had fewer ventilator days (.3 vs. .8, P < .0001), longer length of stay (7 vs. 5, P < .0001), and higher mortality (6% vs. 4%, P < .0001) vs both negative.

CONCLUSION

CXR and PXR can be used to assess for intra-abdominal injury and need for laparotomy. GBT patients with either positive X-rays should continue workup regardless of mechanism due to the high specificity of this tool for abdominal injury and need for laparotomy.

Risk scoring models fail to predict pulmonary embolism in trauma patients

BACKGROUND

We aimed to identify risk factors and risk scoring models to help identify post-traumatic pulmonary embolisms (PE).

METHODS

We performed a retrospective review (2014-2019) of all adult trauma patients admitted to our Level I trauma center that received a CT pulmonary angiogram (CTPA) for a suspected PE. A systematic literature search found eleven risk scoring models, all of which were applied to these patients. Scores of patients with and without PE were compared.

RESULTS

Of the 235 trauma patients that received CTPA, 31 (13%) showed a PE. No risk scoring model had both a sensitivity and specificity above 90%. The Wells Score had the highest area under the curve (0.65). After logistic regression, no risk scoring model variables were independently associated with PE.

CONCLUSIONS

In trauma patients with clinically suspected PE, clinical variables and current risk scoring models do not adequately differentiate patients with and without PE.

Platelet Dysfunction after Traumatic Brain Injury: A Review

Coagulopathy is a known sequela of traumatic brain injury (TBI) and can lead to increased morbidity and mortality. Platelet dysfunction has been identified as one of several etiologies of coagulopathy following TBI and has been associated with poor outcomes. Regardless of whether the platelet dysfunction occurs as a direct consequence of the injury or because of pre-existing medical comorbidities or medication use, accurate detection and monitoring of response to therapy is key to optimal patient care. Platelet transfusion has been proposed as a potential therapeutic intervention to treat platelet dysfunction, with several studies using platelet function assays to monitor response. The development of increasingly precise diagnostic testing is providing enhanced understanding of the specific derangement in the hemostatic process, allowing clinicians to provide patient-specific treatment plans. There is wide variability in the currently available literature on the incidence and clinical significance of platelet dysfunction following TBI, which creates challenges with developing evidence-based management guidelines. The relatively high prevalence of platelet inhibitor therapy serves as an additional confounding factor. In addition, the data are largely retrospective in nature. We performed a literature review to provide clarity on this clinical issue. We reviewed 348 abstracts, and included 97 manuscripts in our final literature review. Based on the currently available research, platelet dysfunction has been consistently demonstrated in patients with moderate-severe TBI. We recommend the use of platelet functional assays to evaluate patients with TBI. Platelet transfusion directed at platelet dysfunction may lead to improved clinical outcome. A randomized trial guided by implementation science could improve the applicability of these practices.

Modifiable factors to improve work-life balance for trauma surgeons

INTRODUCTION

A balance between work and life outside of work can be difficult for practicing physicians to achieve, especially for trauma surgeons. Work-life balance (WLB) has been associated with burnout and career changes. The specific aim of this study was to investigate factors associated with WLB for trauma surgeons. We hypothesized that trauma surgeons are dissatisfied with their WLB, and there are modifiable factors that can be adjusted to improve and maintain WLB.

METHODS

Survey study of AAST members including detailed questions regarding demographics, clinical practice, family, lifestyle, and emotional support. Primary outcome was WLB, while the secondary outcome was surgeon burnout.

RESULTS

A total of 1,383 American Association for the Surgery of Trauma members received an email with the survey, and 291 (21%) completed the survey. There was a total of 125 members (43%) satisfied with their WLB, and 166 (57%) were not. Factors independently associated with satisfying WLB included hobbies (2.3 [1.1-4.7], p = 0.03), healthy diet (2.6 [1.2-4.4], p = 0.02), exercise (2.6 [1.3-5.1], p = 0.006), vacation weeks off (1.3 [1.0-1.6], p = 0.02), and fair compensation (2.6 [1.3-5.3], p = 0.008). Conversely, factors independently associated with a poor WLB included being midcareer (0.3 [0.2-0.7], p = 0.002), more work hours (0.4 [0.2-0.7], p = 0.006), fewer awake hours at home (0.2 [0.1-0.6], p = 0.002), and feeling that there is a better job (0.4 [0.2-0.9], p = 0.02]. Risk factors for burnout were the same as those for poor WLB.

CONCLUSION

Only 43% of trauma surgeons surveyed were satisfied with their WLB, and 61% reported burnout. Modifiable factors independently associated with a satisfying WLB were related to lifestyle and fair compensation. Factors independently associated with poor WLB and suffering burnout were being midcareer, increased hours at work, decreased awake hours at home, and feeling that there was a better job for yourself. Many factors associated with trauma surgeon WLB are modifiable. Trauma surgeons, as well as trauma leaders, should focus on these modifiable factors to optimize WLB and minimize burnout.

LEVEL OF EVIDENCE

Care management, Level III.

Does preoperative magnetic resonance imaging alter the surgical plan in patients with acute traumatic cervical spinal cord injury?

