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Introduction: Computed Tomography Angiography (CTA) is being used to identify traumatic intracranial aneurysms (TICA) in patients with findings such as skull fracture and intracranial haemorrhage on initial Computed Tomography (CT) scans after blunt traumatic brain injury (TBI). However, the incidence of TICA in patients with blunt TBI is unknown. The aim of this study is to report the incidence of TICA in patients with blunt TBI and to assess the utility of CTA in detecting these lesions. Methods: A 10-year retrospective study (2003-2012) was performed at a Level 1 trauma centre. All patients with blunt TBI who had an initial non-contrasted head CT scan and a follow-up head CTA were included. Head CTAs were then reviewed by a single investigator and TICAs were identified. The primary outcome measure was incidence of TICA in blunt TBI. Results: A total of 10 257 patients with blunt TBI were identified, out of which 459 patients were included in the analysis. Mean age was 47.3 ± 22.5, the majority were male (65.1%) and median ISS was 16 [9-25]. Thirty-six patients (7.8%) had intracranial aneurysm, of which three patients (0.65%) had TICAs. Conclusion: The incidence of traumatic intracranial aneurysm was exceedingly low (0.65%) over 10-years. This study adds to the growing literature questioning the empiric use of CTA for detecting vascular injuries in patients with blunt TBI. [ABSTRACT FROM AUTHOR]

Objectives To determine whether frail elderly adults are at greater risk of fracture after a ground-level fall ( GLF) than those who are not frail. Design Prospective observational study. Setting Level 1 trauma center. Participants All elderly (≥65) adults presenting after a GLF over 1 year (N = 110; mean age ± SD 79.5 ± 8.3, 54% male). Measurement A Frailty Index ( FI) was calculated using 50 preadmission frailty variables. Participants with a FI of 0.25 or greater were considered to be frail. The primary outcome measure was a new fracture; 40.1% (n = 45) of participants presented with a new fracture. The secondary outcome was discharge to an institutional facility (rehabilitation center or skilled nursing facility). Multivariate logistic regression was performed. Results Forty-three (38.2%) participants were frail. The median Injury Severity Score was 14 (range 9-17), and the mean FI was 0.20 ± 0.12. Frail participants were more likely than those who were not frail to have fractures (odds ratio ( OR) = 1.8, 95% confidence interval ( CI) = 1.2-2.3, P = .01). Thirty-six (32.7%) participants were discharged to an institutional facility. Frail participants were more likely to be discharged to an institutional facility ( OR = 1.42, 95% CI = 1.08-3.09, P = .03) after a GLF. Conclusion Frail individuals have a higher likelihood of fractures and discharge to an institutional facility after a GLF than those who are not frail. The FI may be used as an adjunct for decision-making when developing a discharge plan for an elderly adult after a GLF. [ABSTRACT FROM AUTHOR]

Background: Assessment of operative risk in geriatric patients undergoing emergency general surgery (EGS) is challenging. Frailty is an established measure for risk assessment in elective surgical cases. Emerging literature suggests the superiority of frailty measurements to chronological age in predicting outcomes. The aim of this study was to assess the outcomes in elderly patients undergoing EGS using an established Rockwood frailty index.Study Design: We prospectively measured preadmission frailty in all geriatric (aged 65 years and older) patients undergoing EGS at our institution during a 2-year period. Frailty index (FI) was calculated using the modified 50-variable Rockwood Preadmission FI. Frail patients were defined by FI ≥ 0.25. Outcomes measures were in-hospital complications, development of major complications, and mortality. Multivariate regression analysis was performed.Results: A total of 220 patients were enrolled, of which 82 (37%) were frail. Frailty index score did not correlate with age (R = 0.64; R(2) = 0.53; p = 0.1) and poorly correlated with American Society of Anesthesiologists score (R = 0.51; R(2) = 0.44; p = 0.045). Thirty-five percent (n = 77) of patients had postoperative complications and 19% (n = 42) had major complications. Frailty index was an independent predictor for development of in-hospital complications (odds ratio = 2.13; 95% CI, 1.09-4.16; p = 0.02) and major complications (odds ratio = 3.87; 95% CI, 1.69-8.84; p = 0.001). Age and American Society of Anesthesiologists score were not predictive of postoperative and major complications. Our FI model had 80% sensitivity, 72% specificity, and area under the curve of 0.75 in predicting complications in geriatric patients undergoing EGS. The overall mortality rate was 3.2% (n = 7) and all patients who died were frail.Conclusions: Frailty index independently predicts postoperative complications, major complications, and hospital length of stay in elderly patients undergoing emergency general surgery. Use of FI will provide insight into the hospital course of elderly patients, allowing for identification of patients in need and more efficient allocation of hospital resources. [ABSTRACT FROM AUTHOR]

