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BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is being increasingly adopted to manage noncompressible torso hemorrhage, but a recent analysis of the 2015 to 2016 Trauma Quality Improvement Project (TQIP) data set showed that placement of REBOA was associated with higher rates of death, lower extremity amputation, and acute kidney injury (AKI). We expand this analysis by including the 2017 data set, quantifying the potential role of residual confounding, and distinguishing between traumatic and ischemic lower extremity amputation. METHODS This retrospective study used the 2015 to 2017 TQIP database and included patients older than 18 years, with signs of life on arrival, who had no aortic injury and were not transferred. Resuscitative endovascular balloon occlusions of the aorta placed after 2 hours were excluded. We adjusted for baseline variables using propensity scores with inverse probability of treatment weighting. A sensitivity analysis was then conducted to determine the strength of an unmeasured confounder (e.g., unmeasured shock severity/response to resuscitation) that could explain the effect on mortality. Finally, lower extremity injury patterns of patients undergoing REBOA were inspected to distinguish amputation indicated for traumatic injury from complications of REBOA placement. RESULTS Of 1,392,482 patients meeting the inclusion criteria, 187 underwent REBOA. After inverse probability of treatment weighting, all covariates were balanced. The risk difference for mortality was 0.21 (0.14-0.29) and for AKI was 0.041 (-0.007 to 0.089). For the mortality effect to be explained by an unmeasured confounder, it would need to be stronger than any observed in terms of its relationship with mortality and with REBOA placement. Eleven REBOA patients underwent lower extremity amputation; however, they all suffered severe traumatic injury to the lower extremity. CONCLUSION There is no evidence in the TQIP data set to suggest that REBOA causes amputation, and the evidence for its effect on AKI is considerably weaker than previously reported. The increased mortality effect of REBOA is confirmed and could only be nullified by a potent confounder. LEVEL OF EVIDENCE Therapeutic/care management, level IV.

BACKGROUND Geriatric patients with rib fractures are at risk for developing complications and are often admitted to a higher level of care (intensive care units [ICUs]) based on existing guidelines. Forced vital capacity (FVC) has been shown to correlate with outcomes in patients with rib fractures. Complete spirometry may quantify pulmonary capacity, predict outcome, and potentially assist with admission triage decisions. METHODS We prospectively enrolled 86 patients, 60 years or older with three or more isolated rib fractures presenting after injury. After informed consent, patients were assessed with respect to pain (visual analog scale), grip strength, FVC, forced expiratory volume 1 second (FEV1), and negative inspiratory force on hospital days 1, 2, and 3. Outcomes included discharge disposition, length of stay (LOS), pneumonia, intubation, and unplanned ICU admission. RESULTS Mean age was 77.4 (SD, 10.2) and 43 (50.0%) were female. Forty-five patients (55.6%) were discharged home, median LOS was 4 days (interquartile range, 3-7). Pneumonias (2), unplanned ICU admissions (3), and intubation (1) were infrequent. Spirometry measures including FVC, FEV1, and grip strength predicted discharge to home and FEV1, and pain level on day 1 moderately correlated with the LOS. Within each subject, FVC, FEV1, and negative inspiratory force did not change for 3 days despite pain at rest and pain after spirometry improving from day 1 to 3 (p = 0.002, p < 0.001 respectively). Change in pain also did not predict outcomes and pain level was not associated with respiratory volumes on any of the 3 days. After adjustment for confounders, FEV1 remained a significant predictor of discharge home (odds ratio, 1.03; 95% confidence interval, 1.01-1.06) and LOS (p = 0.001). CONCLUSION Spirometry measurements early in the hospital stay predict ultimate discharge home, and this may allow immediate or early discharge. The impact of pain control on pulmonary function requires further study. LEVEL OF EVIDENCE Diagnostic test, level IV.

