Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) is the standard of care for the treatment of blunt thoracic aortic injury (BTAI) requiring intervention. Data suggest that low-grade BTAI (grade I [intimal tears] or grade II [intramural hematoma]) will resolve spontaneously if treated with nonoperative management (NOM) alone. There has been no comparison specifically between the use of NOM vs TEVAR for low-grade BTAI. We hypothesize that these low-grade injuries can be safely managed with NOM alone.

STUDY DESIGN

Retrospective analysis of all patients with a low-grade BTAI in the Aortic Trauma Foundation Registry from 2016 to 2021 was performed. The study population was 1 primary outcome was mortality. Secondary outcomes included complications, ICU length of stay, and ventilator days.

RESULTS

A total of 880 patients with BTAI were enrolled. Of the 269 patients with low-grade BTAI, 218 (81%) were treated with NOM alone (81% grade I, 19% grade II), whereas 51 (19%) underwent a TEVAR (20% grade I, 80% grade II). There was no difference in demographic or mechanism of injury in patients with low-grade BTAI who underwent NOM vs TEVAR. There was a difference in mortality between NOM alone and TEVAR (8% vs 18%, p = 0.009). Aortic-related mortality was 0.5% in the NOM group and 4% in the TEVAR group (p = 0.06). Hospital and ICU length of stay and ventilator days were not different between the 2 groups.

CONCLUSIONS

NOM alone is safe and appropriate management for low-grade BTAI, with lower mortality and decreased rates of complication when compared with routine initial TEVAR.

Structural Racism, Residential Segregation, and Exposure to Trauma: The Persistent Impact of Redlining

INTRODUCTION

As part of New Deal era federal housing policy, the Home Owners Loan Corporation (HOLC) developed maps grading US neighborhoods by perceived financial security. Neighborhoods with high concentrations of racial and ethnic minorities were deemed financially unstable and denied federal investment, a practice colloquially known as redlining. The aim of this study was to assess the association of historical redlining within Austin, Texas to spatial patterns of penetrating traumatic injury.

METHODS

Retrospective cross sectional study utilizing data from violent penetrating trauma admissions between January 1, 2014 - December 31, 2021, at the single Level 1 trauma center in Austin, Texas. Using ArcGIS, addresses where the injury took place were geocoded and spatial joining was used to match them to their corresponding census tract, for which 1935 HOLC financial designations are classified as: "Hazardous", "Definitely Declining", "Still Desirable", "Best", or "Non HOLC Graded". Tracts with designations of "Hazardous" and "Definitely Declining" were categorized as Redlined. The adjusted incidence rate ratio comparing rates of penetrating trauma among historically Redlined vs. Not Redlined and Not Graded census tracts was calculated.

RESULTS

1,404 violent penetrating trauma admissions were identified for the study period, of which 920 occurred within the county of interest. Among these, 5% occurred in census tracts that were Not Redlined, 13% occurred in Redlined tracts, and 82% occurred in non HOLC graded tracts. When adjusting for differences in current census tract demographics and social vulnerability, historically Redlined areas experienced a higher rate of penetrating traumatic injury (Not Redlined IRR = 0.42, 95% CI 0.19-0.94, p = 0.03; Not Graded IRR = 0.15, 95% CI 0.07-0.29, p < 0.001).

CONCLUSIONS

Neighborhoods unfavorably classified by HOLC in 1935 continue to experience a higher incidence rate of violent penetrating trauma today. These results underscore the persistent impacts of structural racism and of historical residential segregation policies on exposure to trauma.

LEVEL OF EVIDENCE

Level IV, Prognostic and Epidemiological.

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.

Temporal changes in the prehospital management of trauma patients: 2014-2021

INTRODUCTION

Aggressive prehospital interventions (PHI) in trauma may not improve outcomes compared to prioritizing rapid transport. The aim of this study was to quantify temporal changes in the frequency of PHI performed by EMS.

METHODS

Retrospective chart review of adult patients transported by EMS to our trauma center from January 1, 2014 to 12/31/2021. PHI were recorded and annual changes in their frequency were assessed via year-by-year trend analysis and multivariate regression.

RESULTS

Between the first and last year of the study period, the frequency of thoracostomy (6% vs. 9%, p ​= ​0.001), TXA administration (0.3% vs. 33%, p ​< ​0.001), and whole blood administration (0% vs. 20%, p ​< ​0.001) increased. Advanced airway procedures (21% vs. 12%, p ​< ​0.001) and IV fluid administration (57% vs. 36%, p ​< ​0.001) decreased. ED mortality decreased from 8% to 5% (p ​= ​0.001) over the study period. On multivariate regression, no PHI were independently associated with increased or decreased ED mortality.

CONCLUSION

PHI have changed significantly over the past eight years. However, no PHI were independently associated with increased or decreased ED mortality.

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.

