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Background The most recent management guidelines advocate computed tomography angiography (CTA) for any suspected vascular or aero-digestive injuries in all zones and give zone II injuries special consideration. We hypothesized that physical examination can safely guide CTA use in a “no zone” approach. Methods An 8-year retrospective analysis of all adult trauma patients with penetrating neck trauma (PNT) was performed. We included all patients in whom the platysma was violated. Patients were classified into three groups as follows: hard signs, soft signs, and asymptomatic. CTA use, positive CTA (contrast extravasation, dissection, or intimal flap) and operative details were reported. Primary outcomes were positive CTA and therapeutic neck exploration (TNE) (defined by repair of major vascular or aero-digestive injuries). Results A total of 337 patients with PNT met the inclusion criteria. Eighty-two patients had hard signs and all of them went to the operating room, of which 59 (72%) had TNE. One hundred fifty-six patients had soft signs, of which CTA was performed in 121 (78%), with positive findings in 12 (10%) patients. The remaining 35 (22%) underwent initial neck exploration, of which 14 (40%) were therapeutic yielding a high rate of negative exploration. Ninty-nine patients were asymptomatic, of which CTA was performed in 79 (80%), with positive findings in 3 (4%), however, none of these patients required TNE. On sub analysis based on symptoms, there was no difference in the rate of TNE between the neck zones in patients with hard signs ( P = 0.23) or soft signs ( P = 0.51). Regardless of the zone of injury, asymptomatic patients did not require a TNE. Conclusions Physical examination regardless of the zone of injury should be the primary guide to CTA or TNE in patients with PNT. Following traditional zone-based guidelines can result in unnecessary negative explorations in patients with soft signs and may need rethinking. [ABSTRACT FROM AUTHOR]

Background Multiple prior studies have suggested an association between survival and beta-blocker administration in patients with severe traumatic brain injury (TBI). However, it is unknown whether this benefit of beta-blockers is dependent on heart rate control. The aim of this study was to assess whether rate control affects survival in patients receiving metoprolol with severe TBI. Our hypothesis was that improved survival from beta-blockade would be associated with a reduction in heart rate. Methods We performed a 7-y retrospective analysis of all blunt TBI patients at a level-1 trauma center. Patients aged >16 y with head abbreviated injury scale 4 or 5, admitted to the intensive care unit (ICU) from the operating room or emergency room (ER), were included. Patients were stratified into two groups: metoprolol and no beta-blockers. Using propensity score matching, we matched the patients in two groups in a 1:1 ratio controlling for age, gender, race, admission vital signs, Glasgow coma scale, injury severity score, mean heart rate monitored during ICU admission, and standard deviation of heart rate during the ICU admission. Our primary outcome measure was mortality. Results A total of 914 patients met our inclusion criteria, of whom 189 received beta-blockers. A propensity-matched cohort of 356 patients (178: metoprolol and 178: no beta-blockers) was created. Patients receiving metoprolol had higher survival than those patients who did not receive beta-blockers (78% versus 68%; P = 0.04); however, there was no difference in the mean heart rate (89.9 ± 13.9 versus 89.9 ± 15; P = 0.99). Nor was there a difference in the mean of standard deviation of the heart rates (14.7 ± 6.3 versus 14.4 ± 6.5; P = 0.65) between the two groups. In Kaplan–Meier survival analysis, patients who received metoprolol had a survival advantage ( P = 0.011) compared with patients who did not receive any beta-blockers. Conclusions Our study shows an association with improved survival in patients with severe TBI receiving metoprolol, and this effect appears to be independent of any reduction in heart rate. We suggest that beta-blockers should be administered to all severe TBI patients irregardless of any perceived beta-blockade effect on heart rate. [ABSTRACT FROM AUTHOR]

Background Studies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI. Methods Version 7.2 of the National Trauma Data Bank (2007-2010) was queried for all patients with isolated blunt severe TBI (Head Abbreviated Injury Score ≥4) and blood ETOH levels recorded on admission. Primary outcome measure was mortality. Multivariate logistic regression analysis was performed to assess factors predicting mortality and in-hospital complications. Results A total of 23,983 patients with severe TBI were evaluated of which 22.8% (n = 5461) patients tested positive for ETOH intoxication. ETOH-positive patients were more likely to have in-hospital complications (P = 0.001) and have a higher mortality rate (P = 0.01). ETOH intoxication was an independent predictor for mortality (odds ratio: 1.2, 95% confidence interval: 1.1-2.1, P = 0.01) and development of in-hospital complications (odds ratio: 1.3, 95% confidence interval: 1.1-2.8, P = 0.009) in patients with isolated severe TBI. Conclusions ETOH intoxication is an independent predictor for mortality in patients with severe TBI patients and is associated with higher complication rates. Our results from the National Trauma Data Standards differ from those previously reported. The proposed neuroprotective role of ETOH needs further clarification. [ABSTRACT FROM AUTHOR]

Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP. FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost. During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs. In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency. [ABSTRACT FROM AUTHOR]

Background Sepsis remains the leading cause of death in the surgical intensive care unit. Prior studies have demonstrated a survival benefit of remote ischemic conditioning (RIC) in many disease states. The aim of this study was to determine the effects of RIC on survival in sepsis in an animal model and to assess alterations in inflammatory biochemical profiles. We hypothesized that RIC alters inflammatory biochemical profiles resulting in decreased mortality in a septic mouse model. Materials and methods Eight to 12 week C57BL/6 mice received intra-peritoneal injection of 12.5-mg/kg lipopolysaccharide (LPS). Septic animals in the experimental group underwent RIC at 0, 2, and 6 h after LPS by surgical exploration and alternate clamping of the femoral artery. Six 4-min cycles of ischemia-reperfusion were performed. Primary outcome was survival at 5-d after LPS injection. Secondary outcome was to assess the following serum cytokine levels: interferon-γ (IFN-γ), interleukin (IL)-10, IL-1β, and tumor necrosis factoralpha (TNFα) at the baseline before LPS injection, 0 hour after LPS injection, and at 2, 4, 24 hours after induction of sepsis (RIC was performed at 2 h after LPS injection). Kaplan–Meier survival analysis and log-rank test were used. ANOVA test was used to compare cytokine measurements. Results We performed experiments on 44 mice: 14 sham and 30 RIC mice (10 at each time point). Overall survival was higher in the experimental group compared to the sham group (57% versus 21%; P = 0.02), with the highest survival rate observed in the 2-hour post-RIC group (70%). On Kaplan–Meier analysis, 2-h post-RIC group had increased survival at 5 days after LPS ( P = 0.04) with hazard ratio of 0.3 (95% confidence interval = 0.09-0.98). In the RIC group, serum concentrations of IFN-γ, IL-10, IL-1β, and TNFα peaked at 2 h after LPS and then decreased significantly over 24 hours ( P < 0.0001) compared to the baseline. Conclusions RIC improves survival in sepsis and has the potential for implementation in the clinical practice. Early implementation of RIC may play an immune-modulatory role in sepsis. Further studies are necessary to refine understanding of the observed survival benefits and its implications in sepsis management. [ABSTRACT FROM AUTHOR]

Background Brain Trauma Foundation (BTF) guidelines recommend intracranial pressure (ICP) monitoring for traumatic brain injury (TBI) patients with a Glasgow Coma Scale score of 8 or less with an abnormal head computed tomography, or a normal head computed tomography scan with systolic blood pressure ≤90 mm Hg, posturing, or in patients of age ≥40. The benefits of these guidelines on outcome remain unproven. We hypothesized that adherence to BTF guidelines for ICP monitoring does not improve outcomes in patients with TBI. Methods All TBI patients with an admission Glasgow Coma Scale ≤8 admitted to our level I trauma center over a 3-y period were identified. Adherence to the individual components of our institutional TBI Bundle (ICP monitoring, SpO2 ≥95%, PaCO2 30-39 mm Hg, systolic blood pressure ≥90 mm Hg, cerebral perfusion pressure ≥60 mm Hg, ICP ≤25 mm Hg, and temperature 36°C-37°C) was assessed. Patients were stratified into two groups as follows: patients with ICP monitoring (ICP) and patients without ICP monitoring (no-ICP). Outcome measures were survival and discharge disposition. Multivariate regression analysis was performed. Results We identified 2618 TBI patients, 261 of whom met the BTF criteria for ICP monitoring. After excluding those with nonsurvivable injuries (n = 67), 194 patients were available for analysis. The two groups were similar in demographics and severity of head injury. Survival rate was higher in the no-ICP group compared with that in the ICP group (98% versus 76%, P < 0.004). Non-monitored patients were discharged with higher levels of function per discharge location (28% home versus 4% home; P < 0.001). Patients without ICP monitoring were 1.21 times more likely to survive compared with that of patients with ICP monitoring (odds ratio: 1.21, 95% confidence interval [1.1-1.9], P = 0.01). In the ICP group, the overall compliance rate to the ICP and cerebral perfusion pressure goals as required by the BTF guidelines was poor. Conclusions Our data suggest that there is a subset of patients meeting BTF criteria for ICP monitoring that do well without ICP monitoring. This finding should provoke reevaluation of the indication and utility of ICP monitoring in TBI patients. [ABSTRACT FROM AUTHOR]