Background Survivors of gun violence may develop significant mental health sequelae and are at higher risk for reinjury through repeat violence. Despite this, survivors of gun violence often return to the community where they were injured with suboptimal support for their mental health, emotional recovery, and well-being. The goal of this study was to characterize the posthospitalization recovery experience of survivors of gun violence. Methods We conducted a qualitative research study with a community-based participatory research approach. In partnership with a community-based organization, we conducted in-depth one-on-one interviews and used snowball sampling to recruit survivors of gun violence. We applied the constant comparison method of qualitative analysis to catalogue interview transcript data by assigning conceptual codes and organizing them into a consensus list of themes. We presented the themes back to the participants and community members for confirmation. Results We conducted 20 interviews with survivors of gun violence; all were black men, aged 20 years to 51 years. Five recurring themes emerged: (1) Isolation, physical and social restriction due to fear of surroundings; (2) Protection, feeling unsafe leading to the desire to carry a gun; (3) Aggression, willingness to use a firearm in an altercation; (4) Normalization, lack of reaction driven by the ubiquity of gun violence in the community; and (5) Distrust of health care providers, a barrier to mental health treatment. Conclusion Survivors of gun violence describe a disrupted sense of safety following their injury. As a result, they experience isolation, an increased need to carry a firearm, a normalization of gun violence, and barriers to mental health treatment. These maladaptive reactions suggest a mechanism for the violent recidivism seen among survivors of gun violence and offer potential targets to help this undertreated, high-risk population. Level of evidence Care management/Therapeutic V.

BACKGROUND Expected performance rates for various outcome metrics are a hallmark of hospital quality indicators used by Agency of Healthcare Research and Quality, Center for Medicare and Medicaid Services, and National Quality Forum. The identification of outlier hospitals with above- and below-expected mortality for emergency general surgery (EGS) operations is therefore of great value for EGS quality improvement initiatives. The aim of this study was to determine hospital variation in mortality after EGS operations, and compare characteristics between outlier hospitals. METHODS Using data from the California State Inpatient Database (2010-2011), we identified patients who underwent one of eight common EGS operations. Expected mortality was obtained from a Bayesian model, adjusting for both patient- and hospital-level variables. A hospital-level standardized mortality ratio (SMR) was constructed (ratio of observed to expected deaths). Only hospitals performing three or more of each operation were included. An "outlier" hospital was defined as having an SMR with 80% confidence interval that did not cross 1.0. High- and low-mortality SMR outliers were compared. RESULTS There were 140,333 patients included from 220 hospitals. Standardized mortality ratio varied from a high of 2.6 (mortality, 160% higher than expected) to a low of 0.2 (mortality, 80% lower than expected); 12 hospitals were high SMR outliers, and 28 were low SMR outliers. Standardized mortality was over three times worse in the high SMR outliers compared with the low SMR outliers (1.7 vs. 0.5; p < 0.001). Hospital-, patient-, and operative-level characteristics were equivalent in each outlier group. CONCLUSION There exists significant hospital variation in standardized mortality after EGS operations. High SMR outliers have significant excess mortality, while low SMR outliers have superior EGS survival. Common hospital-level characteristics do not explain the wide gap between underperforming and overperforming outlier institutions. These findings suggest that SMR can help guide assessment of EGS performance across hospitals; further research is essential to identify and define the hospital processes of care which translate into optimal EGS outcomes. LEVEL OF EVIDENCE Epidemiologic Study, level III.

Background Although cervical spine CT (CSCT) accurately detects bony injuries, it may not identify all soft tissue injuries. Although some clinicians rely exclusively on a negative CT to remove spine precautions in unevaluable patients or patients with cervicalgia, others use MRI for that purpose. The objective of this study was to determine the rates of abnormal MRI after a negative CSCT. Methods Blunt trauma patients who either were unevaluable or had persistent midline cervicalgia and underwent an MRI of the C-spine after a negative CSCT were enrolled prospectively in eight Level I and II New England trauma centers. Demographics, injury patterns, CT and MRI results, and any changes in cervical spine management as a result of MRI imaging were recorded. Results A total of 767 patients had MRI because of cervicalgia (43.0%), inability to evaluate (44.1%), or both (9.4%). MRI was abnormal in 23.6% of all patients, including ligamentous injury (16.6%), soft tissue swelling (4.3%), vertebral disc injury (1.4%), and dural hematomas (1.3%). Rates of abnormal neurological signs or symptoms were not different among patients with normal versus abnormal MRI. (15.2 vs. 18.8%, p = 0.25). The c-collar was removed in 88.1% of patients with normal MRI and 13.3% of patients with an abnormal MRI. No patient required halo placement, but 11 patients underwent cervical spine surgery after the MRI results. Six of the eleven had neurological signs or symptoms. Conclusions In a select population of patients, MRI identified additional injuries in 23.6% of patients despite a normal CSCT. It is uncertain if this is a true limitation of CT technology or represents subtle injuries missed in the interpretation of the scan. The clinical significance of these abnormal MRI findings cannot be determined from this study group. Level of evidence Therapeutic study, level IV.

