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Chest pain is a common reason that patients may present for evaluation in both ambulatory and emergency department settings, and is often of musculoskeletal origin in the former. Chest wall syndrome collectively describes the various entities that can contribute to chest wall pain of musculoskeletal origin and may affect any chest wall structure. Various imaging modalities may be employed for the diagnosis of nontraumatic chest wall conditions, each with variable utility depending on the clinical scenario. We review the evidence for or against use of various imaging modalities for the diagnosis of nontraumatic chest wall pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

BACKGROUND Little is known about patient characteristics predicting postdischarge pleural space complications (PDPSCs) after thoracic trauma. We sought to analyze the patient population who required unplanned hospital readmission for PDPSC. METHODS Retrospective review of adult patients admitted to a Level I Trauma Center with a chest Abbreviated Injury Scale (AIS) score of 2 or greater between January 2015 and August 2020. Those readmitted within 30 days of index hospitalization discharge for PDPSC were compared with those not readmitted. Demographics, injury characteristics, surgical procedures, imaging, and readmission data were retrieved. RESULTS Out of 17,192 trauma evaluations, 3,412 (19.8%) suffered a chest AIS score of 2 or greater injury and 155 experienced an unplanned 30-day hospital readmission. Of those, 49 (1.4%) were readmitted for the management of PDPSC (readmit PDPSC) and were compared with patients who were not readmitted (no readmit, n = 3,257). The readmit PDPSC group was significantly older age, heavier, comprised of fewer men, and suffered a higher mean chest AIS score. The readmit PDPSC group had a significantly higher incidence of rib fractures, flail chest, pneumothorax, hemothorax, scapula fractures, and a higher rate of tube thoracostomy placement during index admission. The discharge chest X-ray in the readmit PDPSC group demonstrated a pleural space abnormality in 36 (73%) of patients. Mean time to readmission was 10.2 (7.2) days, and hospital length of stay on readmission was 5.8 (3.7) days. Pleural effusion was the most common readmission diagnosis (44 [90%]), and 42 (86%) required tube thoracostomy. CONCLUSION We describe the subset of chest wall injury patients who require hospital readmission for PDPSC. Characteristics from index hospitalization associated with PDPSC include older age, female sex, heavier weight, presence of rib fractures, pleural space abnormality, scapular fracture, and chest tube placement. Further studies are needed to characterize this at-risk chest wall injury population, and to determine what interventions can facilitate outpatient management of postdischarge pleural space complications and mitigate readmission risk. LEVEL OF EVIDENCE Prognostic and epidemiologic, Level IV; Care management, Level V.

BACKGROUND Although guidelines are established for the prevention and management of venous thromboembolism (VTE) in trauma, no consensus exists regarding protocols for the diagnostic approach. We hypothesized that at-risk trauma patients who undergo duplex ultrasound (DUS) surveillance for lower extremity deep venous thrombosis (DVT) will have a lower rate of symptomatic or fatal pulmonary embolism (PE) than those who do not undergo routine surveillance. METHODS Prospective, randomized trial between March 2017 and September 2019 of trauma patients admitted to a single, level 1 trauma center, with a risk assessment profile score of ≥5. Patients were randomized to receive either bilateral lower extremity DUS surveillance on days 1, 3, and 7 and weekly during hospitalization ultrasound group (US) or no surveillance no ultrasound group (NoUS). Rates of in-hospital and 90-day DVT and PE were reported as was DVT propagation and all-cause mortality. Standard care for the prevention and management of VTE per established institutional protocols was provided to all patients. RESULTS A total of 3,236 trauma service admissions were screened, and 1,989 moderate- and high-risk patients were randomized (US, 995; NoUS, 994). The mean ± SD age was 62 ± 20.1 years, Injury Severity Score was 14 ± 9.7, risk assessment profile was 7.1 ± 2.4, and 97% suffered blunt trauma. There was no difference in demographics or VTE risk factors between the groups. There were significantly fewer in-hospital PE in the US group than the NoUS group (1 [0.1%] vs. 9 [0.9%], p = 0.01). The US group experienced more in-hospital below-knee DVTs (124 [12.5%] vs. 8 [0.8%], p < 0.001) and above-knee DVTs (19 [1.9%] vs. 8 [0.8%], p = 0.05). There was no difference in 90-day PE or DVT, or overall mortality. CONCLUSION The implementation of a selective routine DUS protocol was associated with significantly fewer in-hospital PE. More DVTs were identified with routine screening; however, surveillance bias appears to exist primarily with distal DVT. Larger trials are needed to further characterize the relationship between routine DUS screening and VTE outcomes in the high-risk trauma population. LEVEL OF EVIDENCE Therapeutic/care management, level II.