Post-Traumatic Amputations Epidemiology and Outcomes Within The National Trauma Data Bank: Improved Survival Over Time Results in Increased Population in Need of Rehabilitation Support

OBJECTIVE

Acute trauma care has significantly reduced mortality over the last two decades. The last study to examine the epidemiology of traumatic amputees predates these gains. The majority of those who sustain traumatic amputation are male; therefore, limited data exist on female amputees. This study aimed to (1) provide a current epidemiological analysis of traumatic amputees, and (2) compare male and female amputees.

DESIGN

All patients sustaining a major limb amputation in the National Trauma Data Bank (NTDB) from 2013 to 2017 were identified. First, descriptive analyses of patient demographics and injury characteristics were performed and compared with a prior 2000-2004 NTDB study. Second, female and male traumatic amputees were compared in this study.

RESULTS

From 2013 to 2017 we identified 7,016 patients who underwent major limb amputation. Compared to prior years, the current amputees were older and more severely injured. Mortality was 6.3% in the current years compared to 13.4% in the prior years (odds ratio [OR] 0.44, 95% CI = 0.37 to 0.51, p < 0.001). After multivariable analysis, mortality remained significantly decreased, with no difference in hospital length of stay.

CONCLUSIONS

Contemporary NTDB analysis demonstrated that patients with traumatic amputations, regardless of sex, often survive until hospital discharge, despite more severe injuries.

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.

Is Chest X-Ray a Reliable Screening Tool for Blunt Thoracic Aortic Injury? Results from the American Association for the Surgery of Trauma/Aortic Trauma Foundation Prospective Blunt Thoracic Aortic Injury Registry

BACKGROUND

Traditional teaching continues to espouse the value of initial trauma chest x-ray (CXR) as a screening tool for blunt thoracic aortic injury (BTAI). The ability of this modality to yield findings that reliably correlate with grade of injury and need for subsequent treatment, however, requires additional multicenter prospective examination. We hypothesized that CXR is not a reliable screening tool, even at the highest grades of BTAI.

STUDY DESIGN

The Aortic Trauma Foundation/American Association for the Surgery of Trauma prospective BTAI registry was used to correlate initial CXR findings to the Society for Vascular Surgery injury grade identified with computed tomographic angiography.

RESULTS

We analyzed 708 confirmed BTAI injuries with recorded CXR findings and subsequent computed tomographic angiography injury characterization from February 2015 to August 2021. The presence of any of the classic CXR findings was observed in only 57.6% (408 of 708) of injuries, with increasing presence correlating with advanced Society for Vascular Surgery BTAI grade (39.1% [75 of 192] of grade 1; 55.6% [50 of 90] of grade 2; 65.2% [227 of 348] of grade 3; and 71.8% [56 of 78] of grade 4). The most consistent single finding identified was widened mediastinum, but this was only present in 27.7% of all confirmed BTAIs and only 47.4% of G4 injuries (7.8%% of grade 1, 23.3%, of grade 2, 35.3% of grade 3, and 47.4% of grade 4).

CONCLUSIONS

CXR is not a reliable screening tool for the detection of BTAI, even at the highest grades of injury. Further investigations of specific high-risk criteria for screening that incorporate imaging, mechanism, and physiologic findings are warranted.

The more you have, the more you lose: Muscle mass changes in trauma patients with prolonged hospitalizations

INTRODUCTION

Sarcopenia is a clinically relevant loss of muscle mass with implications of increased morbidity and mortality in adult trauma populations.  Our study aimed to evaluate loss of muscle mass change in adult trauma patients with prolonged hospital stays.

METHODS

Retrospective analysis using institutional trauma registry to identify all adult trauma patients with hospital length of stay >14 days admitted to our Level 1 center between 2010 and 2017. All CT images were reviewed, and cross-sectional area (cm²) of the left psoas muscle was measured at the level of the third lumbar vertebral body to determine total psoas area (TPA) and Total Psoas Index (TPI) normalized for patient stature.  Sarcopenia was defined as a TPI on admission below gender specific thresholds of 5.45(cm²/m²) in men and 3.85(cm²/m²) in women.  TPA, TPI, and rates of change in TPI were then evaluated and compared between sarcopenic and non-sarcopenic adult trauma patients.

RESULTS

There were 81 adult trauma patients who met inclusion criteria. The average change in TPA was -3.8 cm² and TPI was -1.3 cm². On admission, 23% (n = 19) of patients were sarcopenic while 77% (n = 62) were not. Non-sarcopenic patients had a significantly greater change in TPA (-4.9 vs. -0.31, p<0.0001), TPI (-1.7 vs. -0.13, p<0.0001), and rate of decrease in muscle mass (p = 0.0002). 37% of patients who were admitted with normal muscle mass developed sarcopenia during admission.  Older age was the only risk factor independently associated with developing sarcopenia (OR: 1.04, 95%CI 1.00-1.08, p = 0.045).

CONCLUSION

Over a third of patients with normal muscle mass at admission subsequently developed sarcopenia with older age as the primary risk factor. Patients with normal muscle mass at admission had greater decreases in TPA and TPI, and accelerated rates of muscle mass loss compared to sarcopenic patients.

