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COVID-19 has impacted how we deliver care to patients, and much remains unknown regarding optimal management of respiratory failure in this patient population. There are significant controversies regarding tracheostomy in patients with COVID-19 related to timing, location of procedure, and technique. In this narrative review, we explore the recent literature, publicly available guidelines, protocols from different institutions, and clinical reports to provide critical insights on how to deliver the most benefit to our patients while safeguarding the health care force. Consensus can be reached that patients with COVID-19 should be managed in a negative-pressure environment with proper personal protective equipment, and that performing tracheostomy is a complex decision that should be made through multidisciplinary discussions considering patient prognosis, institutional resources, staff experience, and risks to essential health care workers. A broad range of practices exist because there is no conclusive guidance regarding the optimal timing or technique for tracheostomy.

The extended focused assessment with sonography for trauma (eFAST) ultrasound examination is an essential step in the initial assessment of trauma patients. Its accuracy depends on the ability to acquire high-quality ultrasound images, and we hypothesized that increasing BMI was associated with increased odds for incorrect eFAST. All adult blunt trauma activations at a high-volume urban trauma center in 2016 that underwent eFAST and CT chest, abdomen, and pelvis were included (n = 446). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the eFAST were calculated with CT results as reference. The association of BMI and eFAST accuracy was determined using univariate analyses. Sensitivity and specificity of the eFASTexamination were 27.1 per cent and 91.7 per cent, respectively, with an overall 76.2 per cent accuracy. At BMI 36 kg/m2, the odds of having incorrect eFAST results increased to odds ratio (OR) = 1.85 (95% confidence interval, 1.03–3.32; P = 0.05). For those with BMI > 40 kg/m2, the OR increased to OR = 3.12 (95% confidence interval, 1.45–6.69; P = 0.01). One-third of patients in this study were obese or morbidly obese. The latter was associated with increased odds for incorrect eFAST results, particularly the abdominal examination component.

Patient physiology and crash characteristics are essential components of field triage for motor vehicle crashes. We aimed to identify prehospital information that predicted high injury severity or critical patient condition on hospital arrival. The association of demographics, shock index (SI), Glasgow Coma Scale, and 10 crash characteristics of trauma activations for motor vehicle crashes with injury severity score (ISS) ≥ 16 and a composite of hypotension, need for blood transfusions, or immediate operation was determined using univariate and multivariate analyses. A total of 133 of 498 patients (27%) had ISS ≥ 16; SI ≥ 0.9, Glasgow Coma Scale ≤, 8, speed ≥ 55 mph, seatbelt use, airbag deployment, ambulatory patient, severe vehicle damage, ejection, and extrication were associated with ISS ≥ 16. Only abnormal SI and high speed remained independent predictors for ISS ≥ 16 with Odds Ratio (OR) = 10.76 (95% confidence interval (CI), 1.14-101, P = 0.04) and OR = 10.37 (95% CI, 1.48–72.93, P = 0.02), respectively. SI ≥ 0.9 predicted the composite outcome with OR = 5.92 (95% CI, 2.32–15.08, P < 0.01). Many commonly reported crash characteristics did not predict clinically important outcomes. Improvements in road and vehicle safety may be resulting in lower injury severity despite major crash mechanisms.

The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study.Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study.Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively.This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

Background Most triage guidelines for blunt chest wall trauma focus on advanced age and multiple fractured ribs to indicate a high-risk patient population that should be admitted to an intensive care unit (ICU). Overly sensitive ICU admission criteria, however, may result in overutilization of resources. We revised our rib fracture triage guideline to de-emphasize age and number of rib fractures, hypothesizing that we could lower ICU admission rates without compromising outcomes. Methods Patients admitted to our level 1 trauma center over 9 months after the institution of the revised guideline (N = 248) were compared with those admitted over 6 months following the original guideline (N = 207) using Fisher’s exact and Wilcoxon-Mann-Whitney tests, as appropriate. Univariate followed by multivariate analyses were performed to determine risk factors for complications. Results The ICU admission rate significantly decreased from 73% to 63% ( P = .02) after the institution of the revised guideline, despite an increase in the patient’s age and injury acuity of the cohort. There was no significant difference in respiratory complications, unplanned ICU admission rates, and overall mortality. Poor incentive spirometer effort (750 mL or less) and dyspnea in the trauma bay were the strongest predictors of an adverse composite outcome and prolonged hospital length of stay. Discussion A revised rib fracture triage guideline with less emphasis on the patient’s age and the number of fractured ribs safely lowered ICU admission rates. Poor functional status rather than age and anatomy was the strongest predictor of complications and prolonged hospital stay.

Background Current evidence-based screening algorithms for blunt cerebrovascular injury (BCVI) may miss more than 30% of carotid or vertebral artery injuries. We implemented universal screening for BCVI with computed tomography angiography of the neck at our level 1 trauma center, hypothesizing that only universal screening would identify all clinically relevant BCVIs. Methods Adult blunt trauma activations from July 2017 to August 2019 underwent full-body computed tomography scan including computed tomography angiography neck with a 128-slice computed tomography scanner. We calculated sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of common screening criteria. We determined independent risk factors for BCVI using multivariate analyses. Results A total of 4,659 patients fulfilled the inclusion criteria, 2.7% (n = 126) of which had 158 BCVIs. For the criteria outlined in the American College of Surgeons Trauma Quality Improvement Program Best Practices Guidelines, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 72.2%, 64.9%, 6.8%, 98.5%, and 65.2%, respectively; for the risk factors suggested in the more extensive expanded Denver criteria, they were 82.5%, 50.4%, 5.3%, 98.9%, and 51.4%, respectively. Twenty-three percent (n = 14) of patients with BCVI grade 3 or higher would not have been captured by any screening criteria. Cervical spine, facial, and skull base fractures were the strongest predictors of BCVI with odds ratios and 95% confidence intervals of 8.1 (5.4-12.1), 5.7 (2.2-15.1), and 2.7 (1.5-4.7), respectively. Eighty-three percent (n = 105) of patients with BCVI received antiplatelet agents or therapeutic anticoagulation, with 4% (n = 5) experiencing a bleeding complication, 3% (n = 4) a BCVI progression, and 8% (n = 10) a stroke. Conclusion Almost 20% of patients with BCVI, including a quarter of those with BCVI grade 3 or higher, would have gone undiagnosed by even the most extensive and sensitive BCVI screening criteria. Implementation of universal screening should strongly be considered to ensure the detection of all clinically relevant BCVIs. Level of evidence Diagnostic study, level III.

Trauma is a major problem in the United States. Mortality from trauma is the number one cause of death under the age of 45 in the United States and is the third leading cause of death for all age groups. There are approximately 200,000 deaths per year due to trauma in the United States at a cost of over $671 billion in combined healthcare costs and lost productivity. Unsurprisingly, trauma accounts for approximately 30% of all life-years lost in the United States. Due to immense development of trauma systems, a large majority of trauma patients survive the injury, but then go on to die from complications arising from the injury. These complications are marked by early and significant metabolic changes accompanied by inflammatory responses that lead to progressive organ failure and, ultimately, death. Early resuscitative and surgical interventions followed by close monitoring to identify and rescue treatment failures are key to successful outcomes. Currently, the adequacy of resuscitation is measured using vital signs, noninvasive methods such as bedside echocardiography or stroke volume variation, and other laboratory endpoints of resuscitation, such as lactate and base deficit. However, these methods may be too crude to understand cellular and subcellular changes that may be occurring in trauma patients. Better diagnostic and therapeutic markers are needed to assess the adequacy of interventions and monitor responses at a cellular and subcellular level and inform clinical decision-making before complications are clinically apparent. The developing field of metabolomics holds great promise in the identification and application of biochemical markers toward the clinical decision-making process.