BACKGROUND The efficacy of surgical stabilization of rib fracture (SSRF) in patients without flail chest has not been studied specifically. We hypothesized that SSRF improves outcomes among patients with displaced rib fractures in the absence of flail chest. METHODS Multicenter, prospective, controlled, clinical trial (12 centers) comparing SSRF within 72 hours to medical management. Inclusion criteria were three or more ipsilateral, severely displaced rib fractures without flail chest. The trial involved both randomized and observational arms at patient discretion. The primary outcome was the numeric pain score (NPS) at 2-week follow-up. Narcotic consumption, spirometry, pulmonary function tests, pleural space complications (tube thoracostomy or surgery for retained hemothorax or empyema >24 hours from admission) and both overall and respiratory disability-related quality of life (RD-QoL) were also compared. RESULTS One hundred ten subjects were enrolled. There were no significant differences between subjects who selected randomization (n = 23) versus observation (n = 87); these groups were combined for all analyses. Of the 110 subjects, 51 (46.4%) underwent SSRF. There were no significant baseline differences between the operative and nonoperative groups. At 2-week follow-up, the NPS was significantly lower in the operative, as compared with the nonoperative group (2.9 vs. 4.5, p < 0.01), and RD-QoL was significantly improved (disability score, 21 vs. 25, p = 0.03). Narcotic consumption also trended toward being lower in the operative, as compared with the nonoperative group (0.5 vs. 1.2 narcotic equivalents, p = 0.05). During the index admission, pleural space complications were significantly lower in the operative, as compared with the nonoperative group (0% vs. 10.2%, p = 0.02). CONCLUSION In this clinical trial, SSRF performed within 72 hours improved the primary outcome of NPS at 2-week follow-up among patients with three or more displaced fractures in the absence of flail chest. These data support the role of SSRF in patients without flail chest. LEVEL OF EVIDENCE Therapeutic, level II.

Introduction The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis in blunt solid organ injury (BSOI) patients is debated. We hypothesize that 1) BSOI patients are hypercoagulable within 12 h of injury and 2) hypercoagulability dominates in patients who develop clot complications (CC). Material and methods This is a prospective study of BSOI patients admitted to two Level-1 Trauma Centers’ trauma intensive care units (ICU). Serial kaolin thrombelastography (TEG) and tissue plasminogen activator (tPA)-challenge TEGs were performed. CC included VTE and cerebrovascular accidents. Results On ICU admission, all patients (n = 95) were hypercoagulable, 58% were in fibrinolysis shutdown, and 50% of patients were tPA-resistant. Twelve patients (13%) developed CC. Compared to those without CC, they demonstrated decreased fibrinolysis at 12 h and higher clot strength at 48 h Conclusions BSOI patients are universally hypercoagulable upon ICU admission. VTE chemoprophylaxis should be started immediately in BSOI patients with hypercoagulability on TEG.

Background Indications for intervention after high-grade renal trauma (HGRT) remain poorly defined. Certain radiographic findings can be used to guide the management of HGRT. We aimed to assess the associations between initial radiographic findings and interventions for hemorrhage after HGRT and to determine hematoma and laceration sizes predicting interventions. Methods The Genitourinary Trauma Study is a multicenter study including HGRT patients from 14 Level I trauma centers from 2014 to 2017. Admission computed tomography scans were categorized based on multiple variables, including vascular contrast extravasation (VCE), hematoma rim distance (HRD), and size of the deepest laceration. Renal bleeding interventions included angioembolization, surgical packing, renorrhaphy, partial nephrectomy, and nephrectomy. Mixed-effect Poisson regression was used to assess the associations. Receiver operating characteristic analysis was used to define optimal cutoffs for HRD and laceration size. Results In the 326 patients, injury mechanism was blunt in 81%. Forty-seven (14%) patients underwent 51 bleeding interventions, including 19 renal angioembolizations, 16 nephrectomies, and 16 other procedures. In univariable analysis, presence of VCE was associated with a 5.9-fold increase in risk of interventions, and each centimeter increase in HRD was associated with 30% increase in risk of bleeding interventions. An HRD of 3.5 cm or greater and renal laceration depth of 2.5 cm or greater were most predictive of interventions. In multivariable models, VCE and HRD were significantly associated with bleeding interventions. Conclusion Our findings support the importance of certain radiographic findings in prediction of bleeding interventions after HGRT. These factors can be used as adjuncts to renal injury grading to guide clinical decision making. Level of evidence Prognostic and Epidemiological Study, Level III and Therapeutic/Care Management, Level IV.

To test the hypothesis that undergoing nephrectomy after high-grade renal trauma is associated with higher mortality rates.We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS≤8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure90 mmHg), and Glasgow Coma Scale (GCS).A total of 1181 high-grade renal trauma patients were included. Median age was 31 and trauma mechanism was blunt in 78%. Injuries were graded as III, IV, and V in 55%, 34%, and 11%, respectively. There were 96 (8%) mortalities and 129 (11%) nephrectomies. Mortality was higher in the nephrectomy group (21.7% vs 6.5%, P.001). Those who died were older, had higher ISS, lower GCS, and higher rates of shock. After adjusting for patient and injury characteristics nephrectomy was still associated with higher risk of death (RR: 2.12, 95% CI: 1.26-2.55).Nephrectomy was associated with higher mortality in the acute trauma setting even when controlling for shock, overall injury severity, and head injury. These results may have implications in decision making in acute trauma management for patients not in extremis from renal hemorrhage.