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.

Racial and Ethnic Disparity in Prehospital Pain Management for Trauma Patients

BACKGROUND

Although evidence suggests that racial and ethnic minority (REM) patients receive inadequate pain management in the acute care setting, it remains unclear whether these disparities also occur during the prehospital period. The aim of this study is to assess the impact of race and ethnicity on prehospital analgesic use by emergency medical services (EMS) in trauma patients.

STUDY DESIGN

Retrospective chart review of adult trauma patients aged 18 to 89 years old transported by EMS to our American College of Surgeons-verified level 1 trauma center from 2014 to 2020. Patients who identified as Black, Asian, Native American, or Other for race and/or Hispanic or Latino or Unknown for ethnicity were considered REM. Patients who identified as White, non-Hispanic were considered White. Groups were compared in univariate and multivariate analysis. The primary outcome was prehospital analgesic administration.

RESULTS

A total of 2,476 patients were transported by EMS (47% White and 53% REM). White patients were older on average (46 years vs 38 years; p < 0.001) and had higher rates of blunt trauma (76% vs 60%; p < 0.001). There were no differences in Injury Severity Score (21 vs 20; p = 0.22). Although REM patients reported higher subjective pain rating (7.2 vs 6.6; p = 0.002), they were less likely to get prehospital pain medication (24% vs 35%; p < 0.001), and that difference remained significant after controlling for baseline characteristics, transport method, pain rating, prehospital hypotension, and payor status (adjusted odds ratio [95% CI], 0.67 [0.47 to 0.96]; p = 0.03).

CONCLUSIONS

Patients from racial and ethnic minority groups were less likely to receive prehospital pain medication after traumatic injury than White patients. Forms of conscious and unconscious bias contributing to this inequity need to be identified and addressed.

Clinical relevance of the blanking period on late recurrence after catheter ablation of atrial fibrillation

INTRODUCTION

Recurrence of atrial fibrillation (AF) within the blanking period after catheter ablation (CA) is traditionally classified as a transient and benign event. However, recent findings suggest that early recurrence (ER) is associated with late recurrence (LR), challenging the predefined "blanking period". We aimed to determine the clinical and procedural predictors of ER and LR after CA and establish the risk of LR in patients who experience ER.

METHODS AND RESULTS

Retrospective single-centre study including all patients who underwent a first procedure of AF CA between 2017 and 2019. ER was defined as any recurrence of AF, atrial flutter or atrial tachycardia >30 s within 90 days after CA and LR as any recurrence after 90 days of CA. A total of 399 patients were included, 37% women, median age of 58 years [49-66] and 77% had paroxysmal AF. Median follow-up was 33 months (from 13 to 61). ER after CA was present in 14% of the patients, and LR was reported in 32%. Among patients who experienced ER, 84% also had LR (p < .001). Patients with ER had a higher prevalence of moderate/severe valvular heart disease, persistent AF, previous electrical cardioversion, a larger left atrium, higher coronary artery calcium score, and higher rates of intraprocedural electrical cardioversion and cardiac fibrosis on eletroanatomical mapping compared with patients without ER. After covariate adjustment, ER and female sex were defined as independent predictors of LR (hazard ratio [HR] 4.69; 95% confidence interval [CI], 2.99-7.35; p < .001 and HR 2.73; 95% CI, 1.47-5.10; p = .002, respectively).

CONCLUSION

The risk of LR after an index procedure of CA was significantly higher in patients with ER (five-fold increased risk). These results support the imperative need to clarify the clinical role of the blanking period.

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.

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.

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.

Antithrombotic therapy for postinterventional management of peripheral arterial disease

PURPOSE

Evidence on the use of antithrombotic pharmacotherapy in patients undergoing revascularization of lower extremities for symptomatic peripheral arterial disease (PAD) is reviewed.

SUMMARY

Individuals with PAD can experience leg pain, intermittent claudication, critical limb ischemia, and acute limb ischemia. In such patients, revascularization may be indicated to improve the quality of life and to prevent amputations. Antithrombotic therapy is often intensified in the postrevascularization period to prevent restenosis of the index artery and to counteract the prothrombotic state induced by the intervention. Therapeutic modalities include dual antiplatelet therapy (DAPT), anticoagulation, a combination of antiplatelet and anticoagulation therapy, and addition of cilostazol to single antiplatelet therapy. Subgroup analyses of data from randomized clinical trials provided low-quality evidence for the use of DAPT in patients with a below-knee prosthetic bypass graft and anticoagulation for those with a venous bypass graft. Cilostazol, when added to aspirin therapy, has been shown to prevent index vessel reocclusion after an endovascular intervention in patients at low risk for thrombosis in several small randomized trials.

CONCLUSION

There is a considerable paucity of high-quality evidence on the optimal antithrombotic regimen for patients undergoing lower extremity revascularization, with no particular therapy shown to consistently improve patient outcomes. The decision to initiate intensified antithrombotic therapy should include a close examination of its risk-benefit profile. The demonstrated benefit of such treatment is restricted to the prevention of index artery reocclusion, while an increased risk of bleeding may lead to significant morbidity and mortality.