BACKGROUND

Whether magnetic resonance imaging (MRI) adds value to surgical planning for patients with acute traumatic cervical spinal cord injury (ATCSCI) remains controversial. In this study, we compared surgeons' operative planning decisions with and without preoperative MRI. We had two hypotheses: (1) the surgical plan for ATCSCI would not change substantially after the MRI and (2) intersurgeon agreement on the surgical plan would also not change substantially after the MRI.

METHODS

We performed a vignette-based survey study that included a retrospective review of all adult trauma patients who presented to our American College of Surgeons-verified level 1 trauma center from 2010 to 2019 with signs of acute quadriplegia and underwent computed tomography (CT), MRI, and subsequent cervical spine surgery within 48 hours of admission. We abstracted patient demographics, admission physiology, and injury details. Patient clinical scenarios were presented to three spine surgeons, first with only the CT and then, a minimum of 2 weeks later, with both the CT and MRI. At each presentation, the surgeons identified their surgical plan, which included timing (none, <8, <24, >24 hours), approach (anterior, posterior, circumferential), and targeted vertebral levels. The outcomes were change in surgical plan and intersurgeon agreement. We used Fleiss' kappa (κ) to measure intersurgeon agreement.

RESULTS

Twenty-nine patients met the criteria and were included. Ninety-three percent of the surgical plans were changed after the MRI. Intersurgeon agreement was "slight" to "fair" both before the MRI (timing, κ = 0.22; approach, κ = 0.35; levels, κ = 0.13) and after the MRI (timing, κ = 0.06; approach, κ = 0.27; levels, κ = 0.10).

CONCLUSION

Surgical plans for ATCSCI changed substantially when the MRI was presented in addition to the CT; however, intersurgeon agreement regarding the surgical plan was low and not improved by the addition of the MRI.

LEVEL OF EVIDENCE

Diagnostic, level II.

A Prospective Study of Family Satisfaction Changes After Tracheostomy Placement in Trauma Patients

BACKGROUND

Tracheostomy is a commonly performed procedure in surgical intensive care units. Although the indications and benefits of this procedure are well known, little has been studied in the adult surgical/trauma population about patient family satisfaction after tracheostomy placement.

MATERIALS AND METHODS

We performed a prospective study at our academic level I trauma center from 2015-2016 in patients who underwent elective tracheostomy. Family members were asked to complete an eight-point questionnaire using a forced Likert scale of graded responses. Questionnaires were administered prior to tracheostomy and again at 24-and 72-hour post-tracheostomy placement. Responses were compared using univariate analysis.

RESULTS

A total of 26 family members completed all 3 surveys. Family members believed loved ones appeared more comfortable, were more interactive, and were better progressing clinically. After 72 hours, family members felt less anxiety. There was no difference in perceptions of patient distress, ability to provide support, or their worry about scars, or comfort in visiting them.

DISCUSSION

Family members believed tracheostomies provided greater patient comfort, increased interactive abilities, better progress in their care, and experienced less anxiety after placement. Family satisfaction may therefore be an additional benefit in support of earlier tracheostomy.

Risk Factors for Failure of Splenic Angioembolization: A Multicenter Study of Level I Trauma Centers

BACKGROUND

Angioembolization (AE) is an adjunct to nonoperative management (NOM) of splenic injuries. We hypothesize that failure of AE is associated with blood transfusion, grade of injury, and technique of AE.

METHODS

We performed a retrospective (2010-2017) multicenter study (nine Level I trauma centers) of adult trauma patients with splenic injuries who underwent splenic AE. Variables included patient physiology, injury grade, transfusion requirement, and embolization technique. The primary outcome was NOM failure requiring splenectomy. Secondary outcomes were mortality, complications, and length of stay.

RESULTS

A total of 409 patients met inclusion criteria; only 33 patients (8%) required delayed splenectomy. Patients who failed received more blood in the first 24 h (P = 0.009) and more often received massive transfusion (P = 0.01). There was no difference in failure rates for grade of injury, contrast blush on computed tomography, and branch embolized. After logistic regression, transfusion in the first 24 h was independently associated with failure of NOM (P = 0.02). Patients who failed NOM had more complications (P = 0.002) and spent more days in the intensive care unit (P < 0.0001), on the ventilator (P = 0.0001), and in the hospital (P < 0.0001). Patients who failed NOM had a higher mortality (15% versus 3%, P = 0.007), and delayed splenectomy was independently associated with mortality (odds ratio, 4.2; 95% confidence interval, 1.2-14.7; P = 0.03).

CONCLUSIONS

AE for splenic injury leads to effective NOM in 92% of patients. Transfusion in the first 24 h is independently associated with failure of NOM. Patients who required a delayed splenectomy suffered more complications and had higher hospital length of stay. Failure of NOM is independently associated with a fourfold increase in mortality.

The characteristics of dockless electric rental scooter-related injuries in a large U.S. city

OBJECTIVE

To describe the characteristics of dockless electric rental scooter ("e-scooter")-related injuries presenting to two emergency departments in one large U.S. city.

METHODS

This observational cohort study utilized the city's public health syndromic surveillance system to prospectively identify patients with e-scooter-related injuries presenting between September and November 2018. The medical records for all adult patients treated at the two participating emergency departments were manually reviewed to extract demographic and clinical data. Cases involving mobility scooters or non-electric scooters were excluded.