Introduction: The Patient Protection and Affordable Care Act (ACA) was implemented to guarantee financial coverage for health care for all Americans. The implementation of ACA is likely to influence the insurance status of Americans and reimbursement rates of trauma centers. The aim of this study was to assess the impact of ACA on the patient insurance status, hospital reimbursements, and clinical outcomes at a Level I trauma center. We hypothesized that there would be a significant decrease in the proportion of uninsured trauma patients visiting our Level I trauma center following the ACA, and this is associated with improved reimbursement., Methods: We performed a retrospective analysis of the trauma registry and financial database at our Level I trauma center for a 27-month (July 2012 to September 2014) period by quarters. Our outcome measures were change in insurance status, hospital reimbursement rates (total payments/expected payments), and clinical outcomes before and after ACA (March 31, 2014). Trend analysis was performed to assess trends in outcomes over each quarter (3 months)., Results: A total of 9,892 patients were included in the study. The overall uninsured rate during the study period was 20.3%. Post-ACA period was associated with significantly lower uninsured rate (p < 0.001). During the same time, there was as a significant increase in the Medicaid patients (p = 0.009). This was associated with significantly improved hospital reimbursements (p < 0.001).On assessing clinical outcomes, there was no change in hospitalization (p = 0.07), operating room procedures (p = 0.99), mortality (p = 0.88), or complications (p = 0.20). Post-ACA period was also not associated with any change in the hospital (p = 0.28) or length of stay at intensive care unit (p = 0.66)., Conclusion: The implementation of ACA has led to a decrease in the number of uninsured trauma patients. There was a significant increase in Medicaid trauma patients. This was associated with an increase in hospital reimbursements that substantially improved the financial revenues. Despite the controversies, implementation of ACA has the potential to substantially improve the financial outcomes of trauma centers through Medicaid expansion., Level of Evidence: Economic and value-based evaluation, level III.

Introduction: Assessment of operative risk in geriatric patients undergoing emergency general surgery (EGS) is challenging. Frailty is an established measure for risk assessment in surgical cases. The aim of our study was to validate a modified 15-variable EGS-specific frailty index (EGSFI)., Methods: We prospectively collected geriatric (age older than 65 years) EGS patients for 2 years. Postoperative complications were collected. Frailty index was calculated for 200 patients based on their preadmission condition using 50-variable modified Rockwood frailty index. Emergency general surgery-specific frailty index was developed based on the regression model for complications and the most significant factors in the frailty index. Receiver operating characteristic curve analysis was performed to determine cutoff for frail status. We validated our results using 60 patients for predicting complications., Results: A total of 260 patients (developing, 200; validation, 60) were enrolled in this study. Mean age was 71 ± 11 years, and 33% developed complications. Most common complications were pneumonia (12%), urinary tract infection (9%), and wound infection (7%). Univariate analysis identified 15 variables significantly associated with complications that were used to develop the EGSFI. A cutoff frailty score of 0.325 was identified using receiver operating characteristic curve analysis for frail status. Sixty patients (frail, 18; nonfrail, 42) were enrolled in the validation cohort. Frail patients were more likely to have postoperative complications (47% vs. 20%; p < 0.001) compared to nonfrail patients. Frail status based on EGSFI was a significant predictor of postoperative complications (odds ratio, 7.3; 95% confidence interval, 1.7-19.8; p = 0.006). Age was not associated with postoperative complications (odds ratio, 0.99; 95% confidence interval, 0.92-1.06; p = 0.86)., Conclusion: The 15-variable validated EGSFI is a simple and reliable bedside tool to determine the frailty status of patients undergoing EGS. Frail status as determined by the EGSFI is an independent predictor of postoperative complications and mortality in geriatric EGS patients., Level of Evidence: Prognostic study, level II.

