Warfarin, not direct oral anticoagulants nor antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: implications in this new era of novel anticoagulants: An EAST Multicenter study

INTRODUCTION

To assess perioperative bleeding complications & in-hospital mortality in patients requiring emergency general surgery (EGS) presenting with a history of antiplatelet (AP) vs. direct oral anticoagulant (DOAC) vs warfarin use.

METHODS

Prospective observational study across 21 centers between 2019-2022. Inclusion criteria were age ≥ 18 years, & DOAC, warfarin or AP use within 24 hours of an EGSP. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using ANOVA, Chi-square, and multivariable regression models.

RESULTS

Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, & 40 (9.7%) warfarin use. Most common indications for surgery were obstruction (23% (AP), 45% (DOAC), 28% (warfarin)), intestinal ischemia (13%, 17%, 23%), & diverticulitis/peptic ulcers (7%, 7%, 15%). Compared to DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (OR 4.4 [2.0, 9.9]). There was no significant difference in perioperative bleeding complication between DOAC & AP use (OR 0.7 [0.4, 1.1]). Compared to DOAC use, there was no significant difference in mortality between warfarin use (0.7 [0.2, 2.5]) or AP use (OR 0.5 [0.2, 1.2]). After adjusting for confounders, warfarin use (OR 6.3 [2.8, 13.9]), medical history and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR 1.3 [0.39, 4.7]), whereas intraoperative vasopressor use (OR 4.7 [1.7, 12.8)), medical history & postoperative bleeding (OR 5.5 [2.4, 12.8]) were.

CONCLUSIONS

Despite ongoing concerns about the increase in DOAC use & lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease & comorbidities rather than type of antiplatelet or anticoagulant use.

MultiCenter Study of Intra-Abdominal Abscess Formation After Major Operative Hepatic Trauma

INTRODUCTION

One of the significant complications of operative liver trauma is intra-abdominal abscesses (IAA). The objective of this study was to determine risk factors associated with postoperative IAA in surgical patients with major operative liver trauma.

METHODS

A retrospective multi-institutional study was performed at 13 Level 1 and Level 2 trauma centers from 2012 to 2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Univariate and multivariate analyses were performed.

RESULTS

Three hundred seventy-two patients were included with 21.2% (n = 79/372) developing an IAA. No difference was found for age, gender, injury severity score, liver injury grade, and liver resections in patients between the groups (P > 0.05). Penetrating mechanism of injury (odds ratio (OR) 3.42, 95% confidence interval (CI) 1.54-7.57, P = 0.02), intraoperative massive transfusion protocol (OR 2.43, 95% CI 1.23-4.79, P = 0.01), biloma/bile leak (OR 2.14, 95% CI 1.01-4.53, P = 0.04), hospital length of stay (OR 1.04, 95% CI 1.02-1.06, P < 0.001), and additional intra-abdominal injuries (OR 2.27, 95% CI 1.09-4.72, P = 0.03) were independent risk factors for IAA. Intra-abdominal drains, damage control laparotomy, total units of packed red blood cells, number of days with an open abdomen, total abdominal surgeries, and blood loss during surgery were not found to be associated with a higher risk of IAA.

CONCLUSIONS

Patients with penetrating trauma, massive transfusion protocol activation, longer hospital length of stay, and injuries to other intra-abdominal organs were at higher risk for the development of an IAA following operative liver trauma. Results from this study could help to refine existing guidelines for managing complex operative traumatic liver injuries.

When is it safe to start venous thromboembolism prophylaxis after blunt solid organ injury? A prospective American Association for the Surgery of Trauma multi-institutional trial

BACKGROUND

The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial, as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests that VTEp ≤48 hours is safe and effective. This study was undertaken to validate this clinical practice.

METHODS

Blunt trauma patients presenting to 19 participating trauma centers in North America were screened over a 1-year study period beginning between August 1 and October 1, 2021. Inclusions were age older than 15 years; ≥1 liver, spleen, or kidney injury; and initial nonoperative management. Exclusions were transfers, emergency department death, pregnancy, and concomitant bleeding disorder/anticoagulation/antiplatelet medication. A priori power calculation stipulated the need for 1,158 patients. Time of VTEp initiation defined study groups: Early (≤48 hours of admission) versus Late (>48 hours). Bivariate and multivariable analyses compared outcomes.