RESULTS

For the 124 included adult patients with e-scooter-related injuries, the median age was 30 years (IQR: 22-43), they were predominantly male (59.7%), and approximately half (51.6%) arrived by ambulance. Falling from the scooter (84.7%) was the most common mechanism; twelve patients (9.7%) had collided with a motor vehicle. Head and face injuries (45.5%) were common; only 2 patients (1.6%) were documented as wearing a helmet at the time of injury. Most patients (n = 112, 90.3%) required imaging, more than half (n = 78, 62.9%) required an emergency department procedure, and 26 (21.0%) required surgical intervention. Most patients were discharged home, but 35 (28.2%) were admitted to hospital. Two patients (1.6%) were admitted to the intensive care unit.

CONCLUSIONS

E-scooters are an emerging transportation technology associated with a wide range of potentially serious injuries that consume substantial emergency department and hospital resources. Head injuries are a particular concern, as few e-scooter riders are wearing helmets at the time of injury.

Risk Factors for Falls among Hospitalized Trauma Patients

Inpatient falls lead to an injury in 30 per cent of cases and serious injury in 5 per cent. Increasing staffing and implementing fall prevention programs can be expensive and require a significant use of resources. We hypothesized that trauma patients have unique risk factors to sustain a fall while hospitalized. This is a retrospective cohort study from 2005 to 2010 of all trauma patients admitted to an urban Level I trauma center. Patients who fell while hospitalized were compared with patients who did not fall to identify risk factors for sustaining an inpatient fall. There were 16,540 trauma patients admitted during the study period and 128 (0.8%) fell while hospitalized. Independent risk factors for a trauma patient to fall while hospitalized included older age (odds ratio [OR], 1.02 [1.01 to 1.03], P < 0.001), male gender (OR, 1.6 [1.0 to 2.4], P = 0.03), blunt mechanism (OR, 5.1 [1.6 to 16.3], P = 0.006), Glasgow Coma Score at admission (OR, 0.59 [0.35 to 0.97], P = 0.04), intensive care unit admission (OR, 2.3 [1.4 to 3.7], P = 0.001), and need for mechanical ventilation (OR, 2.2 [1.2 to 3.9], P = 0.01). Trauma patients who fell while hospitalized sustained an injury in 17 per cent of cases and a serious injury in 5 per cent. Inpatient falls in hospitalized trauma patients are uncommon. Risk factors include older age, male gender, blunt mechanism, lower Glasgow Coma Score, and the need for intensive care unit admission or mechanical ventilation. Trauma patients with these risk factors may require higher staffing ratios and should be enrolled in a formal fall prevention program.

Occupational traumatic injuries rarely affect genitourinary organs: a retrospective, comparative study

PURPOSE

To determine the mechanisms of injury associated with occupational injuries (OI) to genitourinary (GU) organs and compare GU OIs with GU non-OIs.

METHODS

A single institution, retrospective study was conducted at a level 1 trauma center between 2010 and 2016 of all patients with GU injuries. OI was defined as any traumatic event that occurred in the workplace requiring hospital admission. Types of occupations were recorded in addition to the location of injury, mechanisms of injury, concomitant injuries, operative interventions, total cost, and mortality. GU OI patients were then compared to GU non-OI patients.

RESULTS

623 patients suffered a GU injury, of which 39 (6.3%) had a GU OI. Fall (43%) was the most common mechanism of injury; followed by motor vehicle collision/motorcycle crash (31%), crush injury (18%), and pedestrian struck (8%). The adrenal gland (38%) and kidney (38%) were the most commonly injured organs. There was no difference in mortality (13% GU OI vs. 15% GU non-OI, p = 0.70) or total direct cost ($21,192 ± 28,543 GU OI vs. $28,215 ± 32,332 GU non-OI, p = 0.45). Total costs were decreased with mortality from a GU injury (odds ratio (OR) 0.3, CI 0.26-0.59; p = < 0.001) and increased with higher injury severity scores (OR 1.1, CI 1.09-1.2; p = < 0.0001). Total costs were not affected by OI status.

CONCLUSIONS

Occupational GU trauma presents with similar patterns of injury, hospital course, and direct cost as GU trauma that occurs in non-occupational settings.

Rib Fractures and Mortality: Breaking the Causal Relationship

Rib fractures have long been considered as a major contributor to mortality in the blunt trauma patient. We hypothesized that rib fractures can be an excellent predictor of mortality, but rarely contribute to cause death. We performed a retrospective study (2008-2015) of blunt trauma patients admitted to our urban, Level I trauma center with one or more rib fractures. Medical records were reviewed in detail. Rib fracture deaths were those from any respiratory sequelae or hemorrhage from rib fractures. There were 4413 blunt trauma patients who sustained one or more rib fractures and 295 (6.8%) died. Rib fracture patients who died had a mean Injury Severity Score = 38 and chest Abbreviated Injury Score = 3.4. Rib fractures were the cause of death in only 21 patients (0.5%). After excluding patients who were dead on arrival, patients dying as a result of their rib fractures were found to be older (P < 0.0001) and had a higher admission respiratory rate (P = 0.02). Multivariable logistic regression found that age ≥65 was the only variable independently associated with mortality directly related to rib fractures (odds ratio 4.1, 95% confidence interval = 1.3-13.3, P value < .0001). Mortality in patients with rib fractures is uncommon (7%), and mortality directly related to rib fractures is rare (0.5%). Older patients are four times more likely to die as a direct result of rib fractures and may require additional resources to avoid mortality.