Background: Over 1 million healthcare providers have participated in the Advanced Trauma Life Support course. No studies have evaluated factors that predict course performance. This study aims to identify these predictors., Methods: All participants taking the course at 2 centers over a 4-year period were identified. Demographics, background, and performance data were extracted. Participants who failed were compared with those who did not. Stepwise logistic regression analysis was used to identify independent risk factors for failure., Results: Seven hundred forty-four healthcare providers participated in the course; 89.5% passed and 10.5% failed. Failure rates were lowest (.0%) among Trauma/Surgical Critical Care (SCC) providers and highest among pediatric providers (28.6%). Stepwise logistic regression identified age greater than 55, English as a second language, pretest score less than 75, and non-Trauma/SCC and non-Emergency Medicine background as predictors of failure., Conclusions: A failure rate of 10.5% was demonstrated among the course participants. Age greater than 55, English as second language, pretest score less than 75, and non-Trauma/SCC and non-Emergency Medicine backgrounds were associated with failure. These subgroups may benefit from performance improvement measures., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Brain Trauma Foundation (BTF) guidelines recommend intracranial pressure (ICP) monitoring for traumatic brain injury (TBI) patients with a Glasgow Coma Scale score of 8 or less with an abnormal head computed tomography, or a normal head computed tomography scan with systolic blood pressure ≤90 mm Hg, posturing, or in patients of age ≥40. The benefits of these guidelines on outcome remain unproven. We hypothesized that adherence to BTF guidelines for ICP monitoring does not improve outcomes in patients with TBI., Methods: All TBI patients with an admission Glasgow Coma Scale ≤8 admitted to our level I trauma center over a 3-y period were identified. Adherence to the individual components of our institutional TBI Bundle (ICP monitoring, SpO2 ≥95%, PaCO2 30-39 mm Hg, systolic blood pressure ≥90 mm Hg, cerebral perfusion pressure ≥60 mm Hg, ICP ≤25 mm Hg, and temperature 36°C-37°C) was assessed. Patients were stratified into two groups as follows: patients with ICP monitoring (ICP) and patients without ICP monitoring (no-ICP). Outcome measures were survival and discharge disposition. Multivariate regression analysis was performed., Results: We identified 2618 TBI patients, 261 of whom met the BTF criteria for ICP monitoring. After excluding those with nonsurvivable injuries (n = 67), 194 patients were available for analysis. The two groups were similar in demographics and severity of head injury. Survival rate was higher in the no-ICP group compared with that in the ICP group (98% versus 76%, P < 0.004). Non-monitored patients were discharged with higher levels of function per discharge location (28% home versus 4% home; P < 0.001). Patients without ICP monitoring were 1.21 times more likely to survive compared with that of patients with ICP monitoring (odds ratio: 1.21, 95% confidence interval [1.1-1.9], P = 0.01). In the ICP group, the overall compliance rate to the ICP and cerebral perfusion pressure goals as required by the BTF guidelines was poor., Conclusions: Our data suggest that there is a subset of patients meeting BTF criteria for ICP monitoring that do well without ICP monitoring. This finding should provoke reevaluation of the indication and utility of ICP monitoring in TBI patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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