This review focuses on pitfalls and lessons learned during the development, implementation, and sustainability of hospital community-based youth violence prevention program. In the USA, homicide is the third leading cause of death among youth aged 10–24. The re-injury rate seen at Virginia Commonwealth University Trauma center (VCU-TR) is comparable to the nationally observed rate of 10 to 50%. VCU-TR, along with several other Trauma Centers, has taken an active role in the development of hospital community-based youth violence prevention programs. The efforts have been effective in reducing recidivism and the risks of violence. Significant pitfalls can be avoided in the development and sustainability of an evidence-based, collaborative, hospital community-based youth violence prevention programs. This review highlights the effectiveness of hospital community-based violence prevention programs in reducing the risks of re-injury. There are significant pitfalls to avoid both internal within the institution as well as external with the community partners.

Panamerican Trauma Society was born 30 years ago with the mission of improving trauma care in the Americas by exchange of ideas and concepts and expanding knowledge of trauma and acute illness. The authors, immediate-past leaders of the organization, review the evolution of this assembly of diverse cultures and nationalities. How to cite this article Ivatury RR, Aboutanos M. Panamerican Trauma Society: The First Three Decades. Panam J Trauma Crit Care Emerg Surg 2017;6(2):90-123.

BackgroundAccurate medication reconciliation in trauma patients is essential but difficult. Currently there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS) based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival.MethodsPlasma samples were collected from 356 patients who provided informed consent including-10 healthy controls, 19 known positive or negative controls and 327 trauma patients over 65 years of age who were evaluated at our large, urban Level 1 Trauma Center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage was compared with LCMS results to determine overall accuracy, sensitivity, specificity and positive and negative predictive values (PPV, NPV) of the assay.ResultsOf 356 patients, 39 were on DOACs (10.96%): 21 were on Apixaban, 14 on rivaroxaban and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.06%, (PPV 92.50% and NPV 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.11% (PPV 86.36% and NPV 99.40%). There were three false positive results and two false negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity.ConclusionsThis LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients.Study type: diagnostic testBasic Science paper: therefore does not require a level of evidence.

Fifty percent of women killed in intimate partner violence (IPV) were seen by a health care provider within a year of their death. As guest speaker to Virginia Commonwealth University Trauma Center (VCU-TC), Dr. James Davis (Western Trauma Association past president) challenged VCU-TC to develop a hospital-based IPV program. This research examines the development and impact of an integrated hospital/VCU-TC-based IPV program.The IPV survey was carried out to determine need for training and screening. Hospital forensic nurse examiners case logs were evaluated to determine IPV prevalence. An integrated IPV program-Project Empower was developed, consisting of staff education, patient screening, victim crisis fund, and interdisciplinary sexual assault/domestic violence intervention team. Between 2014 and 2018, patients admitted with an IPV consult to Project Empower were entered into a secure database capturing demographics, mechanisms, income data, and social determinants of risk. Program feasibility was evaluated on patient engagement via screening and case management. Program impact was evaluated on crisis intervention, safety planning, and community referral.Forensic nurse examiner data and IPV survey evaluation noted 20% IPV prevalence and lack of IPV screening and training. The IPV patients (N = 799) were women (90%), unmarried (79%) and African-American (60%). Primary mechanisms were firearm (44%) or stabbing (34%). Survivors were perpetrated by a cohabiting (42%) or dating partner (18%). Monthly income averaged US $622. Forty percent had no health insurance. Advocates provided 62% case management. Survivors received victim crisis funds (16%), safety planning (68%), crisis intervention (78%), sexual and domestic violence education (83%), and community referral (83%). Within 5 years, 35 (4%) were reinjured and seen in the emergency department. Thirty-one (4%) were readmitted for IPV-related injuries. Two deaths were attributed to IPV.Critical call for hospital-based IPV intervention programs as a priority for trauma centers to adopt cannot be underestimated but can be answered in a comprehensive integrated model.Therapeutic, level I.

BACKGROUND Acute-care surgery (ACS), trauma, and surgical critical care (SCC) fellowships graduate fellows deemed qualified to perform complex cases immediately upon graduation. We hypothesize international fellow rotations can be a resource to supplement operative case exposure. METHODS A survey was sent to all program directors (PDs) of ACS and SCC fellowships via e-mail. Data were captured and analyzed using the REDCap (Research Electronic Data Capture) tool. RESULTS The survey was sent to 113 PDs, with a response rate of 42%. Most fellows performed less than 150 operative cases (59.5%). The majority of PDs thought the operative exposure either could be improved or was not enough to ensure expertise in trauma and emergent general surgery. Only a minority of the PDs found their case load exceptional (can be improved: 43%, not enough: 30% exceptional: 27%). Most PDs thought an international experience could supplement the breadth of cases, provide research opportunities, and improve understanding of trauma systems (70%). Ten sites offered international rotations (70%). Most fellowships would be willing to provide reciprocity to the host institution (90%). CONCLUSIONS The majority of PDs for ACS, trauma, and SCC programs perceive a need for increased quality and quantity of operative cases. The majority recognize international fellow rotations as a valuable tool to supplement fellows' education.

To determine the role of cell swelling in severe hemorrhagic shock and resuscitation injury.Circulatory shock induces the loss of energy-dependent volume control mechanisms. As water enters ischemic cells, they swell, die, and compress nearby vascular structures, which further aggravates ischemia by reducing local microcirculatory flow and oxygenation. Loading the interstitial space with cell impermeant molecules prevents water movement into the cell by passive biophysical osmotic effects, which prevents swelling injury and no-reflow.Adult rats were hemorrhaged to a pressure of 30 to 35 mm Hg, held there until the plasma lactate reached 10 mM, and given a low-volume resuscitation (LVR) (10%-20% blood volume) with saline or various cell impermeants (sorbitol, raffinose, trehalose, gluconate, and polyethylene glycol-20k (PEG-20k). When lactate again reached 10 mM after LVR, full resuscitation was started with crystalloid and red cells. One hour after full resuscitation, the rats were euthanized. Capillary blood flow was measured by the colored microsphere technique.Impermeants prevented ischemia-induced cell swelling in liver tissue and dramatically improved LVR outcomes in shocked rats. Small cell impermeants and PEG-20k in LVR solutions increased tolerance to the low flow state by two and fivefold, respectively, normalized arterial pressure during LVR, and lowered plasma lactate after full resuscitation, relative to saline. This was accompanied by higher capillary blood flow with cell impermeants.Ischemia-induced lethal cell swelling during hemorrhagic shock is a key mediator of resuscitation injury, which can be prevented by cell impermeants in low-volume resuscitation solutions.