Fatal crashes in the 5 years after recreational marijuana legalization in Colorado and Washington

Colorado and Washington legalized recreational marijuana in 2012, but the effects of legalization on motor vehicle crashes remains unknown. Using Fatality Analysis Reporting System data, we performed difference-in-differences (DD) analyses comparing changes in fatal crash rates in Washington, Colorado and nine control states with stable anti-marijuana laws or medical marijuana laws over the five years before and after recreational marijuana legalization. In separate analyses, we evaluated fatal crash rates before and after commercial marijuana dispensaries began operating in 2014. In the five years after legalization, fatal crash rates increased more in Colorado and Washington than would be expected had they continued to parallel crash rates in the control states (+1.2 crashes/billion vehicle miles traveled, CI: -0.6 to 2.1, p = 0.087), but not significantly so. The effect was more pronounced and statistically significant after the opening of commercial dispensaries (+1.8 crashes/billion vehicle miles traveled, CI: +0.4 to +3.7, p = 0.020). These data provide evidence of the need for policy strategies to mitigate increasing crash risks as more states legalize recreational marijuana.

Rectal Injury After Foreign Body Insertion: Secondary Analysis From the AAST Contemporary Management of Rectal Injuries Study Group

BACKGROUND

Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion.

METHODS

Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative).

RESULTS

After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management.

CONCLUSIONS

Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.

Risk stratification tools in emergency general surgery

The use of risk stratification tools (RST) aids in clinical triage, decision making and quality assessment in a wide variety of medical fields. Although emergency general surgery (EGS) is characterized by a comorbid, physiologically acute patient population with disparately high rates of perioperative morbidity and mortality, few RST have been explicitly examined in this setting. We examined the available RST with the intent of identifying a tool that comprehensively reflects an EGS patients perioperative risk for death or complication. The ideal tool would combine individualized assessment with relative ease of use. Trauma Scoring Systems, Critical Care Scoring Systems, Surgical Scoring Systems and Track and Trigger Models are reviewed here, with the conclusion that Emergency Surgery Acuity Score and the American College of Surgeons National Surgical Quality Improvement Programme Universal Surgical Risk Calculator are the most applicable and appropriate for EGS.

Acute Alcohol Use, History of Homelessness, and Intent of Injury Among a Sample of Adult Emergency Department Patients

BACKGROUND

The literature is clear that adults who are currently homeless also have higher rates of intentional injuries, such as assault and suicide attempts. No study has assessed whether intentional injuries are exacerbated because of substance use among adults with a history of homelessness.

METHODS

Data were obtained from a cohort of adults admitted to 3 urban emergency departments (EDs) in Texas from 2007 to 2010 (N = 596). Logistic regression analyses were used to determine whether a history of homelessness was associated with alcohol use at time of injury in intentional violent injuries (gunshot, stabbing, or injury consistent with assault).

RESULTS

39% adults with a history of homelessness who were treated at trauma centers for a violent injury. Bivariate analyses indicated that adults who had ever experienced homelessness have 1.67 increased odds, 95% confidence interval (CI) [1.11, 2.50], of any intentional violent injury and 1.95 increased odds (95% CI [1.12, 3.40]) of a stabbing injury than adults with no history of homelessness.

CONCLUSIONS

Adults who experienced homelessness in their lifetime were more likely to visit EDs for violencerelated injuries. Given our limited knowledge of the injuries that prompt ED use by currently homeless populations, future studies are needed to understand the etiology of injuries, and substance-related injuries specifically, among adults with a history of homelessness.

Crash Fatality Rates After Recreational Marijuana Legalization in Washington and Colorado

OBJECTIVES

To evaluate motor vehicle crash fatality rates in the first 2 states with recreational marijuana legalization and compare them with motor vehicle crash fatality rates in similar states without recreational marijuana legalization.

METHODS

We used the US Fatality Analysis Reporting System to determine the annual numbers of motor vehicle crash fatalities between 2009 and 2015 in Washington, Colorado, and 8 control states. We compared year-over-year changes in motor vehicle crash fatality rates (per billion vehicle miles traveled) before and after recreational marijuana legalization with a difference-in-differences approach that controlled for underlying time trends and state-specific population, economic, and traffic characteristics.

RESULTS

Pre-recreational marijuana legalization annual changes in motor vehicle crash fatality rates for Washington and Colorado were similar to those for the control states. Post-recreational marijuana legalization changes in motor vehicle crash fatality rates for Washington and Colorado also did not significantly differ from those for the control states (adjusted difference-in-differences coefficient = +0.2 fatalities/billion vehicle miles traveled; 95% confidence interval = -0.4, +0.9).

CONCLUSIONS

Three years after recreational marijuana legalization, changes in motor vehicle crash fatality rates for Washington and Colorado were not statistically different from those in similar states without recreational marijuana legalization. Future studies over a longer time remain warranted.