RESULTS

In total, 1,173 patients satisfied the study criteria with 571 liver (49%), 557 spleen (47%), and 277 kidney injuries (24%). The median patient age was 34 years (interquartile range, 25-49 years), and 67% (n = 780) were male. The median Injury Severity Score was 22 (interquartile range, 14-29) with Abbreviated Injury Scale Abdomen score of 3 (interquartile range, 2-3), and the median American Association for the Surgery of Trauma grade of solid organ injury was 2 (interquartile range, 2-3). Early VTEp patients (n = 838 [74%]) had significantly lower rates of VTE (n = 28 [3%] vs. n = 21 [7%], p = 0.008), comparable rates of nonoperative management failure (n = 21 [3%] vs. n = 12 [4%], p = 0.228), and lower rates of post-VTEp blood transfusion (n = 145 [17%] vs. n = 71 [23%], p = 0.024) when compared with Late VTEp patients (n = 301 [26%]). Late VTEp was independently associated with VTE (odd ratio, 2.251; p = 0.046).

CONCLUSION

Early initiation of VTEp was associated with significantly reduced rates of VTE with no increase in bleeding complications. Venous thromboembolism chemoprophylaxis initiation ≤48 hours is therefore safe and effective and should be the standard of care for patients with blunt solid organ injury.

LEVEL OF EVIDENCE

Therapeutic and Care Management; Level III.

Anastomotic leak rates after repair of mesenteric bucket-handle injuries: A multi-center retrospective cohort study

BACKGROUND

Primary aim was to assess the relative risk (RR) of anastomotic leak (AL) in intestinal bucket-handle (BH) compared to non-BH injury.

METHODS

Multi-center study comparing AL in BH from blunt trauma 2010-2021 compared to non-BH intestinal injuries. RR was calculated for small bowel and colonic injury using R.

RESULTS

AL occurred in 20/385 (5.2%) of BH vs. 4/225 (1.8%) of non-BH small intestine injury. AL was diagnosed 11.6 ± 5.6 days from index operation in small intestine BH and 9.7 ± 4.3 days in colonic BH. Adjusted RR for AL was 2.32 [0.77-6.95] for small intestinal and 4.83 [1.47-15.89] for colonic injuries. AL increased infections, ventilator days, ICU & total length of stay, reoperation, and readmission rates, although mortality was unchanged.

CONCLUSION

BH carries a significantly higher risk of AL, particularly in the colon, than other blunt intestinal injuries.

Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study

BACKGROUND

While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs).

METHODS

This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis.

RESULTS

Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups. After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality.

CONCLUSION

Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Long-term physical and mental health outcomes of pediatric firearm-injured victims: A prospective cohort study

BACKGROUND

Firearms are a leading cause of injury among US youth. There is little research describing outcomes after pediatric firearm injuries, particularly past 1 year.

OBJECTIVE

This study aimed to assess long-term physical and mental health outcomes among nonfatal firearm versus motor vehicle collision (MVC)-injured victims and versus a standard population.

METHODS

We retrospectively identified firearm and MVC-injured pediatric patients seen at one of our four trauma centers (January 2008 to October 2020) and prospectively assessed outcomes using validated patient-reported outcome measures. Eligible patients were English speaking, injured ≥5 months before study start, younger than 18 years at time of injury, and 8 years or older at study start. All firearm patients were included; MVC patients were matched 1:1 with firearm patients for Injury Severity Score (dichotomized <15 or ≥15), age range (±1 year), and year of injury. We conducted structured interviews of patients and parents using validated tools (Patient-Reported Outcomes Measurement Information System tools, Children's Impact of Event Scale for younger than 18 years and parent proxies). Patient-Reported Outcomes Measurement Information System scores are reported on a T score metric (mean [SD], 50 [10]); higher scores indicate more of the measured domain. We used paired t tests, Wilcoxon signed-rank tests, and McNemar's test to compare demographics, clinical characteristics, and outcomes.

RESULTS

There were 24 participants in each of the MVC and firearm-injured groups. Compared with MVC-injured patients, firearm-injured patients younger than 18 years had similar scores, and firearm-injured patients 18 years or older had higher anxiety scores (59.4 [8.3] vs. 51.2 [9.4]). Compared with a standard population, patients younger than 18 years had worse global health scores (mean [SD], 43.4 [9.7]), and participants 18 years or older reported increased fatigue (mean [SD], 61.1 [3.3]) and anxiety (mean [SD], 59.4 [8.3]).

CONCLUSION

Long-term effects of firearm-injured patients were poorer than matched MVC and the standard population in few domains. Further study in a larger, prospectively recruited cohort is warranted to better characterize physical and mental health outcomes.