BackgroundNovel crystalloid solutions containing polyethylene glycol polymers (PEG-20k) produce dramatic resuscitation effects but dose-dependently produce a hypocoagulative state. The objective of this study was to examine possible mechanisms of this effect. Based on previous thromboelastography data, we hypothesize the effect is largely due to platelet interactions with the polymers.MethodsWhole citrated blood from healthy volunteers was diluted ex-vivo 10% with crystalloids and tested for coagulation and platelet function. The specific tests included prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and von Willebrand factor (vWf) activity, thrombin generation, thromboelastography with and without platelet mapping, platelet flow cytometry, and erythrocyte sedimentation rate.FindingsFibrinogen and vWF activities, PT, and aPTT were not affected by PEG-20k dilutions. Thrombin activity was mildly suppressed with PEG-20k (TTP- 20%). Platelet mapping demonstrated significantly greater % inhibition of both ADP and arachidonic acid-induced platelet aggregation with PEG-20k, but direct ADP-activated gpIIa/IIIb (PAC1) and P-selectin (CD62P) binding site expression was not altered. Mild dose-dependent suppression of TEG-MA was seen with PEG-20k using platelet poor plasma. Erythrocyte Sedimentation Rates (ESR) were dramatically accelerated after dilution with 10% PEG-20k, which was competitively blocked by smaller PEG polymers, suggesting nonspecific PEG-20k cell binding effects.ConclusionsPEG-20k creates a mild hypocoagulative state in whole blood at concentrations ≥10%, which may be due to platelet-PEG interactions at the IIb/IIIa interface with lesser effects on fibrin polymerization. This interaction may cause a functional thrombasthenia induced by nonspecific platelet surface passivation by the PEG polymer.

Introduction and objectives Injuries and noncommunicable diseases account for greater than 73% deaths and 76% disability adjusted life years (DALYs) in Latin America, where trauma care is challenging especially when resources are scarce. Education and training is a basic step in trauma systems development, which was shown to improve survival. Except for urban areas, trauma courses are unavailable and unaffordable in the Latin region. The aim of this study is to evaluate the feasibility of implementation of a basic trauma education course (BTC) for resource-limited areas adopted and promulgated by the Panamerican Trauma Society (PTS) since 2011. Materials and methods Basic trauma education course was administered in Paraguay, Medellin, Chile, and Panama during the PTS congresses (2011-2013). The two-day course was based on the patient's pathway system, addressing the management of the patient through various echelon of care from rural health centers to local provincial hospital and tertiary treatment facilities. It contained 20 hours of didactic lectures and hands on skill labs on basic trauma resuscitation, stabilization, and transport, as well as trauma system-oriented teaching (triage, EMS, kinematics, trauma registries). Panamerican Trauma Society international and national instructors administered the courses. Course logistics and coordination were carried out by international and local coordinators and by trauma league medical students. Pre and post (30 multiple-choice questions) tests were used to assess participants. Paired t-test was used to compare scores. Results Fifty-four students (rural physicians, EMS providers, students, nurses, and administrators) participated. Pre and posttest score comparison showed significant improvement 74% vs 85% respectively, p-value < 0.0001. Conclusion A tailored trauma course and evaluation can be feasible in educating local providers. The PTS can promulgate the application of BTCs that may serve as a model for continuing trauma care education in developing countries. Course follow-up evaluation is pending. How to cite this article Mata LV, Mora FE, Quiodettis M, Fischer J, Machain GM, Salamea JC, Rodas EB, Aboutanos MB. Panamerican Trauma Society Basic Trauma Education Course Administration in Resource-limited Areas. Panam J Trauma Crit Care Emerg Surg 2016;5(2):83-87.

NJURIES TO THE HEART and great vessels can occur by almost any mechanism in patients who have sustained trauma. These injuries can be categorized into injuries that are so devastating that patients die at the scene and injuries that are stable enough for patients to arrive at the hospital. In the hospital setting, several factors affect the management of patients who sustain cardiac or great vessel injuries, including the mechanism of injury (penetrating v blunt), patient stability (unstable v stable), and injury location (cardiac v great vessels). When a patient presents with an obvious cardiac injury, the anesthesiology team should be prepared to initiate several key interventions immediately. These interventions include airway management, obtaining intravenous access, and determining which patients are candidates for extreme lifesaving maneuvers. The anesthetic management in the operating room (OR) includes supporting the circulation, providing maneuvers that aid surgical repair, and identifying the extent of cardiac injury. Postoperatively, it is important to ensure adequate resuscitation and continue close monitoring. The following case highlights various issues that need to be considered when managing a patient who presents with a significant cardiac injury. CASE REPORT A 31-year-old man (height 175 cm, weight 77 kg) was brought to the trauma center after sustaining stab wounds with a machete. One wound was to the left shoulder, and a second wound was to the left anterior chest. He arrived without vital signs and receiving cardiopulmonary resuscitation (CPR). The total time without vital signs was reported by prehospital personnel to be o10 minutes. The patient underwent immediate tracheal intubation, intravenous access was obtained, and an anterolateral resuscitative thoracotomy was performed in the emergency department (ED). Because of cardiac tamponade, a decision was made to open the pericardium. A large amount of blood clot was evacuated from the pericardial space. Two large lacerations were identified involving both left and right ventricles. These lacerations were closed emergently with staples. After continued CPR and administration of crystalloids and blood, the heart began exhibiting unorganized electrical activity. The heart was defibrillated with internal paddles, and organized cardiac activity was obtained. The patient was rushed to the OR. In the OR, the patient was placed in the supine position. A 9F central venous catheter was inserted in the right internal jugular vein. A right radial arterial catheter also was placed. The trauma center’s massive transfusion protocol was initiated, and the patient’s intravenous access was connected to a rapid infusion device. Scopolamine, 0.4 mg, rocuronium, 80 mg, fentanyl, 250 μg (in divided doses), and cefazolin, 2 g, were administered. Sevoflurane was used for anesthetic maintenance as tolerated by the patient’s blood pressure. Careful attention was given to avoid large fluctuations in blood pressure because of concern that severe hypertension would increase bleeding or disrupt the initial repair. The goal was to maintain the patient’s systolic blood pressure (SBP) at 80 to 90 mmHg. An initial dose of epinephrine, 100 μg, was administered owing to severe hypotension. After incision, a median sternotomy was performed, and the pericardium was reopened. The laceration at the apex of the right ventricle, which had been closed temporarily with staples, was oversewn with a 3-0 polypropylene (Prolene) suture and pledgets in a running fashion. The injury to the left ventricle was repaired in a similar fashion via the anterolateral thoracotomy wound. When the cardiac injuries were closed, a left lung injury was sutured, and bleeding was controlled. Two left-sided chest tubes, one right-sided chest tube, and a mediastinal chest tube were placed, and the sternotomy was closed with sternal wires. Skin incisions were closed with staples. The patient’s initial pH and base excess in the OR were 6.8 and � 16.5, respectively. Fluid totals for the case were 8 L of crystalloid, 17 units of packed red blood cells, 7 units of fresh frozen plasma, and 10 units of platelets. The estimated blood loss was 8,500 mL, and urine output was 405 mL. On leaving the OR, the pH was 7.3, and base excess was � 5.9. The patient was transported intubated to the trauma intensive care unit

The American Association for the Surgery of Trauma (AAST) recently established a grading system for uniform reporting of anatomic severity of several emergency general surgery (EGS) diseases. There are five grades of severity for each disease, ranging from I (lowest severity) to V (highest severity). However, the grading process requires manual chart review. We sought to evaluate whether International Classification of Diseases, 9th and 10th Revisions, Clinical Modification (ICD-9-CM, ICD-10-CM) codes might allow estimation of AAST grades for EGS diseases. The Patient Assessment and Outcomes Committee of the AAST reviewed all available ICD-9-CM and ICD-10-CM diagnosis codes relevant to 16 EGS diseases with available AAST grades. We then matched grades for each EGS disease with one or more ICD codes. We used the Official Coding Guidelines for ICD-9-CM and ICD-10-CM and the American Hospital Association's "Coding Clinic for ICD-9-CM" for coding guidance. The ICD codes did not allow for matching all five AAST grades of severity for each of the 16 diseases. With ICD-9-CM, six diseases mapped into four categories of severity (instead of five), another six diseases into three categories of severity, and four diseases into only two categories of severity. With ICD-10-CM, five diseases mapped into four categories of severity, seven diseases into three categories, and four diseases into two categories. Two diseases mapped into discontinuous categories of grades (two in ICD-9-CM and one in ICD-10-CM). Although resolution is limited, ICD-9-CM and ICD-10-CM diagnosis codes might have some utility in roughly approximating the severity of the AAST grades in the absence of more precise information. These ICD mappings should be validated and refined before widespread use to characterize EGS disease severity. In the long-term, it may be desirable to develop alternatives to ICD-9-CM and ICD-10-CM codes for routine collection of disease severity characteristics.