Hospital Characteristics Affect Consent and Conversion Rates for Potential Organ Donors

Consent and conversion rates of potential organ donors in the United States need to be maximized to match the number of individuals awaiting organ donation. Studies to date have not focused on characteristics of centers with better outcomes. We performed an 8-year (2006-2014) retrospective study of our local organ procurement organization database. We categorized hospitals in our region as academic centers versus nonacademic centers, trauma centers versus nontrauma centers, and large (≥400 beds) centers versus small (<400 beds) centers. We also compared trauma centers with Level I designation to all other centers. Primary outcomes included consent and conversion rates for potential organ donors. There were 22,732 referrals to our organ procurement organization that resulted in 1,057 eligible deaths. When comparing academic to nonacademic hospitals, academic hospitals had higher consent (71% vs 59%, P < 0.0001) and conversion (73% vs 64%, P = 0.008) rates. Level I trauma centers had better consent and conversion rates when compared to all other hospitals, 73 versus 55 per cent and 76 versus 61 per cent respectively, P < 0.0001 for both. The small, academic, trauma centers had the highest consent and conversion rates, 77 and 78 per cent, respectively, P < 0.0001 for both. Hospital characteristics such as academic involvement, Level I trauma designation, and size impact consent and conversion rates for potential organ donors. Small (<400 bed), academic, trauma centers have the highest consent rates and conversion rates. Factors for success in these institutions should be examined and applied to assist in improving donor rates across all types of hospitals.

PTSD in those who care for the injured

BACKGROUND

Post Traumatic Stress Disorder (PTSD) has become a focus for the care of trauma victims, but the incidence of PTSD in those who care for injured patients has not been well studied. Our hypothesis was that a significant proportion of health care providers involved with trauma care are at risk of developing PTSD.

METHODS

A system-wide survey was applied using a modified version of the Primary Care PTSD Screen [PC-PTSD], a validated PTSD screening tool currently being used by the VA to screen veterans for PTSD. Pre-hospital and in-hospital care providers including paramedics, nurses, trauma surgeons, emergency medicine physicians, and residents were invited to participate in the survey. The survey questionnaire was anonymously and voluntarily performed online using the Qualtrix system. Providers screened positive if they affirmatively answered any three or more of the four screening questions and negative if they answered less than three questions with a positive answer. Respondents were grouped by age, gender, region, and profession.

RESULTS

546 providers answered all of the survey questions. The screening was positive in 180 (33%) and negative in 366 (67%) of the responders. There were no differences observed in screen positivity for gender, region, or age. Pre-hospital providers were significantly more likely to screen positive for PTSD compared to the in-hospital providers (42% vs. 21%, P<0.001). Only 55% of respondents had ever received any information or education about PTSD and only 13% of respondents ever sought treatment for PTSD.

CONCLUSION

The results of this survey are alarming, with high proportions of healthcare workers at risk for PTSD across all professional groups. PTSD is a vastly underreported entity in those who care for the injured and could potentially represent a major problem for both pre-hospital and in-hospital providers. A larger, national study is warranted to verify these regional results.

A Comprehensive Investigation of Comorbidities, Mechanisms, Injury Patterns, and Outcomes in Geriatric Blunt Trauma Patients

The geriatric population is growing and trauma providers are often tasked with caring for injuries in the elderly. There is limited information regarding injury patterns in geriatric trauma patients stratified by mechanism of injury. This study intends to investigate the comorbidities, mechanisms, injury patterns, and outcomes in geriatric blunt trauma patients. A retrospective study of the 2012 National Trauma Databank was performed. Adult blunt trauma patients were identified; geriatric (>/=65) patients were compared with younger (<65) patients regarding admission demographics and vital signs, mechanism and severity of injury, and comorbidities. The primary outcome was injuries sustained and secondary outcomes included mortality, length of stay in the intensive care unit and hospital, and ventilator days. There were 589,830 blunt trauma patients who met the inclusion criteria, including 183,209 (31%) geriatric and 406,621 (69%) nongeriatric patients. Falls were more common in geriatric patients (79 vs 29%, P < 0.0001). Geriatric patients less often had an Injury Severity Score >/=16 (18 vs 20%, P < 0.0001) but more often a head Abbreviated Injury Scale >/=3 (24 vs 18%, P < 0.0001) and lower extremity Abbreviated Injury Scale >/=3 (24% vs 8%, P < 0.0001). After logistic regression older age was an independent risk factor for mortality for the overall population and across all mechanisms. Falls are the most common mechanism for geriatric trauma patients. Geriatric patients overall present with a lower Injury Severity Score, but more often sustain severe injuries to the head and lower extremities. Injury patterns vary significantly between older and younger patients when stratified by mechanism. Mortality is significantly higher for geriatric trauma patients and older age is independently associated with mortality across all mechanisms.