Incidence and Risk Factors for Acute Kidney Injury in Severely Injured Patients Using Current Kidney Disease: Improving Global Outcomes Definitions

BACKGROUND

Acute kidney injury (AKI) is a significant cause of morbidity and mortality for critically injured trauma patients. The Kidney Disease: Improving Global Outcomes (KDIGO) practice guideline is the most up-to-date classification for AKI. The aims of this study were to determine the incidence and risk factors for AKI in critically injured trauma patients using the current KDIGO definitions.

STUDY DESIGN

A prospective cohort study was performed at our academic, level 1 trauma center, from September 2017 to August 2018. All adult trauma patients admitted to the surgical ICU were included. The primary outcome was the development of AKI, as defined by KDIGO. Secondary outcomes included hospital and ICU length of stay, ventilator days, and mortality.

RESULTS

There were 466 patients included and 314 (67%) developed AKI. Those who developed AKI were more often hypotensive on admission (7% vs 2%), had higher Injury Severity Scores (ISS) (19 vs 13), were more likely to have severe injuries to the chest (40% vs 24%) and extremities (20% vs 6%), received transfusion (41% vs 21%), sustained crush injuries (8% vs 1%), received radiocontrast (75% vs 47%), nephrotoxic medication (74% vs 60%), or vasopressors (15% vs 3%). After multivariate analysis, risk factors independently associated with AKI include age, Injury Severity Score (ISS), severe extremity injuries, radiocontrast, and vasopressors. Those who developed AKI had higher mortality (9% vs 2%).

CONCLUSIONS

Using current KDIGO criteria, the incidence of AKI in critically injured trauma patients was higher than previously reported. Older patients, with more severe injuries to their extremities and chest and who have suffered crush injuries, appear to be the most a risk. AKI in the critically injured patient results in an almost 5-fold increase in mortality.

Timing of Redébridement after Initial Source Control Impacts Survival in Necrotizing Soft Tissue Infection

Necrotizing soft tissue infections (NSTIs) are associated with a high mortality rate. There is a lack of literature examining outcomes in NSTI when surgical redébridements are performed in early versus delayed intervals. We hypothesized that early redébridement is associated with improved survival. Patients with NSTIs were prospectively enrolled between January 2006 and December 2011. Patient demographics, comorbidities, primary infection site, laboratory values, tissue cultures, time to surgery, and time between subsequent débridements were obtained. Two study groups with divergent redébridement protocols were observed: a short interval redébridement (SIRD) and an extended interval redébridement (EIRD). Univariate and multivariate statistics were performed. The primary outcome evaluated was in-hospital mortality. Sixty-four patients (46 SIRD, 18 EIRD) were included in the analysis. The two groups had comparable demographics. Polymicrobial NSTI was noted in 61 per cent of patients with Staphylococcus species being the predominant causative organism (59%). Multivariate analysis showed the EIRD protocol to be associated with a significantly increased incidence of acute kidney injury (adjusted odds ratio, 4.9 [1.1 to 22.5]; P = 0.04) and worse overall survival (hazard ratio, 10.6 [2.1 to 53.9]; P = 0.004). Delayed redébridement after initial source control in NSTIs results in worse survival and an increased incidence of acute kidney injury. Further studies to identify the optimal time interval for redébridement are warranted.

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.

Transabdominal open abdominal aortic aneurysm repair is associated with higher rates of late reintervention and readmission compared with the retroperitoneal approach

OBJECTIVE

Limited data exist comparing the transabdominal and retroperitoneal approaches to open abdominal aortic aneurysm (AAA) repair, especially late mortality and laparotomy-related reinterventions and readmissions. Therefore, we compared long-term rates of mortality, reintervention, and readmission after open AAA repair through a transabdominal compared with a retroperitoneal approach.

METHODS

We identified all patients in the Vascular Quality Initiative (VQI) undergoing open AAA repair from 2003 to 2015. Patients with rupture or supraceliac clamp were excluded. We used the VQI linkage to Medicare to ascertain rates of long-term outcomes, including rates of AAA-related and laparotomy-related (ie, hernia, bowel obstruction) reinterventions and readmissions. We used multivariable Cox regression to account for differences in comorbidities, aneurysm details, and operative characteristics.

RESULTS

We identified 1282 patients in the VQI with linkage to Medicare data, 914 (71%) who underwent a transperitoneal approach and 368 (29%) who underwent a retroperitoneal approach. Patients who underwent a retroperitoneal approach were slightly more likely to have preoperative renal insufficiency but were otherwise similar in terms of demographics and comorbidities. They more often had a clamp above at least one renal artery (61% vs 36%; P < .001) and underwent concomitant renal revascularization (9.5% vs 4.3%; P < .001). Patients who underwent a transabdominal approach more often presented with symptoms (14% vs 9.0%; P < .01) and had a femoral distal anastomosis (15% vs 7.1%; P < .001). There was no difference in 5-year survival (62% vs 61%; log-rank, P = .51). However, patients who underwent a transabdominal approach experienced higher rates of repair-related reinterventions and readmissions (5-year: 42% vs 34%; log-rank, P < .01), even after adjustment for demographic and operative differences (hazard ratio, 1.5; 95% confidence interval, 1.1-1.9; P < .01).