Background Post-traumatic stress disorder (PTSD) has become a recognized healthcare crisis. Urban trauma centers (UTC) treat a high rate of violently injured patients, a known risk factor for PTSD. A quality improvement (QI) project related to PTSD was implemented to assess the prevalence of PTSD symptomology post-discharge and the need for inpatient screening and referral. Study design In 2013, 3,525 patients were admitted to a UTC, of which 560 suffered a violent injury. One hundred and twentysix (23%) were provided PTSD education and offered resources for mental health treatment (MHT). Patients in police custody, with self-inflicted injuries, with injuries related to domestic violence, or who were non-English speaking were not included in the QI analysis (37%). At 4 to 6 weeks post-discharge, patients were contacted and administered a four item PTSD screening tool. Referral to MHT was offered and provided if requested. Results One hundred and twenty-six patients were evaluated. Sixty-four (51%) patients were reached at 4 to 6 weeks postdischarge and 60 (48%) completed the full 4-item tool. Fifty (78%) had GSW, 7 (11%) had stab wounds, and 7 (11%) had assault. Sixty-two percent reported experiencing at least one major symptom of PTSD, and 52% experienced >2 major symptoms. Eighty-seven percent of patients who developed symptoms of PTSD refused referrals pre-discharge. Post-discharge, patients with at least one PTSD symptom (37) requested MHT at a significantly higher rate than those without symptoms (23; p = < 0.0001). Patients with 3 to 4 symptoms requested referral information at a higher rate than those with 0 to 2 symptoms (p ≤0.0001). Conclusion Violently injured patients are at risk for the development of PTSD symptoms post-discharge. Trauma centers have a unique opportunity to implement PTSD screening, referral and post-discharge follow-up to effect change for this at-risk population. How to cite this article Jordan A, Goldberg S, Bivins J, Hogue B, Wolfe L, Aboutanos MB. Post-traumatic Stress Symptoms in a Violently Injured Civilian Population: A Need for Hospital Identification and Resources. Panam J Trauma Crit Care Emerg Surg 2015;4(2):54-58.

OBJECTIVES Limited transthoracic echocardiography (LTTE) has been introduced as a hemodynamic tool for trauma patients. The aim of this study was to evaluate the utility of LTTE during the evaluation of nonsurviving patients who presented to the trauma bay with traumatic cardiac arrest. METHODS Approval by the Institutional Review Board was obtained. All nonsurviving patients with traumatic cardiac arrest who reached the trauma bay were evaluated retrospectively for 1 year. Comparisons between groups of patients in whom LTTE was performed as part of the resuscitation effort and those in whom it was not performed were conducted. RESULTS From January 2012 to January 2013, 37 patients did not survive traumatic cardiac arrest while in the trauma bay: 14 in the LTTE group and 23 in the non-LTTE group. When comparing the LTTE and non-LTTE groups, both were similar in sex distribution (LTTE, 86% male; non-LTTE, 74% male; P = .68), age (34.8 versus 24.1 years; P= .55), Injury Severity Score (41.0 versus 38.2; P= .48), and percentage of penetrating trauma (21.6% versus 21.7%; P = .29). Compared with the non-LTTE group, the LTTE group spent significantly less time in the trauma bay (13.7 versus 37.9 minutes; P = .01), received fewer blood products (7.1% versus 31.2%; P = .789), and were less likely to undergo nontherapeutic thoracotomy in the emergency department (7.14% versus 39.1%; P < .05). The non-LTTE group had a mean of $3040.50 in hospital costs, compared with the mean for the LTTE group of $1871.60 (P = .0054). CONCLUSIONS In this study, image-guided resuscitation with LTTE decreased the time in the trauma bay and avoided nontherapeutic thoracotomy in nonsurviving trauma patients. Limited TTE could improve the use of health care resources in patients with traumatic cardiac arrest.

Currently, there is no established system for assessing disease severity in emergency general surgery (EGS) patients. The purpose of this project was to develop a uniform grading system for measuring anatomic severity of disease in this patient population.The Committee on Patient Assessment and Outcomes of the American Association for the Surgery of Trauma developed a proposal by consensus of experts for grading severity of EGS diseases. It was then reviewed and approved by the Board of Managers of the American Association for the Surgery of Trauma.A uniform grading system for measuring anatomic severity of disease in EGS is described, with specific grades for eight commonly encountered gastrointestinal conditions. These grades range from Grade I through Grade V, reflecting an escalating clinical progression from mild disease limited within the organ itself to severe disease that is widespread.This article provides a unified grading system for measuring anatomic severity of disease that is essential to advance the science of EGS. Once validated, a description of disease grade should be included in the emerging EGS registries and in research studies involving EGS patients.

Endovascular technology during the past decade has introduced innovative strategies to manage vascular trauma. The purpose of this study was to evaluate the current use catheter-based endovascular damage-control techniques (CDET) in North, Central, and South America. A survey was sent to the presidents of local societies in Latin America, members of the board, and past presidents of the Pan-American Trauma Society. The survey was sent using the Research Electronic Data Capture collection tool. A total of 67 surveys were sent with an 85 % response rate. Surgeons from 15 countries participated in the survey. All of the centers in North America had capabilities to perform these procedures. In none of these centers, however, were they performed by trauma and acute care surgeons. In Central and South America, 64 % of the surgeons responded that they have an interventional radiology service, and in 56 % of the cases, trauma and acute care surgeons were already performing CDET. Eight-eight percent of those surveyed thought that the addition of CDET to trauma would improve patient care; 86 % would be interested in further training in this technique if such programs were available. Finally, 68 % thought that the addition of CDET would help the field of acute care surgery and trauma financially. CDET is being performed already by trauma and acute care surgeons in Latin American countries. More research is necessary to evaluate the role of the trauma surgeon in the endovascular suite as well as training requirements.

Acute care surgery encompasses trauma, surgical critical care, and emergency general surgery (EGS). While the first two components are well defined, the scope of EGS practice remains unclear. This article describes the work of the American Association for the Surgery of Trauma to define EGS.A total of 621 unique International Classification of Diseases-9th Rev. (ICD-9) diagnosis codes were identified using billing data (calendar year 2011) from seven large academic medical centers that practice EGS. A modified Delphi methodology was used by the American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes to review these codes and achieve consensus on the definition of primary EGS diagnosis codes. National Inpatient Sample data from 2009 were used to develop a national estimate of EGS burden of disease.Several unique ICD-9 codes were identified as primary EGS diagnoses. These encompass a wide spectrum of general surgery practice, including upper and lower gastrointestinal tract, hepatobiliary and pancreatic disease, soft tissue infections, and hernias. National Inpatient Sample estimates revealed over 4 million inpatient encounters nationally in 2009 for EGS diseases.This article provides the first list of ICD-9 diagnoses codes that define the scope of EGS based on current clinical practices. These findings have wide implications for EGS workforce training, access to care, and research.