Objective The aim of the study was to compare the relative predictive value of Marshall Classification System and Rotterdam scores on long-term rehabilitation outcomes. This study hypothesized that Rotterdam would outperform Marshall Classification System. Design The study used an observational cohort design with a consecutive sample of 88 participants (25 females, mean age = 42.0 [SD = 21.3]) with moderate to severe traumatic brain injury who were admitted to trauma service with subsequent transfer to the rehabilitation unit between February 2009 and July 2011 and who had clearly readable computed tomography scans. Twenty-three participants did not return for the 9-mo postdischarge follow-up. Day-of-injury computed tomography images were scored using both Marshall Classification System and Rotterdam criteria by two independent raters, blind to outcomes. Functional outcomes were measured by length of stay in rehabilitation and the cognitive and motor subscales of the Functional Independence Measure at rehabilitation discharge and 9-mo postdischarge follow-up. Results Neither Marshall Classification System nor Rotterdam scales as a whole significantly predicted Functional Independence Measure motor or cognitive outcomes at discharge or 9-mo follow-up. Both scales, however, predicted length of stay in rehabilitation. Specific Marshall scores (3 and 6) and Rotterdam scores (5 and 6) significantly predicted subacute outcomes such as Functional Independence Measure cognitive at discharge from rehabilitation and length of stay. Conclusions Marshall Classification System and Rotterdam scales may have limited utility in predicting long-term functional outcome, but specific Marshall and Rotterdam scores, primarily linked to increased severity and intracranial pressure, may predict subacute outcomes.

Current decision algorithms involving surgical stabilization of rib fractures (SSRF) do not consider either specific fracture locations or other chest wall bony injuries. Our objective was to characterize the impact of scapula fractures on morbidity among patients who underwent fixation of sub-scapular rib fractures. We hypothesized that an ipsilateral scapula fracture was associated with poor acute and long-term outcomes. Retrospective review of two institutions’ prospectively maintained SSRF databases (October 2010 to January 2019). Patients who underwent repair of ≥ 1 sub-scapular rib fracture were included. Patients were grouped by the presence of an ipsilateral scapula fracture. Outcomes were acute SSRF complications, long-term rib implant removal, and quality of life via phone survey. A total of 144 patients were analyzed; 53 (36.8%) had an ipsilateral scapula fracture. Patients with a scapula fracture had a higher injury severity score (p = 0.02), degree of pulmonary contusion (p

Background: Concussion (mild) and other moderate traumatic brain injury (TBI) and Alzheimer's disease (AD) share overlapping neuropathologies, including neuronal pre-programmed cell death (PPCD), and clinical impairments and disabilities. Multiple clinical trials targeting mechanisms based on the Amyloid Hypothesis of AD have so far failed, indicating that it is prudent for new drug developments to also pursue mechanisms independent of the Amyloid Hypothesis. To address these issues, we have proposed the use of an animal model of concussion/TBI as a supplement to AD transgenic mice to provide an indication of an AD drug candidate’s potential for preventing PPCD and resulting progression towards dementia in AD. Methods: We searched PubMed/Medline and the references of identified articles for background on the neuropathological progression of AD and its implications for drug target identification, for AD clinical trial criteria used to assess disease modification outcomes, for plasma biomarkers associated with AD and concussion/TBI, neuropathologies and especially PPCD, and for methodological critiques of AD and other neuropsychiatric clinical trial methods. Results: We identified and address seven issues and highlight the Thal-Sano AD ‘Time to Onset of Impairment' Design for possible applications in our clinical trials. Diverse and significant pathological cascades and indications of self-induced neuronal PPCD were found in concussion/TBI, anoxia, and AD animal models. To address the dearth of peripheral markers of AD and concussion/TBI brain pathologies and PPCD we evaluated Extracellular Vesicles (EVs) enriched for neuronal origin, including exosomes. In our concussion/TBI, anoxia and AD animal models we found evidence consistent with the presence of time-dependent PPCD and (-)-phenserine suppression of neuronal self-induced PPCD. We hence developed an extended controlled release formulation of (-)-phenserine to provide individualized dosing and stable therapeutic brain concentrations, to pharmacologically interrogate PPCD as a drug development target. To address the identified problems potentially putting any clinical trial at risk of failure, we developed exploratory AD and concussion/TBI clinical trial designs. Conclusions: Our findings inform the biomarker indication of progression of pathological targets in neurodegenerations and propose a novel approach to these conditions through neuronal protection against self-induced PPCD.

Background Venous thromboembolism is a cause of morbidity and mortality in trauma patients. Chemoprophylaxis with low-molecular-weight heparin at a standardized dose is recommended. Conventional chemoprophylaxis may be inadequate. We hypothesized that a weight-adjusted enoxaparin prophylaxis regimen would reduce the frequency of venous thromboembolism in hospitalized trauma patients and at 90-day follow-up. Methods This prospective, randomized pilot study enrolled adult patients admitted to a level 1 trauma center between July 2013 and January 2015. Subjects were randomized to receive either standard (30 mg subcutaneously every 12 hours) or weight-based (0.5mg/kg subcutaneously every 12 hours) enoxaparin. Surveillance duplex ultrasound for lower extremity deep vein thrombosis was performed on hospital days 1, 3, and 7, and weekly thereafter. The primary outcome was deep vein thrombosis during hospitalization. Secondary outcomes included venous thromboembolism at 90 days and significant bleeding events. Results Two hundred thirty-four (124 standard, 110 weight-based) subjects were enrolled. There was no difference between standard and weight-based regarding age, body mass index, percentage female gender, injury severity score, or percentage that had surgery. There was a trend toward less in-hospital deep vein thrombosis in weight-based (12 [9.7%] standard vs 4 [3.6%] weight-based, P = .075). At 90 days, there was no difference in venous thromboembolism (12 [9.7%] standard vs 6 [5.5%] weight-based, P =.34). There was 1 bleeding event, which occurred in a standard subject. Conclusion Weight-based enoxaparin dosing for venous thromboembolism chemoprophylaxis in trauma patients may provide better protection against venous thromboembolism than standard. A definitive study is necessary to determine whether weight-based dosing is superior to standard.