Although anticoagulation with warfarin has been associated with increased risk of adverse outcomes after trauma, the effects of the new oral agents (NOA) such as dabigatran, apixaban, rivaroxaban are not yet well characterized.A retrospective review of a level 1 trauma center database identified all patients aged ≥ 50 admitted after trauma during a 24 month period starting September 2013. Demographics, including preadmission anticoagulation agents, injuries, hospital course and outcomes were abstracted from the electronic medical record.Over the 24-month period, 3,392 patients were admitted; 112 (3.3%) were anticoagulated with NOA and 373 (11.0%) with warfarin with a trend toward increasing utilization of the new agents compared with warfarin over that period. Although comparable in age, injury severity scores, and mechanism of injury, patients anticoagulated with warfarin had both a higher overall mortality (10.9%) compared with the NOA (6.25%) and the non-anticoagulated control (5.5%) groups (p0.001) as well as a higher trauma-related mortality (9.0%) versus NOA (2.8%) and control (3.7%) groups (p0.001). Patients on warfarin or NOA were admitted to intensive care unit or step down unit more frequently than control patients. (45.0% and 41.9% vs. 35.7% respectively; p0.001). The incidence of traumatic brain injury was similar among the three groups. Although it did not reach statistical significance, trauma-specific mortality in the traumatic brain injury subset was higher in the warfarin group (19.3%) than the NOA (16.7%) or control (10.9%) groups (p = 0.08). In a multivariable logistic regression, warfarin (odds ratio, 2.215; 95% confidence interval, 1.365-3.596; p = 0.001), but not the NOA (odds ratio, 0.871; 95% confidence interval, 0.258-2.939; p = 0.823), was an independent predictor for mortality.Although the experience with the new oral anticoagulation agents is still limited, patients on these agents appear to have lower mortality after traumatic injury than patients on warfarin.Epidemiologic study, level III.

Delayed splenic hemorrhage after nonoperative management (NOM) of blunt splenic injury (BSI) is a feared complication, particularly in the outpatient setting. Significant resources, including angiography (ANGIO), are used in an effort to prevent delayed splenectomy (DS). No prospective, long-term data exist to determine the actual risk of splenectomy. The purposes of this trial were to ascertain the 180-day risk of splenectomy after 24 hours of NOM of BSI and to determine factors related to splenectomy.Eleven Level I trauma centers participated in this prospective observational study. Adult patients achieving 24 hours of NOM of their BSI were eligible. Patients were followed up for 180 days. Demographic, physiologic, radiographic, injury-related information, and spleen-related interventions were recorded. Bivariate and multivariable analyses were used to determine factors associated with DS.A total of 383 patients were enrolled. Twelve patients (3.1%) underwent in-hospital splenectomy between 24 hours and 9 days after injury. Of 366 discharged with a spleen, 1 (0.27%) required readmission for DS on postinjury Day 12. No Grade I injuries experienced DS. The splenectomy rate after 24 hours of NOM was 1.5 per 1,000 patient-days. Only extravasation from the spleen at time of admission (ADMIT-BLUSH) was associated with splenectomy (odds ratio, 3.6; 95% confidence interval, 1.4-12.4). Of patients with ADMIT-BLUSH (n = 49), 17 (34.7%) did not have ANGIO with embolization (EMBO), and 2 of those (11.8%) underwent splenectomy; 32 (65.3%) underwent ANGIO with EMBO, and 2 of those (6.3%, p = 0.6020 compared with no ANGIO with EMBO) required splenectomy.Splenectomy after 24 hours of NOM is rare. After the initial 24 hours, no additional interventions are warranted for patients with Grade I injuries. For Grades II to V, close observation as an inpatient or outpatient is indicated for 10 days to 14 days. ADMIT-BLUSH is a strong predictor of DS and should lead to close observation or earlier surgical intervention.Prognostic/epidemiological study, level III; therapeutic study, level IV.