CONCLUSIONS

A transabdominal exposure for AAA repair is associated with higher rates of late reintervention and readmission than with the retroperitoneal approach, which should be considered when possible in operative decision-making.

Mild to Moderate to Severe: What Drives the Severity of ARDS in Trauma Patients?

Acute respiratory distress syndrome (ARDS) is a complex inflammatory process with multifactorial etiologies. Risk factors for its development have been extensively studied, but factors associated with worsening severity of disease, as defined by the Berlin criteria, are poorly understood. A retrospective chart and trauma registry review identified trauma patients in our surgical intensive care unit who developed ARDS, defined according to the Berlin definition, between 2010 and 2015. The primary outcome was development of mild, moderate, or severe ARDS. A logistic regression model identified risk factors associated with developing ARDS and with worsening severity of disease. Of 2704 total patients, 432 (16%) developed ARDS. Of those, 100 (23%) were categorized as mild, 176 (41%) as moderate, and 156 (36%) as severe. Two thousand two hundred and seventy-two patients who did not develop ARDS served as controls. Male gender, blunt trauma, severe head and chest injuries, and red blood cell as well as total blood product transfusions are independent risk factors associated with ARDS. Worsening severity of disease is associated with severe chest trauma and volume of plasma transfusion. Novel findings in our study include the association between plasma transfusions and specifically severe chest trauma with worsening severity of ARDS in trauma patients.

Mild to Moderate to Severe: What Drives the Severity of ARDS in Trauma Patients?

Acute respiratory distress syndrome (ARDS) is a complex inflammatory process with multifactorial etiologies. Risk factors for its development have been extensively studied, but factors associated with worsening severity of disease, as defined by the Berlin criteria, are poorly understood. A retrospective chart and trauma registry review identified trauma patients in our surgical intensive care unit who developed ARDS, defined according to the Berlin definition, between 2010 and 2015. The primary outcome was development of mild, moderate, or severe ARDS. A logistic regression model identified risk factors associated with developing ARDS and with worsening severity of disease. Of 2704 total patients, 432 (16%) developed ARDS. Of those, 100 (23%) were categorized as mild, 176 (41%) as moderate, and 156 (36%) as severe. Two thousand two hundred and seventy-two patients who did not develop ARDS served as controls. Male gender, blunt trauma, severe head and chest injuries, and red blood cell as well as total blood product transfusions are independent risk factors associated with ARDS. Worsening severity of disease is associated with severe chest trauma and volume of plasma transfusion. Novel findings in our study include the association between plasma transfusions and specifically severe chest trauma with worsening severity of ARDS in trauma patients.

Discontinuity of the Bowel Following Damage Control Operation Revisited: A Multi-institutional Study

BACKGROUND

Discontinuity of the bowel following intestinal injury and resection is a common practice in damage control procedures for severe abdominal trauma. However, there are concerns that complete occlusion of the bowel, especially in the presence of hypotension or edema that may result in ischemic bowel changes or increase bacterial or toxin translocation.

METHODS

This was a retrospective study from three Level-1 trauma centers. Included were trauma patients who required bowel resection and damage control. The study population was stratified into two groups based on the management for bowel injury: bowel discontinuity versus primary anastomosis. Outcomes included anastomotic leak, organ space infection, bowel ischemia, and mortality.

RESULTS

A total of 167 cases were included. In 84 cases, continuity of the bowel was established, and in 83, the bowel was left in discontinuity. The epidemiological, admission, and intraoperative physiological characteristics, the abdominal Abbreviated Injury Scale, type of intra-abdominal injury, and transfusion requirements were similar in the two study groups. The mortality was 8.3 % in the continuity group and 16.9 % for the discontinuity group (p = 0.096). On the crude bivariate and adjusted regression analyses, there was a higher rate of bowel ischemia at the take-back operation in the discontinuity group (p = 0.003 for the crude and p = 0.034 for the adjusted). The organ space infection and anastomotic leak rate were not significantly different between the study groups.

CONCLUSIONS

Discontinuity of the bowel following damage control operation is associated with a higher risk of bowel ischemia than in patients with anastomosis. Further prospective observational and randomized studies are warranted.

LEVEL OF EVIDENCE

III.

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.

The contemporary management of penetrating splenic injury

INTRODUCTION

Selective non-operative management (NOM) is standard of care for clinically stable patients with blunt splenic trauma and expectant management approaches are increasingly utilised in penetrating abdominal trauma, including in the setting of solid organ injury. Despite this evolution of clinical practice, little is known about the safety and efficacy of NOM in penetrating splenic injury.