BACKGROUND Surgical stabilization of rib fractures (SSRF) has become pivotal in the management of severe chest injuries. Recent literature supports improved outcomes and mortality in severe fracture and flail chest patients who undergo SSRF compared with nonoperative management (NOM). A 2014 National Trauma Data Bank review provided a point prevalence of 0.7% SSRF in flail patients. We hypothesize that this prevalence is increasing and that temporal, regional, and American College of Surgeons (ACS) trauma designation vary in SSRF utilization. METHODS Retrospective National Trauma Data Bank data were extracted for years 2007 to 2014 for patients with rib fractures. Cases were divided into SSRF versus NOM. SSRF frequencies were analyzed across year, region, and ACS level. Patient demographics, injury severity score, number of fractured ribs, and hospital characteristics were identified for multivariable analysis. RESULTS Between 2007 and 2014, 687,137 rib fracture patients were identified; 29,981 (4.36%) underwent SSRF. SSRF increased by 76% nationally during the review period (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.50-1.67; p < 0.001). Compared with the north, SSRF was used more in the west (OR, 1.6; 95% CI, 1.57-1.71), south (OR, 1.48; 95% CI, 1.43-1.54), then midwest (OR, 1.4; 95% CI, 1.34-1.46; p < 0.001). Although likelihood of SSRF is higher at ACS Level I (LI) centers compared with Level II (LII) centers (OR, 0.67; 95% CI, 0.65-0.69) or Level III (LIII) (OR, 0.24; 95% CI, 0.22-0.26); p < 0.001), frequency of SSRF increased dramatically at lower-level centers from 2007 to 2014 (LI, 41.4%; LII, 53.6%; LIII, 60.0%).Overall SSRF mortality was 1.58% (NOM, 5.3%; p < 0.001), decreasing significantly between 2007 and 2014 (p < 0.0001). ACS LII had higher mortality than LI (OR, 1.82; 95% CI, 1.39-2.39; p < 0.0001), controlled by Injury Severity Score. CONCLUSION Utilization of SSRF has risen considerably nationwide. Prevalence varies by region and ACS level. Although greatest growth is occurring at LII hospitals, mortality is also the highest at these centers. Further research is needed to determine the need for regionalization of care and center of excellence designation. LEVEL OF EVIDENCE Epidemiological study, level III.

Chest wall trauma is common, and contributes significantly to morbidity and mortality of trauma patients. Early identification of major chest wall and concomitant intrathoracic injuries is critical. Generalized management of multiple rib fractures and flail chest consists of adequate pain control (including locoregional modalities); management of pulmonary dysfunction by invasive and noninvasive means; and, in some cases, surgical fixation. Multiple studies have shown that patients with flail chest have substantial benefit (decreased ventilator and intensive care unit days, improved pulmonary function, and improved long-term functional outcome) when they undergo surgery compared with nonoperative management.

Background Platelet dysfunction associated with isolated traumatic brain injury (TBI) can be measured using thromboelastography-platelet mapping (TEG-PM). We hypothesized that platelet dysfunction can be detected after blunt TBI, and the degree of dysfunction is associated with increased TBI severity and in-hospital mortality. Methods This was a retrospective review of adult trauma patients admitted to a single level 1 trauma center from August 2013 to March 2015 who suffered isolated severe blunt TBI. Subjects were included if they received a TEG-PM within 24 h from injury, and excluded if on preinjury antiplatelet medications. Results 119 subjects were analyzed. Severe TBI subjects (AIS-head 5) had ADPi 18.4 points higher than moderate TBI subjects (AIS-head 3) (p = 0.001). Platelet dysfunction was not associated with TBI progression. ADPi significantly predicted mortality (OR 1.033; 95% CI 1.005–1.061, p = 0.02). Conclusion Platelet dysfunction occurs immediately after isolated blunt TBI, is more pronounced with increasing TBI severity, and is associated with higher odds of in-hospital mortality. Further investigation is needed to determine whether this is a marker of disease severity or a therapeutic target.

Background The Charlson and Elixhauser comorbidity indices are mortality predictors often used in clinical, administrative, and research applications. The Intermountain Mortality Risk Scores (IMRS) are validated mortality predictors that use all factors from the complete blood count and basic metabolic profile. How IMRS, Charlson, and Elixhauser relate to each other is unknown. Methods All inpatient admissions except obstetric patients at Intermountain Healthcare’s 21 adult care hospitals from 2010–2014 (N = 197,680) were examined in a observational cohort study. The most recent admission was a patient’s index encounter. Follow-up to 2018 used hospital death records, Utah death certificates, and the Social Security death master file. Three Charlson versions, 8 Elixhauser versions, and 3 IMRS formulations were evaluated in Cox regression and the one of each that was most predictive was used in dual risk score mortality analyses (in-hospital, 30-day, 1-year, and 5-year mortality). Results Indices with the strongest mortality associations and selected for dual score study were the age-adjusted Charlson, the van Walraven version of the acute Elixhauser, and the 1-year IMRS. For in-hospital mortality, Charlson (c = 0.719; HR = 4.75, 95% CI = 4.45, 5.07), Elixhauser (c = 0.783; HR = 5.79, CI = 5.41, 6.19), and IMRS (c = 0.821; HR = 17.95, CI = 15.90, 20.26) were significant predictors (p