BACKGROUND: The Rothman index (RI) is a numerical score calculated hourly from 26 data points in the electronic medical record by a commercial software package. Although it is purported to serve as an indicator of change in a patient’s condition, it has not been extensively evaluated in the literature. Our objective was to determine whether the RI can be used to predict early surgical intensive care unit (SICU) readmissions. METHODS: This is a single-institution, retrospective 12-month period review of all patients transferred from the SICU to the surgical floor. Patients readmitted to the SICU within 48 hours were compared with patients who did not require readmission during this time (control). Demographics and continuous RI scores were collected at admission, 24 hours before SICU transfer, and for the first 48 hours on the surgical floor or until readmission to the SICU. RESULTS: A total of 1,152 SICU patients were transferred to the surgical floor; 27 patients were readmitted within 48 hours of transfer. Demographics were similar in both groups. The SICU length of stay was longer in the readmission group (mean [SD], 4.7 [8.1] vs. 16.5 [15.2]; p G 0.001). The RI immediately before SICU transfer was higher in the control group (70.4 [20.3] vs. 49.1 [20.9], p G 0.001) and was uniformly improved from the RI at the initial SICU admission. In comparison, readmitted patients had more variable RI trends from admission to SICU transfer (mean$, 6.51; range, j54.10 to 48.6), and 40.74% of readmitted patients actually had a decreased RI score on transfer. No patient with a RI score greater than 82.90 required readmission within 48 hours. CONCLUSION: An increased RI score or a score greater than 82.90 correlates with appropriateness for SICU transfer to the surgical floor. A decreased RI score is strongly associated with SICU readmission within 48 hours and should be explored as a potential quality metric. (J Trauma Acute Care Surg. 2014;77: 78Y82. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

BACKGROUND: During the last century, the management of blunt force trauma to the liver has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma in the Practice Management Guidelines for Nonoperative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the previous Eastern Association for the Surgery of Trauma guideline. METHODS: The National Library of Medicine and the National Institutes of Health MEDLINE database were searched using PubMed (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords liver injury and blunt abdominal trauma. RESULTS: One hundred seventy-six articles were reviewed, of which 94 were used to create the current practice management guideline for the selective nonoperative management of blunt hepatic injury. CONCLUSION: Most original hepatic guidelines remained valid and were incorporated into the greatly expanded current guidelines as appropriate. Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age. Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries. Repeated imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography, percutaneous drainage, endoscopy/endoscopic retrograde cholangiopancreatography and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature. (J Trauma Acute Care Surg. 2012;73: S288YS293.

Small-bowel obstruction (SBO) represents as many as 16% of surgical admissions and more than 300,000 operations annually in the United States. The optimal strategies for the diagnosis and management of SBO continue to evolve secondary to advances in imaging techniques, critical care, and surgical techniques. This updated systematic literature review was developed by the Eastern Association for the Surgery of Trauma to provide up-to-date evidence-based recommendations for SBO.A search of the National Library of Medicine MEDLINE database was performed using PubMed interface for articles published from 2007 to 2011.The search identified 53 new articles that were then combined with the 131 studies previously reviewed by the 2007 guidelines. The updated guidelines were then presented at the 2012 annual EAST meeting.Level I evidence now exists to recommend the use of computed tomographic scan, especially multidetector computed tomography with multiplanar reconstructions, in the evaluation of patients with SBO because it can provide incremental clinically relevant information over plains films that may lead to changes in management. Patients with evidence of generalized peritonitis, other evidence of clinical deterioration, such as fever, leukocytosis, tachycardia, metabolic acidosis, and continuous pain, or patients with evidence of ischemia on imaging should undergo timely exploration. The remainder of patients can safely undergo initial nonoperative management for both partial and complete SBO. Water-soluble contrast studies should be considered in patients who do not clinically resolve after 48 to 72 hours for both diagnostic and potential therapeutic purposes. Laparoscopic treatment of SBO has been demonstrated to be a viable alternative to laparotomy in selected cases.