Background Falls from ladders account for a significant number of hospital visits. However, the epidemiology, injury pattern, and how age affects such falls are poorly described in the literature. Materials and methods Patients ≥18 y who suffered falls from ladders over a 51/2-y period were identified in our trauma registry. Dividing patients into three age groups (18-45, 46-65, and >66 y), we compared demographic characteristics, clinical data, and outcomes including injury pattern and mortality. The odds ratios (ORs) were calculated with the group 18-45 y as reference; group means were compared with one-way analysis of variance. Results Of 27,155 trauma patients, 340 (1.3%) had suffered falls from ladders. The average age was 55 y, with a male predominance of 89.3%. Average fall height was 9.8 ft, and mean Injury Severity Score was 10.6. Increasing age was associated with a decrease in the mean fall height (P < 0.001), an increase in the mean Injury Severity Score (P < 0.05), and higher likelihood of admission (>66 y: OR, 5.3; confidence interval [CI], 2.5-11.5). In univariate analysis, patients in the >66-y age group were more likely to sustain traumatic brain injuries (OR, 3.4; CI, 1.5-7.8) and truncal injuries (OR, 3.6; CI, 1.9-7.0) and less likely to sustain hand and/or forearm fractures (OR, 0.3; CI, 0.1-0.9). Conclusions Older people are particularly vulnerable after falling from ladders. Although they fell from lower heights, the elderly sustained different and more severe injury patterns. Ladder safety education should be particularly tailored at the elderly. [ABSTRACT FROM AUTHOR]

Background Geriatric patients are at higher risk for adverse outcomes after injury because of their altered physiological reserve. Mortality after trauma laparotomy remains high; however, outcomes in geriatric patients after trauma laparotomy have not been well established. The aim of our study was to identify factors predicting mortality in geriatric trauma patients undergoing laparotomy. Methods A retrospective study was performed of all trauma patients undergoing a laparotomy at our level 1 trauma center over a 6-y period (2006-2012). Patients with age ≥55 y who underwent a trauma laparotomy were included. Patients with head abbreviated injury scale (AIS) score ≥ 3 or thorax AIS ≥ 3 were excluded. Our primary outcome measure was mortality. Significant factors in univariate regression model were used in multivariate regression analysis to evaluate the factors predicting mortality. Results A total of 1150 patients underwent a trauma laparotomy. Of which 90 patients met inclusion criteria. The mean age was 67 ± 10 y, 63% were male, and median abdominal AIS was 3 (2-4). Overall mortality rate was 23.3% (21/90) and progressively increased with age (P = 0.013). Age (P = 0.02) and lactate (P = 0.02) were the independent predictors of mortality in geriatric patients undergoing laparotomy. Conclusions Mortality rate after trauma laparotomy increases with increasing age. Age and admission lactate were the predictors of mortality in geriatric population undergoing trauma laparotomies. [ABSTRACT FROM AUTHOR]

Abstract: Background: Most studies have categorized all antiplatelet drugs into one category. The aim of our study was to evaluate the utility of repeat head computed tomography (RHCT) and outcomes in patients on low-dose aspirin (acetylsalicylic acid; ASA) therapy. Methods: Patients with traumatic brain injury with intracranial hemorrhage on initial head computed tomography (CT) were prospectively enrolled. Patients on prehospital low-dose (81 mg) aspirin therapy were matched with patients exclusive of antiplatelet and anticoagulation therapy using propensity score matching in a 1:1 ratio for age, Glasgow Coma Scale, head Abbreviated Injury Scale score, Injury Severity Score, and neurological examination. Outcome measures were progression on RHCT and subsequent neurosurgical intervention. Results: A total of 144 patients who had intracranial hemorrhage on initial CT scan (ASA group: 72; No-ASA group: 72) were enrolled. The mean age was 72.8 ± 11.7 years, 59.7% were male, and median head Abbreviated Injury Scale was 3 (2–3). There was no difference in progression on RHCT (25% in ASA versus 16.6% in no-ASA), change in management as a result of RHCT (1.4% versus 1.4%), RHCT as a result of neurological decline (0 versus 1.4%), discharge Glasgow Coma Scale (15 [14–15] versus 15 [14–15]), and mortality (0 versus 1.4%) between the two groups. Conclusions: Low-dose aspirin therapy is not associated with progression of initial insult on RHCT or clinical deterioration. Prehospital low-dose aspirin therapy as a sole criterion should not warrant a routine repeat head CT in traumatic brain injury. [Copyright &y& Elsevier]