Acute Care Surgery and Surgical Rescue: Expanding the Definition

BACKGROUND

Surgical rescue (SR) is the recovery of patients with surgical complications. Patients transferred (TP) for surgical diagnoses to higher-level care or inpatients (IP) admitted to nonsurgical services may develop intra-abdominal infection (IAI) and require emergency surgery (ES). The aims were to characterize the SR population by the site of ES consultation, open abdomen (OA), and risk of mortality.

STUDY DESIGN

This was an international, multi-institutional prospective observational study of patients requiring ES for IAI. Laparotomy before the transfer was an exclusion criterion. Patients were divided into groups: clinic/ED (C/ED), IP, or TP. Data collected included demographics, the severity of illness (SOI), procedures, OA, and number of laparotomies. The primary outcome was mortality. Multivariable logistic regression models were constructed.

RESULTS

There were 752 study patients (C/ED 63.8% vs TP 23.4% and IP 12.8%), with a mean age of 59 years and 43.6% women. IP had worse SOI scores (Charlson Comorbidity Index, American Society of Anesthesiologists Physical Status Classification System, and Sequential Organ Failure Assessment). The most common procedures were small and large bowel (77.3%). IP and TP had similar rates of OA (IP 52.1% and TP 52.3 %) vs C/ED (37.7%, p < 0.001), and IP had more relaparotomies (3 or 4). The unadjusted mortality rate was highest in IP (n = 24, 25.0%) vs TP (n = 29, 16.5%) and C/ED (n = 68, 14.2%, p = 0.03). Adjusting for age and SOI, only SOI had an impact on the risk of mortality (area under the curve 86%).

CONCLUSIONS

IP had the highest unadjusted mortality after ES for IAI and was followed by the TP; SOI drove the risk of mortality. SR must be extended to IP for timely recognition of the IAI.

Missed blunt cerebrovascular injuries using current screening criteria - The time for liberalized screening is now

Diagnostic Criteria Study BACKGROUND: The morbidity and mortality associated with ischemic stroke attributable to blunt cerebrovascular injury (BCVI) warrant aggressive screening. The Denver Criteria (DC) and Expanded Denver Criteria (eDC) have imprecise elements that can be difficult and subjective in application and can delay or prevent screening. We hypothesize these screening criteria lack adequate ability to consistently identify BCVI and that the use of a liberalized screening approach with CT angiography (CTA) is superior without increasing risk of acute kidney injury (AKI).

METHODS

This was a multi-institutional retrospective cohort study of trauma patients who presented between 2015-2020 with radiographically confirmed BCVI diagnosed using each institutions' liberalized screening protocol, defined as automatic CTA of the head and neck for all patients undergoing head and neck CT. Outcomes of interest included AKI, stroke, and death due to BCVI. Outcomes were reported as frequency, percent, and 95% confidence interval as calculated by the Clopper-Pearson method. Incidence of medical follow-up within 1 year of first medical visit was quantified as the median and inter-quartile range of days to follow-up visit.

RESULTS

We identified 433 BCVI patients with a mean age of 45.2 (standard deviation 18.9) years, 256 men and 177 women, 1.73 m (0.10) tall, and weighed 80.3 kg (20.3). Forty-one patients had strokes (9.5% [95% confidence interval 6.9, 12.6] and 12 patients (2.8% [1.4, 4.5]) had mortality attributable to BCVI. Of 433 total cases, 132 (30.5% [26.2, 35.1]) would have been missed by DC and 150 (34.6% [30.2, 39.3]) by eDC. Incidence of AKI in our BCVI population was 6 (1.4% [0.01, 3.0]).

CONCLUSIONS

BCVI would be missed over 30% of the time using the DC and eDC compared to liberalized use of screening CTA. Risk of AKI due to CTA did not occur at a clinically meaningful level, supporting liberal CTA screening.

General surgeon involvement in the care of patients designated with an American Association for the Surgery of Trauma-endorsed ICD-10-CM emergency general surgery diagnosis code in Wisconsin

BACKGROUND

The current national burden of emergency general surgery (EGS) illnesses and the extent of surgeon involvement in the care of these patients remain largely unknown. To inform needs assessments, research, and education, we sought to: (1) translate previously developed International Classification of Diseases (ICD), 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes representing EGS conditions to ICD 10th Revision, CM (ICD-10-CM) codes and (2) determine the national burden of and assess surgeon involvement across EGS conditions.

