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Background Pelvic fractures are often complicated by hemorrhage contributing to morbidity and mortality. Management of these patients is multifaceted and computed tomography (CT) imaging plays an integral diagnostic role. The purpose of this study was to identify radiographic and clinical predictors of therapeutic angiography in patients with blunt pelvic fractures. Methods All patients with blunt pelvic fractures who underwent angiography following admission CT scan were identified over a 6-year period. A radiologist reviewed the CT scans to identify potential predictors of pelvic hemorrhage. Patients were stratified by intervention [therapeutic angiography (TA) vs non-therapeutic angiography (NTA)] and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of TA. Youden’s index was used to identify the optimal value of selected predictors identified on MLR. Results 177 patients were identified: 42% underwent TA and 58% underwent NTA. Patients undergoing TA were more likely to have a higher injury burden and greater resuscitative transfusion requirements, display both a brighter blush density on arterial phase CT and a larger % change in arterial to venous phase blush density. The optimal arterial blush density was determined to be 250 HU. MLR identified pre-angiography transfusion requirements (OR 1.175; 95% CI 1.054-1.311, P = .0189) and arterial blush density (OR 1.011; 95% CI 1.005-1.016, P < .0001) as independent predictors of therapeutic angiography. Conclusion CT imaging remains vital in assessing patients with pelvic fractures and associated hemorrhage following blunt trauma. For patients requiring multiple resuscitative transfusions with CT findings of an arterial blush measuring ≥250 HU, early angiography should be the preferred approach.

Introduction The role of serial computed tomography (CT) in the nonoperative management of blunt splenic injuries (NOMSIs) remains unclear. The purpose of the study was to determine the utility of serial CT of Grade 2-5 NOMSI in the modern era. Methods Blunt splenic injuries were identified over a 3.5-year period, ending in 6/2020. Our institutional protocol for NOMSI mandates a repeat 24-hour CT for Grade 2-5 injuries. Patients ageResults 219 patients with Grade 2-5 NOMSI had both an initial and 24-hour CT after exclusions. 24-hour CT identified 14 patients with new PSA(s) and 11 (5%) went to angiography within 24 hours with 9 (4%) undergoing angioembolization and 4 (2%) had splenectomy. Two hundred and four (93%) had no intervention though eventually 12 went on to angiography and 6 went for splenectomy. The 24-hour CT rarely altered management in the absence of clinical indication or prior PSA on initial CT with 5 (2%) receiving a therapeutic embolization and 2 (1%) had a nontherapeutic angiogram. No deaths were attributable to splenic injury. Conclusions Routine 24-hour CT for NOMSI did not impact management. Clinical status and change in exam may warrant repeat CT in select cases in the setting of a plausible alternate explanation. Prompt angioembolization or splenectomy is more appropriate in clear-cut cases of failed NOMSI.

The burden of postoperative adverse events (AE) weighs immediately on the patient as unanticipated stress and on the healthcare system as unreimbursed cost. Applying the Clavien-Dindo (C-D) system of AE gradation as a surrogate of cost, we analyzed 4 years' data from a single-state National Surgical Quality Improvement Program (NSQIP) collaboration, hypothesizing that trends of AE were consistent over time and that more frequently performed cases would be associated with less and more minor AE.The NSQIP defined AEs, consisting of 21 listed postoperative occurrences, which were analyzed using deidentified 30-day postoperative data for 2015 to 2018. Each AE was graded using (C-D) severity (1, lowest; 4, highest with survival). The C-D severity weight, as defined in previous multi-institutional studies, was used as a surrogate for cost and unplanned patient burden. Adverse event incidence was calculated as sum AE/case volume, and population burden as total AE burden/case volume.There were 12,567 surgical cases recorded by members of the state collaborative. The overall data demonstrated no significant difference in AE incidence; however, the burden of AE increased by 18.8%. The 8 most common Current Procedural Terminology codes had approximately 50% lower AE incidence compared with overall cases; however, the incidence increased by 56.0% and the AE burden/case increased by 48.0%.Although the 8 most common Current Procedural Terminology codes showed a 50% lower AE incidence compared with overall cases, the incidence increased over the study period. Surgical quality initiatives should be patient centered and focus on high burden AE.

Background Management of penetrating chest injuries with a positive pericardial window (PW) are presumed cardiac injuries and traditionally result in sternotomy. However, there is some evidence in the literature that select patients can be managed with PW, lavage, and drainage (PWLD). Methods All patients with penetrating chest trauma who underwent PW and/or sternotomy over a 5-year period were identified. Patients were stratified by operative intervention [PW + sternotomy vs PWLD] and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of therapeutic sternotomy. Results Of the 146 patients who underwent PW and/or sternotomy included in the study, 126 patients underwent PW, 39 underwent sternotomy, and 10 underwent PWLD. There was no difference in demographics, LOS, ICU LOS, vent days, or mortality in patients who underwent PW + sternotomy, compared to patients who underwent PWLD. In the PWLD group, one patient returned to the OR for recurrent pericardial effusion and no patients required sternotomy. Multivariable logistic regression identified ISS as an independent predictor of therapeutic sternotomy (OR 1.160; 95% CI 1.006-1.338, P = .0616). Interestingly, positive FAST, significant CT findings, and trajectory were not predictors of therapeutic sternotomy. There were 7 patients with a left hemothorax and negative FAST found to have a positive PW and cardiac injury mandating sternotomy and repair. Conclusion Penetrating cardiac injury can be managed with PWLD in select patients. Positive FAST, significant findings on CT, and trajectory do not mandate sternotomy. A negative FAST in the setting of a hemothorax does not rule out a cardiac injury.

Background Patients with unstable cervical spine (C-spine) fractures are at a significant risk of respiratory failure. There is no consensus on the optimal timing of tracheostomy in the setting of recent operative cervical fixation (OCF). This study evaluated the impact of tracheostomy timing on surgical site infections (SSIs) in patients undergoing OCF and tracheostomy. Methods Trauma Quality Improvement Program (TQIP) was used to identify patients with isolated cervical spine injuries who underwent OCF and tracheostomy between 2017 and 2019. Early tracheostomy (Results Of 1438 patients included, 20 had SSI (1.4%). There was no difference in SSI between early vs delayed tracheostomy (1.6% vs 1.2%, P = .5077). Delayed tracheostomy was associated with increased ICU LOS (23.0 vs 17.0 days, P < .0001), ventilator days (19.0 vs 15.0, P < .0001), and hospital LOS (29.0 vs 22.0 days, P < .0001). Increased ICU LOS was associated with SSI (OR 1.017; CI 0.999-1.032; P = .0273). Increased time to tracheostomy was associated with increased morbidity (OR 1.003; CI 1.002-1.004; P < .0001) on multivariable analysis. Time from OCF to tracheostomy correlated with ICU LOS (r (1354) = .35, P < .0001), ventilator days (r (1312) = .25, P < .0001), and hospital LOS (r (1355) = .25, P < .0001). Conclusion In this TQIP study, delayed tracheostomy after OCF was associated with longer ICU LOS and increased morbidity without increased SSI. This supports the TQIP best practice guidelines recommending that tracheostomy should not be delayed for concern of increased SSI risk.