Objective Obesity is a risk factor for morbidity and mortality in the polytraumatized patient. The aim of this study is to determine if obesity is an independent risk factor for missed injury in chest X-ray after trauma. Materials and methods Institutional Review Board approval was obtained. We performed a retrospective review of patients who presented to a level one trauma center as the higher acuity alerts from September 2010 to July 2011. We compared the chest X-ray with the chest computed tomography (CT) findings. Variables, such as age, BMI, mechanism, admission to the ICU and mortality during the same hospital stay, were evaluated. Results A total of 224 patients met these criteria. The majority of patients were of male gender (79%). Average age was 40 years. Average ISS was 19.7. Mean BMI was 26.7 with 103 patients with BMI < 25 and with 123 patients with BMI >25. Mechanisms included blunt (n = 167), penetrating (n = 50) and burns (n = 7). A total of 123 patients (54.4%) had undiagnosed thoracic injuries by chest X-ray that were found on chest CT scan. Eighty-five percent of patients with missed injuries on chest X-ray required ICU admission as a result of the thoracic trauma. Missed injuries were as follows; rib fractures with or without flail chest (n = 62), pneumothorax (n = 40), hemothorax (n = 42), sternal fracture (n = 15), pulmonary lacerations/contusion (n = 60), great vessel injuries (n = 6), and blunt ventricular rupture (n = 1). Strikingly, there was no significant difference in missed injury, ICU admission or mortality when obese patients were compared to nonobese patients. Conclusion Chest X-ray undermines the degree of injury in blunt trauma patients. BMI is not an independent predictor of missed injury, ICU admission or mortality during the same hospital stay. How to cite this article Vanguri P, Anand R, Aboutanos M, Ivatury R, Ferrada P. Body Mass Index is not an Independent Predictor for Missed Injury on Chest X-ray compared with Chest Computed Tomography. Panam J Trauma Critical Care Emerg Surg 2013;2(1):45-48.

Introduction Limited transthoracic echocardiogram (LTTE) has been shown to be a useful tool in guiding resuscitation in adult trauma patients. Our hypothesis is that image-guided resuscitation in pediatric trauma patients with LTTE is feasible. Methods A retrospective chart review was performed on highest level pediatric trauma alerts (age 18 years or younger) at our level I trauma center during a 6-month period. Patients were divided into 2 groups as follows: those who had LTTE performed (LTTE group) and those who did not have LTTE performed (non-LTTE group). Results A total of 31 charts were reviewed; 4 patients were excluded because they died on arrival to the emergency department. Fourteen patients had LTTE performed (LTTE group); 13 patients did not have LTTE performed (non-LTTE group). There was no difference in mechanism of injury, age, injury severity score, weight, or intensive care unit admission between the groups. The LTTE group received significantly less intravenous fluid than the non-LTTE group (1.2 vs 2.3 L, P = 0.0013).Within the LTTE group, 8 patients had "full" inferior vena cava (IVC) and 6 patients had "empty" IVC. There was no difference in injury severity score between these subgroups (P = 0.1018). Less fluid was given in the group labeled with full IVC [1.1 L (0.8-1.2)] than the group with empty IVC [2.4 L (1.7-2.6)], P = 0.0005. Four of the 6 patients with "empty" IVC had a confirmed source of bleeding. Conclusions Limited transthoracic echocardiogram can limit the amount of unnecessary crystalloid resuscitation given to pediatric trauma patients who are not hypovolemic.

BACKGROUND Variability exists in the approach to cervical spine (c-spine) clearance after significant trauma. Using concurrently gathered data on more than 9,000 such patients, the current study develops an evidence-based and readily adoptable algorithm for c-spine clearance aimed at timely removal of collar, optimal use of imaging, and appropriate spine consultations. METHODS Prospective study of adult blunt trauma team alert (TTA) patients presenting at a Level I trauma center who underwent screening computed tomography (CT) to diagnose/rule out c-spine injury (January 2008 to May 2014). Regression analysis comparing patients with and without c-spine injury-fracture and/or ligament-was used to identify significant predictors of injury. The predictors with the highest odds ratio were used to develop the algorithm. RESULTS Among 9,227 patients meeting inclusion criteria, c-spine injury was identified in 553 patients (5.99%). All 553 patients had a c-spine fracture, and of these, 57 patients (0.6% of entire population and 10.31% of patients with injury) also had a ligamentous injury. No patient with a normal CT result was found to have an injury. The five greatest predictors of ligament injury that follow were used to develop the algorithm: (1) CT evidence of ligament injury; (2) fracture pattern "not" isolated transverse/spinous process; (3) neurologic symptoms; (4) midline tenderness; and (5) Glasgow Coma Scale score

Background Neurological trauma represents a major cause of global death and disability, with low and middle income countries representing the greatest burden of disease. The goal of this study was to assess the capability of Ecuadorian hospitals to manage head and spinal cord injury utilizing the International Association for Trauma Surgery and Intensive Care (IATSIC)/World Health Organization (WHO) Guidelines for Essential Trauma Care (EsTC). Materials and methods Site visits were performed at 24 hospitals in 7 provinces of southeastern Ecuador. The 23 human and physical resources required for management of head injury (HI) and spinal injury (SI) were evaluated using EsTC criteria. Resource capabilities were graded as 3 (adequate, >90%), 2 (partially adequate, >50%), 1 (inadequate, Results Five tertiary (TH) and 12 general (GH) public hospitals were included in the final assessment. Initial assessment of neurological injuries was at least partially adequate for HI (100% TH/GH) and partially adequate for SI (100%TH, 83.3% GH). Maintenance of normotension and oxygenation to prevent secondary neurological injury was partially adequate in TH (100% HI/SI) and inadequate in GH (only 58.3% were partially adequate for HI and 67.7% for SI). Surgical capabilities for treatment of neurological injuries were partially adequate with wide variability in TH. Familiarity or compliance with AANS guidelines and international classifi cation systems for HI and SI were absent at all facilities. CT and MRI capabilities were universally inadequate. Conclusion Based on WHO/IATSIC EsTC guidelines, signifi cant improvement in physical and human resources is needed for proper management of neurologically injured patients in Southeastern Ecuador. How to cite this article Aboutanos MB, Johnston EM, Mora FE, Rodas EB, Salamea JC, Ivatury RR. Evaluation of Head and Spinal Cord Injury Care in Ecuador using the IATSIC/WHO Essential Guidelines for Trauma Care. Panam J Trauma Critical Care Emerg Surg 2012;1(1):6-11.

Resuscitation end point markers such as lactate and base deficit (BD) are used in trauma to identify and treat a state of compensated shock. Lactate and BD levels are also elevated by alcohol. In blunt trauma patients with positive blood alcohol levels, lactate may be a poor indicator of injury. Retrospective data were collected on 1083 blunt trauma patients with positive blood alcohol levels admitted a Level I trauma center between 2003 and 2006. Patients were stratified by Injury Severity Score, age, gender, and Glasgow Coma Score. Logistic regression analyses were used to assess lactate and BD as independent risk factors for mortality. Seventy-four per cent of patients had an abnormal lactate level compared with 28 per cent with abnormal BD levels. In patients with mild injury, lactate levels were abnormal in more than 70 per cent of patients compared with less than 20 per cent of patients with abnormal BD levels. Linear regression showed lactate is not a significant predictor of mortality. Regardless of Injury Severity Score, lactate appeared to be more often abnormal than BD in the setting of alcohol ingestion. Additionally, because BD, and not lactate, was shown to be an independent predictor of mortality, lactate may not be a reliable marker of end point resuscitation in this patient population.