A Comprehensive Investigation of Comorbidities, Mechanisms, Injury Patterns, and Outcomes in Geriatric Blunt Trauma Patients

The geriatric population is growing and trauma providers are often tasked with caring for injuries in the elderly. There is limited information regarding injury patterns in geriatric trauma patients stratified by mechanism of injury. This study intends to investigate the comorbidities, mechanisms, injury patterns, and outcomes in geriatric blunt trauma patients. A retrospective study of the 2012 National Trauma Databank was performed. Adult blunt trauma patients were identified; geriatric (>/=65) patients were compared with younger (<65) patients regarding admission demographics and vital signs, mechanism and severity of injury, and comorbidities. The primary outcome was injuries sustained and secondary outcomes included mortality, length of stay in the intensive care unit and hospital, and ventilator days. There were 589,830 blunt trauma patients who met the inclusion criteria, including 183,209 (31%) geriatric and 406,621 (69%) nongeriatric patients. Falls were more common in geriatric patients (79 vs 29%, P < 0.0001). Geriatric patients less often had an Injury Severity Score >/=16 (18 vs 20%, P < 0.0001) but more often a head Abbreviated Injury Scale >/=3 (24 vs 18%, P < 0.0001) and lower extremity Abbreviated Injury Scale >/=3 (24% vs 8%, P < 0.0001). After logistic regression older age was an independent risk factor for mortality for the overall population and across all mechanisms. Falls are the most common mechanism for geriatric trauma patients. Geriatric patients overall present with a lower Injury Severity Score, but more often sustain severe injuries to the head and lower extremities. Injury patterns vary significantly between older and younger patients when stratified by mechanism. Mortality is significantly higher for geriatric trauma patients and older age is independently associated with mortality across all mechanisms.

Adenosine diphosphate platelet dysfunction on thromboelastogram is independently associated with increased morality in traumatic brain injury

PURPOSE

The purpose of this study is to determine if adenosine diphosphate (ADP) platelet dysfunction on thromboelastogram (TEG) is associated with increased in-hospital mortality in patients with head trauma. The hypothesis is that ADP dysfunction is associated with increased mortality.

METHODS

This retrospective review evaluated trauma patients admitted to a level 1 trauma center from February 2011 to October 2013 who received a TEG. Patients were included if the TEG was drawn within the first 24 h of admission and the head abbreviated injury score was greater than or equal to three. Patients were categorized as severe ADP dysfunction if the degree of ADP inhibition on TEG exceeded 60 %.

RESULTS

A total of 90 patients were included (no ADP dysfunction n = 37; ADP dysfunction n = 53). Initial Glasgow Coma Scale [GCS (12 ± 4 vs. 11 ± 5; p = 0.26)] and use of pre-injury antiplatelet agents (30 vs. 28 %; p = 0.88) were similar. Patients with ADP dysfunction on TEG had a higher in-hospital mortality rate (8 vs. 32 %; p < 0.01). ADP dysfunction was independently associated with in-hospital mortality upon fixed logistic regression (OR 6.2; 95 % CI 1.2-33) while controlling for age, gender, hypotension, pre-injury antiplatelet agents, GCS and Injury Severity Score.

CONCLUSION

ADP dysfunction on TEG is associated with increased mortality in patients with traumatic brain injury.

Thromboelastography Does Not Detect Preinjury Antiplatelet Therapy in Acute Trauma Patients

Thromboelastography (TEG) with platelet mapping has been proposed as an assay to detect the presence of antiplatelet agents (APA), yet no study has evaluated TEG markers of platelet dysfunction in acute trauma patients stratified by the use of preinjury APA. We hypothesized that patients on preinjury APA would demonstrate prolonged TEG markers of platelet dysfunction compared with those not on preinjury APA. This retrospective review evaluated all trauma patients admitted to a Level I trauma center from February 2011 to April 2013 who received a TEG within the first 24 hours of admission. Patients were classified as receiving preinjury APA or no APA if their documented medications included either aspirin or adenosine diphosphate (ADP) antagonists, including clopidogrel, prasugrel, and ticagrelor. A total of 129 patients were included (APA, n = 35; no APA n = 94) in the study. The time from admission to the first TEG was similar (APA 175 ± 289 minutes versus no APA 216 ± 321 minutes, P = 0.5). There was no significant difference in TEG markers of platelet dysfunction, including per cent ADP inhibition (APA 61.7 ± 25.8% versus no APA 62.3 ± 28.8%; P = 0.91) or per cent arachidonic acid inhibition (APA 58.2 ± 31% versus no APA 53.8 ± 34%; P = 0.54). Both groups had similar proportion of severe platelet dysfunction, defined as ADP inhibition greater than 70 per cent (APA 40% versus no APA 40%; P = 0.8) and arachidonic acid inhibition greater than 70 per cent (APA 40% versus no APA 39%; P = 0.89). In conclusion, platelet dysfunction after major trauma is common. Therefore, TEG alone should not be used to evaluate for the presence of APA due to apparent lack of specificity.

Restrictive Transfusion in Geriatric Trauma Patients

To determine whether a restrictive strategy of red cell transfusion was safe in elderly trauma patients, we compared those treated with a restrictive transfusion strategy versus those who were liberally transfused. We performed a retrospective study of elderly (age ≥ 70 years) trauma patients admitted to our Level I trauma center from 2005 to 2013. Patients with a hemoglobin (Hg) < 10 g/dL after 48 hours were included. We excluded patients with an Injury Severity Score > 25 or active cardiac ischemia. Patients who were transfused for an Hg < 10 g/dL (liberal group) were compared to those who were transfused for an Hg< 7 g/dL (restrictive group). There were 382 patients included, 229 and 153 in the liberal and restrictive transfusion groups, respectively. All patients in the liberal group and 20 per cent of patients in the restrictive group received a transfusion (P < 0.0001). Patients in the liberal group had more overall complications (52 vs 32%, P = 0.0001). On multivariate analysis, receiving a transfusion was an independent risk factor to develop a complication [odds ratio = 2.3 (1.5-3.6), P < 0.0001]. For survivors, patients in the liberal group spent more days in the hospital (nine versus seven days, P = 0.007) and intensive care unit (two versus one day, P = 0.01). There was no difference in mortality (3 vs 4%, P = 0.82). In conclusion, restrictive transfusion appears to be safe in elderly trauma patients and may be associated with decreased complications and shortened length of stay.