Background: Senate Bill 1108 (SB-1108) allows adult citizens to carry concealed weapons without a permit and without completion of a training course. It is unclear whether the law creates a "deterrent factor" to criminals or whether it escalates gun-related violence. We hypothesized that the enactment of SB-1108 resulted in an increase in gun-related injuries and deaths (GRIDs) in southern Arizona., Methods: We performed a retrospective cohort study spanning 24 months before (prelaw) and after (postlaw) SB-1108. We collected injury and death data and overall crime and accident trends. Injured patients were dichotomized based on whether their injuries were intentional (iGRIDs) or accidental (aGRIDs). The primary outcome was any GRID. To determine proportional differences in GRIDs between the two periods, we performed χ analyses. For each subgroup, we calculated relative risk (RR)., Results: The number of national and state background checks for firearms purchases increased in the postlaw period (national and state p < 0.001); that increase was proportionately reflected in a relative increase in state firearm purchase in the postlaw period (1.50% prelaw vs. 1.59% postlaw, p < 0.001). Overall, victims of events potentially involving guns had an 11% increased risk of being injured or killed by a firearm (p = 0.036) The proportion of iGRIDs to overall city violent crime remained the same during the two periods (9.74% prelaw vs. 10.36% postlaw; RR, 1.06; 95% confidence interval, 0.96-1.17). However, in the postlaw period, the proportion of gun-related homicides increased by 27% after SB-1108 (RR, 1.27; 95% confidence interval, 1.02-1.58)., Conclusion: Both nationally and statewide, firearm purchases increased after the passage of SB-1108. Although the proportion of iGRIDs to overall city violent crime remained the same, the proportion of gun-related homicides increased. Liberalization of gun access is associated with an increase in fatalities from guns., Level of Evidence: Epidemiologic study, level III.

Background: Patients with fatal gunshot wounds (GSWs) to the head often have poor outcomes but are ideal candidates for organ donation. The purpose of this study was to evaluate the effects of aggressive management on organ donation in patient with fatal GSWs to the head., Methods: A 5-year review of all patients at a trauma center with GSWs to the head was performed. The primary outcome was organ donation after fatal GSW to the head., Results: A total of 98 patients with fatal GSWs to the head were identified. The rate of potential organ donation was 70%, of whom 49% eventually donated 72 solid organs. Twenty-five percent of patients were not considered eligible for donation as a result of disseminated intravascular coagulopathy. The T4 protocol lead to significant organ procurement rates (odds ratio, 3.6; 95% confidence interval, 1.3 to 9.6; P = .01). Failures to organ donation in eligible patients were due to lack of family consent and cardiac arrest., Conclusions: Organ donation after fatal GSW to the head is a legitimate goal. Management goals should focus on early aggressive resuscitation and correction of coagulopathy., (Published by Elsevier Inc.)

Background: As the role of acute care surgery (ACS) becomes more prevalent, clinicians in this specialty will be placing more percutaneous endoscopic gastrostomy (PEG) tubes. In this contemporary series of ACS PEG procedures, we hypothesized that technical aspects of PEG tube placement may play an important role., Methods: For our retrospective study, we queried our tertiary Level I trauma center's prospectively maintained ACS database for PEG tube placement. Our study period was from July 1, 2010, through June 30, 2012. We excluded patients who underwent "push" PEG placement, an outpatient PEG tube placement, or an open or laparoscopic gastrostomy tube operation. We conducted a multivariate logistic regression analysis of factors contributing to complications., Results: During our 24-month study period, of 184 patients, 133 underwent "pull" PEG tube placement with sufficient data for analysis. The mean (SD) age was 56 (22) years; 66% were male. Overall, 33 (25%) experienced complications: 13 (10%) were major and 20 (15%) were minor complications. In our multivariate logistic regression analysis, we found that an extreme bumper height (<2 or >5 cm) (odds ratio, 1.57; 95% confidence interval, 1.14-2.16) and upper aerodigestive tract malignancy as the operative indication (odds ratio, 1.54; 95% confidence interval, 1.06-2.26) were significantly associated with complications., Conclusion: Although pull PEG tube placement is typically a straightforward procedure, morbidity can be significant. Bumper height is an easily modifiable variable; obtaining the proper height for each patient could decrease complications after PEG tube placement., Level of Evidence: Therapeutic study, level IV.