METHODS

Trauma registry and medical record review identified all consecutive patients presenting to LAC+USC Medical Center with penetrating splenic injury between January 2001 and December 2011. Associated injuries, incidence and nature of operative intervention, local and systemic complications and mortality were determined.

RESULTS

During the study period, 225 patients experienced penetrating splenic trauma. The majority (187/225, 83%) underwent emergent laparotomy. Thirty-eight clinically stable patients underwent a deliberate trial of NOM and 24/38 (63%) were ultimately managed without laparotomy. Amongst patients failing NOM, 3/14 (21%) underwent splenectomy while an additional 6/14 (42%) had splenorrhaphy. Hollow viscus injury (HVI) occurred in 21% of all patients failing NOM. Forty percent of all NOM patients had diaphragmatic injury (DI). All patients undergoing delayed laparotomy for HVI or a splenic procedure presented symptomatically within 24h of the initial injury. No deaths occurred in patients undergoing NOM.

CONCLUSIONS

Although the vast majority of penetrating splenic trauma requires urgent operative management, a group of patients does present without haemodynamic instability, peritonitis or radiologic evidence of hollow viscus injury. Management of these patients is complicated as over half may remain clinically stable and can avoid laparotomy, making them potential candidates for a trial of NOM. HVI is responsible for NOM failure in up to a fifth of these cases and typically presents within 24h of injury. Delayed laparotomy, within this limited time period, did not appear to increase mortality nor preclude successful splenic salvage. In clinically stable patients, diagnostic laparoscopy remains essential to evaluate and repair occult DI. As NOM for penetrating abdominal trauma becomes more common, multi-centre data is needed to more accurately define the principles of patient selection and the limitations and consequences of this approach in the setting of splenic injury.

Angiointervention: an independent predictor of survival in high-grade blunt liver injuries

BACKGROUND

The role of angiointervention (ANGIO) in the management of high-grade liver injuries is not clear and there are concerns about increased complications.

METHODS

National Trauma Data Bank study, isolated grade IV and V blunt liver injuries. Patients with major associated intra-abdominal or extra-abdominal injuries were excluded. Logistic regression analysis was performed to identify independent predictors of mortality and complications.

RESULTS

Six thousand four hundred two patients met the criteria for inclusion. Laparotomy was performed in 32% of the patients and nonoperative management in 68%. Overall, 11% of the patients underwent ANGIO. Patients in the ANGIO group were significantly more likely to be older than 55 years than non-ANGIO patients and more likely to have Injury Severity Scores greater than 25. After stepwise logistic regression, ANGIO was an independent predictor of survival (P < .001). In the group of patients managed operatively, it was independently associated with a lower mortality (P < .001). Similarly, in the nonoperative group, it was independently associated with a lower mortality (5.4% vs 9.5%, P = .008). ANGIO was associated with increased systemic complications.

CONCLUSIONS

ANGIO in blunt, severe liver injuries is associated with reduced mortality and increased complications, in both operative and nonoperative management.

Infective endocarditis associated superior mesenteric artery pseudoaneurysm

BACKGROUND

Since William Osler first described mycotic aneurysms in the setting of endocarditis in 1885, few pseudoaneurysms (PAs) of the superior mesenteric artery (SMA) have been reported in the literature. We report 2 cases of SMA PA related to infective endocarditis that were managed with open surgery.

RESULTS

Here we report 2 cases of SMA PAs treated with different surgical techniques. A 59-year-old male with a history of intravenous drug use presented with abdominal pain and was found to have Streptococcus viridans endocarditis and an SMA PA. A laparotomy was performed, and proximal and distal control of the SMA PA was obtained. After ensuring that Doppler signals were still present in the distal mesentery and the entirety of the bowel was viable, the SMA was ligated proximal and distal to the PA. The patient recovered uneventfully. The second case is a 35-year-old female who presented with abdominal pain and was found to have Streptococcos gordonii endocarditis and an SMA PA for which the patient was initially observed. After several weeks, the patient's condition deteriorated and the patient underwent open ligation of the SMA, proximal and distal to the PA, with a bypass from the infrarenal abdominal aorta to a distal unnamed SMA branch and resection of 3 ft of ischemic small bowel. The patient continued to have recurrent bowel ischemia over the next several weeks and ultimately died.

CONCLUSIONS

SMA PAs associated with infective endocarditis are rare, but carry a high risk of rupture and associated morbidity and mortality. Delay in surgical management may increase this risk.

Intracranial pressure versus cerebral perfusion pressure as a marker of outcomes in severe head injury: a prospective evaluation

BACKGROUND

Intracranial pressure (ICP) monitoring is a standard of care in severe traumatic brain injury when clinical features are unreliable. It remains unclear, however, whether elevated ICP or decreased cerebral perfusion pressure (CPP) predicts outcome.