Restrictive Transfusion in Geriatric Trauma Patients

To determine whether a restrictive strategy of red cell transfusion was safe in elderly trauma patients, we compared those treated with a restrictive transfusion strategy versus those who were liberally transfused. We performed a retrospective study of elderly (age ≥ 70 years) trauma patients admitted to our Level I trauma center from 2005 to 2013. Patients with a hemoglobin (Hg) < 10 g/dL after 48 hours were included. We excluded patients with an Injury Severity Score > 25 or active cardiac ischemia. Patients who were transfused for an Hg < 10 g/dL (liberal group) were compared to those who were transfused for an Hg< 7 g/dL (restrictive group). There were 382 patients included, 229 and 153 in the liberal and restrictive transfusion groups, respectively. All patients in the liberal group and 20 per cent of patients in the restrictive group received a transfusion ( P < 0.0001). Patients in the liberal group had more overall complications (52 vs 32%, P = 0.0001). On multivariate analysis, receiving a transfusion was an independent risk factor to develop a complication [odds ratio = 2.3 (1.5–3.6), P < 0.0001]. For survivors, patients in the liberal group spent more days in the hospital (nine versus seven days, P = 0.007) and intensive care unit (two versus one day, P = 0.01). There was no difference in mortality (3 vs 4%, P = 0.82). In conclusion, restrictive transfusion appears to be safe in elderly trauma patients and may be associated with decreased complications and shortened length of stay.

Prehospital endotracheal intubation vs extraglottic airway device in blunt trauma

OBJECTIVE

The objective of the study is to compare outcomes in blunt trauma patients managed with prehospital insertion of an extraglottic airway device (EGD) vs endotracheal intubation (ETI). The null hypothesis was that there would be no difference in mortality for the 2 groups.

METHODS

This is a retrospective study of blunt trauma patients with Glasgow Coma Scale score less than or equal to 8 transported by ground emergency medical services directly from the scene of injury to a single urban level 1 trauma center. Patients managed with only noninvasive airway techniques were excluded, leaving patients undergoing either EGD placement or ETI. Outcomes included in-emergency department (ED) traumatic arrest and hospital mortality. Multivariable logistic regression was used to control for the potential confounding effects of demographic and clinical variables. For all analyses, P < .05 was used to establish statistical significance.

RESULTS

In bivariate analysis, patients managed with EGD were more likely than those managed with ETI to have an in-ED traumatic arrest (36.5% vs 17.1%; P = .005), but eventual hospital mortality did not significantly differ between the 2 groups (75.7% vs 67.1%; P = .228). After controlling for demographic and clinical characteristics, patients managed with EGD were no more likely than patients managed with ETI to experience traumatic arrest in the ED (adjusted odds ratio, 1.67; 95% confidence interval, 0.72-3.89), and there was also no difference in overall hospital mortality (adjusted odds ratio, 0.912; 95% confidence interval, 0.36-2.30).

CONCLUSION

In this preliminary, retrospective analysis, we found no difference in overall survival among trauma patients managed with prehospital EGD and those managed with prehospital ETI.

Use of Magnetic Resonance Cholangiopancreatography in Clinical Practice: Not as Good as We Once Thought

BACKGROUND

Magnetic resonance cholangiopancreatography (MRCP) is believed to be a useful tool to evaluate the biliary tree and pancreas for stones, tumors, or injuries to the ductile system. The purpose of this study was to compare the accuracy of MRCP to the gold standard, endoscopic retrograde cholangiopancreatography (ERCP), in our institution.

STUDY DESIGN

We performed a retrospective review of all MRCP followed by ERCP (follow-on ERCP) at a single institution over a 6-year period. Exam findings from MRCP were compared with findings on the follow-on ERCP and compared. Studies were grouped into 2 main classifications: tests being performed for patients with suspected choledocholithiasis (stone disease) and tests being performed for concerns of malignant strictures or duct injuries (non-stone disease).

RESULTS

A total of 81 patients had MRCPs and follow-on ERCPs in this time period. Thirty-six patients had positive findings on MRCP and ERCP for stones in the common duct system, and 14 patients had positive findings on MRCP and subsequent ERCP for masses and strictures of the common duct. Three patients had positive MRCP and ERCP findings for pancreatic duct abnormalities. The specificity and positive predictive value of MRCP were 94% and 98%, respectively. However, 13 of 28 patients had lesions identified on ERCP after a normal MRCP. The sensitivity and negative predictive value were 80% and 54%, respectively.