Quantitative bronchoalveolar lavage (BAL) is used to diagnose ventilator-associated pneumonia (VAP). We prospectively compared semiquantitative (SQ) and quantitative (Qu) culture of BAL for VAP diagnosis. Ventilated patients suspected of VAP underwent bronchoscopic BAL. BAL fluid was examined by both Qu (colony-forming units [CFUs]/mL) and SQ culture (none, sparse, moderate, or heavy) and results were compared. VAP was defined as 105CFU/mL or greater on Qu culture. Over 36 months, 319 BALs were performed. Sixty-three of 319 (20%) showed diagnostic growth by Qu culture identifying a total of 81 organisms causing VAP. All 63 specimens showed growth of some organism(s) on SQ culture with 79 of 81 causative organisms identified and two ( Pseudomonas, one; Corynebacterium, one) not identified. The remaining 256 specimens did not meet the threshold for VAP by the Qu method. Among these, 79 did not show any growth on SQ culture. Among the 240 specimens showing some growth on SQ culture, a total of 384 organisms were identified. VAP rates in relation to strength of growth on SQ culture were: sparse, 10 of 140 (7%); moderate, 24 of 147 (16%); and heavy, 45 of 97 (46%). Sensitivity (Sn), specificity (Sp), positive (PPV), and negative (NPV) predictive values of SQ culture of BAL fluid for the diagnosis of VAP were 97, 21, 21, and 97 per cent, respectively. Nonquantitative culture of BAL fluid is fairly accurate in ruling out VAP (high Sn and NPV). It however has poor Sp and PPV and using this method will lead to unnecessary antimicrobial use with its attendant complications of toxicity, cost, and resistance.

We hypothesized that flexion extension (FE) films do not facilitate the diagnosis or treatment of ligamentous injury of the cervical spine after blunt trauma. From January 2000 to December 2008 we reviewed all patients who underwent FE films and compared five-view plain films (5view) and cervical spine CTC with FE in the diagnosis of ligamentous injury. There were 22,929 patients with blunt trauma and of these, 271 patients underwent 303 FE films. Average age was 39.6 years, Injury Severity Score was 10.8, Glasgow Coma Score was 14.1, lactate was 2.6 mmol/L, and hospital length of stay was 6 days. Compared with FE, 5view and CTC had a sensitivity of 80 per cent (8 of 10), positive predictive value of 47.1 per cent (8 of 17), specificity of 96.55 per cent (252 of 261), and negative predictive value of 99.21 per cent (252 of 254). For purposes of analysis, incomplete and ambiguous FE films were listed as negative; however, 20.5 per cent (62 of 303) were incomplete and 9.2 per cent (28 of 303) were ambiguous. Management did not change for the 2 patients with missed ligament injuries. The 303 studies cost $162,105.00 to obtain. FEs are often incomplete and unreliable making it difficult to use them to base management decisions. They do not facilitate treatment and may lead to increased cost and prolonged cervical collars.

The purpose of the present study was to evaluate the usefulness of the International Association for Trauma Surgery and Intensive Care (IATSIC)/World Health Organization (WHO)'s Guidelines for Essential Trauma Care (EsTC Guidelines) in providing an internationally applicable and standardized template to assess trauma care capabilities in the South American Region.Field assessment was conducted in seven provinces (urban and rural, pop. 2,239,509) and 24 facilities (5 large hospitals (LH); 15 small hospitals (SH); 4 basic hospitals (BH)) in Ecuador using EsTC criteria. A total of 260 individual items in Human Resources (HR- availability, clinical knowledge, skills) and physical resources (PR) were evaluated via inspection, review of local statistics, and administrative and staff interviews. EsTC was evaluated on a scale as follows: 0 (absent); 1(inadequate; 50%); 2 (partly adequate 50%); 3 (adequate-100%).210,045 Emergency Department (ED) visits and 61,365 (29%) ED trauma visits were recorded (incidence rate 2,740/100,000 population). Deficits were noted in prehospital trauma care (inadequate coordination, communication), education and training (ATLS 30%, TNCC 0%), facility based trauma care (poor physical resources [PR] and human resources [HR]), and quality assurance (1/27 hospitals).The IATSIC/WHO EsTC Guidelines provide a simple and useful template to assess trauma care capability in variable facilities and international settings, and they could serve as a valuable tool for trauma system development. Endorsement of EsTC Guidelines by the Panamerican Health Organization and lead trauma societies (the Panamerican Trauma Society) should be considered.

The purpose of this study was to compare flexion-extension (FE) plain films with MRI as the gold standard in the diagnosis of ligamentous injury (LI) of the cervical spine after trauma. A retrospective review of patients sustaining blunt trauma from January 2000 to December 2008 (n = 22929) who had both FE and MRI of the cervical spine was performed. Two hundred seventy-one patients had 303 FE films. Forty-nine also had MRI. The average Injury Severity Score was 15.6 ± 10.2, Glasgow Coma Scale was 13.8 ± 3.5, lactate 2.2 ± 1.7 mmol/L, and hospital stay of 8 ± 11.2 days. FE failed to identify all eight LIs seen on MRI. FE film sensitivity was 0 per cent (zero of eight), specificity 98 per cent (40 of 41), positive predictive value 0 per cent (zero of one), and negative predictive value 83 per cent (40 of 48). Although classified as negative for purposes of analysis, FE was incomplete 20.5 per cent (62 of 303) and ambiguous 9.2 per cent (28 of 303) of the time. The charge of FE is $535 so $48150 (90 incomplete/ambiguous films) could have been saved by eliminating these films. FE should no longer be used to diagnose LI. Given the rare incidence of these injuries, MRI should be used when there is high clinical suspicion of injury.

We evaluated the benefit of a central venous line (CVL) protocol on bloodstream infections (BSIs) and outcome in a trauma intensive care unit (ICU) population. We prospectively compared three groups: Group 1 (January 2003 to June 2004) preprotocol; Group 2 (July 2004 to June 2005) after the start of the protocol that included minimizing CVL use and strict universal precautions; and Group 3 (July 2005 to December 2006) after the addition of a line supply cart and nursing checklist. There were 1622 trauma patients admitted to the trauma ICU during the study period of whom 542 had a CVL. Group 3 had a higher Injury Severity Score (ISS) compared with both Groups 2 and 1 (28.3 ± 13.0 vs 23.5 ± 11.7 vs 22.8 ± 12.0, P = 0.0002) but had a lower BSI rate/1000 line days (Group 1:16.5; Group 2:15.0; Group 3: 7.7). Adjusting for ISS group, three had shorter ICU length of stay (LOS) compared with Group 1 (12.11 ± 1.46 vs 18.16 ± 1.51, P = 0.01). Logistic regression showed ISS ( P = 0.04; OR, 1.025; CI, 1.001-1.050) and a lack of CVL protocol ( P = 0.01; OR, 0.31; CI, 0.13-0.76) to be independent predictors of BSI. CVL protocols decrease both BSI and LOS in trauma patients. Strict enforcement by a nurse preserves the integrity of the protocol.

Background: Poor follow-up by patients with trauma results in a lack of knowledge of postdischarge health-related issues. This study reports on postdischarge health-related issues discovered by a program of active postdischarge contact or follow-up. Methods. All patients discharged home from the trauma service were followed up in the following manner: within 4 weeks of discharge, telephonic follow-up was attempted three times followed by scanning of electronic records. Failing that, other physicians (specialists or primary care) were contacted. Once contact was established, the patient, family member, or physician was questioned about the general well-being, any specific health-related issue, and the resolution. Results: During the 13-month study period ending September 2007, a total of 1,353 patients met entry criteria. Contact was established with 692 (51%). Of these, 116 (17%) were found to have significant health issues: (1) severe uncontrolled pain, 45; (2) missed injury, 17 (spine fractures, 4; clavicle or hand or foot fractures, 6; facial bone fractures, 3; soft tissue, 3; hematuria, 1); (3) wound infections, 17; (4) other infections, 17 (urinary, 8; pulmonary, 7; blood stream, 2) (5) venous thromboembolism, 10; and (6) other, 9 (psychiatric, 6; nontraumatic, 3). One patient died at home within 24 hours of discharge. The issues were significant enough for the patients to seek medical care (outpatient, 39; emergency department visits, 52; hospitalization, 24). Conclusion: A significant proportion of patients with trauma have moderate to severe health-related issues postdischarge that are often not found by the trauma team or the trauma registry. Active follow-up can identify the nature of the medical issues and help in designing system changes to reduce or eliminate them.