METHODS

This is a prospective observational study of patients sustaining severe blunt head injury, admitted to the surgical intensive care unit at the Los Angeles County and University of Southern California Medical Center between January 2010 and December 2011. The study population was stratified according to the findings of ICP and CPP. Primary outcomes were overall in-hospital mortality and mortality because of cerebral herniation. Secondary outcomes were development of complications during the hospitalization.

RESULTS

A total of 216 patients met Brain Trauma Foundation guidelines for ICP monitoring. Of those, 46.8% (n = 101) were subjected to the intervention. Sustained elevated ICP significantly increased all in-hospital mortality (adjusted odds ratio [95% confidence interval]: 3.15 [1.11, 8.91], P = .031) and death because of cerebral herniation (adjusted odds ratio [95% confidence interval]: 9.25 [1.19, 10.48], P = .035). Decreased CPP had no impact on mortality.

CONCLUSIONS

A single episode of sustained increased ICP is an accurate predictor of poor outcomes. Decreased CPP did not affect survival.

Prospective evaluation of early follow-up chest radiography after penetrating thoracic injury

BACKGROUND

In asymptomatic patients with penetrating thoracic trauma and a normal initial chest x-ray, successive prospective trials have decreased the minimum observation period required for exclusion of significant injury from 6 to 3 h. Despite the quality of these studies, this interval remains arbitrary and the true requisite observation time for safe discharge remains unknown. The current study evaluates the ability of "early" repeat chest x-ray, at intervals approaching 1 h, to exclude clinically significant injury.

METHODS

Eighty-eight, asymptomatic patients with penetrating chest trauma and normal initial chest radiographs were prospectively enrolled in this study. All patients received an "early" follow-up chest x-ray, at a median interval of 1 h and 34 min (interquartile range: 1 h 35 min to 2 h 22 min), and a second repeat x-ray at a "delayed" interval no earlier than 3 h postadmission. Radiographic abnormalities in clinically stable patients were followed with serial examination and repeat imaging for a minimum of 6 h. All patients received both "early" and "delayed" repeat CXRs with no patient discharged before full assessment.

RESULTS

One of the 88 patients with initially normal chest x-ray underwent tube thoracostomy at the discretion of the attending surgeon before any repeat imaging. Of the remaining patients, 4 of 87 (4.6 %) demonstrated radiographic abnormalities on "early" repeat imaging. Two patients had pneumothoraces, successfully managed without intervention; the remaining two demonstrated evidence of hemothorax, subsequently undergoing tube thoracostomy. Two more patients (2.3 %) developed pneumothoraces on "delayed" imaging, both successfully observed without intervention.

CONCLUSIONS

In asymptomatic patients with penetrating thoracic trauma and normal initial chest radiographs, "early" repeat chest x-ray, at intervals approaching 1 h, appears sufficient to exclude clinically significant pathology and to allow safe patient discharge.

Effect of delaying same-admission cholecystectomy on outcomes in patients with diabetes

Background

Recent studies have suggested that same-admission delayed cholecystectomy is a safe option. Patients with diabetes have been shown to have less favourable outcomes after cholecystectomy, but the impact of timing of operation for acute cholecystitis during the same admission is unknown.

Methods

This was a retrospective analysis of patients undergoing laparoscopic cholecystectomy for acute cholecystitis between 2004 and 2010, from the American College of Surgeons National Surgical Quality Improvement Program database. Patients with no significant co-morbidities (American Society of Anesthesiologists grade I or II) were included. Propensity score matching (PSM) was used to match patients with diabetes with those who did not have diabetes, in a ratio of 1 : 3, to ensure homogeneity of the two groups. Logistic regression models were applied to adjust for differences between early (within 24 h) and delayed (24 h or more) surgical treatment. The primary outcome was development of local and systemic infectious complications. Secondary outcomes were duration of operation and length of hospital stay.

Results

From a total of 2892 patients, 144 patients with diabetes were matched with 432 without diabetes by PSM. Delaying cholecystectomy for at least 24 h after admission in patients with diabetes was associated with significantly higher odds of developing surgical-site infections (adjusted odds ratio 4·11, 95 per cent confidence interval 1·11 to 15·22; P = 0·034) and a longer hospital stay. For patients with no diabetes, however, delaying cholecystectomy had no impact on complications or length of hospital stay.

Conclusion

Patients with diabetes who undergo laparoscopic cholecystectomy 24 h or more after admission may have an increased risk of postoperative surgical-site infection and a longer hospital stay than those undergoing surgery within 24 h of admission.

Intracranial pressure monitoring in severe head injury: compliance with Brain Trauma Foundation guidelines and effect on outcomes: a prospective study

Object

The Brain Trauma Foundation (BTF) has established guidelines for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). This study assessed compliance with these guidelines and the effect on outcomes.

Methods

This is a prospective, observational study including patients with severe blunt TBI (Glasgow Coma Scale score ≤ 8, head Abbreviated Injury Scale score ≥ 3) between January 2010 and December 2011. Demographics, clinical characteristics, laboratory profile, head CT scans, injury severity indices, and interventions were collected. The study population was stratified into 2 study groups: ICP monitoring and no ICP monitoring. Primary outcomes included compliance with BTF guidelines, overall in-hospital mortality, and mortality due to brain herniation. Secondary outcomes were ICU and hospital lengths of stay. Multiple regression analyses were deployed to determine the effect of ICP monitoring on outcomes.