CONCLUSIONS

Magnetic resonance cholangiopancreatography was not useful in the management algorithm of either stone or non-stone disease of the biliary tree or pancreas. It should be abandoned as a diagnostic tool for work-up of biliary duct pathology.

Late venous thromboembolism prophylaxis after craniotomy in acute traumatic brain injury

The objective of this study is to compare rates of venous thromboembolism (VTE) in patients who receive enoxaparin prophylaxis compared with no enoxaparin prophylaxis after craniotomy for traumatic brain injury (TBI). This retrospective cohort evaluated all trauma patients admitted to a Level I trauma center from January 2006 to December 2011 who received craniotomy after acute TBI. Patients were excluded if developed VTE before administration of enoxaparin or they died within the first 72 hours of hospital admission. A total of 271 patients were included (enoxaparin prophylaxis, n = 45; no enoxaparin prophylaxis, n = 225). The median time until enoxaparin initiation was 11 ± 1 days. There was no significant difference in the proportion of patients who developed a VTE when using enoxaparin prophylaxis compared with no enoxaparin prophylaxis (2 vs 4%; P = 0.65). Rates of deep vein thrombosis (2 vs 3%; P = 0.87) and pulmonary embolism (0 vs 1%; P = 0.99) were similar between treatment groups, respectively. Late enoxaparin prophylaxis did not demonstrate a protective effect for VTE. Given the overall low event rate, the administration of pharmacologic prophylaxis against VTE late in the treatment course may not be routinely warranted after craniotomy for acute TBI. Further investigation with early administration of enoxaparin is needed.

Late Venous Thromboembolism Prophylaxis after Craniotomy in Acute Traumatic Brain Injury

The objective of this study is to compare rates of venous thromboembolism (VTE) in patients who receive enoxaparin prophylaxis compared with no enoxaparin prophylaxis after craniotomy for traumatic brain injury (TBI). This retrospective cohort evaluated all trauma patients admitted to a Level I trauma center from January 2006 to December 2011 who received craniotomy after acute TBI. Patients were excluded if developed VTE before administration of enoxaparin or they died within the first 72 hours of hospital admission. A total of 271 patients were included (enoxaparin prophylaxis, n = 45; no enoxaparin prophylaxis, n = 225). The median time until enoxaparin initiation was 11 ± 1 days. There was no significant difference in the proportion of patients who developed a VTE when using enoxaparin prophylaxis compared with no enoxaparin prophylaxis (2 vs 4%; P = 0.65). Rates of deep vein thrombosis (2 vs 3%; P = 0.87) and pulmonary embolism (0 vs 1%; P = 0.99) were similar between treatment groups, respectively. Late enoxaparin prophylaxis did not demonstrate a protective effect for VTE. Given the overall low event rate, the administration of pharmacologic prophylaxis against VTE late in the treatment course may not be routinely warranted after craniotomy for acute TBI. Further investigation with early administration of enoxaparin is needed.

Computed Tomography to Diagnose Blunt Diaphragm Injuries: Not Ready for Prime Time

Diaphragm injuries after blunt trauma are uncommon but require early diagnosis to expedite repair. The advancing technology of computed tomography (CT) scanners has improved the detection of almost all traumatic injuries; however, the literature regarding the diagnostic accuracy of CT scan for blunt diaphragm injuries is lacking. The purpose of this study was to determine the CT scan findings in the setting of known blunt diaphragm injury. We performed a retrospective review of all blunt trauma patients with a known diaphragm injury confirmed at laparotomy who also had a preoperative CT scan of the torso. Every CT scan was retrospectively reviewed by a board-certified radiologist for evidence of diaphragm injury as well as associated abdominal and thoracic injuries. Forty-two patients sustaining blunt trauma had preoperative CT scans of the torso and a diaphragm injury confirmed at laparotomy. Only 57 per cent of CT scans showed evidence of diaphragmatic injury. The most common thoracic injury identified was a pulmonary contusion (79%). Although the advancement of imaging technology has markedly improved the diagnosis and management of blunt traumatic injuries, the detection of diaphragm injuries using CT continues to be low and reconstructions do not help in finding diaphragm injuries.

Computed tomography to diagnose blunt diaphragm injuries: not ready for prime time

Diaphragm injuries after blunt trauma are uncommon but require early diagnosis to expedite repair. The advancing technology of computed tomography (CT) scanners has improved the detection of almost all traumatic injuries; however, the literature regarding the diagnostic accuracy of CT scan for blunt diaphragm injuries is lacking. The purpose of this study was to determine the CT scan findings in the setting of known blunt diaphragm injury. We performed a retrospective review of all blunt trauma patients with a known diaphragm injury confirmed at laparotomy who also had a preoperative CT scan of the torso. Every CT scan was retrospectively reviewed by a board-certified radiologist for evidence of diaphragm injury as well as associated abdominal and thoracic injuries. Forty-two patients sustaining blunt trauma had preoperative CT scans of the torso and a diaphragm injury confirmed at laparotomy. Only 57 per cent of CT scans showed evidence of diaphragmatic injury. The most common thoracic injury identified was a pulmonary contusion (79%). Although the advancement of imaging technology has markedly improved the diagnosis and management of blunt traumatic injuries, the detection of diaphragm injuries using CT continues to be low and reconstructions do not help in finding diaphragm injuries.