Recreational use of small-wheeled vehicles (SWVs), which include skateboards, longboards, nonmotorized scooters, ice skates, and roller skates or rollerblades, results in numerous injuries in the United States.To describe the nature and severity of traumatic brain injuries (TBIs) that result from the use of SWVs in Utah.Patients who were admitted to any Utah hospital after a SWV-related injury from 2001 through 2010 were identified from the Utah State Trauma Registry. Patients who sustained TBI were identified by International Classification of Diseases, Ninth Revision, codes.Of 907 patients admitted with SWV injury, 392 (43%) had a TBI (85% male). Their mean age was 19.8 ± 0.5 years, including 234 (60%) aged ≤18 and 119 (30%) aged 19 to 29. Most patients sustained TBI while using a skate- or longboard (87%). Mean Glasgow Coma Scale score in the emergency department was 12.8 ± 0.2. Thirty-nine percent were admitted to an intensive care unit, and 6% (23) underwent emergent neurosurgical intervention. Thirty-three (8.4%) patients had a concussion; the rest had nonoperative intracranial hemorrhage. Among patients for whom helmet use data were available, 8 out of 291 (2.7%) patients with TBI were wearing a helmet, whereas 24 out of 190 (12.6%) non-TBI patients were wearing helmets (P.001). Overall mortality was higher in TBI patients than in non-TBI patients (2.3% vs 0.2%, P = .003).Young people, especially males, who ride SWVs in Utah are at risk for serious TBI, admission to the intensive care unit, neurosurgical intervention, and death. Helmet use in these patients is likely rare, but may reduce the risk of TBI and death.ED, emergency departmentSWV, small-wheeled vehicleTBI, traumatic brain injury.

BACKGROUND Current guidelines suggest that traumatic pneumothorax (tPTX) is a contraindication to commercial airline travel, and patients should wait at least 2 weeks after radiographic resolution of tPTX to fly. This recommendation is not based on prospective, physiologic study. We hypothesized that despite having a radiographic increase in pneumothorax size while at simulated altitude, patients with a recently treated tPTX would not exhibit any adverse physiologic changes and would not report any symptoms of cardiorespiratory compromise. METHODS This is a prospective, observational study of 20 patients (10 in Phase 1, 10 in Phase 2) with tPTX that has been treated by chest tube (CT) or high flow oxygen therapy. CT must have been removed within 48 hours of entering the study. Subjects were exposed to 2 hours of hypobaria (554 mm Hg in Phase 1, 471 mm Hg in Phase 2) in a chamber in Salt Lake City, Utah. Vital signs and subjective symptoms were recorded during the "flight." After 2 hours, while still at simulated altitude, a portable chest radiograph (CXR) was obtained. tPTX sizes on preflight, inflight, and postflight CXR were compared. RESULTS Sixteen subjects (80%) were male. Mean (SD) age and ISS were 49 (5) years and 10.5 (4.6), respectively. Fourteen (70%) had a CT to treat tPTX, which had been removed 19 hours (range, 4-43 hours) before the study. No subject complained of any cardiorespiratory symptoms while at altitude. Radiographic increase in tPTX size at altitude was 5.6 (0.61) mm from preflight CXR. No subject developed a tension tPTX. No subject required procedural intervention during the flight. Four hours after the study, all tPTX had returned to baseline size. CONCLUSION Patients with recently treated tPTX have a small increase in the size of tPTX when subjected to simulated altitude. This is clinically well tolerated. Current prohibitions regarding air travel following traumatic tPTX should be reconsidered and further studied. LEVEL OF EVIDENCE Therapeutic study, level IV.

Objective To examine the rate of urethral trauma and pubic symphysis diastasis in saddle horn injury, which occurs when horseback riders are bucked into the air and land with their perineum striking the rigid saddle horn, compared to pelvic fracture from other mechanisms. Methods A retrospective review was performed of male patients presenting to our level-1 trauma center with pelvic ring fractures between January 1, 2001 and December 30, 2016. Demographics, injury severity score, mechanism of injury (saddle horn vs other), pubic symphysis diastasis, and lower genitourinary (GU) injuries (bladder and urethra) were identified in the trauma registry. Chart review confirmed accuracy of lower GU trauma. Results A total of 1195 males presented with pelvic ring fractures, average age 43 years (SD 19 years). Of these, 87 of 1195 (7%) presented with lower GU injuries. Saddle horn injuries had a higher rate of lower GU injuries, 12/60 (20%) versus 75 of 1135 (7%) [P = .001]. In those with lower GU injuries, 47 of 87 (54%) had urethral injury. The rate of urethral injury was significantly higher in the saddle horn cohort, 10 of 12 (83%) versus 37 of 75 (49%) [P = .03]. Furthermore, rate of pubic symphysis diastasis was higher amongst saddle horn injuries, 12 of 12 (100%) versus other mechanisms 39 of 75 (52%) [P = .001]. Conclusion We found that urethral injury and pubic symphysis diastasis were higher in patients with saddle horn injury compared to other mechanisms of pelvic ring disruption. Clinicians should be aware of these associations when treating pelvic fracture following equestrian injuries.