We examined the outcome of elderly trauma patients with pelvic fractures. Patients 65 years of age and older (elderly) with pelvic fractures were retrospectively compared with patients younger than 65 years with pelvic fractures and also with elderly patients without fracture. Over the study period, 1223 patients sustained a pelvic fracture (younger than 65 years, n = 1066, 87.2%; elderly, n = 157,12.8%). These patients were also compared with 1770 elderly patients with blunt trauma without fracture. Although the pelvic fracture patients were equally matched for Injury Severity Score (21.2 ± 13.4 nonelderly vs 20.5 ± 13.6 elderly), hospital length of stay was increased in the elderly (12.5 ± 13.1 days vs 11.5 ± 14.1 days) and they had a higher mortality rate (20.4% [32 of 157] vs 8.3% 88 of 1066]). The elderly without fracture also had a higher mortality rate when compared with the younger patients (10.9% [191 of 1760]; P < 0.03). The elderly were more likely to die from multisystem organ failure (25.0% [eight of 32] vs 10.2% [nine of 88]), whereas the nonelderly group was more likely to die from exsanguination (45.5% [40 of 88] younger than 65 years vs 21.9% [seven of 32] 65 years or older; P < 0.05). Elderly patients with pelvic fracture have worse outcomes than their younger counterparts despite aggressive management at a Level I trauma center.

Background: Quantitative broncho-alveolar lavage (qBAL) is increasingly being used for diagnosing ventilator-associated pneumonia (VAP). The current study prospectively evaluates the accuracy of broncho-alveolar lavage fluid Gram's stain (GS) in predicting both the presence of VAP and the class of causative microorganism in patients suspected of VAP. Methods: Patients suspected of VAP in a trauma or surgical intensive care unit underwent bronchoscopic qBAL with GS. Presence and class of organisms seen on GS were correlated respectively with the presence of VAP, as diagnosed by qBAL, and class of causative microorganism. VAP was defined as qBAL >10 5 colony forming units/mL. All data were gathered prospectively. Results: During a 28-month study period, 229 patients underwent 309 qBALs for suspected VAP. Seventy-one (23%) specimens were positive for VAP (qBAL>10 5 CFU/mL). Fifty-four specimens (77%) had one causative microorganism, 13 (18%) had two, 3 (4%) had three, and 1 (1%) demonstrated four microorganisms giving a total of 93 VAPs. Forty-one (62%) of 66 specimens showing moderate or many microorganisms on GS were positive for VAP. However, 7 (4%) of 167 specimens showing none and 23 (30%) of 76 showing few microorganisms on GS were also positive for VAP. Of the 64 qBAL specimens positive for VAP and where the GS showed microorganisms, 6 (23%) of 26 showing only G+ microorganisms on GS had G-VAP (G- alone, 4; G+ and G-, 2), and 1 (8%) of 12 showing G- microorganisms only had G+ and G- VAP. Of the seven qBAL specimens positive for VAP where the GS did not show microorganisms, one had G+ and six had G- VAP. With the threshold of positivity of GS at more than none, the sensitivity, specificity, positive, and negative predictive values of GS for the presence of VAP were 90%, 67%, 45%, and 96% respectively. Conclusions: Broncho-alveolar lavage fluid GS is poor in predicting the presence of VAP and predicting the class of causative microorganism. Using GS to determine necessity of and to select class of antimicrobial therapy will result in delayed or inappropriate VAP therapy or both.

BACKGROUND: Motor vehicle crashes (MVC) are the leading cause of maternal injury during pregnancy. It is estimated that 1,300 to 13,000 fetal deaths/yr result from maternal MVC. METHODS: Pregnant women with injuries were identified by ICD-9 codes containing pregnancy and injury from hospital medical records and Trauma/ED registries. Records were reviewed for demographic data, fetal gestational age, mechanism of injury, injuries sustained, Glasgow Coma Score, loss of consciousness (LOC), Injury Severity Score (ISS), and maternal and fetal outcome. Fisher's exact test, t test, and logistic regression analysis were performed to analyze statistical analysis. RESULTS: From 2001 to 2005, 29,066 pregnant patients were seen at our institution. Five thousand two hundred forty-four of these patients visited the ED, and 294 of them reported injuries. One hundred forty-eight (50.3%) patients were involved in MVC. The average maternal age was 23.8 years. The mean gestational age was 20 weeks. The majority of patients were drivers (n=97, 70%) versus passengers (n=42, 30%), and 66% were restrained versus 34% unrestrained. There were no maternal deaths; however, seven mothers (4.7%) had poor fetal outcome (six fetal deaths and one hydrops fetalis). Increased maternal age, LOC, high ISS, and pelvic injury were risk factors for poor fetal outcome. Logistic regression revealed LOC and pelvic injury to be independent risk factors. CONCLUSIONS: Increased maternal age, LOC, and maternal pelvic fractures sustained during MVC contribute toward high ISS and significantly impacts fetal outcome. Despite fetal gestational age, aggressive radiographic pursuit of pelvic fractures may be warranted. Language: en

Background: Quantitative bronchoalveolar lavage (qBAL) is used for accurate diagnosis of ventilator-associated pneumonia (VAP). The current study aims at defining the incidence, outcomes and therapeutic implications of false-negative (FN) qBAL. methods: Ventilated trauma, surgery, and burn, patients suspected of VAP underwent bronchoscopic qBAL. VAP was defined as qBAL with >105 CFU/mL (threshold). To identify FN BALs, blood cultures drawn concomitant with BAL (±5 days of BAL) were analyzed. qBAL specimens growing

The purpose of this study was to determine if anemia in isolated head trauma patients results in a higher mortality rate that would justify a more liberal use of blood transfusions.A retrospective review of isolated blunt head trauma patients was performed between January 2001 and December 2006. Comparisons were made between survivors and nonsurvivors regarding demographics, laboratory values, transfusions received, and lengths of stay.There were 788 patients with 735 survivors who were significantly younger (46.3 y +/- 21.5 survivors versus 68.9 y +/- 18.8 nonsurvivors, P0.0001) and less injured [(ISS: 14.7 +/- 5.2 survivors versus 23.2 +/- 4.7 nonsurvivors, P0.0001), (head abbreviated injury severity: 3.7 +/- 0.7 survivors versus 4.7 +/- 0.5 nonsurvivors, P0.0001)] than those who died (n = 53). The survivors also had shorter lengths of stay (days) [(ICU: 2.4 +/- 4.2 versus 5.6 +/- 11.7, P = 0.03), (hospital: 6.3 +/- 9.8 versus 7.8 +/- 14.8, P = 0.02)]. Multivariate logistic regression showed age (OR 1.063, CI 1.042-1.084), ISS (OR 1.376, CI 1.270-1.491), minimum hemoglobin (OR 0.855, CI 0.732-1.000), and total blood products transfused (OR 1.073, CI 1.008-1.142) to be independent predictors of mortality with an ROC of 0.942. Outcome was independent of the operative procedures, hematocrit and packed red blood cells transfused at 24, 48, and 72 h. Hemoglobin levels of8 mg/dL were more predictive of death than8 mg/dL (P = 0.01).This study supports the need to balance mild anemia with judicious blood product use in the head trauma patient. Given the risk with blood product use, each transfusion should be carefully considered and the patient re-evaluated regularly to determine the need for further intervention.