METHODS

We converted ICD-9-CM codes to candidate ICD-10-CM codes using General Equivalence Mappings then iteratively refined the code list. We used National Inpatient Sample 2016 to 2017 data to develop a national estimate of the burden of EGS disease. To evaluate surgeon involvement, using Wisconsin Hospital Association discharge data (January 1, 2016 to June 30, 2018), we selected adult urgent/emergent encounters with an EGS condition as the principal diagnosis. Surgeon involvement was defined as a surgeon being either the attending provider or procedural physician.

RESULTS

Four hundred and eighty-five ICD-9-CM codes mapped to 1,696 ICD-10-CM codes. The final list contained 985 ICD-10-CM codes. Nationally, there were 2,977,843 adult patient encounters with an ICD-10-CM EGS diagnosis. Of 94,903 EGS patients in the Wisconsin Hospital Association data set, most encounters were inpatient as compared with observation (75,878 [80.0%] vs. 19,025 [20.0%]). There were 57,780 patients (60.9%) that underwent any procedure. Among all Wisconsin EGS patients, most had no surgeon involvement (64.9% [n = 61,616]). Of the seven most common EGS diagnoses, surgeon involvement was highest for appendicitis (96.0%) and biliary tract disease (77.1%). For the other five most common conditions (skin/soft tissue infections, gastrointestinal hemorrhage, intestinal obstruction/ileus, pancreatitis, diverticular disease), surgeons were involved in roughly 20% of patient care episodes.

CONCLUSION

Surgeon involvement for EGS conditions ranges from highly likely (appendicitis) to relatively unlikely (skin/soft tissue infections). The wide range in surgeon involvement underscores the importance of multidisciplinary collaboration in the care of EGS patients.

LEVEL OF EVIDENCE

Prognostic/epidemiological, Level III.

Multi-center validation of the Bowel Injury Predictive Score (BIPS) for the early identification of need to operate in blunt bowel and mesenteric injuries

INTRODUCTION

The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study.

MATERIALS AND METHODS

Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study.

RESULTS

Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS < 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively.

CONCLUSION

This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

The Emergency Surgery Score accurately predicts the need for postdischarge respiratory and renal support after emergent laparotomies: A prospective EAST multicenter study

BACKGROUND

The Emergency Surgery Score (ESS) was recently validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively evaluate whether ESS can predict the need for respiratory and/or renal support (RRS) at discharge after emergent laparotomies (EL).

METHODS

This is a post hoc analysis of a 19-center prospective observational study. Between April 2018 and June 2019, all adult patients undergoing EL were enrolled. Preoperative, intraoperative, and postoperative variables were systematically collected. In this analysis, patients were excluded if they died during the index hospitalization, were discharged to hospice, or transferred to other hospitals. A composite variable, the need for RRS, was defined as the need for one or more of the following at hospital discharge: tracheostomy, ventilator dependence, or dialysis. Emergency Surgery Score was calculated for all patients, and the correlation between ESS and RRS was examined using the c-statistics method.

RESULTS

From a total of 1,649 patients, 1,347 were included. Median age was 60 years, 49.4% were men, and 70.9% were White. The most common diagnoses were hollow viscus organ perforation (28.1%) and small bowel obstruction (24.5%); 87 patients (6.5%) had a need for RRS (4.7% tracheostomy, 2.7% dialysis, and 1.3% ventilator dependence). Emergency Surgery Score predicted the need for RRS in a stepwise fashion; for example, 0.7%, 26.2%, and 85.7% of patients required RRS at an ESS of 2, 12, and 16, respectively. The c-statistics for the need for RRS, the need for tracheostomy, ventilator dependence, or dialysis at discharge were 0.84, 0.82, 0.79, and 0.88, respectively.

CONCLUSION

Emergency Surgery Score accurately predicts the need for RRS at discharge in EL patients and could be used for preoperative patient counseling and for quality of care benchmarking.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

The emergency surgery score (ESS) and outcomes in elderly patients undergoing emergency laparotomy: A post-hoc analysis of an EAST multicenter study

INTRODUCTION

We sought to evaluate whether the Emergency Surgery Score (ESS) can accurately predict outcomes in elderly patients undergoing emergent laparotomy (EL).

METHODS

This is a post-hoc analysis of an EAST multicenter study. Between April 2018 and June 2019, all adult patients undergoing EL in 19 participating hospitals were prospectively enrolled, and ESS was calculated for each patient. Using the c-statistic, the correlation between ESS and mortality, morbidity, and need for ICU admission was assessed in three patient age cohorts (65-74, 75-84, ≥85 years old).