BACKGROUNDRed blood cell distribution width (RDW) is a component of the complete blood count (CBC) that is traditionally used to identify iron-deficiency anemia. RDW has been shown to predict mortality in patients with multiple different medical conditions and in general populations. It is unknown w

The use of prophylactic anticonvulsants to prevent early post-traumatic seizures (PTSs) is recommended but inconsistently employed in patients with traumatic brain injury (TBI). The authors evaluated outcomes associated with prophylaxis administration in patients with TBI at a Level 1 trauma center. All patients admitted with TBI from October 2007 through May 2012 were included. Our primary outcome was the incidence of early PTSs. Secondary outcomes included mortality, length of hospital and intensive care unit (ICU) stays, and incidence of late seizures. Of the 2,111 patients with TBI, 557 (26.4%) received seizure prophylaxis and 1,554 (73.6%) did not. Two early PTSs occurred in the prophylaxis group (0.4%), whereas 21 occurred in the non-prophylaxis group (1.4%) (p = 0.05). The overall mortality rate was higher in patients who received prophylaxis (14.2% vs. 6.2%; p < 0.001), and the mean hospital length of stay (LOS) was longer (6.8 ± 6.9 vs. 3.8 ± 5 days; p < 0.001). In patients with severe and moderate TBI, the rate of prophylaxis administration was approximately half, whereas significantly fewer patients with mild TBI received prophylaxis than did not (20.2% vs 79.8%, p < 0.001). Lower Glasgow Coma Scale (GCS) score and longer hospital LOS were associated with early PTS (p = 0.008 for both comparisons), but sex and age were not. Brain hemorrhage was present in 78.3% of those patients who experienced early seizures. In our cohort, patients who received seizure prophylaxis had a lower GCS score, higher overall mortality rate, longer LOS, and more frequent ICU admissions, suggesting that patients who received prophylaxis were likely more severely injured.

The purpose of this study was to design and implement a domestic violence (DV) screening protocol. Trauma patients meeting inclusion criteria (hospitalized > 48 hours) were given a four question DV screen. If abuse was found, a comprehensive DV questionnaire followed. Barriers to screening and results were recorded. Compliance during the pilot test showed 23 of 157 (14.6%) admitted patients were screened. In the implementation year, 446 of 721 (61.9%) were screened. During the 10-month follow-up, 499 of 619 (80.6%) patients were screened. Lack of social work resources was the primary barrier to screening, but compliance increased and was maintained after the study period.

Background Retained hemothorax (RH) is relatively common after chest trauma and can lead to empyema. We hypothesized that patients who have surgical fixation of rib fractures (SSRF) have less RH and empyema than those who have medical management of rib fractures (MMRF). Methods Admitted rib fracture patients from January 2009 to June 2013 were identified. A 2:1 propensity score model identified MMRF patients who were similar to SSRF. RH, and empyema and readmissions, were recorded. Variables were compared using Fisher exact test and Wilcoxon rank–sum tests. Results One hundred thirty-seven SSRF and 274 MMRF were analyzed; 31 (7.5%) had RH requiring 35 interventions; 3 (2.2%) SSRF patients had RH compared with 28 (10.2%) MMRF ( P = .003). Four (14.3%) MMRF subjects with RH developed empyema versus zero in the SSRF group ( P = .008); 6 (19.3%) RH patients required readmission versus 14 (3.7%) in the non-RH group ( P = .002). Conclusions Patients with rib fractures who have SSRF have less RH compared with similar MMRF patients. Although not a singular reason to perform SSRF, this clinical benefit should not be overlooked.

Background My colleagues and I compared trauma patient demographics and outcomes between two time periods in the last 10 years in our Level I trauma center to evaluate the impact of the marked evolution in trauma care and determine additional opportunities for improvement. Methods Our trauma registry was queried for adult trauma patients admitted from 1991 to 1993 (EARLY) and 1999 to 2001 (LATE). The EARLY period predated creation and maturation of a dedicated trauma service and Level I trauma center verification. Continuous data were compared using Student's t-test, and categorical data using chi-square. Results Increased transfers of severely injured patients from regional hospitals, combined with fewer admissions for "observation," resulted in fewer, but sicker, patients admitted in the LATE period. Patients were considerably older in the LATE period and mortality was higher. Despite higher acuity of patients, hospital and ICU lengths of stay were shorter in the LATE period. Nonoperative management of solid organ injuries was more common in the LATE period, but the overall operative volume was similar. Nonsurvivors in the LATE period had higher Injury Severity Scores and were older compared with the EARLY period. Mortality attributable to blunt CNS injury was higher, and that attributed to late sepsis and multiple organ failure was lower in the LATE period. Conclusions Over the past decade, more older, severely injured patients have been admitted to our Level I trauma center. Overall mortality among these higher acuity patients has increased, with a marked shift in attributable mortality to CNS injury and away from late sepsis and multiple organ failure. This highlights the need for continued efforts to identify optimal management strategies for severe brain injury. Additional areas for improvement include enhancement of our regional trauma network and injury prevention initiatives.