Abstract: Background: Variability exits in the ability to predict overall recovery after trauma and inpatient rehabilitation. The aim of this study was to identify factors predicting functional improvement in trauma patients undergoing inpatient rehabilitation. Methods: We performed a 3-y retrospective cohort analysis on a prospectively collected database of all trauma patients discharged from a level I trauma center to a single inpatient rehabilitation center. Patient's Functional Independence Measures (FIM) scores on hospital discharge and on discharge from the rehabilitation center were collected. Delta FIM was defined as the difference in FIM between rehabilitation center discharge and hospital discharge. Multiple linear regressions were performed to identify hospital admission factors associated with delta FIM. Results: We included 160 patients, 69% were male, mean age 54.6 ± 22 y, and median Injury Severity Score 14 [10–50]. Based on rehabilitation admission FIM scores, 29 were totally dependent and 131 were partially dependent. The mean change in FIM was 39.4 ± 13. Age, gender, Glasgow Coma Scale on presentation, Injury Severity Score, systolic blood pressure on presentation, and intensive care unit length of stay were not predictive of delta FIM. Hospital length of stay and head Abbreviated Injury Score on hospital admission were negative predictors of delta FIM. Conclusions: In our study, age as an independent factor was not predictive of functional outcome after injury. The extent of head injury continues to negatively affect the overall functional improvement based on FIM. [Copyright &y& Elsevier]

Abstract: Background: Sleep deprivation, common in intensive care unit (ICU) patients, may be associated with increased morbidity and/or mortality. We previously demonstrated that significant numbers of nocturnal nursing interactions (NNIs) occur during the routine care of surgical ICU patients. For this study, we assessed the quantity and type of NNIs in different ICU types: medical, surgical, cardiothoracic, pediatric, and neonatal. We hypothesized that the number and type of NNIs vary among different ICU types. Material and methods: We performed a prospective observational cohort study at our academic medical center examining potential sleep disruption in ICU patients secondary to NNIs from the hours 2200–0600 nightly. From May through November 2011, bedside nursing staff in five different ICUs collected data on NNIs, including the frequency and nature of each event (patient care activity, nursing intervention, nursing assessment, or patient-initiated contact) as well as the length of time of each event and whether the bedside care provider thought that the event could have been safely omitted without negatively affecting patient care. Additional data collected included patient demographics, the need for mechanical ventilation, and sedative/narcotic use. Results: Two hundred ICU patients were enrolled over 51 separate nocturnal time periods (3.9 patients/nocturnal time period). Of those 200 patients, 53 (26.5%) were mechanically ventilated; 12.5% underwent sedative infusion; and 23.0% underwent narcotic infusion. There were a total of 1831 NNIs; most (67%) were due to nursing assessment or patient care activity. The surgical ICU had the most frequent NNIs (11.8 ± 9.0), although they were the shortest (6.66 ± 6.06 min), as well as the highest proportion of NNIs that could have been safely omitted (20.9%). Nursing staff estimated that, of all NNIs in all ICU types, 13.9% could have been safely omitted. Conclusions: NNIs occur frequently and vary across different ICU types. Many NNIs are due to nursing assessment and patient care activities, much of which could be safely omitted or clustered. A protocol for nocturnal sleep promotion is warranted in order to standardize ICU NNIs and minimize nighttime sleep disruptions. [Copyright &y& Elsevier]

Background: The purpose of this article is to describe a new model of traumatic intra-cavitary hemorrhage in a hypothermic, hemodiluted liver injury model that incorporates damage control principles and allows for survival. Materials and Methods: Twenty swine underwent a standardized 35% blood volume hemorrhage followed by resuscitation. Ten animals sustained nonsurgical and 10 a surgical high-grade liver injury. In the surgical liver injury, damage control gauze packing was performed. No operative treatment was provided for the nonsurgical liver injury, which was designed to test the efficacy of systemic hemostatic agents. After a 15min treatment phase, the abdominal cavity was closed, with the packing in place for the surgical injury, and all animals were resuscitated. Necropsy was performed at 48h post-injury. Results: At the time of liver injury, the animals were hemodiluted and hypothermic. Both injuries caused a 20% drop in the mean arterial pressure from baseline (P <0.001). Comparing baseline thromboelastography results with the results after hemodilution, hypothermia, and liver injury, a hypercoagulopathic state was observed. Mortality was 30% for both types of liver injury. The mean volume of intra-abdominal blood present at autopsy was similar for both types of liver injuries (202±161mL and 214±203mL, respectively). Conclusion: A new model of traumatic intra-cavitary hemorrhage in a hypothermic, hemodiluted liver injury model with damage control that allows for survival has been described. The mortality rate of 30% allows for the comparison of therapeutic interventions that may lead to improved survival. [Copyright &y& Elsevier]