RESULTS

715 patients were included, of which 52% were 65-74, 34% were 75-84, and 14% were ≥85 years old; 51% were female, and 77% were white. ESS strongly correlated with postoperative mortality (c-statistic:0.81). Mortality gradually increased from 0% to 20%-60% at ESS of 2, 10 and 16 points, respectively. ESS predicted mortality, morbidity, and need for ICU best in patients 65-74 years old (c-statistic:0.81, 0.75, 0.83 respectively), but its performance significantly decreased in patients ≥85 years (c-statistic:0.72, 0.64, 0.67 respectively).

CONCLUSION

ESS is an accurate predictor of outcome in the elderly EL patient 65-85 years old, but its performance decreases for patients ≥85. Consideration should be given to modify ESS to better predict outcomes in the very elderly patient population.

Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications

Background

The Brain Injury Guidelines provide an algorithm fortreating patients with traumatic brain injury (TBI) and intracranial hemorrhage(ICH) that does not mandate hospital admission, repeat head CT, orneurosurgical consult for all patients. The purposes of this study are toreview the guidelines' safety, to assess resource utilization, and to proposeguideline modifications that improve patient safety and widespreadreproducibility.

Methods

A multi-institutional review of TBI patients was conducted. Patients with ICH on CT were classified as BIG 1, 2, or 3 based on the guidelines. BIG 3 patients were excluded. Variables collected included demographics, Injury Severity Score (ISS), hospital length of stay (LOS), intensive care unit LOS, number of head CTs, type of injury, progression of injury, and neurosurgical interventions performed.

Results

269 patients met inclusion criteria. 98 were classifiedas BIG 1 and 171 as BIG 2. The median length of stay (LOS) was 2 (2,4)days and the ICU LOS was 1 (0,2) days. Most patients had a neurosurgeryconsultation (95.9%) and all patients included had a repeat head CT. 370repeat head CT scans were performed, representing 1.38 repeat scans perpatient. 11.2% of BIG 1 and 11.1% of BIG 2 patients demonstratedworsening on repeat head CT. Patients who progressed exhibited a higherISS (14 vs. 10, p=0.040), and had a longer length of stay (4 vs. 2 days;p=0.015). After adjusting for other variables, the presence of epiduralhematoma (EDH) and intraparenchymal hematoma were independent predictors ofprogression. Two BIG 2 patients with EDH had clinical deteriorationrequiring intervention.

Discussion

The Brain Injury Guidelines may improve resourceallocation if utilized, but alterations are required to ensure patientsafety. The modified Brain Injury Guidelines refine the originalguidelines to enhance reproducibility and patient safety while continuing toprovide improved resource utilization in TBI management.

Protocol driven management of suspected common duct stones: A Southwestern Surgical Congress multi-centered trial

BACKGROUND

Several options exist for the diagnosis and management of suspected common duct stones. We hypothesized that a protocol-directed approach would shorten length of stay in this patient population.

METHODS

Patients from four participating institutions with a peak bilirubin <4 mg/dL underwent surgery as the initial procedure, whereas patients with a bilirubin ≥4 mg/dL underwent endoscopy. The primary endpoint was length of stay. Analysis involved chi square and Wilcoxon-Mann-Whitney test with significance at p < 0.05.

RESULTS

214 patients were managed under the protocol during six-month study period. 111 patients (52%) required endoscopy and surgery. Length of stay and the number of MRCPs performed pre-operatively significantly decreased following protocol implementation (p < 0.05).

CONCLUSIONS

"Surgery first" approach in patients with bilirubin <4 ml/dL resulted in low morbidity and mortality, reduced MRCP, and length of stay.

Infection after penetrating brain injury-An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15-19, 2019, in Austin, Texas

BACKGROUND

Fatality rates following penetrating traumatic brain injury (pTBI) are extremely high and survivors are often left with significant disability. Infection following pTBI is associated with worse morbidity. The modern rates of central nervous system infections (INF) in civilian survivors are unknown. This study sought to determine the rate of and risk factors for INF following pTBI and to determine the impact of antibiotic prophylaxis.

METHODS

Seventeen institutions submitted adult patients with pTBI and survival of more than 72 hours from 2006 to 2016. Patients were stratified by the presence or absence of infection and the use or omission of prophylactic antibiotics. Study was powered at 85% to detect a difference in infection rate of 5%. Primary endpoint was the impact of prophylactic antibiotics on INF. Mantel-Haenszel χ and Wilcoxon's rank-sum tests were used to compare categorical and nonparametric variables. Significance greater than p = 0.2 was included in a logistic regression adjusted for center.