Objective To examine associations of patient and injury characteristics with outcomes at inpatient rehabilitation discharge and 9 months postdischarge for patients with traumatic brain injury (TBI). Design Prospective, longitudinal observational study. Setting Inpatient rehabilitation centers. Participants Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, and divided into 5 subgroups based on rehabilitation admission FIM cognitive score. Interventions Not applicable. Main Outcome Measures Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge. Results Severity indices increased explained variation in outcomes beyond that accounted for by patient characteristics. FIM motor scores were generally the most predictable. Higher functioning subgroups had more predictable outcomes then subgroups with lower cognitive function at admission. Age at injury, time from injury to rehabilitation admission, and functional independence at rehabilitation admission were the most consistent predictors across all outcomes and subgroups. Conclusions Findings from previous studies of the relations among patient and injury characteristics and rehabilitation outcomes were largely replicated. Discharge outcomes were most strongly associated with injury severity characteristics, whereas predictors of functional independence at 9 months postdischarge included both patient and injury characteristics.

Background Limited data exist regarding the efficacy of weight-based dosing of low–molecular weight heparin for venous thromboembolism (VTE) prophylaxis in obese trauma patients. Methods Consecutive obese trauma patients were placed on a weight-based protocol for VTE prophylaxis (enoxaparin .5 mg/kg subcutaneously every 12 hours). Peak anti-Xa levels were drawn, and bilateral lower extremity duplex ultrasound was performed. The incidence of VTE and bleeding complications were recorded. Results Eighty-six patients met the study criteria. Seventy-four patients achieved target prophylactic anti-Xa concentrations, with a mean level of .42 ± .01 IU/mL. Eighteen patients were found to have deep vein thrombosis. However, in 16 of these patients, deep vein thrombosis was diagnosed before weight-based low–molecular weight heparin initiation. No bleeding complications occurred, and no symptomatic pulmonary emboli were identified. Conclusions In obese trauma patients, weight-based enoxaparin is an efficacious regimen that provides adequate VTE prophylaxis, as measured by anti-Xa levels, and appears to be safe without bleeding complications.

Blunt chest wall trauma and the resultant fracture of ribs is exceedingly common and is the source of significant morbidity and potential mortality. Surgical repair for markedly displaced rib fractures, particularly in the setting of flail chest has been attempted sporadically for over 50 years. In the last decade, rib-specific plating systems have been introduced. These have helped to usher in the era of modern rib repair and have made surgical stabilization of rib fractures (SSRF) technically easier, safer, and arguably more effective. Recently published consensus statements have attempted to codify the indications, contra-indications, timing, and technical aspects of SSRF. Patients with three or more severely displaced rib fractures or flail chest should be considered for repair whether they require mechanical ventilation or not. Other candidates may include patients who fail optimal nonoperative management regardless of fracture pattern, and patients with rib fractures who require thoracotomy for another reason. Severe traumatic brain injury and unstable spine fracture are absolute contraindications to immediate SSRF. The role of pulmonary contusion in the decision to repair the unstable chest wall remains controversial, but in general is not a contraindication. Several rib-specific plating systems are now commercially available. They share multiple design features; notably, semi-rigid fixation with anterior plate positioning and locking screws. The flexible nature of ribs makes locking screws critical to minimize failure. These systems are low profile, made from titanium, and easily shapeable. Most rib repairs in the United States are performed by trauma or thoracic surgeons, although this varies from by center. Surgeons new to the principles of osteosynthesis may wish to enlist the help of an orthopedist colleague as they navigate their early experience.

Enteroatmospheric fistula (EAF), a special subset of enterocutaneous fistula (ECF), is defined as a communication between the gastrointestinal (GI) tract and the atmosphere. It is one of the most devastating complications of "damage control" laparotomy (DCL) and results in significant morbidity and mortality. The published incidence of EAF ranges from 5%-19% of patients who have undergone DCL and survived long enough to develop complications. Their etiology is complex and ranges from persistent abdominal infection, anastomotic leakage, adhesions of the bowel to itself or fascia, and repeated bowel manipulation during return trips to the operating room or dressing changes. Prevention is clearly the best treatment strategy but may be difficult to achieve. Once an EAF occurs, immediate management consists of treatment of sepsis if present; nutrition, fluid, and electrolyte support in the form of parenteral nutrition (PN); and wound/effluent control and protection of surrounding tissues and exposed bowel. It should be noted that EAF almost never close spontaneously, and definitive repair usually requires major surgical intervention and abdominal wall reconstruction 6 to 12 months after the original insult. Enteral feeding should be attempted once the anatomy of the EAF is defined and reliable enteral access is obtained. Most patients can tolerate some amount of enteral and even oral feeding and do not need to be maintained on PN alone. Professional judgment, experience, and teamwork are key to successfully managing the patient with EAF.