We prospectively compared clinical examination (CE) with plain films (PXR) and both tools with CT in patients sustaining blunt trauma. There were 1388 patients who had both PXR and CT of whom 168 (12.1%) were diagnosed with a fracture by CT. CE findings most predictive of fracture included age (OR, 1.025; CI, 1.011–1.039), hip pain (OR, 4.971; CI, 2.508–9.854), internal rotation of the leg (OR, 4.880; CI, 1.980–12.027), or tenderness to palpation over the sacrum (OR, 2.297; CI, 1.144–4.612), over the right or left hip (OR, 3.626; CI, 1.823–7.214), or diffusely throughout the pelvis (OR, 16.445; CI, 4.277–63.237). These factors were still predictive of pelvic fractures even in patients with a Glasgow Coma Scale score less than 13. There were 136 fractures identified by PXR all of which were identified by CE (sensitivity 100% [136 of 136], negative predictive value 100% [619 of 619]). There were six patients with negative clinical examinations and positive CTs (sensitivity 96.4% [162 of 168], negative predictive value 99.03% [613 of 619]), none of which were hemodynamically significant. The sensitivity for PXR compared with CT was 79.17 per cent (133 of 168) and the NPV was 97.2 per cent (1217 of 1252). CE is a reliable way to diagnose pelvic fractures and PXR is a poor screening tool for these injuries compared with CT. Because the majority of patients undergo CT after blunt trauma, routine screening radiographs should be eliminated.

Injury Severity Score (ISS) and lactate are controversial in predicting fetal outcome. A retrospective review was conducted to determine whether ISS and lactate are valuable in predicting fetal survival in injured pregnant patients. Injured pregnant women were identified by ICD-9 codes from our Trauma Registry, Emergency Department Registry, and hospital medical records. Records were reviewed for demographic data, mechanism of injury, ISS, Glascow Coma Scale, lactate, vital signs, and maternal/fetal outcome. To determine statistical analysis, χ2 and t test analysis was performed. From 2001 to 2005, 294 women reported injuries. Most patients (51.7%) were discharged from the Emergency Department, yet 18 per cent were admitted to Trauma Surgery. The average maternal and gestational age was 23.4 years and 19.6 weeks, respectively. Seventy-two (33.3%) patients were in the first trimester. The majority of patients (88.1%) were involved in blunt trauma, and 10 (3.9%) had poor fetal outcome (nine fetal deaths and one hydrops fetalis). There were no maternal deaths. Maternal age, first trimester, elevated lactate, and high ISS were significant risk factors for poor fetal outcome (P = 0.044, P = 0.0173, P = 0.0001, and P = 0.0001, respectively). Specific parameters (ISS, lactate, maternal age, and gestational age) may be helpful in predicting poor fetal outcome and directing patient management.

Background The American Association for the Surgery of Trauma (AAST) has developed a new grading system for uniform description of anatomic severity of emergency general surgery (EGS) diseases, ranging from Grade I (mild) to Grade V (severe). The purpose of this study was to determine the relationship of AAST grades for acute colonic diverticulitis with patient outcomes. A secondary purpose was to propose an EGS quality improvement program using risk-adjusted center outcomes, similar to National Surgical Quality Improvement Program and Trauma Quality Improvement Program methodologies. Methods This was a retrospective study of 1,105 patients (one death) from 13 centers. At each center, two reviewers (blinded to each other's assignments) assigned AAST grades. Interrater reliability was measured using κ coefficient. Relationship between AAST grade and clinical events (complications, intensive care unit use, surgical intervention, and 30-day readmission) as well as length of stay was measured using regression analyses to control for age, comorbidities, and physiologic status at the time of admission. Final model was also used to calculate observed-to-expected (O-E) ratios for adverse outcomes (death, complications, readmissions) for each center. Results Median age was 54 years, 52% were males, 43% were minorities, and 22% required a surgical intervention. Almost two thirds had Grade I or II disease. There was a high level of agreement for grades between reviewers (κ = 0.81). Adverse events increased from 13% for Grade I, to 18% for Grade II, 28% for Grade III, 44% for Grade IV, and 50% for Grade V. Regression analysis showed that higher disease grades were independently associated with all clinical events and length of stay, after adjusting for age, comorbidities, and physiology. O-E ratios showed statistically insignificant variations in risk of death, complications, or readmissions. Conclusion AAST grades for acute colonic diverticulitis are independently associated with clinical outcomes and resource use. EGS quality improvement program methodology that incorporates AAST grade, age, comorbidities, and physiologic status may be used for measuring quality of EGS care. High-quality EGS registries are essential for developing meaningful quality metrics. Level of evidence Prognostic study, level V.

Background Acute gangrenous cholecystitis (AGC) is a medical emergency that carries high morbidity. The objective of this study is to define risk factors for this disease. Methods A retrospective review of patients who underwent cholecystectomy while admitted to the Acute Care Surgery Service from January 2009 to April 2014 was performed. Specimen reports were evaluated to identify patients with AGC and cholecystitis without necrosis (CN). Preoperative factors as well as outcomes were compared between the groups. Results A total of 483 patents underwent cholecystectomy. Four hundred fifty-nine patients were found to have CN and 24 patients were found to have AGC. Pre-existent factors such as diabetes, coronary artery disease, and systemic inflammatory response syndrome predicted AGC on a logistic regression. Patients with AGS were also more commonly older, male, and had a higher preoperative bilirubin. Mortality was significantly higher in patients with AGC (12.5% vs .9%, P = .003). Conclusions AGC carries an increased mortality rate compared with CN. Older patients with diabetes, coronary artery disease, and elevated bilirubin should be suspected of having AGC.

Background: Obesity has proven to be an independent risk factor of mortality in the intensive care unit (ICU) in both nontrauma and trauma patients. The purpose of this study was to determine whether the detrimental effect of obesity extend to morbidity as well as mortality in the intensive and nonintensive care blunt trauma patients. Methods: A retrospective comparison of obese (body mass index [BMI] >30 kg/m 2 ) to nonobese (BMI

This study evaluates whether an initial blood glucose level is similarly predictive of injury severity and outcome as admission lactate in trauma patients. Between February 2004 and June 2005, we prospectively compared patients with presenting blood sugars of ≤150 mg/dL (LBS) with those with blood sugars >150 mg/dL (HBS). Fifty patients had BS above 150 mg/dL, whereas 176 patients were ≤150 mg/dL. These groups had similar demographics except for age. Injury Severity Score (ISS) of ≥15 was seen in 56.0 per cent of HBS patients versus 28.4 per cent of LBS patients (P = 0.0006). HBS patients had similar infection rates (12.0% HBS vs. 5.7% LBS, P = 0.13) but a higher mortality (30.0% HBS vs. 5.7% LBS, P < 0.0001). There was a linear relationship between ISS and BS (r2 = 0.18, P < 0.0001) and ISS and lactate (r2 = 0.17, P < 0.0001). Blood sugar trended with the lactate (r = 0.25, P = 0.0001). Hyperglycemic patients were more severely injured with higher mortality. BS correlated with lactate, and because it is easily obtainable, it may serve as a readily available predictor of injury severity and prognosis.