Background: Sleep deprivation, common in intensive care unit (ICU) patients, may be associated with increased morbidity and/or mortality. We previously demonstrated that significant numbers of nocturnal nursing interactions (NNIs) occur during the routine care of surgical ICU patients. For this study, we assessed the quantity and type of NNIs in different ICU types: medical, surgical, cardiothoracic, pediatric, and neonatal. We hypothesized that the number and type of NNIs vary among different ICU types., Material and Methods: We performed a prospective observational cohort study at our academic medical center examining potential sleep disruption in ICU patients secondary to NNIs from the hours 2200-0600 nightly. From May through November 2011, bedside nursing staff in five different ICUs collected data on NNIs, including the frequency and nature of each event (patient care activity, nursing intervention, nursing assessment, or patient-initiated contact) as well as the length of time of each event and whether the bedside care provider thought that the event could have been safely omitted without negatively affecting patient care. Additional data collected included patient demographics, the need for mechanical ventilation, and sedative/narcotic use., Results: Two hundred ICU patients were enrolled over 51 separate nocturnal time periods (3.9 patients/nocturnal time period). Of those 200 patients, 53 (26.5%) were mechanically ventilated; 12.5% underwent sedative infusion; and 23.0% underwent narcotic infusion. There were a total of 1831 NNIs; most (67%) were due to nursing assessment or patient care activity. The surgical ICU had the most frequent NNIs (11.8 ± 9.0), although they were the shortest (6.66 ± 6.06 min), as well as the highest proportion of NNIs that could have been safely omitted (20.9%). Nursing staff estimated that, of all NNIs in all ICU types, 13.9% could have been safely omitted., Conclusions: NNIs occur frequently and vary across different ICU types. Many NNIs are due to nursing assessment and patient care activities, much of which could be safely omitted or clustered. A protocol for nocturnal sleep promotion is warranted in order to standardize ICU NNIs and minimize nighttime sleep disruptions., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The saying goes that a picture is worth a thousand words, but what then is the value of video? For the care of trauma and emergency surgical patients, the use of video consultation between medical providers may be worth its weight in gold. Telemedicine has become an important tool in reducing the disparity among the haves and the have not's, in this case facilities with a trauma service and those without. This article presents the use of live video for trauma consultations between the only level 1 trauma center in Southern Arizona and several smaller rural hospitals. We also expand on what we believe the future and direction of telesurgery in the fields of critical care and trauma surgery.

Objectives: The popularity of all-terrain vehicles (ATVs) continues to increase, but this form of recreation is not as well regulated and can impact children disproportionately. This study examines the epidemiology of ATV injuries in Arizona with emphasis on pediatric injuries and compares ATV injuries to those associated with motorcycle (MCC) and motor vehicle crashes (MVC)., Methods: The trauma registry of a level 1 trauma center was used to identify all ATV crashes during a 5-year period (2004-2008) in patients younger than 16 years. Registration data of ATV were obtained from the state DMV. All-terrain vehicle-related injuries were compared with both MVC and MCC., Results: A total of 250 pediatric ATV crashes were observed during the 5-year period, rising from 29 in 2004 to 53 in 2008. The median age of patients with ATV-related injuries was 13 years, which is higher than that of patients with MVC-related injuries (9 years). Only 34% of the patients with ATV-related injuries were helmeted, compared with 55% of patients with MCC-related injuries. All-terrain vehicle-related crashes were at least 30 times more likely than MVCs and almost 20 times more likely than MCCs. Statewide pediatric ATV deaths rose during the study period., Conclusions: All-terrain vehicle-related crashes have increased during this study period and have become a significant source of injuries. Public education and awareness of the dangers associated with ATV use need to be targeted toward both parents and children likely to use ATVs.