Background: Splenic artery angioembolization (EMBO) has been promoted to increase the success rate of nonoperative management of splenic injuries. Our institutional clinical pathway calls for EMBO in the setting of ongoing splenic bleeding or contrast blush on computed tomography scan. We perceived a higher rate of failure than that reported in the literature. The purpose of this study was to review our experience with splenic EMBO to identify predictors of failure of nonoperative/EMBO management. Methods: The trauma registry and interventional radiology database of a Level I trauma center were reviewed for patients with splenic injuries from January 2000 through June 2004. Charts and films of patients undergoing EMBO were reviewed. Results: There were 221 patients admitted with blunt splenic injuries. Of these, 165 (75%) were selected for nonoperative management; 41 (25%) of them underwent splenic EMBO. Of the 41, 11 patients (27%) failed nonoperative/EMBO management. Of nine patients with low-grade injury (I, II) and small or no hemoperitoneum, none failed EMBO, whereas 10 of 23 (43%) with high-grade injury (III, IV, V) and moderate or large hemoperitoneum failed. EMBO was more likely to fail if extravasation was seen on angiography (59% vs. 4%). Coils (vs. particles) and main (vs. selective) artery EMBO were more often successful. Of EMBO patients who experienced transient hypotension, 57% required splenectomy. Conclusions: EMBO may have salvaged many spleens, but splenectomy was required in 27% of EMBO patients. Patient selection is critical to successful management. Any hypotension in the face of a contrast blush probably warrants laparotomy. The combination of high grade injury and significant hemoperitoneum, or extravasation on angiogram, predict a high risk of failure and thus warrant a low threshold for splenectomy if bleeding persists. Technical EMBO considerations may impact success, but this requires further investigation.

Background The optimal management of clinically stable patients with anterior abdominal stab wounds (AASWs) is debated. We implemented a protocol of serial clinical assessments to determine the need for laparotomy. The purpose of this study was to determine whether the approach is safe and effective. Methods Records of patients sustaining AASWs from 1999 to 2003 were reviewed. Results Seventy-seven patients sustained AASWs. Twenty-five were taken directly to the operating room because of hypotension (5), evisceration (7), or peritonitis (15). Seventeen patients had diagnostic peritoneal lavage (DPL) for associated thoracoabdominal wounds and 5 had local wound exploration (LWE) off protocol. The remaining 30 patients were managed with serial clinical assessments and were discharged uneventfully. Conclusion Patients sustaining AASWs who present without hypotension, evisceration, or peritonitis may be managed safely under a protocol of serial clinical evaluations. This approach should be compared with LWE/DPL in a prospective, randomized multicenter trial.

Background: Splenic embolization can increase nonoperative salvage. However, complications are not clearly defined. A retrospective multicenter review was performed to delineate the risks and benefits of splenic embolization. Methods: A retrospective chart review of all patients undergoing splenic embolization from 1997 to 2002 at four separate Level I trauma centers was performed. Reviewed results included patient demographics, admission and follow-up computed tomographic scan results, angiographic technique, and patient outcomes including splenic salvage rate and procedural complications. Results: A total of 140 patients were reviewed. The majority were young male patients involved in motor vehicle crashes. These patients had high abdominal computed tomographic grades of splenic injury and moderate Injury Severity Scores. The splenic salvage rate was 87%, which decreased with increasing injury grade. However, over 80% of splenic injury grades 4 and 5 were successfully managed nonoperatively. Significant hemoperitoneum did not affect success, but the presence of arteriovenous fistula was associated with a high failure rate, even with embolization. Salvage rates were similar between main coil and subselective embolization groups. Patients over 55 years of age did no worse than younger patients. Major complications included bleeding in 16 patients; 6 splenic abscesses, with 5 patients requiring splenectomy; and 1 episode of arterial injury requiring operative repair. Conclusion: Splenic embolization remains a valuable technique in splenic salvage, especially in higher grade injuries. Complications are common but do not seem to affect outcome.

Background Day-of-injury (DOI) brain lesion volumes in traumatic brain injury (TBI) patients are rarely used to predict long-term outcomes in the acute setting. The purpose of this study was to investigate the relationship between acute brain injury lesion volume and rehabilitation outcomes in patients with TBI at a level one trauma center. Methods Patients with TBI who were admitted to our rehabilitation unit after the acute care trauma service from February 2009-July 2011 were eligible for the study. Demographic data and outcome variables including cognitive and motor Functional Independence Measure (FIM) scores, length of stay (LOS) in the rehabilitation unit, and ability to return to home were obtained. The DOI quantitative injury lesion volumes and degree of midline shift were obtained from DOI brain computed tomography scans. A multiple stepwise regression model including 13 independent variables was created. This model was used to predict postrehabilitation outcomes, including FIM scores and ability to return to home. A p value less than 0.05 was considered significant. Results Ninety-six patients were enrolled in the study. Mean age was 43 ± 21 years, admission Glasgow Coma Score was 8.4 ± 4.8, Injury Severity Score was 24.7 ± 9.9, and head Abbreviated Injury Scale score was 3.73 ± 0.97. Acute hospital LOS was 12.3 ± 8.9 days, and rehabilitation LOS was 15.9 ± 9.3 days. Day-of-injury TBI lesion volumes were inversely associated with cognitive FIM scores at rehabilitation admission (p = 0.004) and discharge (p = 0.004) and inversely associated with ability to be discharged to home after rehabilitation (p = 0.006). Conclusion In a cohort of patients with moderate to severe TBI requiring a rehabilitation unit stay after the acute care hospital stay, DOI brain injury lesion volumes are associated with worse cognitive FIM scores at the time of rehabilitation admission and discharge. Smaller-injury volumes were associated with eventual discharge to home. Volumetric neuroimaging in the acute injury phase may improve surgeons' ultimate outcome predictions in TBI patients. Level of evidence Prognostic/epidemiologic study, level V.