RESULTS

Seven hundred sixty-three patients with pTBI were identified over 11 years. 7% (n = 51) of patients developed an INF. Sixty-six percent of INF patients received prophylactic antibiotics. Sixty-two percent of all patients received one dose or greater of prophylactic antibiotics and 50% of patients received extended antibiotics. Degree of dural penetration did not appear to impact the incidence of INF (p = 0.8) nor did trajectory through the oropharynx (p = 0.18). Controlling for other variables, there was no statistically significant difference in INF with the use of prophylactic antibiotics (p = 0.5). Infection was higher in patients with intracerebral pressure monitors (4% vs. 12%; p = <0.001) and in patients with surgical intervention (10% vs. 3%; p < 0.001).

CONCLUSION

There is no reduction in INF with prophylactic antibiotics in pTBI. Surgical intervention and invasive intracerebral pressure monitoring appear to be risk factors for INF regardless of prophylactic use.

LEVEL OF EVIDENCE

Therapeutic, level IV.

A modern, multicenter evaluation of hepatic angioembolization - Complications and readmissions persist

BACKGROUND

Indications for angioembolization (AE) following liver injury are not clearly defined. This study evaluated the outcomes and complications of hepatic AE. We hypothesize hepatic angioembolization is a useful adjunct to non-operative management of liver injury but with significant morbidity.

METHODS

Subjects were identified utilizing trauma registries from centers in a regional trauma network from 2010 to 2017 with an Abbreviated Injury Scale (AIS) coded hepatic injury and an ICD9/10 for hepatic angiography (HA).

RESULTS

1319 patients with liver injuries were identified, with 30 (2.3%) patients undergoing HA: median ISS was 26, and median liver AIS was 4. Twenty-three subjects required AE. 81% had extravasation on CT from a liver injury. 63% underwent HA as initial intervention. 43% of AE subjects had liver-related complications with 35% 30-day readmission but with zero 30-day mortality.

CONCLUSIONS

While there were zero reported deaths, a high rate of morbidity and readmission was found. This may be due to the angioembolization or the liver injury itself.

Aerial drone misadventure: A novel case of trauma resulting in ocular globe rupture

Purpose

The purpose of this case report is to present the novel findings of a drone causing such a traumatic ocular injury and provide recommendations for how it might be prevented.

Observations

We report on a recent case where a child presented to our Emergency Department after incurring a blow to the face by the propeller of a remote controlled drone. The patient suffered significant trauma including rupture of the right globe.

Conclusions

As drone sales continue to rise, it is important that physicians be prepared to treat the potential injuries that may result from using these devices. Furthermore, in an attempt to reduce the number of visits associated with remote controlled drones, physicians should be prepared to provide advice as to how patients can reduce the risks of injury.

Importance

We hope that the framework and recommendations below will help physicians decrease adverse outcomes related to this unusual injury pattern.

Emergency department management of patients with rib fracture based on a clinical practice guideline

Background

Clinical practice guidelines (CPGs) have the ability to increase efficiency and standardize care. A CPG based on forced vital capacity (FVC) for rib fractures was developed as a tool for triage of these patients. The objectives of this study were to assess the efficacy and compliance of physicians with this rib fracture CPG.

Methods

Patients >18 that were discharged from an urban level 2 trauma center emergency department (ED) between the dates of January 1, 2014, to December 31, 2016, were eligible for the study. Demographics, mechanism, outcomes and FVC were abstracted by review of the electronic medical record. Compliance with the CPG was examined, and comparisons were made between patients successfully discharged and patients who returned.

Results

455 patients met were identified during the study period. 233 were eligible after exclusions. 64% of the cohort was male with median age of 53 years. Falls were the most common mechanism (59.6%). The median number of rib fractures was 2 and median FVC 2500 mL. 28 (12.0%) of the 233 returned to the ED after discharge. The groups were well matched with no significant differences. The most common reason for return was pain (95%). Adjusted analysis showed that increasing age (adjusted OR (AOR) 0.968) and FVC (AOR 0.999) were independent predictors. Adherence with the CPG was good for hemothorax/pneumothorax and bilateral fractures (96%), but lagged with the number of fractures (74%).

Conclusions

This study confirms that the rib fracture CPG is safe and an FVC of 1500 mL is a safe criterion for discharging patients with rib fractures. Interestingly, it appears that older age is protective. More work needs to be done on effective pain control to decrease return to ED visits using this CPG.

Level of evidence

IV.

Type of study

Therapeutic.