Background: Lethal injuries can be repaired under asanguineous hypothermic arrest (suspended animation) with excellent survival. This experiment was designed to test the impact of this strategy on neuronal and astroglial damage in a swine model of lethal hemorrhage. Furthermore, our goal was to correlate the histological changes in the brain with neurological outcome, and the levels of circulating brain specific markers. Materials and methods: Uncontrolled hemorrhage was induced in 32 female swine (80–120 lbs) by creating an iliac artery and vein injury, followed 30 min later by laceration of the thoracic aorta. Through a thoracotomy approach, organ preservation fluid was infused into the aorta using a roller pump. Experimental groups included normothermic controls (no cooling, NC), and groups where hypothermia was induced at three different rates: 0.5°C/min (slow, SC), 1°C/min (medium, MC), or 2°C/min (fast, FC). Profound hypothermia (core temperature of 10°C) was maintained for 60 min for repair of vascular injuries, after which the animals were re-warmed (0.5°C/min) and resuscitated on cardiopulmonary bypass (CPB). Circulating levels of neuron specific enolase (NSE) and S-100β were serially measured as markers of damage to neurons and astrocytes, respectively. Light microscopy and quantitative immunohistochemical techniques were used to evaluate hippocampal CA1 area and caudate putamen for neuronal injury and astrogliosis (astrocyte hyperplasia/hypertrophy). Surviving animals were observed for 6 weeks and neurological status was documented on an objective scale, and cognitive functions were evaluated using a technique based upon the concept of operant conditioning. Results: Normothermic arrest resulted in clinical brain death in all of the animals. None of the surviving hypothermic animals displayed any neurological deficits or cognitive impairment. On histological examination, normothermic animals were found to have ischemic changes in the neurons and astrocytes (hypertrophy). In contrast, all of the hypothermic animals had histologically normal brains. The circulating levels of brain specific proteins did not correlate with the degree of brain damage. The changes in NSE levels were not statistically significant, whereas S-100β increased in the circulation after CPB, largely independent of the temperature modulation. Conclusions: Profound hypothermia can preserve viability of neurons and astrocytes during prolonged periods of cerebral hypoxia. This approach is associated with excellent cognitive and neurological outcome following severe shock. Circulating markers of central nervous system injury did not correlate with the actual degree of brain damage in this model. [Copyright &y& Elsevier]

Background: Matrix metalloproteinases (MMPs) and their specific physiological inhibitors, tissue inhibitors of metalloproteinases (TIMPs), are thought to play an essential role in tissue repair, cell death and morphogenesis. We have previously discovered unexpected up-regulation of genes coding for multiple MMP/TIMP family members in a rat model of hemorrhagic shock and resuscitation. However, the effect of different resuscitation protocols at the level of protein expression and function remains unknown. Materials and methods: Male Sprague-Dawley rats (n = 50; 10/group) were subjected to a three-stage volume controlled hemorrhage and resuscitated as follows: 1) lactated Ringer’s solution (LR), 3:1 volume of lost blood; 2) 7.5% hypertonic saline (HTS), 9.7 ml/kg; 3) plasma, 1:1 volume. Sham hemorrhage and sham resuscitation groups were used as controls. Expression of lung and spleen MMPs (-2, -7, -9, -10, -14, and -16), and TIMPs (-1, -2, and -3) was analyzed at transcriptional, functional and protein expression level using RT-PCR, ELISA, Western blotting, and gelatin zymography techniques. Results: Spleen was affected more than lung by the resuscitation strategy and the largest number of changes was caused by HTS resuscitation. RT-PCR confirmed an increased levels of MMP-2, MMP-9, MMP-7, MMP-14, MMP-16, and TIMP-1, TIMP-2 in the spleen of HTS group compared to sham groups, whereas in lungs transcriptional levels of only TIMP-3 and TIMP-1 were significantly changed. Conclusion: Expression of MMP and TIMP in lung and spleen following hemorrhage is modulated by the resuscitation strategy. [Copyright &y& Elsevier]