Results

A total of 216 patients met the BTF guideline criteria for ICP monitoring. Compliance with BTF guidelines was 46.8% (101 patients). Patients with subarachnoid hemorrhage and those who underwent craniectomy/craniotomy were significantly more likely to undergo ICP monitoring. Hypotension, coagulopathy, and increasing age were negatively associated with the placement of ICP monitoring devices. The overall in-hospital mortality was significantly higher in patients who did not undergo ICP monitoring (53.9% vs 32.7%, adjusted p = 0.019). Similarly, mortality due to brain herniation was significantly higher for the group not undergoing ICP monitoring (21.7% vs 12.9%, adjusted p = 0.046). The ICU and hospital lengths of stay were significantly longer in patients subjected to ICP monitoring.

Conclusions

Compliance with BTF ICP monitoring guidelines in our study sample was 46.8%. Patients managed according to the BTF ICP guidelines experienced significantly improved survival.

Timing of redébridement after initial source control impacts survival in necrotizing soft tissue infection

Necrotizing soft tissue infections (NSTIs) are associated with a high mortality rate. There is a lack of literature examining outcomes in NSTI when surgical redébridements are performed in early versus delayed intervals. We hypothesized that early redébridement is associated with improved survival. Patients with NSTIs were prospectively enrolled between January 2006 and December 2011. Patient demographics, comorbidities, primary infection site, laboratory values, tissue cultures, time to surgery, and time between subsequent débridements were obtained. Two study groups with divergent redébridement protocols were observed: a short interval redébridement (SIRD) and an extended interval redébridement (EIRD). Univariate and multivariate statistics were performed. The primary outcome evaluated was in-hospital mortality. Sixty-four patients (46 SIRD, 18 EIRD) were included in the analysis. The two groups had comparable demographics. Polymicrobial NSTI was noted in 61 per cent of patients with Staphylococcus species being the predominant causative organism (59%). Multivariate analysis showed the EIRD protocol to be associated with a significantly increased incidence of acute kidney injury (adjusted odds ratio, 4.9 [1.1 to 22.5]; P = 0.04) and worse overall survival (hazard ratio, 10.6 [2.1 to 53.9]; P = 0.004). Delayed redébridement after initial source control in NSTIs results in worse survival and an increased incidence of acute kidney injury. Further studies to identify the optimal time interval for redébridement are warranted.

Dalteparin versus Enoxaparin for the prevention of venous thromboembolic events in trauma patients

BACKGROUND

The use of low-molecular-weight heparin (LMWH) for the chemoprophylaxis of venous thromboembolism (VTE) in trauma patients is supported by Level-1 evidence. Because Enoxaparin was the agent used in the majority of studies for establishing the efficacy of LMWH in VTE, it remains unclear if Dalteparin provides an equivalent effect.

OBJECTIVE

To compare Dalteparin to Enoxaparin and investigate their equivalence as VTE prophylaxis in trauma.

PATIENTS/SETTING

Trauma patients receiving VTE chemoprophylaxis in the Surgical Intensive Care Unit of a Level-1 Trauma Center from 2009 (Enoxaparin) to 2010 (Dalteparin) were included.

MEASUREMENTS

The primary outcome was the incidence of clinically significant VTE. Secondary outcomes included heparin-induced thrombocytopenia (HIT), major bleeding, and drug acquisition cost savings. Equivalence margins were set between -5 and 5 %.

MAIN RESULTS

A total of 610 patient records (277 Enoxaparin, 333 Dalteparin) were reviewed. The two study groups did not differ significantly: blunt trauma 67 vs. 62 %, p = 0.27; mean Injury Severity Score (ISS) 17 ± 10 vs. 16 ± 10, p = 0.34; Acute Physiology and Chronic Health Evaluation (APACHE) II score 17 ± 9 vs. 17 ± 10, p = 0.76; time to first dose of LMWH 69 ± 98 vs. 65 ± 67 h, p = 0.57). The rates of deep venous thrombosis (DVT) (3.2 vs. 3.3 %, p = 1.00), pulmonary emboli (PE) (1.8 vs. 1.2 %, p = 0.74), and overall VTE (5.1 vs. 4.5 %, p = 0.85) did not differ. The absolute difference in the incidence of overall VTE was 0.5 % [95 % confidence interval (CI): -2.9, 4.0 %, p = 0.85]. The 95 % CI was within the predefined equivalence margins. There were no significant differences in the frequency of HIT or major bleeding. The total year-on-year cost savings, achieved with 277 patients during the switch to Dalteparin, was estimated to be $107,778.

CONCLUSIONS

Dalteparin is equivalent to Enoxaparin in terms of VTE in trauma patients and can be safely used in this population, with no increase in complications and significant cost savings.