BACKGROUND: Airway pressure release ventilation (APRV) is used both as a rescue therapy for patients with acute lung injury and as a primary mode of ventilation. Unlike assist-control volume (ACV) ventilation that uses spontaneous breathing trials, APRV weaning consists of gradual decreases in supporting pressure. We hypothesized that the APRV weaning process increases total ventilator days compared with those of spontaneous breathing trialsYbased weaning. METHODS: A retrospective review of a Level I trauma center’s database identified trauma admissions from January 1, 2007, to December 31, 2010, which required mechanical ventilation for more than 24 hours and survived. Demographics, injuries, in-hospital complications, ventilation mode(s), and total ventilator days were abstracted. RESULTS: A total of 362 patients fulfilled study entry criteria; 53 patients with more than one ventilator mode change were excluded. Seventy-five patients were successfully liberated from mechanical ventilation on APRV and 234 on ACV. The APRVand ACV groups, respectively, were similar in age (46.1 vs. 44.6 years) and sex (72% vs. 73% male) but differed in Injury Severity Score (20.8 vs. 17.5; p = 0.03). Patients on APRV had higher rates of abdominal compartment syndrome (6.7% vs. 0.8%, p = 0.003) and were more likely to have a higher chest Abbreviated Injury Scale (AIS) score Q3 (57.3% vs. 30.8%, p G 0.001). Ventilator days were significantly greater in the APRV group (19.6 vs. 10.7 days, p G 0.001). Multiple regression was performed to adjust for the clinical differences between the two groups, identifying APRV as an independent predictor for increased number of ventilator days (B = 6.2 T 1.5, p G 0.001) in addition to male sex, abdomen AIS score of 3 or higher, spine AIS score of 3 or higher, acute renal failure, and sepsis. CONCLUSION: APRV is frequently used for patients who are more severely injured or who develop in-hospital complications such as pneumonia. However, after controlling for potential confounding factors in a multiple regression model, the APRV mode itself seems to increase ventilator days. (J Trauma Acute Care Surg .2 012;73: 507Y510. Copyright * 2012 by Lippincott Williams & Wilkins)

The aim of this article is to review a single institution's experience with airway pressure release ventilation (APRV) with respect to safety, complications, and efficacy at correcting hypercarbia and hypoxemia.Patients transitioned from either volume- or pressure-targeted ventilation to APRV in a university hospital surgical intensive care unit were retrospectively reviewed. Patients whose ventilator strategy started with APRV were excluded. Abstracted data included age, sex, diagnosis, ventilation parameters, indication for altering the ventilator strategy, laboratory values, and ventilator-associated complications. Data before and after transitioning to APRV were compared using a two-tailed unpaired t test or χ2 test as appropriate; significance assumed for p ≤ 0.05.Patient mix (n = 38) was 43% trauma, 32% sepsis, 8% cardiac surgery, 12% vascular surgery, and 5% other. Transitioning to APRV was undertaken most often for hypoxemia (88%) and less frequently for hypercarbia (12%). The mean time to correct hypoxemia (SA(O2)92%) was 7 minutes ± 4 minutes, while the mean time to correct P(CO2) (P(CO2) ≤40 mm Hg) was 42 minutes ± 7 minutes. The mean time to maximal CO2 clearance was 66 minutes ± 12 minutes. The mean minute ventilation decreased on APRV by 3.3 L/min ± 0.9 L/min but achieved superior CO2 clearance and oxygenation. The mean time to FIO2 ≤0.6 was 5.2 hours ± 0.9 hours. Four of the 38 patients developed a pneumothorax. Ninety-seven percent of patients on APRV who were transported out of the intensive care unit using bag-valve ventilation (with appropriate positive end-expiratory pressure valve settings) with P(high) ≥20 cm H2O developed hypoxemia within 5 minutes. Hundred percent of patients with a P(high) ≤20 cm H2O were safely hand ventilated during transport without developing hypoxemia.APRV is a safe mode of ventilation for hypoxemic or hypercarbic respiratory failure. Improvements in PO2 and PCO2 are achieved at lower minute ventilations than with volume- or pressure-targeted modes.III.