Background: The injury mechanism of blunt cervical spine injury (CSI) involves two forces: (1) an acceleration-deceleration force or change in velocity (delta v) that causes significant head and neck movement, resulting in flexion-extension injury pattern and (2) a direct force to the head or face against an immovable object with force transmitted down the cervical spine. Combining those two forces creates what bioengineers call imparted energy (IE). In blunt assault to the head or face, IE is low; hence, the reported incidence of CSI is low. The goal of our study was to identify the incidence, pattern, and outcome of CSI in blunt assaulted patients., Method: We queried the trauma registry at our Level I trauma center for patients admitted with the diagnosis of blunt assault over a 5-year period (2005-2009). Patients with CSI were identified by International Classification Diagnosis (Ninth Revision) codes of 805, 806, 839, or 952. We only included the patients who received the blow to the head and face. For eligible patients, we extracted data from trauma registry and inpatient chart review, including radiographic reports. A single author (N.K.) reviewed computed tomography (CT) scan of all individuals with CSI. We performed summary and Spearman rank correlation statistical analysis with p value <0.05 considered significant., Results: During the study period, 1,335 patients met our study inclusion criteria. All underwent CT of the head, cervical spine, and/or face. CSI was suspected in 78 patients; however, 65 had normal CT results and were diagnosed instead with a cervical sprain. Of the remaining 13 patients, two had a herniated disc, two had spinal stenosis, and nine had a fracture or dislocation, yielding a CSI incidence of 0.7%. We found no correlation between an increased incidence of CSI and either severe head trauma (low Glasgow Coma Scale [GCS] score) (r = -0.02, p = 0.58) or severe facial trauma (high face Abbreviated Injury Scale score [f-AIS]) (r = 0.02, p = 0.59). Three patients had significant subluxation; only two had associated spinal cord injury (SCI). All three required surgical fusion, and all three reported a fall after assault without significant head or face trauma., Conclusion: The incidence of CSI after blunt assault is very low, and the pattern of injury and severity is related to a fall occurring after the assault. Our results should encourage clinicians to find out if patient falls after the assault.

Background: The gap between demand of transplantable organs and their supply continues to widen. Trauma patients constitute a significant proportion of organ donors. The incidence of organ donation after traumatic cardiopulmonary arrest (TCPA), however, is not clear. The goals of this study were to determine the success rate of organ donation in patients undergoing cardiopulmonary resuscitation (CPR) after trauma and to determine if there are variables that may predict successful organ donation., Methods: All trauma patients who sustained TCPA from April 2007 to March 2010 were reviewed. We identified all patients who required CPR in the field or the trauma center. Patients were classified as donors if the heart, lung, kidney, small bowel, pancreas, or liver was harvested. Primary outcome was organ donation after CPR., Results: A total of 252 patients required CPR for TCPA in the field or in the trauma center. There were 39 (15.5%) survivors and 213 (84.5%) fatalities. Only 19 of 213 (8.9%) patients who died after TCPA became organ donors. A total of 26 organs were harvested including 15 kidneys, 6 livers, 4 hearts, and 1 pancreas. Of those who failed to donate organs, 64.7% had a cardiac arrest after the donor network had been contacted but before their arrival., Conclusions: Survival rate after TCPA is low but organ donation is an important secondary outcome. Patients with predominant head injuries, without thoracic and minimal extremity injuries, should be identified as having a higher chance of going on to organ donation. The greatest barrier to organ donation in TCPA patients is cardiac arrest before donor network arrival., (Copyright © 2011 Elsevier Inc. All rights reserved.)